anesthesia clinical topic

Anesthesia considerations for the patient with high alcohol intake

By Thomas Davis, DNAP, MAE, CRNA

Sometimes the simple things make a big difference in the practice of anesthesia. During the preop assessment, elements of the patient’s social history are noted including smoking, alcohol intake and level of activity. Frequently, “social drinker” is noted but the amount of alcohol consumed is not. In an otherwise healthy patient, an anesthesia provider gives it a quick glance and moves forward with the case.

Recently I was made aware of a case in which a male in his late 70’s, normal BMI, otherwise healthy and noted to consume 15 alcohol drinks per week was scheduled for a case using a block and propofol sedation. The block was successfully placed however when the propofol sedation was started, the man exhibited constant movement which continued even as the propofol infusion was increased. Finally, the airway was secured and high dose propofol was infused until the restless movement was calmed. What’s up with that?

An AI review of the literature related to high alcohol intake and paradoxical movement with propofol sedation revealed the following:

Heavy alcohol drinkers are more likely to experience an excitement response including abnormal movement during propofol sedation.
Agitation and restlessness are more likely during sedation in patients who drink heavily compared to those who drink little or no alcohol.
Patients with high alcohol intake are more difficult to achieve optimal sedation with propofol and higher doses of other sedative drugs may be needed.
Depending upon whether the patient has normal liver function, the onset and duration of sedative drugs may be altered in high alcohol intake patients.
High alcohol intake may interfere with central nervous system function making it more difficult for the patient to move with coordination and respond predictably.

Both the National Institute for Health and a review published by Florida Anesthesia Services supports the overview listed above and offer suggestions for anesthesia and the high alcohol intake patient.

Preoperative considerations. Assess and clarify alcohol intake during the preop interview. Ask the patient to define “social drinker” and assume that patients commonly under report their actual alcohol intake. In the case mentioned above, the man who reported 15 drinks per week likely consumed more than admitted. The NIH has an alcohol intake questionnaire that can be used when you suspect that your patient consumes large amounts of alcohol. In addition to clarifying the alcohol intake, assess your patients baseline mobility, nervous system, particularly numbness, and their cognitive function.
Intraoperative considerations. In the high alcohol patient, higher doses of propofol will likely be required for induction of general anesthesia and hypotension following induction should be anticipated. If a block is planned, consider that the nervous system may be depressed and therefore blocks may last longer than anticipated. When using propofol sedation with a block, anticipate that higher doses may be required to prevent paradoxical movement. If higher doses of sedatives are required, keep in mind the increased risk of postoperative cognitive dysfunction in elderly patients receiving midazolam.
Postoperative considerations. Heavy drinkers increase the risk of postoperative complications 5 times more than light or nondrinkers. The incidence of delirium, tachycardia, seizures, or a depressed immune system is greatly increased in heavy drinkers. Because we do many of our cases on an outpatient basis it is important to assess the cognitive function of the patient before discharge. In these cases, it is essential to have a reliable person at home to be with the patient immediately after surgery.

In the practice of anesthesia, sometimes the little things make a big difference. After assessing the case of the elderly man with paradoxical movement during propofol sedation followed by a review of the literature, I have a new respect for reviewing the patient’s social history including alcohol consumption. This insight will help me to manage future cases, including a thorough postop evaluation before releasing the patient to go home.

Tom is an experienced leader, educator, author, and requested speaker. Click here for a video introduction to Tom’s talk topics.

Opioid Free Anesthesia, The future of our profession

By Thomas Davis, DNAP, MAE, CRNA

Evidence-based delivery of anesthesia is the foundation for our current practice as CRNAs. Going back four decades when I was an eager student in a hospital-based anesthesia program, the standard of care for general anesthesia consisted of nitrous oxide, opioids, sedatives, and volatile anesthetic agents. The goal was to deliver a hemodynamically stable patient to the recovery room and trust that the patient would wake up without incident. Because pulse oximetry had not yet been invented, visible breathing was all that was necessary, and we had no knowledge of oxygen saturation in the blood. Issues such as PONV and residual muscle weakness were treated by the PACU nurse as we moved on to the next case. We have come a long way since those early days in my career.

Fast forward to our current practice and the advancement of our profession to modern times where we are actively researching issues related to our practice and modifying the standard of care based on evidence. Among the modifications to current practice triggered by evidence is the shift to opioid-free anesthesia where possible.

Moving to opioid-free anesthesia

Historically, opioids have been integral to the administration of general anesthesia. However, evidence gathered over the past few decades has revealed that the use of opioids is not without risk and new alternatives to opioids have opened the door to opioid free anesthesia. To support the shift away from opioid use, the Society for Opioid-free anesthesia was established with the following goals:

Summarize the existing literature on this anesthetic technique and provide evidence-based recommendations.
Promote new research in this area of anesthesia.
Educate and help guide anesthesia professionals as they learn about the transition to practicing opioid free anesthesia.

Those interested in learning more about the Society for Opioid Free anesthesia are encouraged to visit their web site, https://goopioidfree.com/

NIH supports moving away from opioid use

The National Institute for Health has the stated mission “seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability.” After reviewing current research related to the use of opioids during anesthesia, the NIH lists the following as adverse side effects related to the use of opioids during anesthesia.

Respiratory depression/apnea
Hypotension
Bradycardia
Somnolence
Confusion
Urinary retention
Constipation/ileus
Increased intracranial pressure related to hypercapnia
Rigidity
Delayed emergence
Delirium
PONV
Opioid induced hyperalgesia
Development of long-term opioid abuse

The findings by the NIH reinforce the goals of the Society for Opioid Free anesthesia to move away from the routine use of opioids for anesthesia or analgesia in the perioperative period.

Why opioid free and why now?

The advancement of anesthesia practice requires that we modify our practice when new evidence emerges to support safer and more effective ways to achieve our goals. From a review of the literature, here are compelling reasons to move to opioid free anesthesia.

Improved patient outcomes. Short term, there is less respiratory depression, nausea, and cognitive dysfunction in the recovery area. Long term, there is a reduction in urinary retention, constipation, pruritis, and cognitive dysfunction. In addition, there is evidence that certain types of cancer have a higher metastatic rate when opioids are used during removal of the primary tumor.
Lower risk of opioid dependence. Opioid use can lead to an up regulation of pain sensation and the desire for even more opioids to provide relief. Over time, this may lead to long term opioid abuse.
Enhanced recovery following surgery. ERAS protocols were initially developed to enhance recovery following bowel surgery and currently the protocols are being developed to include other types of surgery. At the core of the ERAS protocol is the elimination of opioids and the use of multimodal techniques for pain control.

Alternatives are available

Going back several decades, the alternatives to opioids had not yet been developed and anesthesia providers were obligated to use opioids as an adjunct to volatile agents when administering general anesthesia. Now, with the development of a variety of alternatives, the use of opioids is totally optional. When possible, the use of a nerve block with propofol sedation and multimodal supplements removes the need for opioids. Drugs such as dexmedetomidine, ketamine, acetaminophen and a variety of NSAIDS administered during and following a procedure provides adequate pain relief to the patient. Other supplements such as ice, gentile massage, relaxation techniques and gentle stretching add to the effectiveness of the multimodal approach. Preoperative teaching to educate the patient regarding realistic expectations and non-pharmacologic methods to alleviate discomfort further enhance the effectiveness of the multimodal approach.

Challenge yourself to go opioid free

Now is the time to challenge yourself to move away from the use of opioids in your practice of anesthesia and master the skills necessary for pain control without the use of narcotics. A quick search of the internet will provide a plethora of information about alternatives to opioids. For additional support, consider joining the Society for Opioid Free Anesthesia.

Tom is an experienced leader, educator, author, and requested speaker. Click here for a video introduction to Tom’s talk topics.

Clinical Topic: Obstructive Sleep Apnea and Outpatient Surgery

The evolving changes in the delivery of Healthcare in general and anesthsia in particular has created an emphasis on patient safety. With the push for more cost effective delivery of healthcare, more procedures are being done on an outpatient basis on sicker patients. Combining the new economics with the obesity epidemic in America has created the scenario where an increasing number of patients with Obstructive Sleep Apnea are presenting for outpatient surgery. As anesthetists, we are tasked with providing safe care and answering the question of who is or is not a candidate for outpatient surgery.

In 2006 the ASA published guidelines for the perioperative management of patients with OSA. Although the guidelines were good at the time, the Society for Ambulatory Anesthesia felt that the ASA guidelines were due for review and updating, did a comprehenhive review, and published their findings.

An article by Joshi et al published in Anesth Analg 2012 (Society for Ambulatory Anesthesia Consensus Statement on Preoperative Selection of Adult Patients with Obstructive Sleep Apnea Scheduled for Ambulatory Surgery) reviewed the ASA guidelines. They went on to note that the Society for Ambulatory Anesthesia task force on practice guidelines developed a consensus statement for the selection of patients with OSA scheduled for ambulatory surgery. Some key points include:

Patients with a known diagnosis of OSA and optimized comorbid medical conditions can be considered for ambulatory surgery, if they are able to use a continuous positive airway pressure device in the postoperative period.
Patients with a presumed diagnosis of OSA, based on screening tools such as the STOP–Bang questionnaire, and with optimized comorbid conditions, can be considered for ambulatory surgery, if postoperative pain can be managed predominantly with nonopioid analgesic techniques.
On the other hand, OSA patients with nonoptimized comorbid medical conditions may not be good candidates for ambulatory surgery.

Click here for an abstract of the Joshi article.

As anesthetists, how do we assess patients and how do we determine who is at risk? The Society for Ambulatory Anesthesia recommends the use of the STOP-Bang assessment tool. The questionnaire asks 8 basic questions and gives the anesthtist valuable information about the OSA risk during the preoperative evaluation.

Click here for the STOP-Bang tool in a PDF format which can be downloaded and printed.

Combining a good physical evaluation with the STOP-Bang assessment will help identify those at risk and enable the anesthetist to make an informed decision regarding who should or should not receive outpatient care.

Chief CRNA: Disabled Alarms Cost Lives

Do you ever get tired of listening to monitor alarms? Many anesthesia providers who are confident in their vigilance and their ability to “know when something is wrong” mute the alarms when they feel that they are needlessly alarming. Unfortunately, patients are injured or killed every years in anesthesia related mishaps which could have been prevented had the alarms been fully functional.

According to Ana McKee, MD from the Joint Commission “Alarm fatigue and management of alarms are important safety issues that we must confront”. Between January 2009 and June 2012, the commission received 98 voluntary reports of alarm-related events, 80 of which resulted in patient deaths and 13 in serious injuries. (The Dangers of Alarm Fatigue)

An article published in Outpatient Surgery describes one such case in which a 17 year old female was given Fentanyl in the recovery room in a bay where the monitor had been silenced. The narcotic caused a respiratory arrest which went unnoticed due to the curtain pulled around the bed. The patient suffered severe brain damage and died a few weeks later. The settlement in the case was 6 million dollars and the CRNA was named in the suit along with the PACU staff because the anesthetist had left the patient with a monitor that had been muted. Click here to read about the case.

The Joint Commission has named alarm fatigue as one of the top healthcare technology hazards and makes the following recommendations:

standard operating procedures for alarm management and response
an inventory of devices that sound alarms
guidelines for alarm settings and situations when alarm signals are not clinically necessary
regular training on alarm management and inspection of alarm-equipped devices
discussions to determine how to reduce nuisance alarms

Click here to read more from The Joint Commission regarding alarm fatigue

Monitor alarms are an important tool in the quest for patient safety and should not be disabled or muted.

New Product: Handwashing Bracelet Improves Handwashing Compliance

According to the CDC, nearly 2 million people get infections while in US hospitals annually and around 100,000 of those people die. Hand washing is one of the most important and easy ways of reducing the transfer of pathogens from person to person.

An Article by By Ruth LeTexier, RN, BSN, PHN (Preventing Infection Through Handwashing) makes the following points:

In the healthcare setting, handwashing is often cited as the primary weapon in the infection control arsenal. The purpose of handwashing in the healthcare setting is microbial reduction in an effort to decrease the risk of nosocomial infections.
The CDC has identified handwashing as the single most important means of preventing the spread of infection.5 The premise of the handwashing CDC guideline is infection control. The CDC recommendations for handwashing are as follows:

Handwashing Indications
In the absence of a true emergency, personnel should always wash their hands:

1) Before performing invasive procedures (Category I).

2) Before taking care of particularly susceptible patients, such as those who are severely immunocompromised and newborns (Category I).

3) Before and after touching wounds, whether surgical, traumatic, or associated with an invasive device (Category I).

4) After situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or body fluids, and secretions or excretions (Category I).

5) After touching inanimate sources that are likely to be contaminated with virulent or epidemiologically important microorganisms; these sources include urine-measuring devices or secretion collecting apparatuses (Category I).

6) After taking care of an infected patient or one who is likely to be colonized with microorganisms of special clinical or epidemiologic significance, for example multiple-resistant bacteria (Category I).

7) Between contacts with different patients in high-risk units (Category I).

An article by Cory Schultz (A new wristband measures hand washing compliance by healthcare providers) describes a new product which improves handwashing compliance:

The creators of IntelligentM have designed a bracelet/wristband that vibrates when the wearer has scrubbed their hands for a sufficient length of time.
An accelerometer can detect how long an employee spends washing their hands; the wristband buzzes once if the procedure is done correctly and three times if it’s not.

Click here to read about the new handwashing bracelet and how it can improve compliance with CMS and CDC standards.

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.

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.

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

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

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: “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.

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.

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.

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.

Clinical Topic: Intraoperative Hypotension and Stroke

As guardians of patient safety during the surgical procedure, anesthetists are tasked with the prevention of adverse intraoperative events. Of the many risks of surgery, death and stroke are two of the most devastating events that can occur. Ischemic stroke occurs in 0.1-3% of patients undergoing general anesthesia. Thus, maintenance of cerebral perfusion is essential during the perioperative period.

In an article by Bijker JB et al titled Intraoperative Hypotension and Perioperative Ischemic Stroke After General Anesthesia (Anesthesiology. 2009 Dec;111(6):1217-26) the relationship between intraoperative hypotension and stroke is evaluated. The purpose of the study was not only to validate a correlation between hypotension and stroke, but also to determine the degree of hypotension and the length of time associated with an adverse outcome.

The study found that the incidence of ischemic events was increased when the blood pressure dropped 30% below baseline. The longer the blood pressure was below the critical level, the greater the incidence of adverse outcome. In the words of the author:

“Our results suggest that intraoperative hypotension accounts for an increase in stroke risk of approximately 1.3% per minute hypotension (i.e., the risk is increased 1.013 times for every minute of hypotension), depending on the definition of IOH that is used (in this case a decrease in mean blood pressure more than 30% from baseline). For example, a cumulative duration of 10 min of hypotension will result in a 1.14 times increased stroke risk (1.01310). If applied to the POISE trial, this would mean an increase in absolute stroke risk from 0.5% (POISE trial control patients) to 0.57%.”

Again, in the words of the authors: “In conclusion, the most widely proposed mechanism of a postoperative stroke is arterial embolism. Nonetheless, the results of the current study support the hypothesis that hypotension can influence the evolution of a postoperative stroke by compromising (collateral) blood flow to ischemic areas. In this context, hypotension is best defined as a decrease in mean blood pressure relative to a preoperative baseline, rather than an absolute low blood pressure value.”

Since patients present with a wide variety of baseline blood pressures, there is no magic number for a mean blood pressure to be maintained during surgery. The anesthetist is advised to calculate each patients lowest acceptable blood pressure based on maintaining the blood pressure within 30% of baseline.

Click here to read the complete article

Clinical Topic: Prewarming, Does it really matter?

Peri-operative hypothermia is a common problem related to the practice of anesthesia. Numerous studies have documented the negative effects of hypothermia to the extent that SCIP has made patient temperature a marker of quality care. In an attempt to reduce hypothermia, many anesthesia providers recommend patient pre-warming in the holding area prior to surgery.

An article by Horn EP et al published in Anaesthesia (The effect of short time periods of pre-operative warming in the prevention of peri-operative hypothermia., Anaesthesia. 2012 Jun;67(6):612-7) evaluated the effects of 10, 20 and 30 minutes of forced air pre-warming on surgical patients. The study found that those who were not pre-warmed experienced a greater temperature drop during surgery regardless of the active measures used in the operating room to maintain body temperature. The Authors recommended a minimum of 10 minutes of pre-warming prior to surgery.

Click here for an abstract of the Horn et al study

In a separate study by Wagner, D published in AORN, the causes and problems related to hypothermia are listed. According to the author, the following factors place the patient at risk:

Cold ambient temperatures
Cold beds
Reduced Metabolism
Anesthesia / pharmacological agents
Evaporative heat loss

Patients who become hypothermic experience the following problems:

Negative nitrogen balance with reduced kidney perfusion
Respiratory distress
Reduced metabolism of medications
Delayed recovery from anesthesia
Impaired platelet function and clotting
Impaired wound healing
Increased wound infections.

To prevent intraoperative hypothermia, the author recommends forced air pre-warming

Click here to view the author’s article.

Clinical Topic: Predicting Sleep Apnea, the STOP-BANG scale

A foundational skill required of all anesthetists is airway management. With the obesity epidemic in our nation, obstructive sleep apnea (OSA) is becoming more common and presenting challenges to the anesthetist. Predicting which patients are at increased risk for OSA is an important part of the preoperative assessment. In a recent report published in the british J Anaesth, 2012; 108:5: 768-75, Chung F et all evaluated the correlation of the STOP-Bang scale to the occurrence of sleep apnea.

The STOP-BANG evaluation scale is simple to use. It consists of asking the patient yes or no questions regarding the following 8 items:

Snoring. Do you snore?
Tired. Are you frequently tired during the day?
Obstruction. Have you ever been told that you stop breathing when you are asleep?
Pressure. Do you have high blood pressure
BMI Is your BMI over 35?
Age. Are you over age 50?
Neck Circumference. Is your neck circumference over 40 cm?
Gender. Are you male? (should be obvious)

If the answer is yes to 3 or more of these questions, the patient is at increased risk for obstructive sleep apnea. The higher the number, the greater the risk. Of interest, a male over 50 starts with a score of 2 regardless of the other risk factors.

Click here to review the on line assessment tool published by thesleepmd.com

Click here to review the article by Chung et al. as presented by the Virginia Assn of Nurse Anesthetists.

Clinical Topic: JCAHO Sentinal Event Regarding Opioids

Patient safety is a foundational responsibility of all health care workers. The Joint Commission identifies “sentinel events” related to patient safety and distributes them to Hospitals. During accreditation visits, JCAHO evaluates the Hospital’s effectiveness in addressing, reporting, and eliminating sentinel events.

“A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness.” wikipedia

Examples of sentinel event are:

Infant abduction
Rape
Suicide
Transfusion reaction
Wrong surgery
Wrong radiation dose

Recently, the Joint Commission published a Sentinel Event related to the use of opioids in the Hospital. The following points are included in the Sentinel event report:

Implement effective practices, such as monitoring patients who are receiving opioids on an ongoing basis, use pain management specialists or pharmacists to review pain management plans, and track opioid incidents.
Use available technology to improve prescribing safety of opioids such as creating alerts for dosing limits, using tall man lettering in electronic ordering systems, using a conversion support system to calculate correct dosages and using patient-controlled analgesia (PCA).
Provide education and training for clinicians, staff and patients about the safe use of opioids.
Use standardized tools to screen patients for risk factors such as oversedation and respiratory depression.

By posting the Sentinel event, the Joint Commission has established guidelines for health care workers to follow, including anesthetists. Click here to read the advisory published by the Joint Commission.

Clinical Topic: What’s your favorite Anesthesia APP?

Controversy remains as to whether or not cell phones (hand held computers with audio capability) and iPads have a place in the operating room. It is true that they can be a distraction for healthcare workers but they also put a wealth of information at your finger tips. When used appropriately, they provide instant information to the anesthetist that could make a difference in patient safety.

Recently, I posed the question to several of my colleagues; What is your favorite Anesthesia APP? Below are a few of the favorites. I am asking porcrna.com readers the same question. What is your favorite APP? Look over the APPs listed below and use the comment box below to share your experience with these APPs or to add your own favorites.

Epocrates: This free drug reference is the #1 mobile drug reference for U.S. physicians. With it you can search brand, generic, and OTC medicines. Plus, you can customize your homepage for quick access to the features you use most frequently.

abeoCoder gives access to CPT®, ASA CROSSWALKS®, and ICD codes right from your iPhone or BlackBerry. abeoCoder app provides you with codes, base units, descriptions and more.
Coding Made Easy.

Pedi Safe is an advanced airway management and cardiac resuscitation app. In an emergency, healthcare providers can quickly identify a patient’s weight or Broselow color, and then Pedi Safe displays all appropriate weight based dosing, equipment sizes, and normal vital signs. An excellent reference for doctors, nurses and paramedics!

drawMD; Using the iPad, Anesthesiologists can create interactive visual guides as a way to explain complex issues and possible medical and surgical solutions for Anesthesia and Critical Care-specific conditions and procedures, such as a central line chest tube, intubation, spinal epidural, etc.

One more just for fun…….and this one works on your pet too!

Alivecor has developed the iPhone ECG—a case that transforms the iPhone into a wireless, clinical quality heart monitor. The case is able to monitor one’s heart rate almost immediately, and can even measure through a cotton shirt!

Browse, enjoy and leave a comment to share your favorite APP with your colleagues.