Author: admin

Clinical Topic: Intraoperative Hypotension and Stroke

As guardians of patient safety during the surgical procedure, anesthetists are tasked with the prevention of adverse intraoperative events.  Of the many risks of surgery, death and stroke are two of the most devastating events that can occur.  Ischemic stroke occurs in 0.1-3% of patients undergoing general anesthesia.  Thus, maintenance of cerebral perfusion is essential during the perioperative period.

In an article by Bijker JB et al titled Intraoperative Hypotension and Perioperative Ischemic Stroke After General Anesthesia  (Anesthesiology. 2009 Dec;111(6):1217-26) the relationship between intraoperative hypotension and stroke is evaluated.   The purpose of the study was not only to validate a correlation between hypotension and stroke, but also to determine the degree of hypotension and the length of time associated with an adverse outcome.

The study found that the incidence of ischemic events was increased when the blood pressure dropped 30% below baseline.  The longer the blood pressure was below the critical level, the greater the incidence of adverse outcome.  In the words of the author:

“Our results suggest that intraoperative hypotension accounts for an increase in stroke risk of approximately 1.3% per minute hypotension (i.e., the risk is increased 1.013 times for every minute of hypotension), depending on the definition of IOH that is used (in this case a decrease in mean blood pressure more than 30% from baseline). For example, a cumulative duration of 10 min of hypotension will result in a 1.14 times increased stroke risk (1.01310). If applied to the POISE trial, this would mean an increase in absolute stroke risk from 0.5% (POISE trial control patients) to 0.57%.”

Again, in the words of the authors: “In conclusion, the most widely proposed mechanism of a postoperative stroke is arterial embolism. Nonetheless, the results of the current study support the hypothesis that hypotension can influence the evolution of a postoperative stroke by compromising (collateral) blood flow to ischemic areas. In this context, hypotension is best defined as a decrease in mean blood pressure relative to a preoperative baseline, rather than an absolute low blood pressure value.”

Since patients present with a wide variety of baseline blood pressures, there is no magic number for a mean blood pressure to be maintained during surgery.  The anesthetist is advised to calculate each patients lowest acceptable blood pressure based on maintaining the blood pressure within 30% of baseline.

Click here to read the complete article

 

CRNA Wellness: Beverages are Making Us Fat

Driven to Drink?
The 6:30 a.m. drive-through line is long but the beverage baristas inside have got the gig down.  Take the order, take the money, write on the cup, hand it off and move’em forward.  Just across the overpass to our medical center, Starbucks customers line up bumper to bumper on their way to work.  And another of the Seattle-based ‘bucks right inside the entrance to the med center picks up the slack.  Mmmmm, creamy, sweet, warm…what’s not to like about lapping up your favorite frap on the way to tackling a heavy work schedule?  Answer:  The heavy part. Beverages are making us fat.

Getting Juiced
Let’s start with juice.  Orange juice and the members of its expanding family, are loaded with sugar.  They may be fortified with vitamin C, added calcium, or may contain those magical anti-oxidants that didn’t make it into your lunch bag, but most juices are also fortified with sugar, frequently over 15 grams of sugar per 8-ounce serving.  An 8-ounce glass of Tropicana original orange juice has 114 calories.  70 calories are sugar and though it may satisfy 96% of your daily requirement for vitamin C, there is only a tad of added calcium and a smaller tad of vitamin A.  Ounce for bounce, the payoff isn’t there.  A fresh orange, however, has a much lower 62 calories of which 48 are natural sugar(fructose), and it provides 116% of your necessary vitamin C.  An orange supplies twice the natural calcium as juice, three times the vitamin A plus 3.1 grams of natural fiber.  Plus, you get to chew!

There are entire aisles devoted to fruit- flavored beverages in bottles, boxes and cans in your shiny, upscale grocery chain, but nothing satisfies your body’s needs like fresh, whole fruit, the more color and the more variety, the better.  If ya just hafta have your bananas and berries in a beverage, get out the blender and give it a whirl.  You won’t need to sweeten the pot.

Smooth Move 
Blenders are used for making the smoothie. Originally, the smoothie was a fruit and ice beverage, sometimes with added sugar.  Although it debuted as a beverage in the 1930’s, Wikipedia says that the term smoothie/smoothy was actually conjured up by the hippies, though I don’t remember seeing any at Woodstock, and that California, with its ready access to fresh seasonal fruit was the original venue for vending it.  Now we blend smoothies choosing from yogurt, protein powder, kale, carrots, blueberries, strawberries, milk…the list is endless but the calories are increasing with the options.  It isn’t difficult to find a smoothie shop right around the corner from your produce market, only you’ll drink close to 300 calories if you buy it already made.  Go back around the corner, concoct your own smoothie and you take control.  To get through a busy day in the OR and still get your nutrients, a smoothie is a great choice. Opt for low fat, no sugar-added, skimmed-milk, light yogurt or water-based, make either fruit or veggie drinks, and avoid expensive, high-calorie add-ins.  If your smoothie is meant to enhance your work-out, a tablespoon of protein powder is a fine idea.  If dessert is a smoothie, go back to the original 1930’s recipe by using simply fresh fruit and ice. Eliminate the sugar and pour it in a six-ounce wine glass. Now that’s a juice bar!

Are You a Soda Jerk?
Coke, 7-up, Pepsi, Dr. Pepper, Sprite, Mountain Dew, Orange/Strawberry/Grape/Teenage Crush(just checking to see if you’re reading closely), Cream soda and Root Beer are just a few of today’s and yesterday’s beverages-that-make-you-belch.  For some reason, we get a kick out of slugging down that nutrient-free, sweet, fizzy bev and emitting a healthy g-blurp! within seconds after downing the drink.  But colas do not satisfy thirst.  They are wet and sometimes wild, but the ingredients are more de-hydrating than satisfying.  If you choose a caffeine-loaded, high-sugar cola bathed in dark dyes, you are headed for more thirst after drinking than before.  And you just slurped up at least 96 calories per 8 ounces.  A 12-ounce Classic coke is 144 calories and the same fluid measurement of Pepsi or Dr. Pepper weighs in equally at 150. Don’t forget, there’s sodium in them thar streams of sugar and diet sodas have even more. When you just want a little something sweet, a clear soda is the better choice, and a tall, glass, glass of iced cold water is best of all.

The Buzz
Alcoholic beverages are a whole other fast track to fat.  We try to jump-start the day with coffee; we imagine we’re getting a nutrient-dense kick with juice; we substitute meals and assume we’re enhancing exercise with smoothies; we pretend to quench our thirst with sodas; but there’s no denying the reason for consuming that 16-ounce margarita or two 6-ounce glasses of Menage e Trois…red or white.  It’s recreation.  Recreational drinking isn’t a sin, but be aware and compare.  One 4-6 ounce glass of red wine is typically 120-150 calories, no worse than a large serving of crunchy, sweet, juicy, red seedless grapes full of fiber and dessert-like qualities, but hey, I only said, “Be aware!”  White wine, though lower than red in calories by 25%, does not supply the same number of nutrients as red wine, obviously.  Think spinach and mushrooms, dark and light.  But neither red nor white is great for metabolizing fat… it’s alcohol, after all.  You’ll still need to drink plenty of water and skip the sucrose to avoid those heart-pounding chest rhythms.  And do you really want your morning mouth to feel like a cardboard balloon?

Hard liquors are worse for you than wine.  If you insist on preserving your right to imbibe the hard stuff, keep these things in mind.  On a regular diet of hard drink, Your tummy will get soft fast and your red nose may qualify for holiday hire.  Above the others in calories ounce for ounce, more toxic to your internal organs, completely free of nutrients, and potentially more addictive than adult beverages with lower alcoholic content, hard stuff is a poor choice all the way around. Particularly if you are on a wellness program that includes weight loss, deep six the Ten.

There are those who think that a nice cold one quenches the thirst after a nice hot one.  It doesn’t.  You will not cool down by drinking two pints of Fat Tire after mowing the yard or after playing baseball for two hours. But you can get a fat tire.  Beer does not re-hydrate; it doesn’t even hydrate; it is not a substitute for water.  What’s not to understand?  And if you have any interest at all in a flat tummy, fresh, sweet breath, skin that isn’t sticky and smelly and sweaty at bedtime, and if you’d like less opportunity to make a fool of yourself during Sunday afternoon’s TV Testosteronathan, then load up on water before watching the game, drink at least a quart before playing in one, and don’t touch a beer after mowing until you’ve fully re-hydrated with agua fria.  That beer-belly syndrome?  It’s nasty-looking, it’s high-risk and it’s for real.   Try Sparks.

Be-hold!
Here’s a last word about the extent to which industry here in the States has embraced the beverage boom. Behold the cup holder!  We are so dependent on doing something with our hands that nothing with wheels passes market inspection unless it sports a holder for a cup.  Nothing with wheels is exempt.  There’s a cup holder in your car, your truck, your child’s stroller, your grocery cart, your golf cart, your bicycle(okay, safety issue, fair enough), your yard wagon, your oversized cooler, your computer bag, your rolling backpack, your commercial bus, train or plane tray, and your beach roller bag, not to mention purses, fanny packs, exercise belts, cardboard drink holders…the list is endless, but not surprising, at least in the USA.  In Germany, a Bavarian Motorwerks standard issue comes cup-free, but in Spartanburg, SC, BMW assembles the high-end European parts and adds cupholders, “nur fuer uns!”

You Can Lead a Person to Water, but Can You Make ‘em Think?
When you are offered “something to drink,” do you think coffee, water, or a shot of Jack?
Okay, so that may depend on what kind of day you’ve had in the OR and whether it’s
6:00 a.m. or p.m., but, truthfully, if you are a two-fisted cola consumer, a caffeine dependent addict, a juice bar fly, or a regular consumer at Friday Nights Live, it may be time to balance your beverage accounts.  Click on some of the links below to read some nutrition facts and beverage tips’info.  Start thinking about what, why, and how much you drink BEFORE you drink it.  A flat tire is a lot easier to fix than a fat one.  Prost!

Compare the Keurig Chai Latte to the Starbucks Frappuccino

Click here for Smoothies

How many calories in a glass of wine?  Click here

How many calories in a non-alcoholic beer?  Click here

What drinks cause dehydration?  Click here

The truth about green tea…Click here

Please visit Liz at www.bdyfrm.com to read the daily Lizlines and Friday Lizlimerick.  Discover

Liz’s Bands In The Park mobile browser, a perfect companion for your walking or running group.

Clinical Topic: Prewarming, Does it really matter?

Peri-operative hypothermia is a common problem related to the practice of anesthesia.  Numerous studies have documented the negative effects of hypothermia to the extent that SCIP has made patient temperature a marker of quality care.  In an attempt to reduce hypothermia, many anesthesia providers recommend patient pre-warming in the holding area prior to surgery.

An article by Horn EP et al published in Anaesthesia  (The effect of short time periods of pre-operative warming in the prevention of peri-operative hypothermia.,  Anaesthesia. 2012 Jun;67(6):612-7) evaluated the effects of 10, 20 and 30 minutes of forced air pre-warming on surgical patients.  The study found that those who were not pre-warmed experienced a greater temperature drop during surgery regardless of the active measures  used in the operating room to maintain body temperature.  The Authors recommended a minimum of 10 minutes of pre-warming prior to surgery.

Click here for an abstract of the Horn et al study

In a separate study by Wagner, D published in AORN,  the causes and problems related to hypothermia are listed.    According to the author, the following factors place the patient at risk:

  • Cold ambient temperatures
  • Cold beds
  • Reduced Metabolism
  • Anesthesia / pharmacological agents
  • Evaporative heat loss

Patients who become hypothermic experience the following problems:

  • Negative nitrogen balance with reduced kidney perfusion
  • Respiratory distress
  • Reduced metabolism of medications
  • Delayed recovery from anesthesia
  • Impaired platelet function and clotting
  • Impaired wound healing
  • Increased wound infections.

To prevent intraoperative hypothermia, the author recommends forced air pre-warming

Click here to view the author’s article.

 

Clinical Topic: Predicting Sleep Apnea, the STOP-BANG scale

A foundational skill required of all anesthetists is airway management.   With the obesity epidemic in our nation, obstructive sleep apnea (OSA) is becoming more common and presenting challenges to the anesthetist.  Predicting which patients are at increased risk for OSA is an important part of the preoperative assessment.  In a recent report published in the british J Anaesth, 2012; 108:5: 768-75, Chung F et all evaluated the correlation of the STOP-Bang scale to the occurrence of sleep apnea.

The STOP-BANG evaluation scale is simple to use.  It consists of asking the patient yes or no questions regarding the following 8 items:

  • Snoring.    Do you snore?
  • Tired.    Are you frequently tired during the day?
  • Obstruction.   Have you ever been told that you stop breathing when you are asleep?
  • Pressure.    Do you have high blood pressure
  • BMI   Is your BMI over 35?
  • Age.   Are you over age 50?
  • Neck Circumference.   Is your neck circumference over 40 cm?
  • Gender.    Are you male?   (should be obvious)

If the answer is yes to 3 or more of these questions, the patient is at increased risk for obstructive sleep apnea.  The higher the number, the greater the risk.  Of interest, a male over 50 starts with a score of 2 regardless of the other risk factors.

Click here to review the on line assessment tool published by thesleepmd.com

Click here to review the article by Chung et al. as presented by the Virginia Assn of Nurse Anesthetists.

Clinical Topic: JCAHO Sentinal Event Regarding Opioids

Patient safety is a foundational responsibility of all health care workers.  The Joint Commission identifies “sentinel events” related to patient safety and distributes them to Hospitals.  During accreditation visits, JCAHO evaluates the Hospital’s effectiveness in addressing, reporting, and eliminating sentinel events.

“A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness.”  wikipedia

Examples of sentinel event are:

  • Infant abduction
  • Rape
  • Suicide
  • Transfusion reaction
  • Wrong surgery
  • Wrong radiation dose

Recently, the Joint Commission published a Sentinel Event related to the use of opioids in the Hospital.  The following points are included in the Sentinel event report:

  • Implement effective practices, such as monitoring patients who are receiving opioids on an ongoing basis, use pain management specialists or pharmacists to review pain management plans, and track opioid incidents.
  •  Use available technology to improve prescribing safety of opioids such as creating alerts for dosing limits, using tall man lettering in electronic ordering systems, using a conversion support system to calculate correct dosages and using patient-controlled analgesia (PCA).
  •   Provide education and training for clinicians, staff and patients about the safe use of opioids.
  •   Use standardized tools to screen patients for risk factors such as oversedation and respiratory depression.

By posting the Sentinel event, the Joint Commission has established guidelines for health care workers to follow, including anesthetists.  Click here to read the advisory published by the Joint Commission.

 

 

 

Chief CRNA: Are your Electronic Records Secure?

Patient privacy and the security of protected health information is a hot issue throughout healthcare from the primary physician’s office through diagnostic testing and including  records of hospitalization.  The Federal Government is urging health care workers to move to total electronic records and have initiated bonus money to encourage compliance.  However, the move to electronic records presents the challenge of security.

Writing for the on line blog The Anesthesiology Insider, Tony Mira states:

“Collecting, analyzing, reporting and storing electronic patient information present perhaps even greater HIPAA challenges than does the use of paper records, however.  Data entered on a computer can be copied more easily, more cheaply, more prolifically and even passively.  Once unsecured data are moved from the computer on which they are created to other media, manually or wirelessly, controlling the information becomes nearly impossible. “

A recent case settled with the Phoenix Cardiac Surgery Center demonstrates the cost of not securing protected patient information.  In this case, the center was fined $100,000 for their breach of security related to protected health information.

The Department of Health and Human Services Office of Civil Rights is actively investigating breaches of security related to protected health information.   A recent post on procrna.com discussed the HHS/OCR pilot program to investigate 20 health care institutions looking specifically for breaches in security.   Patients are being made aware of their rights to security of their records and the Office of Civil Rights has a web page with instructions for patients to file a complaint related to unsecured records.

As Chief CRNAs working in departments that either have automated record keeping or are moving in that direction, we must ask “where are the records stored and how are they secured?”  Any breach of security can be costly.

Clinical Topic: What’s your favorite Anesthesia APP?

Controversy remains as to whether or not cell phones (hand held computers with audio capability) and iPads have a place in the operating room.  It is true that they can be a distraction for healthcare workers but they also put a wealth of information at your finger tips.   When used appropriately, they provide instant information to the anesthetist that could make a difference in patient safety.

Recently, I posed the question to several of my colleagues; What is your favorite Anesthesia APP?  Below are a few of the favorites.  I am asking porcrna.com readers the same question.  What is your favorite APP?   Look over the APPs listed below and use the comment box below to share your experience with these APPs or to add your own favorites.

Epocrates:  This free drug reference is the #1 mobile drug reference for U.S. physicians. With it you can search brand, generic, and OTC medicines.  Plus, you can customize your homepage for quick access to the features you use most frequently.

 

abeoCoder gives access to CPT®, ASA CROSSWALKS®, and ICD codes right from your iPhone or BlackBerry. abeoCoder app provides you with codes, base units, descriptions and more.
Coding Made Easy.

 

Pedi Safe is an advanced airway management and cardiac resuscitation app. In an emergency, healthcare providers can quickly identify a patient’s weight or Broselow color, and then Pedi Safe displays all appropriate weight based dosing, equipment sizes, and normal vital signs. An excellent reference for doctors, nurses and paramedics!

drawMD; Using the iPad, Anesthesiologists can create interactive visual guides as a way to explain complex issues and possible medical and surgical solutions for Anesthesia and Critical Care-specific conditions and procedures, such as a central line chest tube, intubation, spinal epidural, etc.

 

One more just for fun…….and this one works on your pet too!

Alivecor has developed the iPhone ECG—a case that transforms the iPhone into a wireless, clinical quality heart monitor. The case is able to monitor one’s heart rate almost immediately, and can even measure through a cotton shirt!

Browse, enjoy and leave a comment to share your favorite APP with your colleagues.

Chief CRNA: “Sterile Cockpit” and distracted workers.

Despite what the name suggests, a sterile cockpit is not an excessively clean area of an airplane. Rather it is a distraction-free cockpit–a time when the captain and crew engage only in flight-related conversation.

“The Sterile Cockpit Rule is an FAA regulation requiring pilots to refrain from non-essential activities during critical phases of flight, normally below 10,000 feet. The FAA imposed the rule in 1981 after reviewing a series of accidents that were caused by flight crews who were distracted from their flying duties by engaging in non-essential conversations and activities during critical parts of the flight. One such notable accident was Eastern Air Lines Flight 212, which crashed just short of the runway at Charlotte/Douglas International Airport in 1974 while conducting an instrument approach in dense fog. The National Transportation Safety Board (NTSB) concluded that a probable cause of the accident was distraction due to idle chatter among the flight crew during the approach phase of the flight.”    Wikipedia.

The Sterile cockpit philosophy has been applied to conversation in the operating room by several specialties. David J. Rosinski, MPS, LCP writes in J Thorac Cardiovasc Surg about the importance of protocol-driven communication between cardiothoracic surgeons and perfusionists noting that eliminating idle chatter improves safety.

Anesthetists, like pilots, are the busiest and need the most focus during take-off (induction) and landing (emergence).  Unfortunately, those are times when the room is full of commotion and idle chatter.  Gillian Campbell writing in Anaesthesia reported a study where video surveillance was assessed for distractions during critical times and found that distractions during emergence were common.

The following statement comes from the Oregon Patient Safety Commission; “While the sterile cockpit concept is associated with specific times in the flight process, in healthcare the concept is not only applied to specific times in a process (e.g., patient emergence from anesthesia), but also to specific activities (e.g., critical events in cardiovascular surgery) and specific places (e.g., a “no interruption” zone during medication preparation in an intensive care unit). According to Wadhera et al. (2010), “…effective communication can be structured around critical events rather than defined intervals analogous to the sterile cockpit, with reduction in communication breakdowns.”

As Health care professionals and anesthesia providers, we have an obligation to patient safety.  There is a clear need for us to take the lead in eliminating distractions in the operating room during critical times related to anesthesia.

What are your thoughts and experiences?

Clinical Topic: Learning Ultrasound Guided Regional Anesthesia

Ultrasound guided regional anesthesia has quickly established itself as the preferred technique for placing blocks.  Several models of ultrasound devices are available and each vendor touts their product as the best.  Time for placement, success of the block and patient satisfaction all reinforce ultrasound guided placement as the method of choice for regional anesthesia.

CME meetings across the country are offering hands on workshops to teach anesthesia providers how to properly use this new technology.  Likewise, Nurse Anesthesia training programs have added ultrasound guided regional anesthesia to the curriculum.  Educators agree that mastering ultrasound technology is important but to date teaching techniques have not been evaluated.

A study by John Gasko, CRNA et al funded by the AANA Foundation and recently published in AANA Journal — August 2012 Supplement  (Effects of Using Simulation Versus CD-ROM in the Performance of Ultrasound-Guided Regional Anesthesia) compares two techniques for teaching ultrasound guided regional anesthesia to Student Nurse Anesthetists.  Students were divided into groups and were taught either by the use of CD-ROM based teaching or by simulation with human subjects.  A third group was taught using a combination of both approaches.

The authors found that there was no difference in learning between those using CD-ROM versus simulation.  However, the study found that a combination of CD-ROM and simulation was clearly more effective than either technique separately.

Click here to read the original article published in the AANA Journal

Click here to learn about how you can support CRNA research through the AANA Foundation.

Return to procrna.com and share your comments with your colleagues.

Clinical Topic: Ipad APP for Anesthesia Patient Teaching

Are you still trying to justify whether or not to break down and buy and iPad?  As the use of technology continues to grow and develop, devices such as the Ipad are becoming important tools for the anesthetist.  Writing for the on-line Barton Blog, author Ben Amirault describes a newly developed APP for the iPad which enables the provider to better educate patients in the pre-op environment.  According to Mr. Amiralut, “An informed patient is a happy patient. Providers who can effectively communicate with their patients can expect high patient satisfaction scores and improved outcomes.”

The drawMD APP has diagrams and descriptions of common anesthesia related procedures and enables the provider to better explain the planned anesthetic to the patient and the family.  The APP is currently free and can be obtained through the iTunes store.  As described by the vendor “drawMD Anesthesia & Critical Care enhances doctor-patient communication by offering a new paradigm for explaining the complex issues surrounding the intensive monitoring and care provided by anesthesiologists and critical care physicians. In order to improve patient understanding of medical problems, drawMD utilizes the iPad’s unique interface to allow anyone to sketch, stamp, or type directly on the detailed anatomic images included in the application.”

Click here to read the blog post by Mr Amirault

Click here to view the APP at the iTunes store

Download it, try it, and return to PROCRNA.COM and leave a comment.

Clinical Topic: CRNA liable for poor communication

Despite the requirement for all health care workers to have annual training related to fire safety, hospital fires continue to occur.  Operating rooms have an ample supply of each of the elements required to ignite a fire and the anesthetist must be vigilant to the threat of fire at all times.

Ann Latner, JD, writing for the online blog clinicaladvisor.com describes an interesting scenario in which a fire occurred on a patient during a procedure.  To summarize:

  • Routine case (facial area) with patient receiving Monitored Anesthesia Care
  • Patient’s Oxygen sat drops and CRNA applies supplemental oxygen
  • Oxygen buildup under the drapes
  • Surgeon uses cautery
  • prep solution ignites and patient receives a facial burn

In addition to the burns, the patient required psychiatric follow-up and filed a law suit against the CRNA, the surgeon and the Hospital.  At trial, each of the defendants had separate lawyers and each gave testimony.  The Hospital affirmed that they had provided the required fire safety training.  The surgeon testified that had he known oxygen was in use, he never would have used cautery.  The CRNA was the only one of the three found to be liable for damages.

In the words of Ann Latner, the author, “Good communication is one of the best ways to avoid being a party to a lawsuit. Whether it is talking with your patient or a colleague, when making referrals, or even in chart notes (an important form of medical communication), having clear, direct, and open lines of communication can prevent unfortunate results. Mrs. H would have never been injured had Mr. D simply notified the surgeon of the oxygen use. No amount of testimony could make up for those few missing words during the procedure. Communication is key to better patient outcomes and to protecting yourself.”

Click here to read the full article and return with your comments.

Clinical Topic: Intraoperative Hypothermia

Reducing or eliminating postoperative surgical site infection is an ongoing challenge to health care professionals.   Infection following surgery constitutes up to 38% of nocosomial infections.   Avoiding intraoperative hypothermia is thought to be an important to overall survival, especially in trauma patients.  To improve the quality of care, SCIP protocol mandates the recording of intraoperative temperature and the use of forced air warming systems when patients are at risk for hypothermia.

A recent study by Seamon MJ, et al, (Ann Surg. 2012 Apr;255(4):789-95.) attempted to determine the impact of intraoperative temperatures on the incidence of surgical site infections in patients with abdominal trauma.  Patients were supine on warm water blankets and forced air warmers were applied to upper and lower extremities.  Antibiotics were administered per protocol.  A total of 524 patients were included in the study, most were young males who had received either gunshot or stab wounds.  Temperatures were closely monitored and patients were tracked for the development of postoperative infection.

The authors found that increased surgical site infection was correlated with hypothermia with a critical body temperature being 35 degrees C.   The authors recommend that intraoperative normothermia should be strictly maintained in trauma patients.

Click here to read an abstract of the original work

Chief CRNA: 360 Degree Evaluations

As the regulatory requirements continue to increase, the need for 360 degree evaluations has emerged as a part of JCAHO certification.  The concept is that those who do evaluations of their staff should also be evaluated by their staff.  In the case of CRNAs it means that the anesthetist should be evaluating the supervising Anesthesiologist.  Wilma Gillis from Madison Wisconsin is facing this issue in her department and wrote the following for CRNAs who read procrna.com.  Please use the comment box below to share your thoughts and experiences.

Hey friends,
I am canvassing a few department leaders preliminarily who work in management or in large institutions to see what your place of employment does about this “new” and controversial concept for implementing 360 degree evaluation of ALL team members.  Does your institution have a way for its CRNAs to evaluate the anesthesiologists?

To give you some background on this, twice we in our group decided this would be an important contribution to our concerns.  We wrote a tool over the last years and it was shut down by our administration due to absolute fury by several anesthesiologists. The aspects of performance included in this tool had nothing to do with evaluating their medical practice.  It revolved around things that were important to harmonious, collaborative practice.

Now JCAHO is mandating the idea after several years of hinting at it.  I am very interested in learning of your various departmental evaluation processes and tools.  If any of you have given evaluations to anesthesiologists, how did it go?  Repercussions?

Wilma Gillis.

Clinical Topic: Ultrasound Guidance in Anesthesia

For nearly 60 years ultrasonography has been in use in clinical medicine.  Over the past few decades the use of ultrasonography in anesthesia has increased.  As imaging machines improve in technology and the use of ultrasonography becomes everyday practice, patients are benefiting in terms of safety, comfort and cost.  The number of hands on workshops to teach anesthesia providers the proper use of ultrasonography is an indication of the importance and popularity of the technique.

An excellent article by Jonathan P. Kline, CRNA, MSNA titled “Ultrasound Guidance in Anesthesia” and published in the AANA Journal (AANA Journal, June 2011, Vol. 79, No. 3) gives a comprehensive overview of ultrasonography in Anesthesia.  The author describes the history of imaging, scanning techniques and use of the Doppler mode.  Most important, the author describes the use of the technique for the following specific procedures:

  • Central line placement
  • Spinal and epidural placement
  • Regional blocks
  • Perivascular injections

This comprehensive review reinforces the knowledge of those already experienced in the use of the ultrasound and tweaks the interest of those who have yet to learn the technique.  As ultrasonography becomes main stream in anesthesia practice, patient expect their provider to be skilled with the technique.

 Click here to read the original articles and view the pictures.

Research: Steep Trundelenburg and Postoperative Visual Loss

Postoperative visual loss is a rare but catastrophic event that has an increased in frequency with robotic surgery in the steep head-down position.    Studies have been conducted and reported in the literature relating intraocular pressure to postoperative visual loss.   One study conducted in the steep head-down position with laparoscopic surgery demonstrated increased intraocular pressure as time progressed.  Normally, cerebral and ophthalmic circulatory autoregulation prevent increased intraocular pressure, however, this may not be the case during general anesthesia in the steep head-down position.

Research conducted by Bonnie Molloy, CRNA, PhD  (A Preventive Intervention for Rising Intraocular Pressure: Development of the Molloy/Bridgeport Anesthesia Associates Observation Scale) and published in the AANA Journal (AANA Journal, June 2012, Vol. 80, No. 3) is a “must read” for any anesthesia provider administering anesthesia to patients in the steep head-down position.  This comprehensive review of postoperative visual impairment following head-down surgery details the pathophysiology and describes observable, physical changes that will alert the observant provider that intraocular pressures are increasing.

Data obtained by the author revealed that increasing intraocular pressure in the patient in the steep head-down position correlates to increasing eyelid and conjunctival edema.   These physical signs can be used to determine when it is advisable to level the patient and allow the intraocular pressures to decrease.

The result of this excellent, well documented study was the development of the Molloy/Bridgeport Anesthesia Associates Observation Scale.   Using the signs of eyelid and conjunctival edema, the anesthetist can predict when intraocular pressures are increasing.  The original work is complete with illustrations to guide the anesthetist in the use of the observation scale.

This original work was funded in part by a grant from the AANA Foundation and is essential knowledge for anybody routinely doing cases in the steep trundelenburg position lasting greater than 2-3 hours.  Click here to view the original publication.

Product Review: enFlow fluid warming system

PROCRNA.COM presents new products of interest to the anesthesia community.   Inclusion on this web site does not constitute an endorsement of the product.  Please review this information, visit the enFlow web site and obtain a demonstration from your local representative. 

Keeping surgical patients at a normal body temperature is a daily struggle for those in the medical field. Among the 45 million inpatient1 and 34.7 million ambulatory2 surgeries occurring annually in the United States, it is estimated that 50-90% suffer from hypothermia (defined as a core temperature below 36 degrees Celsius).3 Hypothermia in the perioperative environment is caused by a variety of factors including low operating room temperatures, large surgical incisions, a core-to-peripheral redistribution of body heat as a result of anesthetics, chilled IV solutions, surgical procedure length, and more.4 Hypothermia has a significant impact on postoperative outcomes, which are almost exclusively undesirable.

Hypothermia is one of the most preventable complications resulting from an operative procedure, and prevention is most effective when warming begins preoperatively5 and continues across the surgical workflow. Vital Signs Inc., a GE Healthcare Company, has introduced an IV fluid/blood warmer that helps hospitals start the warming process early and continue warming across the patient’s care journey to reduce the occurrence of hypothermia.

The enFlow* IV Fluid/Blood Warming System is helping hospitals warm their patients with mobility, speed, and accuracy. The patient-dedicated cartridge attaches in-line to standard IV fluid/blood delivery sets at the start of procedures and moves with the patient, allowing care givers an easy, efficient, and cost effective way to warm across each stage of the surgical process. When it is time to move from one area of the surgical workflow to another, the user simply removes the cartridge from the enFlow warming unit, allowing the IV set in its’ entirety to be moved with the patient when transported. Once the patient arrives at the next area, the cartridge is easily inserted into an enFlow warming unit stationed in that area and is back to heating within seconds. In addition to mobility and speed, the system also enables accurate temperature control with a differentiated warmer that sits close to the patient (reducing the opportunity for fluids to cool in the IV line) and has eight temperature sensors ensuring fluids are the right temperature for patients.

To learn more about the enFlow IV Fluid/Blood Warming System and the impact it can have on your Anesthesia Department.  Click here to visit the enflow web site.

*enFlow is a trademark of General Electric Company

1 Center for Disease Control and Prevention, FastStats. Inpatient Surgery, Data are for the U.S. Accessed November 29, 2011. http://www.cdc.gov/nchs/fastats/insurg.htm.
2 Center for Disease Control and Prevention. U.S. Outpatient Surgeries on the Rise. Accessed November 29, 2011. http://www.cdc.gov/media/pressrel/2009/r090128.htm.
3 Young, V. Watson, M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006; 551-571.
4 Kurz A, Sessler DI, Lenkhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996;334:1209-15.
5 Paulikas, CA. Prevention of Unplanned Perioperative Hypothermia. AORN J. 2008; 88(3): 358-365. DOC1194144

Clinical Topic: Does Anesthetic Technique Make a Difference?

The belief that the choice of anesthetic technique has little effect on long term outcome is being challenged.  New evidence is being presented in the literature suggesting that anesthetic technique, in fact, may make a difference in long term outcome.

A recent study by Kavanagh T, and Buggy DJ. (Curr Opin Anaesthesiol. 2012 Apr;25(2):185-98.) titled Can anaesthetic technique effect postoperative outcome? examines aspects of anesthetic management that may effect postoperative outcomes.  According to the authors, a review of the literature has revealed the following:

  • Administration of supplemental oxygen and the avoidance of perioperative hypothermia, allogeneic blood transfusion, hyperglycaemia or large swings in blood glucose levels reduces postoperative infection rates.
  • The use of regional anaesthesia techniques reduces chronic postsurgical pain.
  • The avoidance of nitrous oxide reduces the long-term risk of myocardial infarction.

The authors point out that the findings of many studies can be debated and recommend large scale studies with long term followup to gather better data.  Such studies could better identify correlations between anesthetic technique and cancer recurrence, neurotoxicity, and the development of postoperative cognitive dysfunction.

Click here to read an abstract of the original work and return to procrna.com and share your thoughts.

 

 

 

 

 

Clinical Topic: Control Infection with disposable ECG wires

Hospital acquired infection effects nearly 2 million patients annually and has become a marker for quality care.  The SCIP guidelines have specific requirements for antibiotic administration in the peri-operative period, however, antibiotics are only one piece of the infection control puzzle.  Sterile instruments and hand washing with every patient contact are also essential elements.  One area that is often overlooked is the use of contaminated ECG wires from patient to patient and the risk of introducing organisms to an otherwise clean/sterile area.

A study by Laura Boegli, Elinor Pulcini, Ph.D. and Garth James, Ph.D,  (Bacterial Migration on Reuseable Electrocardiography (ECG) Lead Wires)   The study cultured 100 randomly selected ECG telemetry leads and found that 77% were contaminated with at least one antibiotic resistant pathogen.  The authors make the following comments regarding the difficulty in cleaning ECG wires and cables:

“Reusable ECG cables and lead wires also have specific cleaning challenges that may cause cleaning to be inconsistent and ineffective such as (1) numerous “nooks and crannies” that patient’s blood and body fluids can seep into thereby providing an environment for bacterial growth (2) inability to submerge for cleaning and cleaning agents potentially degrading the product efficacy and functionality over time and (3) multiple surfaces on ECG lead wires and cables which may make it difficult for cleaning agents to reach all surfaces when cleaning in between patients.”

Click here to read the study.  It is a PDF download and starts with the conclusion.  The reader must forward to the start of the article.

Covidian has introduced disposable ECG wires to the marketplace enabling each patient to have clean ECG wires starting in the OR and then going with the patient to PACU and on to ICU or the patient room if necessary.  This product eliminates the risk of patient to patient transfer of antibiotic resistant organisms in the operating room.  Click here to view the manufacturer’s information and return to procrna.com with your comments.

Make the Most of the AANA Meeting in San Francisco

Boston, Seattle, San Francisco, Honolulu, Jackson Hole, San Antonio…there are some amazing destinations for anesthesia meetings right here in the USA. Most of the venues are places where there is a long list of thing s to see and do. And all of the destinations provide plenty of opportunities for you to stay active.

 

Run For Fun

AANA’s annual meeting has been offering a 5-K fun run for just under a decade. It’s an easy 3.1 mile course along the city’s most scenic route with shuttle service provided start and finish. Runners, walkers, strollers (those are the people who stayed up late the night before) are all welcome and you’re the celebrity. Beautiful surroundings, beautiful celebs, and a free t-shirt as beautiful as t-shirts get, make all that exercise a beautiful bonus. Sometimes the local ANA offers early morning fitness classes at the host hotel with leadership provided by CRNA’s who apparently enjoy waking people up as much as putting them to sleep. Click here for the AANA wellness run in San Francisco

Take Your Bands

Exercise bands are almost as easy to use as they are to pack. You can do a complete work-out in your hotel room, in the hotel gym, in a park, at the beach or looking out over the harbor in Seattle or Boston. All you need is two or three bands, a doorjamb, railing or a pole to anchor them, a little backpack to carry them, or a waist small enough to tie them around your middle. With access to cool water and a hotel-sized washcloth, aka sweat rag, you’re good to go. Bands weigh less than an I-pad and they pack flatter than a ten-dollar bill.

Rent A Bike

One of the best ways to see your city and get some great exercise at the same time is to rent a bike. Google “bicycle tours in Vancouver” or “rent a bicycle in Austin” and refine the search from there. Be sure to use the word bicycle because otherwise you’ll end up with Harley Suzuki as your travel companion, which might be a blast, but you won’t get much exercise unless you fall off and have to walk back. You may be able to get a private, guided bicycle tour – more money, of course, but if you like to be at the head of the class asking questions, money talks and the expense will pay off. Click here to learn about bike rental in San Francisco.

Many cities have initiated bike-share programs. This service goes by a variety of names – like Q-bikes in Portland, B-cycle in San Antonio, or simply Bike-share in Boston – and features a fleet of bicycles that anyone can use. Just swipe your credit card at the vertical terminal, release one of many bikes from its locked stall, then ride it on marked cycling routes throughout the city, or directly to a destination. Parking stalls and routes are indicated on maps at each bike installation so you won’t get lost. Each time you stop to sight-see near a bike-share stall, just slide the bike into a rack, it locks automatically, and very shortly it will become someone else’s exercise partner. The beauty of the service is that it generally doesn’t require a helmet. One of the drawbacks of the service is that it generally doesn’t require a helmet… AND if you have to wait for a bike to become available when you’re in Brooklyn, you could be late for cocktails in the Bronx. Click here to learn about community bike share in San Francisco.

Walk

If you didn’t download a city map and a printable walking tour before leaving town for your meeting, you can ask your hotel concierge to highlight the best walking destinations on a brochure and outline some routes for you. Check things off on your brochure as you go so you don’t miss the major attractions, and don’t be afraid to get off the beaten path. Make note of noteworthy and eccentric establishments as your cabbie whisks you through the city from the airport, then go back and find them on your feet. You’ll run into the best coffee art cafes, the most interesting old houses, and charming little corner stores that you won’t find on Tourist Avenue. You may burn enough calories to almost justify the mouth-watering apple fritter you found at Dave’s Sugar Shack not to mention the energy you’ll have the rest of the day just from staying on your toes. If Rick Steves or Lonely Planet has published a travel guide for the city you’re visiting, it’ll be a quality purchase, and when it rains, you can walk the halls, climb stairs between 2nd and 12th, or go to the hotel fitness club. Remember to pack your Nike’s and your fitness duds so you can avoid blisters and excuses. Click here to learn about walking tours in San Francisco.

Go to The Fitness Club

One of the criteria for selecting a hotel is the quality of the fitness club. Every large hotel in a large city has a fitness center and some of them have glitz galore. The Omni in San Diego, the Sheraton in Seattle, the Sheraton in Boston, even the Holiday Inn in Columbia, MO all have exceptional facilities for working out. Check online or talk to the actual hotel desk staff before you reserve your room and ask about these items: Cardio equipment(treadmills, elliptical trainers, lifecycles, walking tracks); strength-training equipment(training circuit, free weights, vertical bands stations); abs room or abs corner (mats, fitballs, body bars, medicine balls); and towel service as well as a decent-sized pool. Gym-rats are going to get to the facility early, so go really early or go a bit late, but get going.

Your anesthesia meeting is a place to learn more about your ever-changing industry but it’s also a place to have fun with old friends and to make news ones, a place to experience a new city in a new way. Hike Aspen Mountain, jog the stairs next to the San Diego Convention Center, power walk the promenade while cruising between glaciers in Alaska, cycle from Fenway Park to The Old South Church. You won’t be putting anyone to sleep or trying to stay awake for one whole week. Go make the most of it!

You can visit Liz at www.bdyfrm.com and learn more about her Traveling Bands comprehensive work-out indoors or out, and how to gain access to the Bands In the Park mobile browser. Read motivational, entertaining Lizlines every weekday including the weekly original Lizlimerick.

 

Chief CRNA: CRNA supervision requirement reviewed by CMS

Physician supervision of CRNAs has been an ongoing topic of debate within the Anesthesia community for decades.  Under current law, CRNAs are required to be supervised by a physician unless the individual State “opts out” of the requirement.   To date, 17 States (Kentucky the most recent) have opted out of the requirement.

In a post on The Anesthesia Insider, blogger Neda Mirafzali, Esq  (Anesthesiologists Targeted in CMS’ Review of Existing Rules)  states that Health and Human Services (HHS) has been directed to review all existing rules related to health care and make them more effective, efficient, flexible and streamlined.   As a part of the review, CMS is looking at the issue of CRNA supervision as a condition of participation in the care of Medicare and Medicaid patients with the possibility that the supervision requirement be removed on a Federal level.

The blog post includes a brief but excellent review of who may supervise a CRNA and what constitutes supervision.  Changing the regulations would have no effect on the states that have already opted out of the requirement for supervision.  The remaining 33 States would, in essence, be automatically opted out by virtue of the rule change

Click here to read the original blog post and return to procrna.com to make a comment.

Clinical Topic: SSEP Not required for Cervical Spine surgery

As anesthetists, we are frequently called upon to administer safe and effective anesthesia to patients with cervical spine disease.  Patients with symptomatic spondylosis or stenosis have symptoms of myelopathy and/or radiculopathy.  The goal for the surgeon and the anesthetist is for the patient to be free of neurologic symptoms postoperatively.

Somatosensory evoked potential  (SSEP) monitoring has been used to detect adverse surgical effects on nerve roots during scoliosis surgery.  In recent years, SSEP monitoring has been used increasingly for other types of spine surgery, including decompression.  This study was done to evaluate the value of the use of SSEP for Cervical Decompression surgery.

Dr. VINCENT C. TRAYNELIS, MD a Neurosurgeon from Rush University did a comprehensive record review of cases involving decompression of the Cervical Spine between 2000 and 2009. The results were published in J Neurosurg Spine. (2012 Feb;16(2):107-13. Epub 2011 Nov 11.)  The records of 720 patients who had a total of 1,534 levels decompressed without the use of SSEP were reviewed.  Specifically, the authors were seeking new neurological symptoms related to the surgery.  They found 3 patients with new neurologic symptoms after surgery,  1 had a preoperative diagnosis of radiculopathy, while the other 2 were treated for myelopathy.   The new postoperative deficits completely resolved in all 3 patients and did not require additional treatment.

The authors concluded that decompression of the cervical spine without intraoperative monitors is not only safe but offers a significant savings.  In this case, the authors speculated that the cost of monitoring the patients who were reviewed would have been 1,024,754.

Click here to read the original abstract and return to procrna.com to leave a comment.

Chief CRNA: Corporate takeover of your Department?

As Healthcare workers, we watch the reports on the evening news about corporate takeovers in the business community and are relieved that we don’t have to worry about things like that in our profession, but are we really safe?   An post on Anesthesia Reviews Blog by William Hass, MD, MBA explains why investors with venture capital investing in and profiting from the Healthcare industry. He lists the following reasons for their new interest in making profit from Healthcare:

  • The stock market as a whole has barely risen in the past decade,
  • Bond yields are unusually low
  • With the global savings glut there is just so much capital chasing too few worthwhile investments.

Among the options are anesthesia management companies who undercut your contract to provide services.  Once they have secured the contract to provide services at your hospital (your job), all staffing and equipment decisions are made based on generating a profit for investors.  Sadly, the group of people who are not actively managing the business of anesthesia and maintaining contracts are the anesthesia professionals.  Dr Hass lists the following as things that we could and should be doing to protect our jobs and the quality of care offered to our patients;

  • Be politically active at the facility, community, state, or national level
  • Spend money and time for business education
  • Develop and utilize an effective human resource program
  • Understand anesthesia service and OR management
  • Give group leaders time to lead
  • Educate and develop the next generation of leaders

This warning by Dr Hass reinforces the experience that small anesthesia departments are having across the nation.  Now is the time for CRNA leaders to be proactive and solidify the relationship between the Hospital and the anesthesia group.  Failure to maintain vigilance in the front office may cost you your job.

Click here to read the original blog post by Dr Hass and return to procrna.com to make a comment.

Clinical Topic: Fluid management in Major Surgery

Fluid management during major surgery has been a topic of discussion for decades.  The goal of evidence based practice has produces many studies related to fluid management.  Despite the number of studies that have been published, to date there is no universal protocol recommending optimal fluid management guidelines

A review by Corcoran,T et al published in Anes Analg  (2012 Mar;114(3):640-51. Epub 2012 Jan 16) titled Perioperative fluid management strategies in major surgery: a stratified meta-analysis looked at major works that have been published in an attempt to clarify whether goal directed fluid therapy had an advantage over liberal fluid replacement during major surgery.  Those in the goal directed group had fluids administered based on hemodynamic targets.

The study reviewed databases from 1950 to 2009.  Postoperative complication such as pneumonia, pulmonary edema, time to first bowel movement and length of hospitalization were all greater in the liberal fluid group.  They found no difference in wound infection/dehiscence, myocardial infarction, renal complications or mortality.

The goal directed patients received more colloid fluids during surgery and had shorter hospitalization with fewer renal complications.  The authors concluded that the goal directed group had better outcomes than the liberal fluid group.  However, they could not state that goal directed therapy is superior to liberal fluid use.

Click here to read an abstract of the original article.

Research: What is the best handwashing technique?

Postoperative infections are a major concern throughout the healthcare industry to the extent that infection rates have become a marker of “quality care”.   Patients expect health care workers to protect them from exposure to harmful organisms and, as we know, handwashing is foundational for any infection control program.  As anesthesia care providers, we are called upon for insertion of invasive lines where a sterile field is as essential as the sterile field required by the surgeon.  Therefore, handwashing among anesthesia providers is essential for patient safety.

Since the advent of the germ theory, handwashing has been the first line of defense against pathogenic organisms.  In the operating room, handwashing has evolved into a full 5 minute scrub using a bacteriocidal soap or solution.  Recently waterless antiseptic solutions have emerged on the market and have been touted as being equally effective as the full 5 minute hand scrub.   The efficacy of the antiseptic solutions is still being studied.

A study by Burch et al, Anesth Analg. 2012 Mar;114(3):622-5 (Is alcohol-based hand disinfection equivalent to surgical scrub before placing a central venous catheter?)   Looks specifically at anesthesia providers using various techniques for hand cleaning prior to insertion of a Central Venous Catheter.  Five different hand cleaning techniques were used and hands were cultured after cleaning.  The techniques were as follows

  • Traditional 5 minute hand scrub
  • Traditional 5 minute hand scrub, 15 minute break, then alcohol only cleanser
  • Alcohol only cleanser
  • Alcohol only cleanser, 15 minute break, then traditional 5 minute scrub
  • Waterless surgical scrub alone

The authors found that method 3, the alcohol only cleanser was significantly less effective than the traditional hand scrub.  This study supports the theory that hands are best decontaminated by using the full 5 minute scrub at the beginning of each day.

Click here to read an abstract of the original work.

Research: Partner’s Presence During Epidural Placement

The constant pursuit of patient safety and satisfaction is foundational to excellence in patient care.  Involvement of the patient’s family has been shown to increase satisfaction and enhance the overall medical experience.  Many hospitals allow parents into the operating room for induction of anesthesia in their children.  In the area of labor and delivery, epidural anesthesia has been shown to not only reduce the pain of labor but also relieve anxiety of both the patient and the partner.  A question yet to be answered is whether or not the presence of the partner during placement of the epidural reduces anxiety and increases satisfaction.

A study by Orbach-Zinger et al published in Anesth Analg 2012 (Partner’s presence during initiation of epidural labor analgesia does not decrease maternal stress: a prospective randomized controlled trial.) seeks to assess whether the partner’s presence during labor epidural chtheter placement reduces mother and partner anxiety level.  The study included 84 couples who were divided into two groups; partner present or partner absent during catheter placement.  Anxiety levels, pain and time to placement were measured.

At baseline, there was no difference in anxiety or pain between the groups.  During catheter placement, anxiety levels and pain during insertion were significantly higher in the group with the partner present.  The authors concluded that partner presence during epidural catheter insertion did not decrease anxiety levels.  The anxiety and pain of catheter placement were greater with the partner present.

Click here to read the original abstract of this study.