# 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. After dantrolene is started, his serum potassium is 6.4 mEq/L (normal 3.5–5.0 mEq/L) and frequent ventricular ectopic beats appear. All orders are for intravenous use. Which medication order should the circulating nurse question?

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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.

After dantrolene is started, his serum potassium is 6.4 mEq/L (normal 3.5–5.0 mEq/L) and frequent ventricular ectopic beats appear. All orders are for intravenous use. Which medication order should the circulating nurse question?

## 보기

1. Calcium chloride
2. Regular insulin with dextrose
3. Sodium bicarbonate
4. Verapamil **✔ 정답**

**정답: 4**

## 해설

Hyperkalemia and dysrhythmias in malignant hyperthermia are treated with the usual measures such as calcium, insulin with dextrose, and bicarbonate. Calcium channel blockers such as verapamil must not be given with dantrolene because the combination can cause hyperkalemia and cardiovascular collapse.

## 심화 해설

Core clinical issue Malignant hyperthermia (MH) produces a hypermetabolic crisis in skeletal muscle that releases large amounts of potassium into the circulation. The resulting hyperkalemia—here 6.4 mEq/L—can provoke ventricular ectopy, and treatment must lower potassium and stabilize the myocardium without worsening the underlying calcium-handling defect.

Why hyperkalemia and dysrhythmias occur in MH In MH, uncontrolled calcium release from the sarcoplasmic reticulum drives sustained muscle contraction and ATP consumption. The failing energy supply damages the muscle membrane, allowing intracellular potassium to leak into plasma. The same membrane instability and hyperkalemia make the myocardium irritable, producing ectopic beats and potentially lethal ventricular arrhythmias. Management therefore combines three strategies: directly antagonize the myocardial effects of potassium with calcium, shift potassium back into cells with insulin and dextrose, and buffer the accompanying metabolic acidosis with bicarbonate.

Why verapamil must be questioned Dantrolene is the specific antidote for MH because it reduces calcium release from the sarcoplasmic reticulum of skeletal muscle. Calcium channel blockers such as verapamil are contraindicated in combination with dantrolene because the two drugs together can precipitate severe hyperkalemia and cardiovascular collapse. The mechanism involves additive suppression of calcium movement: dantrolene already impairs calcium handling in muscle, and verapamil further depresses cardiac conduction and contractility. The result can be profound bradycardia, hypotension, and asystole. In this scenario, the circulating nurse should question the verapamil order before preparing or administering it.

Watch out! Hyperkalemia itself can be treated with intravenous calcium, but this does not mean calcium channel blockers are safe. Calcium chloride provides free calcium to stabilize cardiac membranes; verapamil blocks calcium entry into cells and worsens the hemodynamic compromise when dantrolene is on board.

Comparing the four orders

| Medication order | Role in MH-related hyperkalemia | Safety with dantrolene |
| --- | --- | --- |
| Calcium chloride | Antagonizes myocardial effects of hyperkalemia; stabilizes cardiac membrane | Safe; does not act as a calcium channel blocker |
| Regular insulin with dextrose | Shifts potassium from extracellular to intracellular compartment | Safe |
| Sodium bicarbonate | Corrects metabolic acidosis and promotes potassium shift into cells | Safe |
| Verapamil | Calcium channel blocker; no role in acute hyperkalemia management | Contraindicated with dantrolene; risk of hyperkalemia and cardiovascular collapse |

Pathophysiology link to the evidence The underlying defect in MH is uncontrolled sarcoplasmic calcium release through functionally altered calcium release receptors [2][3]. This calcium storm activates energy-producing pathways and ultimately causes muscle membrane breakdown, hyperkalemia, and acidosis [4]. Because dantrolene works at the level of the sarcoplasmic reticulum, adding a calcium channel blocker creates a dangerous pharmacodynamic interaction. The circulating nurse must recognize that the combination of dantrolene and verapamil is specifically associated with life-threatening hyperkalemia and cardiovascular collapse, making verapamil the order to question.

Key point! In an MH crisis with hyperkalemia and ectopy, the safe interventions are calcium chloride, insulin with dextrose, and sodium bicarbonate. Verapamil or any calcium channel blocker is contraindicated once dantrolene has been administered.References (research sources)

- [2]Management of malignant hyperthermia: diagnosis and treatment.Research articleSchneiderbanger D, Johannsen S, Roewer N, Schuster F (2014) · DOI: 10.2147/TCRM.S47632

- [3]Malignant hyperthermia.Research articleRosenberg H, Davis M, James D, Pollock N, Stowell K (2007) · DOI: 10.1186/1750-1172-2-21

- [4]Malignant hyperthermia.Research articleAli SZ, Taguchi A, Rosenberg H (2003) · DOI: 10.1016/j.bpa.2003.09.012

## 임상 시나리오

MH Crisis: Hyperkalemia ManagementSafe medication selection after dantrolene initiation
In malignant hyperthermia, hyperkalemia is treated with calcium chloride for myocardial stabilization, insulin with dextrose for intracellular potassium shift, and sodium bicarbonate for acidosis correction.

Verapamil must never be given with dantrolene because the combination can cause severe hyperkalemia and cardiovascular collapse.

CautionThe circulating nurse should question any order for a calcium channel blocker in a patient receiving dantrolene, as this is a life-threatening drug interaction.

## 핵심 개념

- **Malignant hyperthermia** — A hypermetabolic crisis of skeletal muscle triggered by volatile anesthetics or succinylcholine, causing hyperkalemia, acidosis, and hyperthermia.
- **Dantrolene** — Specific antidote for malignant hyperthermia that reduces calcium release from the sarcoplasmic reticulum in skeletal muscle.
- **Verapamil** — A calcium channel blocker contraindicated with dantrolene due to risk of severe hyperkalemia and cardiovascular collapse.
- **Hyperkalemia** — Elevated serum potassium level that can cause cardiac dysrhythmias and requires urgent treatment.
- **Ventricular ectopy** — Abnormal ventricular beats arising from myocardial irritability, often triggered by hyperkalemia or membrane instability.

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