A family history of deaths under general anesthesia – an unlikely nightmare for the modern anesthesiologist. But for Dr. Jim Villiers, that was a challenge he had to face for his patient in 1960s Melbourne, Australia. Malignant hyperthermia (MH), a topic we all gain familiarity with during our training years, only became apparent in the 1960s, when Dr. Villiers was informed he had an add-on case for the afternoon: a young Melbourne man named Rob Evans with a compound fracture and a history of relatives dying from ether anesthesia. After induction, Dr. Villiers was faced with his patient becoming hemodynamically unstable, cyanotic, hot, and sweaty! Thanks to the combined efforts between his anesthesiologist and orthopedic surgeon, Evans became the first recorded person to survive MH, and his case was researched over the next 20 years (Anaesth Intensive Care 2007;35:26-31).

As trainees, we learn about the significance of MH as a rare, autosomal dominant disorder with life-threatening sequelae following exposure to triggering agents. Some encounter it solely in simulations, while others witness its progression during a case like Evans’, leaving a lasting impression etched in our minds. MH is firmly within the domain of anesthesiology, linked to its triggering agents: volatile gases and succinylcholine. However, there is room for improvement in MH management, as highlighted by the work of Riazi et al. (Anesth Analg 2014;118:381-7). Their research emphasizes a higher risk of complications associated with delays in administering dantrolene, particularly in non-OR locations.

The incidence of MH crises in patients undergoing surgery in ambulatory care centers is estimated at one in 500,000, though the overall prevalence in the general population may be higher. Previously fatal in 70%-80% of cases, advancements in end-tidal carbon dioxide monitoring and the increased availability of the life-saving treatment dantrolene have reduced mortality to 6%-10%. Despite technological advances and the widespread implementation of MH treatment carts, MH remains a serious disease with severe complications if not promptly recognized and properly treated.

The Malignant Hyperthermia Association of the United States (MHAUS) recommends dantrolene be accessible within 10 minutes of the first signs of MH to decrease the risk of MH-related morbidity. The likelihood of a medical complication during an MH crisis increases 1.6 times for every 30-minute delay in administering the first dose of dantrolene. Rapid recognition and response to signs of an MH crisis are crucial for providing high-quality perioperative care.

Simulation-based learning is a recognized tool for educating health care professionals in managing real-life clinical scenarios. In addition to increasing knowledge through mock drills, immediate access to dantrolene can be facilitated by introducing innovative portable treatment boxes. The University at Buffalo Department of Anesthesiology and Kaleida Health Quality Leadership Training Program launched a two-fold quality improvement project that aims to streamline dantrolene access and provide perioperative education on MH crisis preparedness for multidisciplinary teams through educational simulation and standardized treatment boxes across diverse hospital settings. Detachable, portable boxes stored on MH emergency carts were installed and filled with selected essentials for MH management: 250 mg of dantrolene sodium, 5 mL of sterile water, and an MH crisis pocket reference. These were implemented throughout John R. Oishei Children’s Hospital and Buffalo General Medical Center. MH simulation drills were created for out-of-OR settings, including the intensive care unit (ICU), emergency department, labor/delivery unit, and cardiac catheterization suites. The drills were then trialed, and participating staff were surveyed. Positive feedback signals from staff were observed, particularly toward improved MH readiness and recognition.

In addition to the above simulations, experiments were carried out to determine the efficacy of the use of detachable treatment boxes. A measuring wheel was used to measure distances between expected MH response locations (i.e., ORs, emergency department, ICU, and satellite procedure rooms) ranging 105-745 feet. The average times of six individuals with different body types pushing the MH cart were compared to the time it took the same individuals to walk with only the detachable treatment box. Simulations included a 50-foot straight path, 50-foot stretches with a turn, time to walk up one hospital flight of stairs, and time to walk down one hospital flight of stairs. Average elevator call times and average elevator floor trajectory times were also measured.

This pilot study illustrated promising results. During a simulated pathway of eight turns and 400 feet, the portable treatment box’s agility allowed for a 34% reduction in response time when compared to the MH cart. Considering unpredictable elevator waiting times and pushing a bulky cart, the portable box allows for rapid dantrolene delivery while the remaining MH cart and support services are mobilized.

An MH crisis is a feared complication for any anesthesiologist. Luckily, most of us will not see an MH case in our careers. However, it is paramount that we are prepared in the event that we do. Increasing access to dantrolene and improving knowledge about appropriate MH management during a crisis are critical to positive perioperative outcomes. In our experience, utilizing detachable MH boxes has the ability to improve treatment delivery in the event that an MH crisis occurs, in any area of the hospital setting. Implementation of detachable MH boxes at your institutions will require interdisciplinary collaboration with the perioperative team. Evidence-based, high-fidelity drills designed for multidisciplinary teams have the potential to improve health care provider knowledge and facilitate an effective MH crisis response. Given our positive experience, we recommend that your training institutions consider implementing an MH box model.