KEIT Day Hospital protocols

Malignant hyperthermia prevention and management protocol

Official Manual of Clinical, Care and Organizational Protocols

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Prevention and Management of Malignant Hyperthermia Anaesthetic Safety
KEIT DAY HOSPITAL

Malignant hyperthermia prevention and management protocol

Official Manual of Clinical, Care and Organizational Protocols
Document CodeKEIT-SOP-13Version2.0
Revision02StatusOfficial
Issue Date28/03/2026Next Review28/03/2027
Prepared byMedical Directorate / QualityApproved by
Signature and DateDistributionControlled - Internal Use
Purpose of the document. To officially define the scope, responsibilities, operating procedure, KEIT standards, records and protocol review criteria.

1. Document Control Information

ApplicationAll clinical, nursing, technical and organizational personnel involved in the described process.
ArchivingKEIT internal document management system and controlled copy in the relevant areas.
ReviewAt least annually or earlier in the event of regulatory, organizational or technological updates.

2. Scope of Application

Applicable to all patients undergoing general anesthesia and to personnel involved in the response to intraoperative emergencies.

3. Responsibilities

  • Anesthesiologist: early identification, coordination of treatment and immediate clinical decision-making.
  • Anesthesia nurse and operating room nurse: rapid preparation of dantrolene, logistical support and documentation.
  • Clinical Directorate: maintenance of the minimum required stock and periodic staff training.

4. Operating Procedure

  • Assess the patient’s personal and family history for features suggestive of malignant hyperthermia or unusual anesthetic events.
  • Recognize suspicious clinical and monitoring signs at an early stage and declare the emergency without delay.
  • Immediately discontinue potential anesthetic triggering agents and ventilate the patient with high-flow oxygen in accordance with the emergency anesthesia protocol.
  • Administer dantrolene according to the current dosage and operational regimen, preparing additional doses when necessary.
  • Treat hypercapnia, hyperthermia, acidosis, electrolyte abnormalities and hemodynamic complications according to the internal algorithm.
  • Arrange intensive monitoring and, when necessary, transfer to a higher level of care.
  • Document the event and inform the patient regarding future anesthetic procedures.

5. KEIT Operational Standards

  • KEIT maintains a complete dose of dantrolene readily available as a patient safety measure.
  • This emergency is included in the anesthesia team’s training and simulation programs.

6. Records and Documentation

  • Emergency/MH cart checklist.
  • Emergency medication register.
  • Critical incident report.

7. Review and Updates

Verification of the required stock at least every six months and dedicated simulation exercises.

Implementation Note
This document is an internal operational draft. Before final adoption, review by the Medical Directorate, Clinical Directorate, Legal Advisor and the relevant department managers is recommended.

8. Related Attachments and Forms

  • Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol.
  • Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.

9. Final Approval

PositionName and SignatureDate
Medical Directorate

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