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University of North Dakota Nurse Anesthesia Specialization Student Presentations
Spinal Hematoma Formation Following Neuraxial Anesthesia in the Anticoagulated Patient Lisa Bell, SRNA University of North Dakota
The formation of a spinal hematoma is strongly correlated with the use of anticoagulation medications.
Incidence of epidural hematoma formation is 1:150,000.
Ratio of hematoma formation decreases slightly with spinal blocks, with a reported incidence of 1:220,000.
The number of patients on medications that alter clotting status continues to increase.
When patients present with altered coagulation, anesthesia providers are challenged with deciding which regional anesthetic procedures can be safely performed.
(Tyagi & Bhattacharya, 2002)
Available guidelines that focus on anticoagulation and the performance of regional anesthesia vary from source to source.
Therefore, nurse anesthetists are required to make decisions based on their best judgment, rather than a consistent guideline, in attempt to ensure patient safety.
The purpose of this project was to explore the association between neuraxial anesthesia, anticoagulation therapy, and spinal hematoma formation.
Anticoagulation guidelines were reviewed to determine when regional anesthesia could be safely performed based on available laboratory data.
The appropriate timing of spinal or epidural needle placement and catheter removal relative to the timing of anticoagulant drug administration was also examined.
This project was aimed at compiling the diverse recommendations that are available to serve as a reference for anesthesia providers in attempt to prevent the formation of a spinal hematoma.
The recommendations were condensed into a small pocket guide to remind anesthetists of the factors that need to be considered prior to the performance of a regional technique in an anticoagulated patient.
A comprehensive literature review that included: available guidelines, retrospective reviews, case reports, and prospective studies was conducted.
The findings were compiled and presented in a power point format which displayed the association between spinal hematoma formation and anticoagulation therapy.
The physiologic framework of adaptation and homeostasis was used as the theoretical basis for the project.
When heparin is administered IV, the activated partial thromboplastin time (aPTT) is utilized to monitor its anticoagulant effect.
The normal range for an aPTT is 20-35 seconds in an adult. (Kee, 1999)
When patients are receiving subcutaneous (SQ) heparin in doses of 5000 Units or less, the aPTT is not usually monitored. (Tyagi & Bhattacharya, 2002)
Needle insertion and catheter removal can occur at any time following SQ administration of heparin in doses less than 5000 Units. (UWMC, 2006)
In doses greater than 5000 Units, and when heparin is administered IV, needle placement should not occur unless the aPTT is less than 40 seconds. Under these same circumstances, the administration of heparin should be avoided when an indwelling catheter is in place. (UWMC, 2006)
Unfractionated Heparin (cont.)
If a regional anesthetic technique is planned on a patient that is receiving anticoagulation, the administration of heparin should not occur for one hour following the placement of the needle.
Indwelling catheters should not be discontinued for 2-4 hours after the last administered heparin dose.
When heparin is administered with other anticoagulant medications, there may be an increased risk of spinal hematoma formation.
A platelet count should be drawn prior to needle insertion or catheter removal on patients that have received heparin for greater than four days.
(Horlocker et al., 2003)
Low Molecular Weight Heparin (LMWH)
The response of LMWH is very predictable, which eliminates the requirement for aPTT monitoring.
A normal dose of enoxaparin is 40 mg SQ daily or 30 mg SQ twice daily.
Needle placement and indwelling catheter removal should be delayed for at least 10-12 hours following a normal dose of LMWH.
Higher than normal doses of LMWH include amounts of 1 mg/kg twice daily or 1.5 mg/kg daily.
The administration of neuraxial anesthesia to patients on higher than normal doses of LMWH should be delayed for at least 24 hours.
(Horlocker et al., 2003)
If single daily dosing is planned, the first dose of LMWH can be administered approximately 6-8 hours postoperatively. However, the second postoperative dose should not occur prior to 24 hours of the first dose.
When continuous epidural anesthesia is planned, the catheter can be left in place overnight and removed the next day.
The anesthesia provider should wait approximately two or more hours before administering LMWH to a patient that has just had the indwelling catheter removed.
(Horlocker et al., 2003)
Platelet function must be normal before regional anesthetic techniques are performed.
A normal platelet count generally ranges from 150,000 to 400,000 mm 3 in an adult. (Kee, 1999)
The effect of aspirin therapy lasts the entire lifetime of the platelet, which is generally 8-10 days. (Katzung, 2004)
Other nonsteroidal anti-inflammatory agents (NSAIDs) also alter platelet aggregation, however, normal platelet function is resumed approximately 1-3 days after the NSAIDs are discontinued. (Katzung, 2004)
The use of NSAID therapy does not increase the risk of spinal hematoma formation following neuraxial anesthesia. (Horlocker et al., 2003)
Antiplatelet Agents (cont.)
Clopidogrel and ticlopidine administration irreversibly inhibits platelet function. (Katzung, 2004)
Ticlopidine should be discontinued 14 days prior to receiving neuraxial anesthesia and clopidogrel should be discontinued seven days prior to the scheduled regional procedure. (Horlocker et al., 2003)
The risk of spinal hematoma formation following thienopyridine administration is unknown. (Horlocker et al., 2003)
Prothrombin time (PT) and international normalized ratio (INR) are utilized to monitor the anticoagulant effect of warfarin therapy.
A normal PT generally ranges from 10-13 seconds in an adult. (Kee, 1999)
The INR is an international standardized test for PT that should only be used after the patient has been stabilized on warfarin. (Kee, 1999)
Central neuraxial procedures should be delayed until the INR is within the range of 1.0-1.3. (Horlocker et al., 2003)
Warfarin administration must be stopped 4-5 days before a regional procedure is performed.
If a dose of warfarin is administered before a scheduled surgery, a PT and INR level need to be checked prior to the regional technique.
The PT and INR also need to be assessed prior to discontinuing an indwelling catheter on a patient that has received low doses of warfarin, 5 mg or less, throughout continuous epidural therapy.
The catheter should not be removed until the INR is less than 1.5.
Concurrent use of anticoagulation medications may increase the risk of spinal hematoma formation without affecting the PT or INR.
(Horlocker et al., 2003)
In attempt to reduce the occurrence of spinal hematoma formation, anesthesia providers need to be aware of all the risk factors, in addition to anticoagulant medications, that may contribute to this undesirable complication.
This may be achieved by conducting a more complete assessment of the patient’s physical presentation, medical history, laboratory data, and current medication history prior to the administration of regional anesthesia.
Horlocker, T.T., Benzon, H.T., Brown, D.L., Enneking, F.K., Heit, J.A., Mulroy, M.F. et al. (2003). Regional anesthesia in the anticoagulated patient: Defining the risks. Retrieved April 15, 2007, from http:// www.asra.com/Consensus_Conferences
Katzung, B.G. (2004). Basic and clinical pharmacology (9 th ed.). New York: McGraw-Hill Companies.
Tyagi, A., & Bhattacharya, A. (2002). Central neuraxial blocks and anticoagulation: A review of current trends. European Journal of Anesthesiology , 19, 317-329.
University of Washington Medical Center. (2006). Anticoagulation guidelines for neuraxial procedures: Guidelines to prevent spinal hematoma following epidural/intrathecal/spinal procedures. Retrieved April 15, 2007 from http://www.uwmcacc.org/pdf/neuraxial.pdf
Perioperative Myocardial Infarction Lorrissa Bohlman, SRNA University of North Dakota
Today, many patients who undergo surgery are older with more chronic comorbid medical illnesses.
Complications are common in this population and cardiac complications, including perioperative myocardial infarction, remain the leading cause of perioperative morbidity and mortality.
The purpose of this project is to examine the perioperative identification and management of surgical patients at risk for perioperative myocardial infarction.
Review of Physiology: Myocardial Oxygen Balance
Coronary perfusion pressure is determined by the difference in the arterial end-diastolic pressure and the left ventricular end-diastolic pressure.
Decreases in aortic pressure or increases in ventricular pressure severely compromise coronary perfusion.
Myocardial oxygen demand is directly proportionate to myocardial blood flow. Any increase in demand must be met by an increase in blood flow.
Factors that Affect Myocardial Oxygen Supply and Demand
Coronary perfusion pressure
Arterial oxygen content
Coronary vessel diameter
Determinants of CO and BP
B.P. = C.O. x T.P.R
C.O. = S.V. x H.R
BP = Blood Pressure
HR = Heart Rate
TPR = Total Peripheral Resistance
CO = Cardiac Output
Surgical Triggers of Myocardial Infarction
This type of ischemia is characterized by ST segment depression and is usually proceeded by an increase in heart rate.
Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Identified by ACC & AHA)
Unstable coronary syndromes
Unstable or severe angina* (CCS class III or IV) Recent MI Decompensated HF (NYHA functional class IV; worsening or new-onset HF)
Significant arrhythmias: High-grade atrioventricular block, Mobitz II atrioventricular block, Third-degree atrioventricular heart block, Symptomatic ventricular arrhythmias, Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR greater than 100 bpm at rest)
Newly recognized ventricular tachycardia
Severe valvular disease
Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic)
Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)
Preoperative History: Functional Capacity
Functional capacity, exercise tolerance, is expressed using metabolic equivalent treadmill study levels (METs). Functional capacity is classified according to the level of daily activity the patient can tolerate.
A study of 600 patients found perioperative myocardial infarction was increased in patients unable to meet a 4 MET demand.
Noncardiac functional limitations (back/joint pain) may falsely elevate cardiac risk.
Can you take care of yourself?
Walk indoors around the house?
Climb a flight of stairs or walk up a hill?
Scrub the floor or move furniture?
Golf? Bowel? Dance?
Swimming? Tennis? Basketball?
The American College of Cardiology (ACC) and American Heart Association (AHA) group clinical predicators associated with increased perioperative cardiovascular risk into three main groups:
Major clinical predictors : The presence of 1 or more of these conditions mandates intensive management and may result in delay or cancellation of surgery unless the surgery is emergent: unstable or severe angina, significant arrhythmias, and severe valvular disease.
Intermediate : ischemic heart disease, compensated or prior heart failure, cerebrovascular disease, diabetes mellitus and renal insufficiency, history of MI, abnormal Q waves by ECG.
Minor: (markers for cardiovascular disease that have not been proved to increase perioperative risk independently) advanced age (greater than 70), abnormal ECG (LV hypertrophy, LBBB, ST-T abnormalities), rhythm other than sinus and uncontrolled systemic hypertension.
Surgery Specific Risk
The ACC and AHA guidelines grade the surgery specific risks as high (cardiac risk greater than 5%), intermediate (less than 5%), and low (less than 1%).
High: emergent major operations particularly in the elderly, aortic and other major vascular surgery, peripheral vascular surgery, and anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss.
Intermediate: carotid endarterectomy, head and neck surgery, intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery.
Low: endoscopic procedures, superficial procedures, cataract surgery and breast surgery.
Framework for Determining which Patients are Candidates for Further Cardiac Testing Fleisher, L. A. et al. Circulation 2007;116:e418-e499
Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac surgery Fleisher, L. A. et al. Circulation 2007;116:e418-e499
Current studies suggest that beta blockers reduce perioperative ischemia and may reduce the risk of MI and death in high-risk patients.
The dose should be titrated to achieve a resting heart rate of 60 beats per min (bpm) to increase the benefit of beta blockade.
Rate control with beta blockers should continue during the intraoperative and postoperative period to maintain a heart rate of 60 to 65 bpm.
Intraoperative Technique and Agent
There is no “ideal” agent or technique
All anesthetic agents have some degree of effect on the cardiovascular system
The choice of anesthetic technique and intraoperative monitors is left to the discretion of the anesthesia care team
Recognition of the perioperative plan is helpful in guiding intraoperative decisions
Remember to consider:
Postoperative monitoring, ventilation, analgesia
Use of antiplatelet agents or anticoagulants
Myocardial Infarction: Management
Despite the classification of myocardial infarction management is dictated by the patient’s hemodynamic status
Treatment of a hemodynamically stable patient should incorporate beta-blockers and intravenous nitroglycerine
Treatment of a hemodynamically unstable patient should focus on supporting circulation with positive inotropes and intra-aortic balloon pump
Involve a cardiac expert in management immediately
Myocardial Infarction: Management
While fibrinolytic therapy reduces mortality a substantial risk of surgical site bleeding exists
Time to reperfusion is critical in outcome
Patients with acute coronary occlusion benefit from angiography and revascularization within 12 hours
These reperfusion procedures should not be performed unless acute coronary occlusion is the suspected cause
Example: Hypertension and tachycardia increasing myocardial demand
Treatment: Lowering the heart rate and blood pressure provides increased benefit and decreased risk
Goals during the postoperative period do not differ significantly from the preoperative and intraoperative period
Prevention of ischemia
Adequate pain management
Pain can lead to increased myocardial oxygen demands
Continue supplemental oxygen
Early detection of myocardial ischemia or infarction
Prompt treatment as dictated by the patient’s level of hemodynamic stability
Adesanya, A.O., de Lemos, J.A., Greillich, N.B., & Whitten, C.W. (2006). Management of perioperative myocardial infarction in noncardiac surgical patients. Chest, 130 (2), 1-21.
Agency for Health Care Research Quality. (2001).Beta blockers and reduction of perioperative cardiac exerts. In: AHRQ Publication No. 91-EO58, Rockville, MD: Retrieved March 15, 2007, from http://www.ahrq.gov/clinic/ptsaftey/chap25.htm
American College of Cardiology. (2002). Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Retrieved February 1, 2007, from http:// www.acc.org/clinical/guidelines/perio/dirIndex.htm
American College of Cardiology. (2006). Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy (Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Retrieved February 1, 2007, from http://content.onlinejacc.org/cgi/content/full/47/11/2343
American Society of Anesthesiologists. (2005). Standards for basic anesthetic monitoring. Amended: October 25, 2005; Approved: House of Delegates October 21, 1986. Retrieved February 15, from http://www.asahq.org/publicationsAndServices/standards/09.htm
Ashton, C.M., Petersen, N.J., Wray, N.P., Kiefe, C.I., Dunn, J.K., Wu, L., et al. (1993). The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery. Annals of Internal Medicine, 118 (7), 504-510.
Baxter, A. & Kanji, S. (2007). Protocol implementation in anesthesia: Beta-blockade in non-cardiac surgery patients. Canadian Journal of Anesthesia, 54 (2), 114-123.
Boersma, E., Poldermans, D., Bax, J.J., Steyerberg, E.W., Thompson, I.R., Banga, J.D.,et al. (2001). Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and B-blocker therapy. Journal of the American Medical Association, 285 (14), 1865-1873.
Bois, S., Couture, P., Boudreault, D., Lacombe., Fugere, F., Girard, F., et al. (1997). Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery. Anesthesia and Analgesia, 85 (6), 1233-1239.
Breen, P., Lee, J., Pomposelli, F., Park, K.W. (2004). Timing of high-risk vascular surgery following coronary artery bypass surgery: a 10 year experience from and academic medical center. Anaesthesia, 59 (5), 422-427.
Deveraux, P.J., Goldman, L., Yusuf, S., Gilbert, K., Leslie, K., & Guyatt, G.H. (2005a). Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ, 173 (7), 627-634.
Deveraux, P.J., Goldman, L., Yusuf, S., Gilbert, K., Leslie, K., & Guyatt, G.H. (2005b). Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ, 173 (7), 779-788.
Dodds, T.M., Stone, J.G., Coromilas, J., Weinberger, M., & Levy, D.G. (1993). Prophylactic nitroglycerin infusion during noncardiac surgery does not reduce perioperative ischemia. Anesthesia and Analgesia, 76 (4), 705-713.
Dupuis, J.Y., & Labinaz, M. (2005). Noncardiac surgery in patients with coronary artery stent: what should the anesthesiologist know?. Canadian Journal of Anesthesia, 52 (4), 356-361.
Eagle, K.A., Rihal, C.S., Michel, M.C., Holmes, D.R., Foster, E.D., & Gersh, B.J. (1997). Cardiac risk of noncardiac surgery: Influence of coronary artery disease and type of surgery in 3368 operations. Circulation, 96 (6), 1882-1887.
Ellis, J.E., Drijvers, G., Pedlow, S., Laff, S.P., Sorrentino, J.F., Foss, J.F., et al. (1994). Premedication with oral and transdermal clonidine provides safe and efficacious postoperative sympatholysis. A nesthesia and Analgesia, 75 (6), 133-1140.
Frank, S.M., Fleisher, L.A., Breslow, M.J., Higgins, M.S., Olson, K.F., Kelly, S., et al. (1997). Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: A randomized clinical trial. Journal of the American Medical Association, 277 (14), 1127-1134.
Hebert, P.C., Wells, G., Blajchman, M.A., Marshall, J., Martin, C., Pagliarello, G., et al. (1999). A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. The New England Journal of Medicine, 340 (6), 409-417.
Houge, C.W., Goodnough, L.T., & Monk, T.G. (1998). Perioperative myocardial ischemic episodes are related to hematocrit level in patients undergoing radical prostatectomy. Transfusion, 38 (10), 924-931.
Joint European Society of Cardiology & American College of Cardiology.(2000). Myocardial infarction redefined. Journal of the American College of Cardiology, 36 (3), 959-969.
Joint International Society and Federation of Cardiology & World Health Organization. (1979). Nomenclature and criteria for diagnosis of ischemic heart disease. Circulation, 59 (3), 607-609.
Landesberg, G. (2003). The pathophysiology of perioperative myocardial inarction: facts and perspectives. Journal of cardiothoracic and Vascular Anesthesia, 17 (1), 90-100.
Landesberg, G., Morris, M., Wolf, Y., Vesselov, Y., & Weissman, C. (2002). Periopertive myocardial ischemia and infarction. Anesthesiology, 96 (2), 264-270.
Landesberg, G., Mosseri, M., Zahger, D., Wolf, Y., Perouansky, M., Anner, H., et al. (2001). Myocardial infaraction after vascular surgery: The role of prolonged, stress-induced, ST depression-type ischemia. Journal of the American College of Cardiology, 37 (7), 1839-1845.
London, M.J. (2002). Multilead precordial ST-segment monitoring: The next generation?. Anesthesiology, 96 (2), 259-261.
London, M.J., Hollenberg, M., Wong, M.G., Levenson, L., Tubau, J.F., Browner, W., et al. (1988). Intraoperative myocardial ischemia: Localization by continuous 12-lead electrocardiography. Anesthesiology, 69 (2), 232-241.
McFalls, E.O., Ward, H.B., Mortiz, T.E., Goldman, S., Krupski, W.C., Littooy, F., et al. (2004). Coronary-artery revascularization before elective major vascular surgery. New England Journal of Medicine, 351 (27), 2795-2804.
Nyhan, D., & Roger, A.J. (2005). Anesthesia for cardiac surgery procedures. In R.D. Miller (Ed.), Miller’s Anesthesia (6th ed., pp.1941-1995).Philadelphia: Elsevier.
Morgan, E.G., Mikhail, M.S., & Murray, M.J. (2006). Clinical Anesthesiology . New York: Lang Medical Books/McGraw-Hill Medical Publishing Division.
Poldermans, D., Boersma, E., Bax, J.J., Tjhomson, I.R., Louis, L.M., Ven, V.D., et al. (1999). The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. New England Journal of Medicine, 341 , 1789-1794.
Polanczyk, C.A., Marcantonio, E., Goldman, L., Rhode, L.E., Orav, J., Mangoine., et al. (2001). Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Annals of Internal Medicine, 134 (8), 637-643.
Raby, K.E., Brull, S.J., Timimi, F., Akhtar, S., Rosenbaum, S., Naimi, C., et al. (1999). The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery. Anesthesia and Analgesia, 88 (3), 477-482.
Reilly, D.F., McNeely, M.J., Doerner, D., Greenberg, D.L., Staiger, T.O., Geist, M.J., et al. (1999). Self-reported exercise tolerance and the risk of serious perioperative complications. Archives of Internal Medicine, 159 , 2185-2192.
Rodgers, A., Walker, N., Schug, S., McKnee, A., Kehlet, H.,Van Zundert, A., et al. (2000). Reduction of postoperative mortality and morbidity with epidural or spinal anesthesia: Results from overview of randomized trials. British Medical Journal, 321 (7275) 1493-1497.
Selzman, C.H., Miller, S.A., Zimmerman, M.A., & Harken, A.H.(2001). The case for B-adrenergic blockade as prophylaxis against perioperative cardiovascular morbidity and mortality. Arch Surg, 136, 286-290.
Sprung, J., Abdelmalak, B., Gottlieb, A., Mayhew, C., Hammel, J., Levy, P.J., et al. (2000). Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery. Anesthesiology, 93 (1), 129-140.
Symons, J.A., & Myles, P.S. (2006). Myocardial protection with volatile anaesthetic agents during coronary artery bypass surgery: A meta-analysis. British Journal of Anaesthesia, 97 (2), 127-136.
Warltier, D.C., Pagel, P.S., & Kersten, J.R. (2000). Approaches to the prevention of perioperative myocardial ischemia. Anesthesiology, 92 (1), 253-259.
Wijeysundera, D.N., & Beattie, W.S. (2003). Calcium channel blockers for reducing cardiac morbidity after noncardiac surgery: A meta-analysis. Anesthesia and Analgesia, 97 (3), 634-641.
Wilson, S.H., Fasseas, P., Orford, J.L., Lennon, R.J., Horlocker, T., Charnoff, N.E., et al. (2003). Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. Journal of the American College of Cardiology, 42 (2), 234-240.
Cerebral Oximetry Monitoring in Adult Cardiac Surgery Kate Busker, SRNA University of North Dakota
Provide education on cerebral perfusion during adult cardiac bypass surgery.
Provide information on cerebral oximetry application, benefits, and limitations.
Discuss anesthetic interventions with cerebral oximetry.
To optimize care of adult cardiac bypass patients.
40% of myocardial revascularization has evidence of persistent cognitive decline
(Edmonds et al. 2004)
On average, a patient ends up staying a minimum of 3 days longer in hospital
(Yao, et al. 2001)
The neurological deficits seen post-cardiac bypass has accumulated an increase in patient costs up to 11%
Produced by Somanetics in Troy, MI
What is Cerebral Oximetry?
Utilizes Near-Infrared Spectroscopy (NIRS)
various wavelengths of infrared light that are transmitting through the skull into the cerebral tissue
Monitoring regional saturation of oxygen (rSO2) of grey matter in brain.
75% venous and 25% arterial volume
Healthy levels of rSO2= 58% to 82%.
Data collected and displayed every 4-5 sec.
The following research questions guided this study:
1. Does cerebral oximetry monitoring decrease the incidence of post-operative cognitive dysfunction in the adult cardiac surgical patient?
2. Does cerebral oximetry decrease the length of hospital stays for adult cardiac surgical patients?
The central nervous system is the least monitored physiological system during anesthesia.
Current neurological monitoring modalities include EEG, cerebral oximetry, and transcranial Doppler.
Cerebral oximetry detected cerebral desaturation in 38% of cases, EEG in 22% of cases and the Doppler in only 6% of cases. (Ganzel et al., 2002)
Technology utilizes two different wavelengths of light: 730nm & 810nm
Beer-Lambert Law: with a known intensity of light with a known dimension of chamber > concentration of dissolved substance can be measured
Same concept as pulse oximetry
The difference between oxyhemoglobin and deoxyhemoglobin
Shallow signal vs deep signal > can eliminate extra-cerebral perfusion
How the Infrared Works…
Review of Literature
Cerebral autoregulation remains intact when CPP is 70-90 mmHg.
A CPP change > 30 mmHg results in severely compromised CBF
Oxygen levels directly affect perfusion
Hyperoxia has little effect
Hypoxia (PaO2 < 60 mmHg) causes vasodilation leading to an increase in CBF
Review of Literature
CBF has linear relationship with PaCO2.
If PaCO2 were to increase from 20 to 40, CBF would double
CBF changes 1-2 ml/100 g/min for every 1 mmHg change in PaCO2
Altering PaCO2 immediately affects CBF & returns to normal within 6-8 hours.
Relationship not valid when PaCO2 < 25 mmHg
Temperature: for every 1 degree decrease, cerebral metabolic rate decreases 6-7%
Normal venous sat. : 58%-82%
Pediatric will be higher (70%-92%)- incr EBV
Intervention threshold: anything < 50% or decrease of 20% from baseline
Very important to have established baseline cerebral saturations
Cerebral autoregulation impairment:
This is due to supply and demand imbalance (Coming off pump: incr. metabolism with incr. temp > decreased perfusion > unable to meet demand)
Reasons for low cerebral sat’s:
High cerebral metabolism, hyperthermia
Low Hgb, Anemia
Low PaCO2, alkalosis
Low CBF (cannula or head position)
Intervention: Increase Oxygen
Incr. hematocrit (RBC’s)
Incr. BP / CO
Incr. CO2 > incr. CBF
Anesthetic Interventions: Decrease metabolism
Incr. volatile anesthetic
< 1 MAC : CMR decreased > CBF increased
1 MAC : unchanged (both equal)
> 1 MAC : CBF increased > CMR decreased
IV anesthetics (benzo’s, barb’s, propofol, & etomidate) will reduce CMR up to 30%
But autoregulation sets in quickly d/t quick metabolism
Ketamine exception d/t SNS stimulation
Assumptions & Limitations
Literature was collected accurately and is the most recent data available
Anesthesia providers will be interested in this project
Participants in this presentation will benefit from the information provided
Small sample sizes in studies
Information collected limited to adult cardiac surgery
Information provided is limited to those attending presentation
Cerebral oximetry has been shown to:
Decrease hospital stay by minimum 3 days
Improve cerebral perfusion
Reduces incidence of neurological deficits
Reduce costs to patient by up to $11,000
Can have beneficial effects on all major body systems
Barash P. B., Cullen, B. F., Stoelting, R. K. (2006). Clinical Anesthesia (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Barash P. B., Cullen, B. F., Stoelting, R. K. (2006). Handbook of Clinical Anesthesia (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Casati, A., Fanelli, G., Pietropaoli, P., Proietti, R., Montanini, S. (2003). In a population of elderly patients undergoing elective non-cardiac surgery cerebral oxygen desaturation is associated with prolonged length of stay. Journal of American Society of Anesthesiologists , 99 , 551.
Casati, A., Spreafico, E., Putzu, M., Fanelli, G. (2006). New technology for noninvasive brain monitoring: continuous cerebral oximetry. Minerva Anesthesiology, 72, 605-625.
Edmonds, H. L. (2002). Multimodality neurophysiologic monitoring for cardiac surgery. The Heart Surgery Forum, 3 , 225-228.
Ganzel, B. L., Cerrito, P. B., Edmonds, H. L. (2002, January). Multimodality neuromonitoring improves CABG recovery. Paper presented at Society of Thoracic Surgeons Annual Meeting, Fort Lauderdale, FL.
Talpahewa, S. P., Lovell, A. T., Angelini, G. D., Ascione, R. (2004). Effect of cardiopulmonary bypass on cortical cerebral oxygenation during coronary artery bypass grafting. European Journal of Cardiothoracic Surgery , 26 , 676-681.
Yao, F. F., Levin, S. K., Wu, D., Illner, P., Yu, J., Huang, S. W., Tseng, C. (2001). Maintaining cerebral oxygen saturation during cardiac surgery shortened ICU and hospital stays [Abstract]. Anesthesia and Analgesia, 92 , 133.
Yao, F. F., Tseng, C. A., Ho, C. A., Levin, S. K., Illner, P. (2004) Cerebral oxygen desaturation is associated with early postoperative neuropsychological dysfunction in patients undergoing cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia , 18 , 552-558.
Twelve Lead ECG Interpretation Christian Conner, SRNA University of North Dakota
Twelve Lead ECG
Been around since the late nineteenth century
Mid 1800s- Alaxander Kollicker and John Mueller
Sciatic nerve of a frog falls into its heart
Both contract simultaneously
1872- Muirhead and Sanderson
First to put electrical activity on paper
Twelve Lead ECG
Turn of the century- Augustus Waller
Able to place electrical activity on paper in a “real-time” manner
Credited with inventing the electrocardiogram by placing letters to the cardio-electric current recorded on paper and relating them to the heart beat
ECG and Anesthesia
Anesthetists routinely look at 12-lead ECGs pre-operatively
Good predictor of intra-operative cardiac complications
Look at multiple areas of the heart in terms of electrical current
Determine areas of infarct/ischemia
Twelve lead ECG interpretation is not routinely taught to ICU nurses
Also not included in many nurse anesthesia programs
Limited research available when looking at accurate ECG interpretation among nurse anesthesia students
Where do we learn twelve lead ECG interpretation?
Medical schools only introduce med-students to twelve lead ECG interpretation (Hurst, 2006)
Study- Only 17-63% of medical students are able to correctly interpret twelve lead ECGs (Hatala & Brooks, 1999)
25% of non-cardiologists routinely identify accurate PR and QT intervals ( Montomery, et al., 1994)
Yet, Storey, Rowley, and colleagues found that nurses demonstrated an 84-94% accuracy rate when identifying criteria on an ECG that required thrombolytic therapy (1997)
Purpose of Project
To educate a class of first year nurse anesthesia students on how to perform a basic interpretation of a twelve lead ECG
To provide a summery of cardio-electrophysiology
To educate these students on what specific things to look for when looking at a twelve lead ECG in order to better predict potential intra-operative cardiac complications
SRNAs/CRNAs are expected to provide a detailed pre-operative assessment on every patient they plan to anesthetize
Accurate twelve lead ECG interpretation can predict intra-op and post-op cardiac complications
Twelve lead ECG interpretation results may influence the type of monitor or type of anesthesia a patient receives.
Most importantly- patient safety!
How well do current SRNAs interpret twelve lead ECGs without any formal training?
Will a twelve lead ECG workshop significantly improve a SRNAs performance when interpreting twelve lead ECGs?
Will current SRNAs feel as though a twelve lead ECG workshop has improved their education?
Develop a twelve lead ECG workshop
Anatomy/ P hysiology of the Heart
Basic Heart Rhythms
Electrical Waveform Morphology
Bundle Branch Blocks
Ventricular Tachycardia (VT) versus Supraventricular Tachycardia (SVT)
Acute Coronary Syndromes
Likert scale with short answer option
Before and after testing utilizing four sample ECGs
90% accuracy rate is hoped to be gained among those SRNAs participating in the project at workshop conclusion
Brady, W. J., Perron, A. D., & Chan, T. (2001). Electrocardiographic ST-segment elevation: correct identification of acute myocardial infarction (AMI) and non-AMI syndromes by emergency physicians. Adademy of Emergency Medicine, 8, 349-360.
Hatala, R., Norman, G. R., & Brooks, L. R. (, 1999). Impact of a clinical scenario on accuracy of electrocardiogram interpretation. Journal of General Internal Medicine, 14, 126-129.
Hurst, J. W. (2006). The interpretation of electrocardiograms: Pretense or a well-developed skill?. Cardiology Clinics, 24, 305-307.
Montgomery, H., Hunter, S., Morris, S., Naunton-Morgan, R., & Marshall, R. M. (1994). Interpretation of electrocardiograms by doctors. BMJ, 309, 1551-1552.
Storey, R. F., & Rowley, J. M. (1997). Electrocardiogram interpretation as a basis for thrombolysis. JR Coll Physicians London, 31, 536-540.
Teaching Regional Anesthesia to Nurse Anesthesia Students Garrel Kinzler, SRNA UND Nurse Anesthesia
Teaching Regional Anesthesia
This independent study examines methods used to teach regional anesthesia to students
The field of anesthesia is growing more complex and there is more material for students to learn
Increasing numbers of aged patients (baby boomers) needing surgery dictates the use of regional anesthesia due to increased comorbidities
With obesity on the rise regional anesthesia is becoming a safer alternative with less cardiovascular effects, less respiratory changes, and decreased blood loss
Teaching Regional Anesthesia
This demands more focus and more study/practice on regional methods from emerging practitioners
How is this being done?
The purpose of this study is to review current thoughts and methods of teaching regional anesthesia
Use the described methods to teach a regional lesson on cadavers to the nurse anesthesia students
A careful review of the principles of pharmacology, instrumentation, landmark/anatomy orientation on cadavers and models better prepares students to provide regional anesthesia for patients undergoing surgery
SRNAs are expected to provide, under CRNA supervision, safe and effective regional anesthesia to patients undergoing surgery and painful procedures
There is a profound learning curve influenced by many variables including the practice and teaching styles of the CRNA and the past experiences of the student
With patient safety and comfort as primary goals of practice, the better prepared the student is the safer and more effective the regional anesthesia delivered
Study was based on Malcolm Knowles adult learning theory and Androgogical model
Knowles believes adult learning is separate and distinct from child learning and that adults are motivated differently
Six assumptions about adult learning including:
need to know
Review of literature was done using PubMed, SCOPUS and CINAHL databases
Findings showed that there are over forty distinct blocks to learn in regional anesthesia
Limited research on how to appropriately teach regional methods
Teaching Regional Anesthesia
Conclusion is that regional anesthesia skills should be continuous, repetitive with consistent technique
All graduates should master the most commonly used blocks, femoral, interscalene, axillary, spinal and epidural
Teaching Regional Anesthesia
Teaching methods should include variety
video, models, cadavers, supervision
Students should be coached by an experienced mentor until consistent success is achieved and the mentor approves of the technique
Teaching Regional Anesthesia
There is no standard minimum number or type of blocks to be completed
Regional skills are much more difficult to learn then general anesthesia skills
Teaching Regional Anesthesia
The best teaching method would be a repetitive multiformat approach with as much hands on as possible
Student progress should be used to plan clinical rotations accordingly
A lesson on brachial plexus anesthesia was offered to the first year nurse anesthesia students
Video cadaver lessons were utilized to augment regional knowledge
The cadaver lab was utilized for hands on experience
History and utilization of Interscalene blocks and axillary blocks reviewed
Anatomy reviewed including landmarks and positive nerve stimulator signs
Coverage achieved with each block reviewed
Preparation, including equipment for each block
Commonly used recipes and volumes for each block
Level of sedation along with proper positioning and technique
Adverse reactions discussed
risk of epidural injection
“ Pick up” injections identified
Cadaver lab experience included:
Identification of the brachial plexus
Nerve arrangement around vasculature in the sheath
Injection angles, landmarks
Location of surrounding structures such as phrenic nerve and epidural root sheaths
Evaluation of learning will be done with pre- and post- testing
Carpedivila, X. & Dadure, C. (2004). Perioperative management for one day hospital admission: Regional Anesthesia is better than General Anesthesia. Acta Anaesthesiologica Belgica, Supplement, 55, 33-36.
Hadzic, A., & Vloka, J., (2004). Peripheral nerve blocks: Principles and practice. New York: McGraw-Hill.
Hadzic, A., Vloka, J., & Koenigsamen, J. (2002). Training requirements for peripheral nerve blocks. Anaesthesiology, 15(6), 669-673.
Knowles, M. (1990). The adult learner: A neglected species (4 th ed.). Houston: Gulf Publishing Company.
McDonald, S., & Thompson, G. (2002). “See one, do one, teach one, have one”: A novel variation on Regional Anesthesia training. Regional Anesthesia and Pain Medicine, 27(5), 456-459.
Miller, R., Fleisher, L., Johns, R., Savarese, J., Wiener-Kronish, J., & Young, W. (Eds.) (2005). Miller’s anesthesia (6 th ed.). Philadelphia: Elsevier.
Morgan, G., Jr., Mikhail, M., & Murray, M. (2006). Clinical anesthesiology (4 th ed.). New York: Lange Medical Books/McGraw-Hill Medical Publishing Division.
Clinical application of the LMA CTrach
University of North Dakota
Through improved technology, experience, and education, anesthesia providers are better prepared to effectively manage a difficult airway.
Because of visual confirmation of tracheal intubation, fiberoptic devices are preferred for management of the difficult airway by most anesthesia providers.
Anesthesia departments often have several fiberoptic devices available, it is difficult to maintain skills with these devices or to stay current with new technology.
CRNAs tend to only use the devices they are familiar with
However, it is very important to have a back-up plan when a difficult airway arises (sometimes more than one)
To be able to use new devices successfully, proper training and skill maintenance is important.
The purpose of this study is to review the LMA CTrach and to apply its use to clinical practice to assist CRNAs so they can make an informed decision when to use this device if they so choose.
Time is the worst enemy for any anesthesia provider trying to ventilate a compromised difficult airway resulting in inadequate oxygenation.
Therefore, it is important for CRNAs managing these airways to have knowledge of equipment needed to establish an effective airway before permanent brain injury or death ensues.
LMAs have been well established as an effective airway adjunct for many years.
The LMA and intubating laryngeal mask airway (ILMA) or Fastrach are devices that are useful in patients that are difficult to ventilate with a bag/mask and have the capability of acting as a conduit to place an ETT.
The LMA CTrach is the newest version of the intubating LMA.
It is essentially the LMA Fastrach with integrated fiberoptic technology that allows direct visualization of the larynx and vocal cords while the ETT is advanced through the glottis.
The CTrach is composed of two parts: the airway itself and the viewing screen.
The viewing screen connects to the end of the CTrach airway making it easily portable.
Unique Components of the LMA CTrach
The epiglottic elevating bar (EEB )
has an aperture or window to allow for visualization of the larynx from two fiberoptic channels which terminate at the distal end of the airway tube.
2 Fiberoptic channels
10,000 pixel image guide that broadcasts the image of the larynx to the viewer.
On the top portion of the LMA is a magnetic latch connector which allows for easy attachment and detachment of the viewer.
Has a rechargeable battery – up to 30 minutes of continuous use
The viewer is a high resolution, 86 mm LCD display and is lightweight (about 200 grams).
Sizing, placement, indications, contraindications, warnings and adverse effects are the same as the LMA Fastrach
Will focus on pertinent findings from studies and case reports using the CTrach.
Then, discuss the keys to successful intubation.
Findings in initial Clinical studies
The CTrach gives real time images of the common causes of intubation failure with the Fastrach with a 96-98% success rate of intubation. ( Goldman, Wender, Rosenblatt, and Theil, 2006)
The time interval for intubation using the CTrach takes longer (119 ± 44 seconds) than DL (69 ± 52 seconds). ( Dhonneur and Ndoko, 2007)
The most common causes of the poor views with the CTrach were noted to be a downfolded epiglottis, the arytenoids(LMA in too deep), and secretions. ( Liu, Goy, and Chen, 2006)
There is no correlation between Cormack-Lehane grade and successfully obtaining a view of the larynx (P=0.110) or between the Cormack-Lehane grade and success of intubation (P=0.38). ( Liu, Goy, and Chen , 2006)
One patient who was approximately 74 inches in height was not successfully intubated with the CTrach due to long neck. The CTrach could not be advanced any further into the mouth because the handle was at the maxilla (Limitation for tall or long anatomy). ( Timmermann, Russo, and Graf, 2006)
Findings with Obesity
Oxygenation was always maintained with ventilations through the LMA with the obese patient. (Dhonneur et al , 2007)
Used less propofol with induction suggesting that insertion of the CTrach is less stimulating than DL . (Dhonneur et al , 2007)
There is a risk for aspiration with the obese patient even without a history of GERD with increased intragastric pressure and that any LMA does not fully protect against aspiration.
Positioning (ramping patient or reverse trendelenburg) and cricoid pressure can be done to prevent upward migration of stomach contents.
Obesity case report
Abdi, Ndoko, Amathieu, and Dhonneur (2008)
The CTrach was used as a rescue airway for a morbidly obese patient with symptomatic gastric reflux .
This was the first reported case of aspiration of stomach contents into the lungs using the CTrach even though it was used as rescue airway and with successful intubation.
The article does not state whether cricoid pressure was used throughout the procedure which may have prevented gastric contents migrating upward.
None-the-less, any LMA, including the CTrach, does not fully protect the lungs from aspiration.
Difficult airway case reports
With several case reports of expected and unexpected difficult airways, even though the Cormac-Lehane grade was poor after failed attempts with DL and bougie, the view with the Ctrach gave a full view of the glottis for intubation.
In one article, Fiberoptic bronchoscopy failed in two patients secondary to increased secretions and blood in the airway, but the CTrach was successful. (Goldman and Rosenblatt, 2006)
The theory why the CTrach was able to visualize the glottis better than the bronchoscope was that the laryngeal mask tamponaded the bleeding in the airway and isolated the larynx from the bleeding.
Awake intubation case reports
Wender and Goldman (2007)
Used the CTrach LMA for awake intubation in three morbidly obese patients with Mallampati class 3 airways and history of sleep apnea.
These patients were ramped with a foam wedge and the oropharynx was anesthetized with topical lidocaine 4%, however, below the glottis was not anesthetized.
The CTrach was inserted, once the vocal cords were in view the sevoflurane vaporizer was set at 5% and spontaneous respirations were maintained with some assisted respirations-> intubated.
Advantage is the continuous 100% oxygenation throughout the procedure with less risk of desaturation.
Awake intubation case reports
Bilgin and Y’ylmaz (2006)
CTrach for awake intubation in three patients with an unstable cervical spine.
Dexmedetomidine infusion for sedation
Lidocaine 10% spray was applied and let set-up for two minutes.
The CTrach was lubricated with lidocaine 2% jelly and inserted, and when a clear image of the glottis was attained, 3 ml of lidocaine 2% was then injected into glottis and upper trachea.
The ETT was then introduced.
The cervical spine easily remained in neutral position, but one issue that may cause difficulty with an unstable c-spine is a restricted mouth opening.
Keys to Success for intubation
Prefocus, antifogging solution, lubricate
Antisialogogue, oral suction prior to insertion
Whiteout in viewer (epiglottis, secretions, lubricant)
Adjust brightness, up-down maneuver(x2), pass suction catheter, may need to remove LMA to clean fiberoptic lens
Chandy maneuver, side-to-side manipulation, laryngeal manipulation cephalad or caudad, jaw thrust, or simple cricoid pressure
If unable to visualize, try to insert ETT 1 cm beyond 15 cm depth marker on ETT, consider different size, try gentle blind insertion
Can use FOB
Initial clinical studies suggest
That the CTrach increases the intubation success rate of the Fastrach
Fastrach ≈ 80% success rate
CTrach ≈ 96-98% success rate
There is no correlation between Cormack-Lehane grade and the glottic view obtained with the CTrach
Can achieve full glottic view with a grade IV
and is effective with a difficult airway (including obese)
CTrach has been used successfully in Awake intubation
However, intubation time is longer for LMA CTrach than DL
Also, the LMA CTrach does not protect against aspiration
Can do maneuvers such as cricoid pressure, ramping patient’s head or reverse trendelenburg to minimize upward flow of stomach contents
Anesthesia providers should continue to use the equipment they are comfortable using
It is important to be trained using different intubation equipment to be prepared for a worse case scenario (can’t ventilate/can’t intubate with low O2 sats.)
The LMA CTrach is easily inserted as an airway , but does have a learning curve when trying to achieve a full glottic view for intubation
Finally, it is important to practice using a new intubating device such as the CTrach with normal airways to become proficient before use with a difficult airway.
Abdi, W., Ndoko, S., Amatheiu, R., and Dhonneur, G. (2008). Evidence of pulmonary aspiration during difficult airway management of a morbidly obese patient with the LMA CTrach. British Journal of Anaesthesia; 100(2): 275-277.
American Society of Anesthesiologists Task Force on Management of the Difficult
Airway. (2003). Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology; 98(5): 1269-1277.
Barash, P. G., Cullen, B. F., and Stoelting, R. K. (2006). Clinical Anesthesia . (5 th edition). Philadelphia: Lippincott, Williams, and Wilkins.
Bilgin, H. and Y’ylmaz, C. (2006). Awake intubation through the CTrach in the presence of an unstable cervical spine. Anaesthesia; 61: 505-517.
Bjerkelund, C.E. (2005). Use of a new intubating laryngeal mask- CTrach- in patients with known difficult airways. Acta Anaesthsiologica Scandinavica; 50: 388.
Bokhari, A., Benhan, S. W., and Popat, M. T. (2004). Management of unanticipated difficult intubation: a survey of current practice in Oxford region. European Journal of Anaesthesiology ; 21: 123-127.
Goldman, A.J. and Rosenblatt, W.H. (2006). Use of the fibreoptic intubating LMA-CTrach in two patients with difficult airways. Anaesthesia; 61: 601-603.
Goldman, A.J. and Rosenblatt, W.H. (2006). The LMA CTrach in airway resuscitation: six case reports. Anaesthesia; 61: 975-977.
Goldman, A.J., Rosenblatt, W.H., and Theil, D. (2006). The fibreoptic intubating LMA-CTrach: an initial device evaluation. Anesthesia & Analgesia; 103(2): 508.
Greenland, K.B. (2007). Fastrach tubes: modifying the design for use with the LMA CTrach. British Journal of Anaesthesia; 62(9): 948-951.
Henderson, J. J., Popat, M. T., Latto, I. P., and Pearce, A. C. (2004). Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia ; 59, 675-694.
Kristensen, M.S. (2006). The LMA CTrach for awake intubation combines the features of the LMA Fastrach and the fiberoptic bronchoscope, but cannot replace this combination in all patients. Acta Anaesthesiologica Scandinavica; 50: 526.
Liu, E.H.C. and Goy, R.W.L. (2006). The LMA CTrach for unanticipated difficult intubation. Anaesthesia; 61: 1007-1019.
Liu, E.H.C., Goy, R.W.L., and Chen, F.G. (2006). The LMA CTrach, a new laryngeal mask airway for endotracheal intubation under vision: evaluation in 100 patients. British Journal of Anaesthesia; 96(3): 396-400.
Liu, E.H.C., Goy, R.W.L., and Chen, F.G. (2006). An evaluation of poor LMA CTrach views with a fibreoptic laryngoscope and the effectiveness o corrective measures. British Journal of Anaesthesia; 97(6): 878-882.
LMA CTrach Instruction Manual. (2006). Retrieved December 4, 2007, from http://www.lmana.com/docs/US%20CTrach%20IFU.pdf
LMA CTrach in three morbidly obese patients with potentially difficult airways. Anaesthesia; 62: 948-951.
Maurtua, M.A., Maurtua, D.B., Zura, A., and Doyle, D.J. (2007). Improving intubation success using the CTrach laryngeal mask airway. Anesthesiology; 106: 640-641.
Micaglio, M., Ori, C. and Bergamasco, C. (2006). Use of the LMA CTrach in unexpected difficult airway: a case report. European Journal of Anaesthesiology; 23: 440-448.
Miller, R. D., Fleisher, L. A., Johns, R. A., Savarese, J. J., Wiener-Kronish, J. P., and Young, W. L. (2005). Miller’s Anesthesia. (6 th edition). Philadelphia: Elsevier, Churchill Livingstone.
Peterson, G. N., Domino, K. B., Caplan, R. A., Posner, K. L., Lee, L. A., Cheney, F. W. (2005). Management of the difficult airway: a closed claims analysis. Anesthesiology ; 103: 33-39.
Ramachandran, K. and Santhanagopalan, K. (2004). Laryngeal mask airway and the difficult airway. Current Opinion in Anaesthesiology ; 17: 491-493.
Smith, C. E. and DeJoy, S. J. (2001). New equipment and techniques for airway management in trauma. Current Opinion in Anaesthesiology ; 14: 197-209.
Timmermann, A., Russo, S., and Graf, B.M. (2006). Evaluation of the CTrach- an intubating LMA with integrated fibreoptic system. British Journal of Anaesthesia; 96(4): 516-521.
Walls, R. M., Murphy, M. F., Luten, R. C., and Schneider, R. E. (2004). Manual of Emergency Airway Management . (2 nd ed.). Philadelphia: Lippincott, Williams, and Wilkins.
Wender, R. and Goldman, A.J. (2007). Awake insertion of the fibreoptic intubating LMA CTrach in three morbidly obese patients with potentially difficult airways. Anaesthesia; 62: 948-951.
Unique Challenges to Nurse Anesthetists in Rural Settings Jeffrey Olson, SRNA University of North Dakota
Study ideas sparked by upbringing
Small town values referred to as Gemeinschaft (Strasser, 2003)
Unique challenges for anesthetists in rural settings
Urban areas have many resources… (ancillary staff, difficult airway equipment)
Statement of the Problem
Lack of resources
Lack of staffing
Educational needs – training r/t unique rural settings
Stress on staff
All lead to potential lack of funding from third party payers
Purpose of the Project
Educate new clinicians on how above listed problems manifest in clinical settings
Expose new problems causing patient safety issues and unwanted stress
Discover new ways of effectively dealing with situations
Develop brochure for anesthesia providers new to rural healthcare
Significance of Project
Enhanced knowledge regarding quality of practice issues
Suggestions of remedies for some rural healthcare issues
Take away information to make improvements to individual practices
Rural practices already practice safely and effectively
Hope to provide at least some new ideas
One must assume there are areas for improvement
Limited to number of practices able to reach
Rural areas are more difficult to reach, and those practicing in these areas may not be able to get away for a weekend to attend presentation
Review of Literature
“… nurse anesthetists have been and continue to be the principle anesthesia providers in rural hospitals in the United States.” (Gunn, 2000)
One of the biggest problems in rural healthcare is uneven distribution of providers, which causes shortages in certain areas (Hart et al, 2002)
According to Strasser (2003), the foremost issue in rural healthcare is accessibility to resources
Other problems in rural healthcare include provider supply and recruitment and retention
Review of Literature
CRNA’s in rural areas provide a broader array of services with less resources (Gunn, 2000)
*Standards of practice are the same in rural settings*
Shortages cause difficulty with meeting external standards. *Third party payers then refuse to contract in rural areas* (Moscovice & Rosenblatt, 2000)
Review of Literature
“ Rural residents are poorer and less likely to have job-related health insurance.” (Gunn, 2000)
This is why it is important to keep CRNA’s in this area due to the ability to provide more cost effective care
*Patients still expect same level of care no matter where they receive it*
Difficulty meeting standards becomes a vicious cycle with keeping staffing adequate
Review of Literature
Higher rates of avoidable death in rural areas cannot be blamed on lack of healthcare services
Stoic population (particularly farmers)
Danger in rural activities (eg. Mining, fishing, timberwork)
Rural residents spend more time traveling at high speeds on highways to reach destinations
Review of Literature
Rural CRNAs already providing very high level of care
Rural CRNA average response time from home = approx. 20 mins
Urban CRNA average response time from in-house = approx 20 mins
WONCA Rural Health Initiative – collaborating with WHO to improve health of rural health population (Strasser, 2003)
“ to establish rural health administrative structures; for the allocation of financial resources; to increase rural health research; and to enhance the development and representation of rural doctor issues.”
Side note – WONCA stands for the World Organization of Family Doctors. The name comes from the first letters of the first five words of W orld O rganization of N ational C olleges, A cademies and Academic Associations of General Practitioners/Family Physicians. ( www.aafp.org )
Halaas, Zink, Brooks, and Miller developed a model for students
Case studies developed for patients who presented with common diagnoses in the rural setting
distinguish urgent from non-urgent clinical presentation
use clinical guidelines for making decisions
communicate effectively in stressful situations
uncover a significant clinical issue with a different presenting complaint
Could a similar plan be developed for SRNAs?
-Present with difficult airway scenarios and require the student to practice delegation skills in these situations
Description of Audience
All CRNA’s working in rural settings in the state of North Dakota
Preferably new employees as well as anesthesia department managers
Brochures distributed to CRNAs at the 2008 Spring NDANA convention
Individual interviews during rural clinical rotation – Still open for suggestions!!!
Distribution of brochures to those willing to participate at NDANA convention
Distribution of pre- and post- tests
Evaluation Plan for the Project
Evaluation Should Include:
Pre- and post-tests distributed to audience
Success measured through test scores
Open for suggestions for additions to brochure following presentation
Expected Results of the Project
Bring to light difficulties in rural anesthesia practice
Discover new ways of coping with rural anesthesia issues
Development of brochure that is useful to all who are new to rural anesthesia practice
Expected Implications for Nursing
Decrease stress on staff
Increase patient safety
Bring to light the need for further education in preparation for rural practice
Develop new ideas for further studies in this area
Expected Implications for Nursing (cont’d)
Provide a tool for rural hospitals to educate new staff
Educate existing facilities to make practice run more smoothly
Spark ideas for educating SRNAs about rural practice
Gunn, I.P. (2000). Rural health care and the nurse anesthetist. CRNA, 11 (2), 77-86
Hart, L.G., Salsberg, E. Phillips, D.M., & Lishner, D.M. (2002). Rural health care providers in the United States. Journal of Rural Health, 18, 211-232
Moscovice, I. & Rosenblatt, R. (2000). Quality-of-care challenges for rural health. Journal of Rural Health, 16 (2), 168-176.
Strasser, R. (2003). Rural health around the world: challenges and solutions. Oxford Journal of Family Practice, 20 (4), 457-463
Interviews with Robert Splichal, CRNA; Heidi Generou, CRNA; and Rita Vaughn, CRNA
Spinal vs Epidural Anesthesia for the Management of Patients with Preeclampsia
Intro & Problem
Hypertensive disorders related to pregnancy cause the greatest number of maternal complications worldwide.
HTN disorders related to pregnancy are the direct cause of 17.6% of maternal deaths in the US.
Preeclampsia creates complex situations for anesthesia providers performing regional analgesia & anesthesia for pain management during labor & delivery.
Decisions about which regional technique, spinal or epidural, are important in providing the best overall obstetric outcome.
Understand pathophysiology of preeclampsia & its effects on the decisions CRNAs make while providing obstetric analgesia & anesthesia
Understand how regional anesthesia affects maternal hemodynamics
Discuss the pros/cons of regional as well as general anesthesia in patients with preeclampsia using current evidence-based research
Determine which type of regional anesthetic, spinal or epidural, is the best option to obtain adequate analgesia and anesthesia in patients with preeclampsia without affecting maternal and neonatal outcomes
Areas of Inquiry
Pathophysiology of hypertensive disorders of pregnancy
Gestational HTN &Transient HTN
Preeclampsia & Eclampsia
Preeclampsia Superimposed on Chronic HTN
Spinal & epidural analgesia & anesthesia use in preeclampsia
Evidence Based Research
Establishes the basis for best practices in administration of analgesia & anesthesia to women with preeclampsia during labor & delivery
Educates nurse anesthesia providers using the most current information available about obstetric analgesia and anesthesia in patients with preeclampsia
Comprehensive literature review
Pamphlet containing “Fast Facts” about PIH syndromes & Regional Anesthesia
As epidural anesthesia was initially the regional anesthetic of choice due to the more gradual onset and lesser degree of hypotension, the recent literature provides data that indicate the safety & effectiveness of spinal anesthesia in patients with preeclampsia needing cesarean deliveries, especially if it avoids the use of general anesthesia.
Previous perceptions of anesthesia providers was that spinal anesthesia in patients with HTN & preeclampsia are at an increased risk for substantial decreases in blood pressure thus placental perfusion, causing hypoxic incidences in the fetus
More recent evidence states that spinal anesthesia does provide a safe & efficient means of anesthesia for patients who are undergoing elective or urgent cesarean sections
The majority of findings show no significant differences in decrease in BP of preeclamptic patients when comparing spinals & epidurals
Additionally, spinal anesthesia offers many advantages compared to epidurals in situations requiring urgent cesarean delivery
Less technically difficult, quicker onset, greater reliability
CRNAs work as part of a collaborative team properly managing analgesia and anesthesia in women with preeclampsia during labor and delivery
Because of the complex nature of preeclampsia & direct effects anesthesia has on hemodynamic stability, providing regional analgesia and anesthesia, such as spinals and epidurals, needs careful planning.
American College of Obstetricians and Gynecologists Practice Bulletin (2002). Diagnosis of management of preeclampsia and eclampsia. International Journal of Gynecology and Obstetrics, 77 (1), 67-75.
Hood, D. D. (2002). Spinal anesthesia is the preferred technique for cesarean section in severe preeclampsia: a proponent position. Acta Anaesthesiologica Belgica, 53, 305-310.
Bloom, S. L., Spong, C. Y., Weiner, S. J., Landon, M. B., Rouse, D. J., Varner, M. W., et al. (2005). Complications of anesthesia for cesarean delivery. Obstetrics & Gynecology, 106 (2), 281-287.
Mandal, N. G., & Surapaneni, S. (2004). Regional anaesthesia in pre-eclampsia: advantages and disadvantages. Drugs, 64 (3), 223-236.
Morgan, G. E., Mikhail, M. S., & Murray, M. J. (2006). Clinical Anesthesiology (4th ed.). New York: McGraw-Hill Companies, Inc.
National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy (2000). Report of the national high blood pressure education program working group on high blood pressure in pregnancy. American Journal of Obstetrics and Gynecology, 183 (1), S1-S22.
Perioperative Considerations of a Patient with an Implantable Pacemaker Cloris Schmidt, SRNA University of North Dakota
Patients with implantable pacemakers are more frequently being encountered by anesthesia providers
Over 1 million Americans currently have pacemakers
More than 325,000 pacemakers are implanted in the USA each year
Nurse anesthetists often have limited knowledge of the perioperative management of patients with these devices
Although complications from electromagnetic interference are rare, they are serious and often life threatening when they do occur
Purpose and Significance
To enhance the anesthetists knowledge of how to care for a patient with an implantable cardiac device throughout the perioperative period
Educate participants on pacemaker function
Effects of electromagnetic interference
Perioperative management of these patients
Should facilitate safe, effective care and reduce the incidence of adverse events
Extensive review of current literature
Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm Management Devices
Developed by the American Society of Anesthesiologists
Case reports of adverse outcomes
Published articles by credible sources
Personal interview with Guidant representative
Determine type and mode of the cardiac device
Consult with a cardiologist or pacemaker programmer highly recommended
Perform a thorough interrogation of the device
Provide recommendations for perioperative programming
Examination of EKG to determine proper pacemaker function
Determine the patient’s underlying rhythm and if they are pacemaker dependent
Usually performed by the programmer or cardiologist
No spontaneous ventricular activity when the pacemaker is programmed to VVI pacing mode at the lowest programmable rate
A spike is noted prior to every beat on the preoperative EKG
Determine whether EMI is anticipated during the planned procedure
Electrocautery is most common source
Pacemaker senses cautery as a tachyarrthymia and fails to pace
If the patient is pacemaker dependent
The device should be reprogrammed to an asynchronous mode above the intrinsic rate
If the patient is not pacemaker dependent
Programmed modes should not be changed
Anesthesia provider should have a magnet available to place pacemaker in asynchronous mode, if severe EMI inhibits pacing or causes hemodynamic instability
Rate-responsive pacemakers should be reprogrammed out of the rate-responsive mode prior to surgery
These devices rely on minute ventilation or movement sensors for rate modulation
Prevent inappropriate tachycardia as a result of mechanical ventilation changes, shivering, or other operative movement
Two ways the rate responsive mode can be shut off prior to surgery
Mode deactivated by a programmer
Placement of a magnet over the device
Will also place the pacemaker in asynchronous mode
Magnet placement on pacemaker
Will not hear a tone emitted from device
Places the pacemaker in asynchronous mode
Usually set for a rate of 85, 90, or 100 depending on the model
No longer senses or responds to EMI or patients own intrinsic activity
Paces at set rate regardless
Intraoperative monitoring of the device and heart function
Routine monitors required by ASA standards
Continuous five-lead ECG monitoring
Mechanical evidence of pacemaker capture
Palpation of the pulse
Auscultation of heart sounds
Arterial line tracing
Ultrasound peripheral pulse monitoring
Potential influences on cardiac device function
Type I antiarrhythmic drugs
Cause an increase in pacing threshold
May cause failure to pace
These factors should be avoided whenever possible
Potential influences on cardiac device function
Should be used with caution in patients with unipolar pacemakers
Skeletal muscle fasciculations may result in pacemaker oversensing and ultimately failure to pace
Defasciculating dose of non-depolarizing relaxant recommended prior to administration of succinylcholine
Minimizing sources of EMI
Bipolar or ultrasonic (harmonic) scalpel should be used in place of unipolar cautery whenever possible
Bipolar cautery causes significantly less EMI with the pacemaker
Ultrasonic scalpel completely avoids EMI with the pacemaker
Disposable set has increased cost compared to reusable electrocautery
Provides slower cutting and coagulation
Minimizing EMI produced during unipolar cautery
Use of short, intermittent bursts at the lowest possible amplitude
Pauses of at least 10 seconds between bursts
For special head, neck, or thoracic procedures, the grounding pad may need to be placed on a site other than the thigh
Careful to avoid positioning the cardiac device between the grounding pad and cautery tip
The path between the grounding pad and the electrocautery tip should be as far from the device as possible
15 cm being the minimum
Emergency equipment should be available, especially if patient is pacemaker dependent
External temporary pacemaker
Contact numbers for pacemaker representative
What If a Life Threatening Arrhythmia Develops?
Atropine may not work, if patient is pacemaker dependent or has underlying 2 nd degree type II or complete heart block
Temporary external pacing may be necessary
What If a Life Threatening Arrhythmia Develops?
Pulseless V-tach, V-fib, or unstable tachycardia
Emergency defibrillation or cardioversion necessary
Current flowing through the pulse generator and lead system should be minimized
Pads should be positioned as far from the pulse generator as possible and in an anterior-posterior position
Despite these recommendations, damage to the device, an increase in pacing threshold, or a reversion to a backup mode may still occur
A thorough pacemaker interrogation should occur after defibrillation or cardioversion
What if the Case is Emergent?
Use bipolar cautery with short bursts
Place a magnet on the device until you can find out if the patient is pacemaker dependent and if the device is a pacemaker or ICD
May be able to get this information from the patient, family, or medical record
If need more information about the device, call the pacemaker representative
Run EKG strip to determine if there is a pacer spike prior to each P-wave or QRS complex
May be pacemaker dependent
Pacing impulses followed by a paced beat and arterial pulse should be confirmed
Post-operative interrogation of the device by a cardiologist or programmer is required any time electrocautery was used in a pacemaker dependent patient
Assures proper functioning of the device and that the device was not inadvertently damaged or reprogrammed during surgery
Continuous EKG monitoring is recommended until the postoperative interrogation of the device can be made