Tag: CRNA research

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: Systemic Lidocaine Improves Recovery

As anesthetists we face the challenge of providing a safe, comfortable and speedy recovery to our patients.  Narcotics improve analgesia at the expense of nausea and speed of recovery.  The use of non-opioid drugs to supplement and reduce the amout of narcotic administered should, in theory, provide a comfortable and speedy recovery.  In this study, the use of systeminc lidocaine was evaluated.

A study published in Anesth Analg 2012, 115(2) 262-7 by De Oliveira GS Jr et al, (Systemic lidocaine to improve postoperative quality of recovery after ambulatory laparoscopic surgery.)  examined the use of systemic lidocaine in 63 female patients undergoing laparoscopic surgery.   Following induction, patients were given a loading dose of lidocaine 1.5 mg/kg followed by an infusion of 2mg/kg/hour for the duration of the case.

Assessment following surgery found that those receiving lidocaine had a decided improvement in the quality of postoperative recovery.   Patients in the Lidocaine group had higher scores in physical independence and comfort with a 23% improvement in global recovery scores.  There was significantly less opioid used in the lidocaine group.  Also, those receiving lidocaine had a 26 min reduction in time to hospital discharge.  Overall, in an outpatient setting, systemic lidocaine offered a definite advantage.

Click here to read an abstract of the original article.

A similar study by US Navy CRNAs (Grady et al, AANA Journal August 1012) followed a similar protocol.  Although not statistically significant, the authors found that those receiving the intravenous lidocaine reported greater satisfaction and comfort than those in the control group. (P=0.08)  Possibly with a larger N this study would also have reached statistical significance

Click here to read the article in the AANA Journal (page 282)

Clinical Topic: Predictors of Postoperative Sort Throat

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

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

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

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

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

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

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

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

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.

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.