CRNA Fitness: Decompress the stress

PROCRNA asked me to mount the March podium on the issue of stress-reduction which would be nearly laughable…except for the fact that I have so much personal experience. So here it is, the Body Firm method to decompress the stress.

Where do most of my clients turn for comfort during or after a tough day with the head, hands or heart? Why, food, of course. The number one method of coping with pretty much anything these days is comfort food or drink. Some of you will turn to the box of goodies in the lounge, some of you will opt to ingest a 16-ounce cola, and some (more of you than would like to admit it) will eat two or three doughnuts pretending it’s breakfast. But be careful of calorie-dense stress relievers. Sugar elevates your mood very briefly before acting as the downer it really is, dropping you as fast as a plumb line, and leaving unwanted calories and irritation behind. And in the long run, useless food raises your stress. Instead, munch on an orange, or snack on a handful of almonds, or both. An orange will administer quick sugar, it’s true, but it’s loaded with vitamin C and will provide nutrients along with energy. Nuts are a great source of protein that can hold you over until a real meal or simply sustain you through another case. Try walnuts or pecans, too, and limit your serving to a clean, even dozen. The crunch of the munch is very satisfying and brings fast relief.

You may be tempted to just flop on the decrepit sofa in the lounge when someone relieves you in the OR, not always a bad idea. But even better: Walk the hallway, stop to do squats every 12 strides, stretch your calves and quads and stretch your arms above your head, jog down the stairs to 2nd floor and jog up the stairs to 4th. Pause to do a couple of Yoga positions and bring your heart rate back to normal, then re-enter your case room with mental peace restored.

Dr. Coyote howled, Dr. Hound bit, Dr. Wolf snarled throughout the last heart case and, quite possibly, the patient’s heart is now doing better than yours. Instead of chatting it up with staff and cohorts when you exit the room, pull out a good read. Weird Sisters is a current hoot for chicks, and author, Olen Steinauer can capture either gender’s attention in short order. Try reading the daily “funnies” for comic and cardiac relief, or read anything cheerful that will take your mind off the present and help restore your equilibrium and your gift for humor. LOL.

You may not be in charge of selecting music for the gall bladder room. Pink Floyd or
George Strait may be the surgeon’s consistent choice of genre, but when you get to choose, or when you go on a break, listen to music that relieves tension. Relax with alternative sounds like waterfalls or crashing waves from a Narada collection. Classical melody from Smetana’s “The Moldau” or Debussy’s “Daphnis and Chloe,” and even big Wagnerian themes from “Tannheuser” or “Lohengrin” can fill your soul and remove the excess tension. Schubert piano solos or symphonies, unrestrained strains from LAGQ, Chis Botti love tunes on the trumpet or any of the music you simply know and love can take off the edge, and pull you back from it. Massage your hands and feet while you listen to music and get maximum de-fusing.

Finally, here’s one of the best stress-busters known to Venus or Mars – Meditation. You’ll need a quiet corner for this activity unless you’re an excellent self-hynotic. Close your eyes and preferably a door, get seated and settled with good core support, then start with slow, deep breaths in through the nose, out over the lips, switching to all nose breathing when you’re fully “centered.” Tune out any and all distractions and focus on the breath (Toothpaste trumps garlic!); in…and out….in ….and out…”…he loves me….he loves me not….one for you…one for me…” Relaxation is in the focus and in the rhythm.

K, I hate to wake you up, but there you have it – Body Firm’s favorite decompression session. An anesthetist has almost no time to relax during the workday. Morning break is not a given. Lunch can be 11:00 or 2:00 or not at all. The comfort and outcome of the patient will always be your ultimate concern. But put your own health next in line and treat your stress with safe, un-medicated relief. Your patient will benefit, and it may keep you from becoming one.

Visit Liz online at www.bdyfrm.com Read daily Lizlines and leave a stress-free comment!

Chief CRNA: OR Efficiency

The following information was provided by Jay Horowitz, candidate for AANA Region 7 director. With the current budget restraints and emphasis on efficiency, Jay has documented the inherent inefficiency of staffing ratios and the cost to the system. Read Jay’s comments, link to the supporting articles and return to procrna.com and offer your comments.

From Jay: This week an article appears in “Anesthesiology, The Journal of the American Society of Anesthesiologists, Inc.” (!!): Supervision Ratios that gets to the heart of the inefficiencies, waste and fraud inherent in “supervision” and “medical direction” models of anesthesia delivery. With an average 22 minute delay in multiple operating rooms several times a day, and an average Medicare reimbursement rate of $1.43/minute X 250 working days a year X 1000’s of US operating rooms, the money adds up awfully fast! So do the savings with greater CRNA utilization models validated in the recent Health Affairs and Nursing Economics articles with NO compromise in quality of care. Click here to read the ASA article.

I’ve been writing about these inefficiencies for some time now: Streamlining Anesthesia Care and how we might rationally fix the problem. We need to make sure that this kind of information is available to every state and national decision maker and other stakeholders. Click here to read an article from the Herald Tribune.

Read, enjoy, and return to make a comment

Topic: Continuous Capnography Linked to Lower Monitoring Costs

In the age of Health Care Reform where we are all being tasked with providing more care for less money, simple ways to save are gaining popularity. In an article published in Anesthesiology News, Dana Hawkins-Simons discusses the use of capnography in the Intensive Care Unit to save money. In the article, she refers to an study by Courtney Rowan, MD who compared to total number of blood gas measurements done before and after the ICU began using continuous capnography on all patients.

The study showed that after beginning the policy of capnography measurement on all patients, the number of blood gas tests dropped from an average of 21.6 per patient to only 13.8. This reduction in testing resulted in a savings of $985,130. It was speculated that there could have also been savings due to a reduced requirement to transfuse blood in the smallest of patients where frequent drawing of blood for samples resulted in a lowered Hemoglobin level.

Click here to read the article in Anesthesiology News and return to PROCRNA.COM to make a comment and share your opinion.

CRNA Fitness: What goes Up, Must Come Down

What goes up when the rain comes down? Answer: Your weight. If you thought the correct answer was “an umbrella,” then you probably heard it from your kids or grandkids. March does bring rain, but even more than moisture, March brings a change of seasons. And as the season changes, so do your fitness opportunities.

If you have been walking on a row of treadmills all winter, hiking virtual trails while listening to gym-girl Greta’s visions of grandeur, aka gossip, on the machine next to yours, you’re more than ready to hit the pavement, wet or dry. Asphalt streets, dirt trails, and school tracks exist in nearly every community and only really nasty weather should send you back to Greta. Fitness experts often claim that outdoor cardio actually burns calories faster just because of the elements of wind, breathing outdoor air, and dealing with natural changes in elevation. Yes, on Lion days, you can go back inside and adjust your treadmill to outdoor standards, but it would be a shame to miss watching that Bartlett pear tree on the corner of Magnolia and Vine go through its spring metamorphosis. Don’t forget to take drinking water.

Bands work-outs are a fantastic source of strength-training and once you’ve taken them to your favorite park, you just might opt to stay outside in the wind and rain if only to enjoy the freedom and flexibility of the work-out. If you’ve been going to the gym three mornings a week to lift weights, or to do Body Pump, or to zip through the circuit of machines, taking your bands outside to a park will provide a nice break in the winter routine AND if you walk there, you can keep checking on that Bartlett pear. When the nitrates start falling from the sky, you can always take the bands inside at home or at the gym. Is there a fitness center at the hospital where you work? Is there a children’s outdoor area with some poles that support swings or climbing apparatus? Perfect for bands. How about doors with hinges. If there is a low-traffic area inside the hospital where some infrequently used doors with hinges are hanging around, that’s another perfect place for anchoring bands. Maybe you’ll need “permission” to use the space or maybe you’ll need the chief’s approval, but if you really want to do your work-out, you can work it out. Don’t forget your water.

March brings a variety of weather to your exercise routine – rain, wind and even some stubborn snowfall. You will probably need to do a blend of trail walks and treadmill, outdoor cycling and indoor elliptical, and you may need to tote the Totes. But it’s a great time, a hopeful time of year when as the season changes, you can take advantage of the change. Then when April arrives and the rain comes down, the only thing that will go up is your umbrella.

Learn more about the Bands In the Park work-out on mobile browser at www.bdyfrm.com.

Clarus Video System

Having trouble with insertion of the ET tube into the trachea? Would you rather see than feel tracheal rings to insure intubation? There are a number of video laryngoscopes on the market, now Clarus has introduced the video intubating stylet.

The Clarus Video System allows visualization at the end of the distal point of the stylet (ie the end of the tracheal tube). The HD screen of the CVS gives the intubater maximum visualization, making it simple to maneuver the tracheal tube into the airway for both regular and difficult intubations. Also with a click of a button, a red LED light will illuminate the airway and transluminate through the cricothyroid membrane providing additional insurance that the intubation was successful.

We would like to hear from CRNAs who have used this product. How does it compare to the standard video laryngoscope?

Click here to go to the manufacturer’s web site and review the product. Return to PROCRNA.COM and use the comments box to share your thoughts with your colleagues.

Clinical topic: Lower Central line infections

In the midst of the pressure to lower infection rates and meet CMS standards, is it possible to reduce the rate of central line infection to zero? That question was addressed in an article by Kate O’Rourke published in Anesthesiology news. The author states that new research has found that multidisciplinary team approaches are making great strides in dramatically reducing rates. She describes a study done at the University of Massachusetts finding that involving caregivers at all levels and providing frequent, regular feedback on infection rates to hospital staff are two key elements that have made these programs a success, experts said.

The article continues by quoting Matthias Walz, MD, chief of vascular anesthesiology at UMASS Medical Center, who said the guidelines at his facility were developed by a small task force and then approved by the institution’s Critical Care Operations Committee prior to implementation. “From the ICU physicians to the ICU nurses, respiratory therapists, pharmacy team, occupational therapists—everybody is at the table.” Because all disciplines were involved in creating the guidelines, all caregivers feel they have a stake in the process, he said.

A good infection control program will show positive results, however, for the success to be continued, participants must continue to be updated and motivated. Ongoing education is essential. Reducing infection rates is a total team effort by all caregivers. Communication and coordination is mandatory.

Click here to read the article as published. Return to www.procrna.com and leave a comment.

Feature SRNA: Adrianne Collazo

Adrianne Collazo

SRNA

Adriannejc@gmail.com

Mercer University

Will graduate December 2012

Click here to review my CV

Click here to review my student work

Why you should hire me: Team player, people person, eager to learn, teachable, hard worker with a good work ethic. Clinical experience in diverse cases (general and sedative) at Level one trauma center. Excited to become part of an organization that promotes autonomy and self growth.

Chief CRNA: How to balance your life

Life has many demands at home and at work. As CRNAs, we are expected to provide first time value to patients with each encounter and we are expected to be available 24/7. As Chief CRNAs, we add the responsibility of department management to the clinical responsibilities. After a long day at the Hospital, we often go home to a long list of “must do” items leaving little time for rest and relaxation. Over time it takes a toll. As professionals, we must balance our lives if we are to avoid burn out.

In a blog posted on Rock the post, the author presents 7 key tips for bringing your life back into balance. The author concludes, “If you don’t have a sense of harmony between your personal and professional life, things can take a toll on you mentally and physically.” Taking simple approaches, like those listed in the blog, can help you get your life back in balance so that you can be productive at work and have fun with your family and friends.

Click here to go to the blog and read the 7 tips. Return to www.procrna.com and leave your comments.

Chief CRNA: Negotiate Your Salary

In business, everything is negotiable. As a Chief CRNA, you are responsible for not only setting the Corporate climate and enforcing the standards in your work group, but you also must attend to the business of Anesthesia. Being fairly and adequately compensated is foundational to being a loyal and engaged employee. Negotiation is essential both when you are being compensated and when you are hiring new people to work in your group.

An article written by Linda Jenkins on the salary.com web site details some of the elements of successful negotiation. In a negotiation, each party should fulfill the needs of the other party. In order to do so, you must know your strengths and resources and be able to respond to the needs of the other person. She stresses preparation prior to the negotiation.

Click here to read the article in a PDF format or click here to link to the article published on salary.com.

The Chief CRNA area of procrna.com is a forum for those interested in Anesthesia Department Management to share ideas. If you are a Chief CRNA, please use the guestbook on this page to let us know who you are and where you work. Please pass this web site along to your colleagues.

Clinical Topic: Propofol allergy in Children

Propofol is currently the hypnotic drug of choice for anesthetic induction. With the increase in TIVA anesthesia, Propofol is also being used as a maintenance drug. Propofol is a lipid preparation which incorporates egg lecitin, phosphatide and soy oil in the preparation. Egg and Soy allergies are listed as contraindication to the use of propofol. Due to the presence of egg products in the formula, the question emerges as to whether or not propoful should be used in the patient with egg allergy.

In a retrospective chart review study by Murphy A, et al published in Anasth Analg the topic of propofol use in the egg allergic patient is explored. The authors report that egg lecithin used in the propofol formulation has not been found to have residual egg proteins. The literature revealed only one case where an egg allergic patient reacted to the lecithin used in propofol. Since egg lecithin comes from the egg yolk, the authors speculate that up to 75% of pediatric patients with egg allergy could tolerate Propofol without incident. Nevertheless, the authors recommend skin testing of patients with egg allergy prior to propofol use.

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

Clinical Topic: Case Presentation by SRNA

SRNA Brooks Cauley has offered some of her student work for review by the CRNA community. Read, learn, enjoy and make a comment. Brooks will graduate in 2012 and is available for those who seek a motivated addition to their staff.

Case Study: Elderly patient with infrarenal AAA, Aortic stenosis and an intracrainial mass. The review is presented as a series of power point slides with talking points regarding the anesthetic management of each co-existing disease. References are listed at the end. View the slides and return to this page to leave a comment.

Click here for slides

Brooks Cauley

SRNA

bcauley9@yahoo.com

Will graduate December 2012

Why you should hire me: People person, good personality, teachable, eager to learn, good work ethic, understands teamwork. Gaining valuable experience in providing general and sedative anesthesia in diverse cases at a level one trauma center. Excited to become part of an organization that promotes effective, efficient, and quality healthcare. Looking for an organization that promotes autonomy and self growth.

Click here to download CV

Meeting Review: Texas Association of Nurse Anesthetists

Who says you have to go to a big National meeting to obtain quality continuing education? The Texas Association of Nurse Anesthetists once again has done it right. The Texas Association Spring Meeting was held February 17-19 at the Waterfront Marriott in The Woodlands Texas.

The meeting location was a newly developed area with shopping restaurants and movies within easy walking distance. The Hotel was first class and offered a group rate to those attending the meeting.

Speakers were exceptional. All were extremely knowledgible and the topics were relevant to clinical practice. The meeting room was comfortable. The lunch provided on Friday was better than most food served at meetings.

All things considered, this State meeting was exceptional value for the money. The Fall Texas Association meeting will be September 21-23 in San Antonio, Texas. Mark your calendar.

If you attended this or any other Texas meeting, leave a comment.

Clinical Topic: Intubation verification with Ultrasound

As airway experts, we have all been faced with intubating the difficult airway. We line up our toys, develop plans A, B, & C, and then go for it. After intubation, verification of tube placement is essential. The traditional methods of auscultation over the lung and the presence of a CO2 waveform are the gold standard. However, with the expanded use of the ultrasound in the operating room, there are other options.

An article by Pfeiffer P, et al published in Atca Anaesth Scand describes the use of the ultrasound for verification of endotracheal tube placement. The ultrasound can be used several ways to verify intubation. First, by scanning across the cricoid membrane, direct visualization of passage of the tube is possible. Several views in the neck area enable confirmation of tube passage. Ultrasound visualization of diaphragm movement indicates proper intubation. Finally, lung sliding with ventilation confirms tracheal intubation.

In this study, the group used the techniques described above and compared the time to verification using ultrasound versus the traditional auscultation and capnography. The study found that using the ultrasound for verification was reliable and equally quick as auscultation. When compared to auscultation plus capnography, the ultrasound verification was faster.

Click here to review the abstract of the original article. Return to procrna.com and offer your opinion.

CRNA Fitness: Circuit Training

The Circuit Train

Working out can be whole lot simpler when you know the drill! If you need one day a week to “relax your mind” while actually getting your work-out, try circuit-training. There are several good things about using an established circuit and here’s just one. You can go get a member of the training staff for a free orientation around the circuit. Reservations encouraged.

A circuit provides a moderate level work-out and consists of gym-level machines set up in a circle, a neat little rectangle or at the very least, all on the same side of the gym. If they are not grouped, it’s not a simple circuit, it’s a hairy maze. There will be one or two machines for each specific muscle group and in a well-thought-out arrangement, muscles will be grouped to keep you in order. Remember? It’s 4:30 a.m. before a 12-hour day of one heart, two gall bladders and whatever last-minute trauma is scheduled and you’re looking for a straight-forward work-out, not discombobulation. Start with shoulders and begin working your way around the circuit.

Overhead Shoulder Press and perhaps Incline Shoulder Press will be your starting place. If you’ve not had the orientation, you’ll need to read the instructions printed on one of the supporting braces of the press. Adjust the weight plates, adjust the seat front-to-back and up or down, sit with “Body Firm” posture, use an overhand grip and press the contraption overhead(or angled up and outward) until fully extended. Voila! Rest 30 seconds between one or two more “sets” or press onward.

Note: Adjusting the set-up options correctly and appropriately is tantamount to getting the most out of each exercise, but even more importantly, to remaining uninjured. Too much weight can crash back down, hunching shoulders can pinch your neck, exhaling at the wrong time can challenge your heart(and not in a good way), and failing to use your abs will arch and injure your back. Use caution and common sense. You too, Men!

Chest Press and Seated Chest Flies will be next and, once again, read the instructions, adjust all of the set-up options – front to back, seat up or down, weight plates – and be seated. When seated, your feet should be flat on the floor unless there are little angled platforms for your feet. Both of these machines are harder than you think so err on the side of caution and keep it light until you’ve found the level of exertion that challenges without causing pain.

Seated Lat Flies are the reverse of Seated Chest Flies – not to be confused with seated front flies which require elbows bent and arms to open and close like French doors – and may be part of the same machine. To work the chest, you’ll face outward; to work the back, you’ll face inward. And the Seated Lat Row, which has three set-up adjustments, should be next.

These require feet flat on the floor, not tucked behind you so you fall forward, nor extended in front so you can row your boat. You’re not in an outrigger canoe in Hawaii. You’re in the gym, darn it, at 4:30, darn it, before doing a heart, darn it…feet flat on the floor, please.

Triceps and biceps are next on the circuit. Note the work-out moving from strong shoulder exercises, to large chest and back muscles, to the smaller, but potentially so down-right gorgeous tri-bi muscles, the ones that never show in the OR but show big time on a beach…in Hawaii. You can see what’s on my mind in February! Biceps will be a standard Seated Biceps Curl and/or a Preacher Curl. I don’t get why this is called “preacher” but google says it’s because the arm position resembles someone praying. You’ll actually look like someone holding a Bible or a hymnal a whole lot more than praying, but whatever floats your boat is what you should visualize. Just do it! Remember, the key to good biceps curls and triceps curls is the anchoring of the elbow and maintaining neutral wrists. Curl is the basic motion, not the rolling and bending of the wrist to avoid effort.

Legs are next and last. Expect to do Seated – or angled supine – Adduction and Abduction as well as Seated Leg Extensions and maybe Leg Curls. You’re a lucky little guy if there is also a Seated Calf Raise and a Leg Press. A circuit is not generally meant to challenge to the extent or even in the same way as a full-blown 45-set work-out, so three leg machines are really enough. Lunges and squats are “on on your honor.” Crunches can wait.

Okay, you’re done. But if you did only one set of the circuit, take a 60-second break, not a 5-minute text conversation with your broker, and do the circuit again. People tend to monopolize equipment at the gym, especially cardio equipment, but the circuit may be popular, too. So you may just want to claim each machine in its turn and hang onto it until you’ve completed your two or three sets of each. Then when your legs are finished – and they WILL be – you can wobble in and out of the shower, hide your coif under a scrub cap, and take a non-circuitous route to the hospital without looking back.

To learn more about exercising with safe, efficient form, visit Liz at www.bdyfrm.com.

Read Lizlines and the weekly Lizlimerick posted Monday through Friday every week of the year.

Clinical Topic: Malignant Hyperthermia Review

Highlights of Malignant Hyperthermia

Early in our Anesthesia training, we were all taught about the dreaded Malignant Hyperthermia. As we settle into clinical practice, we all remember that MH is a potential risk but give it very little thought. SRNA Ola Akigbogun, from the Mercer University School of Medicine Nurse Anesthesia Program has offered the following review for procrna.com readers. The bullet format allows us to quickly review the highlights of treating MH. Ola will graduate in the fall of 2012. Read his profile and contact him if you are looking for a new graduate who is a motivated and committed to excellence.

Definition

Malignant Hyperthermia is characterized by an acute metabolic state in muscle tissue following induction of general anesthesia and in the post operative phase of anesthesia.
Malignant Hyperthermia is rare 1:15000 in pediatrics and 1:40000 in the adult population.
Most common in pediatric cases.
Patients with mild to moderate MMR, King Denborough syndrome, Duchenne’s muscular dystrophy, Central core disease and Osteogenesis imperfecta are usually susceptible to Malignant Hyperthermia.

History

First formal description in 1960 by Denborough and Lovell
The first case report allowed for a very solid understanding of the pathophysiology of Malignant Hyperthermia. The patient was a young man who stated that his relatives died without any apparent cause during anesthesia.
This patient was anesthetized with halothane and developed tachycardia, hot sweaty skin, and cyanosis. The early recognition of this symptom saved him and lead to the further research and developments of Malignant Hyperthermia
In 1970 many of the clinical symptoms of MH were reported
In 1970 Kalow et al suggested the development of an in vitro diagnostic test which involved the exposure of biopsied muscle to caffeine and Halothane.
In 1975 Harrison reported that dantrolene was successful in the treatment of MH.
MH registry in the United States in the late 1980’s
In 1985, Lopez and His colleagues demonstrated that intracellular calcium concentration was increased during an episode and that dantrolene was successful in its reversal.
In 1990’s molecular biological techniques where applied to identify genes that are susceptible to MH.

Pathophysiology

Triggered by Succinylcholine and halogenated agents in greater than 80% of reported cases.
Why malignant hyperthermia does not occur after every exposure to halogenated agents is not fully understood.
Malignant Hyperthermia is believed to occur due to an uncontrollable increase in the intracellular calcium in skeletal muscle. The sudden release of intracellular calcium removes the inhibitory properties of troponin which results in intense muscle contraction.
Increased adenosine triphophatase activity results in an uncontrollable increase in aerobic and anaerobic metabolism. The severe hypermetabolic state created is responsible for increase oxygen consumption and CO2 production leading to severe lactic acidosis and hyperthermia.
It was first believed that the abnormal ryanodine Ryr1 receptor in patients with MH was responsible, but further studies have shown that MH pts may have a normal ryanodine receptors and that abnormalities in secondary messengers such as fatty acids may be the problem. An abnormal sodium channel may also be responsible for malignant hyperthermia.

Triggering Factors

Halothane
Enflurane
Isoflurane
Desflurane
Sevoflurane
Succinylcholine

Signs of malignant Hyperthermia

The earliest sign and symptom that will present is an increase in ETCO2. ETCO2 can occur due to other reasons, but when other problems are ruled out treatment of MH should begin.
Other additional early signs include tachycardia, tachypnea, and rigidity of the masseter muscle called trismus. However, trismus often occurs with pediatric patients, in particular when intubating, so this sign must be taken into consideration with all other signs and symptoms.

Late Signs

Unstable blood pressure, cyanosis and/or mottling of the skin, diaphoresis, cardiac dysrhythmia
Hyperthermia. The patient’s temperature may elevate as much as 1-2°C every five minutes.
Hyperkalemia, Hypernatremia, Metabolic acidosis, Hyperphosphatemia, elevated CK levels.
Dark red blood in the surgical field
Myoglobinuria

Malignant Hyperthermia Protocol

1. Immediately discontinue anesthesia, including Succinylcholine. Life-threatening surgery will be continued, but with the use of a different anesthetic agent and machine to prevent residual inhalation agent from triggering a second episode.

2. Hyperventilate 100% oxygen at a high flow rate of 10L/min. to treat effects of hypercapnia, metabolic acidosis, and increased oxygen consumption

3. Dantrolene 2.5mg/kg IV as soon as possible; given every five minutes until symptoms subside.

4. Change ventilator tubing and soda lime canister. Some anesthesia providers may still perform this action, but research has shown that it is not necessary to change the breathing circuit and anesthesia machine since the oxygen delivery rapidly clears the machine of the anesthetic gases.

5. Sodium bicarbonate 1-2 mEq/kg IV to combat metabolic acidosis due to increase of lactate in the circulatory system.

6. Ice packs Apply to groin area, axillary regions, and sides of neck – where major arteries are located.

7. Iced lavage the stomach and rectum with cold fluids to lower temperature. It is recommended not to lavage the bladder since the fluids can alter the true amount of urine being excreted by the patient and alters measurement of output.

8. Mannitol or furosemide Muscle cells are destroyed during an MH crisis and the myoglobin that is released accumulates in the kidneys, obstructing urinary flow, referred to as myoglobinuria. Diuretics are given IV to promote and maintain urinary flow in order prevent renal damage. Mannitol 0.25g/kg IV; furosemide 1mg/kg IV; up to four doses each. Urinary output of 2ml/kg/hr or higher must be maintained to prevent renal failure.**skip this step if dantrium IV is used because it contains 3g of mannitol.

9. lidocaine to treat arrhythmias secondary to electrolyte imbalances. Procainamide removed due to practitioners not beeen familiar with the drug.

10. Dextrose and insulin Treat hyperkalemia due to the release of potassium into the circulatory system as muscle cells are destroyed. Dextrose 25-50g IV; regular insulin 10 units in 50ml of 50% dextrose in water given IV.

11. Monitor urine output Insert Foley catheter if one is not in place

12. Monitor electrolyte levels Blood samples taken every 10 minutes to measure sodium, potassium, chlorides,calcium, phosphate, and magnesium levels.

13. Perform clotting studies

14. ABG Every 5 to 10 minutes

15. Arterial blood pressure Insert line if one is not in place

16. Central venous pressure Insert line if one is not in place.

17. Pt should be monitored in PACU for at least 4 hours then transferred to ICU for 24-72 hrs monitoring.

Dantrolene

Hydantoin derivative which intereferes with muscle contraction by binding to the RYr1 receptor and inhibiting calcium ion release from the SR.
2.5mg/kg IV every 5 mins until episode is terminated. Upper dosage is 10mg/kg
Dantrolene is packages in 20mg vials and it is to be reconstituted with 60ml of sterile water. The reconstitution can be very time consuming
Half life is about 6 hrs.
Recent studies show that prophylactic use of dantrolene can increase muscle weakness and is not indicated. The anesthesia provider should proceed with the use of non triggering agents
36 vials of dantrolene should be made available upon diagnosis of MH

References

http://www.jci.org/articles/view/34006/figure/
http://www.agd.org/support/articles/?ArtID=5258
Malignant Hyperthermia Association of the United states. http://medical.mhaus.org/
Clinical Anesthesia by Barash et. al 5^th edition
Clinical Anesthesiology by Morgan et. al. 4^th edition

CRNA Fitness: Calories Count

If you’re really serious about taking off those last ten pounds or just improving the way you eat, use a calorie log. Daily calorie logs provide a source of personal accountability and act as a learning tool. Balancing calories IN and calories OUT will guide you to your goal.

A calorie log should include what you consume, as well as how much you consume, and how often you consume it. And a really good log starts with what you planned to eat and then what actually passed your lips and took the dive. There are numerous online logs to choose from, but building a calorie-log of your own personalizes it and makes it work just for you.

You can develop a short excel food log that takes no more than 15 minutes per day to fill out. Provide spaces to note the date, the time of day that you ate, and, of course, your daily totals. Develop your columns to allow space for food measurements and food descriptions, like poached pears, frozen edamame and fresh tuna. Your excel program has the capacity to total your calorie intake automatically which removes the responsibility from a mind and body on operation overload.

Include a column or block for logging calorie output which applies to cardio, strength-training and power walks. Estimate a calorie per minute for all cardio and adjust upward or downward for maximum or minimum level of exertion. Estimate half that for strength-training. Even though your heart rate and metabolism are elevated after cardio, strength-training immediately afterward doesn’t burn calories at the same rate as non-stop, heart-challenging cardio exercise. When you spend eight to 14 hours a day standing or leaning against your anesthesia chair and turning your head to follow a monitor, your eyes burn and your brain fries, but calories do not. You don’t get to subtract 1 calorie per minute for sitting.

Tweak your excel program to include issues unique to you. Do you want to know what percent of your calories were wasted? Relegate all non-fructose sugars, added fats, junk foods, non-nutrient beverages and excessive or unnecessary foods to the “wasted” column. Then divide wasted calories by gross calories to get the % of should-have-had-something else calories. Do you have GI issues? You may want to have a block on your log that represents how often you fully empty. There will be a relationship between what you eat, how much you eat and how well your GI system functions. How many meals did you eat at a restaurant or inhale on the fly? How many desserts did you consume? Do you drink enough water? Throw in a log block for number of glasses of unenhanced water you drink daily. Do you walk the stairs instead of taking elevators and do you do a lunchtime walk? I have clients who wear pedometers at work in order to track how active they are, a great way to remind yourself to use stairs, to go for 15-minute walks, and to lunge down hallways between patients…unless you’re working on kids, which will keep you running all day! Add a log block for calories burned during your normal daily activity, but don’t subtract it from your gross total. After all, most of our bodies were designed to get a leg up.

It is generally accepted that 3500 calories equals a pound, lost or gained, so to lose a pound, you need to consume fewer calories than your body needs for function. Since you do not actually know how many calories you require, simply take in a few hundred less per day than you usually do. If you want to ditch 10 pounds, reduce your normal daily intake by a couple hundred. If you are morbidly obese – isn’t that a lovely admission of sin? – you will need to drop several hundred unnecessary calories per day, maybe a 1000. But, if you are seriously overweight, the bonus is the rapid, safe weight loss you will enjoy right up front. Thinner people will lose much more slowly, but they get to adjust their intake less dramatically, too. Beware of the RDA recommendations when planning your food day. It does not take 2000 calories to run a 5’4”-female body for 24 hours. In fact, it doesn’t take 2000 calories to maintain a 6’-male body that isn’t active. In further fact, if you eat a nutrient-dense, mostly plant-based diet, it is nearly impossible to consume 2000 calories per day without bloating into a state of flatulent, comatose exhaustion.

At the end of each day, total your column of gross calories(food intake). Add your blocks of expended calories(cardio, strength training, strenuous sport activity). If you’re figuring percent of wasted calories, now’s the time. Then subtract output from intake for the total net calories. Your net should be noticeably less than your intake used to be, and your weekly reduction should be around 3500 to lose one pound. Eight to nine-hundred well-balanced calories is safe for most women and nine to eleven-hundred net works well for average men. Don’t forget: Fried chicken is not the same as grilled chicken breast; broccoli with cheese is not called fresh broccoli; ¼ cup of granola is not ¼ cup plus several-bites-while-measuring; and trail mix with fruit is not an apple. Be honest.

Using a food log gives you control over your daily nutrition plan and your weight loss. By writing down each and every item, you take charge of what you’ve planned and responsibility for what actually went down. The log will reveal to you what works and what doesn’t, when you’re really hungry and when you simply indulge. And it will also give you a sense of power over an issue that used to leave you feeling powerless. To get your power back AND lose ten pounds, count your calories because calories do count.

You can visit Liz online at www.bdyfrm.com where “…a fit body is a friend for life.”

Clinical Topic: Defenses to Negligence

In earlier articles, I discussed some basics about medical malpractice. Now I want to briefly review some defenses to negligence. Keep in mind that all negligence claims are not credible; and even if a credible claim exists, there are many avenues to resolution. If the required elements of negligence are present and cannot be contested, defenses to negligence may be considered.

One method for mounting a defense to medical malpractice is to assert that the plaintiff caused their own injury, and because of the plaintiff’s action the defendant should not be held liable for the injury. A jurisdiction that recognizes contributory negligence would bar recovery by the plaintiff if the plaintiff is found to have contributed to the cause of his injury. A jurisdiction that recognizes comparative negligence (of the plaintiff) would decrease any award for a plaintiff’s claim based on the amount of fault the court determines the plaintiff contributed to the injury. Additionally, if the defense can establish the plaintiff knew the risks involved in an activity and voluntarily performed the activity, then assumption of the risk might be the appropriate defense to relive the defendant of liability. Adherence to these theories is ascertained by reviewing relevant case law in the applicable jurisdiction, and review of relevant statutes in the applicable jurisdiction.

Consider this example: Priscilla Patient arrives at Sunshine Valley Ambulatory Surgical Center (ASC) for a laproscopic appendectomy. After completing and signing all of the required forms in the admitting office, Priscilla is led to the dressing room to disrobe and to change into her gown for surgery. Priscilla disrobes leaving only her underwear remaining under the gown. As Priscilla gathers her belonging and opens the door to exit the changing room, Priscilla’s right great toe makes contact with the door of the dressing room. The contact doesn’t initially bother her so she doesn’t tell anyone about it. The next day, during the follow-up post-operative call, when asked if she has any questions or concerns about her procedure the prior day, Priscilla states, “My surgery went fine, but my right big toe is really hurting where the door hit it. Now it’s swollen and really hot.”

This example is hypothetical. However, at this point many options can occur. If Priscilla decides to sue the ASC for her injured toe, all of the required steps (such as fact gathering and determining if the claim is credible) will begin to be pursued by her legal team. In a claim of negligence against the Sunshine Valley ASC, if a defense to negligence for a claim like this were considered, it is reasonable to suggest that Priscilla had something to do with the injury that she now has because she didn’t tell anyone about it when it occurred. If a court believed that proposition, any award to which Priscilla may have been entitled to would be either barred in a contributory negligence jurisdiction, or reduced in a comparative negligence jurisdiction. If the defense can establish that Priscilla chose to exit the dressing room without foot coverings, knew she was injured before she had surgery, and before she left the facility, and she chose not to inform medical personnel who were readily able to assess and treat any injury if any were present, then assumption of the risk might be the choice to rebut Priscilla’s claim of injury to her toe. The legal team will evaluate the facts of the case and apply the law as indicated.

Pamela Chambers, MSN, CRNA, EJD

About the author: Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted. Click here to learn more about Lex Terrae Legal consulting services.

Clinical Topic: Propofol Related Infusion Syndrome (PRIS)

Propofol Related Infusion Syndrome (PRIS) is typically associated with metabolic acidosis followed by cardiovascular failure. The condition is most commonly reported in ICU patients who require long term sedation. As the incidence of PRIS increase, so do the number of case reports and studies published in the literature.

An excellent review by Fudickar and Bein published in Minerva Anesthesiol offers a historical perspective and details pathophysiologic changes that occur when propofol in infused over a prolonged period of time. The authors describe cytolysis of cardiac and skeletal muscle as being central to the problem. Mitochondrial fatty acid metabolism impairment was implicated. Patients with a low carbohydrate supply, such as children, are at increased risk for developing PRIS. The authors state that their protocol limits propofol to no more than 4mg/kg/hour for long term sedation.

The question arises as to whether or not we place our patients at risk by using TIVA for general anesthesia. Children receive up to 9 mg/kg/hour for up to 4 hour procedures and infusion rates of up to 30mg/kg/hr have been reported when TIVA is used in adults. Are we placing our patients at risk?

An article by Guitton et al published in Neurocritical Care describes the development of PRIS in an adolescent with status epilepticus who received propofol sedation for seizure control. The patient developed a metabolic syndrome with rhabdomylitis after 58 horus of propofol at 8.8mg/kg/hr. Cardiac arrest followed and extracorporal membrane oxygenation was required.

Various articles agree that PRIS is related to dose and length of time that propofol is administered. In the ICU, long term dosage should be kept below 4-5 mg/kg/hour. In the operating room when higher doses are required, the anesthetist should consider stopping the TIVA as soon as it is no longer absolutely required for the procedure. During the procedure, be aware of the dosage you are giving and try to limit it to the lowest effective dose.

Review the articles that this posting links to and then come back and tell us about your experience and recommendations for TIVA

Meeting Review: NWAS, Las Vegas

The following review was submitted by a CRNA attending the recent January 2012 Northwest Anesthesia Seminar in Las Vegas. Procrna.com thanks you for the posting and encourages others to send reviews when they attend meetings.

Date: 1/23/12

Meeting strengths: Interesting topics & speakers. NWAS does a great job recruiting their speakers & provides great information on updates regarding anesthesia practice. The Las Vegas meeting is one of the most popular & it’s a great location! The speakers in January focused on ASC guidelines & updates for discharge. Current recommendation is that the patient does not need to void or drink before being discharged. The L&D and positioning portion of the lectures were week. They also shared good information on pediatric anesthesia & new information on robotic anesthesia. Dr. DeSoto was a great speaker!

Suggested improvement: I would like to see more information on what we as providers can do during our current drug shortages. Also, there was very limited information on difficult airway management which is always a great topic to revisit during CME conferences.

Overall value for the money: Great value for your money if you like Las Vegas. I would not suggest it to anyone who was not interested in visiting Las Vegas. Lots of food, great shows, shopping, gambling, and people watching!

NWAS did a great job scheduling the meeting with two days starting & ending in the morning and the other 2 days starting in the afternoon & ending in early evening.
Paris hotel is in a good location to other things on the strip. The conference rooms were comfortable & the food they provided was great.

CRNA Fitness: Make the Most of Your Meeting

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 2^nd and 12^th, 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.

Meeting Review: Emory University New Horizons

Emory University is proud to announce two upcoming meetings

The first meeting is New Horizons in Anesthesiology in Big Sky, Montana, March 11-16, 2012. We have been running a ski meeting for 24 years. This particular meeting will include topics such as the effects of anesthesia on sleep, patients’ memory as well as patient awareness. Issues pertaining to clinician efficiency and productivity as well as topics relating to staff motivation and practitioner fraud and abuse will be discussed. This course will offer 22 CE credits for CRNA’s.

Big Sky Resort is located in southwestern Montana, just north of Yellowstone and Grand Teton National Parks. Big Sky offers instant access to some of the most diverse skiing and snowboarding amongst breathtaking vistas in the lower 48. Beautiful scenery, abundant wildlife, and gracious hospitality make Big Sky Resort Montana’s premier ski destination.

Our 2nd meeting New Horizons in Anesthesiology – Cozumel, Mexico April 15-20, 2012 in its 13th year will cover topics such as the role of clinical pharmacology in legal cases and allergic and anaphyllactoid reactions. Comparative opioid pharmacology and pharmacologic approaches to managing perioperative hypertension, including information on new clinical trials and discussions on the identification and treatment of the patient at risk for severe postoperative pain will be presented. This course will offer 22 CE credits for CRNA’s.

The meeting will be held at the Presidente Intercontinental Cozumel Resort & Spa. This beachfront hotel offers the perfect blend of accommodations, service, meeting and recreational facilities. Jacques Cousteau declared Cozumel “one of the most beautiful scuba diving areas of the world”. You can leave from the dock of the hotel for daily scuba diving.

Click here for information about the meeting agenda and registration

After you attend the meeting, return to www.procrna.com and leave a comment. Let your colleagues know about your experience

Meeting Review: MUSC, Charleston, S.C.

2012 marks the 25th anniversary of this conference. Enjoy a variety of topics (20 hourse of CE) with a fantastic speaker panel including Debbie Mailina, AANA President, Christine Zambricki AANA Deputy Executive Director, Jackie Rowles Past President talking about Pain and many more.

If you like history and good food, visiting Charleston, SC is always a treat. We have plenty of both and the first week of May is a great time to visit and explore.

Join us in Charleston South Carolina May 4-6 for a great meeting and a memorable experience.

Click here for more information or to register on line. After the meeting, make a comment on procrna.com and share your experience with your colleagues.

Clinical Forum: Evidence Based Management

“Show me the money” “Where’s the beef?” Health care delivery has evolved over the past few decades to evidence based practice. With the emergence of new drugs, techniques, and regulations health care providers are demanding “where’s the evidence”. In our quest for evidence to guide our medical resource management, we often overlook the fact that our personnel are the most important resource that we manage.

An excellent article by Vicki Hess, RN published in Hospital and Health News (Jan 19, 2012) encourages evidence based management as a tool for increasing employee satisfaction and productivity.

In the article, Vicki states that in recent years, scholars have studied and written about evidence-based leadership and evidence-based management. A logical progression in this thinking is evidence-based employee engagement. Employees are engaged when they are satisfied (they like what they do), energized (they put effort behind it) and productive (their work contributes to organizational goals). Leaders who are effective in engaging others are facilitators of the engagement process. Because no one external source can motivate an employee, providing an environment that encourages intrinsic motivators is critical.

The article continues with the concept that employee preferences are an important but often overlooked factor in department management. Engaged managers are in touch with employee preferences and make personal contact with employees on a daily basis.

She concludes that by adopting an evidence-based employee engagement approach that combines current engagement research, leadership insights and employee preferences, leaders can positively impact important business results without subtracting from the bottom line.

Click here to read the excellent article by Vicki Hess, RN

Clinical Forum: Propofol dose in the Obese Patient

As the American population grows both in number and size, anesthetists are challenged with selecting the proper dose of drugs. Some believe that doses should be based on actual body weight while others believe that calculating a dose based on lean weight or ideal weight are better options. In this study published in Anesth Analg. 2011 Jul;113(1):57-62. Epub 2010 Sep 22, Ingrande J, et al compared the induction dose of propofol in obese patients using actual weight and lean body weight.

The authors found that patients receiving propofol based on actual body weight received a larger total dose and shorter time to loss of consciousness. When given based on lean body weight, patients had similar time to loss of consciousness. The authors concluded that lean body weight appears to be the most appropriate plan for dosing propofol in the obese patient.

Click here to read the original abstract of the work described in this post. Return to www.procrna.com and leave a comment.

Clinical Topic: National Nurse Anesthetist Week

Every year the last full week in January is designated as National Nurse Anesthetist week. This is our opportunity to capture media coverage and let the world know who we are and what we do. PROCRNA.com encourages you to offer “CRNA for a day” to your local nursing school. Welcome students at the head of the table as they rotate through the operating room.

The picture on this posting and the suggestions below come directly from the AANA web site. Click here to view the original posting from the AANA.

National Nurse Anesthetists Week Ideas

There are countless possibilities for promoting your profession during National Nurse Anesthetists Week, January 22-28, 2012. Have you considered the following?

1. Legislative Day. Invite your state legislators to a breakfast or coffee at a gathering place near the state capitol, or recruit state association members to pay a visit to your legislators’ offices.

Many state associations have had success with legislative days in years past. If you are interested in organizing a legislative day for your own state association, be sure to contact your state lobbyist for input on state rules and regulations concerning giving gifts to, entertaining, and lobbying legislators.

Community Calendars. Contact your local newspapers and radio/television stations and ask to have your National Nurse Anesthetists Week activities included in their Community Calendars.

Proclamations. Some states are already contacting their legislators, governors, and community leaders to have the week of January 22-28, 2012, publicly proclaimed as National Nurse Anesthetists Week. Try contacting the appointment secretary at the state capitol or governor’s office for information on how to proceed. (See the sample proclamation included in this section of the website.)

Career Days. Contact local junior high schools and high schools, junior colleges, and colleges/universities regarding speaking and exhibiting opportunities to promote careers in nurse anesthesia.

Public Speaking. Opportunities for public speaking are limitless. Contact your chamber of commerce, community center, high school, park district, local chapters of professional associations, or clubs, to name a few possibilities. Or stay closer to home and arrange to give a presentation at the hospital or healthcare facility where you work. Target the general public or specific market segments like senior citizens, other healthcare professionals, expectant mothers, etc.

Billboards. For previous Nurse Anesthetists Weeks, a few states purchased billboard advertising space and reported great results. The Delaware Association of Nurse Anesthetists borrowed from the 2005 Nurse Anesthetists Week materials (“How Do You Say Quality Anesthesia Care?”) to create a billboard that appeared along a busy highway during Nurse Anesthetists Week 2006. AANA has some information concerning billboards that is available upon request. For more comprehensive information, however, search “billboards” on the Internet. Also, if you would like to find out more about DANA’s billboard project, contact Del Price, Jr., CRNA, MSN, via email at delsleeper@aol.com.

Table-top Displays. Obtain permission from your hospital, ambulatory surgical center, or physician’s office to set up a table-top display during National Nurse Anesthetists Week. Put out brochures, giveaways, and a bowl of candy, tack up a poster or two, or get more elaborate and run the videotape The Best Kept Secret in Healthcare: Certified Registered Nurse Anesthetists, which is available through the AANA Bookstore.

Educate Acquaintances about CRNAs. Make it a point during Nurse Anesthetists Week to explain to as many family members, friends, patients, and others as possible, exactly who you are and what you do. The world needs to know, and you are the best ambassador to deliver this message on a one-to-one basis. In fact, make delivering the message part of your daily routine.

Phone-System Message. Obtain permission to record a message about CRNAs and Nurse Anesthetists Week on your hospital’s phone system. When callers to the hospital are put on hold, they will hear the educational/promotional message.

Cinema Ads.
The following information consists of generalized pricing that may vary depending on the number of movie screens at your local cinema complex. For instance, if the cost to show a 30-second public service announcement during the 20 minute preview portion of the movie were $40 per screen, and the theatre has 20 screens, it would cost a total of $800 per week to advertise in that theatre. However, if the theatre complex has four screens, the cost would be $160 per week. In addition, most theaters show an ad for an average of four times per day (at no additional cost), and there may be a one-time cost to digitize the ad. Most theatres contract with a third part company who handles all of their advertising. National CineMedia places advertising in the following movie theatres: AMC, Regal, Century, United Artist, Edwards, and Cinemark. The contact number is 1-800-828-2828. Please call for current figures.

11. Magazine Covers. Northeast Medical Center in Concord, N.C., won an honorable mention in the 2003 PR Recognition Award contest for creatively educating patients and their families about nurse anesthetists. The CRNAs there purchased magazine subscriptions for the hospital’s waiting rooms, and placed each issue of the magazines in clear, protective plastic covers. On each cover they then placed a large sticker that stated the magazines were compliments of the anesthesia department and provided information about nurse anesthetists. The information was read by countless people throughout the year.

Special thanks to those CRNAs who offered ideas and suggestions for Nurse Anesthetists Week. Additional ideas and suggestions are always welcome! Please send to Christopher Bettin, AANA Senior Director of Communications, at cbettin@aana.com.