Malignant hyperthermia; sterilization monitoring; sterilization indicators; multipack needle counts
QUESTION: I work in a freestanding ambulatory surgery center (ASC) that recently scheduled a 10-year-old boy for surgery. The patient was healthy and had not had previous surgeries, but the preoperative interview revealed a strong family history of malignant hyperthermia (MH). The patient’s maternal aunt had experienced an MH crisis and the patient’s mother had tested positive for MH susceptibility. Consequently, the procedure was cancelled, but I wondered if it was appropriate to have scheduled the procedure in our freestanding ASC in the first place. What are the guidelines for treating MH-susceptible patients in outpatient settings? Are there specific preoperative screening measures that should be done differently in an ASC than in a hospital-based setting?
ANSWER: According to the Malignant Hyperthermia Association of the United States (MHAUS), patients who are MH susceptible can be scheduled for surgery in outpatient settings if the anesthesia care provider uses a trigger-free anesthetic technique. (1) An example of a trigger-free anesthetic technique is one that includes propofol, opioids, or non-depolarizing muscle relaxants (eg, pancuronium) and does not include halothane or isoflurane as an inhalation agent. Nitrous oxide is safe for use as an inhaled general anesthetic, and local anesthetics (eg, lidocaine, procaine) also are safe. (2,3) When MH-susceptible patients undergo uneventful general anesthetics in ASCs, they should be monitored for at least 60 minutes in the phase I postanesthesia care unit (PACU) and at least 90 minutes in the phase 2 PACU or step-down unit before being discharged. (1,4,5)
Facility preparedness. Every patient should be considered potentially at risk for developing MH no matter where the patient is scheduled to have surgery. Previous uneventful anesthesia does not eliminate the possibility of MH, because patients may undergo multiple episodes of anesthesia before MH is triggered. (6) Personnel working in any location that administers general anesthetics and/or succinylcholine should be prepared to manage an MH crisis. (3) Preparations include stocking a supply of 36 vials of dantrolene sodium and sterile water, having access to ice, and ensuring availability of the pharmacologic agents and equipment listed in Table 1.
Staff member education. Every facility should include MH training in the orientation plan for new members of the perioperative team and other personnel who will be involved in responding to the crisis. Ongoing periodic reviews also should be scheduled. The MHAUS recommendations suggest that the perioperative team initiate mock MH drills at least twice a year to improve staff member efficiency in treating a patient during an MH crisis. (7)
Dantrolene sodium is difficult to mix, so some institutions reconstitute the outdated medication during staff member education sessions to give hands-on training during the mock drills. Perioperative nurses also may benefit from a review of the electrolyte imbalances and arterial blood gas shifts that occur with respiratory and metabolic acidosis during an MH crisis. Facilities should identify specific tasks assigned to each member of the response team to ensure effective management of an MH crisis. Procedure manuals are available from the MHAUS to assist in assigning specific tasks and to facilitate staff member education. (7)
Signs and symptoms of malignant hyperthermia. Malignant hyperthermia may present with a variety of signs and symptoms during an acute phase or may develop over a course of several hours and present in a subtler fashion. Unexplained tachycardia is often the first sign of an acute MH episode. Jaw muscle rigidity that is severe, sustained, or interferes with intubation should be considered a possible sign of an impending MH crisis.
Guidelines for MH susceptibility. Patients identified as MH susceptible who are undergoing surgery in an ASC and exhibit mild spasms in their jaw or masseter muscle rigidity should not be discharged without further observation. The following guidelines should be used if suspicious symptoms are noted.
* The patient should be observed for at least 10 hours if he or she has demonstrated mild symptoms of jaw tension but no increase in creatine kinase and no signs of myoglobinuria, muscle weakness, muscle soreness, hyperthermia, or abnormal electrolytes. The patient may be discharged after 10 to 12 hours with instructions to return to an emergency room at the first sign of elevated temperature. (3)
* The patient should be observed overnight if the patient has dark or cola-colored urine, increased temperature or pulse rate, or changes in acid-base balance.
* If the patient had severe jaw rigidity but no other symptoms, the patient should be observed overnight to ensure that there is no progression of symptoms and to decrease the risk of an MH crisis. (3-5)
Malignant hyperthermia occurs most frequently during administration of anesthesia. Initial symptoms generally are not seen in the PACU, especially after more than two hours have elapsed since the anesthetic agents were discontinued. (8) When patients present with symptoms of a fever in the PACU, it generally is due to sepsis or iatrogenic heating and is not related to MH. Temperature increases after a patient is discharged generally are not related to MH unless there were signs of MH (eg, myoglobinuria, muscle weakness, muscle rigidity) before discharge. (3)
Screening for MH. Specific screening measures for MH should not be performed differently in an ASC than in a hospital. Patients and their family members, however, should participate in making the decision about where to have surgery scheduled if the patient has been identified as MH susceptible. It is important for patients and their family members to understand that MH is a genetic disease with an autosomal-dominant pattern. This translates to the following inheritance patterns.
* Children of an MH-susceptible person have a 50% chance of inheriting the susceptibility.
* Grandchildren of an MH-susceptible person have a 25% chance of testing positive for MH susceptibility.
* The risk to siblings of an MH-susceptible patient depends upon the genetic status of the MH patient’s parent. If a parent of the MH patient is MH susceptible, the risk to the siblings is 50%.
* More distant relatives have a lesser chance of testing positive for MH susceptibility. (9-13)
A patient whose history seems suspicious for MH, may wish to have a muscle biopsy test performed before undergoing anticipated surgery, but it is not a requirement because anesthesia care providers have the option of using a nontriggering anesthesia technique. (3) Patients are appropriate candidates for muscle biopsy testing if they have a family history of MH or have experienced unexplained hypercarbia and muscle rigidity related to a general anesthetic. (11,13) In the past, dantrolene sodium was used to pretreat patients who were identified as MH susceptible because it stabilizes the muscle cell membrane and limits intracellular calcium levels. Currently, this is not recommended because patients who have had prophylactic dantrolene sodium regimens have experienced muscle weakness or gastrointestinal upset. (14)
When MH susceptibility is identified, perioperative nurses should help the patient and his or her relatives understand the importance of informing the entire surgical team (eg, anesthesia care providers, surgeon, perioperative nurses) about a family history of MH before the patient undergoes any future surgical or invasive procedures requiring general anesthesia. It is critical that patients and their relatives receive counseling and education regarding the pathophysiology and management of MH. If a patient has experienced symptoms suggesting MH during a procedure, the perioperative nurse should suggest that the patient receive and keep a copy of the anesthesia record, laboratory tests, and the PACU/critical care unit notes to show future care providers.
Regardless of whether the surgical procedure is scheduled in an ASC or a hospital setting, nursing care begins when the patient is scheduled for a surgical or other procedure involving general anesthesia. As early as possible in the preoperative phase, the perioperative nurse should ask patients and their family members the following series of questions to help screen for MH susceptibility. (3,8,14,15)
* Has anyone ever told you that you had a “bad” reaction to anesthesia?
* Has anyone ever told you that you or a family member had a problem with anesthesia?
* Have you or a family member experienced a high fever while undergoing anesthesia?
* Has anyone ever told you or a family member that it was difficult to open your or their jaw during general anesthesia?
* Has anyone in your family died unexpectedly in the OR?
* Have you or anyone in your family experienced sunstroke or heat stroke resulting in hospitalization?
* Have you ever noticed dark “cola-colored” urine after general anesthesia or after experiencing a heat-related illness?
Opening a discussion using layman’s terms may help the patient and family members talk about situations that relate to MH susceptibility.
If the perioperative nurse believes a patient is susceptible to MH, the nurse should notify the surgeon and anesthesia care provider. Preoperative education and preparation is crucial for the patient who is identified as being susceptible to MH. It is important that the patient and family members understand that answering “yes” to any of the screening questions will not mean they will be denied anesthesia during a surgical procedure but rather that different considerations may be initiated for their anesthesia care. They should participate in decisions about when and where to go for the surgical procedure and understand that counseling is available.
Patients who are identified as susceptible to MH can safely undergo surgery in outpatient settings when anesthesia care providers are prepared to use nontriggering anesthetics and careful monitoring. Perioperative nurses play a key role in preoperative patient assessment and communication when patients are identified as MH susceptible.
QUESTION: I am new to perioperative nursing and I am confused about the terminology for sterilization process monitoring. I have heard several terms, but I am not sure how to differentiate each one quickly. Can you provide a quick way to reference the following types of monitoring devices: mechanical indicators, Bowie-Dick tests, process challenge devices, chemical indicators, biological indicators, “rapid-read” indicators, “enzyme-only” indicators, and integrators? Where can I read about sterilization process monitoring in more detail?
ANSWER: Perioperative nurses are responsible for verifying that supplies and instruments used during surgery are sterile. To do this, nurses need to understand the purpose and design of sterilization equipment and products used to measure performance in their facility. Following is a brief summary of several monitoring devices (eg, mechanical, chemical, biological, “rapid-read,” enzymeonly, and integrator indicators; dynamic air-removal tests; process challenge devices) identified by the Association for the Advancement of Medical Instrumentation (AAMI) to verify the performance of the equipment being used for the sterilization process. (16)
* Mechanical indicators. These physical monitoring devices, which may include graphs, gauges, or automated digital printouts, monitor sterilization parameters (eg, time, temperature, pressure).
* Dynamic air-removal tests. This is the broader term for Bowie-Dick tests. These diagnostic tests detect air leaks and inadequate steam penetration and determine the adequacy of air removal from the chamber of a prevacuum steam sterilizer (ie, a sterilization chamber that has mechanically assisted air removal). This is not a test for sterilization and is not applicable to gravity-displacement sterilizers.
* Process challenge devices (PCDs). These test packs are designed to provide a challenge to the sterilization process that is equal to or greater than the challenge posed by the most difficult item routinely processed.
* Chemical indicators (CI). Chemical indicators are sterilization process monitoring devices that are used to verify whether items have been exposed to one or more of the critical parameters necessary for sterilization but not that sterilization has been achieved. A visual change, usually a change in color, indicates a defined level of exposure based on the classification of the chemical indicator used. The use of a chemical indicator by itself does not prove that the item monitored by the indicator is sterile. Chemical indicators should be used in coordination with mechanical indicators and biological indicators to document the effectiveness of the sterilization process.
* Biological indicators (BI). These devices are commercially prepared with a known population of highly resistant spores and require incubation to determine whether microorganisms grow or fail to grow. Biological indicators are the only sterilization process monitoring devices that provide a direct measure of the lethality of the sterilization process at a location within a particular load. Perioperative personnel should place a biological indicator within a process challenge device and keep a log to document negative growth. Specific spores should be used for the biological indicator that monitors specific types of sterilizers. Geobacillus stearothermophilus spores should be used for steam sterilizers, low-temperature hydrogen peroxide gas plasma sterilizers, ozone sterilizers, and low-temperature liquid peracetic acid sterilizers. Bacillus atrophaeus spores should be used to test ethylene oxide sterilizers and dry heat sterilizers.
* “Rapid-read” indicators. This type of biological indicator contains enzyme based spores and allows an early readout of the sterilization results. To verify that the early results continue to be accurate, each facility should follow established policies and procedures based on manufacturer’s instructions to periodically continue to incubate the biological indicator with the enzyme-based early-readout indicators past the rapid-read time frame to confirm spore growth based on a visible color change.
* Enzyme-only indicators. This device contains multiple, interactive enzymes of bacterial origin. The performance of enzyme-only indicators has been correlated to the performance of a biological indicator. These indicators, however, do not contain spores and should not be confused with biological indicators that have enzyme-based, early-readout capability.
* Integrator indicators. These chemical indicators are designed to react to all critical parameters over a specified range of sterilization cycles. The performance of these indicators has been correlated to the performance of biological indicators; however, they do not contain spores and cannot be used as a substitute for biological indicators.
AORN recommends including a sterilization process indicator in each package to be sterilized and with all items being flash sterilized. A separate process indicator should be used on the exterior of a package when the process indicator is not visible from the outside of the package. The purpose of external sterilization process indicators is to differentiate between processed and unprocessed items. Internal process monitors do not establish whether an item is sterile but show that the sterilant was able to penetrate the package, exposing the package contents to conditions of sterilization. (17) For more information, refer to AORN’s “Recommended practices for sterilization in the perioperative practice setting” (17) and the ANSI/AAMI ST79, Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. (16)
QUESTION: We use steritization tape on the outside of our instrument sets. Why am I not allowed to cut up the tape or use a similar type of indicator on the inside of the trays to show they have been processed? Are there categories of indicators that I need to know about?
ANSWER: Sterilization tape and other types of external indicators only indicate that the item has been through the sterilization process; they are not intended to be used to indicate that sterilization parameters have been met. These indicators are heat-sensitive and usually change from white to black when exposed to the high temperatures used for the sterilization process. They are intended to be used as an easy method to identify which items have been processed; however, this type of indicator may change color when placed in any location where there is an elevated temperature (eg, a window sill in direct sunlight). Based on this information, perioperative personnel should not store this type of indicator in an area that is exposed to sunlight or heat. Sterilization tape is not an appropriate indicator to be used independently as an internal indicator because it only reacts to heat and does not determine whether an item has been exposed to heat for a set amount of time or to other critical parameters of the sterilization process.
The American National Standards Institute (ANSI) and the Association for the AAMI identify five classes of chemical indicators. (18) Each class of indicator responds to different parameters of sterilization (ie, time, temperature, pressure).
* Class 1–Process indicators. Sterilization tape and other external indicators fall into this category. These indicators are appropriate for use with individual packs or containers to distinguish between processed and unprocessed items.
* Class 2–Indicators used for specific test procedures. Air-removal tests for vacuum steam sterilizers fall into this category. These indicators assess only the efficiency of the vacuum pump and the presence of air leaks or gases in the steam. They indicate the efficiency of the air removal system but not sterilization efficacy.
* Class 3–Single-parameter indicators. These indicators are designed to respond to one critical sterilization parameter, such as temperature. A common type of class 3 indicator is a glass temperature tube containing a chemical that melts and changes color when a minimum temperature is reached. These indicators do not indicate the total time at one temperature or whether the temperature was exceeded. They are used to determine whether the appropriate temperature was achieved at the center of large packs.
* Class 4–Multi-parameter indicators. These indicators are designed to indicate exposure to a sterilization cycle at stated values of the chosen parameters while also reacting to two or more critical parameters of sterilization. An example of this type of indicator would be one containing ink that changes color when exposed to the correct combination of sterilization parameters.
* Class 5–Integrator indicators. These indicators respond to all sterilization parameters and may be used for release of nonimplant loads. All parameters of sterilization have been met if the chemical on the integrator wicks into the “accept” area of the indicator. A biological indicator should be used in addition to a class 5 integrator in a process challenge device to monitor all loads that contain implants. Whenever possible, implants should be quarantined until the biological indicator results are available. (16)
One of the major responsibilities of perioperative RNs is to minimize patient risk of surgical wound infections. To fulfill this responsibility, it is important for nurses to pay continuous attention to all aspects of the sterilization process and sterilizer performance. Nurse managers and nurse educators who work in perioperative settings should advocate to include quality control parameters for the sterilization process in employee orientation and staff development programs for all members of the perioperative team. (17)
QUESTION: It is my understanding that suture packages should not be used to verify needle counts. If this is true, am I supposed to open all the multipack suture packages for the initial count and all subsequent counts rather than using the unopened suture packages?
ANSWER: AORN does not recommend using empty suture packages to rectify a discrepancy in a closing needle count, but it is acceptable to count suture needles initially by the number marked on the suture package before the scrub person opens the individual suture packages. Individual multipack suture packages should be opened as close as possible to the time they are to be used. The number of actual needles should be verified at the time they are opened by the scrub person and circulating nurse. Additional multipack needle packages should be counted simultaneously by the scrub person and circulating nurse when they are added to the sterile field during the procedure as close as possible to the time they are to be used.
Opening multipack suture packages for the initial count could increase the risk of injury to the scrub person because of the high number of unconfined sharps remaining on the back table for a long period of time before they are needed. Furthermore, when sharps are unconfined on the sterile field, there is an increased risk for unintentional transfer into the incision, penetration of barriers, or of misplacing sharps (eg, when they are dropped to the floor). (19)
For answers to your questions contact the Center for Nursing Practice at (800) 755-2676 x 265 or send on e-mail to firstname.lastname@example.org. AORN’s 2007 Standards, Recommended Practices, and Guidelines is now available.
Editor’s note: At various times throughout the year, the Recommended Practices Committee seeks review and comment on proposed recommended practices from members and other interested individuals. When available, these proposed recommended practices appear on AORN Online at http://www.aorn.org. Proposed recommended practice documents are available for review and comment for a 30-day period after they are posted. Interested individuals who do not have access to the Internet may obtain copies of the proposed documents by calling the Center for Nursing Practice, at (800) 755-2676 x 334. A deadline for comments is indicated with each document. Please check these sources frequently to locate proposed recommended practices. All comments received are considered as the document is finalized. Thank you for your participation.
(1.) MHAUS–Malignant Hyperthermia Association of the United States. Medical professional’s FAQs. April 2006. Available at: http://www.mhaus.org/ index.cfm/fuseaction/Content.Display/PagePK/MedicalFAQs.cfm. Accessed December 17, 2006.
(2.) MHAUS–Malignant Hyperthermia Association of the United States. Anesthetic list for MH-susceptible patients. Available at: http://www.mhaus.org/index.cfm/fuseaction/Content. Display / PagePK/AnestheticList.cfm. Accessed December 17, 2006.
(3.) H Rosenberg. Malignant hyperthermia in the ambulatory setting. Seminars in Anesthesia, Perioperative Medicine and Pain. 2001;20:270-274.
(4.) Pollock N, Langton E, McDonnell N, Tiemessen J, Stowell K. Malignant hyperthermia and day stay surgery. Anaesth Intensive Care. 2006;34:4045.
(5.) Bryson G, et al. Patient selection in ambulatory anesthesia–an evidence-based review: part II. Can J Anaesth. 2004;51:782-794.
(6.) Hallsall PJ, Cain PA, Ellis FR. Retrospective analysis of anaesthetics received by patients before susceptibility to malignant hyperthermia was recognized. Br J Anaesth. 1979;51:949-954.
(7.) Malignant Hyperthermia Association of the United States. MH Procedure Manual for Hospitals. Sherbourne, NY: Malignant Hyperthermia Association of the United States; 2006.
(8.) Nagelhout JJ, Zaglaniczny KL. Nurse Anesthesia. 2nd ed. Philadelphia: WB Saunders Company; 2001:728-732.
(9.) Rosenberg H, Dirksen RT. Malignant hyperthermia susceptibility. GeneReviews. Available at: http://www.genetests.org/servlet/access? db=geneclinics&site=gt&id=8888891&key=dI3CP2D7pvtX2&gry=&fcn=y&fw= Vkmd&filename=/profiles/mhs/index.html. Accessed December 17, 2006.
(10.) MHAUS–Malignant Hyperthermia Association of the United States. What is malignant hyperthermia? August 31, 2004. Available at: http://www.mhaus.org/index.cfm/fuseaction/OnlineBrochures.Display/BrochurePK/ 8AABF3FB-13B0-430F-BE20FB32516B02D6.cfm. Accessed December 17, 2006.
(11.) Rosenberg H, Davis M, James D, Stowell N, Stowel K. Malignant hyperthermia. Orphanet. November 2004. Available at: http://www.orpha.net/consor/cgi-bin/data.php?ActType= Pat&Form=Pat&PatId=649.0%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20% 20%20%20%20%20%20%20&PHPSESSID=6cbc5e1cb3a2082a1744d81e45d92abc. Accessed December 17, 2006.
(12.) MHAUS–Malignant Hyperthermia Association of the United States. FAQs–Molecular genetic testing for MH. August 31, 2004. Available at: http://www.mhaus.org/index.crm/fuseaction/Content.Display/PagePK/ MolecularGeneticsFAQ.cfm. Accessed December 17, 2006.
(13.) MHAUS–Malignant Hyperthermia Association of the United States. Molecular Genetic Testing for Malignant Hyperthermia Susceptibility. Sherburne, NY: Malignant Hyperthermia Association of the United States, 2006. Also available at http://www.mhaus.org/index.cfm/fuseaction/eShop*ItemGroupDetail/ItemGroupPK/ 38AE7F31-EB73-479B-B7B3609A3FDB5908.cfm. Accessed December 17, 2006.
(14.) Halaszynski TM, Juda R, Silverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med. 2004;32(suppl 4):S76-S88.
(15.) Wappler F, Fiege M, Steinfath M, et al. Evidence for susceptibility to malignant hyperthermia in patients with exercise-induced rhabdomyolysis. Anesthesiology. 2001;94:95-100.
(16.) Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST79, Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, Va: Association for the Advancement of Medical Instrumentation; 2006.
(17.) Recommended practices for sterilization in the perioperative practice setting. In: Standards, Recommended Practices, and Guidelines. Denver: AORN, Inc; 2006:629-643.
(18.) Association for the Advancement of Medical Instrumentation, ANSI/AAMI ST60, Sterilization of Health Care Prod ucts–Chemical Indicators, Part 1: General Requirements. Arlington, Va: Association for the Advancement of Medical Instrumentation; 1996.
(19.) Recommended practices for sponge, sharp, and instrument counts. In: Standards, Recommended Practices, and Guidelines. Denver: AORN, Inc; 2007.
RN, MS, CNOR
PERIOPERATIVE NURSING SPECIALIST
AORN CENTER FOR NURSING PRACTICE
Malignant Hyperthermia (MH) Cart
Suggested medications Rationale Comments
36 ampules dantrolene Skeletal muscle Dantrolene sodium
sodium IV relaxant contains 3 g mannitol
(20-mg vials) in each vial, (1) so
included on an MH
cart is no longer
2 1000-mL bags or Needed to mix Contact Malignant
bottles sterile, dantrolene sodium Hypothermia
preservative-free Association of the
water (ie, without United States (MHAUS)
a bacteriostatic for special supplies
agent) to reconstitute
5 50-mEq syringes Treats metabolic
8.4% sodium acidosis
2 50-mL vials 50% Treats hyperkalemia
1 100-units/mL bottle Treats hyperkalemia Regular insulin is
regular insulin the only insulin that
(must be kept can be administered
refrigerated) IV; (2) this requires
use of an infusion
4 40-mg ampules Increases urine output
2 10-mL vials 10% Treats life- May use calcium
calcium chloride threatening gluconate or calcium
hyperkalemia chloride; calcium
gluconate may be less
potent but is less
likely to irritate
3 prefilled syringes Treats cardiac Lidocaine does not
2% lidocaine arrhythmias aggravate MH as as
(100 mg/5 mL or previously thought but
100 mg/10 ml) must be administered
by an infusion pump;
procainamide is no
longer maintained on
Anesthesia equipment Comments
1 soda lime canister
2 adult anesthesia breathing
2 pediatric anesthesia
3 each nasogastric (NG)
tubes (various sizes)
2 esophageal tempera- Large-sized probe
ture probes can be used as a
2 general purpose Cannot be used as a
temperature probes stethoscope
6 heparinized arterial ABG kits may be used
blood gas (ABG) syringes
1 each pediatric and
adult ambu bags
1 extra oxygen tank Have readily available
if not on MH cart
2 infusion pumps Have readily available
if not on MH cart
Cooling equipment Use
6 each 1-liter and 3-liter Add these items to the
bags chilled 0.9% cart when the cart is
saline for irrigation requested
6 clear, small or medium For ice
6 clear, large plastic bags For ice
2 large containers For ice
Ice Access to ice machine
or bags of ice
Other equipment Use
5 60-ml, syringes Diluting dantrolene
6 60-mL catheter-tip Irrigation (eg, nasogas-
syringes tric tube, indwelling
10 3-mL syringes ABG analysis if ABG
kits are not available
6 vial spikes
1 box alcohol prep pads
2 4-oz bottles povidone- Prepping arterial-line
iodine paint sites
2 10-each boxes 4 x 4 Dressing IV sites
4 elastic tourniquets Drawing blood
1 central venous pres- Size appropriate to
sure line kit patient population
1 arterial line monitoring Size appropriate to
kit patient population
2 radial artery catheters
4 sets cassette tubing IV infusion pumps
6 each size angiocaths
3/4-inch 24 g
1-inch 22 g
2-inch 16 g,18 g, 20 g
2 rolls each tape
6 each adhesive IV dressings
(ie, small, large)
4 adult IV drip chambers
4 IV solution sets with
4 IV extension tubing
4 “T” connectors
4 three-way stopcocks
4 pediatric arm boards
4 adult arm boards
1 sharps container
Nursing equipment Use
2 large translucent adhesives Wound closure
2 peritoneal lavage trays
1 rectal tube
2 cystoscopy tubing
2 closed-system in-
2 urinary catheter
drainage bags with
2 adult 3-way
2 pediatric 3-way
2 5-in-1 connectors
2 Y connectors
Laboratory testing supplies Use
2 urine specimen containers Myoglobinuria
1 bottle urine test strips Blood in urine
2 each large and small Chemistry screen, complete blood
blood specimen tubes count, creatine kinase,
electrolytes fibrin split products,
fibrinogen, lactic hydrogenase,
myoglobin, platelets, prothrombin
and partial thromboplastin times,
10 Medication labels Consider labeling
sterile water “recon-
6 blood gas slips
2 hematology forms
2 chemistry forms
2 coagulation forms
2 urinalysis forms
2 physician order forms
2 blood requisition forms
1 physician consultation
1 ICU report form or Ambulatory surgery
hand-off transfer report center, office-based
form for ambulance setting
4 anesthesia records May not be needed if
using MHAUS data
Adverse medical Can be printed from
reaction to anesthesia https://www.mhreg.org;
report form from contact NAMHR to
North American receive patient packet
MH Registry with identification
(NAMHR) cards included.
MHAUS label listing Place on front of cart
hotline phone number
MHAUS MH crisis data Can be ordered from
management sheet 800-986-4287; or print-
ed online at http://
Guides, checklists, Training manual (eg,
worksheets designed by MHAUS,
facility specific); work-
Other supplies are Can be ordered from
available through 800-986-4287; or printed
MHAUS (eg, list of online at http://
duties, hand-held cards) www.mhaus.org
(1.) MHAUS Malignant Hyperthermia Association of the United States.
Medical professional’s FAQs–dantrolene. April 2006. Available at:
MedicalFAQs.cfm. Accessed December 17, 2006.
(2.) Lexi-Com. Drug Information Handbook for Perioperative Nursing.
Adapted from Anesthesiology and Critical Care Drug Handbook, 6th ed,
and Drug Information Handbook for Advanced Practice Nursing, 6th ed.
Hudson, Ohio: Lexi-Comp; 2006:933.
Adapted with permission from AORN malignant hyperthermia guideline.
In: Standards, Recommended Practices, and Guidelines. Denver: AORN,
COPYRIGHT 2007 Association of Operating Room Nurses, Inc.
COPYRIGHT 2007 Gale Group