Venous Thromboembolism: New Concepts in Perioperative Management.

Venous thromboembolism (VTE) is a serious pathophysiologic condition that is a major cause of morbidity and mortality, especially during the perioperative period. A collective term, VTE is used to describe a blood clot that develops inside the vasculature and results in a deep vein thrombosis (DVT) and/or a pulmonary embolism (PE). Deep vein thrombosis and PE are the third leading cause of cardiovascular mortality, superseded only by myocardial infarction and stroke. Patients who receive treatment for acute PE are 4 times more likely to die of a recurrent VTE within the next year. In hospitalized patients who have had surgery, the incidence of VTE and PE is estimated to be 100 times more prevalent than in the general population. The Joint Commission has established Surgical Care Improvement Project measures to address prophylactic interventions to minimize the incidence of VTE. This journal course will review the current approaches to pharmacologic and nonpharmacologic prevention and management of VTE during the perioperative period. Identification and treatment of deep vein thrombosis and acute PE are also described.

Anesthesia case management for endovascular aortic aneurysm repair.

The incidence of angiopathology involving the aorta and microvasculature is expected to become more prevalent because of increased life expectancy and incidence of obesity. With the advent of endovascular aortic repair (EVAR), patients who were not considered surgical candidates for abdominal aortic aneurysmectomy because of their tenuous physical status can undergo corrective treatment and return to their activities of daily living. Because of the limited invasiveness of the procedure, it is unnecessary to cross-clamp the aorta, which minimizes hemodynamic variability and release of inflammatory mediators. As a result, the rate of myocardial ischemia, acute kidney injury, mesenteric ischemia, and blood loss is decreased. However, there are serious complications that can occur with EVAR, which include cerebral and myocardial ischemia, rapid massive hemorrhage, damage to access vessels, and endoleak. Presently, the most common anesthetic technique provided to patients undergoing EVAR is local anesthesia and monitored anesthetic care. A thorough understanding of the surgical procedure, perioperative process, and anesthetic considerations is vital to provide comprehensive care.

Anesthesia case management for video-assisted thoracoscopic surgery.

As the population ages, the number of patients in whom lung disease develops and who require surgical intervention will continue to rise. When compared with open thoracotomy, video-assisted thoracoscopic surgery (VATS) offers patients significant advantages. Decreased invasiveness results in less blood loss, a lower rate of infection, and less postoperative pain and allows for quicker recovery. A description of the significant physiologic changes related to pulmonary blood flow, ventilation, and perfusion when patients are placed in the lateral decubitus position is included. A common method of providing one-lung ventilation during VATS is via a double-lumen endotracheal tube. Proper use, placement, ventilation strategies, and methods to minimize the incidence and treat hypoxia for a double-lumen tube are reviewed. One-lung ventilation poses significant challenges for anesthetists. As a result, adequate preparation during the preoperative, intraoperative, and postoperative phases is essential.

Anesthesia case management for bariatric surgery.

An increasing number of bariatric surgeries are performed every year. A thorough understanding of the pathophysiologic changes, surgical procedure, and anesthesia case management for morbidly obese patients and of the pharmacology of weight-reduction and anesthetic drugs is essential to provide high-quality anesthetic care. The various comorbidities associated with obesity may complicate anesthetic management. Anesthetists must perform a thorough preoperative assessment to identify potential risk factors related to anesthesia and adequately prepare for intraoperative management. Intubation, maintenance of oxygenation, and pain management may be particularly challenging, and various strategies are presented. In addition, an obese patient is at higher risk for postoperative complications. Signs and symptoms of surgical complications may mimic medical complications, making diagnosis difficult.

Anesthesia case management for thyroidectomy.

An intimate knowledge of the anatomy, physiology, pathophysiology, pharmacology, and specific issues related to anesthesia case management for thyroidectomy is essential to provide high-quality care. Airway management may be difficult despite a normal airway examination due to impingement of a thyroid mass on the laryngeal and tracheal structures. Anesthetists must be prepared to use emergency airway adjuncts in case a patient cannot be ventilated or intubated. Because sympathetic nervous system hyperactivity is associated with increased amounts of thyroid hormone, it is essential that all patients having an elective thyroidectomy be in a euthyroid state before surgery. There are multiple preoperative antithyroid medication regimens that effectively treat thyroid hormone hypersecretion. However, although a rare event, thyroid storm can still occur during the perioperative period. Anesthetic considerations and surgical complications are presented.

Should I continue or discontinue that medication?

Patients are admitted for surgery while taking a wide array of medications, and nurse anesthetists must evaluate their effectiveness and compatibility with anesthesia. Anesthetists must be familiar with the basic pharmacology of each drug and the potential adverse effects and possible drug interactions that may occur when anesthetic drugs are administered. If a medication requires discontinuation, we must ensure that the patient's disease remains controlled throughout the perioperative period. It is estimated that up to 50% of patients admitted for surgery will be taking some of type of medication preoperatively. The most common types are the drugs used to treat cardiovascular, central nervous system, and gastrointestinal disorders. There are few clinical or evidence-based guidelines regarding the preoperative management of many of these drugs. Most medications taken for minor disorders that do not have systemic effects can be safely continued without incident. Some medications may require discontinuation or temporary alteration of the dosing schedule to avoid problems in the perioperative period. This course reviews the current literature regarding the anesthetic management of several commonly encountered drug classes.

A successful partnership to help reduce health disparities: the Institute for Culturally Competent Care and the Kaiser Permanente School of Anesthesia/California State University Fullerton.

An innovative partnership with Kaiser Permanente's Institute for Culturally Competent Care (ICCC) enabled the Kaiser Permanente School of Anesthesia/California State University Fullerton (KPSA) to present a formal, 4-module cultural competency certification program within the nurse anesthesia curriculum. The goals of developing the cultural competency curriculum were to increase students' awareness of cultural differences and to enhance students' communication skills with an increasingly diverse patient population. The cultural competency courses are integrated throughout the nurse anesthesia curriculum. During their clinical education, nurse anesthesia students travel to numerous urban and rural areas to serve diverse patient populations. The collaboration between the ICCC and KPSA represents a unique opportunity for the organization and for KPSA to have an impact on patient care. This article describes the genesis and evolution of the collaboration as well as the impact of this ongoing educational effort.

AANA journal course. Update for nurse anesthetists. Aspiration prophylaxis: is it time for changes in our practice?

Pulmonary aspiration of gastric contents during anesthesia is a complication that is fortunately rare, yet potentially catastrophic. Despite its infrequency, techniques geared toward preventing this serious outcome influence many of our routine practices and beliefs. Reports on large-scale clinical studies have opened new insights and questions about the effectiveness of long-standing anesthetic practices. These include conventional beliefs about preoperative fasting guidelines, acceptable gastric fluid volumes and pH, effective pharmacologic interventions, risk factors for pulmonary aspiration, and preventative anesthetic techniques such as rapid-sequence induction. This AANA Journal course outlines current knowledge as to the incidence, risk factors, and efficacy of practices geared toward preventing aspiration. It is anticipated that this review will stimulate discussions regarding possible changes in the anesthetic management of patients in individual practice settings.