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Meeting Review: Difficult Airway, Las Vegas

Reviewed by DP,  Texas

Meeting Date:  04/01/2013

 

Meeting location:  Las Vegas

 

Meeting presented by:  Difficult Airway

 

Meeting strengths / interesting topics & speakers

This was a three day conference concentrating on the difficult airway. There was a total of approx 3 hours of lecture and the rest was hands on with some case studies. Overall, very informative review of how to handle difficult airway. Really enjoyed the different case studies. Got lots of practice driving the scope with AFOI and pediatric airway. The days were long however and this is not the kind of conference where one can come and go as you please. This was also a meeting with MDA’s, CRNA’s, AA’s, ER docs.
This meeting was at Planet Hollywood resort and casino. The facilities were nice but the casino itself has a very young party vibe which didn’t fit my personal style. Overall though, very good. Good simulation and presentation of different ways to approach the difficult airway.

Suggested improvements:  The boxed lunch on the first day was awful. The breakfast was decent. The days were long- not a lot of time for fun after the long days if you wanted to be back early for the next day.

Overall value for the money:  We got a total of 21 hrs for about $850. That’s pretty on par for cost of other conferences. I think the value was good though because they did provide simulation and scopes, surgical airways, etc.

Chief CRNA: Are Smartphones safe in the Operating Room?

We live in the age of instant access to information literally in the palm of your hand.  As more and more information becomes available on smartphones, notebooks and pads, their ligitimate use by healthcare workers has increased.   However, the device that delivers information can also create distractions.

Lawyers know that distracted healthcare workers are more likely to make errors and frequently examine phone records when investigating an injury to a patient.  The following come from the leagal blog “FindLaw KnowledgeBase”

  • Medical errors and other adverse events in hospitals claim nearly 180,000 lives every year. This is an astonishing number, and it implicates all types of medical professionals providing care in a hospital setting.
  • More comprehensively, anesthesiologists are responsible for monitoring the condition of the patient throughout the surgical procedure. This includes paying close attention to oxygen levels and temperature.

 

An article published in Anaesth Intensive Care. 2012 Jan;40(1):71-8 By Jorm CM, O’Sullivan G. made the following points

  • Experienced anaesthetists are skilled at multi-tasking while maintaining situational awareness, but there are limits. Noise, interruptions and emotional arousal are detrimental to the cognitive performance of anaesthetists.
  • While limited reading during periods of low task load may not reduce vigilance, computer use introduces text-based activities that are more interactive and potentially more distracting

 

When preparing for legal action, lawyers commonly apply the standards set forth by the professional organization.  Non compliance with established guidelines strengthens the case against the anesthetist.  The AANA does not have a formal policy statement, however they have a position statement 2.18 regarding the use of mobile devices.  The following is from the AANA position statement 2.18

Mobile Devices may:

Aid communication
Cause a contamination risk
May distract anesthetists / reduce vigilance
Should never be used for reading, gaming or texting
Camera use violates HIPAA regulations
Use should follow institutional policy

 

The risks of Anesthetists distracted by mobile devices is well documented.  CRNAs are advised to avoid using devices for personal entertainment and to always base decisions on patient safety.

 

Clinical topic: Do Drug Tests for Cocaine Improve Outcome?

Living and working in a society where substance abuse is not uncommon places the Anesthetist in a position where they may administer anesthesia to a patient who either is high or has recently used illegal drugs.  Cocaine abuse has been associated with acute onset of hemodynamic changes and end organ dysfunction.  This scenario begs the question as to whether or not we should routinely require a cocaine drug screen on preoperative patients.

In an original work by a CRNA and published in the AANA Journal (August 2012) Baxter et al explored the usefulness of Cocaine drug screens to predict safe delivery of general anesthesia.  Three hundred subjects were included in the study with half testing cocaine positive.  Baseline data were obtained and vital signs as well as complications were followed throughout the procedure.

From the Authors:

  • “Our study suports the argument that cocaine-related diseases as well as deaths are due less to overdose than they are the pathophysiology that develops from long-term use.”
  • “This suggests that the risk of anesthesia-related complications or death is unlikely to change based solely on drug screen findings.”
  • “Recent cocaine use alont may not necessarily be a contraindication to surgery if the patient is asymptomatic and has normal vital signs, ECG and review of systems.”

The authors found no benefit from routine Cocaine drug screening.   Baseline vital signs and coexisting disease were more important factors than the presence of a positive Cocaine drug screen.

Click here to read the abstract published in Pubmed or click here to review the original article published in the AANA journal

The AANA foundation provides financial support for original CRNA research.  Please support the AANA foundation with annual gift giving.  Click here to visit the AANA foundation web site.

 

Volunteer Opportunity: CRNA Teachers Needed

A new opportunity for volunteering has emerged.  As the need for qualified anesthesia providers in developing areas of the world increases, there is a great need for anesthesia education in Sierra Leone (western Africa).  I am working with Johns Hopkins University and Health Volunteers Overseas with this project to educate CRNAs.  If you are motivated to teach our critical anesthesia skills (basics regarding drugs, techniques and use of the anesthesia machine) please contact me so that we can discuss this opportunity.  I have worked with this education team for many years providing education and mentoring in Eritrea (eastern Africa).  We expect eager and dedicated students and positive results at this site.  Please consider volunteering.  I can be reached at pc_crna@yahoo.com

And please share this information with every anesthesia professional that you can.

Meeting Review: Frank Moya, Orlando

Reviewed by MB, Texas

The conference provided a sound foundation of anesthetic knowledge related to obstetric anesthesia. It served both as a review of principles and a presentation of new ideas. The faculty was well versed and knowledgeable.

Suggestions for Improvement:   None

Overall value for the money:   Great value for the money.

Clinical Topic: Effects of Cervical Collar on LMA seal

Supraglottic  airway devices have proven to be an acceptable alternative to endotracheal intubation and easier to insert by the less experienced provider.  As a result, paramedics and other first line responders are using the laryngeal mask airway more frequently to ensure an open airway while en route to definitive care.  In addition to inserting the LMA, a cervical collar is commonly placed on the injured person.  It is known that movement of the head and neck can affect the cuff pressure of the LMA, however, the effect of a cervical collar on the cuff pressure is unknown.

In a study by Mann, V et al published in Anaesthesia, 2012 (The effect of a cervical collar on the seal pressure of the LMA Supreme™: a prospective, crossover trial.) the authors examined the effect of a cervical collar on the cuff pressures within the LMA.  Fifty patients were included in the study.  After successful placement of the LMA was confirmed, cuff pressure measurements were made with the head neutral and extended both with and without the cervical collar.

The authors found that placing the cervical collar does not reduce the LMA cuff pressure during extension of the head and, in fact, found that the cervical collar improved the LMA seal.  The authors concluded that the application of the cervical collar prevents the LMA from losing seal pressure if the head is extended and recommend the use of the cervical collar after placement of the LMA in all pre-hospital patients.

Click here to review an abstract of the original work.

Clinical Topic: Who is at risk for post-discharge PONV?

Those who read the anesthesia literature know that post-operative nausea and vomiting is a common topic.  A colleague once said “if I have to read another puke article, I’m going to puke”.  To the anesthetist, post op nausea is a concern.  To the patient experiencing nausea along with post-op pain it is a terrible experience.

A recent article by Apfel et al (who is at risk for postdischarge nausea and vomiting after ambulatory surgery?)  seeks to identify those most at risk for continued problems after discharge from a day surgery unit.  “About one in four patients suffers from postoperative nausea and vomiting. Fortunately, risk scores have been developed to better manage this outcome in hospitalized patients, but there is currently no risk score for postdischarge nausea and vomiting (PDNV) in ambulatory surgical patients.”

The study by Apfel et al demonstrated a 37.1% incidence of post discharge nausea and vomiting (PDNV)  with about 5% having severe vomiting.  If extrapolated to the general outpatient population, about 4.3 million patients experience some form of PDNV.  In this study, anti-emetic medications given in the recovery area did not have sufficient potency or duration to last into the post-discharge phase

The study went on to indentify risk factors for developing PDNV.   They include:

  • female gender
  • age less than 50
  • history of PONV
  • PACU administered opiates
  • experience of nausea in the PACU

The presence of 0, 1, 2, 3, 4,  or 5 of these factors was associated with 10%, 20%, 30%, 50%, 60%,  and 80% respectively.

The author concludes “PDNV affects a substantial number of patients after ambulatory surgery. We developed and validated a simplified risk score to identify patients who would benefit from long-acting prophylactic antiemetics at discharge from the ambulatory care center.”

Click here to read an abstract of the original article

 

 

Chief CRNA: Should You Use Social Media?

We live in a turned-on, linked-in world where instant access to information is the norm.  Long gone are the days of reference books and extensive library searches.  The generation who grew up using web based technology is now entering the workplace and bringing their mobile devices with them.  As Chief CRNAs, it is to our advantage to use social media to enhance the flow of information within our work groups.  However, the use of personal devices in the workplace is not without risk to the patient and administration must establish policies that balance the flow of information with patient privacy and safety.

In a blog by his own name, Phil Baumann makes the case that there is a place for twitter among healthcare workers.  His article lists 140 uses of twitter to enhance communication and efficiency among workers.  A few items on the list include:

  • —  Disaster alerting and response
  • —  Emergency response team management
  • —  Alarming silent codes (psychiatric emergencies, security incidents)
  • —  Biomedical device data capture and reporting
  • —  Triage management in emergency rooms
  • —  Publishing health-related news
  • —  Reporting hospital staff injuries
  • —  Reporting medical device malfunctions
  • —  Discussing HIPAA reform in the age of micro-sharing
  • —  Recruitment of health care staff

 

The blog goes to warn of dangers of using social media in the operating room:

  • Patient dignity and privacy
  • Professional oaths to do no harm (distracted workers and Infection risk)
  • Litigation concerns
  • HIPAA

Click here to read the Baumann Blog

An article by Barker, A et al published in the Journal of Clinical Anesthesia discussed the use of social media by Residency programs.  The Barker group found that only 30% of residency programs have social media policies in place.  They also found that 12% of the programs use a social media search as a part of the initial applicant screening.

The article concluded: “residency programs should have a written policy related to social media use. Residency program directors should be encouraged to become familiar with the professionalism issues related to social media use in order to serve as adequate resident mentors within this new and problematic aspect of medical ethics and professionalism.”

Click here to read an abstract of the Barker article.

Here is the question for PROCRNA.COM readers: Does your department have a social media policy and, if so, is it known by front line workers and enforced by administration?  Please leave your comments below.

 

Chief CRNA: How to Motivate your Staff

Being an effective Chief CRNA involves multitasking to meet the needs of the patient, the institution, the regulatory agencies and the needs of your staff.  Staff engagement is a buzz word in corporate America.  According to Wikipedia, An “engaged employee” is one who is fully involved in, and enthusiastic about their work, and thus will act in a way that furthers their organization’s interests.   As Chief CRNAs, it is easy to become so focused on the daily grind that we often ignore things that will promote engagement within our staff.

An interesting article by Martin Dewhurst et al and published in the McKinsey Quarterly addresses the issue of staff engagement.  All too often, administration relies on financial recognition for motivation of employees.  Dewhurst et al point out that there are more effective non-financial motivators of your staff.  According to the report, the top 3 non-financial motivators are:

  • Praise, commendation and interaction with the supervisor
  • Attention from leaders
  • Opportunities to lead projects or task forces

“The survey’s top three nonfinancial motivators play critical roles in making employees feel that their companies value them, take their well-being seriously, and strive to create opportunities for career growth. These themes recur constantly in most studies on ways to motivate and engage employees.”

“One-on-one meetings between staff and leaders are hugely motivational,” explained an HR director from a mining and basic-materials company—“they make people feel valued during these difficult times.” By contrast, our survey’s respondents rated large-scale communications events, such as the town hall meetings common during the economic crisis, as one of the least effective nonfinancial motivators”

“A chance to lead projects is a motivator that only half of the companies in our survey use frequently, although this is a particularly powerful way of inspiring employees to make a strong contribution at a challenging time. Such opportunities also develop their leadership capabilities, with long-term benefits for the organization.”

Click here to read the original article posted in the McKinsey Quarterly

As Chief CRNAs we need to not only ensure that patients receive the highest quality of care but also that they receive the care from a motivated and engaged staff.  Finding ways to involve and value individual staff members will pay high dividends in the long run.

Clinical Topic: Systemic Lidocaine Improves Recovery

As anesthetists we face the challenge of providing a safe, comfortable and speedy recovery to our patients.  Narcotics improve analgesia at the expense of nausea and speed of recovery.  The use of non-opioid drugs to supplement and reduce the amout of narcotic administered should, in theory, provide a comfortable and speedy recovery.  In this study, the use of systeminc lidocaine was evaluated.

A study published in Anesth Analg 2012, 115(2) 262-7 by De Oliveira GS Jr et al, (Systemic lidocaine to improve postoperative quality of recovery after ambulatory laparoscopic surgery.)  examined the use of systemic lidocaine in 63 female patients undergoing laparoscopic surgery.   Following induction, patients were given a loading dose of lidocaine 1.5 mg/kg followed by an infusion of 2mg/kg/hour for the duration of the case.

Assessment following surgery found that those receiving lidocaine had a decided improvement in the quality of postoperative recovery.   Patients in the Lidocaine group had higher scores in physical independence and comfort with a 23% improvement in global recovery scores.  There was significantly less opioid used in the lidocaine group.  Also, those receiving lidocaine had a 26 min reduction in time to hospital discharge.  Overall, in an outpatient setting, systemic lidocaine offered a definite advantage.

Click here to read an abstract of the original article.

A similar study by US Navy CRNAs (Grady et al, AANA Journal August 1012) followed a similar protocol.  Although not statistically significant, the authors found that those receiving the intravenous lidocaine reported greater satisfaction and comfort than those in the control group. (P=0.08)  Possibly with a larger N this study would also have reached statistical significance

Click here to read the article in the AANA Journal (page 282)

Clinical Topic: Predictors of Postoperative Sort Throat

As Anesthetists, we are known as airway experts.  Both Surgeons and patients trust our skills at maintaining an open airway to ensure patient safety.   At the end of the case, we wake our patients and take them to recovery with an open airway and then move on to the next patient.  In the midst of production pressure we lose sight of the minor things that cause discomfort to our patients.  Postoperative sore throat is an example.

Studies that assess patient concerns for surgery have found postoperative sore throat to be one of the top 10 concerns.  The reported incidence varies but several studies find it to be around 40%.  The problem is usually most severe in the first 6 hours after surgery and is common enough that many feel it is a natural consequence of general anesthesia.

In a study by Jaensson, Gupta, and Nilsson published in the August 2012 AANA Journal research edition, (Risk Factors for Development of Postoperative Sore Throat and Hoarsness After Endotracheal intubation in Women: A Secondary Analysis)  the authors gathered data to determine risk factors for development of postoperative sore throat.  Both patient demographic data and airway management techniques were reviewed.

The authors found that general anesthesia with endotracheal intubation can cause minor sore throat which is more common in the female population.  In most cases, symptoms are minor and resolve spontaneously, however in some cases sever sore throat can cause prolonged discomfort to the patient.  The authors found 3 risk factors for development of sore throat in women:

  • Age greater than 60
  • Use of a throat pack
  • Endotracheal tube size (#7 significantly more sore throats than #6)

The authors speculated that higher mallampati scores, therefore more difficult intubations, would increase the incidence of sore throat but that was not found to be true in this study.  The authors were surprised to find that cuff pressures below 20 were associated with an increased incidence of hoarsness.

The authors noted that the reason for the higher incidence of sore throat in women is unclear and requires further study.

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

Chief CRNA: Patient Safety and the Aging CRNA

We have all heard the stories of the super star who played one season too many leaving the sport at the bottom of his game rather than at the top.  The physical effects of aging are well documented in the literature and we are reminded of those changes every time we pre-op a geriatric patient.  As the baby boomers reach retirement age, many super star CRNAs who carried our professional torch for the past several decades are experiencing many of the physical changes that they see in their aging patient.  The question arises, does the aging healthcare provider pose a safety risk to the patient?  How can the skills of the aging CRNA be fairly assessed to ensure patient safety?  Is aging really a problem anyway?

Canadian researcher Michael J. Tessler M.D. writing in Anesthesiology and published in the on line blog Community Health Network (Older Anesthesiologists have Higher Litigation Rates) notes:

“We found a higher frequency of litigation and a greater severity of injury in patients treated by anesthesiologists in the 65+ group. The reasons for these findings should become an active field of research.”

Click here to read the blog

An editorial published by the ASA addressed the issue of the aging Anesthesiologist.   The editorial reminds the reader that the older provider brings years of experience to the job and has valuable insight to be shared with the younger providers.  From the editorial:

“Older physicians, including anesthesiologists, have developed a wealth of experiences during their years in practice that regularly benefit patients,” said Dr. Warner. “The study’s findings remind all physicians that they need to understand their practices, the changes that they personally will experience as they age and the value of working with colleagues to gain continuous feedback about their personal performance in patient care.”

Dr. Warner added, “All physicians should know their personal limits and adjust their practices as they get older to best serve patients. For example, older physicians may choose to reduce the number of hours they work during the nighttime to ensure that they are well rested and alert when caring for patients.”

Click here to read the editorial

CRNAs tend to be at the front line of patient care and are found at the head of the table providing hands on care.  We need to respect the knowledge and skills of our “experienced” CRNAs while, at the same time, protecting the safety of the patient.

Here is the question for procrna.com readers:  How do we assess the continued competency of the aging CRNA?  Use the comments box below.

 

 

Clinical Topic: Effects of Anesthesia in Children

Anesthetists in locations ranging from community hospitals to large Children’s hospitals are frequently given the opportunity to anesthtize children of all ages.  Three recent studies were recently reviewed by Karen Blum in Anesthesiology News (JANUARY 2013 | VOLUME: 39:1) looking at the effects of anesthesia on children.

Researchers presenting studies at the 2012 International Assembly for Pediatric Anesthesia found that children exposed to general anesthesia before age 1 were 4.5 times more likely to develop a learning disability.  From Anesthesiology News:

“We have kids who are born otherwise healthy who come in for minor procedures, and we like to think they would wind up all right, But after accounting for variables including race, sex, maternal and paternal education, domestic living arrangements and afterschool activities, the only significant predictor of formally diagnosed learning disability was previous exposure to GA.”

The authors recommend looking at alternative methods of anesthesia such as propofol or regional anesthesia to reduce the exposure of small children to general anesthesia.

A second article in the series noted that children who have surgery tend to return for more surgery increasing the number of exposures to general anesthesia

The final article in the trilogy noted that children receiving Sevoflurane anesthesia had significantly higher lactate levels in the brain which increases brain activity and increases the likelyhood of anxiety or delirium upon emergence from anesthesia.

The review of the three articles was brief and well written in the posting by Karen Blum.

Click here to view the original article as published in Anesthesiology News

 

Meeting Review: NAFA Disney World

Have you been to an Anesthesia CME Meeting lately?  Share your experiences with your colleagues.

Meeting Date:  11/25/2012

Meeting location:  Disney World

Meeting presented by:   NAFA

Meeting strengths / interesting topics & speakers:

Overall, the meeting was very good. It was a great value for the money. The location was fantastic as well as the time of year as WDW wasn’t too busy right after Thanksgiving. The meeting facilities were nice and the breakfast was hot. Most of the topics were taught by CRNA’s and had a great diversity to include- politics, pedi, OB, etc. They also started earlier in the morning to allow extra CE’s and went till 1 pm to allow time for family.

Suggested improvements:  None.

Overall value for the money:

They had two early bird sessions for an extra 2 CEU and also it is affiliated with students so they allowed students to put up their posters and we can get an extra CE for commenting on posters. Overall- 23 CE’s for $550. By far the best value as far as CE for money. Plus the meeting rate for the resort was about a 1/3 of what somebody would have to pay regularly. The resort was very nice.

Reviewed by David P, (Texas)

Click here to visit the NAFA web site.

Clinical topic: Should Flu Shots Be Required?

As anesthetists we are on the front line of patient care.  We are trusted with the responsibility to promote wellness and “first, do no harm”.  Recently, we have been required to set aside our personal rights in order to enforce a greater good for our patient
population and the question has emerged “should healthcare workers be required to take a flu shot?”

What is driving the push for flu shots?  The CDC estimates the number of yearly deaths from flu to be in the thousands; in a bad year like this one, it’s likely to be in the tens of thousands.  Older and more debilitated patients are at increased risk of death related to the flu.  Since hospitalized patients often encounter up to 50 different healthcare workers per day, it is important that all workers receive the shot.

In an effort to protect patients the Joint Commission and Medicare both require hospitals to have a program for flu vaccinations for their workers and require hospitals to report compliance data. The incentive for the hospital to require vaccination is obvious. The desire for increased compliance has pushed some hospitals to fire workers who refuse to get the vaccination.

In an excellent article by Bob Wachter, MD published in the blog Healthcare Finance News (Making clinicians get flu shots: More important than simply preventing
the flu) the author makes the case for requiring flu shots for ALL healthcare workers.  In the blog, the author reviews reasons why workers object to receiving the shot and goes on to describe the advantage to both the patient population and the overall culture of the
institution.

The Wachter blog refers to the
Checklist Manifesto which lists common elements of professionalism to include:

  •  Selflessness,
  • Patient’s expectation of skill
  • Patient’s expectation of trustworthiness.

The author suggests that discipline be added to the list.  Discipline involves doing the
right thing for the patient regardless of our personal rights.  Discipline within the organization transcends the “favored status” that some Doctors and Nurses claim for themselves.  The recent push for hand washing is an example of how corporate culture can be changed when care is truly focused on what is best for the patient.

The bottom line is that in a patient centered institution, there are very few valid reasons for refusing the vaccination other than a documented allergy.

Click here to read the blog by Dr Wachter and use the comments box below to offer your opinions.

Chief CRNA: New HIPAA rules released

On January 17th, HHS Office for Civil Rights Director Leon Rodriguez issued a press release announcing the new HIPAA rules being published by the HHS Office of Civil Rights.  The 563 page document strengthen the requirements placed on providers and institutions to protect the privacy and health care information of the patient.  According to Rodriguez “These changes not only greatly enhance a patient’s privacy rights and protections, but also strengthen the ability of my office to vigorously enforce the HIPAA privacy and security protections, regardless of whether the information is being held by a health plan, a health care provider, or one of their business associates.”

Some of the items in the new rule:

  • Increase the protection and control of health information.
  • Especially effects health information associates, contractors and subcontractors who help healthcare workers gather and store information.  Some of the largest breaches have been by associates.
  • Maximum penalty for violation has been increased to 1.5 million per violation
  • New rules also strengthen the requirement to report breaches to HHS and to notify the patient.
  • New rules make it easier for a patient to share their information for research purposes
  • Patients can ask for a copy of medical records in an electronic form
  • New rules regarding how information can be used for marketing and fundraising

The new rules add new regulations and stiff penalties related to gathering and storing protected information.  The actual implementation and enforcement of new rules will become apparent over the upcoming months but as anesthesia providers, we can expect questions about our health information security during future CMS visits.

For those with insomnia, click here to review the entire 563 page document

 

Chief CRNA: “Never Events” in Anesthesia

Never events are inexcusable actions in a health care setting, the things we talk about in the lounge and just can’t believe actually happened.   We wonder how somebody could have possibly made such a terrible mistake.  The National Quality Forum has formulated a list of 28 never events in the hospital setting.   In the Operating room, never events include things such as wrong patient, wrong operation, wrong body part, use of contaminated drugs and many other issues.  Click here for a list of never events.

A recent press release from Johns Hopkins University School of Medicine states that across the country, never events occur at lease 4000 times per year.  The press release refers to research done over a 10 year period to quantify the occurence rate of never events.  Among other things, the study found:  Of the 80,000 patients who were affected by never events, 6.6% died, 32.9 % suffered permanent injury, and 59.2% suffered temporary injury as a result of the mistake. The events also led to 9,744 paid malpractice claims over the same period with payments totaling $1.3 billion.

The press report mentions policies hospitals and healthcare centers can implement to prevent never events, including mandatory “timeouts” in the operating room before operations begin to make sure medical records and surgical plans match the patient on the table. Other steps include surgical checklists as well as surgical instruments with electronic bar codes that allow for precise counts of materials and limit human error.

Click here to read the press release from Johns Hopkins.

As  CRNAs, we are instrumental in developing a corporate culture of safety.  As leaders in the perioperative area, CRNAs can make a difference.

 

 

Chief CRNA: The anesthesia team of the future

In the era of Healthcare reform, the practice of anesthesia is being redefined by both the advancement of technology and the impact of regulations.  As the scope of anesthesia care emerges from the head of the table to include care across the entire perioperative course, the anesthesia team must evolve to meet the new demands.

An article by Bartels K, et al published in Curr Opin Anaesthesiol. 2011 Dec;24(6):687-92, speculates on the anesthesia team of the future.

According to Bartels, the anesthesia team of the future must provide well tolerated, efficient, and cost-effective perioperative care.  Some of the points made are:

  • The team of the future must develop standards for simulation assuming that simulation will improve healthcare delivery
  • The team of the future will draw large volumes of information and generate data that is more accurate and complete related to the patient’s physiologic parameters.  The providers will use smart phones and other devices to add portability to the data they compile.
  • Electronic resources will provide real time updates along with physilologic data and pictures to help the provider determine interventions for optimal patient care.
  • Merging of databases will streamline operating room utilization, hospital bed utilization and supply ordering and storage

The anesthesia team of the future will utilize all available emerging technology to provide expertise across the perioperative continuum.

Click here to review an abstract of the original work

 

Meetings: Pinnacle Partners In Medicine, Dallas

Pinnacle Partners In Medicine is hosting their 10th Annual Clinical Seminar “Emerging Issues in Anesthesia Practice” on Saturday, February 2, 2013.  The seminar will be located at the Omni Dallas Hotel Park West (1590 LBJ Freeway, Dallas, TX 75234). The seminar will be from 7:00am – 2:00pm.

Do not miss out on a great opportunity to continue your education. This program has been approved by the American Association of Nurse Anesthetists for 4 CE credits.

Click here for registration for the event or for more information.

Clinical Topic: Cerebral O2 Saturation and Cognitive Dysfunction

Postoperative cognitive dysfunction (POCD) is a common complication after major surgery with general anaesthesia in the elderly.   Due to the increase of average life expectancy, an increasing number of elderly patients undergo surgery. Following surgery, elderly patients may exhibit  cognitive changes.

Anesthesia researchers have speculated that single lung ventilation places an elderly patient at increased risk for reduced cerebral oxygenation and also speculate that reduced cerebral oxygenation correlates with postoperative cognitive dysfunction.   Two recent studies have addressed the issues described above.

In the first study by Tang L, et al (Br J Anaesth. 2012 Apr;108(4):623-9. doi: 10.1093/bja/aer501. Epub 2012 Feb 5.) titled “Reduced cerebral oxygen saturation during thoracic surgery predicts early postoperative cognitive dysfunction.” studied seventy-six patients undergoing thoracic surgery with single-lung ventilation (SLV) of an expected duration of >45 min were enrolled. Monitoring consisted of standard clinical parameters and absolute oximetry (S(ct)O(2)). The Mini-Mental State Exam (MMSE) test was used to assess cognitive function before operation and at 3 and 24 h after operation.  In this study, the authors found that postoperative cognitive dysfunction correlated with reduced cerebral oxygenation during surgery

Click here to read the abstract of the original work.

A similar study by Suehiro K. et al found similar results.  The study titled “Duration of cerebral desaturation time during single-lung ventilation correlates with mini mental state examination score.” published in J Anesth. 2011 Jun;25(3):345-9. doi: 10.1007/s00540-011-1136-1. Epub 2011 Apr 12.  looked at “Sixty-nine patients , each of whom received combined thoracic epidural and general anesthesia. rSO(2) was measured using INVOS 5100 (Somanetics, Troy, MI, USA) before anesthesia (baseline value) and until SLV was completed. Patient cognitive function was assessed using the mini mental state examination (MMSE) on the day before surgery (baseline) and then repeated 4 days after surgery. The patients were classified into two groups: with (desaturation group, group D) and without (nondesaturation group, group N) cerebral desaturation during SLV. Cerebral desaturation was defined as a reduction of rSO(2) during SLV less than 80% of the baseline value.”  They found that the duration of cerebral desaturation correlated with postoperative cognitive dysfunction.

Click here to read the abstract of the original work

Cerebral oxymetry is becoming increasingly available and should be considered for the elderly patient scheduled for one lung ventilaion.

Clinical topic: The Preanesthetic Set-up

Ensuring that the necessary equipment is present and in working condition is foundational in providing safe anesthetic care to each patient and is a standard of care to which we are held.  Patients expect their anesthetist to be properly prepared for each and every case.  The following comes from the Anesthesia Patient Safety Foundaton:

“While chatting with a patient about to undergo a laparoscopic cholecystectomy, you administer an induction dose of propofol and an intubating dose of vecuronium. The patient loses consciousness and spontaneous respiration ceases. You adjust the mask on the patient’s face to establish a secure fit and squeeze the reservoir bag, only to find that you are unable to deliver a positive pressure breath. A quick visual inspection of the breathing circuit does not reveal the cause of the problem. Can you reliably ventilate this patient before he becomes hypoxic? Is an alternative method of ventilation readily available and functioning? Is there a reliable source of oxygen? Furthermore, you are using a relatively new anesthesia machine that performs an automated checkout procedure. What functions of the anesthesia machine did the automated checkout actually evaluate? Did you perform a thorough check of the machine before use that could have detected the source of this problem?”

An article by Samuel Demaria, Jr., MD published in Anesthesia/Analgesia in 2011 titled Missed Steps in the Preanesthetic Set-Up  discusses common steps that are omitted in the set-up process and offers a revised set-up procedure with the following steps being essential on every case:

  • Manual ventilation device
  • Full machine checkout done
  • Adequate suction
  • Emergency airway devices (endotracheal tube, laryngeal mask airway)
  • Emergency drugs
  • Working IV
  • ASA monitors

The study found that The most frequently omitted step was the availability of a manual resuscitation device.  Another notable finding was that rooms with 5 or more cases scheduled had a higher incidence of missed steps when compared with rooms with less than 5 cases.

Click here to read the original article and review the guidelines.

The Anesthesia Patient Safety Foundation is committed to ensuring a safe anesthetic for every patient.  In the APSF newsletter Spring 2008, Jeffrey M. Feldman, MD, MSE  presented New Guidelines Available for Pre-Anesthesia Checkout.

Click here to read the article as published in the APSF newsletter.

“Do no harm” is one of the foundational tenets of healthcare and patients (and their lawyers) expect anesthesia providers to be prepared for each and every case.  Review the articles and guidelines above and return to procrna.com to leave a comment.

CRNA Topic: Volunteer Your Time and Talent.

Hello everyone.  I want to tell all of you about another exciting opportunity for us to pay it forward.  Earlier in the year, I wrote an article about volunteerism.  My first opportunity to teach other nurses anesthesia education outside of the United States was in Eritrea (Eastern Africa).  Now I am honored to have another opportunity to again be the Nurse Anesthesia program director for a joint venture between Health Volunteers Overseas and Johns Hopkins University.  I worked with Dr. John Sampson of Johns Hopkins for many years in the advancement of anesthesia education.  We first met and worked together as colleagues at Walter Reed Army Medical Center when I was on active duty in the early 2000’s.  Since then, Dr. Sampson and I have collaborated on anesthesia education overseas with great success.  Our next site is Sierra Leone in Western Africa.
The primary lecture site in country will be the Prince Christian Maternity Hospital.  Johns Hopkins already has a presence in Sierra Leone, so no one needs to worry that we are going to the site as the first educators from the U.S.  Currently one of the goals of the Hopkins program is to implement a distance-learning program for anesthetists in Sierra Leone.  Instructors in the program would be from Johns Hopkins, but also interested volunteers from HVO may be invited to participate.  Another CRNA colleague of mine, Terry English and I would screen and mentor HVO nurse anesthesia volunteers for involvement in Sierra Leone.  Length of engagement would be a minimum of 2 weeks.  Pending funding for the next iteration of nurse anesthesia students from the health ministry, the goal is to begin sending volunteers in March 2013.

The following list is the desired structure of the HVO / JHH program developed by Dr. Sampson and his colleagues at Hopkins.

•    There shall be an anesthesiology program director and a nurse anesthetist program director.
•    The two program directors will need to continuously communicate with each other about the activities and problems encountered in their respective areas.
•    Volunteers will come from a nation-wide pool of applicants and all volunteers will have to pass through the usual HVO process for registering and serving as a volunteer.
•    A Johns Hopkins based meeting will take place monthly where nurse anesthetists and anesthesiology physicians will discuss methods of enhancing the impact of educational efforts and methods of assessing this impact.
•    An effort will be made to teleconference and video-teleconference interested individuals who are remote to Johns Hopkins Hospital so that they may participate in the development of nurse anesthesia education in Sierra Leone.
•    Every effort will be made to accommodate the time of year choices made by the volunteer applicants.
•    Every effort will be made to coordinate the trips so that experienced travelers make trips in pairs with novice travelers.
•    All volunteers are asked to keep a record of both the intellectual and material contributions that they make toward improving nurse anesthesia education in Sierra Leone.
•    A discussion group web site will be established whereby Sierra Leone nurse anesthetists are able to discuss clinical and academic questions with past and future volunteers to the program.

According to Dr. Sampson, the latest information is as follows.  Current airfare ticket prices are approximately $1300.  Of course this will vary and the individual volunteer will need to research this accordingly.  The hotel rate negotiated is currently $80 per day (breakfast included) other meals are $7 per day.  Transportation from the hotel to hospital via taxi is about $5 each way.  Regarding cabs, we will generate a list of cab drivers with cell phones and encourage visitors to use the same drivers daily because in the morning the cab drivers are so busy picking up groups of people that finding a dedicated cab to the hospital can be a challenge.
The hotel is the Kona Lodge (http://thekonalodgesl.com).  The distance to the hospital is about 7 miles.  But due to traffic congestion, the trip can take up to 45 minutes.  The best time to travel to the hospital in the shortest amount of time would be in the early morning hours.
Our goal is 12 volunteers per year.  A standard classroom is available and is dedicated to nurse anesthesia education. An LCD projector can be arranged for presentations.  Johns Hopkins will assist with education program development.
Even though the country made headlines in the 90’s because of hostilities in the nation, since the peace of 2002 Sierra Leone has become a vibrant city attracting investors and holiday travelers alike.  Reconstruction is evident in many parts of the country.  However, Freetown has the usual Western comforts.  Plus the beaches are beautiful and not yet crowded by commercial ventures.  Leisure activities are centered around the Aberdeen Beach area.  Regarding attire for the volunteers, shorts pants  (shorts, mini skirts) are not recommended. Casual to business casual dress is appropriate attire.  Scrubs are to be worn in the hospital only.  Standard urban precautions against petty theft are prudent and plenty of Christian churches from a variety of denominations are present.
I urge any of you who read this to strongly consider volunteering.  Visit the HVOusa.org website and learn about what we do on a large scale.

If you have any questions please contact me at lexterrae1230@gmail.com.

Pamela Chambers, CRNA

Clinical Topic: Fluid optimization improves outcome

The clinical anesthetist is frequently challenged with the critically ill patient presenting for non-cardiac surgery.  Often, they are in a weakened condition with very little physiologic reserve.  It is essential that fluid administration is goal directed to optimize outcome.  In this patient population, hypovolemia will lead to hypotension and related complications.  However, excessive fluid administration will lead to heart failure.  Therefore, fluid optimization is essential in the critically ill patient.

An essay published by the Edwards Company “Using Fluid Optimization to Improve Hemodynamics : FloTrac Sensor”  makes the following statement:

  • Successful fluid optimization has been shown in numerous clinical studies to lead to improved patient outcomes, including reduced morbidity and shorter hospital stays
  • The studies are typically based on the physiological principles outlined by the Frank-Starling curve, which states that an increase in preload or volume will lead to cardiac flow-related improvement (e.g., better stroke volume) up to a certain  point, after which the “law of diminishing returns”  applies.

The essay goes on to state that there are 3 ways to assess fluid status:

  • Stroke Volume Variation (SVV): For control-ventilated  patients, SVV has been proven to be a highlysensitive and specific indicator for preload responsiveness.  As a dynamic parameter, SVV has the advantage of predicting whether a patient will benefit from volume before the fluid is given.
  • Passive Leg Raising (PLR): In situations where it is not possible to use SVV (i.e., during arrhythmias, when patients are not on control-mode of ventilation, or in patients at risk of complications from fluid loading), simply raising the legs has been proven clinically to act like a “self volume challenge” to indicate the patient’s status on the Frank-Starling curve. If the patient is fluid-responsive, SV will increase substantially.
  • SV Fluid Challenge: In the rare case when neither SVV nor PLR is feasible, the FloTrac system provides a highly efficient method for assessing fluid responsiveness via a standard fluid challenge.  The administration of a small volume of fluid (e.g., 250-500 mL) and observance of the corresponding change in SV and/or CO can indicate whether further volume will improve cardiac performance.

Click here to read the essay

Maxime Cannesson MD, University of California, Irvine  has published a full lecture complete with slides detailing the importance of goal directed fluid therapy during the intraoperative period.   The lecture may be viewed on Youtube and will give the viewer a foundational understanding of optimizing fluid therapy.  Click here to view the video.

To assist the anesthetist with goal directed fluid therapy, the Edwards Lifesciences Corporation has introduced the FloTrac Sensor and Vigileo monitor to clinical practice.  These devices help the anesthetist to evaluate the patient’s fluid status with respect to the Frank Starling curve and make appropriate goal directed decisions with relation to fluid administration

Click here to go to the Edwards web site and learn about the FloTrac sensor and Vigileo monitor.

PROCRNA.COM would like to hear from anesthetists with experience using the Vigileo monitor.  Please read the articles, view the video and return to share your comments with your colleagues.

Chief CRNA: Billing audits, Are You At Risk?

Every year the Department of Health and Human Services Office of the Inspector General conducts audits and on-site inspections of Health Care Facilities to ensure that billing and payment policies are being followed.   Recovery audit contractors are utilized to make the inspections and are reimbursed by collecting a percentage of the money saved due to the inspection.   In other words, the more billing discrepancies they uncover, the more they make.   The office of the Inspector General has over 600 auditors, the largest number of auditors of any Federal Agency.

Writing for the on-line blog MiraMed, Tony Mira discusses the 2013 OIG work plan and the implication for hospitals.    According to Mira,

“While the Work Plan sets forth the OIG’s attention for the upcoming year, it also provides insight into the attention other agencies and contractors (e.g., the Centers for Medicare and Medicaid Services (CMS), Recovery Audit Contractors (RACs), etc.) will pay, as well.  When the OIG cracks down on one body (e.g., CMS), that body cracks down on bodies beneath it (e.g., Medicare Administrative Contractors (MACs)), sending a ripple downstream all the way to the provider.  As such, it is important for providers to be aware of the OIG’s focal points in the upcoming year as they, too, will feel the impact.”

Click here to review the OIG 2013 work plan

According to the plan, several ongoing areas of review remain from previous work plans:

  • Hospitals—Same-Day Readmissions
  • Program Integrity—Medical Review of Part A and Part B Claims Submitted by Top Error-Prone Providers
  • Program Integrity—High Cumulative Part B Payments
  • Physicians—Error Rate for Incident-To Services Performed by Nonphysicians
  • Physicians—Place-of-Service Coding Errors
  • Evaluation and Management (E/M) Services—Potentially Inappropriate Payments in 2010

New areas of interest for review in 2013 include:

  • Hospitals—Inpatient Billing for Medicare Beneficiaries
  • Hospitals—The DRG Window
  • Hospitals—Non-Hospital-Owned Physician Practices Using Provider-Based Status
  • Hospitals—Compliance with Medicare’s Transfer Policy

 The OIG has published a video discussing the priorities of the 2013 work plan.  Click here to view the video.

As anesthetists, it is essential that our records and the billing for our services are accurate.   Inspectors have a plan to uncover billing fraud and recover excess payment.  As providers, we must be aware of the issues being audited.

Clinical Topic: Bis and Postoperative Cognitive Dysfunction

As anesthetists, we pride ourselves in our vigilance and our ability to maintain hemodynamic stability during difficult surgical situations.  However, for the patient, the surgical experience is just one point in time in the continuum of life.  They recover, leave the hospital and continue with life.  The ability of an elderly patient to participate in the activities of daily living can be impaired by postoperative cognitive dysfunction.

The risk of postoperative cognitive dysfunction in the elderly was documented by JT Moller MD et al in an article published in The Lancet (Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study,  The Lancet, Volume 351, Issue 9106, Pages 857 – 861, 21 March 1998)  The authors speculated that hypotension and hypoxemia might be correlated to cognitive dysfunction and state the following findings:

  • Postoperative cognitive dysfunction was present in 266 (25·8% [95% CI 23·1—28·5]) of patients 1 week after surgery and in 94 (9·9% [8·1—12·0]) 3 months after surgery, compared with 3·4% and 2·8%, respectively, of UK controls (p<0·0001 and p=0·0037, respectively). Increasing age and duration of anaesthesia, little education, a second operation, postoperative infections, and respiratory complications were risk factors for early postoperative cognitive dysfunction, but only age was a risk factor for late postoperative cognitive dysfunction. Hypoxaemia and hypotension were not significant risk factors at any time.

Click here for an abstract of the original article

A study  by MT Chan et al (BIS-guided Anesthesia Decreases Postoperative Delirium and Cognitive Decline,  PMID:23027226 [PubMed – as supplied by publisher])  utilized the BIS monitor to guide the amount of anesthesia administered and to correlate depth of anesthesia to postoperative cognitive dysfunction.  In this study the BIS group had anesthesia adjusted to maintain a BIS level between 40-60.  The control group had anesthesia administered based on clinical signs.

Based on their findings, the authors concluded:

  • BIS-guided anesthesia reduced anesthetic exposure and decreased the risk of POCD at 3 months after surgery. For every 1000 elderly patients undergoing major surgery, anesthetic delivery titrated to a range of BIS between 40 and 60 would prevent 23 patients from POCD and 83 patients from delirium.

Click here for an abstract of the original article

The debate remains….”to BIS or not to BIS”   Many providers are comfortable that the depth of anesthesia is adequate without BIS guidance, however, the BIS may be useful in preventing excessive depth of anesthesia and, therefore, reducing the incidence of postoperative cognitive dysfunction in the elderly.

What say you?  Please share your thoughts with your colleagues.