Category: clinical forum

Clinical Topic: Ultrasound Guidance in Anesthesia

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

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

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

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

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

Clinical Topic: Does Anesthetic Technique Make a Difference?

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

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

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

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

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

 

 

 

 

 

Clinical Topic: Control Infection with disposable ECG wires

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

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

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

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

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

Clinical Topic: SSEP Not required for Cervical Spine surgery

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

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

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

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

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

Clinical Topic: Fluid management in Major Surgery

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

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

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

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

Click here to read an abstract of the original article.

Clinical Topic: Glucose Control in the OR

The intra-operative management of the Diabetic patient poses many challenges to the anesthetist.  Theories abound related to the advantages of “tight control” using an insulin infusion versus a less strict approach using bolus dosing.   Regardless of your beliefs regarding blood sugar control, being informed and having a plan is essential for the safety of your patient.

An excellent review article by Joseph F. Answine, M.D. titled Peri-operative Diabetes Management for Dummies: Just Check the Sugar! and published by the Pennsylvania Society of Anesthesiologists discusses the foundational points to be considered when administering anesthesia to the diabetic patient.

From Dr Answine: “What do we know about peri-operative glucose control? We know that infection rate, length of hospital stay, overall cost for the hospitalization, and morbidity and mortality are directly proportional to peri-operative blood glucose levels. We also know that there are numerous studies demonstrating improved overall outcomes with improved glucose control.”

The article goes on to advise the anesthetist to know the patient’s normal and work to keep the intraoperative blood sugar as close to the patient’s normal as possible.  The use of the glucometer intraoperatively is essential as is documentation.  When the patient comes with an insulin pump it is best to leave it on and check glucose levels frequently.

Other basics of managing the diabetic patient:

  • Do diabetics first case of the day
  • If outpatient, discuss post op glucosecontrol both  pre op and again before discharge
  • Test glucose pre-op
  • Know when patient last took diabetic medications
  • Know your patient’s history for self-control of diabetes
  • Intraop….infusions are better than a bolus
  • If the patient tells you how to manage their diabetes…..listen carefully

The bottom line is to know your patient’s history and glucose level.  With that knowledge, treat the patient appropriately.

The Full article continues with a chart showing the types of insulin, peak, and duration of action.  Click here to read the full article and return to www.procrna.com with your comments.

 

Clinical Topic: Propofol – Remifentanil Sedation

Epidural Anesthesia is becoming increasingly popular for Orthopedic procedures of the lower extremities.  Anesthetists are tasked with keeping the patient comfortably sedated while the Epidural provides adequate anesthesia during the procedure.   The goal is to keep the patient oxygenated and comfortable with hemodynamic stability and a rapid wake up at the end of the case.   An increasing number of anesthetists are finding that the combination of propofol – remifentanil is the answer.

A.A. Samaan and V. Srinivasan published an observational study  done in the Department of Anaesthesia, Diana Princess of Wales Hospital, Grimsby, England.

As reported by the authors: “Regional anaesthesia offers many advantages for major joint replacement surgery of the lower limb. These operations are usually lengthy and carried out on elderly patients. There is a need for effective and controllable sedation with fast recovery profile. This   obviates the need to administer general anaesthesia in addition to the regional anaesthesia. We undertook to evaluate the efficacy and side effects of combined infusions of Propofol and Remifentanil in this clinical set up.”

“This is an observational study of 123 consecutive patients who required joint replacement surgery; primary hip, primary knee, revision hip, revision knee and bilateral hip replacement.  Epidural anaesthesia was performed in 111 patients.  The Epidural site was either high lumbar or low thoracic. The Local Anaesthetic used was Bupivacaine 0.5%, warmed to body temperature, with Adrenaline added to achieve the strength of 1:200,000. The motor and the sensory functions were checked to ensure adequate blockade.”

Patients were sedated during the surgery with a manually controlled Remifentanil infusion (20 mg per ml solution) and a Target Controlled Infusion of Propofol.

The authors conclude “Sedation with Propofol and Remifentanil complemented successful Epidural regional anaesthesia for major joint replacement surgery.  It was especially valuable in prolonged surgery such as in the case of revision hip replacements. This avoided the need for general anaesthesia.  Sedation with Propofol and Remifentanil is associated with minimal side effects, even in prolonged operations of durations up to 260 minutes, provided there is adherence to a carefully titrated dosage.  In our experience the average infusion rate for Propofol was 2.5 mg.kg.hr and 0.02 mg.kg .min for Remifentanil.”

Click here to read the study and return to procrna.com to share your comments with your colleagues.

Clinical Topic: Patient Safety, The Helsinki Declaration

The European Board of and Society of Anesthesiology have adopted the Helsinki Declaration for Patient Safety in Anesthesia and have made recommendations for standards that further improve patient safety.

The authors state that patient safety has 3 components; a set of guiding principles, a body of knowledge and a collection of tools.  The basic principles are the tendency for things to go wrong is both natural and normal, rather than an opportunity to find someone to blame; safety can be improved by analyzing errors and critical incidents, rather than pretending they have not happened; and humans, machines and equipment are all part of a system, the component parts of which interact to make the system safe or unsafe.

The following Abstract was printed in the European Journal of Anesthesiology:

Anaesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, pain therapy and emergency medicine, has always participated in systematic attempts to improve patient safety. Anaesthesiologists have a unique, cross-specialty opportunity to influence the safety and quality of patient care. Past achievements have allowed our specialty a perception that it has become safe, but there should be no room for complacency when there is more to be done. Increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, new drugs and devices and simple chance all pose hazards in the work of anaesthesiologists. In response to this increasingly difficult and complex working environment, the European Board of Anaesthesiology (EBA), in cooperation with the European Society of Anaesthesiology (ESA), has produced a blueprint for patient safety in anaesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anaesthesiology, was endorsed by these two bodies together with the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients’ Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. The Declaration represents a shared European view of that which is worthy, achievable, and needed to improve patient safety in anaesthesiology in 2010. The Declaration recommends practical steps that all anaesthesiologists who are not already using them can successfully include in their own clinical practice. In parallel, EBA and ESA have launched a joint patient safety task-force in order to put these recommendations into practice. It is planned to review this Declaration document regularly.

The original article by Staender et al is a “must read” for all providers who sincerely seek to improve patient safety.  Click here to read the original article.

Return to procrna.com to share your thoughts with your colleagues.

Clinical Forum: Sevoflurane with RSI in Obese Patient

With the growing Obesity epidemic in America, anesthetists are continually facing the risk of induction and intubation with a potentially difficult airway.  Many theories are in the literature about the “best” technique for safe induction of the morbidly obese patient.  Pre-oxygenation is essential and proper positioning increases the odds of successful airway management.

A recent article by Toso et al. published in the European Journal of Anesthesiology (Eur J Anaesthesiol. 2011 Nov;28(11):781-7. described adding a component of inhalation anesthesia to the rapid sequence induction technique for morbidly obese patients.  In this study, the authors positioned and pre-oxygenated patients.   When ready for induction, the researchers turned on Sevoflurane and after 30 seconds of breathing the agent, they followed with a rapid sequence induction using propofol, alfentanil and Succinylcholine.  All patients were easily intubated on the first attempt and there were not occasions of desaturation.

The authors demonstrated that adding Sevoflurane to the RSI sequence provided conditions for a safe and controlled induction of anesthesia.

Click here to read an abstract of the original article.  Return to Procrna.com and share your opinion with your colleagues.

 

Topic: Continuous Capnography Linked to Lower Monitoring Costs

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

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

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

Clinical topic: Lower Central line infections

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

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

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

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

Clinical Topic: Propofol allergy in Children

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

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

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

 

 

Clinical Topic: Case Presentation by SRNA

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

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

Click here for slides

 

 

Brooks Cauley

SRNA

bcauley9@yahoo.com

Will graduate December 2012

 

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

Click here to download CV

 

Clinical Topic: Intubation verification with Ultrasound

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

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

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

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

 

 

Clinical Topic: Malignant Hyperthermia Review

Highlights of Malignant Hyperthermia

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

Definition

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

History

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

Pathophysiology

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

 

Triggering Factors

  • Halothane
  • Enflurane
  • Isoflurane
  • Desflurane
  • Sevoflurane
  • Succinylcholine

Signs of malignant Hyperthermia

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

Late Signs

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

Malignant Hyperthermia Protocol

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

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

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

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

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

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

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

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

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

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

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

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

13. Perform clotting studies

14. ABG Every 5 to 10 minutes

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

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

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

 

Dantrolene

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

 

References

Clinical Topic: Propofol Related Infusion Syndrome (PRIS)

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

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

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

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

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

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

Clinical Forum: Propofol dose in the Obese Patient

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

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

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

 

Clinical Topic: 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.

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.

Evidence Spoilage

Submitted by Pamela Chambers, CRNA, MSN, EJD

As we continually strive to provide the highest level of patient care to the guests in our facility, we cannot help but learn from the mistakes of others.  In an article published in the Dallas Morning News regarding the CMS findings at Parkland Hospital, one issue (of many) struck me as something many of us may not think about on a daily basis as we provide patient care. Document preservation, a.k.a. evidence preservation.

As electronic medical records, storage, and retrieval becomes the norm across the nation, all healthcare providers must be vigilant to not only document the care that is provided – but also produce any records about that care that are requested pursuant to any legal action in a timely manner.  Unreasonable (re: any) delay in production of records can have harsh adverse consequences.

SPOLIATION: the intentional destruction, mutilation, alteration, or concealment of evidence… If proven, spoliation may be used to establish that the evidence was unfavorable to the party responsible. (Black’s Law Dictionary, 8th Ed.)

While discovery is the process of collecting information to support the allegations and to otherwise build a case; Electronic discovery (E-discovery) is the collection, preparation, review, distribution, and production of electronic documents in litigation discovery. Electronic discovery includes files stored on office CPUs, laptops, network servers, Personal Digital Assistants (PDAs),CDROMs, DVD-ROMs, MP3 players, smart cell phones, backup tapes, flash memory cards and devices, other archive media, and third party storage systems. Also, voice mails become digital evidence, as collectable as e-mail. All of this digital content can become an important part of litigation.

During 2003 and 2004, United States District Court Judge Shira A. Scheindlin issued five groundbreaking opinions in the case of Zubulake vs UBS Warburg LLC.  Zubulake involved a typical employee discrimination claim, alleging gender discrimination and retaliation. The defendant produced approximately 100 pages of e-mails pursuant to the plaintiff’s request for production of all relevant documents but failed to search its backup tapes for e-mails that may have been deleted or stored elsewhere. Since the plaintiff had saved more than 400 e-mails herself, she knew the defendant did not produce all relevant information. Zubulake’s attorney was permitted to argue to the jury that the defendant intentionally destroyed incriminating documents. Ultimately, the court found that the defendant had deleted emails, lost backup tapes, and failed to diligently and thoroughly produce all its relevant files.

The court penalized the defendant by allowing an “adverse inference” instruction to the jury, noting that the jury could assume that the missing documents contained information adverse to the defendant’s case. In the end, the plaintiff was awarded more than $29 million in damages.

A party to litigation, or to litigation that is reasonably foreseeable, has a duty to preserve evidence in its possession or control that may be relevant. Adequate preservation of electronic stored information (ESI) requires more than simply refraining from efforts to destroy or dispose of such evidence. The party must immediately intervene to prevent loss due to routine operations or malfeasance. If a party destroys evidence in its custody or control, it can be subject to sanctions that range from an assessment of costs and fees to suppression of evidence, an adverse jury instruction, or even dismissal of the case.

Food for thought…….

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??

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.

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.