1. Carter-Templeton, Heather RN, MSN

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William Elcott is admitted to PACU after undergoing orthopedic surgery. Almost immediately, you notice some alarming signs and symptoms: muscle rigidity, tachypnea, and tachycardia. Mr. Elcott's blood pressure is 154/90 mmHg and his pulse rate is 110 beats/ minute, his respiratory rate is 28 breaths/minute, and his temperature is 102.2[degrees] F (39[degrees] C). His monitor shows sinus tachycardia and his SpO2 is 92%. A quick glance at his chart tells you his vital signs have changed since the surgery ended.


Mr. Elcott's signs and symptoms indicate malignant hyperthermia (MH). If left untreated, the condition can be rapidly fatal. You notify the anesthesia pro-vider immediately, call for a MH cart or tackle box, and additional staff to help you; administer 100% oxygen via a nonrebreather mask, and closely monitor his cardiac rhythm and vital signs.


You initiate cooling strategies that include administering cold 0.9% sodium chloride I.V. infusion, placing the patient on a cooling blanket, and placing cold packs on the groin, armpits, and neck. To avoid hypothermia, stop all of these cooling measures when the patient's temperature reaches 100.4[degrees] F (38[degrees] C).


Continuous care

The anesthesia provider orders I.V. dantrolene (Dan-trium), a direct-acting skeletal muscle relaxant and the drug of choice for treating MH. It's administered by continuous rapid I.V. push, beginning with a minimum dose of 1 mg/kg (the provider orders an initial dose of 2.5 mg/kg for Mr. Elcott) and continuing until symptoms subside or the maximum cumulative dose of 10 mg/kg is reached. Monitor Mr. Elcott closely for respiratory depression.


Watch for brownish urine; it could signal myoglob-inuria. Obtain blood samples for lab work, and obtain an arterial blood gas analysis. Monitor for abnormally high levels of potassium, calcium, magnesium, and creatine kinase and for signs of respiratory or metabolic acidosis; administer treatment as ordered.


Monitor the patient for ventricular dysrhythmias and treat according to advanced cardiac life support guidelines. Never give a calcium channel blocker to a patient with MH who's been treated with dantrolene. A serious drug interaction can occur and cause severe hyperkalemia, ventricular fibrillation, and cardiac arrest.


A full recovery

In Mr. Elcott's case, your quick work has avoided a potential disaster. Although he's making an unscheduled stop in the ICU before discharge, Mr. Elcott's chances for a full recovery are very good. While in the ICU, he'll continue to receive I.V. dantrolene for the next 24 to 48 hours to prevent a recurrence of MH. He'll also be monitored closely for signs of complications, like acute renal failure and disseminated intravascular coagulation, an abnormal condition of coagulation characterized by diffuse bleeding and hypercoagulability that can arise with MH.


When Mr. Elcott's ready to be discharged home, he should be informed about his condition. The Malig-nant Hyperthermia Association of the United States is an excellent resource for printed and online patient-teaching materials and genetic counseling. Because malignant hyperthermia is an autosomal dominant trait, the aberrant gene need be present in only one parent for it to be passed down to offspring.


Be sure to instruct Mr. Elcott to alert his primary healthcare provider of his susceptibility to MH and to wear a medical-alert bracelet. That way, if he's unable to speak and needs to be given anesthesia, triggering agents can be avoided.