Tag: procrna.com

Chief CRNA: Automated Recordkeeping

Automated Anesthesia Recordkeeping (AARK) has been available for over 20 years and is being used in more and more operating rooms across America and around the world.   Despite becoming mainstream technology, AARK continues to generate controversy.   Is the advantage of automatic physiologic data capture offset by a loss of vigilence by the anesthesia provider?  Several studies have investigated the loss of vigilence related to AARK.

J. Allard, R, D. Zwoncaky et al published the results of a study in the British Journal of Anaesthesia addressing the issue of the effects of AARK on provider vigilence.

As stated by the Authors: “Proponents of this technology profess that automated record keepers reduce record keeping time thereby leaving more time for data interpretation and patient care . Moreover, others suggest that computer-generated records are more accurate and complete than those charted manually . On the other hand, critics argue that allowing the AARK to chart the vital signs removes the anesthetist from the information feedback loop and thereby has an adverse effect on vigilance . The main intent of this study was to determine the effect of an AARK on intraoperative record keeping time and vigilance.”

“Thirty-seven cases were charted manually and the remaining 29 were charted with a commercially available AARK. In order to evaluate vigilance, a physician examiner entered the operating room unannounced once during 33 of the manually charted cases and during 22 of the automatically charted cases and asked the anesthetist to turn away from the monitors and recall the current value of eight patient physiological variables. The examiner recorded the recalled values and also the actual current monitor values of these variables. The videotapes were reviewed and the anesthetist’s intraoperative time was categorized into 15 predefined activities, including intraoperative anesthesia record keeping time. We compared recalled and actual variable values to determine if the recalled values were within clinically relevant error limits.”

The authors conclude the use of the AARK did not significantly affect vigilance.  They go on to state that it appears that in using an AARK, the provider reallocates intraoperative record keeping time from manual charting to dealing with problems.

Click here to read the complete study and return to procrna.com with your comments.

CRNA Wellness: The fitness group

  The Fitness Group – Not Just a Numbers Game

There’s strength in numbers.  If you need proof, count the number of defensive players on the football field; observe the light produced by one streetlamp compared to a dozen; taste the difference between a chicken breast with one tablespoon of pepper and one teaspoon; shake hands with each member of the medical team that successfully separated conjugal twins.  A group with a goal cannot be stopped.  If you want great results in your wellness program, call some numbers and form a group.

Men’s Health Magazine suggests signing up for an event as one of its “top twenty ways” in which “to keep yourself on a fitness program.”  The motivation of preparing for a contest involving lots of people – and perhaps prizes – keeps you focused.  And focus is something all anesthesia professionals can do. There are fun runs involving 100’s, maybe a few thousand people, somewhere every weekend through October as well as cycling tours, tennis ladders, bi and triathlons galore and all it takes is one other person to help keep you motivated.  If you have more than 2 or 3 on your anesthesia team, you can have the same number on your walking team.  Are you going to San Francisco for the 2012 AANA meeting?  Take the team for the fun run and make healthy headlines.  Did the recruiter entice you to move kit and caboodle to Kansas City?  Your fitness groupies can gather at the head of the 17-mile trail at the south end and power a walk all the way to Town Center in Leawood, or keep going on a bicycle into Missouri!  Promise the Biggest Loser a lean latte at Dewey’s Coffee Café or buy the “most improved” person a bagel at Einstein’s. Re-set the bar a teeny bit higher every week the team meets.  Improvement and reward are inherent in teamwork.

Though expansion is a curse word of the weight-watcher, it’s the goal of the group.  Your companions at the clinic need not be limited to anesthesia junkies (I use the term loosely), so once your “team” is up and running, let it grow.  Evite another department, then another, and another to join you in the effort to be well.  Perhaps you already have a wellness offer at your hospital and perhaps you regularly participate.  Great!  Now get out and evangelize and expand!  Your improved level of energy and your own success at achieving and maintaining a fit, healthy body are perfect advertisements.  Add your voice to the ads, and the group will go viral.  Your team should “change up” because that’s what keeps it vibrant and challenging – sorta like 10,000 minutes on the schedule with five anesthetists on vacation!

Scott and White Medical Center, Temple, TX, has a hospital-wide cycling group that meets once or twice weekly, year ‘round.  It is highly organized – matching shirts and shorts! – and has become so popular that spouses and community residents frequently join the 145+ membership for the Saturday morning ride policy of “no cyclist left behind.”  Watertown Regional Medical Center in Wisconsin offers patients and employees one-on-one personal training sessions and several group fitness events each year.  Cleveland Clinic in greater Cleveland offers free employee membership to its fitness centers where you’ll participate with a group of 1,000’s!  Your upstate New York group can have a cross-country skiing team and your WEE employees in Colorado (We Enjoy Exercise!) can form a hiking club.  New Mexican anesthetists can train together for the annual climb to Sandia Peak and Georgians can scramble as a team up the backside of Stone Mountain.  The opportunities to form a cohesive, enthusiastic group committed to the freedom of wellness are only limited by your imaginations and the Dunkin’ Donuts sticking together in the anesthesia lounge.

It takes a leader and one friend to form a fitness group.  Add a little organization with some consistent commitment, and “they will come.”   Your health will improve as the result of being part of a team, and if it’s a good team, strength isn’t just added – it’s multiplied.

 Click here for Cleveland Clinic’s wellness program

Click here for Scott & White cycling club

 Click here for Kansas City bike trails

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: Propofol – Remifentanil Sedation

Epidural Anesthesia is becoming increasingly popular for Orthopedic procedures of the lower extremities.  Anesthetists are tasked with keeping the patient comfortably sedated while the Epidural provides adequate anesthesia during the procedure.   The goal is to keep the patient oxygenated and comfortable with hemodynamic stability and a rapid wake up at the end of the case.   An increasing number of anesthetists are finding that the combination of propofol – remifentanil is the answer.

A.A. Samaan and V. Srinivasan published an observational study  done in the Department of Anaesthesia, Diana Princess of Wales Hospital, Grimsby, England.

As reported by the authors: “Regional anaesthesia offers many advantages for major joint replacement surgery of the lower limb. These operations are usually lengthy and carried out on elderly patients. There is a need for effective and controllable sedation with fast recovery profile. This   obviates the need to administer general anaesthesia in addition to the regional anaesthesia. We undertook to evaluate the efficacy and side effects of combined infusions of Propofol and Remifentanil in this clinical set up.”

“This is an observational study of 123 consecutive patients who required joint replacement surgery; primary hip, primary knee, revision hip, revision knee and bilateral hip replacement.  Epidural anaesthesia was performed in 111 patients.  The Epidural site was either high lumbar or low thoracic. The Local Anaesthetic used was Bupivacaine 0.5%, warmed to body temperature, with Adrenaline added to achieve the strength of 1:200,000. The motor and the sensory functions were checked to ensure adequate blockade.”

Patients were sedated during the surgery with a manually controlled Remifentanil infusion (20 mg per ml solution) and a Target Controlled Infusion of Propofol.

The authors conclude “Sedation with Propofol and Remifentanil complemented successful Epidural regional anaesthesia for major joint replacement surgery.  It was especially valuable in prolonged surgery such as in the case of revision hip replacements. This avoided the need for general anaesthesia.  Sedation with Propofol and Remifentanil is associated with minimal side effects, even in prolonged operations of durations up to 260 minutes, provided there is adherence to a carefully titrated dosage.  In our experience the average infusion rate for Propofol was 2.5 mg.kg.hr and 0.02 mg.kg .min for Remifentanil.”

Click here to read the study and return to procrna.com to share your comments with your colleagues.

Chief CRNA: HHS to Audit for HIPAA Violations

Is Big Brother watching?  You bet!   The Office of Civil Rights from the Department of Health and Human Services has initiated a pilot program to audit Hospitals and assure that HIPPA standards are being met.   Fines of up to $50,000 per occurence are in place and the auditors are ready to search for violations.

As reported by Drinker Biddle,  ” The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has begun auditing covered entities for compliance with the Health Insurance Portability and Accountability Act (HIPAA) under the HIPAA Audit Program (Audit Program). The Audit Program is funded by the Health Information Technology for Economic Clinical Health (HITECH) Act and requires HHS to conduct periodic audits to ensure both covered entities and business associates are complying with the HIPAA Privacy and Security Rules, as well as all Breach Notification standards.”

The department of HHS has released information regarding the audit plan.  The information provided by HHS includes information about who will be audited, how the program works and the timeline for auditing.  Click here to review the information provided by HHS.

Share this information with your Chief CRNA colleagues and return to this page to make a comment and share your opinions.

 

Research: Anesthesia causes jet-lag

A press release from the University of Aickland dated April 17th, 2012 described a recent study done there that linked anesthesia to a feeling of jet-lag following surgery.

The researcher, Dr. Guy Warman, noted,  “Our work shows that general anesthesia effectivly shifts you to a different time zone, producing chemically-induced jet-lag.  It provides scientific explanation for why people wake up from surgery feel as though very little time has passed.”

Dr. Warman goes on to state, “It’s been known for sometime that after anesthesia, people’s biological clocks are disrupted and this can compromise their sleep pattern and mood as well as wound healing and immune function.”

This interesting work was done on honey bees which are known to have a keen sense of time.

Click here to read the original press release

CRNA Wellness: Wake-up call

My humorous Native American name for my younger daughter was Face In The Soup.    When she was tired, SHE WAS TIRED, and by the 6:00 p.m. dinner hour, her face went down on the table and it didn’t come up.  As a young mother, I learned quickly to make sure she had received all of life’s necessities before OUR dinner time because no matter what happened in my own life, at 6:00 p.m. her curtain was going down.  If she were now an anesthetist on the job, her adopted name could be Dies on the Table or Puts Patients at Risk.

Chuck Biddle, CRNA, PhD, chief editor of the AANA Journal and multi-published author of sleep deprivation articles, quotes another anesthesia industry sleep expert, June J. Pilcher, when he reports that:  Fatigue caused by lack of adequate sleep results in diminished cognitive function, impaired vigilance, decay in problem-solving ability, degradation in memory, and eroded motivation.
Click here to read the article.

Okay, so I can’t tell you anything that will make the surgeon close that thoracic cavity in time for you to be eating dinner by 6:00, or to watch Dancing With The Stars, or to shower off the sounds, smells and stress from the OR and still drop into bed by 10:00.  But I can give you some simple fitness suggestions for making sleep more useful when your head makes contact with the pillow-top.  People who are fit and healthy sleep better than those who aren’t.  Simple.  True.

Physical exercise is way at the top of ways in which to elevate energy but tire the body in such a manner as to make sleep deeper and easier.  Although it is a personal choice as to what time of day you should do your cardio or tote that bail, you can figure it out in just a few morning or evening trips to the gym, or on the elliptical in front of your Netflix pick.  Morning cardio elevates your metabolism and your heart rate which energizes you for the better part of the day but fatigues you in a pleasant way by or before gall bladder number six.  Doing your cardio before bed does the same thing to metabolism and heart rate so you probably want to take a bit of down time between cardio and vespers.  Some of you may prefer to do a lunchtime cardio on the days it’s possible, a great substitute for pop ‘n pizza.  Try to create some routine so that your body says, “It’s time to cardio; it’s time to eat; it’s time to don the scrubs; it’s time to let down; it’s time to sleep.”

Stretching and crunching before bed is another great way to relax and create routine before the sandman comes.  Tom S. Davis, CRNA,  MAE, likes to say, “Every day that I don’t make time to stretch is one day closer to the day I won’t be able to.”  If you don’t have a designated work-out area at home, keep a Pilates mat, a towel and a 55cm fitball (inflatable stability ball) in your bedroom so that it’s easily available every evening.  Do various crunches that access all areas of the abs followed by a thorough five-minute stretch routine that leaves you feeling loose, relaxed and calm.  Wind down by finishing your toilette routine.  Then crawl in and let go.

Eat dinner right before bed…and you’ll sleep poorly.  Drink coffee right before bed…and you’ll have to interrupt your sleep to offload.  Consume alcohol in excess…and reflux, insomnia and restless sleep will be your companions.  Wear a belly to bed that looks like an eminent delivery, and you’ll wake yourself up with your own snores, not to mention that you’ll be sleeping alone. In short, what you put in your body all day is the very same thing you’ll put into bed that night and your sleep will thrive or dive because of it. Lower the bad fat in your diet, especially lower the sugar, decrease the volume of intake and put down the fork, fingers or chopsticks between every few bites.  Intentional eating of reasonable kinds and amounts of food are your fitness friend, and quality sleep will become a close relative.

Finally, stay away from negative news, time-consuming e-mails, family complaints and anything else that puts your head in a quandry and reduces your tranquility.  Say, “Good-night,” to your honey, calmly go through your affirmations, prayers or meditation minutes and put out your lights.  Six hours, seven hours, preferably eight hours later, your fit, healthy Self will be refreshed and ready to take your life back. Then go pop into the OR bright-eyed and bushy-tailed and clip on your nametag:   Saves The Lives of Others.

Other Tips
Take a power nap during your break.
Don’t stop for restaurant food on the way home.
Don’t drink alcohol.
Avoid drugs and sleep aides.
Get extra sleep BEFORE call.
Avoid arguments.
Split your cardio into morning and evening.
Eat very lightly if it’s late.
Read relaxing lit.
Do Yoga.
Meditate.
Say, “Good-night, Gracie!”

You can visit Liz during your waking hours at www.bdyfrm.com.  Read the motivational, entertaining Lizlines Monday through Friday and watch for her original Lizlimerick once a week.   Ms Liz

Fitnotes
Chuck Biddle, CRNA, PhD, is a professor and staff anesthetist at Virginia
Commonwealth University, Richmond, Virginia. He is editor in chief of the AANA Journal. Email: cbiddle@hsc.vcu.edu.
Tom Davis, CRNA, MAE is chief nurse anesthetist at Scott and White Medical Center, Temple, Tx and former assistant professor of nurse anesthesia at University of Kansas.  He is the owner of and consultant for Procrna.com.  Email:  tom@swcrna.com

Clinical Topic: Patient Safety, The Helsinki Declaration

The European Board of and Society of Anesthesiology have adopted the Helsinki Declaration for Patient Safety in Anesthesia and have made recommendations for standards that further improve patient safety.

The authors state that patient safety has 3 components; a set of guiding principles, a body of knowledge and a collection of tools.  The basic principles are the tendency for things to go wrong is both natural and normal, rather than an opportunity to find someone to blame; safety can be improved by analyzing errors and critical incidents, rather than pretending they have not happened; and humans, machines and equipment are all part of a system, the component parts of which interact to make the system safe or unsafe.

The following Abstract was printed in the European Journal of Anesthesiology:

Anaesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, pain therapy and emergency medicine, has always participated in systematic attempts to improve patient safety. Anaesthesiologists have a unique, cross-specialty opportunity to influence the safety and quality of patient care. Past achievements have allowed our specialty a perception that it has become safe, but there should be no room for complacency when there is more to be done. Increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, new drugs and devices and simple chance all pose hazards in the work of anaesthesiologists. In response to this increasingly difficult and complex working environment, the European Board of Anaesthesiology (EBA), in cooperation with the European Society of Anaesthesiology (ESA), has produced a blueprint for patient safety in anaesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anaesthesiology, was endorsed by these two bodies together with the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients’ Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. The Declaration represents a shared European view of that which is worthy, achievable, and needed to improve patient safety in anaesthesiology in 2010. The Declaration recommends practical steps that all anaesthesiologists who are not already using them can successfully include in their own clinical practice. In parallel, EBA and ESA have launched a joint patient safety task-force in order to put these recommendations into practice. It is planned to review this Declaration document regularly.

The original article by Staender et al is a “must read” for all providers who sincerely seek to improve patient safety.  Click here to read the original article.

Return to procrna.com to share your thoughts with your colleagues.

Clinical Forum: Sevoflurane with RSI in Obese Patient

With the growing Obesity epidemic in America, anesthetists are continually facing the risk of induction and intubation with a potentially difficult airway.  Many theories are in the literature about the “best” technique for safe induction of the morbidly obese patient.  Pre-oxygenation is essential and proper positioning increases the odds of successful airway management.

A recent article by Toso et al. published in the European Journal of Anesthesiology (Eur J Anaesthesiol. 2011 Nov;28(11):781-7. described adding a component of inhalation anesthesia to the rapid sequence induction technique for morbidly obese patients.  In this study, the authors positioned and pre-oxygenated patients.   When ready for induction, the researchers turned on Sevoflurane and after 30 seconds of breathing the agent, they followed with a rapid sequence induction using propofol, alfentanil and Succinylcholine.  All patients were easily intubated on the first attempt and there were not occasions of desaturation.

The authors demonstrated that adding Sevoflurane to the RSI sequence provided conditions for a safe and controlled induction of anesthesia.

Click here to read an abstract of the original article.  Return to Procrna.com and share your opinion with your colleagues.

 

Chief CRNA: CRNAs as OR Leaders

Across the Nation, Chief CRNAs are probably among the most under utilized group of talented health care providers.  In addition to developing the work schedule and assuring that providers are present to support the posted schedule, Chief CRNAs know the strengths and weaknesses of the staff members and are in a unique position to guide the work flow to optimize patient care.

An original article Written by Sabrina Rodak details why Anesthesia providers are well positioned to guide the work flow in the operating room.  Click here to read the original article.

Three experts on anesthesia services explain why anesthesia providers are best positioned to lead the operating room of a hospital.

1. “The perioperative leader should be an excellent communicator with a deep knowledge of OR management in order to successfully make the necessary changes required in carrying out the hospital’s overall goals. As anesthesiologists are present in the OR every single day, it is important that the anesthesia chair takes on this role to promote consistency across the board through this time of change,” says Leo Penzi, MD, executive vice chair of the department of anesthesia at North Shore University Hospital in Manhasset, N.Y., a member of the board of directors of North American Partners in Anesthesia and assistant professor in the department of anesthesiology at Hofstra North Shore-Long Island Jewish School of Medicine.

2. In a case study presented by Surgical Directions, a hospital recruited anesthesia providers to drive perioperative performance by granting them leadership positions and aligning incentives. The anesthesiologists received financial rewards for increasing patient volume and a stipend for fulfilling certain service standards, including increasing the availability of regional blocks, accommodating add-ons and participating in the OR’s daily huddle, a process in which the OR team discusses issues from recent cases and prepares for the next day’s schedule. Anesthesia leadership was an important element of the hospital’s success in perioperative services.

3. Proper anesthesia leadership in the OR is a key element of integrated delivery of care. Robert Stiefel, MD, a principal with Enhance Healthcare, defines this as “healthcare professionals and supporting facilities working towards one goal: optimized patient care that is more efficient and cost effective.” Integrated care in the OR depends on the coordination of hospital administration, OR staff, surgeons and anesthesiologists. Anesthesia providers’ involvement in all aspects of the OR makes them prime candidates to oversee this coordination. “Anesthesia providers are the most consistent component of the entire perioperative experience,” Dr. Stiefel says.

Chief CRNA: Delivering value

As Anesthetists, delivering quality anesthesia care is foudational to our work.  As Chief CRNAs, we must ensure that developing and delivering value also includes delivering value to our Hospitals / organizations as well as our patients.   The following information was Posted by William Hass, MD, MBA in Anesthesiareviews.    Read the work below or click here to go to the original posting by Dr. Hass.

Developing and delivering value is part of business strategy.  This concept can be used for an entire organization or any of its parts or functions.  Usually the focus of the value proposition is externally toward customers, but a locally owned and operated anesthesia service cannot provide external value unless its support functions are providing internal value to the group.

Support services for a community anesthesia services can be incestuous.  In-laws, family friends, and childhood acquaintances may be providing some or all of its support services including billing, benefits, accounting, and legal services.  These inbred services are quite variable in cost and quality ranging from well-priced high quality services to high priced poorly functioning pseudo-payoffs.  The value proposition of a group’s support service becomes important when there is subsidy request.

Why should a facility pay for your poor management?
Can you produce superior clinical services without adequate support?

This is where anesthesia management companies (“AMCs”) and physician practice management companies (“PPMCs”) have an advantage because they’re supposed to have a well-oiled administrative “engine.” Some do and some do not.

Their management may be centralized, but can provide excellent on-site management?
Can they get the “little things” and the not so “little things” right at a distant site?
Do they understand the culture of the facility from somewhere over the horizon?

Some PPMCs never really get anesthesia billing right because their experience is in other specialties.  (Believe it or not, PPMC anesthesia billing can be significantly better than the billing services provided by the lowest bidder to a facility or multi-facility corporation.)  Diligent review is required when selecting an AMC or PPMC.

There is an important problem.  The progress and development of management service organizations (“MSOs”) are being slowed by nepotism.  While an MSO’s advantages of lowering the overhead costs and expanding services are easy to understand, ending a combined friendship/business relationship with an in-law, family friend, and childhood buddy can be difficult, if not traumatic.  If attention is not paid to the business aspects of its practice, the choices for an anesthesia group may be between amputation (of nepotism) to join an MSO or execution/extinction by an AMC or PPMC.

Survival and success in business requires difficult decisions.  Anesthesia group leaders may need to make hard and unpopular decisions unless they want someone else to be making hard and unpopular decisions for them.

Take Home Points:

Nepotism can slow the development of MSOs
MSOs can lower costs and improve group management
Survival and success in business requires hard decisions
Anesthesia group leaders need to hard and unpopular decisions unless they want someone else to be making hard and unpopular decisions for them

Legal Topic: Documentation

Same Song Different Verse – If It Wasn’t Documented…..

Consider for a moment, that you or a colleague is facing legal action that, on the face of things, appears absurd.  How absurd? Well, think for a moment about the first time that you learned how to place an intravenous (IV) line.  The first thing that you were taught to do (after determining the correct patient, catheter size, and limb selection) was – clean the site.  Traditionally we used alcohol either provided in an IV start kit or provided by our facility.  How many of us thought about, or consulted the relevant science, regarding which preparation solution was actually better for patient care?

Now lets take it up notch. Consider what you do as an anesthesia provider when you are preparing to place an epidural catheter or a subarachnoid block.  Most of the kits that we used in school and current practice have supplied within them a skin cleansing preparation.  According to one manufacturer, B. Braun (bbraunusa.com/images/bbraun_usa/bbrauncatalog.pdf; F3), the supplied cleaning preparation in standard single dose epidural trays is povidone iodine.  Again, how many of us question the skin preparation solution provided in a kit by a manufacturer that our facility has chosen to select for us?  Relevant science indicates that a better skin preparation solution for neuraxial blocks is chlorhexidine.  Furthermore, this solution is optimal when used from a single use package, instead of poured from a multi-use container.

What is the importance of such minutiae?  Well, suppose a post-partum patient presented to the ER 4 days after discharge from the mother-baby unit of Smallville Community Hospital with the following symptoms: low grade fever, back ache, intermittent weakness of the right lower extremity.  During her ER workup, the on call anesthesiologist, Dr. Nurves, is consulted since the patient had an epidural for labor analgesia.  After his physical exam, Dr. Nurves suspects the patient has an epidural abscess.  He orders an MRI that confirms his suspicions.  Now fast forward 18 months.  The patient decides to file a claim against her anesthesia providers for causing the pain and disability from which she now suffers.  She suspects her current problems are from the epidural abscess…….

When an attorney is tasked to evaluate this type of claim, the attorney will seek a healthcare professional who is familiar with the standards of care surrounding the activities related the client’s labor epidural for analgesia.  Imagine the professional conundrum provided by the following clause on the anesthesia record “Sterile prep and drape” without further elaboration.  Would it make any difference if we added another detail: the epidural was placed by a trainee (either physician or nurse) and the use of the trainee was NOT noted on the anesthesia record.  Additionally, the patient, and her spouse, recalls multiple attempts at placing the epidural; this is also not noted on the chart.  So how does one determine if standards of customary practice were met in such a situation?  The use of the trainee, and the multiple attempts at placing the epidural catheter are not documented in the records.  These items are not facts in evidence.  It is a fact however, that if cultures are obtained from an epidural abscess with bacterium that are not normally found in the epidural space, AND the patient’s physical exam prior to the placement of the epidural does not specifically indicate a bacterial infection in the area where the epidural catheter was to be placed AND (perhaps most importantly to us) the modality for transmission of bacterium into the epidural space is under the exclusive control of the anesthesia provider, then supporting data can be introduced to create a scenario whereby the anesthesia providers who placed the epidural catheter caused the epidural abscess AND the related sequela.  What type of supporting data?  Standards of care regarding neuraxial blockade; sterile skin preparation; and care documentation.  Documents of professional standards, along with several peer- reviewed clinical reports regarding sterile skin preparation are readily available in any medical library (electronic or traditional) or via the world wide web.

A well researched review providing the who, what, when, where, and why of how we are supposed to practice our craft can speak volumes to a trier of fact (a judge or a jury) as to whether or not a patient’s claim has merit.  So what is the take home message: Know and adhere to your professional standards of care (review them if necessary) and keep up with the state of your science.

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

References
Barash, P.G., Cullen, B.F., & Stoelting, R.K. Clinical Anesthesia 3rd Ed.  Ch 26 Epidual and Spinal Anesthesia p 651 Lippincott Raven, New York 1997

Birnbach D.J. et al, Povidone Iodine and skin disinfection before initiation of epidural anesthesia. Anesthesiology. 1998; 88:668-672

Nagelhout, J. J., Zaglaniczny, K.L. Nurse Anesthesia 3rd Ed. Ch 44 Obstetric Anesthesia p 1066     Elsevier Saunders, St. Louis 2005

Stoelting, R. K., Miller, R.D. Basics of Anesthesia 3rd Ed., Ch. 12  Spinal and Epidural Anesthesia p 173, Churchill Livingstone, New York. 1994

Pamela Chambers, MSN, CRNA, EJD
www.lexterraeconsulting.com

CRNA Fitness: Decompress the stress

PROCRNA asked me to mount the March podium on the issue of stress-reduction which would be nearly laughable…except for the fact that I have so much personal experience. So here it is, the Body Firm method to decompress the stress.

Where do most of my clients turn for comfort during or after a tough day with the head, hands or heart?  Why, food, of course.  The number one method of coping with pretty much anything these days is comfort food or drink.  Some of you will turn to the box of goodies in the lounge, some of you will opt to ingest a 16-ounce cola, and some (more of you than would like to admit it) will eat two or three doughnuts pretending it’s breakfast.  But be careful of calorie-dense stress relievers.  Sugar elevates your mood very briefly before acting as the downer it really is, dropping you as fast as a plumb line, and leaving unwanted calories and irritation behind.  And in the long run, useless food  raises your stress. Instead, munch on an orange, or snack on a handful of almonds, or both.  An orange will administer quick sugar, it’s true, but it’s loaded with vitamin C and will provide nutrients along with energy.  Nuts are a great source of protein that can hold you over until a real meal or simply sustain you through another case.  Try walnuts or pecans, too, and limit your serving to a clean, even dozen.  The crunch of the munch is very satisfying and brings fast relief.

You may be tempted to just flop on the decrepit sofa in the lounge when someone relieves you in the OR, not always a bad idea.  But even better:  Walk the hallway, stop to do squats every 12 strides, stretch your calves and quads and stretch your arms above your head, jog down the stairs to 2nd floor and jog up the stairs to 4th.  Pause to do a couple of Yoga positions and bring your heart rate back to normal, then re-enter your case room with mental peace restored.

Dr. Coyote howled, Dr. Hound bit, Dr. Wolf snarled throughout the last heart case and, quite possibly, the patient’s heart is now doing better than yours.  Instead of chatting it up with staff and cohorts when you exit the room, pull out a good read.  Weird Sisters is a current hoot for chicks, and author, Olen Steinauer can capture either gender’s attention in short order.  Try reading the daily “funnies” for comic and cardiac relief, or read anything cheerful that will take your mind off the present and help restore your equilibrium and your gift for humor.  LOL.

You may not be in charge of selecting music for the gall bladder room.  Pink Floyd or
George Strait may be the surgeon’s consistent choice of genre, but when you get to choose, or when you go on a break, listen to music that relieves tension.  Relax with alternative sounds like waterfalls or crashing waves from a Narada collection.  Classical melody from Smetana’s “The Moldau” or Debussy’s “Daphnis and Chloe,” and even big Wagnerian themes from “Tannheuser” or “Lohengrin” can fill your soul and remove the excess tension.  Schubert piano solos or symphonies, unrestrained strains from LAGQ,  Chis Botti love tunes on the trumpet or any of the music you simply know and love can take off the edge, and pull you back from it.  Massage your hands and feet while you listen to music and get maximum de-fusing.

Finally, here’s one of the best stress-busters known to Venus or Mars – Meditation.  You’ll need a quiet corner for this activity unless you’re an excellent self-hynotic.  Close your eyes and preferably a door, get seated and settled with good core support, then start with slow, deep breaths in through the nose, out over the lips, switching to all nose breathing when you’re fully “centered.”  Tune out any and all distractions and focus on the breath (Toothpaste trumps garlic!); in…and out….in ….and out…”…he loves me….he loves me not….one for you…one for me…”  Relaxation is in the focus and in the rhythm.

K, I hate to wake you up, but there you have it – Body Firm’s favorite decompression session.  An anesthetist has almost no time to relax during the workday.  Morning break is not a given.  Lunch can be 11:00 or 2:00 or not at all. The comfort and outcome of the patient will always be your ultimate concern.  But put your own health next in line and treat your stress with safe, un-medicated relief.  Your patient will benefit, and it may keep you from becoming one.

Visit Liz online at www.bdyfrm.com  Read daily Lizlines and leave a stress-free comment!

Chief CRNA: OR Efficiency

The following information was provided by Jay Horowitz, candidate for AANA Region 7 director.  With the current budget restraints and emphasis on efficiency, Jay has documented the inherent inefficiency of staffing ratios  and the cost to the system.  Read Jay’s comments, link to the supporting articles and return to procrna.com and offer your comments.

From Jay: This week an article appears in “Anesthesiology, The Journal of the American Society of Anesthesiologists, Inc.” (!!): Supervision Ratios that gets to the heart of the inefficiencies, waste and fraud inherent in “supervision” and “medical direction” models of anesthesia delivery. With an average 22 minute delay in multiple operating rooms several times a day, and an average Medicare reimbursement rate of $1.43/minute X 250 working days a year X 1000’s of US operating rooms, the money adds up awfully fast! So do the savings with greater CRNA utilization models validated in the recent Health Affairs and Nursing Economics articles with NO compromise in quality of care.  Click here to read the ASA article.

I’ve been writing about these inefficiencies for some time now: Streamlining Anesthesia Care and how we might rationally fix the problem. We need to make sure that this kind of information is available to every state and national decision maker and other stakeholders.   Click here to read an article from the Herald Tribune.

Read, enjoy, and return to make a comment

 

Topic: Continuous Capnography Linked to Lower Monitoring Costs

In the age of Health Care Reform where we are all being tasked with providing more care for less money, simple ways to save are gaining popularity.  In an article published in Anesthesiology News, Dana Hawkins-Simons discusses the use of capnography in the Intensive Care Unit to save money.  In the article, she refers to an study by Courtney Rowan, MD who compared to total number of blood gas measurements done before and after the ICU began using continuous capnography on all patients.

The study showed that after beginning the policy of capnography measurement on all patients, the number of blood gas tests dropped from an average of 21.6 per patient to only 13.8.  This reduction in testing resulted in a savings of $985,130.  It was speculated that there could have also been savings due to a reduced requirement to transfuse blood in the smallest of patients where frequent drawing of blood for samples resulted in a lowered Hemoglobin level.

Click here to read the article in Anesthesiology News and return to PROCRNA.COM to make a comment and share your opinion.

Clarus Video System

Having trouble with insertion of the ET tube into the trachea? Would you rather see than feel tracheal rings to insure intubation?  There are a number of video laryngoscopes on the market, now Clarus has introduced the video intubating stylet.

The Clarus Video System allows visualization at the end of the distal point of the stylet (ie the end of the tracheal tube).  The HD screen of the CVS gives the intubater maximum visualization, making it simple to maneuver the tracheal tube into the airway for both regular and difficult intubations.  Also with a click of a  button, a red LED light will illuminate the airway and transluminate through the cricothyroid membrane providing additional insurance that the intubation was successful.

We would like to hear from CRNAs who have used this product.   How does it compare to the standard video laryngoscope?

Click here to go to the manufacturer’s web site and review the product.  Return to PROCRNA.COM and use the comments box to share your thoughts with your colleagues.

Clinical topic: Lower Central line infections

In the midst of the pressure to lower infection rates and meet CMS standards, is it possible to reduce the rate of central line infection to zero?  That question was addressed in an article by Kate O’Rourke published in Anesthesiology news.   The author states that new research has found that multidisciplinary team approaches are making great strides in dramatically reducing rates.  She describes a study done at the University of Massachusetts finding that involving caregivers at all levels and providing frequent, regular feedback on infection rates to hospital staff are two key elements that have made these programs a success, experts said.

The article continues by quoting Matthias Walz, MD, chief of vascular anesthesiology at UMASS Medical Center,  who said the guidelines at his facility were developed by a small task force and then approved by the institution’s Critical Care Operations Committee prior to implementation. “From the ICU physicians to the ICU nurses, respiratory therapists, pharmacy team, occupational therapists—everybody is at the table.” Because all disciplines were involved in creating the guidelines, all caregivers feel they have a stake in the process, he said.

A good infection control program will show positive results, however, for the success to be continued, participants must continue to be updated and motivated.  Ongoing education is essential.  Reducing infection rates is a total team effort by all caregivers.  Communication and coordination is mandatory.

Click here to read the article as published.  Return to www.procrna.com and leave a comment.

Chief CRNA: How to balance your life

Life has many demands at home and at work.  As CRNAs, we are expected to provide first time value to patients with each encounter and we are expected to be available 24/7.  As Chief CRNAs, we add the responsibility of department management to the clinical responsibilities.  After a long day at the Hospital, we often go home to a long list of “must do” items leaving little time for rest and relaxation.  Over time it takes a toll.  As professionals, we must balance our lives if we are to avoid burn out.

In a blog posted on Rock the  post, the author presents 7 key tips for bringing your life back into balance.  The author concludes, “If you don’t have a sense of harmony between your personal and professional life, things can take a toll on you mentally and physically.”  Taking simple approaches, like those listed in the blog, can help you get your life back in balance so that you can be productive at work and have fun with your family and friends.

Click here to go to the blog and read the 7 tips.  Return to www.procrna.com and leave your comments.

Clinical Topic: Propofol allergy in Children

Propofol is currently the hypnotic drug of choice for anesthetic induction.  With the increase in TIVA anesthesia, Propofol is also being used as a maintenance drug.  Propofol is a lipid preparation which incorporates egg lecitin, phosphatide and soy oil in the preparation.  Egg and Soy allergies are listed as contraindication to the use of propofol.  Due to the presence of egg products in the formula, the question emerges as to whether or not propoful should be used in the patient with egg allergy.

In a retrospective chart review study by Murphy A, et al published in Anasth Analg the topic of propofol use in the egg allergic patient is explored.  The authors report that egg lecithin used in the propofol formulation has not been found to have residual egg proteins.  The literature revealed only one case where an egg allergic patient reacted to the lecithin used in propofol.  Since egg lecithin comes from the egg yolk, the authors speculate that up to 75% of pediatric patients with egg allergy could tolerate Propofol without incident.  Nevertheless, the authors recommend skin testing of patients with egg allergy prior to propofol use.

Click here to read an abstract of the original work and return to procrna.com to leave a comment.

 

 

Clinical Topic: Case Presentation by SRNA

SRNA Brooks Cauley has offered some of her student work for review by the CRNA community.  Read, learn, enjoy and make a comment.  Brooks will graduate in 2012 and is available for those who seek a motivated addition to their staff.

Case Study:  Elderly patient with infrarenal AAA, Aortic stenosis and an intracrainial mass.  The review is presented as a series of power point slides with talking points regarding the anesthetic management of each co-existing disease.  References are listed at the end.  View the slides and return to this page to leave a comment.

Click here for slides

 

 

Brooks Cauley

SRNA

bcauley9@yahoo.com

Will graduate December 2012

 

Why you should hire me: People person, good personality, teachable, eager to learn, good work ethic, understands teamwork. Gaining valuable experience in providing general and sedative anesthesia in diverse cases at a level one trauma center. Excited to become part of an organization that promotes effective, efficient, and quality healthcare. Looking for an organization that promotes autonomy and self growth.

Click here to download CV

 

Meeting Review: Texas Association of Nurse Anesthetists

Who says you have to go to a big National meeting to obtain quality continuing education?  The Texas Association of Nurse Anesthetists once again has done it right.  The Texas Association Spring Meeting was held February 17-19 at the Waterfront Marriott in The Woodlands Texas.

The meeting location was a newly developed area with shopping restaurants and movies within easy walking distance.  The Hotel was first class and offered a group rate to those attending the meeting.

Speakers were exceptional.  All were extremely knowledgible and the topics were relevant to clinical practice.   The meeting room was comfortable.  The lunch provided on Friday was better than most food served at meetings.

All things considered, this State meeting was exceptional value for the money.  The Fall Texas Association meeting will be September 21-23 in San Antonio, Texas.  Mark your calendar.

If you attended this or any other Texas meeting, leave a comment.

 

 

Clinical Topic: Intubation verification with Ultrasound

As airway experts, we have all been faced with intubating the difficult airway.  We line up our toys, develop plans A, B, & C, and then go for it.  After intubation, verification of tube placement is essential.  The traditional methods of auscultation over the lung and the presence of a CO2 waveform are the gold standard.  However, with the expanded use of the ultrasound in the operating room, there are other options.

An article by Pfeiffer P, et al published in Atca Anaesth Scand describes the use of the ultrasound for verification of endotracheal tube placement.  The ultrasound can be used several ways to verify intubation.  First, by scanning across the cricoid membrane, direct visualization of passage of the tube is possible.  Several views in the neck area enable confirmation of tube passage.  Ultrasound visualization of diaphragm movement indicates proper intubation.  Finally, lung sliding with ventilation confirms tracheal intubation.

In this study, the group used the techniques described above  and compared the time to verification using ultrasound versus the traditional auscultation and capnography.  The study found that using the ultrasound for verification was reliable and equally quick as auscultation.  When compared to auscultation plus capnography, the ultrasound verification was faster.

Click here to review the abstract of the original article.  Return to procrna.com and offer your opinion.

 

 

CRNA Fitness: Circuit Training

  The Circuit Train

Working out can be whole lot simpler when you know the drill!  If you need one day a week to “relax your mind” while actually getting your work-out, try circuit-training.  There are several good things about using an established circuit and here’s just one.  You can go get a member of the training staff for a free orientation around the circuit.  Reservations encouraged.

A circuit provides a moderate level work-out and consists of gym-level machines set up in a circle, a neat little rectangle or at the very least, all on the same side of the gym.  If they are not grouped, it’s not a simple circuit, it’s a hairy maze. There will be one or two machines for each specific muscle group and in a well-thought-out arrangement, muscles will be grouped to keep you in order.  Remember?  It’s 4:30 a.m. before a 12-hour day of one heart, two gall bladders and whatever last-minute trauma is scheduled and you’re looking for a straight-forward work-out, not discombobulation.  Start with shoulders and begin working your way around the circuit.

Overhead Shoulder Press and perhaps Incline Shoulder Press will be your starting place.  If you’ve not had the orientation, you’ll need to read the instructions printed on one of the supporting braces of the press.  Adjust the weight plates, adjust the seat front-to-back and up or down, sit with “Body Firm” posture, use an overhand grip and press the contraption overhead(or angled up and outward) until fully extended.  Voila!  Rest 30 seconds between one or two more “sets” or press onward.

Note:  Adjusting the set-up options correctly and appropriately is tantamount to getting the most out of each exercise, but even more importantly, to remaining uninjured.  Too much weight can crash back down, hunching shoulders can pinch your neck, exhaling at the wrong time can challenge your heart(and not in a good way), and failing to use your abs will arch and injure your back.  Use caution and common sense.  You too, Men!

Chest Press and Seated Chest Flies will be next and, once again, read the instructions, adjust all of the set-up options – front to back, seat up or down, weight plates –  and be seated.  When seated, your feet should be flat on the floor unless there are little angled platforms for your feet.  Both of these machines are harder than you think so err on the side of caution and keep it light until you’ve found the level of exertion that challenges without causing pain.

Seated Lat Flies are the reverse of Seated Chest Flies – not to be confused with seated front flies which require elbows bent and arms to open and close like French doors – and may be part of the same machine. To work the chest, you’ll face outward; to work the back, you’ll face inward.  And the Seated Lat Row, which has three set-up adjustments, should be next.

These require feet flat on the floor, not tucked behind you so you fall forward, nor extended in front so you can row your boat.  You’re not in an outrigger canoe in Hawaii.  You’re in the gym, darn it, at 4:30, darn it, before doing a heart, darn it…feet flat on the floor, please.

Triceps and biceps are next on the circuit.  Note the work-out moving from strong shoulder exercises, to large chest and back muscles, to the smaller, but potentially so down-right gorgeous tri-bi muscles, the ones that never show in the OR but show big time on a beach…in Hawaii.  You can see what’s on my mind in February!  Biceps will be a standard Seated Biceps Curl and/or a Preacher Curl. I don’t get why this is called “preacher” but google says it’s because the arm position resembles someone praying.  You’ll actually look like someone holding a Bible or a hymnal a whole lot more than praying, but whatever floats your boat is what you should visualize.  Just do it!  Remember, the key to good biceps curls and triceps curls is the anchoring of the elbow and maintaining neutral wrists.  Curl is the basic motion, not the rolling and bending of the wrist to avoid effort.

Legs are next and last.  Expect to do Seated – or angled supine – Adduction and Abduction as well as Seated Leg Extensions and maybe Leg Curls.  You’re a lucky little guy if there is also a Seated Calf Raise and a Leg Press.  A circuit is not generally meant to challenge to the extent or even in the same way as a full-blown 45-set work-out, so three leg machines are really enough.  Lunges and squats are “on on your honor.”  Crunches can wait.

Okay, you’re done.  But if you did only one set of the circuit, take a 60-second break, not a 5-minute text conversation with your broker, and do the circuit again.  People tend to monopolize equipment at the gym, especially cardio equipment, but the circuit may be popular, too.  So you may just want to claim each machine in its turn and hang onto it until you’ve completed your two or three sets of each. Then when your legs are finished – and they WILL be – you can wobble in and out of the shower, hide your coif under a scrub cap, and take a non-circuitous route to the hospital without looking back.

To learn more about exercising with safe, efficient form, visit Liz at www.bdyfrm.com.

Read Lizlines and the weekly Lizlimerick posted Monday through Friday every week of the year.

Clinical Topic: Malignant Hyperthermia Review

Highlights of Malignant Hyperthermia

Early in our Anesthesia training, we were all taught about the dreaded Malignant Hyperthermia.  As we settle into clinical practice, we all remember that MH is a potential risk but give it very little thought.   SRNA Ola Akigbogun, from the Mercer University School of Medicine Nurse Anesthesia Program has offered the following review for procrna.com readers. The bullet format allows us to quickly review the highlights of treating MH.   Ola will graduate in the fall of 2012.  Read his profile and contact him if you are looking for a new graduate who is a motivated and committed to excellence.

Definition

  • Malignant Hyperthermia is characterized by an acute metabolic state in muscle tissue following induction of general anesthesia and in the post operative phase of anesthesia.
  • Malignant Hyperthermia is rare 1:15000 in pediatrics and 1:40000 in the adult population.
  •   Most common in pediatric cases.
  • Patients with mild to moderate MMR, King Denborough syndrome, Duchenne’s muscular dystrophy, Central core disease and Osteogenesis imperfecta are usually susceptible to Malignant Hyperthermia.

History

  • First formal description in 1960 by Denborough and Lovell
  • The first case report allowed for a very solid understanding of the pathophysiology of Malignant Hyperthermia. The patient was a young man who stated that his relatives died without any apparent cause during anesthesia.
  • This patient was anesthetized with halothane and developed tachycardia, hot sweaty skin, and cyanosis. The early recognition of this symptom saved him and lead to the further research and developments of Malignant Hyperthermia
  • In 1970 many of the clinical symptoms of MH were reported
  • In 1970 Kalow et al suggested the development of an in vitro diagnostic test which involved the exposure of biopsied muscle to caffeine and Halothane.
  • In 1975 Harrison reported that dantrolene was successful in the treatment of MH.
  • MH registry in the United States in the late 1980’s
  • In 1985, Lopez and His colleagues demonstrated that intracellular calcium concentration was increased during an episode and that dantrolene was successful in its reversal.
  • In 1990’s molecular biological techniques where applied to identify genes that are susceptible to MH.

Pathophysiology

  • Triggered by Succinylcholine and halogenated agents in greater than 80% of reported cases.
  • Why malignant hyperthermia does not occur after every exposure to halogenated agents is not fully understood.
  • Malignant Hyperthermia is believed to occur due to an uncontrollable increase in the intracellular calcium in skeletal muscle. The sudden release of intracellular calcium removes the inhibitory properties of troponin which results in intense muscle contraction.
  • Increased adenosine triphophatase activity results in an uncontrollable increase in aerobic and anaerobic metabolism. The severe hypermetabolic state created is responsible for increase oxygen consumption and CO2 production leading to severe lactic acidosis and hyperthermia.
  • It was first believed that the abnormal  ryanodine Ryr1 receptor in patients with MH was responsible, but further studies have shown that MH pts may have a normal ryanodine receptors and that abnormalities in secondary messengers such as fatty acids may be the problem. An abnormal sodium channel may also be responsible for malignant hyperthermia.

 

Triggering Factors

  • Halothane
  • Enflurane
  • Isoflurane
  • Desflurane
  • Sevoflurane
  • Succinylcholine

Signs of malignant Hyperthermia

  • The earliest sign and symptom that will present is an increase in ETCO2.  ETCO2 can occur due to other reasons, but when other problems are ruled out treatment of MH should begin.
  • Other additional early signs include tachycardia, tachypnea, and rigidity of the masseter muscle called trismus. However, trismus often occurs with pediatric patients, in particular when intubating, so this sign must be taken into consideration with all other signs and symptoms.

Late Signs

  • Unstable blood pressure, cyanosis and/or mottling of the skin, diaphoresis, cardiac dysrhythmia
  • Hyperthermia. The patient’s temperature may elevate as much as 1-2°C every five minutes.
  • Hyperkalemia, Hypernatremia, Metabolic acidosis, Hyperphosphatemia, elevated CK levels.
  • Dark red blood in the surgical field
  • Myoglobinuria

Malignant Hyperthermia Protocol

1. Immediately discontinue anesthesia, including Succinylcholine. Life-threatening surgery will be continued, but with the use of a different anesthetic agent and machine to prevent residual inhalation agent from triggering a second episode.

2. Hyperventilate 100% oxygen at a high flow rate of 10L/min. to treat effects of hypercapnia, metabolic acidosis, and increased oxygen consumption

3. Dantrolene 2.5mg/kg IV as soon as possible; given every five minutes until symptoms subside.

4. Change ventilator tubing and soda lime canister. Some anesthesia providers may still perform this action, but research has shown that it is not necessary to change the breathing circuit and anesthesia machine since the oxygen delivery rapidly clears the machine of the anesthetic gases.

5. Sodium bicarbonate 1-2 mEq/kg IV to combat metabolic acidosis due to increase of lactate in the circulatory system.

6. Ice packs Apply to groin area, axillary regions, and sides of neck – where major arteries are located.

7. Iced lavage the stomach and rectum with cold fluids to lower temperature. It is recommended not to lavage the bladder since the fluids can alter the true amount of urine being excreted by the patient and alters measurement of output.

8. Mannitol or furosemide Muscle cells are destroyed during an MH crisis and the myoglobin that is released accumulates in the kidneys, obstructing urinary flow, referred to as myoglobinuria. Diuretics are given IV to promote and maintain urinary flow in order prevent renal damage. Mannitol 0.25g/kg IV; furosemide 1mg/kg IV; up to four doses each. Urinary output of 2ml/kg/hr or higher must be maintained to prevent renal failure.**skip this step if dantrium IV is used because it contains 3g of mannitol.

9. lidocaine to treat arrhythmias secondary to electrolyte imbalances. Procainamide removed due to practitioners not beeen familiar with the drug.

10. Dextrose and insulin Treat hyperkalemia due to the release of potassium into the circulatory system as muscle cells are destroyed. Dextrose 25-50g IV; regular insulin 10 units in 50ml of 50% dextrose in water given IV.

11. Monitor urine output Insert Foley catheter if one is not in place

12. Monitor electrolyte levels Blood samples taken every 10 minutes to measure sodium, potassium, chlorides,calcium, phosphate, and magnesium levels.

13. Perform clotting studies

14. ABG Every 5 to 10 minutes

15. Arterial blood pressure Insert line if one is not in place

16. Central venous pressure Insert line if one is not in place.

17. Pt should be monitored in PACU for at least 4 hours then transferred to ICU for 24-72 hrs monitoring.

 

Dantrolene

  • Hydantoin derivative which intereferes with muscle contraction by binding to the RYr1 receptor and inhibiting calcium ion release from the SR.
  • 2.5mg/kg IV every 5 mins until episode is terminated. Upper dosage is 10mg/kg
  • Dantrolene is packages in 20mg vials and it is to be reconstituted with 60ml of sterile water. The reconstitution can be very time consuming
  • Half life is about 6 hrs.
  • Recent studies show that prophylactic use of dantrolene can increase muscle weakness and is not indicated. The anesthesia provider should proceed with the use of non triggering agents
  • 36 vials of dantrolene should be made available upon diagnosis of MH

 

References

Clinical Topic: Propofol Related Infusion Syndrome (PRIS)

Propofol Related Infusion Syndrome (PRIS)  is typically associated with metabolic acidosis followed by cardiovascular failure.  The condition is most commonly reported in ICU patients who require long term sedation.  As the incidence of PRIS increase, so do the number of case reports and studies published in the literature.

An excellent review by Fudickar and Bein published in Minerva Anesthesiol  offers a historical perspective and details pathophysiologic changes that occur when propofol in infused over a prolonged period of time.  The authors describe cytolysis of cardiac and skeletal muscle as being central to the problem.   Mitochondrial fatty acid metabolism impairment was implicated.  Patients with a low carbohydrate supply, such as children, are at increased risk for developing PRIS.  The authors state that their protocol limits propofol to no more than 4mg/kg/hour for long term sedation.

The question arises as to whether or not we place our patients at risk by using TIVA for general anesthesia.  Children receive up to 9 mg/kg/hour for up to 4 hour procedures and infusion rates of up to 30mg/kg/hr have been reported when TIVA is used in adults.  Are we placing our patients at risk?

An article by Guitton et al published in Neurocritical Care describes the development of PRIS in an adolescent with status epilepticus who received propofol sedation for seizure control.   The patient developed a metabolic syndrome with rhabdomylitis after 58 horus of propofol at 8.8mg/kg/hr.  Cardiac arrest followed and extracorporal membrane oxygenation was required.

Various articles agree that PRIS is related to dose and length of time that propofol is administered.  In the ICU, long term dosage should be kept below 4-5 mg/kg/hour.   In the operating room when higher doses are required, the anesthetist should consider stopping the TIVA as soon as it is no longer absolutely required for the procedure.  During the procedure, be aware of the dosage you are giving and try to limit it to the lowest effective dose.

Review the articles that this posting links to and then come back and tell us about your experience and recommendations for TIVA

CRNA Fitness: Make the Most of Your Meeting

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 2nd and 12th, 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.