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Promises, Promises

Submitted by Pamela Chambers, CRNA, MSN, EJD

A guy walks into a bar… he says to the guy next to him, “My laryngoscope is bigger than your laryngoscope”.  Unbeknownst to guy #1, guy #2 was a surgeon and was offended to be mistaken for an anesthetist.  So guy #2, Dr. Alice, punches guy #1, Dr. Guedel, in the jaw.

Now Dr. Alice has an injured and deformed right hand.  He goes to see his friend Dr. Adson – the plastic surgeon.  Dr. Adson observes how distraught Dr. Alice is and tells him he can indeed fix his injured hand.  Dr Adson tells Dr. Alice that he can give him a good hand so that he can return to surgery.

During the procedure, Dr. Adson realizes he must apply a skin graft to effectively correct Dr. Alice’s injured hand.  The operative consent gives Dr. Adson permission to use a skin graft if necessary during the procedure.  Dr. Adson obtains skin from Dr. Alices’s chest for use in the skin graft.

Days later, Dr. Alice returns to see Dr. Adson for a follow-up visit and to have his bandages removed.  Both doctors observe hair growing from the grafted skin that now is growing on Dr. Alice’s right hand.   Dr. Alice is distraught and decides to sue Dr. Adson.  But under what theory?  If a malpractice suit is filed, Dr. Adson would have to establish negligence and all of the required elements necessary to sustain such a theory.  Additionally, expert witness testimony would be needed to establish standard of care and the deviation from it if present.

Dr. Alice sued Dr. Adson for breach of contract.  Dr. Adson promised Dr. Alice “a good hand”, presumably that meant a hand free of hair.  Does this sound absurd?  Well a contract claim can be more advantageous in some circumstances over a malpractice claim.  Why?  Because, the remedy that is awarded in a contract claim is the difference between what was promised in the contract and what is present.  There is no question of wrongdoing, no questions of standards of care, and no pesky expert witness.   When there exists a dispute as to the terms of a contract, courts try to interpret contracts based what the parties intended at the time of the agreement.  In Guilmet vs. Campbell, 385 Mich.57. 188 N.W.2d 601 (1971), a jury found for the plaintiff under a breach of contract theory. In this case the surgeon promised a particular result. The patient suffered severe postoperative after-effects – which were very different from the promise of “it’s a very simple operation… you’ll be out of work 3-4 weeks at most”.

As with all areas of jurisprudence, the measure of damages in a breach of contract suit can be computed various ways.  Expectancy damages would be some amount that would place the plaintiff in the position that he would have had if the contract had been performed as promised.  Whereas restitution damages would be an amount equivalent to the benefit conferred upon the defendant by breaching the contract.  In Sullivan vs. O’Connor, 363 Mass.579, 296 N.E2d 183 (1973) the court decided to compute damages using an intermediate method – reliance damages.  In Sullivan, the plaintiff recovered expenditures and costs that he bore as a result of the defendant’s breach of their contract.

Who said the only contracts in the hospital were the ones in administration??

Belmont Rapid Infusion System

The Belmont Rapid Infusion System has had wide use by the Military in the Middle East war.  The system enables the rapid delivery of large volumes of warmed fluid during a resuscitation.   The following testimonial was reported on the manufacturer’s web site:

Soldiers are Alive Today Because of the Belmont
“We were able to sustain their lives long enough so the surgeons could fix them. When we were in Baghdad we pumped over 100 units of blood products through the Belmont on this single patient,and ten years ago…he would not have lived.”

This rapid infusion system is gaining popularity in trauma centers throughout the United States.  Again, a testimonial from the manufacturer’s web site:

The Anesthesiology Practice at a Major New York Metro Area Medical Center
“Switched from the Level 1 to the Belmont Rapid Infuser about three months ago. We purchased two, one for our main O.R. and one for Obstetrics. We have already used it in a case requiring more than 32 units of blood. It was flawless and clean.”
Major New York Metro Area Medical Center

For more information about the infusion system, click here to go to the manufacturer’s web site.

PROCRNA.COM would like to hear from those using the Belmont Rapid Infusion System.  How is it working for you?  Leave a comment and help your colleagues who are in need of a rapid infusion system.

LMA Supreme

Over the past 20 years the LMA has earned it’s place among the options for quick, safe, and easy airway management.

Improving upon existing technology, the LMA Supreme has been introduced to the marketplace.  The integrated drain tube allows fluids to channel away from the airway and the integrated bite block ensures airway integrity if the patient bites down.

PROCRNA.com would like to hear from those who are using this product.  Click here to view the manufacturer’s information regarding the LMA supreme.  After reviewing the information, return to this site and leave a comment.

NBCRNA Recertifican Exam proposal

The following message comes from the NBCRNA regarding the proposed recertification exam for CRNAs:

At the AANA Annual Meeting in Boston, the NBCRNA unveiled a draft of the Continued Professional Certification (CPC) program developed over the past three years. The intent of the recertification process is to ensure that the CRNA credential represents an acknowledged commitment to excellence, and continues to distinguish us from others in the field.

The proposal is in draft form. To accommodate major changes to our website, the official comment period for the proposed changes is scheduled to start September 6, 2011 and runs through November 14, 2011. However, many of you already have written us with questions and comments, some supportive, others challenging the need for change, and most simply asking for more information. We have posted answers to the most frequently asked questions at www.nbcrna.com. We welcome your thoughts prior to the official comment date via email at recertification@nbcrna.com.

The NBCRNA understands your concerns about changes to the recertification process and wants to reassure you that the proposed recertification exam will NOT be similar to the rigorous entry level certification exam. The recertification exam will evaluate clinically relevant knowledge in which all certified registered nurse anesthetists must be proficient regardless of their practice setting. These areas include 4 core competencies: airway management, pharmacology, pathophysiology and anesthesia technology. The recertification exam will contribute to ensuring that those who hold a CRNA credential are seen as committed to being the best educated, best prepared workforce possible.

The proposed changes would go into effect in 2015, and the first recertification exam will be available in 2019. Those individuals who are planning to retire by the end of 2023 will not be required to take the recertification examination. To assure constituents fully understand both the goals and specifics of the program as drafted, we will shortly announce a series of web based town hall meetings to give people an additional opportunity to discuss the proposed changes in the Continued Professional Certification program. We look forward to your participation and receiving your input.

Prevention of Intraoperative Awareness in a High-Risk Surgical Population

To Bis or not to Bis….the controversy continues.  A study reported in the New England Journal of Medicine (Avidan et al, August 18,2011) evaluated using BIS versus end tidal agent concentration in the prevention of intraoperative awareness.

In this study, 6041 patients were randomly assigned to either have BIS or end tidal agent to determine anesthetic depth.  After surgery patients were assessed regarding intraoperative awareness.

Findings were that the superiority of BIS was not established and fewer patients had awareness in the end tidal agent group than in the BIS group.

Click here for article

In the same issue of NEJM, an editorial by Gregory Crosby, MD reviews the evolution of patient monitoring with regard to awareness and cautions that end tidal agent in and of itself may not be the answer to the problem.

Click here for editorial

Review the original article and make a comment….to Bis or not to Bis, that is the question.

AANA National Meeting, Boston

The AANA National meeting was held in Boston August 6-10.  Once again, the meeting exceeded all expectations.  The host City of Boston was welcoming to the visitors from across the country and offered many attractions for CRNAs in attendance.

Educational sessions were organized and presented by the top CRNA speakers from across the country.  Topics were relevant to practice and presented in a professional manner.

My best memory of the meeting was the number of top quality people in our association who give of themselves on a daily basis to make a difference in the life of our patients and the life of our organization.

Attendance at the National Meeting is a must at least one time for every CRNA.  See you in San Francisco 2012.

Medication vial label study

The United States Pharmacopeia is sponsoring a research study concerning the usage and disposal terms on injectable medication vial labels. The objective of the study is to acquire input from professional healthcare providers on possible changes to the terms on the label describing the use and disposal of the drug product.

The AANA and other professional organizations respectfully request your participation in this research study, as your input may help improve the clarity of terms used on labels and improve the safe use of injectable drug products in the future.

This brief survey should take no more than 10 minutes of your time.

Please click here to participate in the study

Northwest Anesthesia Seminars, Waikiki meeting

Overall, a great meeting in a great location. The theme for the meeting was trauma and the speakers were knowledgible. There were excellent reviews of mechanisms of trauma as well as airway management and fluid replacement. The review of the massive transfusion protocol, including the type and volume of fluid to be given, was informative. I was satisfied with the meeting and would return to Waikiki for another meeting.

Reviewed by TD in Texas

Risks of Anesthesia Care in Remote Locations

From the ASPF Newsletter

Patients receiving anesthesia in remote locations tend to be older and sicker than those in the Main OR.  In addition, they tend to receive MAC anesthesia more frequently.  Below is a case scenario.  Read the entire article from the ASPF newsletter and add your comments.

A 75-year-old, 100-kg, ASA 2 man was scheduled for endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC). Monitors, including pulse oximetry, blood pressure, and ECG, were placed and the patient was turned prone for the procedure. He was given midazolam 2 mg and fentanyl 50 mcg IV, and he remained anxious. Additional midazolam 2 mg and fentanyl 150 mcg IV were given, but the patient could not tolerate insertion of the endoscope. Propofol 20 mg IV, followed by an infusion of 50-70 mcg/kg/min, was administered, and the procedure was begun with O2 saturations 88-92% on 4 L/min O2 by nasal prongs. After 20 minutes, the O2 saturation decreased to 70%, and the patient became severely bradycardic, and was treated with atropine 1 mg. Attempts at bag-mask ventilation and placement of a laryngeal mask airway failed. Blood pressure was not obtainable and the procedure was aborted. It took 2-3 minutes to push aside the heavy endoscopy equipment, move in a gurney, and turn the patient supine to begin CPR. Although the patient was resuscitated after 10 minutes of CPR, he sustained severe anoxic brain damage, and life support was eventually discontinued.

Cost Effectiveness Evaluation of Anesthesia Providers

Anesthesiologists and certified
registered nurse anesthetists
provide high-quality, efficacious
anesthesia care to the U.S.
population.

This research and analyses
indicate that CRNAs are less
costly to train than anesthesiologists
and have the potential for
providing anesthesia care efficiently.

Anesthesiologists and CRNAs
can perform the same set of
anesthesia services, including
relatively rare and difficult procedures
such as open heart
surgeries and organ transplantations,
pediatric procedures,
and others.

CRNAs are generally salaried,
their compensation lags behind
anesthesiologists, and they
generally receive no overtime
pay.

As the demand for health care
continues to grow, increasing
the number of CRNAs, and permitting
them to practice in the
most efficient delivery models,
will be a key to containing costs
while maintaining quality care.

Read the Full article in Nursing Economic$, 2010;28(3):159-169.

An overview of OFIRMEV

First and only IV acetaminophen in the US

  • Indicated for the management of mild to moderate pain; management of moderate to severe pain with adjunctive opioid analgesics; and reduction of fever
  • For adults and children ≥2 years old2

Comprehensive clinical dataset

  • The approval of OFIRMEV is supported by the results of 20 clinical trials involving 1375 patients1,2
  • IV acetaminophen has been studied in randomized clinical trials across a variety of surgical contexts and patient types1,3-5

Improved pain relief, reduced opioid consumption3

  • In total hip/knee replacement surgery, OFIRMEV 1 g + PCA* morphine demonstrated significant pain relief and reduced opioid consumption compared to placebo + PCA morphine3
  • The clinical benefit of reduced opioid consumption was not demonstrated

Patient satisfaction3

  • The hip/knee replacement study also showed that OFIRMEV 1 g + PCA morphine significantly improved patient satisfaction compared to placebo + PCA morphine†3

Significant fever reduction1

  • In adults with fever, antipyretic onset of action was significantly faster and duration of effect significantly longer with OFIRMEV than with placebo1

Established safety profile and well tolerated in clinical trials1-5

  • OFIRMEV was shown to be well tolerated in clinical trials1-5
  • The safety of IV acetaminophen has been monitored through a postmarketing surveillance program, with more than 400 million doses distributed since its European approval1
  • IV acetaminophen has been used outside the US since 2002 and is approved in over 60 countries1

Dosing for adults and children ≥2 years old2

  • OFIRMEV has a well-described pharmacokinetic profile2
  • Dosing guidelines have been established for children ≥2 years old through adults2
  • OFIRMEV is the first IV analgesic and antipyretic agent approved for children ≥2 years old2

Indication

OFIRMEV is indicated for the management of mild to moderate pain; the management of moderate to severe pain with adjunctive opioid analgesics; and the reduction of fever.

Important Safety Information

Do not exceed the maximum recommended daily dose of acetaminophen.

Administration of acetaminophen by any route in doses higher than recommended may result in hepatic injury, including the risk of severe hepatotoxicity and death.

OFIRMEV is contraindicated in patients with severe hepatic impairment, severe active liver disease or with known hypersensitivity to acetaminophen or to any of the excipients in the formulation.

Acetaminophen should be used with caution in patients with the following conditions: hepatic impairment or active hepatic disease, alcoholism, chronic malnutrition, severe hypovolemia, or severe renal impairment.

OFIRMEV should be administered only as a 15-minute infusion.

Discontinue OFIRMEV immediately if symptoms associated with allergy or hypersensitivity occur.

Do not use in patients with acetaminophen allergy.

The most common adverse reactions in patients treated with OFIRMEV were nausea, vomiting, headache, and insomnia in adult patients and nausea, vomiting, constipation, pruritus, agitation, and atelectasis in pediatric patients

The antipyretic effects of OFIRMEV may mask fever in patients treated for postsurgical pain.

To report SUSPECTED ADVERSE REACTIONS, contact Cadence Pharmaceuticals, Inc.
at 1-877-647-2239 or the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

References: 1. Data on file. Cadence Pharmaceuticals, Inc. 2. OFIRMEV™ (acetaminophen) injection prescribing information. 3. Sinatra RS, Jahr JS, Reynolds LW, Viscusi ER, Groudine SB, Payen-Champenois C. Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology. 2005;102:822-831. 4. Atef A, Fawaz AA. Intravenous paracetamol is highly effective in pain treatment after tonsillectomy in adults. Eur Arch Otorhinolaryngol. 2008;265:351-355. 5. Memis D, Inal MT, Kavalci G, Sezer A, Sut N. Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit. J Crit Care. 2010;25:458-462.

*Patient-controlled analgesia.
†Subjects were asked to evaluate the study treatments, overall, using a 4-point categorical scale.

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This site is intended for US healthcare professionals only.

Keeping Hydrated

by SCOTT & WHITE STAFF on JUNE 13, 2011in HEALTH AND WELLNESS 

Written By: Jenny Kidd, RD, LDThe Central Texas heat is well on its way so it’s that much more important to stay hydrated.  Water is crucial to physical health and makes up about 60% of body weight in adults and more in children. Body water balance is key for maintenance of body temperature, blood volume, and several metabolic processes. 

Most fluid recommendations suggest >3 liters per day for men and >2 liters per day for women. Other factors requiring additional fluid intake include:

  • Increased activity level
  • Increased sweat level
  • Living in a hot and humid environment
  • Living in high altitude
  • Pregnancy/Breastfeeding
  • Fever
  • Vomiting/diarrhea

While water is the most plain and obvious hydration source, other foods and beverages also contain significant amounts of water to contribute to overall hydration.  Many fruits and vegetables contain 70-90% water. Some of the best sources of water in food include:

  • Apples
  • Oranges
  • Grapes
  • Strawberries
  • Tomatoes
  • Watermelon (a summer favorite)
  • Potatoes
  • Corn
  • Broccoli
  • Spinach
  • Lettuce
  • Celery

Even many meats and cheeses contain more than 50% water. While water is typically the best choice, other beverages including skim milk and fruit juice are >90% water. Caffeinated beverages – tea, coffee, sodas and the like will also contribute to total fluid intake, but can contribute significantly to caloric intake. If you have a hard time drinking plain water, look for low calorie beverages to help you meet your fluid goals. Try water with lemon or lime juice, unsweetened tea or artificially sweetened drinks.

Without adequate fluid intake, there is risk of dehydration. The first sign of dehydration is thirst. But don’t wait until you’re thirsty to start drinking fluids. Thirst means your body isn’t keeping up with fluids adequately and needs replenishment. Other symptoms of dehydration include weakness, dizziness, dry mouth, decreased (and more concentrated) urine output, confusion and sometimes a feeling of a pounding heartbeat.

Some medical diagnoses should be cautious of drinking excess amounts of water. Talk to your physician or dietitian if you have questions about your fluid intake.

Northwest Anesthesia Seminars, Caribbean Cruise

February 2011.  A cruise is always a good place to combine meeting and vacation.  There were many good lectures.  The talk on the massive trauma protocol, blood replacement, (1:1:1  FFP, PRBC, 1 pk platelets) should be continued until blood loss is under control.  Overall, a good experience.

Submitted by HA in Texas

Hawaii Assn. of Nurse Anesthetists

I attended the HANA state meeting on Waikiki in Honolulu in February 2011.  The location was exceptional and the hospitality from the Hawaii CRNAs was warm and friendly.  One particular talk on the healing power of humor and Laughter, both for the provider and patient, will effect the way I relate to patients in the future.  Overall, it was a good meeting in a great place to vacation. The food was very good and I earned 17 CEUs.  I would give this meeting a 9 out of 10.

Submitted by YN in Texas

Home

Welcome to PROCRNA.COM

Home for those who seek excellence in clinical practice and healthcare leadership

This web site is for Nurse Anesthetists and others who have a focus on living on the cutting edge of competent practice and inspired leadership.

  • Keep up to date with current clinical practice articles
  • Use empowering leadership to motivate and engage your team
  • Gain insight into leadership skills that give your team a sense of purpose
  • Improve engagement scores and productivity while boosting morale
  • Read meeting reviews to ensure value for your money

 

Click on the Services page for more information.

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Clinical Forum

The PROCRNA clinical forum is your area to present and discuss topics related to clinical anesthesia that interest you. Have you had a case management dilemma that you would like to share? Read more…

Meetings

Have you been to a meeting lately? Was it a great experience or a waste of your valuable time and money? This is your opportunity to rate the meetings that you attend and review the ratings of others… Read more..

Wellness

If we are to give the best possible care to our patients, we must keep ourselves both mentally and physically fit. Become an active promoter of wellness among health care providers…. Read more..

Healthcare Leadership coaching

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PROCRNA Consulting Services

PROCRNA.COM is a web site designed by and for CRNAs. In addition to the professional topics shared on this web site, PROCRNA.COM offers a wide range of consulting services to… read more

Research

Any unpublished research completed by a CRNA or SRNA may be submitted here for a review. Read More…

Equipment/Product review

So many new drugs and devices on the market. Tell us what works and what doesn’t. Submit a product review or read the comments of others. Let the Anesthesia community know what works and what doesn’t. read more

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 for the latest tips on effective and empowered leadership

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