Evaluating a Quality Improvement Initiative to Increase Anesthesia Providers' Use of and Understanding of Quantitative Neuromuscular Monitors.

Improved understanding of the monitoring and dosing practices of anesthesia providers regarding neuromuscular blockade is necessary. The use of subjective methods such as peripheral nerve stimulation and clinical assessment tests can increase the risk of residual neuromuscular blockade and adverse postoperative outcomes. Quantitative monitoring of neuromuscular blockade is an alternative tool to peripheral nerve stimulation to guide neuromuscular blockade; however, it is rarely used by providers. We developed an initiative to improve anesthesia providers' knowledge of neuromuscular blockade pharmacology, physiology, monitoring, and management. After the initiative, an analysis assessed for practice change regarding the use of quantitative monitoring and dosing of neuromuscular blocking agents and neostigmine. The use of quantitative monitoring increased significantly from 14.0% in the preinitiative group to 48.0% after the initiative (P < .001). The least squares mean 95% effective dose (ED95) neuromuscular blocking agents dose was compared between pre-initiative and postinitiative groups, and case length was a significant predictor for patients receiving the highest neuromuscular blocking agents doses. Neostigmine doses were compared between preinitiative and postinitiative groups, and body mass index was a significant predictor of the least squares mean neostigmine dose (P = .002) and the likelihood of receiving a high neostigmine dose (odds ratio = 0.911, 95% CI = 0.870-0.955).

Unknown Pseudocholinesterase Deficiency in a Patient Undergoing TIVA with Planned Motor Evoked Potential Monitoring: A Case Report.

Pseudocholinesterase abnormalities are a genetic cause of aberrant metabolism of the depolarizing muscle relaxant succinylcholine. This article examines a case where succinylcholine was chosen to facilitate intubation due to its ultra short duration and the request of the surgeon to monitor motor evoked potentials. Following succinylcholine administration the neurophysiologist was unable to obtain motor evoked potentials. This case study highlights the intraoperative and postoperative management of an elderly patient with an unknown pseudocholinesterase deficiency.

Reexamining traditional intraoperative fluid administration: evolving views in the age of goal-directed therapy.

Intraoperative volume administration has long been a topic of debate in the field of anesthesia. Only recently, however, has the conversation shifted to a discussion of appropriate intraoperative volume. A thorough review of the literature explores the history of today's widely accepted fluid administration equation and discusses possible explanations and consequences of iatrogenically induced hypervolemia. Current studies exploring various volume administration techniques are reviewed, as are emerging technologies available to help guide anesthesia providers with intraoperative fluid management.

Anesthesia awareness-induced posttraumatic stress disorder.

While the incidence of anesthesia awareness has been well documented, information related to posttraumatic stress disorder (PTSD) symptoms resulting from anesthesia awareness is limited. Particularly scarce are descriptions of specific techniques to treat anesthesia awareness-induced PTSD. This article reviews an individual example of a woman who was experiencing anesthesia awareness-induced PTSD symptoms for 10 years. Treatment included supportive psychotherapy, psychoeducation, psychopharmacology, and group therapy with other individuals experiencing PTSD symptoms. Although this patient responded to these treatment approaches, additional studies are needed to identify optimal treatment options for patients with anesthesia awareness-induced PTSD.

Combined spinal/general anesthesia with postoperative femoral nerve block for total knee replacement in a patient with familial hyperkalemic periodic paralysis: a case report.

Familial hyperkalemic periodic paralysis (HYPP) is a rare genetic disorder in which the sodium channels in skeletal muscle cells have altered structure and function. Small elevations in serum potassium lead to inactivation of sodium channels, causing episodic weakness or paralysis. Exposure to cold, anesthesia, fasting, emotional stress, potassium ingestion, and rest after exercise can stimulate an attack. This case report describes a 65-year-old man with HYPP who was admitted for a right total knee arthroplasty. He had a history of arteriosclerotic heart disease and stenting 8 years earlier, previous inferior wall myocardial infarction with ejection fraction of 65%, anxiety, degenerative joint disease, well-controlled type 2 diabetes mellitus, and a body mass index of 53.3 kg/m2. A combined spinal/general anesthetic with a femoral nerve block for postoperative pain control was chosen. Careful attention was given to monitoring and maintenance of core temperature, use of insulin and glucose to maintain normokalemia, and carbohydrate loading the night before surgery. The patient recovered from the anesthetic without complication and had pain relief for approximately 22 hours postoperatively because of the femoral nerve block. The patient was without weakness or paralysis related to HYPP in the postanesthesia care unit or throughout his hospitalization.

Caudal anesthesia in a patient with severe pulmonary hypertension.

Delivery of anesthesia to patients with severe pulmonary hypertension can be extremely challenging. The profound hemodynamic alterations of the disease can often be exacerbated by alterations in circulatory function brought about by anesthetic and surgical interventions. High perioperative morbidity and mortality rates have been reported. Minimizing adverse outcomes in these patients requires careful perioperative evaluation and planning. Selection of an anesthetic technique suitable for the surgery without causing major hemodynamic alterations, which can lead to cardiac failure and death, is a unique consideration of the anesthesia provider. As shown in this case report, caudal anesthesia, when appropriate, can offer a safe anesthetic for these patients.

Apoptosis: understanding programmed cell death for the CRNA.

Apoptosis, or programmed cell death, is a physiologic mechanism employed by most multicellular organisms to maintain homeostasis of body tissues. In balance with the production of new cells by mitosis, apoptosis provides for the orderly destruction and removal of cells that are no longer needed by the organism. Apoptosis occurs by complex pathways involving multiple biochemical signals and processes. Dysfunctional apoptotic mechanisms are the pathologic basis for many human diseases, including common disorders of the heart, lungs, brain, and endocrine systems. Researchers have demonstrated in animal models that neurodegenerative changes after the administration of anesthetic drugs are related to apoptosis. Anesthesia drugs have been found to induce apoptosis, perhaps through the production of reactive oxygen species. Propofol is a drug used in anesthesia that has unique antioxidant qualities that may be beneficial. The purpose of this article is to review, for nurse anesthesia providers, current information about the process of apoptosis, the role of apoptosis in comorbid diseases, and the implications of the effects of anesthesia drugs on normal apoptotic mechanisms that need to be evaluated as potential sources of risk or benefit to surgical patients.

Use of dexmedetomidine and ketamine infusions during scoliosis repair surgery with somatosensory and motor-evoked potential monitoring: a case report.

Dexmedetomidine and ketamine infusions were the main anesthetic for a 15-year-old girl, who underwent scoliosis repair surgery with intraoperative wake-up test, somatosensory evoked potential (SSEP), and motor-evoked potential (MEP) monitoring. To achieve maintenance of anesthesia, dexmedetomidine and ketamine were administered concomitantly. The dexmedetomidine dose ranged from 0.9 to 1.2 microg/kg per hour throughout the case, and the ketamine dose ranged from 0.4 to 0.6 mg/kg per hour. The analgesic properties of dexmedetomidine and ketamine were complimented by the continuous fentanyl infusion at 1 to 2 microg/kg per hour. The sympatholytic properties of dexmedetomidine were balanced with the sympathomimetic properties of ketamine, and the patient required minimal vasoactive support (only 250 microg of phenylephrine was administered over the course of 12 hours of anesthetic care). This anesthetic regimen, as well as 60% nitrous oxide and 40% oxygen, provided satisfactory conditions for the intraoperative neurophysiologic monitoring. This case report discusses the use of dexmedetomidine and ketamine infusions as an alternative to propofol-based total intravenous anesthesia during scoliosis repair surgery with intraoperative SSEP and MEP monitoring.

Ventricular assist devices and anesthetic implications for noncardiac procedures.

Approximately 5 million Americans experience heart failure, which affects 10 in every 1000 people older than 65 years. Ventricular assist devices (VADs) are a type of mechanical circulatory support that aids in systemic perfusion by maintaining unidirectional flow while reducing the oxygen demand of the failing ventricle. There are 3 generations of VADs in circulation used as a bridge to transplantation, a bridge to recovery, or as destination therapy. Due to the increasing use of these devices, it is likely that anesthetists will encounter patients with these devices more frequently, which requires adequate preoperative discussion with the care team. Intraoperatively, it is important to realize that patients with VADs are at higher risk for aspiration, to recognize electromagnetic interference from surgical devices, to maintain hemodynamic stability, and to monitor coagulation status. With proper knowledge, and adequate preoperative preparation and intraoperative care, anesthetists should be able to achieve safe and successful patient outcomes through anesthesia care.

Code blue: what to do?

Cardiac arrest may occur intraoperatively at any time. The purpose of this article is to help the reader recognize and assist in the management of an intraoperative cardiac arrest. Patients who are at risk for cardiac arrest in the OR are identified and different types of pulseless arrythmias are identified. Roles of perioperative personnel are suggested and documentation during the code is discussed.

Detecting ischemic danger at the source.

Using near-infrared spectroscopy, the INVOS (In-Vivo Optical Spectroscopy) System provides real-time, site-specific cerebral/somatic measurements of de-oxygenated and oxygenated hemoglobin molecules within red blood cells through a noninvasive oximeter. Perioperative professionals can use the vital sign information monitored by this technology to detect and correct site-specific blood oxygenation issues that can lead to complications and poor outcomes. AORN J 90 (September 2009) 431-433. (c) AORN, Inc, 2009.

The perioperative nurse's role in table-enhanced anterior total hip arthroplasty.

The anterior approach to total hip arthroplasty (THA),when performed with the patient in the supine position,is enhanced by the use of a radiolucent, orthopedic table.This technique has numerous advantages: enhanced intraoperative fluoroscopy because of the patient's supine position on a radiolucent table, improved femoral exposure,and reduced soft tissue trauma. Criteria for patients election is not limited as it may be for other arthroplasty techniques.The role of the perioperative nurse during an anterior THA is to ensure optimal function of the orthopedic table and provide safe patient care. A clear understanding of the surgical techniques used and the functions of the table are imperative.

Nurse anesthesia program requirements for esophageal/precordial stethoscope earpieces: a survey.

Student nurse anesthetists are often required to purchase an auscultatory earpiece device for use in the clinical setting. Although the device is required, students have observed that many anesthesia providers in the clinical setting no longer use this piece of equipment. The purpose of this project was to determine the number of anesthesia programs that required mandatory purchase of the auscultatory earpiece by student nurse anesthetists. A brief survey was developed to collect data from the directors of all 105 accredited nurse anesthesia programs in the United States. The survey was completed by 63 (60%) of the program directors, and 62 completed surveys were used in the analysis. Results revealed that 95% of the responding nurse anesthesia programs (59 of 62) require esophageal/ precordial stethoscope earpieces for their students, but 46% (27) of those programs provide the earpieces. Most (76%) of the programs required the use of the earpieces in the clinical setting, but only 45% thought that they should be used for monitoring every anesthetic delivered.

Staff acceptance of video monitoring for coordination: a video system to support perioperative situation awareness.

AIM: To understand staff acceptance of a remote video monitoring system for operating room (OR) coordination. BACKGROUND: Improved real-time remote visual access to OR may enhance situational awareness but also raises privacy concerns for patients and staff. DESIGN: Survey. METHODS: A system was implemented in a six-room surgical suite to display OR monitoring video at an access restricted control desk area. Image quality was manipulated to improve staff acceptance. Two months after installation, interviews and a survey were conducted on staff acceptance of video monitoring. RESULTS: About half of all OR personnel responded (n = 63). Overall levels of concerns were low, with 53% rated no concerns and 42% little concern. Top two reported uses of the video were to see if cases are finished and to see if a room is ready. Viewing the video monitoring system as useful did not reduce levels of concern. Staff in supervisory positions perceived less concern about the system's impact on privacy than did those supervised (p < 0.03). Concerns for patient privacy correlated with concerns for staff privacy and performance monitoring. Technical means such as manipulating image quality helped staff acceptance. CONCLUSIONS: Manipulation of image quality resulted overall acceptance of monitoring video, with residual levels of concerns. OR nurses may express staff privacy concern in the form of concerns over patient privacy. RELEVANCE TO CLINICAL PRACTICE: This study provided suggestions for technological and implementation strategies of video monitoring for coordination use in OR. Deployment of communication technology and integration of clinical information will likely raise concerns over staff privacy and performance monitoring. The potential gain of increased information access may be offset by negative impact of a sense of loss of autonomy.