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: Ipad APP for Anesthesia Patient Teaching

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

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

Click here to read the blog post by Mr Amirault

Click here to view the APP at the iTunes store

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

Clinical Topic: CRNA liable for poor communication

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

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

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

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

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

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

Clinical Topic: Intraoperative Hypothermia

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

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

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

Click here to read an abstract of the original work

Chief CRNA: 360 Degree Evaluations

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

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

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

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

Wilma Gillis.

Clinical Topic: Ultrasound Guidance in Anesthesia

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

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

Central line placement
Spinal and epidural placement
Regional blocks
Perivascular injections

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

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

Product Review: enFlow fluid warming system

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

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

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

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

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

*enFlow is a trademark of General Electric Company

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

Clinical Topic: Does Anesthetic Technique Make a Difference?

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

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

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

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

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

Clinical Topic: Control Infection with disposable ECG wires

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

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

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

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

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

Make the Most of the AANA Meeting in San Francisco

Boston, Seattle, San Francisco, Honolulu, Jackson Hole, San Antonio…there are some amazing destinations for anesthesia meetings right here in the USA. Most of the venues are places where there is a long list of thing s to see and do. And all of the destinations provide plenty of opportunities for you to stay active.

Run For Fun

AANA’s annual meeting has been offering a 5-K fun run for just under a decade. It’s an easy 3.1 mile course along the city’s most scenic route with shuttle service provided start and finish. Runners, walkers, strollers (those are the people who stayed up late the night before) are all welcome and you’re the celebrity. Beautiful surroundings, beautiful celebs, and a free t-shirt as beautiful as t-shirts get, make all that exercise a beautiful bonus. Sometimes the local ANA offers early morning fitness classes at the host hotel with leadership provided by CRNA’s who apparently enjoy waking people up as much as putting them to sleep. Click here for the AANA wellness run in San Francisco

Take Your Bands

Exercise bands are almost as easy to use as they are to pack. You can do a complete work-out in your hotel room, in the hotel gym, in a park, at the beach or looking out over the harbor in Seattle or Boston. All you need is two or three bands, a doorjamb, railing or a pole to anchor them, a little backpack to carry them, or a waist small enough to tie them around your middle. With access to cool water and a hotel-sized washcloth, aka sweat rag, you’re good to go. Bands weigh less than an I-pad and they pack flatter than a ten-dollar bill.

Rent A Bike

One of the best ways to see your city and get some great exercise at the same time is to rent a bike. Google “bicycle tours in Vancouver” or “rent a bicycle in Austin” and refine the search from there. Be sure to use the word bicycle because otherwise you’ll end up with Harley Suzuki as your travel companion, which might be a blast, but you won’t get much exercise unless you fall off and have to walk back. You may be able to get a private, guided bicycle tour – more money, of course, but if you like to be at the head of the class asking questions, money talks and the expense will pay off. Click here to learn about bike rental in San Francisco.

Many cities have initiated bike-share programs. This service goes by a variety of names – like Q-bikes in Portland, B-cycle in San Antonio, or simply Bike-share in Boston – and features a fleet of bicycles that anyone can use. Just swipe your credit card at the vertical terminal, release one of many bikes from its locked stall, then ride it on marked cycling routes throughout the city, or directly to a destination. Parking stalls and routes are indicated on maps at each bike installation so you won’t get lost. Each time you stop to sight-see near a bike-share stall, just slide the bike into a rack, it locks automatically, and very shortly it will become someone else’s exercise partner. The beauty of the service is that it generally doesn’t require a helmet. One of the drawbacks of the service is that it generally doesn’t require a helmet… AND if you have to wait for a bike to become available when you’re in Brooklyn, you could be late for cocktails in the Bronx. Click here to learn about community bike share in San Francisco.

Walk

If you didn’t download a city map and a printable walking tour before leaving town for your meeting, you can ask your hotel concierge to highlight the best walking destinations on a brochure and outline some routes for you. Check things off on your brochure as you go so you don’t miss the major attractions, and don’t be afraid to get off the beaten path. Make note of noteworthy and eccentric establishments as your cabbie whisks you through the city from the airport, then go back and find them on your feet. You’ll run into the best coffee art cafes, the most interesting old houses, and charming little corner stores that you won’t find on Tourist Avenue. You may burn enough calories to almost justify the mouth-watering apple fritter you found at Dave’s Sugar Shack not to mention the energy you’ll have the rest of the day just from staying on your toes. If Rick Steves or Lonely Planet has published a travel guide for the city you’re visiting, it’ll be a quality purchase, and when it rains, you can walk the halls, climb stairs between 2^nd and 12^th, or go to the hotel fitness club. Remember to pack your Nike’s and your fitness duds so you can avoid blisters and excuses. Click here to learn about walking tours in San Francisco.

Go to The Fitness Club

One of the criteria for selecting a hotel is the quality of the fitness club. Every large hotel in a large city has a fitness center and some of them have glitz galore. The Omni in San Diego, the Sheraton in Seattle, the Sheraton in Boston, even the Holiday Inn in Columbia, MO all have exceptional facilities for working out. Check online or talk to the actual hotel desk staff before you reserve your room and ask about these items: Cardio equipment(treadmills, elliptical trainers, lifecycles, walking tracks); strength-training equipment(training circuit, free weights, vertical bands stations); abs room or abs corner (mats, fitballs, body bars, medicine balls); and towel service as well as a decent-sized pool. Gym-rats are going to get to the facility early, so go really early or go a bit late, but get going.

Your anesthesia meeting is a place to learn more about your ever-changing industry but it’s also a place to have fun with old friends and to make news ones, a place to experience a new city in a new way. Hike Aspen Mountain, jog the stairs next to the San Diego Convention Center, power walk the promenade while cruising between glaciers in Alaska, cycle from Fenway Park to The Old South Church. You won’t be putting anyone to sleep or trying to stay awake for one whole week. Go make the most of it!

You can visit Liz at www.bdyfrm.com and learn more about her Traveling Bands comprehensive work-out indoors or out, and how to gain access to the Bands In the Park mobile browser. Read motivational, entertaining Lizlines every weekday including the weekly original Lizlimerick.

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: What is the best handwashing technique?

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

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

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

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

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

Click here to read an abstract of the original work.

Research: Partner’s Presence During Epidural Placement

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

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

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

Click here to read the original abstract of this study.

Topic of the week: An opportunity to excel

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

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

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

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

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

Click here for the article by Dr Arrowsmith

CRNA Wellness: Heat and Hydration

Some very important things come as pairings: Your hair might be colored salt and pepper; it frequently rains cats and dogs; the OR has its ups and downs; Chez Paul offers wine and cheese. And summer? Summer pairs heat and hydration. As the temperature soars along with the humidity, here are some things to help you stay hydrated and withstand the heat.

The standard daily drinking water prescription for adults is eight glasses – that’s eight eight-ounce servings and varies by little from one body type to another. Add extra activity or summer heat to the mix and the recommendation increases to nine or more glasses. Move to an arid climate or humid tropical haven, and set RX-it a glass higher. You don’t need to drink until your food floats (see dilutional hyponatremia) but if you wait until you FEEL dry and thirsty before refilling your tank, you’ve waited too long to refill.

Click here to learn more about avoiding dehydration

Drinking water in most countries outside the USA is served without ice and often at room temp. Although it remains part of the drinking debate, there is a certain amount of logic in drinking your beverages at room temperature, even tepid. But the American Council on Sports Medicine recommends cold water to challenge metabolism and burn the most calories. Others say that water is water; just get wet.

When I counsel clients on their nutritional needs, I encourage them to up their intake of watery vegetables and fruits. Raw, grilled or steamed tender crisp, between all those tiny turgid veggie cells are gazillions of antioxidants wrapped in high-fiber packages and dressed in vibrant, low-calorie color. Stylin’ as well or better than their veggie friends, fresh nutritious fruit comes water-tight. Red watermelon and strawberries (lycopene), orange cantaloupe and papaya(beta carotene), dark blueberries and purple plums (vitamin C ), green kiwi and honeydew melon (potassium, vitamin C) are refreshing, hydrating and abundant in summer. Make use of a juicer, blender, or food processor and create a colorful beverage to accompany your dinner salad. You can eat cold and be hot!

There always seems to be some Dallas Bubba who does his five-mile run mid-day in an adjusted summer temperature of 91 degrees Farenheit. Frequently, Kansas City’s Woodside tennis round robin doesn’t even begin until 9:00 a.m. with the sun bearing down. Golfers in hot, humid Florida are notorious for teeing off after 8:00 a.m. and for some strange reason, there’s always a crowd of daytime skaters in July on both boardwalks, east and west. Are they all nuts? Did they just consume a gallon of water each? Or, fancy this possible explanation: Perhaps members of Active Anonymous tolerate the heat because they are active and in shape. Withstanding both hot and cold temperatures is easier for those who maintain a healthy weight and strong, muscular body. Between the lines you know they have developed good eating habits and skills of endurance to even be labeled “strong and muscular,” but there is also a true chemical composition to the fit body that isn’t in the make-up of a soft, flabby, heart-stopping structure that acts more as a respiratory challenge during hot weather than a shelter in the shade. Only the strong survive the heat; the flabby flail.

While you’re sipping on your unflavored, cool, spring water, contemplate the following quips while remembering: Water hydrates, it softens your skin, it aids in digestion and the absorption of nutrients, it cools the body, it fills you up…and especially during the heat and humidity, it puts out fires.

Water spots

Booze on the Beach and Coffee with Caffeine are hot-weather de-hydrants. Nix the mix.

Being in shape increases your tolerance for heat. Round is a shape, not in shape.

If your body heat comes in flashes, drink water, stay still and switch to flash drive.

Water follows Salt. Take your dips without the chips.

Water is the fountain of youth.

Read Liz’s daily Lizlines Monday through Thursday and enjoy the Frisky Friday Lizlimerick each and every week at www.bdyfrm.com.

Ms Liz is the owner of Body Firm Integrated Fitness Solutions. She has developed the Bands In The Park work-out for indoors or outdoors and provides fitness consultations and complete, integrated online instruction. Contact Liz for a consultation to receive practical, affordable nutrition and fitness assistance and access to over 60 exercises, useful recipes and lesson plans.

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.

Meeting Review: NWAS, Turks and Caicos

Meeting Date: 4/22/2012

Location: Turks and Caicos

Strengths of meeting: Interesting topics and speakers. Beautiful location, great beaches, great for scuba and snorkeling

Suggestions: No suggestions for improving the meeting. The hotel was all inclusive with several dining options. The food was not good and the service was not up to par for the price.

Overall value for the money: Overpriced resort

From PROCRNA.COM: If you have attended a meeting lately and want to share your experience with your colleagues, click on “meeting review” on the navigation tab and submit your review.

From the meeting sponsor: “Northwest Anesthesia Seminars was founded in 1976 with the primary objective of offering high quality continuing education seminars for the anesthesia provider. This remains our principal objective today and our programs are designed to keep you current in the practice of anesthesiology while at the same time providing a forum for professional exchange with your colleagues from around the world. We know that your time is valuable and combining continuing education with a vacation is not only practical, but rewarding as well!

Be sure to browse our full course schedule to explore our locations with something for every traveler’s taste, budget and desire. Visit our website at www.nwas.com or call 1-800-222-6927 to learn more. There are many great reasons to attend a Northwest Anesthesia Seminar and we hope to see you soon.” Click here to visit the NWAS web site.

Chief CRNA: How secure is your work group?

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

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

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

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

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

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

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

Click here to read the full article by Tony Mira

Feature SRNA: Judith Arrington

Name: Judith A. Arrington

Email address: judy.arrington79@gmail.com

Anesthesia School: NorthShore University School of Nurse Anesthesia

Graduation Date: August 24, 2012

CV: Click here to view CV

Preferred geographic region: Central TX

Major work as SRNA: Perceived Anxiety of the Nurse Anesthetist of
Parent Presence during Induction of Anesthesia.

Parent presence during induction of anesthesia (PPIA) is a fairly new concept that is being implemented in order to incorporate family involvement with the pediatric patient in the operating room. Previous studies have not researched PPIA’s effect on the anesthetic provider, specifically nurse anesthetists.

Objectives: This study examined the nurse anesthetist’s perceptions, attitudes, and emotions regarding PPIA; and possibly past experiences which can affect the anesthetic provider’s peri-operative anxiety possibly impacting the outcome.

Click here to read the abstract of this original SRNA work.

Special Interests: boating-that’s why I need to move so I can actually get some use out of our boat!

SRNAs…The future of our profession.
Available to join your group in the Fall of 2012.

Meeting Review: NWAS Philadelphia

Meeting Date: May 24-27, 2012

Quality of Meeting: Overall excellent. The speakers were very good and the topics were relevant to clinical practice. Objectives were met for each of the topics presented. I did not attend the hand’s on ultrasound workshop but was told that it was very good also. I especially enjoyed the topics presented by Dr. Murphy. He was well informed and interacted with the audience

Quality of location: Again, excellent. The host hotel was nice and located in Central Downtown. There were many good restaurants close to the hotel. Philadelphia had many historic sites as well as museums. I was pleasantly surprised at all the murals covering walls in the downtown area. It was an easy area to keep active by walking and biking. I especially enjoyed a bike ride along the trail by the river.

Value for the money: Excellent. NWAS puts on a lot of meetings and have developed a quality faculty. They seek sites that are great getaway locations. I will attend another NWAS meeting next year.

Chief CRNA: Coordinated care; Reduce Cost and Improve Care

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

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

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

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

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

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

Water spots

SRNAs…The future of our profession. Available to join your group in the Fall of 2012.

SRNAs…The future of our profession.
Available to join your group in the Fall of 2012.