# Situation: A 28-year-old man weighing 64 kg undergoes elective open repair of an inguinal hernia under general anesthesia. Succinylcholine was given for intubation, and anesthesia is maintained with sevoflurane. Forty minutes after induction, the anesthesia provider diagnoses malignant hyperthermia and stops the sevoflurane. Dantrolene 2.5 mg/kg intravenous (IV) is ordered as the first dose. Each vial contains 20 mg and must be reconstituted with 60 mL of preservative-free sterile water. Using whole vials, how much sterile water is needed to prepare this first dose?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 28-year-old man weighing 64 kg undergoes elective open repair of an inguinal hernia under general anesthesia. Succinylcholine was given for intubation, and anesthesia is maintained with sevoflurane. Forty minutes after induction, the anesthesia provider diagnoses malignant hyperthermia and stops the sevoflurane.

Dantrolene 2.5 mg/kg intravenous (IV) is ordered as the first dose. Each vial contains 20 mg and must be reconstituted with 60 mL of preservative-free sterile water. Using whole vials, how much sterile water is needed to prepare this first dose?

## 보기

1. 160 mL
2. 480 mL **✔ 정답**
3. 240 mL
4. 1,920 mL

**정답: 2**

## 해설

Dose: 64 kg × 2.5 mg/kg = 160 mg. Vials: 160 mg ÷ 20 mg per vial = 8 vials. Diluent: 8 vials × 60 mL = 480 mL of preservative-free sterile water, which is why several staff are needed to prepare it quickly.

## 심화 해설

Working the calculation step by step
Dantrolene is the specific treatment for malignant hyperthermia. The first dose is 2.5 mg/kg intravenously. For this 64-kg man: dose = 64 kg × 2.5 mg/kg = 160 mg. Each vial contains 20 mg, so 160 mg ÷ 20 mg per vial = 8 vials. Each vial is reconstituted with 60 mL of preservative-free sterile water, so 8 vials × 60 mL = 480 mL. Preparing the first dose requires 480 mL of preservative-free sterile water.

Why the volume matters in practice
Malignant hyperthermia is a life-threatening reaction to triggering agents such as succinylcholine and volatile anesthetics like sevoflurane. It causes uncontrolled skeletal muscle metabolism, with rising end-tidal carbon dioxide, muscle rigidity, tachycardia, hyperkalemia, and a rapid rise in temperature. Dantrolene stops the excessive release of calcium in muscle cells. Because each vial must be mixed with a large volume of water and the powder dissolves slowly, preparing several vials quickly takes many hands. This is why the team calls for help and assigns several staff to reconstitution as soon as the diagnosis is made.

How the distractors arise

| Answer | Error |
| --- | --- |
| 160 mL | Treats the 160-mg dose as 160 mL; skips the vial and diluent steps |
| 240 mL | Uses 1 mg/kg (64 mg), rounds up to 4 vials × 60 mL |
| 1,920 mL | Uses 10 mg/kg (640 mg = 32 vials), the usual cumulative ceiling for repeat doses |
| 480 mL | Correct: 160 mg ÷ 20 mg = 8 vials × 60 mL |

Watch out! Calculation items often include answers that come from skipping a step or using the wrong reference value. The 10 mg/kg figure is real, but it is the usual cumulative ceiling when doses are repeated, not the first dose. Always check which dose the question asks for.

Other nursing actions in malignant hyperthermia
Besides stopping the triggering agent and giving dantrolene, the team hyperventilates the client with 100% oxygen, begins active cooling, treats hyperkalemia and dysrhythmias, monitors urine output for myoglobinuria, and sends blood gases and electrolytes. Dantrolene is repeated according to response. After the crisis, the client and family are told about the condition, since it is inherited, and future anesthetics must avoid triggering agents.

Exam takeaway
Dose in mg = weight × mg/kg; vials = dose ÷ mg per vial; diluent = vials × mL per vial. Key point! With whole vials, round up the number of vials if the division is not exact, then multiply by the diluent volume.

## 임상 시나리오

Dantrolene Preparation in Malignant Hyperthermia64-kg adult, first dose 2.5 mg/kg IV
Dose: 64 kg × 2.5 mg/kg = 160 mg. Vials: 160 ÷ 20 = 8 vials.

Diluent: 8 × 60 mL = 480 mL of preservative-free sterile water. Assign several staff to reconstitute quickly.

Also stop triggering agents, give 100% oxygen, cool actively, and treat hyperkalemia and dysrhythmias.

CautionDo not confuse the first dose with the usual cumulative ceiling of about 10 mg/kg for repeat doses.

## 핵심 개념

- **Malignant hyperthermia** — An inherited, life-threatening muscle reaction to certain anesthetics causing rigidity, hypercarbia, and high fever.
- **Dantrolene** — A muscle relaxant that stops excess calcium release in muscle, used to treat malignant hyperthermia.
- **Reconstitution** — Adding a liquid diluent to a powdered drug to make a solution for administration.
- **Triggering agents** — Drugs such as succinylcholine and volatile anesthetics that can provoke malignant hyperthermia.

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