Point-of-Care Ultrasound in Anesthesia Care: New AANA Practice Document Adopted by AANA Board of Directors.

The American Association of Nurse Anesthetists recently released a practice considerations document titled, "Point-of-Care Ultrasound in Anesthesia Care," that clinicians, administrators, and other stakeholders are encouraged to download and read in their entirety, available at aana.com/PracticeManual.

Considerations for Management of Bupivacaine Formulation Shortage Affecting Obstetric Anesthesia Services.

Healthcare facilities across North America are experiencing a shortage of several formulations of bupivacaine affecting analgesia and anesthesia care, particularly for obstetric services. This editorial will discuss evidence-based considerations to address the bupivacaine shortage including interprofessional team engagement for planning, alternative anesthetic and analgesic management strategies for the obstetrical patient, and safe drug preparation. As leaders in healthcare, nurse anesthetists are encouraged to work closely with their anesthesia, pharmacy, obstetric, and facility leadership to develop best alternative solutions during this drug shortage to provide safe analgesic and anesthetic care.

The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants.

Venous thromboembolism is recognized as a leading cause of maternal death in the United States. Thromboprophylaxis has been highlighted as a key preventive measure to reduce venous thromboembolism-related maternal deaths. However, the expanded use of thromboprophylaxis in obstetrics will have a major impact on the use and timing of neuraxial analgesia and anesthesia for women undergoing vaginal or cesarean delivery and other obstetric surgeries. Experts from the Society of Obstetric Anesthesia and Perinatology, the American Society of Regional Anesthesia, and hematology have collaborated to develop this comprehensive, pregnancy-specific consensus statement on neuraxial procedures in obstetric patients receiving thromboprophylaxis or higher dose anticoagulants. To date, none of the existing anesthesia societies' recommendations have weighed the potential risks of neuraxial procedures in the presence of thromboprophylaxis, with the competing risks of general anesthesia with a potentially difficult airway, or maternal or fetal harm from avoidance or delayed neuraxial anesthesia. Furthermore, existing guidelines have not integrated the pharmacokinetics and pharmacodynamics of anticoagulants in the obstetric population. The goal of this consensus statement is to provide a practical guide of how to appropriately identify, prepare, and manage pregnant women receiving thromboprophylaxis or higher dose anticoagulants during the ante-, intra-, and postpartum periods. The tactics to facilitate multidisciplinary communication, evidence-based pharmacokinetic and spinal epidural hematoma data, and Decision Aids should help inform risk-benefit discussions with patients and facilitate shared decision making.

Consensus Bundle on Prevention of Surgical Site Infections After Major Gynecologic Surgery.

Surgical site infections are the most common complication of surgery in the United states. Of surgeries in women of reproductive age, hysterectomy is one of the most frequently performed, second only to cesarean birth. Therefore, prevention of surgical site infections in women undergoing gynecologic surgery is an ideal topic for a patient safety bundle. The primary purpose of this safety bundle is to provide recommendations that can be implemented into any surgical environment in an effot to reduce the incidence of surgical site infection. This bundle was developed by a multidisciplinary team convened by the Council on Patient Safety in Women's Health Care. The bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. In addition to recommendations for practice, each of the domains stresses communication and teamwork between all members of the surgical team. Although the bundle components are designed to be adaptable to work in a variety of clinical settings, standardization within institutions is encouraged.

Consensus Bundle on Prevention of Surgical Site Infections After Major Gynecologic Surgery.

Surgical site infections are the most common complications of surgery in the United States. Of surgeries in women of reproductive age, hysterectomy is one of the most frequently performed, second only to cesarean birth. Therefore, prevention of surgical site infections in women undergoing gynecologic surgery is an ideal topic for a patient safety bundle. The primary purpose of this safety bundle is to provide recommendations that can be implemented into any surgical environment in an effort to reduce the incidence of surgical site infection. This bundle was developed by a multidisciplinary team convened by the Council on Patient Safety in Women's Health Care. The bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. In addition to recommendations for practice, each of the domains stresses communication and teamwork between all members of the surgical team. Although the bundle components are designed to be adaptable to work in a variety of clinical settings, standardization within institutions is encouraged.

Consensus Bundle on Prevention of Surgical Site Infections After Major Gynecologic Surgery.

Surgical site infections are the most common complication of surgery in the United States. Of surgeries in women of reproductive age, hysterectomy is one of the most frequently performed, second only to cesarean birth. Therefore, prevention of surgical site infections in women undergoing gynecologic surgery is an ideal topic for a patient safety bundle. The primary purpose of this safety bundle is to provide recommendations that can be implemented into any surgical environment in an effort to reduce the incidence of surgical site infection. This bundle was developed by a multidisciplinary team convened by the Council on Patient Safety in Women's Health Care. The bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. In addition to recommendations for practice, each of the domains stresses communication and teamwork between all members of the surgical team. Although the bundle components are designed to be adaptable to work in a variety of clinical settings, standardization within institutions is encouraged.

Treatment and Prevention of Spinal-Induced Hypotension in the Cesarean Section Patient: What Does the Evidence Say?

Most anesthesia providers prefer to do a subarachnoid block (SAB) for cesarean section because of its rapid onset and reliability to provide adequate anesthesia. However an effect of the SAB is that it causes a spinal-induced hypotension (SIH) in up to 85% of the population. There have been multiple studies that assessed fluid administration, vasopressor administration, maternal positioning, or serotonin blockers given prophylactically to attenuate the SIH response. Despite these multiple studies, the method to prevent and treat SIH remains varied from one anesthesia practice to another. The purpose of this chapter is to review the evidence on the various methods used to prevent and treat SIH.

Consensus Bundle on Prevention of Surgical Site Infections After Major Gynecologic Surgery.

Surgical site infections are the most common complication of surgery in the United States. Of surgeries in women of reproductive age, hysterectomy is one of the most frequently performed, second only to cesarean birth. Therefore, prevention of surgical site infections in women undergoing gynecologic surgery is an ideal topic for a patient safety bundle. The primary purpose of this safety bundle is to provide recommendations that can be implemented into any surgical environment in an effort to reduce the incidence of surgical site infection. This bundle was developed by a multidisciplinary team convened by the Council on Patient Safety in Women's Health Care. The bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. In addition to recommendations for practice, each of the domains stresses communication and teamwork between all members of the surgical team. Although the bundle components are designed to be adaptable to work in a variety of clinical settings, standardization within institutions is encouraged.

Comparison of fascia iliaca compartment block and 3-in-1 block in adults undergoing knee arthroscopy and meniscal repair.

Peripheral nerve blocks have become a popular method for treatment of pain after lower-extremity surgical procedures. Two peripheral nerve blocks for knee arthroscopy include the 3-in-1 block and the fascia iliaca compartment block (FICB). There is limited research comparing the efficacy of these blocks in adults undergoing knee arthroscopy and meniscal repair who receive both the peripheral nerve block and general anesthesia. This was a randomized controlled trial of 60 adult patients undergoing knee arthroscopy under general anesthesia and with a 3-in-1 block or FICB using the same local anesthetic admixture. Onset of block, time to postoperative analgesic requirements, pain scores, and overall satisfaction scores were measured. No differences in analgesic requirements or pain scores were noted. A faster onset of anesthesia occurred in the 3-in-7 block group, but there was a longer duration of postoperative analgesia in the FICB group. Patient satisfaction scores were similar between groups. Based on this study we recommend that the choice of block can be determined by the clinical scenario. We recommend a 3-in-1 block if speed of onset is the primary goal of anesthesia before induction, and we recommend the FICB block if prolonged postoperative analgesia is the primary goal.

Effect of intraoperative intravenous lidocaine on postoperative pain and return of bowel function after laparoscopic abdominal gynecologic procedures.

Abdominal surgery has a high incidence of postoperative pain and dysfunctional gastrointestinal motility. This study investigated the effect of a continuous intraoperative infusion of lidocaine on patients undergoing laparoscopic gynecologic surgery. In this double-blind, placebo-controlled investigation, 50 subjects were randomly assigned to control and experimental groups. Both groups received an intravenous lidocaine bolus of 1 mg/kg on induction. The experimental group received a continuous lidocaine infusion of 2 mg/kg/h, initiated following induction and discontinued 15 to 30 minutes before skin closure. Controls received a placebo infusion. Patients in the experimental group had lower postoperative day 3 pain scores using a verbal analog scale (P = .02). Morphine equivalent dose at second request for pain treatment in the postoperative anesthesia care unit was lower in the experimental group (P = .02). There was a statistically significant difference in time interval from surgical start to return of first flatus between the groups (P = .02). Data were analyzed using descriptive and inferential statistics. A P value less than .05 was considered significant. These study results are consistent with previous research suggesting that intraoperative lidocaine infusion may improve postoperative pain levels and may shorten the time to return of bowel function.

Prophylactic isopropyl alcohol inhalation and intravenous ondansetron versus ondansetron alone in the prevention of postoperative nausea and vomiting in high-risk patients.

Patients identified as high risk for postoperative nausea and vomiting (PONV) are often treated prophylactically with intravenous (IV) ondansetron and an additional agent. Limited options exist for a second agent with no adverse effects. The purpose of this investigation was to determine if combining the prophylactic inhalation of isopropyl alcohol (IPA) vapors, an agent with no adverse effects, with IV ondansetron would be more effective than IV ondansetron alone in the prevention of PONV in high-risk patients. A total of 76 patients at high risk for PONV were randomized into control (n = 38) and experimental (n = 38) groups. All patients received IV ondansetron before emergence from general anesthesia. In addition, the experimental group inhaled IPA vapors before induction. Severity of PONV was measured using a 0 to 10 verbal numeric rating scale. Other measured variables included time to onset and incidence of PONV, 24-hour composite nausea score, and satisfaction with nausea control. No significant differences in demographics, surgical or anesthesia time, number of risk factors, severity or incidence of PONV, or satisfaction scores were noted. Prophylactic inhalation of IPA vapors in combination with IV ondansetron was no more efficacious than IV ondansetron alone in the prevention of PONV in a high-risk population.

Biphasic dosing regimen of meclizine for prevention of postoperative nausea and vomiting in a high-risk population.

The purpose of this study was to determine if giving 50 mg of meclizine the night before and on the day of surgery would effectively reduce postoperative nausea and vomiting (PONV) for the entire 24 hours after surgery in patients identified as being at high risk for PONV Subjects were randomly assigned to receive either 50 mg of oral meclizine (experimental group) or a placebo (control group) the night before and the day of surgery. All subjects were intravenously administered 4 mg of ondansetron before the conclusion of surgery. Seventy subjects (35 control; 35 experimental) were included in analysis. postoperaIn the placebo group we noted higher verbal numeric rating scale scores for nausea, a higher incidence oftive nausea and vomiting (PONV) continues to be a common complication after general anesthesia, with the incidence ranging from 17% to 87%.15 It has been reported that PONV increased antiemetic requirements, and lower overall anesthesia satisfaction scores at all time intervals measured, compared with the experimental group, but the differences were not statistically significant until analyzed by postoperative setting. No difference in sedation or side effects was noted between groups. Based on these results, we recommend that the administration of 50 mg of oral meclizine the night before and on the day of surgery be considered effective antiemetic prophylaxis in patients identified as having a high risk for PONV.

Comparison of inhalation of isopropyl alcohol vs promethazine in the treatment of postoperative nausea and vomiting (PONV) in patients identified as at high risk for developing PONV.

Frequently, patients identified as high risk for postoperative nausea and vomiting (PONV) are treated prophylactically with intravenous (IV) ondansetron and postoperatively with IV promethazine. The purpose of this study was to determine if using an aromatic therapy of 70% isopropyl alcohol (IPA) would be more effective than promethazine in resolution of breakthrough PONV symptoms in groups of high-risk patients administered prophylactic ondansetron. All subjects enrolled were identified as high risk for PONV, administered general anesthesia and a prophylactic antiemetic of 4 mg of IV ondansetron, and randomized to receive IPA or promethazine for treatment of breakthrough PONV Demographics, verbal numeric rating scale (VNRS) scores for nausea, time to 50% reduction in VNRS scores, and overall antiemetic and incidence of PONV were measured. The data for 85 subjects were included in analysis; no differences in demographic variables or baseline measurements were noted between groups. The IPA group reported a faster time to 50% reduction in VNRS scores and decreased overall antiemetic requirements. A similar incidence in PONV was noted between groups. Based on these findings, we recommend that inhalation of 70% IPA is an option for treatment of PONV in high-risk patients who have received prophylactic ondansetron.

Will the addition of a sciatic nerve block to a femoral nerve block provide better pain control following anterior cruciate ligament repair surgery?

Two common forms of postoperative analgesia used in patients following an anterior cruciate ligament repair (ACLR) are the femoral nerve block (FNB) and the combined femoral-sciatic nerve block (FSB). The purpose of this study was to determine if the addition of the sciatic nerve block to the FNB is truly beneficial in ACLR patients requesting regional anesthesia for postoperative pain control. All subjects scheduled for an ACLR, requesting general anesthesia and preoperative placement of a peripheral nerve block (PNB), were randomized to receive an FNB or an FSB. Analgesic requirements, pain scores, and overall postoperative analgesic satisfaction were the primary outcomes measured. The data for 56 subjects (FNB, 27; FSB, 29) were used in analysis. Significantly higher analgesic requirements, pain scores, and lower satisfaction scores were noted in the FNB group compared with the FSB group (P < .05). No other differences were noted between groups in demographic data. Based on this investigation, we concluded that the FSB, compared with FNB alone, provides superior postoperative analgesia in patients receiving an ACLR and should be included in the anesthetic care plan in which a PNB is planned to facilitate postoperative analgesia.

Correlating an 11-point verbal numeric rating scale to a 4-point verbal rating scale in the measurement of pruritus.

Pruritus, the subjective sensation of itch, can be a difficult symptom to assess and treat. Evaluating levels of patient discomfort across populations has proven to be challenging because of a lack of a standardized measurement tool to quantify levels of itch. The most widely used tool is the 4-point verbal rating scale (VRS-4), but others use an 11-point verbal numeric rating scale (VNRS-11). Therefore, the purpose of our study was to correlate a VNRS-11 to a VRS-4 for the assessment of pruritus. Fifty parturients were enrolled in this correlational study. Each subject's level of pruritus was measured at five specific intervals after administration of intrathecal opioids. The scales were administered one minute apart in random order. Data analysis demonstrated a strong correlation between these two scales, (r=.910 to .853) indicating that each verbal descriptor on the VRS-4 could readily be substituted with a quantifiable range on the VNRS-11.

Effect of timing of fluid bolus on reduction of spinal-induced hypotension in patients undergoing elective cesarean delivery.

Spinal-induced hypotension remains the most common complication associated with spinal anesthesia for cesarean delivery. Recent evidence indicates that a 20-mL/kg bolus via pressurized infusion system administered at the time of subarachnoid block (SAB) (coload) may provide better prophylaxis than the traditional administration of a 20-mL/kg crystalloid infusion (preload) approximately 20 minutes before SAB; however, this method raises some concerns. We hypothesized that administering half of the fluid bolus (10 mL/kg) before and half immediately following injection of the SAB would provide benefit. Variables included demographics, spinal anesthetic dermatome level obtained, additional intravenous (IV) fluid bolus and vasopressor requirements, and maternal vital signs. We enrolled 87 subjects in this prospective, randomized investigation, 43 preload (control) and 44 preload/coload (experimental). There were no demographic differences between groups. The increased supplemental vasopressors required to treat maternal hypotension in the preload group were not statistically significant. Total IV fluids and supplemental IV bolus requirements were significantly higher in the preload group. No differences in neonatal outcomes were noted between groups. Maternal vital signs were not significantly different between groups; hypotension was treated as it occurred. We recommend replacing standardized prophylactic crystalloid fluid administration with the preload/coload method described herein.

Perceived deprivation in active duty military nurse anesthetists.

There is a shortage of military Certified Registered Nurse Anesthetists (CRNAs). Relative deprivation is a perception of unfairness due to discrepancies between what one has and what one could or should have that is dependent on feelings (subjective data) and facts (objective data). Feelings of relative deprivation could contribute to the military CRNA shortage. The purposes of this study were to measure relative deprivation in active-duty military CRNAs and explore variables that correlate with relative deprivation. The descriptive, correlational study was conducted using a self-administered survey sent to 435 active-duty Army, Navy, and Air Force CRNAs. Surveys were distributed to subjects by mail and could be answered by mail or by secured website. Data were analyzed using descriptive and inferential statistics. Analysis of the data revealed a calculated response rate of 57.7%. There was no significant correlation (P < .05) between years as a CRNA, military pay, promotion opportunity, or scope of practice/autonomy and relative deprivation. Correlations of the psychological factors "wanting" and "deserving" with relative deprivation were significant (P < .001). Further research is indicated to identify definitive factors that can be modified to improve feelings of deprivation as they relate to retention and recruitment of military CRNAs.

Comparison of 2 laryngeal tracheal anesthesia techniques in reducing emergence phenomena.

Endotracheal intubation (ETT) can cause emergence phenomena (EP) including coughing, sore throat, and dysphonia. Two methods used to prevent EP are the administration of local anesthetics directly onto airway structures using a specialized laryngotracheal instillation of topical anesthesia (LITA) tube (Sheridan Catheter Corporation, Argyle, New York) or the placement of a local anesthetic into the ETT cuff. The purpose of this study was to determine which method was better at preventing ERl In this prospective, randomized, comparative analysis, a sample of 160 ASA class I through III patients were randomly assigned to receive their EP prophylaxes either by placement of alkalinized lidocaine directly into the ETT cuff at intubation or by injection into a specialized port on the LITA tube approximately 30 minutes before extubation. Variables measured included the incidence and severity of sore throat, coughing, and dysphonia for the first 24 hours following surgery. The incidence of cough and sore throat was higher in the LITA group, achieving significance in the postanesthesia care unit and after discharge to home. No difference in any of the other variables was noted between groups. Our study demonstrated greater efficacy in decreasing the incidence and severity of EP by placing an alkalinized solution of lidocaine into the ETT cuff on intubation.

The efficacy of ketorolac as an adjunct to the Bier block for controlling postoperative pain following nontraumatic hand and wrist surgery.

Research indicates that using a combination of ketorolac and lidocaine in the administration of a Bier block results in significant postoperative analgesia and decreased inflammation; however, the optimal dose of ketorolac to coadminister with the local anesthetic has not been established. This study was performed to determine if a 20-mg dose of ketorolac is effective in providing prolonged postoperative analgesia without adverse effects. A total of 55 patients (29 lidocaine-ketorolac, 26 lidocaine-placebo) were enrolled in this randomized, double-blind, placebo controlled study. Pain was measured using a 0 to 10 visual analogue scale and analysis of postoperative analgesic requirements. Incidence of bruising and postoperative analgesic satisfaction scores were determined 48 hours following discharge. No difference in demographic variables, adverse effect profiles, or satisfaction scores was noted between groups. Visual analogue scale scores were increased in the placebo group in the hospital but not following discharge to home. There was also a prolonged time to postoperative analgesic requests in the ketorolac group compared with the placebo group following discharge to home, achieving statistical significance for the time to second analgesic request (P = .012). Based on the results of this study we recommend that 20 mg ketorolac be considered in intravenous regional anesthesia.