Local Anesthetic Adjuvants Providing the Longest Duration of Analgesia for Single- Injection Peripheral Nerve Blocks in Orthopedic Surgery: A Literature Review.

Inadequate pain relief after surgery may delay surgical recovery, decrease patient satisfaction, increase length of stay, raise the risk of hospital readmissions, and increase overall healthcare costs. One way to decrease postoperative pain for patients undergoing orthopedic surgery is through the use of peripheral nerve blocks. Anesthesia providers can add many adjuvants to local anesthetics to improve quality and prolong duration of analgesia. The purpose of this literature review is to evaluate local anesthetic adjuvants to peripheral nerve blocks. A review of published studies using PubMed, MEDLINE, and Cochrane search engines was performed using predefined data fields. Based on this literature review, recommendations for practice are provided.

Rapid Handheld Continuous Electroencephalogram (EEG) Has the Potential to Detect Delirium in Older Adults.

BACKGROUND: Delirium-related biochemical derangements lead to electrical changes that can be detected in electroencephalographic (EEG) patterns followed by behavioral signs and symptoms. Studies using limited lead EEG show a large difference between patients with and without delirium while discriminating delirium from other causes. Handheld rapid EEG devices may be capable of detecting delirium before symptom onset, thus providing an objective physiological method to detect delirium when it is most amenable to interventions. OBJECTIVE: The aim of this study was to explore the potential for rapid EEG to detect waveform pattern changes consistent with delirium status. METHODS: This prospective exploratory pilot study used a correlational design and mixed models to explore the relationships between handheld portable EEG data and delirium status. RESULTS: While being under powered minimized opportunities to detect statistical differences in EEG-derived ratios using spectral density analysis, sleep-to-wake ratios tended to be higher in patients with delirium. CONCLUSIONS: Limited lead EEG may be useful in predicting adverse outcomes and risk for delirium in older critically ill patients. Although this population is at the highest risk for mortality, delirium is not easily identified by current clinical assessments. Therefore, further investigation of limited lead EEG for delirium detection is warranted.

Ira P. Gunn: educator, advocate, legend.

This column examines the contributions of nurse anesthetist Ira P. Gunn, CRNA, MLN, FAAN (1927-2011), widely recognized as a visionary and tireless advocate for the profession of nurse anesthesia. Her contributions to nurse anesthesia practice, research, education, publication, consultation, credentialing, and government relations have significantly contributed to the preservation and advancement of nursing and nurse anesthesia.

Team Communication in the Operating Room: A Measure of Latent Factors From a National Sample of Nurse Anesthetists.

Medical errors more often result from miscommunication among providers than lack of medical knowledge. The consequences of miscommunication are well documented, but there is less information about factors contributing to communication errors among providers. In this study, surveys were administered to a national sample of 3,000 nurse anesthetists to measure variables associated with communication attitudes and behaviors. The specific variables measured in the survey were latent cultural factors that contribute to communication behaviors. Previous research found these latent variables contribute to miscommunication among operating room physicians, resulting in patient-related errors that could be avoided. The survey used for this study was based on an intercultural communication theory. Survey items were modified to reflect operating room culture, specifically nurse anesthetist communication. Exploratory factor analyses were used to analyze the survey data. The analyses found distinct patterns of latent cultural communication variables in the sample of 474 completed responses. The communication profiles that resulted from this study can be compared with previously collected physician data to help explain how miscommunication occurs among interprofessional groups of operating room providers, resulting in medical error. Knowledge of these latent variables can be translated to more effective communication training protocols in the future.

Challenges that nurses face in caring for morbidly obese patients in the acute care setting.

BACKGROUND: Despite increasing numbers of morbidly obese patients admitted to acute care facilities for surgery or treatment of nonsurgical conditions, there is little evidence of the problems nurses face in providing care to these patients. Anecdotal evidence suggests that the care of these patients is more demanding than the care of nonobese patients. The objective of this study was to describe nurses' perceptions of the challenges that they face when caring for morbidly obese patients. METHODS: Focus groups of nurses from a tertiary care facility were convened. A trained facilitator posed questions to the group concerning various aspects of care for morbidly obese patients. Comments of respondents were categorized using NVIVO software. RESULTS: Nurses reported concerns about the increased staffing needs required for care of these patients and the particular challenges of the physical care. Concerns also included the availability, placement, and use of specialized equipment. Room size and the absence of some equipment were also problematic. Finally, nurses perceived safety issues, both for themselves and their patients. CONCLUSIONS: Morbidly obese patients in the acute care setting require specialized nursing care in terms of techniques, levels of staffing required, and the use of specialized equipment.

Regional anesthesia with monitored anesthesia care for dermatologic laser surgery.

This article describes an anesthetic technique that the authors have found useful for cutaneous laser surgery in keeping with the standards for office-based anesthesia practice. Although still in its infancy, office-based anesthesia for dermatologic laser procedures has become one of the most challenging yet rewarding fields of anesthesia today. As laser procedures continue to flourish, with seemingly endless technologic advances, surgeons, anesthesia providers, and other medical personnel must work collaboratively in developing appropriate office-based practice. The authors' experience using the anesthetic technique described here has demonstrated that cutaneous laser resurfacing can be conducted safely and efficiently using a combination of facial nerve blocks with intravenous sedation.

Variability in the American Society of Anesthesiologists Physical Status Classification Scale.

The American Society of Anesthesiologists (ASA) Physical Status (PS) Classification is used worldwide by anesthesia providers as an assessment of the preoperative physical health of patients. This score also has been used in policy-making, performance evaluation, resource allocation, and reimbursement of anesthesia services and frequently is cited in clinical research. The purpose of this study was to assess interrater reliability and describe sources of variability among anesthesia providers in assigning ASA PS scores. A questionnaire with 10 hypothetical patients scenarios was given to 70 anesthesia providers who were asked to assign ASA PS scores in each scenario and to provide rationale for their decisions. The data were summarized and stratified according to nurse anesthetist or anesthesiologist and military or nonmilitary anesthesia providers. We hypothesized there would be no difference between any of the anesthesia provider groups in assignment of ASA PS scores. A lack of interrater reliability in assigning ASA PS scores was demonstrated. There were no significant differences between the anesthesia provider groups. There was no correlation between ASA PS scoring and years practicing or any of the other demographic variables. Several sources of variability were identified: smoking, pregnancy, nature of the surgery, potential difficult airway, and acute injury.

Leading through collaboration: a regional academic/service partnership that works.

This article describes a regional education/service partnership that has thrived for > 20 years. The collaboration takes place between a tertiary medical center and a university-based school of nursing located in a rural underserved area. Several critical issues have been creatively addressed by the partners including: the shortage of new nurses and nurse educators; the shortage of advanced practice nurses; the need to foster competence in new employees, particularly new graduates; and the advancement of clinical nursing research. Throughout history, academic/service partnerships have been discussed and developed. Cronenwett suggests that while the models have changed and evolved, there is a long-term history of collaborative partnerships in nursing.(1) Some of the most successful partnerships described in the literature have occurred when hospitals and schools of nursing share their governance structure.(2) However, in today's world, collaboration is based on a pressing need to address complex issues even when schools of nursing and clinical agencies have different governing structures. O'Neil suggests that the building blocks of an effective partnership include a coherent institutional strategy, potential partners that bring value and assets to the partnership, mutually beneficial goals, and accountability to each other.(3) Time and timing, tact, talent, and trust are other essentials of a productive partnership.(4) This article describes a collaborative model in which a university-based school of nursing has collaborated with a tertiary care hospital. The institutions have separate governing structures and each has its own personnel policies, job descriptions, and benefits. The collaboration takes place in a rural area of the state characterized by poverty and high morbidity and mortality. There is one hospital and one baccalaureate program in the region. There are also several associate degree programs in nursing (ADN) and these programs have been involved in many of the collaborative initiatives. Several critical issues have been addressed by the partners including: the shortage of new nurses and nurse educators, the shortage of advanced practice nurses, the need to foster competence in new employees (particularly new graduates), and the advancement of clinical nursing research.

International nursing research and educational exchanges: a review of the literature.

For more than 40 years, nurses have been involved in international programs and networks established to strengthen nursing education and research in developed and developing countries. After discussing international educational and research exchanges at the American Academy of Nursing's International Expert Panel, we reviewed the state of the literature about these collaborations to evaluate the results. MEDLINE and CINAHL were searched for papers between 1982-2003 on international nursing education exchange programs. The 79 papers identified and reviewed included, primarily, descriptions of or experiences with the exchanges. Most were written by faculty, even though most exchanges were for students. Most papers were written by persons from only one side of the exchange. Literature on this topic needs to begin including a theoretical basis and review of the literature; more research on and evaluation of the effects of these programs is needed.