The incidence of torsades de pointes with peri-operative low-dose ondansetron administration.

STUDY OBJECTIVE: The primary objective of this retrospective safety study was to determine the incidence of torsades de pointes (TdP) or death following perioperative administration of low-dose, 4 mg, ondansetron for postoperative nausea and vomiting. DESIGN AND SETTING: This is a single-center retrospective clinical trial. PATIENTS: The authors identified 32,737 patients who received 37,589 doses of ondansetron during a 2-year time frame between March 2009 and February 2011 for surgical nausea prophylaxis or treatment of nausea. MEASUREMENTS AND MAIN RESULTS: Patients were cross-matched with an electrocardiogram and adverse outcome database; this identified 4759 patients with documentation of a QTc >450 milliseconds (ms), all ventricular tachycardias including TdP within 48 hours of receiving ondansetron, or death within 7 days of receiving ondansetron. No patients developed TdP or died as a direct result of ondansetron administration (n = 0; event rate = 0.0 per 10,000, 95% CI 0.0 to 1.1 per 10,000). Forty-six of 32,737 surgical patients had documented monomorphic ventricular tachycardia (VT) (n = 14; event rate = 4.3 per 10,000, 95% CI 2.3 to 7.2 per 10,000) or died (n = 32; event rate = 9.8 per 10,000, 95% CI 6.7 to 13.8 per 10,000) within 48 h of ondansetron administration. All monomorphic VT episodes were precipitated by existing cardiovascular disease; and 7 of 14 patients had documented monomorphic VT prior to receiving ondansetron. Of the 32 surgical patients who died, all deaths were precipitated by pre-existing disease. CONCLUSION: No episodes of TdP were identified in patients receiving ondansetron perioperatively. This suggests that low-dose ondansetron does not contribute to the development of TdP.

Scholarly Work for Practice Doctorate Nurse Anesthesia Programs: Current State and Guidance.

The Standards for Accreditation of Nurse Anesthesia Programs: Practice Doctorate was adopted by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) in January 2015. Balancing academic and clinical preparation for doctoral students, preparation for the National Certification Examination, and requirements for scholarly work represents a major challenge for students, faculty, and programs. With most nurse anesthesia programs having transitioned to the practice doctorate, the COA was in a pivotal position to examine the current state of scholarly work and to produce a white paper to guide programs' development of criteria for scholarly work. To inform the guidance contained in the white paper, nurse anesthesia educators provided input via a survey, a focus group at the 2019 Assembly of Didactic and Clinical Educators meeting, and an active discussion and question-and-answer session during the Assembly. A call for comments was also sent to stakeholders for review and comment on the draft white paper. The guidance set forth in the white paper in no way supersedes institutional and/or other accreditor requirements. The aim of this guidance is to aid nurse anesthesia programs in successfully managing scholarly project curriculum. This article provides an overview of the project.

Operating Room Waste Reduction.

One-fourth of all operating room (OR) waste is attributed to anesthesia-related material. The goal of this project was to reduce the waste and increase cost savings of opened and unused endotracheal (ET) tubes and disposable laryngoscope handles and blades in 2 separate OR environments. The production of these unused anesthesia supplies was assessed weekly in each of 2 OR environments for 8 weeks before an educational intervention, and for 8 weeks following the intervention. The average weekly waste production was summarized for each study period, compared between periods (preintervention vs postintervention), and analyzed per 100 surgeries using the 2-sample t test. The overall average weekly waste for ET tubes was significantly reduced from 26.7 ± 10.7 to 10.0 ± 6.1 from pre to post intervention (P = < .001), representing a 62.6% reduction. A similar significant reduction in waste was observed for laryngoscope handles (15.9 ± 8.1 vs 7.2 ± 3.1; P = .004; a 54.7% reduction) and laryngoscope blades (21.5 ± 11.0 vs 9.9 ± 4.4; P = .004; a 54.0% reduction). These results highlight the significance and feasibility of an educational intervention in reducing the environmental and economic waste produced by anesthetic practices in the OR.

Literature Searching for Practice Research.

In 2007, the American Association of Nurse Anesthetists endorsed the doctor of nurse anesthesia practice (DNAP) for entry into the profession by the year 2025. More and more Certified Registered Nurse Anesthetists (CRNAs) and graduate students are completing or will be required to complete a doctor of nursing practice (DNP) or DNAP project as the final scholarly work culminating in their advanced degrees. Although DNP/DNAP projects may take various forms depending on the academic institution, in most instances, the need to conduct a literature review is a key step in the process. Partnering with academic or hospital librarians in searching the literature is beneficial because of their expertise in information science and time-saving abilities. For CRNA professionals and students who may not be able to work directly with a librarian, this article aims to provide useful strategies for thoroughly searching relevant literature in support of a high-quality DNP/DNAP project and research that a practicing CRNA may conduct.

Surgical and Patient Risk Factors for Severe Arterial Line Complications in Adults.

BACKGROUND: Prior research has provided inconsistent data regarding the risk factors associated with complications from arterial cannulation. The goal of this study was to clearly define the incidence and risks factors associated with arterial cannulation complications. METHODS: After obtaining institutional review board approval, all patients requiring arterial line placement with documentation were included in this retrospective study between January 1, 2006, and December 31, 2012. Leveraging two robust data warehouses, the Perioperative DataMart and the Mayo Clinic Life Silences System, the authors cross-matched arterial line cannulation with a documented vascular consult, neurologic consult, infection, or return to surgery within 30 days in order to identify the initial patient population. RESULTS: A total of 62,626 arterial lines were placed in 57,787 patients, and 90.1% of the catheters placed were 20-gauge catheters. The radial artery was cannulated in 94.5% of patients. A total of 21 patients were identified as having experienced vascular complications or nerve injuries, resulting in a complication rate of 3.4 per 10,000 (95% CI, 2.1 to 5.1). Cardiac surgery had the largest number of catheters placed (n = 15,419) with 12 complications (complication rate = 7.8 per 10,000; 95% CI, 4.0 to 13.6). The rate of complications differed significantly (P < 0.001) across the three most common catheter sizes (2.7 per 10,000 [95% CI, 1.5 to 4.4] for 20 gauge, 17.2 per 10,000 [95% CI, 4.7 to 43.9] for 18 gauge, and 9.4 per 10,000 [95% CI, 1.1 to 34.1] for 5 French). CONCLUSION: In a large retrospective study, the authors document a very low rate of complications with arterial line placement.

Assessment of recent graduates preparedness for entry into practice.

To date no studies have been conducted to assess the preparedness of CRNA graduates for entry into practice by asking graduates and their respective employers to assess specific competencies. The purpose of this study was to assess recent graduates' preparation and performance. It was hypothesized recent graduates are prepared for entry into nurse anesthesia practice. This study was conducted between August 2011 and February 2012. An online survey tool was used to rate graduates' preparedness to perform 17 professional competencies. Surveys were distributed to 2349 CRNAs who graduated in 2009 and 2,663 employers who hired recent graduates. A power of 90% for employers and 85% for graduates was obtained (P = .05). Analysis of a sample size of 148 matched graduate-employer pairs provided 88% power. Overall, 98% of the graduates and 97% of the employers indicated graduates were prepared for practice. Of the 1,407 graduates assessed by employers, 1,343 (96%) would be hired again. Competencies identified as opportunities to enhance include administration of peripheral nerve blocks, insertion of central lines, insertion of pulmonary artery (PA) catheters, and chronic pain management techniques. The majority of employers rated these competencies as not applicable in their practice setting. Results suggest recent graduates are prepared and perform the competencies for entry into practice. While graduates and employers identified opportunities to enhance preparation it may not be sufficient to simply improve education without changing CRNA practice expectations.

Implications of pharmacogenomics for anesthesia providers.

The practice of anesthesia has long been considered an art and a science, with interpatient variability in drug response being the rule, rather than the exception. Pharmacogenomics, which studies the role of genetics in drug response, is emerging as a discipline that may impact anesthetic management. The purpose of this review is to provide clinicians with basic knowledge related to pharmacogenomics and its implications in anesthesia. This review focuses on pharmacogenomics related to commonly used drugs in anesthesia. Pharmacogenomics as a predictor of drug response is increasingly used in medicine and drug development. By expanding the knowledge base of anesthesia providers, pharmacogenomic considerations have the potential to improve therapeutic outcomes and individualize drug therapy, while avoiding toxic effects and treatment failure. However, because pharmacogenomics may not fully explain variability in drug response, implementation should be in conjunction with traditional anesthesia considerations.

A teaching tool in spinal anesthesia.

The purpose of the present study was to develop and evaluate a new model for teaching spinal anesthesia to nurse anesthesia students. The new teaching tool was evaluated to determine if the use of a spinal model allowing visual combined with the haptic sense was more effective than the traditional spinal model using primarily the haptic sense. Specifically, was there a difference in the number of successful passes, the amount of time taken for each spinal attempt, and the number of participants who reached 90% proficiency when comparing the use of both spinal models? Data analysis using a paired t test and Wilcoxon signed rank test revealed that the number of successes, amount of time needed to complete 1 needle pass, and point at which 90% proficiency was reached with the newly designed model were significantly greater than with the traditional model. The present study demonstrated that significant differences exist between participants who used both visual and haptic sense and participants who used primarily the haptic sense when performing spinal anesthesia. Findings of this study will be used to provide information that may be used to change the current curriculum for the training of nurse anesthesia students in spinal anesthetic procedures.