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Clinical Topic: Ethanol intoxication, Brain injury and outcome

All CRNAs who take call in a medical center have had the challenge of caring for the intoxicated driver who arrives at the Hospital with a head injury. Imagine that both drivers sustained a traumatic head injury. One driver was intoxicated and the other was completely sober. Which driver is more likely to have a better outcome?

A study by Lustenberger, T, et al published in the Journal of Neurotrauma looked at outcomes of patients with traumatic brain injury. The aim of this study was to determine the impact of ethanol (ETOH) on the incidence of severe traumatic brain injury associated coagulopathy and to examine the effect of ETOH on in-hospital outcomes in patients sustaining sTBI. The incidence of admission coagulopathy, in-hospital complications, and mortality were compared between patients who were ETOH positive and ETOH negative.

The authors found that coagulopathy was significantly less frequent in the ETOH (+) patients compared to their ETOH (-) counterparts

For brain-injured patients arriving alive to the hospital, ETOH intoxication is associated with a significantly lower incidence of early coagulopathy and in-hospital mortality.

Click here to read an abstract and link to the original article by Thomas Lustenberger.

CRNA Fitness: Cardiovascular Exercise

Cardio is probably the most common form of structured exercise in America.

In the 1960’s Dr Kenneth Cooper, the founder of The Cooper Institute in Dallas, TX, introduced aerobic exercise to the fitness world and made cardio a common household word. Cooper soon after became crowned the “king of hearts.”

Cardiovascular or aerobic exercise is any structured exercise that elevates the heart rate for a sustained period of time such as jogging, power walking, elliptical training, treadmill walking, and lifecycle pedaling and is essential to any quality fitness program. Not only does aerobic exercise strengthen the heart, it raises the metabolism, which burns calories, which helps you lose or maintain weight, not to mention releasing feel-good endorphins which makes you feel good to be around. And you’ll notice that someone who has just completed a cardio work-out doesn’t usually slouch out the gym door..they hustle out. Cardio is better than Boost for raising your level of energy and it’s lower in calories, too.

To get the most out of your cardio, allot a specific amount of time, start out a tad slowly, then pick up the pace, sustaining a challenging speed for the majority of the work-out. Turn on your i-pod or watch a video flick, but take mental time to focus on form and breathe smoothly, with rhythm. Did I mention water? Drink before, drink during, drink after. You do not need any beverage other than cool water for normal work-outs. Remember, you’re trying to burn calories, not drink them. Allow a two to five-minute gradual cool down, wipe up the sweat and stretch. It’s okay to stretch before the session begins, but you won’t be warm enough to do a great job of it. Better to simply be fully awake, get a few calories from an orange or tiny bowl of oatmeal, get partially hydrated and “hit the road.” If you’re really slow at getting warmed up, you can stop after five minutes to stretch before continuing, especially if you’re on pavement, otherwise, five to ten minutes of long leisurely stretching following your cardio is ideal.

Stay off the pavement if you have bad knees, wear padded pants if you cycle, don’t carry anything heavy when you power walk, make like a camel for all cardio, and burn, Baby, burn. You, too, can be crowned the King and Queen of Hearts.

You can visit Liz at www.bdyfrm.com where the unique, informative and entertaining Lizlines are posted Monday through Friday. Don’t miss the weekly Lizlimerick, always a Liz original!

Clinical Topic: Controlled Substances and State Law

CRNAs are certified as qualified to practice by the Council on Certification and Recertification of Nurse Anesthetists. In addition, they must be licensed to practice nursing by the state in which they practice. Questions often arise regarding prescriptive authority and the legal ability to use controlled substances in our daily practice. Laws vary from state to state. Below is an excellent review of the Law of the State of Texas prepared by Pamela Chambers, CRNA. Contact Ms Chambers at Lex Terrae consulting if you have questions about the laws in your state.

Submitted by Pamela Chambers, MSN, CRNA, EJD

Every year new laws become effective that affect all of us. Some are so obscure that we never become aware of them – unless we violate them. As mentioned in earlier articles, ignorance of the law is rarely a defense to violating it. Two recent legislative changes (i.e. new laws) that affect nurse anesthesia practice are the new consent requirements and the controlled substance program requirements.

Title 25 of the Texas Administrative Code (Health Services) Part 7 (Texas Medical Disclosure Panel) Chapter 601 (Informed Consent) codifies the requirements of the Texas Civil Practice and Remedies Code, Chapter 74, Medical Liability, Subchapter C, section 74.102. In English: the new consent rules are laws that further explain the law regarding medical liability in Texas. The importance of this cannot be overstated. The new consent procedure, requiring a specific form to be completed and signed by the anesthesia practitioner, is a law. This is not “just another rule” designed to test our memory of rules. This new law was likely the result of changing health care realities (i.e. such as the patient who awakens from surgery having had procedures that were necessary but not specifically discussed prior to induction). When society changes we have the ability to change our laws to reflect the will of the electorate, and the good of society.

In an effort to protect society by controlling dissemination of federally controlled substances, the Texas Department of Public Safety (DPS) requires registration of all individuals who possess a DEA# for the purpose of prescribing, or dispensing controlled substances in the state of Texas. As with many of our laws in every state of the union, this instance derives from federal law.

In the State of Texas, relevant guidance pertaining to controlled substances is found in the Controlled Substance Act; Title 21 United States Code (USC) sections 801-971 (specifically sections 821-829); Department of Justice Drug Enforcement Agency (DEA) Clarification of Registration Requirements for Individual Practitioners 21 Code of Federal Regulations (CFR) Part 1301; and Texas Occupations Code Title 3 Health Professions Subtitle B Physicians (“medical practice acts”) Chapter 157 Authority of Physician to Delegate Certain Medical Acts.

Additionally, registered nurses are governed by the Texas Occupations Code Title 3 Subchapter E Regulation of Nursing (“nurse practice acts”) Chapter 301 Nurses. Section 301.154 section (a) states the following: Rules regarding delegation of certain medical acts. (a) The board may recommend to the Texas State Board of Medical Examiners the adoption of rules relating to the delegation by physicians of medical acts to registered nurses and vocational nurses licensed by the board. In making a recommendation, the board may distinguish between nurses on the basis of special training and education. Further, chapter 222 of the Texas Board of Nursing Rules and Regulations relating to Nurse Education, Licensure, and Practice states that for approval of prescriptive authority, an RN shall “have full licensure from the Board to practice as an advanced practice registered nurse” and submit an application with evidence of successful completion of specific graduate level courses.
Subsection 157.0511 of the medical practice acts indicates the following: Prescription Drug Orders (a) A physician’s authority to delegate the carrying out or signing of a prescription drug order under this subchapter is limited to: (1) dangerous drugs; and (2) controlled substances to the extent provided by Subsection (b). Subsection (b): A physician may delegate the carrying out or signing of a prescription drug order for a controlled substance only if: (1) the prescription is for a controlled substance listed in Schedule III, IV, or V as established by the commissioner of public health under Chapter 481, Health and Safety Code… (4) (b-1) The board shall adopt rules that require a physician who delegates the carrying out or signing of a prescription drug order under this subchapter to register with the board the name and license number of the physician assistant or advanced practice nurse to whom a delegation is made. The board may develop and use an electronic online delegation registration process for registration under this subsection.
(c) This subchapter does not modify the authority granted by law for a licensed registered nurse or physician assistant to administer or provide a medication, including a controlled substance listed in Schedule II as established by the commissioner of public health under Chapter 481, Health and Safety Code, that is authorized by a physician under a physician’s order, standing medical order, standing delegation order, or protocol.

The Texas Department of Public Safety governs the Texas Prescription Program which regulates the dissemination of controlled substances to consumers in Texas. According to the DPS website, http://www.txdps.state.tx.us/RegulatoryServices/prescription_program/prescriptionforms.htm accessed January 12, 2012, “Every Official Prescription form, produced from January 1982 through the present, contains the practitioner’s DPS and DEA registration numbers, a unique control number and the DPS seal (as a watermark) on the face of the prescription. The modifications to the Official Prescription forms do not invalidate previously issued prescription forms. An Official Prescription form is considered valid if it contains the security features associated with that particular format/layout and the practitioner’s DPS Controlled Substance Registration number is current and valid.” Further, the DPS drug rules, subchapter D section 13.81 indicates specific actions to be taken if a prescription for a controlled substance is questionable, to wit: If a dispensing pharmacist receives an official prescription form that creates a substantial question or doubt in the mind of the dispensing pharmacist, the pharmacist must, before filling the prescription, communicate with the prescribing practitioner in order to resolve the question or doubt. Additionally, Section 481.061 Subsection 2 (h), of the Texas Health and Safety Code was amended to include the following rule “ A pharmacist may dispense a controlled substance listed in Schedule III, IV, or V under a written, electronic, oral, or telephonically communicated prescription issued by a practitioner defined by section 481.002 (39) (C) and only if the pharmacist determines that the prescription was issued for a valid medical purpose and in the course of professional practice…“

The available resources repeatedly indicate the requirement of the DEA# and registration in the DPS controlled substance registration program. Registrants in the Texas DPS controlled substance program may use the specified form which has the DEA# and DPS# preprinted on the prescription form. An advanced practice nurse who has satisfied all of the applicable state and federal requirements, may indeed prescribe controlled substances in Texas. However, an advanced practice nurse may also facilitate a prescription for controlled substances as a delegated duty from a supervising physician. In this capacity, the signature on the prescription form of an advance practice nurse acting on behalf of the supervising physician is the same as a valid signature from the prescribing physician. If, hypothetically, an error or omission is noted on a prescription form – the pharmacist has a duty as indicated in the above referenced statute to contact the prescribing provider to clarify the suspected error or omission.

Let’s use an example that may illustrate the importance of being aware of this law: Let’s say a CRNA has a DEA# because they have at one time practiced as a locums provider in an arrangement that required the individual CRNA have their own DEA# (i.e. without a supervising physician or “medical direction”); then the CRNA changes practice arrangements (i.e. relocates or takes another locums assignment) to a facility, which has its own DEA#, and permits advanced practice nurses practicing within the facility, (with or without “medical direction”), use of the facility DEA#……..Hmmm Such a set of facts might prompt a call from the DEA to inquire about your DPS number. Why? DEA #’s are specific not only to the provider to whom they are issued, but they are also specific to one facility or one state.

Keep in mind, our legislated laws are written for the masses. Thus laws that are designed to cast a very wide net, may inadvertently harm some of the small fish. Forewarned is forearmed.

Additional resource:
http://codes.lp.findlaw.com/uscode/21/13/I/C

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: Post-op Fluids for Children

The literature is full of studies related to postoperative nausea and vomiting. I once heard an Anesthesia instructor say “if I have one more student do a vomiting study, I’m going to puke”. Even so, PONV continues to be a problem and creative investigators continue to find new aspects to study.

A recent study by Mercan et al published in Paediatric Anaesthesia looked at the timing and temperature of the first liquid given after recovery from anesthesia. Different groups of Children were given a first liquid at different time intervals and different temperatures following recovery. Liquids were either at room temperature or at body temperature. The researchers found that children receiving liquids at body temperature had significantly less post-operative vomiting than children receiving liquids at room temperature.

Click here to read more about this study and their findings.

Meeting Review: Utah Association of Nurse Anesthetists

The Utah Association of Nurse Anesthetists (UANA) will hold an annual meeting on January 28, 2012. We will have national representation from the AANA (Debbie Malina, President) and the NBCRNA (Robyn Ward, Secretary/Treasurer). We will cover a variety of clinical topics including: New Drugs on the Horizon, Regional Anesthesia, Pediatrics, Surgical Stress, etc. In addition, we will hear from professionals whose lectures will focus on business and retirement practices. We are offering two breakout sessions which will allow you to select topics that interest you. Attendees who sign in at vendor tables will be entered into a drawing for two iPads.

Register online at uana.org or by mail. Contact April Blair if you have any questions at aprilblair@gmail.com. We hope to see you there.

CRNA Fitness: Procrna Fit-tips

Integrating healthy concepts into your life is like riding a tandem bike. It takes two participants and a bicycle that works. To meet the challenge of getting in shape this month, be sure to integrate both sound nutrition (see January posting) and efficient exercise into a quality plan. Once you have tweaked or completely revamped your daily diet and selected a venue for structured exercise, start supplementing your coffee break with some gentle stretches like slow, easy toe-touches to loosen hamstrings and relieve stress on the lower back. When the lunch-break-boy finally makes it into your room, take a few minutes in the lounge to do seated leg raises and neck rotations. And if some kind soul mercifully shows up to give you a potty break, take an extra minute to carefully lunge back down the hall on your way to relieve the reliever. As your 8-hour day stretches into 12, remember, careful stretching provides relief, while too much coffee requires it.

To read Lizlines and to view seated leg raises, click on www.bdyfrm.com.

Liz Sanner Davis is the owner of Body Firm Integrated Fitness Solutions. She is the author of Lizlines, posted each weekday on her web site.

CRNA Fitness: Nutrition

The Gas Range
By Liz Sanner Davis

Think of the food on your plate as Fuel. Think of the container it comes in as the Gas-can. And label the inside of your body as The Tank. At every meal you must carry the fuel in a gas can and deliver it unpolluted to the tank if you want to have enough gas to live life and to give life in the OR. When the patient is short on gas, he crumps. When you are short on gas, you crump. And when low-grade gas is delivered to the tank ( think paper bags with famous logos, cardboard boxes with grease-covered bottoms, and paper cups with sippy devices), you and your patient may both wind up driving on empty. During the month of January, try making this change in your nutrition habits at work. Bring fresh lunch foods to work prepared in your own kitchen – last night’s leftover salmon is a worthy protein, light yogurt and low-sugar granola, a crisp apple, a ripe avocado big enough to share are all perfect pick-me-ups. Or stack your own turkey sandwich made with whole grain bread, lettuce and tomato. Avoid saltyfoods from the cafeteria and resist the urge to send out Smiling Samantha for pepperoni pizza with stuffed cheese crust, “double-the-olives.” Fill your tank with superior grade fuel delivered in a pollutant-free gas-can. You’ll sustain two lives – yours and the patient’s.

Liz Sanner Davis is owner and trainer at Body Firm Integrated Fitness Solutions, Temple, TX. Visit Liz online at www.bdyfrm.com and read her humorous and motivational Lizlines or Lizlimericks published daily.

CRNA Today; Online CME for CRNAs

To enhance your CME experience, PROCRNA.com offers reviews of meeting attended by our readers. Several readers have requested a review of online CME. CRNA Today is an online CME offering for CRNAs. Read the review, visit their site, and return and offer your comments to your colleagues.

As described by the owners, CRNA Today is a CRNA owned, web based CME offering committed to delivering complete online education for CRNAs in a fresh and engaging way. The platform was created to deliver CE courses online and is centered around making continuing education easy and exciting. Instructors and editors have decades of practical experience as seasoned CRNAs. You can choose from multiple ways to access your course content. We’re committed to constantly updating and adding to our course selections based upon feedback from the CRNAs we serve.

Below is a testimonial from a CRNA who has used CRNAtoday.com to obtain CME credit:

“Your course had very good speakers and informative sessions in the comfort of my home computer. It was a godsend. Not only was it cost effective, but the time involved without leaving my home was wonderful. I would like to thank you for your help in guiding me through the process of taking the quiz at the end of the course. CRNAtoday is one of the best ways for crna’s with limited spare time from their families to get the credits needed every 2 years. Thank you and your staff who got this course off the ground for people like me.”

PROCRNA.com would like to hear from CRNAs who have used the CRNA Today CME program. Write a comment and let us know how it worked for you.

Click here to view CRNAtoday.com How does online CME work for you?

Obesity, The Airway & Good Positioning

Troop Elevation Pillow

Every anesthesia provider across the country cares for obese and morbidly obese patients. Numerous studies now support that the head elevated laryngoscopy position (HELP) facilitates intubation and in general improves airway management of the obese patient. The Troop Elevation Pillow (TEP) was designed by a practicing anesthesiologist to achieve HELP quickly and consistently yields a predictable and stable result. The TEP is meant to replace a pile of unstable blankets; click here to go to Dr. Troop’s teaching web site.

If you have experience with this device, please return after you view Dr. Troop’s web site and write a review for your colleagues.

CRNA Fitness: Selecting a Gym

Losing weight used to be numero uno on the News Year’s Resolution list but lately it’s given way to touchy, feely hopefulness charged with sentiment and inertia. In spite of the second-place status, ‘lose weight’ is a list-maker that will open gym doors and sell overpriced clearance tights…for about three months. Over 30% of the people who join a gym in January, will stop going by March, and may never return. If you are one of those who does follow through on your resolution commitment of losing weight, here are some tips for joining a gym and/or hiring a personal trainer.

The Goals

Establish your basic goals.

That means you may need to sit down at your computer and write down two or three well-defined things you intend to accomplish by joining, then select a gym that has what you need in order to achieve your written goals.

The Proximity

Locate a gym or trainer that is close to home or close to work or right on the precise route that you take to one or the other. If you have to go the least bit out of your way or have to stop at one light a little too long, you’ll be back under the covers in less than a month.

The Money

Gyms and fitness facilities are muy espensivo to operate so they want, they need your money. Still, wangle the best deal you can get. Three-month specials abound (‘cause they know you’re gonna quit in March!) and perks like a free trial visit, personal training packages, free classes, and guest passes are often an option. Accept an automatic withdrawal from your account ONLY if you fully understand the fine print in the contract. Yep! There will be a contract and you won’t get out of it easily in March…or June, either. Read, comprehend, then pay up and USE the place faithfully. Tip: Go as the guest of your buff and beautiful friend so you don’t have to listen to marketing hype first-time in the door.

The Machines and the Maintenance

Machines should be up to date and in good repair– you can tell by getting on one and using it or by counting the number of signs on equipment that say Out Of Order. It doesn’t hurt to take note of the rips and tears in vinyl machine pads, the cracked or missing water holders on cardio machines, or single dumbbells now divorced from their partners. Check out the bathroom, the showers, the toilets – um-hmmm – and ask straight out how often the cleaning service marches their bucket brigade from ellipticals to lockers and beyond. There is no better place to get colds, flus and infected scratches and wounds than at a work-out facility. If you have to step over the spit on the floor next to the squats cage, move on dot com.

The Environment

How’s the music? Can you hear yourself think? Is this a meat market or a family fitness center? Do you recognize some people from work or bridge club? Do people behave respectfully and share equipment and clean up after themselves on the gym floor? Does Jocko Madzilla remove the 800 pounds of weight plates from the leg press when he’s finished and does Little Lucy Latte get off the elliptical promptly when her time is up without re-setting the timer when no-one’s looking? These observations take time so take that time to avoid being sorry.

The Members

Then, ask the members who are there if they are happy with the variety and supply of equipment, with the quality of classes and with the level of maintenance and overall professionalism. Discuss their payment satisfaction and what they like best and least about the facility. Find out if theft is a problem and how issues have been resolved. Observe the members as they arrive and leave, as they work out and socialize, as they interact with personnel and how they treat the place, ‘cause that’s how they’re going to treat you.

The Trainers

This is my area, Kids. I’m an integrated fitness trainer and I take this seriously. If you want a trainer whether short-term or long-term, do your due diligence as real estate people like to say. Look at other client’s results, interview more than one client to get their comments and interview more than one trainer to feel the fit. Inquire about credentials and certifications and if you’re at a gym, ask the gym leadership to tell you what the requirements are for trainers – eg, insurance, certifications, age and experience. Then observe at least one session and don’t look at the trainer’s biceps and glutes; look at the attention he/she gives the client, the focus, the total professionalism. If the client is grunting, pouring sweat and hobbles for three days after the session, run the other way while you have two good feet. Efficiency, form, and safety are tantamount and pushing clients too hard is a deal breaker. Make sure the trainer keeps good records of client progress and has some level of education in nutrition. Supplements of any kind are not necessary for achieving normal, healthy results, but trainers often earn mega extra income by selling them. If you find a high-quality trainer whom you trust and who guides you to your mutual goals, that’s the deal maker. Just offer her/him a good tip and consider yourself pumped!

A well-run fitness facility is a social mecca for exercise where you can pay for the opportunity to get in touch with your wellness and, therefore, your well-being. With precious little time and money to spare during this extended employment drought, do your homework before you slide your card then stick with your plan beyond the Ides of March.

Liz Sanner Davis is owner and trainer at Body Firm Integrated Fitness Solutions, Temple, TX. Visit Liz online at www.bdyfrm.com and read her humorous and motivational Lizlines or Lizlimericks published daily.

Distracted Health Care Providers

Hospitals across the nation have encouraged the use of computers, ipads, smart phones and other devices to improve the access of health care workers to information essential for safe patient care. Information about lab interpretation, drugs, and diagnosis are all readily available on line. In some institutions, the Anesthetist is encouraged to call or text the Recovery area prior to delivering a fresh post-op patient. It now appears that the use of technology can be a two edged sword.

In addition to the intended use of electronic devices to enhance patient care, there is increasing evidence that health care providers are becoming distracted from patient care. A front page article by Matt Richtel in the New York times titled “As Doctors Use More Devices, Potential for Distraction Grows?” tells of a Neurosurgeon taking 10 personal calls during a case in which the patient was harmed. An article in Perfusion magazine reported that nearly half of the perfusionists in a survey admitted to texting or making a personal call while the patient was on cardiopulmonary bypass. Other stories include Circulating nurses making airline reservations during a case as well as texting facebook friends.

Patient advocate Suzanne Gordon writes of the problem of distracted drivers using cell phones and notes that 15 states still do not have laws against texting while driving. When discussing the case of the Neurosurgeon making numerous calls during surgery, she asks “where were the other OR staff when this was going on?” She notes that the same people who are texting in their cars are now texting while doing patient care. Suzanne recommends that one person in the operating room be designated as the only person to have access to cell phones during the case.

The challenge for health care workers is to fix the problem themselves before congress or Joint Commission imposes new rules. We must remember that the welfare of the patient comes first and resist the urge to text, call, or surf the net while providing patient care.

Standards, the Expert Witness

Submitted by Pamela Chambers, MSN, CRNA, EJD

Click here for Lex Terrae consulting

As we all know, legislative bodies enact the laws that we must all abide by – whether we are aware of them or not. Ignorance of the law is rarely a defense to violating it, whereas professions set their own standards of care. Ignorance of the standard of care while not illegal, may be described as poor practice. But how does the public – or the courts, know what constitutes poor practices? How would a court determine the standard of care for nurse anesthesia practice in Temple, TX; or in Dallas, TX; or in Bay City, TX?

The United States Supreme Court held that expert opinion is only admissible when it is generally accepted as reliable the relevant scientific community Frye v. United States, 54 App.D.C. 46, 293 Fed.1013 (1923). The decision handed down in Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993) went a step further in clarifying that expert testimony must have a valid scientific connection to the issues of a particular case. So why is this important to know?

Upon review of Carolan v. Hill, 553 N.W. 2d 882, Iowa 996, the issue on appeal was the admissibility of expert testimony. The harm suffered by the plaintiff (Carolan) was ulnar nerve damage sustained during the administration of anesthesia for a surgical procedure unrelated to plaintiff’s arm. The trial court refused to allow the plaintiff’s expert witness testimony. The trial court relied upon its interpretation of the Iowa Code regarding who could establish standard of care. On appeal, the Iowa Supreme Court clarified the interpretation of the law in Iowa. The relevant code noted that a “person” qualified to provide expert testimony shall be so qualified based on medical or dental qualifications that relate directly to the issues in the case at bar. Furthermore, if the legislature had intended qualified individuals be restricted to physicians and dentists, it would have done so explicitly. In this instance, this issue was reversed (overturned the jury verdict for the defendant anesthesiologist) and remanded to the lower court. Plaintiff’s expert witness was a Nurse Anesthetist.

The Federal Rules of Evidence, rule 702, state the following with regard to expert witnesses: A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if: the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue; the testimony is based on sufficient facts or data; the testimony is the product of reliable principles and methods; and the expert has reliably applied the principles and methods to the facts of the case. This rule is based largely on Daubert, but has been amended and modified as other landmark decisions (such as Kumho Tire Co. v. Carmichael, 119 S.Ct. 1167 (1999) have been decided regarding expert testimony.

Daubert set forth a non-exclusive checklist for trial courts to use in assessing the reliability of scientific expert testimony. The specific factors delineated by the Daubert Court are (1) whether the expert’s technique or theory can be or has been tested—that is, whether the expert’s theory can be challenged in some objective sense, or whether it is instead simply a subjective, conclusory approach that cannot reasonably be assessed for reliability (i.e. an opinion); (2) whether the technique or theory has been subject to peer review and publication; (3) the known or potential rate of error of the technique or theory when applied; (4) the existence and maintenance of standards and controls; and (5) whether the technique or theory has been generally accepted in the scientific community. The Court in Kumho held that these factors might also be applicable in assessing the reliability of nonscientific expert testimony, depending upon “the particular circumstances of the particular case at issue.” 119 S.Ct. at 1175.

So what does all of this mean? How does affect your practice if it affects it at all? Consider this, when you make a decision as to which nondepolarizing muscle relaxant you will use (when you have a choice) ask yourself if the decision you’ve made is accepted practice. When you decide to conduct your anesthetic in a manner that you deem best for your patient, ask yourself if the methods that you use are (still) relevant and valid? If any of us are practicing the “way we’ve always done it”, ask yourself this question – Is this defensible in a court of law?

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.

Radiation Exposure to Anesthetists

Radiation exposure has long been a concern to Radiologists and their assistants. Lead aprons, thyroid shields and more recently leaded eyeware have reduced their exposure to radiation. Anesthetists are frequently assigned to sedate / anesthetize patients in the interventional radiology suite. Like the Radiologist, the anesthetist is exposed to radiation danger.

In a study by Anastasian, ZH, et al published in Anesthesiology, the facial exposure to radiation was compared between the Radiologist and the Anesthetist. Both providers wore lead aprons. The Radiologist wore leaded eyeglasses and stayed behind a leaded acrylic shield to the extent possible. The Anesthesiologist also was instructed to stay behind a leaded shield to the extent possible and to keep maximum distance from the source of radiation.

The authors of the study demonstrated that the Anesthesiologist had a 3 fold increase in facial exposure to radiation than did the Radiologist, thus increasing the risk of developing cataracts. Exposure of the Anesthesiologist was correlated to the number of pharmacologic interventions performed during the case.

The best ways to reduce exposure to radiation are distance and shielding. Lightweight leaded eyeglasses reduce exposure of the cornea by 98% and are recommended for those spending significant time administering anesthesia for interventional radiology

Click here to review the work by Anastasian, ZH et al.

Please return to this site and leave a comment

Anesthesia Awareness and the Bispectral Index

To BIS or not to BIS. That is a common topic for discussion in the anesthesia community. Unanticipated intraoperative awareness is a traumatic event for the patient with many developing post traumatic stress disorder. Anesthetists are challenged with providing safe anesthesia which includes the absence of recall by the patient.

The Bispectral Index was developed from technology related to the processed electroencephalogram. Claims are made that when the BIS value remains below 60 the risk of awareness under anesthesia is greatly reduced.

A study by Avidan et al published in the New Engl J Med studied the effectiveness of the BIS monitor compared to strict monitoring of the end tidal anesthetic gas concentration. Target values of 40-60 were used for the BIS group and 0.7-1.3 MAC for the end tidal anesthetic group. Alarms were set to warn the anesthetist when patient values were outside the prescribed limits.

The authors concluded that use of the BIS monitor did not reduce awareness as compared to strict monitoring of the end tidal anesthetic gas concentration. The study suggests that using the end tidal gas concentration protocol in patients at high risk for awareness could be of benefit. Setting alarms for monitoring end tidal gas concentration is essential.

Click here to read the full article. Please use the “comments” prompt at the top of this page to share your thoughts and experiences.

Dannemiller Nurse Anesthetist Review and Update

November 29 – December 4, 2011, San Antonio, TX

I’ve been attending this Dannemiller offering for years and it consistently meets my continuing education needs. It’s very convenient to visit a beautiful place like San Antonio, TX for a few days and earn enough CE credits for the two year re-certification. This time they provided 32 hours of lecture (including pharmacology credit) and an optional 8 hour hands-on ultrasound guided nerve block workshop. I especially enjoyed the lectures onreactive airway management, pediatric congenital heart disease, geriatric poly-pharmacology, perioperative diabetic management, one lung ventilation, and preoperative pulmonary assessment. Our AANA President Debra Malina provided insightful information regarding current and future nurseanesthesia trends and issues including NBCRNA mandatory recertification. I highly recommend all Dannemiller education products. Check out their website.

Click here to check out their website.

Reviewed by Bill Shopp, CRNA

The Influence of Perioperative Care and Treatment on the 4-Month Outcome in Elderly Patients With Hip Fracture

With the baby boomers coming of age, the demographics of those seeking health care is changing. The percentage of those considered “elderly” in the surgical population has had a steady increase over the past few decades. In a study published in the February 2011 edition of the AANA Journal, Bjorkelund et al discuss risk factors of anesthesia related to the elderly population.

In this study of elderly patients with hip fracture, premedication, prolonged fasting and fracture type were related to postoperative confusion and mortality at 4 month. The authors found that decreased SpO2, prolonged fasting and increased number of units transfused all impaired recovery and were correlated to a higher mortality rate. Patients with the longest fasting times tended to receive a larger volume of fluid which may have stressed physiologic reserve.

The effects of preoperative medication on outcome produced an unexpected finding. In this study, those who received no premedication had a higher rate of confusion and mortality at 4 months. The authors speculate that either the premedication reduced the stress of surgery and improved outcome or that those who were not premedicated were in a higher risk group and possibly not a candidate for sedation.

Click here to view the study published in the AANA Journal.

Promote your Profession

Nurse Anesthesia has a long and proud history dating back to the late 1800’s. Watchful Care by Marianne Bankert documents our history and the contributions made by the early pioneers of the profession. Nurses were selected as the ideal anesthetists because of our attention to detail, vigilance, and commitment to patient safety. Day in and day out, Nurse Anesthetists delivered quality care to patients and service to surgeons.

In the century that followed, many changes in Health care have taken place but one factor remains constant; the safety and quality of patient care delivered by Nurse Anesthetists. To support the quality of care we deliver, we must actively promote our profession and contribute to the body of knowledge If we are to remain trusted and respected in the of delivery of anesthesia services. We must all contribute to promoting our profession. Some will participate in research or Public Relations projects. Others who can not actively work to promote the profession must help by supporting the work of others.

The AANA foundation has the mission of advancing the science of anesthesia through education and research. The Foundation provides an excellent opportunity for each individual CRNA to support our profession by supporting the research done by our colleagues. Original studies to promote safe practice and to validate the safety and cost effectiveness of Nurse Anesthesia have been funded and published by the AANA Foundation.

Did you know that last year the AANA Foundation:

Funded $73,045 in research initiatives

Awarded $129,000 in student scholarships

Awarded $250,000 in Post-Doctoral and Doctoral fellowships

Presented 95 research posters

Please take the opportunity to support your profession through support of the AANA Foundation. Regardless of the size of your contribution, add your name to the list of those who support CRNA research and education through the AANA Foundation. Click here to go to the Foundation web site. After reviewing the site, please contribute.

Opioid-Induced Respiratory Depression

The Anesthesia Patient Safety Foundation is committed to the safe and reliable administration of every anesthetic. An area of concern has been respiratory depression in the immediate postoperative period secondary to narcotic administration. The following information comes directly from the foundation;

The APSF believes that clinically significant, drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality since it was first addressed by the APSF in 2006.1 The APSF envisions that “no patient shall be harmed by opioid-induced respiratory depression in the postoperative period,” and convened the second multidisciplinary conference on this serious patient safety issue in June of this year in Phoenix, AZ, with 136 stakeholders in attendance. The conference addressed “Essential Monitoring Strategies to Detect Clinically Significant Drug-Induced Respiratory Depression in the Postoperative Period.”

Click here to read the full report by the APSF regarding drug-induced depression in the postoperative period. After reading the report, click the back arrow to return to this site and leave a comment for your colleagues.

Ketamine Supplement for Anesthesia

Ketamine is an old drug which has come in and out of favor many times over the past decades. Currently, articles are emerging touting the advantages of Ketamine as a supplement for both general anesthesia and monitored anesthesia care. Below is a description by Pamela Chambers, CRNA regarding her clinical experience using Ketamine as a supplement. Read her excellent review, scan the articles and leave a comment to share your experiences with your colleagues.

Submitted by Pamela Chambers, CRNA

Lexterrae legal consulting service

For the EP case that lasted 6+ hours, GETA with .5 mac Desflurane and Propofol infusion at 30 ug/kg/min, the Propofol Ketamine mixture performed very well. I mixed 50mg Ketamine in each 50ml bottle of propofol. I used less than 3 bottles for the case and never used more than .5 mac Des. I used a total of 25 ug Fent, just after intubation, for the case. The patient was 83 yo male, approx 90 kg, EF 20%.

Upon emergence the patient denied any pain or discomfort. He was appropriately responsive to verbal and did not cough on extubation. VS were stable and he was A&O x3 on arrival to the EP room for phase 2 recovery.

A few days later, I used Ketamine as an analgesic adjunct for another long case (10 hr bilateral mastectomy and tram flap). I used a total of 195 mg Ketamine. The patient was an ASA 1. After 100 ug Fent (and 3mg Versed) prior to induction, I used 30 mg Ketamine approximately 3 mins prior to incision. Then I administered 30 mg Ketamine at hr number 2, and hr #3. Around hr #4, I decreased the Ketamine to 15mg for each hrs successive dose with a plan to halt Ketamine admin when I believed the case was 2 hrs from completion. My last Ketamine dose was at 1430 during the last phases of the case. The patient began spontaneous ventilations after reversal of NDMR at approximately 1640. The case ended at approximately 1730. The patient

received a total of 2200 ug Fent dosed approximately 100 ug every 30-45 mins.

Intermittent rescue doses for SNS spike were not required. Pressor agents were not used. Hemodynamics were extremely stable, almost like the proverbial railroad track!

Total fluid administered was 2 liters NS and 1 liter 5% Albumin, UO was 150 ml, EBL 300ml. I also adminstered 2 mg Versed at 1600 to facilitate decreasing the inhaled agent level and to ameliorate any emergence delirium associated with the Ketamine. The patient was appropriately responsive to verbal prior to extubation, and did not cough during extubation. She also denied any c/o pain immediately post-operatively. No emergence delirium was appreciated.

Click here to read a review article by Laskowshi et. al regarding Ketamine use

Click here to read an article by McCartney et al regarding the role of the NMDA receptor

The Sticky Situation of Adhesion

Submitted by Pamela Chambers, MSN, CRNA, EJD

Click here for Lex Terrae consulting

Two years ago, Joe Sixpack was admitted to your facility to undergo vasectomy. His clinical course in your fine medical center was uneventful. Today, you are seated in the office of the facility mediator and all relevant parties are present: Joe Sixpack, Mrs. Sixpack, little baby Sixpack who will celebrate his first birthday next week, and everyone involved in the clinical care of Mr. Sixpack on that fateful day 2 years ago.

Before beginning the mediation process, the facility’s attorney presents the admitting forms that Joe signed upon arrival to the facility and prior to receiving any sedation for his procedure. One of the forms, a two sided form, contains an explanation of the procedure that Joe has requested on side one, along with the risks, benefits, and options of the procedure and several blank lines at the bottom of the form in case Joe wanted to add anything to the form. Side two of that same form contains the following statement “I hereby release Smallville Medical Center and it’s employees and contractors, from all liability arising from any injury to me resulting from my requested therapeutic procedure to be performed by Dr. Kuttemup and his staff at Smallville Medical Center.” Immediately after this paragraph is Joe’s signature with the date and time the form was signed.

When a healthcare provider has this type of statement in a contract for services for the express purpose of limiting liability relating to the provision of those services, this is termed an exculpatory clause. When this type of clause is a condition to obtaining the requested service this creates a contract of adhesion. While most courts attempt to enforce contracts by trying figure out what the parties intended when the contract was written; courts often find contracts of adhesion unenforceable as a matter of public policy (Weaver v. American Oil Co., 257 Ind. 458, 276 N.E.2d 144 (1971).

The contract to provide health care services is not usually between 2 similarly situated (i.e. equally knowledgeable) parties. If a contract is deemed grossly unfair to one party it will usually be held unenforceable in court. Consider the following release from Olson v. Molzen (558 S.W. 2d 429, Tenn., 1977) “…I therefore release Dr. Molzen and his staff from responsibility associated with any complications that may come up or be apparent in the next 12 months…” The court in this case found the exculpatory clause particularly distasteful because an individual in such a profession, a physician, should not be permitted to hide behind such a shield as a license to commit professional negligence.

Regarding all contracts, there lies a duty to read. This is small comfort to a plaintiff but a court will evaluate the parties intent to contract by evaluating the terms of the contract. Terms that appears grossly unfair (i.e. unconscionable), violate public policy (i.e. one cannot receive the healthcare service with out agreeing to the term), or lack true assent will likely lead to a ruling that the contract is unenforceable.

DNR in the Operating Room

You are scheduled to do a patient coming from the ward with Do Not Resuscitate orders. What does that mean and what do you do? Some would argue that General Anesthesia is a controlled resuscitation on every case, and, therefore either the DNR orders should be suspended or the case should be canceled. Does that choice afford the patient the quality care that he/she expects and deserves?

Across the nation, patients with terminal conditions come to the operating room for procedures that will not extend their lives but will improve the quality of life. Stabilization of a pathologic fracture or the insertion of a feeding tube are but two examples. Click here to read the excellent review of DNR in the operating room from the University of Washington Medical School and then come on back to www.procrna.com. Leave a comment and share your thoughts with your colleagues

LMA in the Prone Position

The LMA (Laryngeal Mask Airway) has been a common airway management device used by the Anesthesia community for two decades. Because the device does not “secure” the airway like a cuffed endotracheal tube would, anesthetists are selective about the patient population and type of surgery when deciding whether or not to use the LMA. Our international colleagues seem to have been bolder with the use of the LMA and report its use in the lateral and sitting positions. An Article by Ng Published in Anesthesia and Analgesia reported a series of over 200 patients who were safely induced in the prone position with the LMA inserted after induction. Click here to read the article and then return to procrna.com and leave a comment. Let us know about your experience using the LMA in the non-supine patient.

ivNOW Fluid Warmer

Patient temperature at the end of the case is an important marker of compliance with SCIP indicators of quality anesthesia care. Achieving the goal of temperature maintenance in the anesthetized patient requires the use of several techniques including warm blankets, forced air warming, the use of a HME in the breathing circuit, and the administration of warm fluids.

To assist the anesthetist with patient warming, Enthermics has developed the ivNOW fluid warmer. Each cavity has a control and L.E.D. display. A sensor in the heating plate detects the presence of a bag and engages the heating mechanism to quickly warm the fluid. Two temperature sensors continuously read the temperature of the fluid bag to engage the heater as necessary to maintain the fluid temperature within +0/-2ºC (+0/-3ºF) of the set point temperature. The electronic control monitors the length of time the bag has been held at temperature, displayed additionally by a status button. The control alerts users when a fluid bag has been held at temperature longer than 14 days.

Click here to go to the ivNOW web site and review the manufacturer’s product information. If you have experience with this product, please leave a comment on PROCRNA.com and share your experience with your colleagues.

Res Ipsa Loquitur

This is a theory of liability that basically states “the thing speaks for itself”. This doctrine is applied in medical malpractice usually in cases where the injury is in a location of the body distinct from the proposed procedure or operation. The classic case is Ybarra v. Spangard, 25 Cal.2d 486, 154 P.2d 687 (1944), here the plaintiff underwent an appendectomy but awoke from surgery with pain in his arm. The court applied Res Ipsa Loquitur to the facts, finding (in part), “the defendant had control at one time or another the of…instrumentalities which might have harmed the patient…”

Three conditions must be met for application of this doctrine: The accident must be the kind that does not ordinarily occur in the absence of someone’s negligence; it must be caused by an agency or instrumentality within the exclusive control of the defendant; and it must not have been due to any voluntary action or contribution on the part of the plaintiff. Dobbs, The Law of Torts Sect 249 (2000).

Some courts have resisted use of this doctrine because of concern that healthcare providers would be in constant fear of liability from rare bad outcomes. In Siverson v. Weber, 57 Cal2d 834, 22 Cal.Rptr 337 P.2d 97 (1962) the court acknowledged this doctrine would place an undue burden on the medical profession and limit the use of innovations even if due care is exercised.

Some states allow a jury to infer negligence vis-à-vis Res Ipsa, others treat the doctrine as a presumption that a defendant must rebut. Appropriate review of recent caselaw is prudent for defense against this type of allegation.

Clean Machine for MH patients

What do you do when you learn that your next patient is MH succeptible? Do you have “clean machine” sitting in the store room or do you change the absorber, turn up the flows and let the machine air out? Studies have shown that it can take over an hour of high flow to sufficiently reduce the residual gas in the machine to acceptable levels. Vapor clean is a product which eliminates trace gases from the circuit immediately.

Prepare Any Anesthesia Machine for Susceptible Patients in Less than 60 Seconds

Newer anesthesia gas machines contain plastic and elastomeric components that absorb volatile anesthetics and then release residual vapor during subsequent anesthetic procedures. The anesthesia gas machine requires high flows and a lengthy time period to remove most of the vapor before the machine can be used for a patient that cannot tolerate breathing trace amounts of volatile anesthetic vapor. The Vapor-Clean filters absorb the trace amounts of isoflurane, sevoflurane and desflurane so that anesthetic vapors do not reach the patient.

Placement of the Vapor-Clean filter canisters on the anesthesia machine allows the machine to be immediately vapor-free (less than 5 parts per million of vapor).

Click here to go to the manufacturer’s web site and review the product information. If you have used this product or have any other information to share regarding safe administration of anesthesia to MH patients, leave a comment.