anesthesia clinical topic – Page 2

Clinical Topic: Ipad APP for Anesthesia Patient Teaching

Are you still trying to justify whether or not to break down and buy and iPad? As the use of technology continues to grow and develop, devices such as the Ipad are becoming important tools for the anesthetist. Writing for the on-line Barton Blog, author Ben Amirault describes a newly developed APP for the iPad which enables the provider to better educate patients in the pre-op environment. According to Mr. Amiralut, “An informed patient is a happy patient. Providers who can effectively communicate with their patients can expect high patient satisfaction scores and improved outcomes.”

The drawMD APP has diagrams and descriptions of common anesthesia related procedures and enables the provider to better explain the planned anesthetic to the patient and the family. The APP is currently free and can be obtained through the iTunes store. As described by the vendor “drawMD Anesthesia & Critical Care enhances doctor-patient communication by offering a new paradigm for explaining the complex issues surrounding the intensive monitoring and care provided by anesthesiologists and critical care physicians. In order to improve patient understanding of medical problems, drawMD utilizes the iPad’s unique interface to allow anyone to sketch, stamp, or type directly on the detailed anatomic images included in the application.”

Click here to read the blog post by Mr Amirault

Click here to view the APP at the iTunes store

Download it, try it, and return to PROCRNA.COM and leave a comment.

Clinical Topic: CRNA liable for poor communication

Despite the requirement for all health care workers to have annual training related to fire safety, hospital fires continue to occur. Operating rooms have an ample supply of each of the elements required to ignite a fire and the anesthetist must be vigilant to the threat of fire at all times.

Ann Latner, JD, writing for the online blog clinicaladvisor.com describes an interesting scenario in which a fire occurred on a patient during a procedure. To summarize:

Routine case (facial area) with patient receiving Monitored Anesthesia Care
Patient’s Oxygen sat drops and CRNA applies supplemental oxygen
Oxygen buildup under the drapes
Surgeon uses cautery
prep solution ignites and patient receives a facial burn

In addition to the burns, the patient required psychiatric follow-up and filed a law suit against the CRNA, the surgeon and the Hospital. At trial, each of the defendants had separate lawyers and each gave testimony. The Hospital affirmed that they had provided the required fire safety training. The surgeon testified that had he known oxygen was in use, he never would have used cautery. The CRNA was the only one of the three found to be liable for damages.

In the words of Ann Latner, the author, “Good communication is one of the best ways to avoid being a party to a lawsuit. Whether it is talking with your patient or a colleague, when making referrals, or even in chart notes (an important form of medical communication), having clear, direct, and open lines of communication can prevent unfortunate results. Mrs. H would have never been injured had Mr. D simply notified the surgeon of the oxygen use. No amount of testimony could make up for those few missing words during the procedure. Communication is key to better patient outcomes and to protecting yourself.”

Click here to read the full article and return with your comments.

Clinical Topic: Intraoperative Hypothermia

Reducing or eliminating postoperative surgical site infection is an ongoing challenge to health care professionals. Infection following surgery constitutes up to 38% of nocosomial infections. Avoiding intraoperative hypothermia is thought to be an important to overall survival, especially in trauma patients. To improve the quality of care, SCIP protocol mandates the recording of intraoperative temperature and the use of forced air warming systems when patients are at risk for hypothermia.

A recent study by Seamon MJ, et al, (Ann Surg. 2012 Apr;255(4):789-95.) attempted to determine the impact of intraoperative temperatures on the incidence of surgical site infections in patients with abdominal trauma. Patients were supine on warm water blankets and forced air warmers were applied to upper and lower extremities. Antibiotics were administered per protocol. A total of 524 patients were included in the study, most were young males who had received either gunshot or stab wounds. Temperatures were closely monitored and patients were tracked for the development of postoperative infection.

The authors found that increased surgical site infection was correlated with hypothermia with a critical body temperature being 35 degrees C. The authors recommend that intraoperative normothermia should be strictly maintained in trauma patients.

Click here to read an abstract of the original work

Chief CRNA: 360 Degree Evaluations

As the regulatory requirements continue to increase, the need for 360 degree evaluations has emerged as a part of JCAHO certification. The concept is that those who do evaluations of their staff should also be evaluated by their staff. In the case of CRNAs it means that the anesthetist should be evaluating the supervising Anesthesiologist. Wilma Gillis from Madison Wisconsin is facing this issue in her department and wrote the following for CRNAs who read procrna.com. Please use the comment box below to share your thoughts and experiences.

Hey friends,
I am canvassing a few department leaders preliminarily who work in management or in large institutions to see what your place of employment does about this “new” and controversial concept for implementing 360 degree evaluation of ALL team members. Does your institution have a way for its CRNAs to evaluate the anesthesiologists?

To give you some background on this, twice we in our group decided this would be an important contribution to our concerns. We wrote a tool over the last years and it was shut down by our administration due to absolute fury by several anesthesiologists. The aspects of performance included in this tool had nothing to do with evaluating their medical practice. It revolved around things that were important to harmonious, collaborative practice.

Now JCAHO is mandating the idea after several years of hinting at it. I am very interested in learning of your various departmental evaluation processes and tools. If any of you have given evaluations to anesthesiologists, how did it go? Repercussions?

Wilma Gillis.

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.

Research: Steep Trundelenburg and Postoperative Visual Loss

Postoperative visual loss is a rare but catastrophic event that has an increased in frequency with robotic surgery in the steep head-down position. Studies have been conducted and reported in the literature relating intraocular pressure to postoperative visual loss. One study conducted in the steep head-down position with laparoscopic surgery demonstrated increased intraocular pressure as time progressed. Normally, cerebral and ophthalmic circulatory autoregulation prevent increased intraocular pressure, however, this may not be the case during general anesthesia in the steep head-down position.

Research conducted by Bonnie Molloy, CRNA, PhD (A Preventive Intervention for Rising Intraocular Pressure: Development of the Molloy/Bridgeport Anesthesia Associates Observation Scale) and published in the AANA Journal (AANA Journal, June 2012, Vol. 80, No. 3) is a “must read” for any anesthesia provider administering anesthesia to patients in the steep head-down position. This comprehensive review of postoperative visual impairment following head-down surgery details the pathophysiology and describes observable, physical changes that will alert the observant provider that intraocular pressures are increasing.

Data obtained by the author revealed that increasing intraocular pressure in the patient in the steep head-down position correlates to increasing eyelid and conjunctival edema. These physical signs can be used to determine when it is advisable to level the patient and allow the intraocular pressures to decrease.

The result of this excellent, well documented study was the development of the Molloy/Bridgeport Anesthesia Associates Observation Scale. Using the signs of eyelid and conjunctival edema, the anesthetist can predict when intraocular pressures are increasing. The original work is complete with illustrations to guide the anesthetist in the use of the observation scale.

This original work was funded in part by a grant from the AANA Foundation and is essential knowledge for anybody routinely doing cases in the steep trundelenburg position lasting greater than 2-3 hours. Click here to view the original publication.

Product Review: enFlow fluid warming system

PROCRNA.COM presents new products of interest to the anesthesia community. Inclusion on this web site does not constitute an endorsement of the product. Please review this information, visit the enFlow web site and obtain a demonstration from your local representative.

Keeping surgical patients at a normal body temperature is a daily struggle for those in the medical field. Among the 45 million inpatient1 and 34.7 million ambulatory2 surgeries occurring annually in the United States, it is estimated that 50-90% suffer from hypothermia (defined as a core temperature below 36 degrees Celsius).3 Hypothermia in the perioperative environment is caused by a variety of factors including low operating room temperatures, large surgical incisions, a core-to-peripheral redistribution of body heat as a result of anesthetics, chilled IV solutions, surgical procedure length, and more.4 Hypothermia has a significant impact on postoperative outcomes, which are almost exclusively undesirable.

Hypothermia is one of the most preventable complications resulting from an operative procedure, and prevention is most effective when warming begins preoperatively5 and continues across the surgical workflow. Vital Signs Inc., a GE Healthcare Company, has introduced an IV fluid/blood warmer that helps hospitals start the warming process early and continue warming across the patient’s care journey to reduce the occurrence of hypothermia.

The enFlow* IV Fluid/Blood Warming System is helping hospitals warm their patients with mobility, speed, and accuracy. The patient-dedicated cartridge attaches in-line to standard IV fluid/blood delivery sets at the start of procedures and moves with the patient, allowing care givers an easy, efficient, and cost effective way to warm across each stage of the surgical process. When it is time to move from one area of the surgical workflow to another, the user simply removes the cartridge from the enFlow warming unit, allowing the IV set in its’ entirety to be moved with the patient when transported. Once the patient arrives at the next area, the cartridge is easily inserted into an enFlow warming unit stationed in that area and is back to heating within seconds. In addition to mobility and speed, the system also enables accurate temperature control with a differentiated warmer that sits close to the patient (reducing the opportunity for fluids to cool in the IV line) and has eight temperature sensors ensuring fluids are the right temperature for patients.

To learn more about the enFlow IV Fluid/Blood Warming System and the impact it can have on your Anesthesia Department. Click here to visit the enflow web site.

*enFlow is a trademark of General Electric Company

1 Center for Disease Control and Prevention, FastStats. Inpatient Surgery, Data are for the U.S. Accessed November 29, 2011. http://www.cdc.gov/nchs/fastats/insurg.htm.
2 Center for Disease Control and Prevention. U.S. Outpatient Surgeries on the Rise. Accessed November 29, 2011. http://www.cdc.gov/media/pressrel/2009/r090128.htm.
3 Young, V. Watson, M. Prevention of Perioperative Hypothermia in Plastic Surgery. Aesthetic Surgery Journal. 2006; 551-571.
4 Kurz A, Sessler DI, Lenkhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996;334:1209-15.
5 Paulikas, CA. Prevention of Unplanned Perioperative Hypothermia. AORN J. 2008; 88(3): 358-365. DOC1194144

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.

Research: What is the best handwashing technique?

Postoperative infections are a major concern throughout the healthcare industry to the extent that infection rates have become a marker of “quality care”. Patients expect health care workers to protect them from exposure to harmful organisms and, as we know, handwashing is foundational for any infection control program. As anesthesia care providers, we are called upon for insertion of invasive lines where a sterile field is as essential as the sterile field required by the surgeon. Therefore, handwashing among anesthesia providers is essential for patient safety.

Since the advent of the germ theory, handwashing has been the first line of defense against pathogenic organisms. In the operating room, handwashing has evolved into a full 5 minute scrub using a bacteriocidal soap or solution. Recently waterless antiseptic solutions have emerged on the market and have been touted as being equally effective as the full 5 minute hand scrub. The efficacy of the antiseptic solutions is still being studied.

A study by Burch et al, Anesth Analg. 2012 Mar;114(3):622-5 (Is alcohol-based hand disinfection equivalent to surgical scrub before placing a central venous catheter?) Looks specifically at anesthesia providers using various techniques for hand cleaning prior to insertion of a Central Venous Catheter. Five different hand cleaning techniques were used and hands were cultured after cleaning. The techniques were as follows

Traditional 5 minute hand scrub
Traditional 5 minute hand scrub, 15 minute break, then alcohol only cleanser
Alcohol only cleanser
Alcohol only cleanser, 15 minute break, then traditional 5 minute scrub
Waterless surgical scrub alone

The authors found that method 3, the alcohol only cleanser was significantly less effective than the traditional hand scrub. This study supports the theory that hands are best decontaminated by using the full 5 minute scrub at the beginning of each day.

Click here to read an abstract of the original work.

Research: Partner’s Presence During Epidural Placement

The constant pursuit of patient safety and satisfaction is foundational to excellence in patient care. Involvement of the patient’s family has been shown to increase satisfaction and enhance the overall medical experience. Many hospitals allow parents into the operating room for induction of anesthesia in their children. In the area of labor and delivery, epidural anesthesia has been shown to not only reduce the pain of labor but also relieve anxiety of both the patient and the partner. A question yet to be answered is whether or not the presence of the partner during placement of the epidural reduces anxiety and increases satisfaction.

A study by Orbach-Zinger et al published in Anesth Analg 2012 (Partner’s presence during initiation of epidural labor analgesia does not decrease maternal stress: a prospective randomized controlled trial.) seeks to assess whether the partner’s presence during labor epidural chtheter placement reduces mother and partner anxiety level. The study included 84 couples who were divided into two groups; partner present or partner absent during catheter placement. Anxiety levels, pain and time to placement were measured.

At baseline, there was no difference in anxiety or pain between the groups. During catheter placement, anxiety levels and pain during insertion were significantly higher in the group with the partner present. The authors concluded that partner presence during epidural catheter insertion did not decrease anxiety levels. The anxiety and pain of catheter placement were greater with the partner present.

Click here to read the original abstract of this study.

Topic of the week: An opportunity to excel

In the Army, one is often tasked to do a job that most consider undesirable (i.e. 20 push-ups in full combat gear, pulling weeds in the parking lot in full combat gear, or painting the commander’s office in full combat gear); at the completion of said task the assigning officer or Drill Sergeant may state (re: yell) “Well, what do you have to say…” The appropriate answer to convey your honor at being chosen to do the push-ups, pull the weeds, or paint the office would be, “Thank Sir/ Drill Sergeant for the opportunity to excel”.

I often think of that phrase when, in my professional life I take on tasks or assignments that no one else wants, or no one else has yet chosen to perform. I was given a wonderful opportunity by a good friend of mine who was, and is, a professor of Critical Care Medicine and Anesthesiology at Johns Hopkins. The task was to help educate nurses and nurse practitioners to learn how to provide anesthesia safely to patients in an austere environment. For Free. This was my first opportunity to do two things that I love – teach and talk about anesthesia – to people who were in dire need of a willing volunteer.

Here in the United States, we take safe anesthesia care for granted. It is a luxury that we expect when we undergo surgery or diagnostic procedures. But I soon learned, in grave detail, that safe anesthesia care is not available to everyone. My first opportunity to volunteer in this capacity was in Asmara, Eritrea in 2003. In Asmara, I met and worked closely with a wonderful nurse anesthetist named Kessette Tweldebrhan. Kessette founded the schools of nurse anesthesia in both Asmara the capital of Eritrea, and in Addis Ababa the capitol of Ethiopia. Among the many, many things that I learned from Kessette was not only the need for anesthesia providers and educators in his and nearby countries; but I also learned about many of the horrible conditions that the citizens in his part of the world endure every day because of the lack of anesthesia providers and a quality anesthesia education.

One problem that I learned about was obstetric fistula. Kessette was fortunate enough to work with Drs. Reginald and Catherine Hamlin in the fistula hospitals in Ethiopia. He gave me the book that they wrote about their experience learning about and devising a plan to combat obstetric fistula. Fast forward 9 years. Recently, I was contacted by another physician who has made it his lifes work to combat obstetric fistula – in Niger. The physician is Dr. Steven Arrowsmith. I came across the accompanying article about Dr. Arrowsmith and his fistula program. Currently they are in dire need of qualified American anesthesia professionals who have the knowledge, skill, will, and desire to step up to the plate and help the women of Niger. I intend to answer the call. Please review the article that I found about Dr. Arrowsmith and visit his website. I’ve also included a few pictures from my travels in Eritrea teaching anesthesia at the Orrota Hospital of Asmara University.

With all of the blessings that we have, consider this as your opportunity to excel. If not you, then who?

Click here for the article by Dr Arrowsmith

Research: Optical Fibers for Nerve Block placement

The application of technology to practice has enabled the CRNA to deliver patient care that is safer and more reliable than at any other time in history. The placement of nerve blocks has always been challenging. Thirty years ago, soliciting paresthesia or trans arterial needle placement were common methods for administering an axillary block. The Ultra sound guided nerve block has increased not only the success rate but also safety to the patient. What can be done to improve on Ultra Sound?

Desjardins AE et al recognized that the success of a nerve block depends upon the proper placement of the needle. They developed a stylet with optical fibers that could collect light for analysis of optical reflectance spectrometry. The theory was that different tissues reflect a different wavelength of light and the stylet could be used to differentiate between nerve and vascular tissues. Click here to read an abstract of their work.

Taking the concept one step further, Balthasar A, et al used the technique on human subjects. They reported that the stylet with optical fibers was able to differentiate between nerve and vascular tissue an on 2 cases detected actual vascular penetration by the needle. Click here to read an abstract of their study.

Will the optical stylet replace ultra sound for nerve block placement? Probably not. However, the addition of the optical stylet which detects penetration of the needle into either vascular or nerve structures could add another element of safety to nerve block placement.

Research: ECG as source of infection

Hospital acquired infections are a major concern to the American Health Care Industry. Each year infections cost an estimated 30-50 Billion dollars and cause 100,00 deaths to patients who trust their health to all levels of providers across the Nation. Research to identify common sources of infection has implicated ECG wires as a reservoir for bacteria.

A study by Gilske, D et al at Advocate Lutheral General Hospital, Park Ridge, IL examined ECG wires as a source of Hospital Acquired infection. In this study, 35 sets of ECG wires from ICU were disinfected using the standard Hospital protocol for cleaning rooms after discharge of a patient. Both wires and snaps were cultured. These researchers found:

From the 35 cultures, 57 organisms were detected

65% positive for coagulase negative stahp
11% positive for methacillin resistant staph aureus
14% positive for vancomycin sensitive enterococcus
3% positive for vancomycin resistant enterococcus

They concluded that standard decontamination methods applied to reusable ECG wires and snaps are not effective.

Click here to review a poster session presenting the original work.

The Lifesync Corporation has introduced a wireless ECG to the marketplace. The disposable leads are placed on the patient and connected to a wireless device which sends signals to a receiver connected to the standard monitor. The immediate and obvious advantage is the reduced risk of infection offered by the disposable ECG leads. The secondary gain for the Anesthetist is removal of wires from the work area. The ability to position the patient lateral or prone without the mess of ECG wires is a definite plus of this system. Click here to go to the Lifesync web site. If you have used this product, please write a review in the comments section of this post.

Disclaimer: PROCRNA.COM has NO financial tie to Lifesync Corporation or it’s products. All questions should be directed to Lifesync.

Chief CRNA: How secure is your work group?

As Chief CRNAs, we are tasked with many roles and responsibilities. In addition to clinical case management, we are tasked with additional duties that included personnel management, scheduling, recruiting, supplies, HR issues, and much more. It is easy to become so involved in the daily work load that we lose sight of the looming threat related to survival of the work group. Across the country, large, for profit management firms are writing contracts with the hospitals and displacing long standing work groups. Market place competition is no longer between CRNA and MDA groups, but between local management versus takeover by a larger group with regional or national interests.

Tony Mira writing in the Anesthesia Insider blog makes the following statement:

“While the business of health care continues to evolve, there is perhaps no part of it changing faster than anesthesia. Numerous factors are quickly shifting the market towards an even more competitive and demanding landscape. The days of anesthesia groups simply providing clinical coverage in a hospital’s operating rooms are, for better or for worse, drawing to a close.”

He goes on to identify factors such as the expanded areas of coverage within the hospital, expanded roles of anesthesia providers, change in reimbursement levels and continued cuts in Medicare as factors that threaten the local work group. The trend is for small practices to be taken over by for profit organizations. The defense may be the merger of your group with other small work groups in your geographic area forming a larger, cohesive group.

The following are advantages of merging small groups into one organization:

One cost for management of the entire consolidated group
Single cost for billing, HR, credentialing, privileges, recruiting
Larger group generates a larger database for QA
leverage in contract negotiation for supplies
Leverage to negotiate a better benefits package
Cross coverage between hospitals within the organization for vacation / sick coverage
Larger group has increased security and is at less risk for takeover by a for profit organization

As Chief CRNAs, it is essential that we are proactive and have a positive working relationship with Hospital administration. Those in an Anesthesia Team environment must have a seat at the table when management decisions are made. Working with the Department Chair for the common good is essential. Those in an all CRNA practice must remain vigilant to the threat of takeover and form strong coalitions with other CRNA groups and even consider maintaining your own identity while merging with larger team oriented groups. The threat is real. Make sure Hospital administration knows the value you add to the organization and maintain a high level of awareness related to a potential take over by an Anesthesia corporation.

Click here to read the full article by Tony Mira

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.

Chief CRNA: Coordinated care; Reduce Cost and Improve Care

Managing health care dollars in more important now than ever in the era of healthcare reform. Limiting the use of extra supplies and running low gas flows is helpful but a coordinated approach involving the entire peri-operative team is needed to achieve maximum results.

Tony Mira of MiraMed Global Services posted a web based article detailing the contribution that anesthesiology makes to coordinated case management in the patient receiving total knee replacement. Tony states “Coordinated care” is one of the key concepts in health system reform. It is central to the cost savings and quality improvements expected from Accountable Care Organizations, value-based purchasing and the medical home.”

He goes on to identify three areas where the anesthetist can add value and reduce cost to the patient receiving a total knee replacement. According to Tony:

Coordinated management of patients. “First, we found that the health system with the lowest in-hospital complication rate had successfully developed and implemented an outpatient preoperative approach that emphasized multi-specialty evaluation of potential arthroplasty candidates, followed by an inpatient co-management approach involving anesthesia, internal medicine, and orthopedic surgery.”
Dedicated operating room team. “The benefit of a dedicated operating room team seems logical, given that total knee replacement is a procedure that requires staff to be familiar with multiple pans of instruments, machinery, and other technologies that are used to implant the knee prostheses. The total knee replacement surgeons agreed that working with an experienced arthroplasty team led to a smoother and faster workday.” The article does not mention anesthesiologists or nurse anesthetists as part of the dedicated OR team, but it seems reasonable that familiarity across both sides of the ether screen would be beneficial.
Management of patients’ expectations. “After having examined its data, one member health care system implemented a patient expectations management process, whereby patients were activated and engaged in the process of discharge planning before admission. The result was an initial reduction in length-of-stay, without a change in complication rates.”

By becoming active participants in the patient’s overall surgical experience we not only reduce the overall cost, but we improve patient satisfaction. CRNAs have a long history of excellence at the head of the table. It is time for us to become more actively involved in the entire process.

Click here to read the original article posted by Tony Mira and return to leave a comment.

Chief CRNA: Automated Recordkeeping

Automated Anesthesia Recordkeeping (AARK) has been available for over 20 years and is being used in more and more operating rooms across America and around the world. Despite becoming mainstream technology, AARK continues to generate controversy. Is the advantage of automatic physiologic data capture offset by a loss of vigilence by the anesthesia provider? Several studies have investigated the loss of vigilence related to AARK.

J. Allard, R, D. Zwoncaky et al published the results of a study in the British Journal of Anaesthesia addressing the issue of the effects of AARK on provider vigilence.

As stated by the Authors: “Proponents of this technology profess that automated record keepers reduce record keeping time thereby leaving more time for data interpretation and patient care . Moreover, others suggest that computer-generated records are more accurate and complete than those charted manually . On the other hand, critics argue that allowing the AARK to chart the vital signs removes the anesthetist from the information feedback loop and thereby has an adverse effect on vigilance . The main intent of this study was to determine the effect of an AARK on intraoperative record keeping time and vigilance.”

“Thirty-seven cases were charted manually and the remaining 29 were charted with a commercially available AARK. In order to evaluate vigilance, a physician examiner entered the operating room unannounced once during 33 of the manually charted cases and during 22 of the automatically charted cases and asked the anesthetist to turn away from the monitors and recall the current value of eight patient physiological variables. The examiner recorded the recalled values and also the actual current monitor values of these variables. The videotapes were reviewed and the anesthetist’s intraoperative time was categorized into 15 predefined activities, including intraoperative anesthesia record keeping time. We compared recalled and actual variable values to determine if the recalled values were within clinically relevant error limits.”

The authors conclude the use of the AARK did not significantly affect vigilance. They go on to state that it appears that in using an AARK, the provider reallocates intraoperative record keeping time from manual charting to dealing with problems.

Click here to read the complete study and return to 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: Handwashing Standards

New patient safety guidelines require increased vigilance in handwashing by healthcare providers. Previous guidelines established by OSHA required soap and water handwashing between every patient contact. Over the past few years, alcohol based handwashing agents have been introduced to the hospital setting raising the question about their efficacy and risk.

An article By Gina Pugliese, RN, MS; Judene Bartley, MS, MPH, CIC; Tammy Lundstrom, MD, reviews the topic of the use of alcohol based handwashing solutions. They state:

“The evidence is clear; HCW compliance with hand hygiene can reduce the 2 million healthcare-associated infections that occur in patients annually, as well as reduce the risk of infections transmitted to workers. But the use of these waterless alcohol-based hand antiseptics, the centerpiece of the new CDC guideline, has been perceived to be in conflict with existing healthcare safety regulations. These include, for example, handwashing requirements from the Occupational Safety and Health Administration (OSHA), flammability issues from the National Fire Protection Agency (NFPA), and corridor obstruction issues from Centers for Medicare and Medicaid Services (CMS).”

The article goes on to discuss the fire risk related to the use of alcohol based handwashing solutions. As CMS tightens enforcement of handwashing in the healthcare workplace, this information is essential for CRNAs. Click here to read the article and return to PROCRNA.COM to share your comments. ( If the link takes you to an ad, wait about 5 seconds and it will go on to the article)

CRNA Wellness: Wake-up call

My humorous Native American name for my younger daughter was Face In The Soup. When she was tired, SHE WAS TIRED, and by the 6:00 p.m. dinner hour, her face went down on the table and it didn’t come up. As a young mother, I learned quickly to make sure she had received all of life’s necessities before OUR dinner time because no matter what happened in my own life, at 6:00 p.m. her curtain was going down. If she were now an anesthetist on the job, her adopted name could be Dies on the Table or Puts Patients at Risk.

Chuck Biddle, CRNA, PhD, chief editor of the AANA Journal and multi-published author of sleep deprivation articles, quotes another anesthesia industry sleep expert, June J. Pilcher, when he reports that: Fatigue caused by lack of adequate sleep results in diminished cognitive function, impaired vigilance, decay in problem-solving ability, degradation in memory, and eroded motivation.
Click here to read the article.

Okay, so I can’t tell you anything that will make the surgeon close that thoracic cavity in time for you to be eating dinner by 6:00, or to watch Dancing With The Stars, or to shower off the sounds, smells and stress from the OR and still drop into bed by 10:00. But I can give you some simple fitness suggestions for making sleep more useful when your head makes contact with the pillow-top. People who are fit and healthy sleep better than those who aren’t. Simple. True.

Physical exercise is way at the top of ways in which to elevate energy but tire the body in such a manner as to make sleep deeper and easier. Although it is a personal choice as to what time of day you should do your cardio or tote that bail, you can figure it out in just a few morning or evening trips to the gym, or on the elliptical in front of your Netflix pick. Morning cardio elevates your metabolism and your heart rate which energizes you for the better part of the day but fatigues you in a pleasant way by or before gall bladder number six. Doing your cardio before bed does the same thing to metabolism and heart rate so you probably want to take a bit of down time between cardio and vespers. Some of you may prefer to do a lunchtime cardio on the days it’s possible, a great substitute for pop ‘n pizza. Try to create some routine so that your body says, “It’s time to cardio; it’s time to eat; it’s time to don the scrubs; it’s time to let down; it’s time to sleep.”

Stretching and crunching before bed is another great way to relax and create routine before the sandman comes. Tom S. Davis, CRNA, MAE, likes to say, “Every day that I don’t make time to stretch is one day closer to the day I won’t be able to.” If you don’t have a designated work-out area at home, keep a Pilates mat, a towel and a 55cm fitball (inflatable stability ball) in your bedroom so that it’s easily available every evening. Do various crunches that access all areas of the abs followed by a thorough five-minute stretch routine that leaves you feeling loose, relaxed and calm. Wind down by finishing your toilette routine. Then crawl in and let go.

Eat dinner right before bed…and you’ll sleep poorly. Drink coffee right before bed…and you’ll have to interrupt your sleep to offload. Consume alcohol in excess…and reflux, insomnia and restless sleep will be your companions. Wear a belly to bed that looks like an eminent delivery, and you’ll wake yourself up with your own snores, not to mention that you’ll be sleeping alone. In short, what you put in your body all day is the very same thing you’ll put into bed that night and your sleep will thrive or dive because of it. Lower the bad fat in your diet, especially lower the sugar, decrease the volume of intake and put down the fork, fingers or chopsticks between every few bites. Intentional eating of reasonable kinds and amounts of food are your fitness friend, and quality sleep will become a close relative.

Finally, stay away from negative news, time-consuming e-mails, family complaints and anything else that puts your head in a quandry and reduces your tranquility. Say, “Good-night,” to your honey, calmly go through your affirmations, prayers or meditation minutes and put out your lights. Six hours, seven hours, preferably eight hours later, your fit, healthy Self will be refreshed and ready to take your life back. Then go pop into the OR bright-eyed and bushy-tailed and clip on your nametag: Saves The Lives of Others.

Other Tips
Take a power nap during your break.
Don’t stop for restaurant food on the way home.
Don’t drink alcohol.
Avoid drugs and sleep aides.
Get extra sleep BEFORE call.
Avoid arguments.
Split your cardio into morning and evening.
Eat very lightly if it’s late.
Read relaxing lit.
Do Yoga.
Meditate.
Say, “Good-night, Gracie!”

You can visit Liz during your waking hours at www.bdyfrm.com. Read the motivational, entertaining Lizlines Monday through Friday and watch for her original Lizlimerick once a week. Ms Liz

Fitnotes
Chuck Biddle, CRNA, PhD, is a professor and staff anesthetist at Virginia
Commonwealth University, Richmond, Virginia. He is editor in chief of the AANA Journal. Email: cbiddle@hsc.vcu.edu.

Tom Davis, CRNA, MAE is chief nurse anesthetist at Scott and White Medical Center, Temple, Tx and former assistant professor of nurse anesthesia at University of Kansas. He is the owner of and consultant for Procrna.com. Email: tom@swcrna.com

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.