Transcript PowerPoint Presentation - NDANA - North Dakota Association of

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
Introduction
• 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)
Problem
• 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.
Purpose
• 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.
Significance
• 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.
Methods
• 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.
Unfractionated Heparin
• 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)
LMWH (cont.)
• 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)
Antiplatelet Agents
• Platelet function must be normal before regional
anesthetic techniques are performed.
– A normal platelet count generally ranges from
150,000 to 400,000 mm3 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)
Warfarin
• 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 (cont.)
• 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)
Summary
• 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.
References
• 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 (9th
ed.). New York: McGraw-Hill Companies.
• Kee, J.L. (1999). Laboratory diagnostic tests with nursing
implications (5th ed.). Stamford, CT: Appleton & Lange.
• 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
Introduction
• 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.
Purpose
• 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
• Supply
– Heart rate
– Coronary
perfusion
pressure
– Arterial oxygen
content
– Hemoglobin
– Coronary vessel
diameter
• Demand
– Basal
requirements
– Heart rate
– SBP
– Preload
– Contractility
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.
Preoperative History
•
•
Active Cardiac Conditions for Which the Patient
Should Undergo Evaluation and Treatment Before
Noncardiac Surgery (Identified by ACC & AHA)
Condition Examples:
– 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)
– Symptomatic bradycardia
– 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.
•
1 MET
– Can you take care of
yourself?
– Walk indoors around the
house?
•
4 METs
– Climb a flight of stairs or
walk up a hill?
– Scrub the floor or move
furniture?
– Golf? Bowel? Dance?
•
10 METs
– Swimming? Tennis?
Basketball?
Clinical Assessment
•
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
Beta-Blockade
• 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
Postoperative Period
• 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
References
•
•
•
•
•
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
Akhtar, S. (2006). Ischemic heart disease. Anesthesiology Clinic,
24, 461-485.
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
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Cerebral Oximetry
Monitoring in Adult
Cardiac Surgery
Kate Busker, SRNA
University of North Dakota
Objectives
• 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.
Goal
• To optimize care of adult
cardiac bypass patients.
Introduction
• 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%
(Edmonds, 2002)
Cerebral Oximeter
• 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.
Research Questions
• 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?
Significance
• 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)
Theoretical Framework
• 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%
Anesthetic
Considerations
• 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)
Anesthetic
Considerations
• Reasons for low cerebral sat’s:
–
–
–
–
–
–
High cerebral metabolism, hyperthermia
Low Hgb, Anemia
Low PaCO2, alkalosis
Low CBF (cannula or head position)
Hypoxia
Vasoconstriction
• Intervention: Increase Oxygen
–
–
–
–
Incr. FiO2
Incr. hematocrit (RBC’s)
Incr. BP / CO
Incr. CO2 > incr. CBF
Anesthetic
Considerations
• Anesthetic Interventions: Decrease
metabolism
– Decrease temperature
– 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
• Assumptions:
– 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
• Limitations:
– Small sample sizes in studies
– Information collected limited to adult
cardiac surgery
– Information provided is limited to those
attending presentation
Results
• 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
Questions??
References
• 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.
References
• 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.
• Miller, R. (2005). Miller’s Anesthesia (6th ed).
Philadelphia, PA: Elsevier Churchill Livingstone.
References
• 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
• Willem Einthoven
– 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 12lead 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
Problem
• 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?
Current Research
• 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)
Current Research
• Other studies
– 57-95% of non-cardiologists routinely determine
ST-segment abnormalities (Brady, Parron, &
Ullman, 2000)
– 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
• Purpose
– 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 cardioelectrophysiology
– 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
Significance
• 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!
Physiological Framework
• Includes
– Cellular physiology
– Electrophysiology
– Anatomy
– Gross physiology
– Hemodynamic physiology
Research Questions
• 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?
Method
• Develop a twelve lead ECG workshop
• Presentation including:
–
–
–
–
–
–
–
–
Anatomy/Physiology of the Heart
Basic Heart Rhythms
Electrical Waveform Morphology
Axis Deviations
Chamber Hypertrophy
Q-T Intervals
Bundle Branch Blocks
Ventricular Tachycardia (VT) versus
Supraventricular Tachycardia (SVT)
– Acute Coronary Syndromes
• Sample ECGs
Evaluation
• Two fold
– 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
References
• Brady, W. J., Perron, A. D., & Chan, T. (2001).
Electrocardiographic ST-segment elevation: correct
identification of acute myocardial infarction (AMI) and nonAMI 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?
Purpose
• 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
Purpose
• 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
Significance
• SRNAs are expected to provide,
under CRNA supervision, safe
and effective regional anesthesia
to patients undergoing surgery
and painful procedures
Significance
• 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
Significance
• 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
Theoretical Framework
• 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
Theoretical Framework
• Six assumptions about adult
learning including:
– need to know
– self-concept
– experience
– preparedness
– orientation
– motivation
Method
• 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
Application
• 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
Application
Application
• 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
Application
• Preparation, including equipment
for each block
• Commonly used recipes and
volumes for each block
• Level of sedation along with
proper positioning and technique
Application
Application
Application
• Proper method
• Adverse reactions discussed
– hemidiaphragmatic paralysis
– risk of epidural injection
– Horner’s syndrome
• “Pick up” injections identified
Application
• 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
Application
• Evaluation of learning will be
done with pre- and post- testing
• Results pending
References
•
•
•
•
•
•
•
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 (4th 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 (6th ed.). Philadelphia:
Elsevier.
Morgan, G., Jr., Mikhail, M., & Murray, M. (2006). Clinical
anesthesiology (4th ed.). New York: Lange Medical Books/McGraw-Hill
Medical Publishing Division.
Clinical application of
the LMA CTrach
Kent Moser,SRNA
University of North Dakota
Introduction
• 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.
Problem
• 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.
Purpose
• 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.
Significance
• 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.
LMA/ILMA
• 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.
LMA CTrach
• 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
– light source
– 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).
LMA CTrach
• 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
•
Prep CTrach
–
•
Prep patient
–
•
–
–
•
Antisialogogue, oral suction prior to insertion
Visualizing glottis
–
•
Prefocus, antifogging solution, lubricate
Whiteout in viewer (epiglottis, secretions, lubricant)
• Adjust brightness, up-down maneuver(x2), pass suction catheter,
may need to remove LMA to clean fiberoptic lens
Dark view
• Adjust brightness
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
Summary
•
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
Conclusion
• 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.
• Questions?
References
•
•
•
•
•
•
•
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): 275277.
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.
(5th 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.
References
•
•
•
•
•
•
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.
References
•
•
•
•
•
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.
References
•
•
•
•
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. (6th 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.
References
•
•
•
•
•
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. (2nd 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
Introduction
• Background
• 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
• Patient safety
• 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
Assumptions/Limitations
• 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
Solutions
• 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 World
Organization of National Colleges, Academies and
Academic Associations of General
Practitioners/Family Physicians. (www.aafp.org)
Preparing students
Preparing Students
• Halaas, Zink, Brooks, and Miller developed a model
for students
• Case studies developed for patients who presented
with common diagnoses in the rural setting
• Goals:
–
–
–
–
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
• Anesthesia students
• Brochures distributed to CRNAs at the
2008 Spring NDANA convention
Procedures/Plan
• Literature Review
• 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
Practice
• Decrease stress on staff
• Increase patient safety
Research
• 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)
Education
• 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
References
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). Qualityof-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
References cont’d
• 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.
Purpose
• 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
– Categories
•
•
•
•
Gestational HTN &Transient HTN
Chronic HTN
Preeclampsia & Eclampsia
Preeclampsia Superimposed on Chronic HTN
• Spinal & epidural analgesia &
anesthesia use in preeclampsia
– Benefits
– Risks
– Best practice
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
Findings
• Comprehensive literature review
• Pamphlet containing “Fast Facts”
about PIH syndromes & Regional
Anesthesia
Findings
• 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
Findings
• 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
Summary
• 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.
Selected References
•
•
•
•
•
•
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), 223236.
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
Problem
• 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
Pacing modes
Effects of electromagnetic interference
Perioperative management of these patients
• Should facilitate safe, effective care and
reduce the incidence of adverse events
Methods
• 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
Findings
• Pre-operative evaluation
– 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
• Appropriately sensing
• Appropriately pacing
• Appropriately capturing
Pre-operative Evaluation
• 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
Pre-operative Preparation
• 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
Pre-operative Preparation
• 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
Pre-operative Preparation
• 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
management
• 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
Pulse oximetry
Auscultation of heart sounds
Arterial line tracing
Ultrasound peripheral pulse monitoring
Intraoperative
management
• Potential influences on cardiac device function
–
–
–
–
–
–
–
–
–
Hyperkalemia
Hypokalemia (hyperventilation)
Myocardial ischemia
Arterial hypoxemia
Severe hyperglycemia
Acidosis
Alkalosis
Bradycardia
Type I antiarrhythmic drugs
• Cause an increase in pacing threshold
– May cause failure to pace
• These factors should be avoided whenever
possible
Intraoperative
management
• Potential influences on cardiac
device function
– Succinylcholine
• 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
Intraoperative
management
• 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
Intraoperative
management
• 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
Intraoperative
management
• Emergency equipment should be
available, especially if patient is
pacemaker dependent
– External temporary pacemaker
– Defibrillator
– Atropine
– Contact numbers for pacemaker
representative
What If a Life Threatening
Arrhythmia Develops?
• Asystole
– Atropine may not work, if patient is
pacemaker dependent or has
underlying 2nd 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
Considerations
• 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