Analysis of cricoid pressure application: anaesthetic trainee doctors vs. nursing anaesthetic assistants / Análise da aplicação de pressão cricoide: residentes em anestesiologia vs. enfermeiros assistentes de anestesia

ABSTRACT BACKGROUND AND OBJECTIVE: To evaluate the ability of anaesthetic trainee doctors compared to nursing anaesthetic assistants in identifying the cricoid cartilage, applying the appropriate cricoid pressure and producing an adequate laryngeal inlet view. METHODS: Eighty-five participants, 42 anaesthetic trainee doctors and 43 nursing anaesthetic assistants, were asked to complete a set of questionnaires which included the correct amount of force to be applied to the cricoid cartilage. They were then asked to identify the cricoid cartilage and apply the cricoid pressure on an upper airway manikin placed on a weighing scale, and the pressure was recorded. Subsequently they applied cricoid pressure on actual anaesthetized patients following rapid sequence induction. Details regarding the cricoid pressure application and the Cormack-Lehane classification of the laryngeal view were recorded. RESULTS: The anaesthetic trainee doctors were significantly better than the nursing anaesthetic assistants in identifying the cricoid cartilage (95.2% vs. 55.8%, p = 0.001). However, both groups were equally poor in the knowledge about the amount of cricoid pressure force required (11.9% vs. 9.3% respectively) and in the correct application of cricoid pressure (16.7% vs. 20.9% respectively). The three-finger technique was performed by 85.7% of the anaesthetic trainee doctors and 65.1% of the nursing anaesthetic assistants (p = 0.03). There were no significant differences in the Cormack-Lehane view between both groups. CONCLUSION: The anaesthetic trainee doctors were better than the nursing anaesthetic assistants in cricoid cartilage identification but both groups were equally poor in their knowledge and application of cricoid pressure.

RESUMO JUSTIFICATIVA E OBJETIVO: Avaliar a capacidade de residentes em anestesiologia em comparação com enfermeiros assistentes de enfermagem para identificar a cartilagem cricoide, aplicar a pressão cricoide adequada e produzir uma vista adequada da entrada da laringe. MÉTODOS: Foram convidados 85 participantes, 42 residentes em anestesiologia e 43 enfermeiros assistentes de enfermagem a responder questionários sobre a quantidade correta de força a ser aplicada na cartilagem cricoide. Os participantes deviam identificar a cartilagem cricoide e aplicar a pressão cricoide em modelos de vias aéreas superiores colocados sobre uma balança de pesagem e a pressão era registada. Posteriormente, aplicaram pressão cricoide em pacientes anestesiados reais após a indução de sequência rápida. Os detalhes sobre a aplicação de pressão cricoide e a classificação de Cormack-Lehane da visibilidade da laringe foram registrados. RESULTADOS: Os residentes em anestesiologia foram significativamente melhores do que os enfermeiros assistentes de enfermagem na identificação da cartilagem cricoide (95,2% vs. 55,8%, p = 0,001). No entanto, o conhecimento de ambos os grupos era precário sobre a quantidade de força necessária para aplicar a pressão cricoide (11,9% vs. 9,3%, respectivamente) e a correta aplicação da pressão cricoide (16,7% vs. 20,9%, respectivamente). A técnica de três dedos foi aplicada por 85,7% dos residentes em anestesiologia e 65,1% dos enfermeiros assistentes de enfermagem (p = 0,03). Não houve diferença significativa entre os dois grupos em relação à classificação de Cormack-Lehane para a visão. CONCLUSÃO: Os residentes em anestesiologia foram melhores do que os enfermeiros assistentes de enfermagem para identificar a cartilagem cricoide, mas ambos os grupos apresentaram um conhecimento igualmente precário sobre a aplicação de pressão cricoide.

Considerable Variability of Procedural Sedation and Analgesia Practices for Gastrointestinal Endoscopic Procedures in Europe

BACKGROUND/AIMS: The use of moderate to deep sedation for gastrointestinal endoscopic procedures has increased in Europe considerably. Because this level of sedation is a risky medical procedure, a number of international guidelines have been developed. This survey aims to review if, and if so which, quality aspects have been included in new sedation practices when compared to traditional uncontrolled sedation practices. METHODS: A questionnaire was sent to the National Associations of Nurse Anesthetists in Europe and the National Delegates of the European Section and Board of Anaesthesiology from January 2012 to August 2012. RESULTS: Huge variation in practices for moderate to deep sedation were identified between and within European countries in terms of safety, type of practitioners, responsibilities, monitoring, informed consent, patient satisfaction, complication registration, and training requirements. Seventy-five percent of respondents were not familiar with international sedation guidelines. Safe sedation practices (mainly propofol-based moderate to deep sedation) are rapidly gaining popularity. CONCLUSIONS: The risky medical procedure of moderate to deep sedation has become common practice for gastrointestinal endoscopy. Safe sedation practices requiring adequate selection of patients, adequate monitoring, training of sedation practitioners, and adequate after-care, are gaining attention in a field that is in transition from uncontrolled sedation care to controlled sedation care.

Effects of bispectral index monitoring as an adjunct to nurse-administered propofol combined sedation during colonoscopy: a randomized clinical trial

BACKGROUND/AIMS: The efficacy of bispectral index (BIS) monitoring during colonoscopic sedation is debated. We aimed to determine whether BIS monitoring was useful for propofol dose titration, and to evaluate differences in sedative administration between expert and inexperienced medical personnel during colonoscopy procedures that required moderate sedation. METHODS: Between February 2012 and August 2013, 280 consecutive patients scheduled to undergo a screening colonoscopy participated in this study and were randomly allocated to the expert or inexperienced endoscopist group. Each group was further divided into either a BIS or a modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) subgroup. Trained nurses administered combined propofol sedation and monitored sedation using either the BIS or MOAA/S scale. RESULTS: The mean BIS value throughout the procedure was 74.3 +/- 6.7 for all 141 patients in the BIS group. The mean total propofol dose administered in the BIS group was higher than that in the MOAA/S group, independently of the endoscopists' experience level (36.9 +/- 29.6 and 11.3 +/- 20.7, respectively; p < 0.001). The total dose of propofol administered was not significantly different between the inexperienced endoscopist group and the expert endoscopist group, both with and without the use of BIS (p = 0.430 and p = 0.640, respectively). CONCLUSIONS: Compared with monitoring using the MOAA/S score alone, BIS monitoring was not effective for titrating the dose of propofol during colonoscopy, irrespective of colonoscopist experience.

Comparison of the Level and Side Effects of Spinal Anesthesia with Hyperbaric Bupivacaine in the Supine, Lateral, and Prone Positions

PURPOSE: This study attempted to test whether there are differences in the level and hemodynamic side effects (blood pressure, heart rate, O2 saturation), and nausea & vomiting of spinal anesthesia using hyperbaric bupivacaine according to position (supine, lateral, and prone positions) in orthopedic surgery patients who received podiatric surgery under spinal anesthesia. METHODS: This study was conducted with 53 patients who had received orthopedic surgery under spinal anesthesia at I General Hospital. Data were analyzed using SPSS 20.0 through repeated-measures ANOVA, post-hoc test, Chi-test, and Fisher's exact test. RESULTS: The change of position after spinal anesthesia with hyperbaric bupivacaine caused a change in the level of spinal anesthesia (F=12.768, p<.001). However, no difference of blood pressure, heart rate, O2 saturation and nausea and vomiting caused by the change in anesthesia level was observed, and in prone position, drug was administered for the correction of side effects. CONCLUSION: As expected, recognizing that there can be a change in the level of spinal anesthesia after the change of position in surgical patients, nurse anesthetists should monitor their conditions carefully and continuously.

Comparison of Job Tasks and Task Elements of Korean Nurse Anesthetists by Type of Medical Institution: Hospital, General Hospital and Higher General Hospital / 간호행정학회지

PURPOSE: This study was done to identify job tasks and task elements of Korean nurse anesthetists according to type of medical institution. METHODS: A job task scale which consisted of 9 job tasks and 40 task elements was developed. Data were collected from December, 2009 to February, 2010 from 182 nurse anesthetists who were working in medical institutions (response rate: 75.8%). RESULTS: Forty-eight percent of nurse anesthetists were independent from anesthesiologists in anesthetic practice. Preanesthetic nursing assessment was much more frequent in small hospitals than in general hospitals (p<.05), and anesthetic nursing intervention, administering the anesthetics, monitoring the patient's status during anesthesia, and provision of safety and compliance with anesthetic ethics were much more frequent in general hospitals than medical centers (p<.001). There were no differences among the medical institutions for job tasks in post-anesthetic nursing interventions (p=.229), administering anesthetics (p=.354) and monitoring patients' status during anesthesia (p=.099), providing safe anesthetic environment (p=.896), and management of ancillary personnel/equipment (p=.617). CONCLUSION: Results indicate that nurse anesthetists contribute significantly to anesthetic practice in small hospitals and general hospitals. Therefore, it recommended that nursing leaders make efforts to enact legal nurse anesthetist-related policies for safe and high quality anesthetic nursing care.

The development of postgraduate anaesthesia and intensive care training at the University of the West Indies / Desarrollo de la anestesia de postgrado y entrenamiento en cuidados intensivos en la Universidad de West Indies

The one-year Diploma in Anaesthetics (DA) was the first postgraduate programme offered by the then Faculty of Medicine of The University of the West Indies (UWI). It was instituted in 1966, when the need for trained physician anaesthetists became paramount. Over 200 physicians have been awarded the DA which was discontinued in 1994. The four-year Doctor of Medicine in Anaesthetics [DM (Anaesthetics)] was commenced in 1974 and continues to train most of the region's physician anaesthetists. The majority of the 119 graduates (as of December 2011) are providing invaluable services to the people of the Caribbean. The time has come for the establishment of a regional certifying body, the Caribbean College of Anaesthetists. This college would determine the standards for the training and clinical practice of anaesthetists as perioperative physicians including: the conduct of anaesthesia, critical care, acute and chronic pain management. It would also facilitate continuing medical education and recertification of all practising anaesthetists within the region.

El Diploma en Anestesia (DA) de un año fue el primer programa de postgrado ofrecido por la entonces Facultad de Medicina de la Universidad de West Indies. Este diplomado se instituyó en 1966, cuando se hizo patente la necesidad de médicos anestesistas entrenados. Más de 200 médicos han recibido el DA, que fue discontinuado en 1994. El programa de Doctor Especialista en Anestesia, comenzó en 1974 y continúa entrenando a la mayoría de anestesiólogos de la región. La mayor parte de los 119 graduados (a partir de diciembre 2011) están proporcionando servicios inestimables a las personas del Caribe. Ya es hora de establecer un organismo de certificación - el Colegio de Anestesistas del Caribe. Dicho colegio determinaría las normas para el entrenamiento y la práctica clínica de los anestesistas como médicos perioperatorios, incluyendo la conducción de la anestesia, el cuidado crítico, y el tratamiento del dolor crónico y agudo. También facilitaría la continuación de la educación médica y la recertificación de todos los anestesistas practicantes de la región.

Evaluation des effets du dichlorate d'hydroxyzine sur l'anxiete preoperatoire et appreciation de l'information donnee aux malades

Evaluer l'anxiete preoperatoire des patients proposes pour une chirurgie elective et apprecier l'information recue du chirurgien et de l'anesthesiste.Type d'etude : Etude prospective et longitudinale sur deux enquetes de pratique hospitaliere. Patients et methode : Tous les patients ages de 16 ans et plus; de classe ASA I et II; admis en hospitalisation pour subir une intervention chirurgicale programmee durant la periode allant du 1er janvier au 30 avril 2007 et apres consentement eclaire; ont ete repartis en deux groupes de facon aleatoire. Les malades appartenant au groupe d'intervention ont recu chacun une premedication au dichlorate d'Hydroxyzine. L'anxiete preoperatoire a ete mesuree dans les deux groupes au moyen de l'echelle visuelle analogique (EVA). Resultats : Sur 145 patients initialement inclus; 139 ont pu participer a l'etude. Il n'y avait pas de difference statistiquement significative entre les deux groupes en ce qui concerne leurs scores d'anxiete avant ou apres la premedication. Par contre; nos resultats montrent que la plupart de nos patients n'avaient recu; en preoperatoire; que partiellement ou pas du tout d'informations sur les actes chirurgicaux et anesthesiques prevus.Conclusion : Les patients sont demandeurs d'informations et une bonne preparation psychologique pourrait reduire de facon sensible l'anxiete preoperatoire et prevenir certains incidents et/ou complications per ou postoperatoires

Description of Surgical and Anaesthetic Services Provided at Two District Hospitals in KwaZulu-Natal in Relation to the Surgical Norms and Standards Outlined in the Service Package for District Hospitals

Provision of surgical services at district hospitals (DHS) is cost effective and important. The District Hospital Service Package for South Africa (package of services) specifies the services that a district hospital should provide. The aim of this study was to document the surgical services provided at two DHS in KwaZulu-Natal and to compare this with the recommendations in the package of services. Methods: In a retrospective quantitative study; data from 2008 were collected from the theatre register at two DHS. Data were analysed and results compared with the norms and standards in the package of services. Results were presented to staff at the hospitals; who then commented on the challenges of providing surgical services at DHS. Results: Only 60 and 30 respectively of procedures listed in the package of services were being carried out at the two hospitals. In total; 3 900 procedures were carried out over the year. Dundee Hospital offered a broader range of surgical procedures and anaesthetics than the Church of Scotland Hospital (COSH). COSH has a large obstetric burden; with 3 666 deliveries each year. A large number of procedures were being carried out by a single operator. Conclusions: Many surgical procedures are being carried out even though neither hospital provides the full complement of surgical services as specified in the package of services. The wide variation between the surgical services offered reflects the surgical and anaesthetic skills at the respective hospitals. Potential medico-legal hazards that require urgent attention were identified. A review of the package of services is essential to identify core procedures that must be provided at DHS

A survey of awareness, opinion and reported use of clinical practice guidelines (CPG) of the Royal College of Anesthesiologists of Thailand.

BACKGROUND: Up to the present (2006), The Royal College of Anesthesiologists of Thailand (RCAT) has proposed and revised six practice guidelines. For guidelines to achieve their objectives, anyone who gets involved needs to be aware of the guidelines, be able to accept, and adhere to them. Although the authors did introduce their guidelines by several passive means, the authors have not yet ascertained what the result were. OBJECTIVE: The primary objective of the present study was to assess awareness, opinion, limitation, and reported use of guidelines. The secondary objective was to identify factors associated with variation, agreement, and reported use of guidelines. MATERIAL AND METHOD: A cross sectional, self-report survey study was conducted. An anonymous questionnaire including prepaid-addressed reply envelopes was mailed to 600 anesthesiologists and 1,300 nurse anesthetists, nationwide, based on the college's list. The questions covered respondents' general characteristics: awareness, agreement, and reported use of the existing guidelines; opinion on implementation media, which guidelines the members need, their local guidelines, and the impact of guidelines on their practice. All data were extracted and reported using descriptive statistics. Multiple logistic regression was done to identify factors associated with an agreement with and a reported use of the guidelines. RESULTS: The overall response rate was 33.4% and nurse anesthetists had a higher response than anesthesiologists. Forty-six percent of the respondents were aware of the existing guidelines. This result corresponded to percentage of those who had read the guidelines (41%). Among the six existing guidelines, the least two guidelines reported use of and agreement with, were those for labor analgesia and conscious sedation (23-28%, 24-28%). The guidelines for spinal anesthesia received the most response (46%). For respondents who had read the guidelines, most of them (80% to 94%) rated the level of agreement and reported use as good to excellent. The respondents also rated the announcement of the guidelines during the annual meeting of the Royal College of Anesthesiologists of Thailand as the best implementation strategy. Impracticability, inadequate dissemination, and un-cooperation among colleagues were the three most important obstacles of using the guidelines. In addition, the present study demonstrated three significant factors, anesthesiologists, regional hospitals, and general hospitals, as associated with reporting frequent use of and high agreement with the guidelines. CONCLUSION: The low level of awareness and reported use of the present guidelines among the members reflects poor implementation and dissemination. However the present study reveals some information that will guide the authors to introduce intensive and targeted interventions to encourage the members to comply and adhere to the guidelines designed to improve the quality of patients' care.

Knowledge and skill after brief ACLS training.

OBJECTIVES: To determine the knowledge level and skill base in nurse anesthetists before and after brief ACLS training, and again three months later. METHOD: Thirty nurse anesthetists were tested for knowledge and skill before ACLS training comprising 1-hr lecture and handout, and 1-hr simulation training. Concepts included ABCD, primary and secondary survey, management, medications, and algorithms for common problems. Skill practice comprised airway management, chest compression and practice with equipment. After the training, the nurse anesthetists were immediately tested and again three months later. RESULTS: Age of participants averaged 39.33 + or - 3.14 years and working experience 10.04 +/- 3.23 years. The knowledge and skill scores pre- vs post-training vs three-months-later was 50.32 +/- 15.24 vs 75.40 +/- 10.29 (p < 0.001) vs 60.48 +/- 11.80 (p < 0.001) and 65.00 + 16.07 vs 79.67 +/- 10.80 (p < 0.001) vs 75.67 +/- 14.53 (p < 0.001), respectively. The pre-training vs three-months-post-training skill scores was not statistically different (p = 0.255). CONCLUSION: After the briefACLS training knowledge and skills were significantly improved, but knowledge was not retained at the post-training test levels until the 3-month check, albeit skills had persisted. More frequent ACLS education is necessary.

Enfermeiro anestesista: uma verticalização do enfermeiro perioperatório / Nurse anesthesia practice: a profound study of the perioperative nurse

O enfermeiro anestesista é aquele que realiza uma prática avançada e especializada, exercida há mais de um século me vários países, com respaldo legal para a administração e a manutenção do processo anestésico. Surgiu em 1870 como a primeira especialidade de Enfermagem Clínica nos Estados Unidos, não sendo, porém, exclusividade norte-americana. Esse profissional executa os cuidados em anestesia nos períodos pré, intra e pós-operatórios, na recuperação anestésica e notratamento da dor aguda e crônica. No entanto, trata-se de uma especialidade inexistente em nosso país. Mas, ao descrevermos e analisarmos as atividades assistenciais do enfermeiro de Centro Cirúrgico no Brasil e as do enfermeiro anestasista nos Estados Unidos, deparamos com semelhanças e limites tênues entre elas e percebemos que há uma sobreposição das atribuições de ambos. ...

A Study on the Demand for Nurse Anesthetists in Korea / 기본간호학회지

PURPOSE: This descriptive study was conducted to project the number of nurse anesthetists needed in hospital settings, up to the year 2015. METHOD: Necessary data and information were collected from various funded reports, professional literature, web sites and personal visits to national and private institutions. The number of nurse anesthetists needed was projected after considering the total number of cases requiring anesthesia including deliveries, workload ratio for caesarean section to total number of deliveries, and percent of deliveries requiring and anesthesia. RESULT: The projected number of nurse anesthetists needed for hospital settings are as follows: 1. The number of registered anesthesia personnel in Korea in 2002 was 2,481 anesthesiologists and 543 nurse anesthetists but only 60%of anesthesiologists and 30% of nurse anesthetists (147) were actually practicing in the field of surgery. 2. By the year 2015, the total number of projected nurse anesthetists needed in hospital settings will be between 214 and 265. CONCLUSION: In order to match the supply to the need, the professional organizations should direct efforts towards enacting legislation. Educational systems should identify strategies to initiating an adequate number of nurse anesthetist programs at the master's level as well as standardizing curriculums across programs.

An Analysis of Anesthesia-related Medico-legal Cases Occurred in a Recent 2 Year Period / 대한마취과학회지

BACKGROUND: 42 anesthesia-related medico-legal cases, consulted to the Korean Society of Anesthesiologists (KSA) in a recent 2 year period (1994, 11~1996, 10) were analysed. METHOD: Results of the analysis were classified into 11 items. RESULTS: Cases sources were 26 cases from civil court, 2 cases from criminal court, 8 cases from police stations and 6 cases from health centers, and involved surgical departments were obstetric & gynecology (17 cases), general surgery (7), orthopedic surgery (6), and others (12). Operation classification were Cesarean section (14 cases), reduction and fixations (5), gastrectomy (4) and others (19), and anesthesia methods were general anesthesia (36 cases), regional anesthesia (3), and local anesthesia (3). Involved hospitals were university hospitals (15), general hospitals (16) and private clinics (11), and involved anesthesiologists (anesthetists) were certified anesthesiologists (34), nurse anesthetists (3), and others (5). Patient's ages were classified into 0~20 years old (4), 20~40 years old (23), 40~60 years old (13) and over 60 years old (2), and patient's sex ratio was 16 (male) to 26 (female). Outcome of victims were deaths (26 cases), severe brain damages (10) and nerve injuries (6), and autopsy findings were hypoxic brain edema (4 cases), coronary artery diseases (3), and other findings (4). Causes of medico-legal problems were hypoxemia by ventilatory failure (12), pre-existing diseases (4), embolisms followed by operation (2), malignant hyperthermia (1), and uncertain cases (21). CONCLUSION: The most common cause of medico-legal problems was hypoxemia by ventilatory failure.