Tag: CRNA education

Meeting Review: Difficult Airway, Las Vegas

Reviewed by DP,  Texas

Meeting Date:  04/01/2013

 

Meeting location:  Las Vegas

 

Meeting presented by:  Difficult Airway

 

Meeting strengths / interesting topics & speakers

This was a three day conference concentrating on the difficult airway. There was a total of approx 3 hours of lecture and the rest was hands on with some case studies. Overall, very informative review of how to handle difficult airway. Really enjoyed the different case studies. Got lots of practice driving the scope with AFOI and pediatric airway. The days were long however and this is not the kind of conference where one can come and go as you please. This was also a meeting with MDA’s, CRNA’s, AA’s, ER docs.
This meeting was at Planet Hollywood resort and casino. The facilities were nice but the casino itself has a very young party vibe which didn’t fit my personal style. Overall though, very good. Good simulation and presentation of different ways to approach the difficult airway.

Suggested improvements:  The boxed lunch on the first day was awful. The breakfast was decent. The days were long- not a lot of time for fun after the long days if you wanted to be back early for the next day.

Overall value for the money:  We got a total of 21 hrs for about $850. That’s pretty on par for cost of other conferences. I think the value was good though because they did provide simulation and scopes, surgical airways, etc.

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: 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.

Dannemiller Nurse Anesthetist Review and Update

November 29 – December 4, 2011,  San Antonio, TX

I’ve been attending this Dannemiller offering for years and it consistently meets my continuing education needs. It’s very convenient to visit a beautiful place like San Antonio, TX for a few days and earn enough CE credits for the two year re-certification. This time they provided 32 hours of lecture (including pharmacology credit) and an optional 8 hour hands-on ultrasound guided nerve block workshop. I especially enjoyed the lectures onreactive airway management, pediatric congenital heart disease, geriatric poly-pharmacology, perioperative diabetic management, one lung ventilation, and preoperative pulmonary assessment. Our AANA President Debra Malina provided insightful information regarding current and future nurseanesthesia trends and issues including NBCRNA mandatory recertification. I highly recommend all Dannemiller education products. Check out their website.

Click here to check out their website.

Reviewed by Bill Shopp, CRNA

Promote your Profession

Nurse Anesthesia has a long and proud history dating back to the late 1800’s.  Watchful Care by Marianne Bankert documents our history and the contributions made by the early pioneers of the profession.  Nurses were selected as the ideal anesthetists because of our attention to detail, vigilance, and commitment to patient safety.  Day in and day out, Nurse Anesthetists delivered quality care to patients and service to surgeons.

In the century that followed, many changes in Health care have taken place but one factor remains constant; the safety and quality of patient care delivered by Nurse Anesthetists.  To support the quality of care we deliver, we must actively promote our profession and contribute to the body of knowledge If we are to remain trusted and respected in the of delivery of anesthesia services.  We must all contribute to promoting our profession.  Some will participate in research or Public  Relations projects.  Others who can not actively work to promote the profession must help by supporting the work of others.

The AANA foundation has the mission of advancing the science of anesthesia through education and research.  The Foundation provides an excellent opportunity for each individual CRNA to support our profession by supporting the research done by our colleagues.  Original studies to promote safe practice and to validate the safety and cost effectiveness of Nurse Anesthesia have been funded and published by the AANA Foundation.

Did you know that last year the AANA Foundation:

Funded $73,045 in research initiatives

Awarded $129,000 in student scholarships

Awarded $250,000 in Post-Doctoral and Doctoral fellowships

Presented 95 research posters

Please take the opportunity to support your profession through support of the AANA Foundation.  Regardless of the size of your contribution, add your name to the list of those who support CRNA research and education through the AANA Foundation.   Click here to go to the Foundation web site.  After reviewing the site, please contribute.

Ketamine Supplement for Anesthesia

Ketamine is an old drug which has come in and out of favor many times over the past decades.  Currently, articles are emerging touting the advantages of Ketamine as a supplement for  both general anesthesia and monitored anesthesia care.  Below is a description by Pamela Chambers, CRNA regarding her clinical experience using Ketamine as a supplement.  Read her excellent review, scan the articles and leave a comment to share your experiences with your colleagues.

Submitted by Pamela Chambers, CRNA

Lexterrae legal consulting service

For the EP case that lasted 6+ hours, GETA with .5 mac Desflurane and Propofol infusion at 30 ug/kg/min, the Propofol Ketamine mixture performed very well.  I mixed 50mg Ketamine in each 50ml bottle of propofol.  I used less than 3 bottles for the case and never used more than .5 mac Des.  I used a total of 25 ug Fent, just after intubation, for the case.  The patient was 83 yo male, approx 90 kg, EF 20%.

Upon emergence the patient denied any pain or discomfort.  He was appropriately responsive to verbal and did not cough on extubation. VS were stable and he was A&O x3 on arrival to the EP room for phase 2 recovery.

A few days later, I used Ketamine as an analgesic adjunct for another long case (10 hr bilateral mastectomy and tram flap).  I used a total of 195 mg Ketamine.  The patient was an ASA 1.  After 100 ug Fent (and 3mg Versed) prior to induction, I used 30 mg Ketamine approximately 3 mins prior to incision.  Then I administered 30 mg Ketamine at hr number 2, and hr #3.  Around hr #4, I decreased the Ketamine to 15mg for each hrs successive dose with a plan to halt Ketamine admin when I believed the case was 2 hrs from completion.  My last Ketamine dose was at 1430 during the last phases of the case. The patient began spontaneous ventilations after reversal of NDMR at approximately 1640.  The case ended at approximately 1730.  The patient

received a total of 2200 ug Fent dosed approximately 100 ug every 30-45 mins.

Intermittent rescue doses for SNS spike were not required. Pressor agents were not used. Hemodynamics were extremely stable, almost like the proverbial railroad track!

Total fluid administered was 2 liters NS and 1 liter 5% Albumin, UO was 150 ml, EBL 300ml. I also adminstered 2 mg Versed at 1600 to facilitate decreasing the inhaled agent level and to ameliorate any emergence delirium associated with the Ketamine.  The patient was appropriately responsive to verbal prior to extubation, and did not cough during extubation.  She also denied any c/o pain immediately post-operatively. No emergence delirium was appreciated.

Click here to read a review article by Laskowshi et. al regarding Ketamine use

Click here to read an article by McCartney et al regarding the role of the NMDA receptor

The Sticky Situation of Adhesion

Submitted by Pamela Chambers, MSN, CRNA, EJD

Click here for Lex Terrae consulting

Two years ago, Joe Sixpack was admitted to your facility to undergo vasectomy.  His clinical course in your fine medical center was uneventful. Today, you are seated in the office of the facility mediator and all relevant parties are present: Joe Sixpack, Mrs. Sixpack, little baby Sixpack who will celebrate his first birthday next week, and everyone involved in the clinical care of Mr. Sixpack on that fateful day 2 years ago.

Before beginning the mediation process, the facility’s attorney presents the admitting forms that Joe signed upon arrival to the facility and prior to receiving any sedation for his procedure.  One of the forms, a two sided form, contains an explanation of the procedure that Joe has requested on side one, along with the risks, benefits, and options of the procedure and several blank lines at the bottom of the form in case Joe wanted to add anything to the form. Side two of that same form contains the following statement “I hereby release Smallville Medical Center and it’s employees and contractors, from all liability arising from any injury to me resulting from my requested therapeutic procedure to be performed by Dr. Kuttemup and his staff at Smallville Medical Center.”  Immediately after this paragraph is Joe’s signature with the date and time the form was signed.

When a healthcare provider has this type of statement in a contract for services for the express purpose of limiting liability relating to the provision of those services, this is termed an exculpatory clause.  When this type of clause is a condition to obtaining the requested service this creates a contract of adhesion. While most courts attempt to enforce contracts by trying figure out what the parties intended when the contract was written; courts often find contracts of adhesion unenforceable as a matter of public policy (Weaver v. American Oil Co., 257 Ind. 458, 276 N.E.2d 144 (1971).

The contract to provide health care services is not usually between 2 similarly situated (i.e. equally knowledgeable) parties.  If a contract is deemed grossly unfair to one party it will usually be held unenforceable in court.  Consider the following release from Olson v. Molzen (558 S.W. 2d 429, Tenn., 1977) “…I therefore release Dr. Molzen and his staff from responsibility associated with any complications that may come up or be apparent in the next 12 months…”  The court in this case found the exculpatory clause particularly distasteful because an individual in such a profession, a physician, should not be permitted to hide behind such a shield as a license to commit professional negligence.

Regarding all contracts, there lies a duty to read.  This is small comfort to a plaintiff but a court will evaluate the parties intent to contract by evaluating the terms of the contract.  Terms that appears grossly unfair (i.e. unconscionable), violate public policy (i.e. one cannot receive the healthcare service with out agreeing to the term), or lack true assent will likely lead to a ruling that the contract is unenforceable.

About the author:  Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted.