Frequently Asked Questions

Category: Stocking an MH Cart

Does MHAUS state a specific temperature range for refrigerated supplies for an MH Event?

MHAUS does not recommend a specific temperature range for refrigerated supplies. We recommend that each institution follow its regulatory guidelines for keeping medications and fluids refrigerated according to the appropriate temperatures. This would include regulatory agencies for hospitals, ambulatory surgery centers, and office-based surgery centers.  

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FAQ Video: Temperature Range For Refrigerated Supplies

Does MHAUS state a specific temperature range for refrigerated supplies for an MH event?

Who Should Stock Dantrolene?

All facilities, including ambulatory surgery centers and offices, where MH triggering anesthetics (isoflurane, desflurane, and sevoflurane) and depolarizing muscle relaxants (succinylcholine) are administered, should stock dantrolene as indicated below, along with the other drugs and devices necessary to treat an MH reaction. If none of these agents are ever in use in the facility, then dantrolene need not be kept on hand.<

Succinylcholine is a potentially life-saving medication used to treat upper airway obstruction, and should be immediately available in any facility that administers anesthesia or sedative agents that have the potential to cause airway obstruction. In the absence of succinylcholine, practitioners should be prepared to administer an immediate-acting paralytic agent to treat life-threatening airway obstruction.

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FAQ Video: Temperature Range For Refrigerated Supplies

Does MHAUS state a specific temperature range for refrigerated supplies for an MH event?

Where Should Dantrolene Be Kept?

Dantrolene should be kept in or very close to the operating room, so that it is available immediately if MH occurs. Dantrolene may be stored at room temperature. A supply of sterile water for injection USP (without a bacteriostatic agent) should be kept nearby to mix with dantrolene before injection (60 ml/vial); the water for diluting dantrolene should not be stored in a refrigerator; it may be stored in a warming cabinet designed to maintain fluid temperatures between 35-40° C. All anesthesia and surgical team members should be aware of this location. NOTE: Dantrolene should not be mixed with any other diluent other than sterile water. The drug will not completely dissolve in crystalloid-containing solutions.

How Quickly Must Dantrolene Be Accessible?

Dantrolene must be available for all anesthetizing locations within 10 minutes of the decision to treat for MH. Dantrolene must be available for all anesthetizing locations where MH trigger agents are used.” This is a slight modification of the current recommendation that the drug be available within five minutes because the five minute recommendation was not made based on consensus discussion and it is often not practical to have a large supply of dantrolene in every area where anesthesia is administered. For example anesthesia administration is now common in locations far from the operating rooms such as interventional radiology suites. This comment and others were made at the MH Hotline – Professional Advisory Council meeting held on May 14, 2011.

Are There Any Advantages In Sharing A Supply of Dantrolene?

No. Minutes count in an MH emergency.

The Professional Advisory Council of MHAUS strongly recommends that an adequate supply of dantrolene be available wherever general anesthesia is administered. Responsibility for treatment rests with the facility where the surgery is performed. Sharing is not a good alternative.

Can Warming the Sterile Water Facilitate Mixing?

Newer formulations of dantrolene are more soluble, making the warming of the sterile water unnecessary.

What Is The Cost Of Dantrolene?

The cost of maintaining dantrolene in stock is a tiny fraction of most facility budgets and a very small price to pay for patient safety. By analogy, a cardiac defibrillator, a necessary emergency tool in all OR suites, is seldom used, and is paid for in time by each patient’s charges. In fact, many hospitals have 30-50 such units deployed at all times. Dantrolene, an emergency drug that is kept in only one location within most institutions, is an appropriate parallel to that situation and is relatively inexpensive when prorated.

*Contact manufacturer for current pricing. Although fulminant MH episodes are unusual, they do happen, and patients still die form MH. Remember that dantrolene is like a defibrillator; it is kept ready for use at all times, even though the need is rare. The cost can be prorated among all patients.

What Should Be On An MH Cart?

What Should be on an MH Cart?

A comprehensive list what should be stocked on an MH Cart.

How Much Dantrolene Should Be Kept On Hand?

To treat an MH episode, an initial dose of dantrolene at 2.5 mg/kg is recommended, with a suggested upper limit of 10 mg/kg. If a patient of average weight (approximately 70 kg) were to require dantrolene at the upper dosing limit, then at least 700 mg of dantrolene would be needed.

• DANTRIUM^®/REVONTO^® – stock a minimum of 36 - 20 mg vials
• RYANODEX^®– stock a minimum of 3 - 250 mg vials

In addition, a review of cases has shown that in a “worse case” scenario of a very large person (i.e., about 100-110 kg or 220 – 250 pounds) having an acute MH incident, as much as 8-10 mg/kg will be needed for treatment; higher doses may be required on rare occasions.

This regimen of dantrolene will allow for initial stabilization and treatment while more vials are being acquired to continue treatment, as needed.

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FAQ Video: Parameters for Dantrolene Sodium Injection

What are the parameters for dosing with Dantrolene Sodium for injection during an MH event?

Why were procainamide and mannitol taken off the list of drugs to stock for an MH episode?

Procainamide, a secondary drug used in the treatment of arrhythmias, is not readily available, and people are generally not familiar with its use. Lidocaine is a primary drug that all physicians have used for years; however, it was previously thought that lidocaine might aggravate MH. Based on a review of the literature and consensus of MH experts, we have determined that it does not, and thus, our MH experts have approved its use during an MH episode. Mannitol has been taken off the list of drugs because dantrolene (Dantrium^® IV) has 3 grams of mannitol included in each vial. The patient will receive 0.375gm/kg mannitol when given 2.5 mg/kg dantrolene.

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FAQ Video: Mannitol Cart Exclusion

Why has Mannitol been taken off the list of drugs to be stocked on the MH cart?

How do I supply a surgicenter for an MH emergency?

A surgicenter in which general anesthesia with potent volatile agents is administered should be equipped to manage MH by stocking an MH cart as outlined here.  Surgicenters that propose to use succinylcholine as an emergency agent should also have dantrolene available and an appropriate MH crisis protocol in place. Timely access to blood gas and electrolyte analysis is recommended.