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The following four things should be done as soon as possible:
– If surgery must be continued, maintain general anesthesia with IV non-triggering anesthetics (e.g., IV sedatives, narcotics, amnestics and non-depolarizing neuromuscular blockers as needed)
– Call for help within your institution; also, call the MHAUS Hotline (1-800-644-9737) for additional advice. (Outside the US, please call: 001-209-417-3722)
– DANTRIUM/REVONTO – Each 20 mg vial should be reconstituted by adding 60 ml of sterile water for injection, USP (without a bacteriostatic agent) and the vial shaken until the solution is clear.
– RYANODEX– Each 250 mg vial should be reconstituted with 5 ml of sterile water for injection, USP (without a bacteriostatic agent) and shaken to ensure an orange-colored uniform, opaque suspension.
If giving large doses (> 10 mg/kg) without symptom resolution, consider alternative diagnoses.
Obtain blood gas (venous or arterial) to determine degree of metabolic acidosis. Consider administration of sodium bicarbonate, 1-2 mEq/kg dose, for base excess greater than -8 (maximum dose 50 mEq).
Cool the patient if core temperature is >39°C or less if rapidly rising. Stop cooling when the temperature has decreased to <38°C.
If hyperkalemia (K > 5.9 or less with ECG changes) is present, treat with:
– 1-2 mEq/kg IV (maximum dose 50 mEq)
– For pediatric patients: 0.1 units regular insulin/kg IV and 0.5 grams/kg dextrose (% in formulation not important)
– For adult patients: 10 units regular insulin IV and 50 ml 50% glucose
– Check glucose levels hourly
For refractory hyperkalemia, consider albuterol (or other beta-agonist), kayexelate, dialysis, or ECMO if patient is in cardiac arrest.
Treat dysrhythmias with standard medication but avoid calcium channel blockers. Treat acidosis and hyperkalemia if present. (See above)
Institute appropriate monitoring including: core temperature, urine output with bladder catheter, and consider arterial and/or central venous monitoring if warranted by the clinical severity of the patient.
Follow: HR, core temperature, ETCO2, minute ventilation, blood gases, K+, CK, urine myoglobin and coagulation studies as warranted by the clinical severity of the patient.
When stable, transfer to post anesthesia care unit or intensive care unit for at least 24 hours. Key indicators of stability include: