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Malignant Hyperthermia Box for Operating Room Use (16.1)

Malignant Hyperthermia Box for Operating Room Use (16.1) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Operating Rooms

16.1

POLICY & PROCEDURE





Effective Date:

May 2003
 Pharmacy Policy Manual
Chapter: Operating Rooms
Operations Procedure Manual
Chapter

Policy #: 16.1

 Original
Revision 07/17

Page 1
of 3

Title: Malignant Hyperthermia Box for
Operating Room Use


I. PURPOSE: This document outlines procedures used in the management of malignant hyperthermia
(MH) medications and supplies in the inpatient (IP) Operating Room and Outpatient Surgical Center
(OSC) at the University Hospital, IP Operating Room and Diagnostic Pavilion at the American
Family Children’s Hospital (AFCH), Digestive Health Center (DHC) and The American Center
(TAC) Operating Rooms.

II. POLICY: Supplies and medications used in the treatment of MH will be maintained in MH boxes in
all operative areas of UW Health. These boxes will be audited daily to ensure availability and
integrity and documentation of these audits will be completed by the associated area pharmacy
technician.

III. FORMS:
A. Malignant Hyperthermia Box Audit Form
B. Malignant Hyperthermia Supply Location List

IV. PROCEDURE:
A. An identical MH box will be maintained in each of these areas:
1. University Hospital: IP OR (E7/391)
2. University Hospital: OSC (F6/206)
3. AFCH: Pharmaceutical OR room (rm 3311)
4. AFCH: Diagnostics Pavilion workroom (rm 1136)
5. TAC: sterile core of OR (rm 1370)
6. TAC: PACU (rm 1330)
7. DHC: Hallway P203 (between rm 227 and 228)
B. Each MH box will contain Dantrolene Sodium (Ryanodex) in addition to other
medications/supplies designated on the Supply Location list. A backup supply of 2 vials of
Dantrolene shall be kept in each area’s pharmaceutical room for subsequent doses, if needed, in
accordance with MHAUS standards. Each MH box will be sealed with a numbered breakaway
plastic lock
C. If the MH box is removed from its location, the individual who removed the box will record the
room to which the box was taken to on the wipe board within the location room.
D. Restocking after use:
1. If the seal on the MH box is broken it needs to be restocked by both pharmacy personnel and
by the anesthesia material specialists (AMS) in the respective OR.
2. The AMS will restock all supply items in the box and then pass the box on to pharmacy to
restock drugs. DHC pharmacy technicians are responsible for restocking both the medications
and supplies.
3. The Pharmacy Technician will complete the following:
a. Restock the medications in the box.
b. Enter the patient charges into Healthlink—bulk order charging.
c. Ensure that no medications will expire until the next scheduled expiration check.
d. Apply a new seal and return the box to the storage location in the pharmaceutical room.
e. Record the new lock number on the Malignant Hyperthermia Box Audit Form.

POLICY & PROCEDURE





Effective Date:

May 2003
 Pharmacy Policy Manual
Chapter: Operating Rooms
Operations Procedure Manual
Chapter

Policy #: 16.1

 Original
Revision 07/17

Page 2
of 3

Title: Malignant Hyperthermia Box for
Operating Room Use

E. MH Box Content
Item Name Number of Item
Dantrolene Sodium Vials 250mg 1
Sterile Water Vials, 10 mL 2
Sodium Bicarbonate 8.4% Vials, 50 mL 5
Dextrose 50% Vials, 50 mL 2
Furosemide Vial, 100mg/10mL 1
Lidocaine 2% Syringes, 100mg/5mL 3
Calcium Chloride Vials, 1gm/10mL 2
4-way Large Bore Stopcocks 5
Mini Spike Dispensing Pins 5
60 cc Syringes 5
5 cc Syringes 5
Blue caps 5
2x2 Sterile gauzes 2
Rectal Probe 1
Pico Arterial Blood Sample syringes 3
Syringe-to-Vacutainer Blood Transfer Devices 4
Red and Yellow Blood Tubes 4 ml 2
Red and Black Tubes 9 ml 3
Green and Black Top Tubes 2
Lavender Top Tubes 2
Blue and Black Top Tubes 3.5 ml 2
Blood Request Slips 10
Biohazard Bags 10
Malignant Hyperthermia Literature 1 package
Vapor-Clean (DO NOT OPEN unless needed) 1

F. Saline Bags for Bladder Cooling
1. 0.9% Sodium Chloride 1000ml bags for bladder cooling will be maintained as follows.
a. IP OR Pharmaceutical Room (E7/391): three bags in the refrigerator
b. OSC: one bag Side A OR corridor refrigerator, two bags Side B OR corridor refrigerator
c. AFCH OR Pharmaceutical Room (rm 3311): six bags in the refrigerator to be used in
both AFCH OR and AFCH Diagnostic Pavilion
d. TAC Inpatient Pharmacy (rm 1301): three bags in the bottom drawer of pass through
refrigerator
e. DHC Pharmacy (rm 011) : three bags in the refrigerator
G. Quality Assurance Audits of the MH Box
1. The MH box is to be checked daily by Pharmacy staff to ensure that the tamper-proof seal is
not broken. Evidence of this MH box integrity check is recorded on the Malignant
Hyperthermia Box Audit Form.

POLICY & PROCEDURE





Effective Date:

May 2003
 Pharmacy Policy Manual
Chapter: Operating Rooms
Operations Procedure Manual
Chapter

Policy #: 16.1

 Original
Revision 07/17

Page 3
of 3

Title: Malignant Hyperthermia Box for
Operating Room Use

2. The MH box is to be audited monthly for expired medications by pharmacy personnel and
supplies by the AMSs.
3. The 0.9% Sodium Chloride bags will be checked for expiration monthly by pharmacy
personnel


V. COORDINATION:
A. AUTHORED BY: Sharon Trang/Aaron Webb
B. COMMITTEE APPROVAL BY: None

Approved By: ____________________________
Director of Pharmacy Services
Date: ____________