Tag: anesthesia topics

Clinical Topic: Obstructive Sleep Apnea and Outpatient Surgery

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

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

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

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

Click here for an abstract of the Joshi article.

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

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

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

Clinical topic: Do Drug Tests for Cocaine Improve Outcome?

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

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

From the Authors:

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

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

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

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

 

Clinical Topic: Predictors of Postoperative Sort Throat

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

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

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

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

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

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

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

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

Clinical topic: Should Flu Shots Be Required?

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

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

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

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

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

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

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

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

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

Chief CRNA: New HIPAA rules released

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

Some of the items in the new rule:

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

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

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

 

Clinical Topic: Cerebral O2 Saturation and Cognitive Dysfunction

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

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

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

Click here to read the abstract of the original work.

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

Click here to read the abstract of the original work

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

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

Chief CRNA: Billing audits, Are You At Risk?

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

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

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

Click here to review the OIG 2013 work plan

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

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

New areas of interest for review in 2013 include:

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

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

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

Clinical Topic: Bis and Postoperative Cognitive Dysfunction

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

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

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

Click here for an abstract of the original article

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

Based on their findings, the authors concluded:

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

Click here for an abstract of the original article

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

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

CRNA Wellness: Beverages are Making Us Fat

Driven to Drink?
The 6:30 a.m. drive-through line is long but the beverage baristas inside have got the gig down.  Take the order, take the money, write on the cup, hand it off and move’em forward.  Just across the overpass to our medical center, Starbucks customers line up bumper to bumper on their way to work.  And another of the Seattle-based ‘bucks right inside the entrance to the med center picks up the slack.  Mmmmm, creamy, sweet, warm…what’s not to like about lapping up your favorite frap on the way to tackling a heavy work schedule?  Answer:  The heavy part. Beverages are making us fat.

Getting Juiced
Let’s start with juice.  Orange juice and the members of its expanding family, are loaded with sugar.  They may be fortified with vitamin C, added calcium, or may contain those magical anti-oxidants that didn’t make it into your lunch bag, but most juices are also fortified with sugar, frequently over 15 grams of sugar per 8-ounce serving.  An 8-ounce glass of Tropicana original orange juice has 114 calories.  70 calories are sugar and though it may satisfy 96% of your daily requirement for vitamin C, there is only a tad of added calcium and a smaller tad of vitamin A.  Ounce for bounce, the payoff isn’t there.  A fresh orange, however, has a much lower 62 calories of which 48 are natural sugar(fructose), and it provides 116% of your necessary vitamin C.  An orange supplies twice the natural calcium as juice, three times the vitamin A plus 3.1 grams of natural fiber.  Plus, you get to chew!

There are entire aisles devoted to fruit- flavored beverages in bottles, boxes and cans in your shiny, upscale grocery chain, but nothing satisfies your body’s needs like fresh, whole fruit, the more color and the more variety, the better.  If ya just hafta have your bananas and berries in a beverage, get out the blender and give it a whirl.  You won’t need to sweeten the pot.

Smooth Move 
Blenders are used for making the smoothie. Originally, the smoothie was a fruit and ice beverage, sometimes with added sugar.  Although it debuted as a beverage in the 1930’s, Wikipedia says that the term smoothie/smoothy was actually conjured up by the hippies, though I don’t remember seeing any at Woodstock, and that California, with its ready access to fresh seasonal fruit was the original venue for vending it.  Now we blend smoothies choosing from yogurt, protein powder, kale, carrots, blueberries, strawberries, milk…the list is endless but the calories are increasing with the options.  It isn’t difficult to find a smoothie shop right around the corner from your produce market, only you’ll drink close to 300 calories if you buy it already made.  Go back around the corner, concoct your own smoothie and you take control.  To get through a busy day in the OR and still get your nutrients, a smoothie is a great choice. Opt for low fat, no sugar-added, skimmed-milk, light yogurt or water-based, make either fruit or veggie drinks, and avoid expensive, high-calorie add-ins.  If your smoothie is meant to enhance your work-out, a tablespoon of protein powder is a fine idea.  If dessert is a smoothie, go back to the original 1930’s recipe by using simply fresh fruit and ice. Eliminate the sugar and pour it in a six-ounce wine glass. Now that’s a juice bar!

Are You a Soda Jerk?
Coke, 7-up, Pepsi, Dr. Pepper, Sprite, Mountain Dew, Orange/Strawberry/Grape/Teenage Crush(just checking to see if you’re reading closely), Cream soda and Root Beer are just a few of today’s and yesterday’s beverages-that-make-you-belch.  For some reason, we get a kick out of slugging down that nutrient-free, sweet, fizzy bev and emitting a healthy g-blurp! within seconds after downing the drink.  But colas do not satisfy thirst.  They are wet and sometimes wild, but the ingredients are more de-hydrating than satisfying.  If you choose a caffeine-loaded, high-sugar cola bathed in dark dyes, you are headed for more thirst after drinking than before.  And you just slurped up at least 96 calories per 8 ounces.  A 12-ounce Classic coke is 144 calories and the same fluid measurement of Pepsi or Dr. Pepper weighs in equally at 150. Don’t forget, there’s sodium in them thar streams of sugar and diet sodas have even more. When you just want a little something sweet, a clear soda is the better choice, and a tall, glass, glass of iced cold water is best of all.

The Buzz
Alcoholic beverages are a whole other fast track to fat.  We try to jump-start the day with coffee; we imagine we’re getting a nutrient-dense kick with juice; we substitute meals and assume we’re enhancing exercise with smoothies; we pretend to quench our thirst with sodas; but there’s no denying the reason for consuming that 16-ounce margarita or two 6-ounce glasses of Menage e Trois…red or white.  It’s recreation.  Recreational drinking isn’t a sin, but be aware and compare.  One 4-6 ounce glass of red wine is typically 120-150 calories, no worse than a large serving of crunchy, sweet, juicy, red seedless grapes full of fiber and dessert-like qualities, but hey, I only said, “Be aware!”  White wine, though lower than red in calories by 25%, does not supply the same number of nutrients as red wine, obviously.  Think spinach and mushrooms, dark and light.  But neither red nor white is great for metabolizing fat… it’s alcohol, after all.  You’ll still need to drink plenty of water and skip the sucrose to avoid those heart-pounding chest rhythms.  And do you really want your morning mouth to feel like a cardboard balloon?

Hard liquors are worse for you than wine.  If you insist on preserving your right to imbibe the hard stuff, keep these things in mind.  On a regular diet of hard drink, Your tummy will get soft fast and your red nose may qualify for holiday hire.  Above the others in calories ounce for ounce, more toxic to your internal organs, completely free of nutrients, and potentially more addictive than adult beverages with lower alcoholic content, hard stuff is a poor choice all the way around. Particularly if you are on a wellness program that includes weight loss, deep six the Ten.

There are those who think that a nice cold one quenches the thirst after a nice hot one.  It doesn’t.  You will not cool down by drinking two pints of Fat Tire after mowing the yard or after playing baseball for two hours. But you can get a fat tire.  Beer does not re-hydrate; it doesn’t even hydrate; it is not a substitute for water.  What’s not to understand?  And if you have any interest at all in a flat tummy, fresh, sweet breath, skin that isn’t sticky and smelly and sweaty at bedtime, and if you’d like less opportunity to make a fool of yourself during Sunday afternoon’s TV Testosteronathan, then load up on water before watching the game, drink at least a quart before playing in one, and don’t touch a beer after mowing until you’ve fully re-hydrated with agua fria.  That beer-belly syndrome?  It’s nasty-looking, it’s high-risk and it’s for real.   Try Sparks.

Be-hold!
Here’s a last word about the extent to which industry here in the States has embraced the beverage boom. Behold the cup holder!  We are so dependent on doing something with our hands that nothing with wheels passes market inspection unless it sports a holder for a cup.  Nothing with wheels is exempt.  There’s a cup holder in your car, your truck, your child’s stroller, your grocery cart, your golf cart, your bicycle(okay, safety issue, fair enough), your yard wagon, your oversized cooler, your computer bag, your rolling backpack, your commercial bus, train or plane tray, and your beach roller bag, not to mention purses, fanny packs, exercise belts, cardboard drink holders…the list is endless, but not surprising, at least in the USA.  In Germany, a Bavarian Motorwerks standard issue comes cup-free, but in Spartanburg, SC, BMW assembles the high-end European parts and adds cupholders, “nur fuer uns!”

You Can Lead a Person to Water, but Can You Make ‘em Think?
When you are offered “something to drink,” do you think coffee, water, or a shot of Jack?
Okay, so that may depend on what kind of day you’ve had in the OR and whether it’s
6:00 a.m. or p.m., but, truthfully, if you are a two-fisted cola consumer, a caffeine dependent addict, a juice bar fly, or a regular consumer at Friday Nights Live, it may be time to balance your beverage accounts.  Click on some of the links below to read some nutrition facts and beverage tips’info.  Start thinking about what, why, and how much you drink BEFORE you drink it.  A flat tire is a lot easier to fix than a fat one.  Prost!

Compare the Keurig Chai Latte to the Starbucks Frappuccino

Click here for Smoothies

How many calories in a glass of wine?  Click here

How many calories in a non-alcoholic beer?  Click here

What drinks cause dehydration?  Click here

The truth about green tea…Click here

Please visit Liz at www.bdyfrm.com to read the daily Lizlines and Friday Lizlimerick.  Discover

Liz’s Bands In The Park mobile browser, a perfect companion for your walking or running group.

Clinical Topic: Prewarming, Does it really matter?

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

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

Click here for an abstract of the Horn et al study

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

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

Patients who become hypothermic experience the following problems:

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

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

Click here to view the author’s article.

 

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

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

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

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

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

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

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

Chief CRNA: Are your Electronic Records Secure?

Patient privacy and the security of protected health information is a hot issue throughout healthcare from the primary physician’s office through diagnostic testing and including  records of hospitalization.  The Federal Government is urging health care workers to move to total electronic records and have initiated bonus money to encourage compliance.  However, the move to electronic records presents the challenge of security.

Writing for the on line blog The Anesthesiology Insider, Tony Mira states:

“Collecting, analyzing, reporting and storing electronic patient information present perhaps even greater HIPAA challenges than does the use of paper records, however.  Data entered on a computer can be copied more easily, more cheaply, more prolifically and even passively.  Once unsecured data are moved from the computer on which they are created to other media, manually or wirelessly, controlling the information becomes nearly impossible. “

A recent case settled with the Phoenix Cardiac Surgery Center demonstrates the cost of not securing protected patient information.  In this case, the center was fined $100,000 for their breach of security related to protected health information.

The Department of Health and Human Services Office of Civil Rights is actively investigating breaches of security related to protected health information.   A recent post on procrna.com discussed the HHS/OCR pilot program to investigate 20 health care institutions looking specifically for breaches in security.   Patients are being made aware of their rights to security of their records and the Office of Civil Rights has a web page with instructions for patients to file a complaint related to unsecured records.

As Chief CRNAs working in departments that either have automated record keeping or are moving in that direction, we must ask “where are the records stored and how are they secured?”  Any breach of security can be costly.

Clinical Topic: What’s your favorite Anesthesia APP?

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

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

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

 

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

 

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

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

 

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

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

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

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: 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.

Chief CRNA: Corporate takeover of your Department?

As Healthcare workers, we watch the reports on the evening news about corporate takeovers in the business community and are relieved that we don’t have to worry about things like that in our profession, but are we really safe?   An post on Anesthesia Reviews Blog by William Hass, MD, MBA explains why investors with venture capital investing in and profiting from the Healthcare industry. He lists the following reasons for their new interest in making profit from Healthcare:

  • The stock market as a whole has barely risen in the past decade,
  • Bond yields are unusually low
  • With the global savings glut there is just so much capital chasing too few worthwhile investments.

Among the options are anesthesia management companies who undercut your contract to provide services.  Once they have secured the contract to provide services at your hospital (your job), all staffing and equipment decisions are made based on generating a profit for investors.  Sadly, the group of people who are not actively managing the business of anesthesia and maintaining contracts are the anesthesia professionals.  Dr Hass lists the following as things that we could and should be doing to protect our jobs and the quality of care offered to our patients;

  • Be politically active at the facility, community, state, or national level
  • Spend money and time for business education
  • Develop and utilize an effective human resource program
  • Understand anesthesia service and OR management
  • Give group leaders time to lead
  • Educate and develop the next generation of leaders

This warning by Dr Hass reinforces the experience that small anesthesia departments are having across the nation.  Now is the time for CRNA leaders to be proactive and solidify the relationship between the Hospital and the anesthesia group.  Failure to maintain vigilance in the front office may cost you your job.

Click here to read the original blog post by Dr Hass and return to procrna.com to make 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: 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.