Malignant hyperthermia can strike at any time

How to Organize Your MH Carts

Standardized supplies will help your staff save a life when every second counts.  GRAB and GO Staff are able to quickly and confidently respond during an emergency response if they know exactly where supplies are located.

Malignant hyperthermia can strike at any time in any patient, but realistic drills and quick recognition of muscle rigidity or uptick in core body temperature won't make a bit of difference if your surgical team is rummaging around the drawers of the MH cart in search of dantrolene, the life-saving reversal agent, and the supplies needed to administer it.

Our MH carts, however, were overstocked and cluttered, potentially making them harder to navigate in an emergency. The supplies and materials were also inconsistent. Supplies would often expire without us knowing. Perhaps the biggest issue: A nurse would have to open 3 drawers to grab the items needed to reconstitute dantrolene. When minutes matter in an emergency, an organized response with organized supplies can mean the difference between life and death.

When our rapidly growing healthcare system expanded to add 4 separate procedural areas where anesthesia would be administered, we added 4 additional MH carts. All of the carts were stocked according to the Malignant Hyperthermia Association of the United States (MHAUS) resources ( However, each new cart was a little bit different than the others. Our hospital brought together a team of staff from each of the 5 clinical areas to develop standardized carts that would be used throughout the health system. Here's how we reevaluated and restocked each cart.  

1. Check the current inventory

You need to know what's already in your carts, so make an itemized list of what you find in each drawer. During our first team meeting, we looked at the lists to see what the differences were among the contents of the carts. While referring to the MHAUS guidelines, we assessed the necessity of every item we stocked belonging there. 

2. Eliminate repeated items

Your anesthesia cart is stocked with many of the supplies recommended on the MHAUS list. You can eliminate clutter in the MH cart and save time and confusion during an emergency response if staff members know some of the needed supplies are in the anesthesia cart. For example, we keep esophageal probes, rectal temperature probes and forehead temperature indicator strips on our anesthesia carts, so we eliminated them from the MH carts with the assumption that if an emergency were to occur, our staff would likely go to the more familiar cart for a temperature-measuring device. We repeated this process with medications as well as equipment. In the end, all carts were the same with one exception: We added arterial lines to the off-site surgery center cart because we don't stock them on our anesthesia carts in that location.

3. Identify the contents

Label all drawers, clearly indicating what's inside. Here's how we organized our carts, based on MHAUS's list of needed supplies.

EASY READ Identify the drawers with clear, clean labels.

DRAWER #1 Sodium bicarbonate (8.4%), dextrose 50%, calcium chloride 10%, regular insulin and lidocaine for injection (2%), per MHAUS recommendations.

DRAWER #2 Well organized and easy to navigate IV supplies.

DRAWER #3 Condensed irrigation and lavage items.

DRAWER #4 All supplies for dantrolene sodium reconstitution are in a single drawer.

DRAWER #5 Items for placing a central line and a bladder catheter.

4. Highlight the Dantrolene 

As we discussed and reviewed our carts, we found that a nurse would have to open 3 separate drawers in order to reconstitute the lifesaving dantrolene sodium. In an effort to make it simpler and save time, we moved all of the supplies needed for reconstitution into one place.

First, we stocked sterile water vials instead of IV bags to eliminate the risk of an unintended infusion error. Each of the 5 locations has the recommended 36 20 mg vials of dantrolene on hand to deliver the recommended initial dose of 2.5 mg/kg. (If you choose to stock Ryanodex, injectable suspension of dantrolene, keep 3 250 mg vials on hand.)

To help keep the vials organized and to ease grabbing the needed supplies during a MH event, we created trays that hold 12 vials of dantrolene, sterile water vials, vial spikes and 12 60 ml syringes. We placed this tray in the same drawer on each cart with big red arrows pointing to the "dantrolene" label on the outside of the drawer.

5. Make staff training easy

Standardization enhances efficient responses when things go sideways. Once we standardized our carts, we developed some tools for staff education. We included a picture of each drawer in our online self-learning module. Each year, staff completes this module to stay up to date on what's inside the MH cart. We hung MHAUS posters on the side of the cart that list the steps and the dosage of dantrolene administration. We also placed a small binder on each cart with a copy of the dantrolene dosage chart, the MH treatment algorithm and a few other helpful documents.

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