AANA Journal Course: Update for Nurse Anesthetists-Optimizing Mechanical Ventilation During General Anesthesia.

Optimal mechanical ventilatory support is a vital component of intraoperative anesthesia care, lung protection, and minimizing postoperative pulmonary sequela. Although concepts surrounding ventilation can be multifaceted and ambiguous, a pragmatic approach coupled with contemporary evidence and skilled assessments will facilitate ideal intraoperative management. Effective mechanical ventilation is dependent on obtaining the best pulmonary mechanics, including compliance, resistance, and gas exchange. Optimally titrated positive end-expiratory pressure is the foundation for ideal pulmonary mechanics, preventing ventilator-induced lung injury, and minimizing postoperative pulmonary complications. A knowledgeable application of pressure support ventilation can offer additional advantages during general anesthesia and emergence, providing synchronized ventilation and augmenting the patient's own respiratory efforts. These concepts, coupled with clinical expertise, will offer insight into the methods, tools, and techniques available to modern anesthetists.

Myasthenia gravis: a careful perioperative anesthetic management of coronary artery bypass grafting.

Nowadays, even hazardous cardiac surgery can be performed on patients with autoimmune diseases like myasthenia gravis. It requires a sensitive perioperative anesthetic approach especially in relation to nondepolarizing muscle relaxant administration. Myasthenic patients produce antibodies against the end-plate acetylcholine receptors causing muscle weakness and sensitivity to nondepolarizing muscle relaxants that could lead to respiratory failure. Perioperative nurse care is critical for uncomplicated course of treatment; therefore, apprehension of surgical procedure should be helpful on an everyday basis. We describe successful management without any pulmonary complications of two patients with myasthenia gravis undergoing coronary artery bypass grafting. In addition, antiacetylcholine receptor antibodies concentrations were evaluated during treatment time. In conclusion, we have found that reduced titrated doses of cisatracurium may be safely used in patients with myasthenia gravis undergoing cardiac surgery without anesthesia and respiratory-related complications.

A randomized double-blind trial of anesthesia provided for colonoscopy by university-degreed anesthesia nurses in Greece: safety and efficacy.

There are numerous studies in the literature of anesthesia administered during colonoscopy including various methods, drugs, and monitoring systems; however, none of them has studied whether a university-degreed nurse anesthesia provider (known as a certified registered nurse anesthetist in the United States) is skillful enough to provide safe anesthesia in patients undergoing endoscopic procedures. The aim of our study was to determine whether anesthesia provided by a university-degreed nurse anesthesia provider during an endoscopic procedure is comparable in terms of safety and efficacy with routine sedation practice. This randomized, double-blind study included 100 adult patients who underwent colonoscopy conducted in the Evgenidion University Hospital during a single year. Subjects were divided into 2 groups: the first group received the usual scheme of intravenous sedation with midazolam and fentanyl administered by a member of the endoscopic team that was blind to Bispectral Index (BIS) values recordings (Group 0). The second group received intravenous bolus injection of propofol bolus by a university-degreed anesthesia registered nurse based on the BIS values (Group 1). The average of the mean BIS values of Group 0 was 85.07 (SD = 8.01) and for Group 1 was 76.1 (SD = 10.88; p = .04). The parameters of "patient memory during procedure" and the satisfaction scores (as self-assessed by the patients as well as 2 gastroenterologists) were also significantly different between the patients of the 2 groups (p = .000). Comparison between the 2 groups showed that the sedation offered by a university-degreed nurse anesthesia provider was absolutely safe and effective, offering particular comfort to the patient during the intervention and contributing significantly to its successful results.

The obese patient. Anaesthetic issues: airway and positioning.

The authors have combined experience of over forty years working within the NHS and private hospitals as registered operating department practitioners. It is widely accepted that obesity is a growing problem in the populations of all developed and, increasingly, developing countries. It is also agreed that this sector of the population present specific challenges when required to undergo general anaesthesia. What is not so evident is a universal approach to assessing, predicting and overcoming these challenges. Furthermore, where there is the presentation of a clearly high risk patient, there can be limitations in optimizing the environment for reasons such as saving time, a lack of resources or sheer apathy. This article reviews the challenges, assessment and solutions available to the clinician faced with a high BMI patient with particular reference to the technique of ramping.

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.

Patient outcomes comparing CRNA-administered peripheral nerve blocks and general anesthetics: a retrospective chart review in a US Army same-day surgery center.

We compared outcomes between patients receiving general anesthesia (GA) vs regional block (RB) in a military same-day surgery unit (SDSU), where Certified Registered Nurse Anesthetists (CRNAs) delivered all RBs and GA. All patient charts from 2003 through 2006 were reviewed. Patients were included if they were 18 years or older, had an ASA physical status I or II, and underwent a shoulder or knee arthroscopy that used either RB or GA. Overall, 342 patients met inclusion criteria: 161 GA and 181 RB. With GA, mean anesthesia time was shorter (109.6 vs 135.5 minutes, P < .001), but recovery times were longer (56.7 vs 36.4 minutes, P < .001). SDSU times were nearly identical (GA vs RB, 71.5 vs 72.8 minutes), resulting in a total hospital time that was not significantly different (352.7 vs 347.5). The GA group received more morphine equivalents of narcotic in the operating room (22.9 vs 15.1 mg, P < .001) yet still had higher pain scores postoperatively than the RB group (1.1 vs 0.3, P < .001). The GA group received a significantly greater number of antiemetic doses intraoperatively (0.58 vs 0.04, P < .001) but still had a higher, although nonsignificant, rate of emesis (15.5% vs 10.0%). Patients receiving RB had less pain and received less analgesia without any increase in postoperative nausea and vomiting, hospital time, or anesthesia-related complications.

Difficult mask ventilation in 5-year-old due to submental hypertrophic scar: a case report.

Airway evaluation and management are of critical importance to providing safe and effective anesthesia. Burn injuries in and around the airway are of particular concern to anesthesia providers. The following is a case report of a 5-year-old patient who had neck contractures and a large hypertrophic scar on his chin secondary to a burn injury. The patient initially was easy to mask ventilate, but ventilation became difficult when muscle relaxants were given and positive-pressure ventilation was attempted. An alteration of conventional hand placement during mask ventilation enabled the anesthesia provider to maintain a patent airway and the surgical procedure to proceed.

A field-expedient Ohmeda Universal Portable Anesthesia Complete draw-over vaporizer setup.

The Ohmeda Universal Portable Anesthesia Complete (U-PAC) draw-over anesthetic system is active in the US Army inventory. It is standard equipment for Certified Registered Nurse Anesthetists assigned to US Army Forward Surgical Teams and Joint Special Operations Command. The purpose of this article is to describe a practical and field-expedient U-PAC draw-over vaporizer setup used during Operation Iraqi Freedom I (February 2003 to July 2003). During the deployment, general anesthesia was administered to 25 patients with penetrating trauma using the Gegel-Mercado setup without system malfunction. This setup strengthens the standard U-PAC draw-over system delivery because it increases fractional inspired oxygen concentrations, promotes hands-free operation, enhances circuit cleanliness reducing cross contamination, and provides an alternate method for draw-over anesthesia administration in austere conditions when a ventilator may not be available or practical. It integrates and builds on the core concepts of draw-over anesthesia delivery in the literature. The Gegel-Mercado setup is combat proven.

Anesthetic management of an infant undergoing radical nephrectomy for Wilms tumor: a case report.

Wilms tumor (WT), also called nephroblastoma, is a solid, malignant renal mass that can sometimes grow so large it spreads outside the kidney and invades other structures. Most experts recommend complete tumor resection as a primary intervention. The clinical manifestations caused by the WT most significantly hypertension, can appear as a barrage of pathophysiological events to the nurse anesthetist. The case presented involves an 8-week-old infant who underwent a radical nephrectomy because of a WT. The occurrence, symptoms, pathophysiology, and intraoperative anesthetic management of WT are discussed.

High-frequency jet ventilation during radiofrequency ablation: a case report.

High-frequency jet ventilation (HFJV) has been used in emergency airway scenarios and various surgical procedures. Although substantial literature is available regarding HFJV in these situations, there is only 1 publication to date concerning its use for cardiac radiofrequency ablation procedures. The following case study describes a 49-year-old man undergoing radiofrequency ablation in which HFJV was used. This method has been used for these procedures for months in our institution with great success. Its effectiveness is attributed to the lack of significant heart movement as compared with conventional intermittent positive-pressure ventilation, which, in turn, has improved surgical conditions and resulted in decreased procedure times. In this case, a newly introduced in-line circuit filter was used. Impedance to passive exhalation was created after the filter became saturated from the high humidification. This event, its management, and the following discussion on the mechanics of HFJV and its use in radiofrequency ablation procedures make this case an educational value to all anesthesia providers.

Asystole during laryngoscopy of a patient with pleural and pericardial effusions: a case report.

A 53-year-old woman presented to the operating room for surgical correction of pericardial and pleural effusions. Her history included stage IV breast cancer, well-controlled hypertension, and diverticulitis. Although her baseline blood pressure, heart rate, and respirations were normal, she was short of breath with diminished breath sounds on the left side of the lungs and required oxygen, 2 L/min via nasal cannula. The nurse anesthesia student, under the direction of the Certified Registered Nurse Anesthetist (CRNA) and anesthesiologist, induced general anesthesia with etomidate, fentanyl, lidocaine, and succinylcholine. During placement of a double-lumen endotracheal tube, the patient became asystolic. The nurse anesthesia student immediately withdrew the laryngoscope, and the patient returned to normal sinus rhythm. A second attempt at laryngoscopy produced asystole as well. Again, the laryngoscope was withdrawn, and the patient returned to normal sinus rhythm. After resuming ventilation with 100% oxygen and administering atropine, 0.4 mg, the next intubation was successful, producing no untoward effects. Reintubation at the end of the case with a single lumen endotracheal tube was uneventful. The patient was transported to the intensive care unit and mechanically ventilated overnight. The next morning, she was extubated with no further anesthetic complications.

Airway management in a child with penetrating pharyngeal wall foreign body injury: a case report.

Penetrating foreign bodies of the oropharynx are encountered in children of all ages, although more frequently between the ages of 3 to 5 years. A thorough preanesthetic evaluation of these patients, including type and extent of injury, must be performed if time allows. As a result of the often emergent nature of these cases, poor patient cooperation, and great potential for airway compromise, special considerations are given to management of the airway. The use of nontraditional equipment may greatly facilitate laryngoscopy and intubation.

Anesthesia services outside of the operating room.

In January 2000, Primary Children's Medical Center (PCMC) nurses and physicians of specific disciplines including hematology/oncology, surgery, Emergency Department (ED), and anesthesia, identified a need to provide general anesthesia for children undergoing procedures outside of the operating room. This need was based upon two factors: (a) limited availability of the operating room, and (b) lack of proper monitoring of children receiving conscious sedation for painful procedures in PCMC clinics. In September 2000, the Rapid Treatment Unit (RTU) service was developed to provide cost-effective, efficient, patient/family-centered care for a variety of procedures. With limited literature on the subject of anesthesia services outside of the operating room, many hours of planning, education, and organizing occurred to develop this unique service. Parents have reported satisfaction with the service verbally and through an anonymous survey. Increasing numbers of patients seeking services from Utah, Idaho, Nevada, Wyoming, and Montana indicate a need for service expansion within the five-state region surrounding Salt Lake City. The RTU Anesthesia service is an important asset to PCMC and continues to expand to provide safe, efficient health care for children.

Anesthetic management in a pediatric patient with Noonan syndrome, mastocytosis, and von Willebrand disease: a case report.

This case report describes anesthetic considerations for a 6-year-old boy, admitted for adenoidectomy under general anesthesia, who had a complicated medical history, including mastocytosis, Noonan syndrome, and von Willebrand disease. Each affected the anesthetic plan and was addressed preoperatively among all surgical and anesthesia providers. Mastocytosis created a major concern, with its increased numbers of histamine-filled mast cells. Each drug that was added or eliminated from the anesthetic plan, to prevent histamine release by the activation of triggers, was considered. Patient handling and temperature control were also concerns. One of Noonan syndrome's characteristics is heart anomalies. This patient had a history of a patent foramen ovale and pulmonary stenosis; therefore, air was carefully removed from all intravenous lines and syringes. The main concern for bleeding difficulties was attributed to the history of von Willebrand disease, which results in prolonged bleeding time and can lead to delayed bleeding or serious postsurgical hemorrhage. Desmopressin was administered preoperatively to increase platelet aggregation and the von Willebrand factor level. The use of aspirin and other nonsteroidal anti-inflammatory drugs was avoided. We discuss the clinical and anesthetic management of this case with a review of pertinent literature.

Use of heliox for intraoperative bronchospasm: a case report.

Bronchospasm is an anesthetic emergency that can lead to disastrous outcomes if treatment is irresolvable. An anesthesia provider must immediately initiate treatment if bronchospasm is suspected in order to avoid negative sequelae. The following is a case report of a 32-year-old man who experienced refractory bronchospasm upon emergence from general anesthesia. This article discusses the initial treatment attempted at resolving the bronchospasm, as well as the use of heliox in the ultimate resolution of the bronchospasm. Although heliox has been used foryears to treat patients with various respiratory complications, it is not currently a common treatment instituted by anesthesia practitioners for the treatment of bronchospasm. Consideration of the use of heliox may provide another option for the treatment of a patient suffering from refractory bronchospasm.