Tag: anesthesia topic of the week

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.

 

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

 

 

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: 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

 

Chief CRNA: “Never Events” in Anesthesia

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

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

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

Click here to read the press release from Johns Hopkins.

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

 

 

Chief CRNA: The anesthesia team of the future

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

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

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

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

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

Click here to review an abstract of the original work

 

Clinical topic: The Preanesthetic Set-up

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

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

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

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

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

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

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

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

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

CRNA Topic: Volunteer Your Time and Talent.

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

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

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

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

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

Pamela Chambers, CRNA

Clinical Topic: Fluid optimization improves outcome

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

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

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

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

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

Click here to read the essay

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

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

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

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

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: Learning Ultrasound Guided Regional Anesthesia

Ultrasound guided regional anesthesia has quickly established itself as the preferred technique for placing blocks.  Several models of ultrasound devices are available and each vendor touts their product as the best.  Time for placement, success of the block and patient satisfaction all reinforce ultrasound guided placement as the method of choice for regional anesthesia.

CME meetings across the country are offering hands on workshops to teach anesthesia providers how to properly use this new technology.  Likewise, Nurse Anesthesia training programs have added ultrasound guided regional anesthesia to the curriculum.  Educators agree that mastering ultrasound technology is important but to date teaching techniques have not been evaluated.

A study by John Gasko, CRNA et al funded by the AANA Foundation and recently published in AANA Journal — August 2012 Supplement  (Effects of Using Simulation Versus CD-ROM in the Performance of Ultrasound-Guided Regional Anesthesia) compares two techniques for teaching ultrasound guided regional anesthesia to Student Nurse Anesthetists.  Students were divided into groups and were taught either by the use of CD-ROM based teaching or by simulation with human subjects.  A third group was taught using a combination of both approaches.

The authors found that there was no difference in learning between those using CD-ROM versus simulation.  However, the study found that a combination of CD-ROM and simulation was clearly more effective than either technique separately.

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

Click here to learn about how you can support CRNA research through the AANA Foundation.

Return to procrna.com and share your comments with your colleagues.

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

Clinical Topic: Ultrasound Guidance in Anesthesia

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

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

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

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

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

Clinical Topic: Does Anesthetic Technique Make a Difference?

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

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

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

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

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

 

 

 

 

 

Clinical Topic: Control Infection with disposable ECG wires

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

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

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

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

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

Chief CRNA: CRNA supervision requirement reviewed by CMS

Physician supervision of CRNAs has been an ongoing topic of debate within the Anesthesia community for decades.  Under current law, CRNAs are required to be supervised by a physician unless the individual State “opts out” of the requirement.   To date, 17 States (Kentucky the most recent) have opted out of the requirement.

In a post on The Anesthesia Insider, blogger Neda Mirafzali, Esq  (Anesthesiologists Targeted in CMS’ Review of Existing Rules)  states that Health and Human Services (HHS) has been directed to review all existing rules related to health care and make them more effective, efficient, flexible and streamlined.   As a part of the review, CMS is looking at the issue of CRNA supervision as a condition of participation in the care of Medicare and Medicaid patients with the possibility that the supervision requirement be removed on a Federal level.

The blog post includes a brief but excellent review of who may supervise a CRNA and what constitutes supervision.  Changing the regulations would have no effect on the states that have already opted out of the requirement for supervision.  The remaining 33 States would, in essence, be automatically opted out by virtue of the rule change

Click here to read the original blog post and return to procrna.com to make a comment.

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.

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.

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

Clinical Topic: Glucose Control in the OR

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

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

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

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

Other basics of managing the diabetic patient:

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

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

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

 

Clinical Topic: 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)

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.