Anesthesia and Perioperative Considerations for Patients With Myasthenia Gravis.

Patients with neuromuscular diseases such as myasthenia gravis can present as complicated anesthetic cases. This article reviews anesthetic considerations for optimal perioperative care of patients with myasthenia gravis. The pathophysiology of myasthenia gravis, cholinergic and myasthenic crises, and perioperative management are discussed; this includes the pharmacology of acetylcholinesterase inhibitors vs sugammadex, extubation criteria, pain management, and risk factors for postoperative myasthenic crisis. Anesthesia recommendations include reversal of nondepolarizing neuromuscular blockade agents with sugammadex, obtaining sufficient spontaneous breathing with absolutely no residual curarization before extubation, limited use of opioids and sedatives, avoidance of routine admission to the intensive care unit, and consideration of peripheral nerve blocks for adjunct pain control.

Comparing Forced-Air to Resistive-Polymer Warming for Perioperative Temperature Management: A Retrospective Study.

PURPOSE: Compare perioperative temperature management between forced-air warming (FAW) and resistive-polymer heating blankets (RHBs). DESIGN: A retrospective, quasi-experimental study. METHODS: Retrospective data analysis of nonspine orthopedic cases (N = 426) over a one-year period including FAW (n = 119) and RHBs (n = 307). FINDINGS: FAW was associated with a significantly higher final intraoperative temperature (P = .001, d = 0.46) than the RHB. The incidence of hypothermia was not found to be significantly different at the end (P = .102) or anytime throughout surgery (P = .270). Of all patients who started hypothermic, the FAW group had a lower incidence of hypothermia at the end of surgery (P = .023). CONCLUSIONS: FAW was associated with higher final temperatures and a greater number of normothermic patients than RHBs. However, no causal relationship between a warming device and hypothermia incidence should be assumed.

Nitrous Oxide for the Management of Labor Analgesia.

This article reviews nitrous oxide and explores current practice standards for use of nitrous oxide in managing labor analgesia. Inhaled nitrous oxide is used in the labor process for analgesia as well as for anxiolysis in many countries but is rarely offered in the United States. Because of its minimal invasiveness, highsafety index, effectiveness, and relatively low cost, it is reemerging as a consideration for use during labor and is worthy of further research.

Update on Guidelines for Perioperative Antibiotic Selection and Administration From the Surgical Care Improvement Project (SCIP) and American Society of Health-System Pharmacists.

Antibiotic prophylaxis plays an important role in the prevention of surgical site infections. For healthcare institutions to receive reimbursement, compliance with current measures introduced by the Surgical Care Improvement Project is required. Anesthesia providers commonly administer prophylactic antibiotics and are in the position to provide valuable input in the perioperative setting. This review provides a summary of the most common antibiotics used in the surgical setting-cefazolin, clindamycin, and vancomycin-and their implications to the anesthesia provider, such as proper dosing, targeting bacteria, and side effects.

Tranexamic Acid in Anesthetic Management of Surgical Procedures.

Blood loss during surgical procedures poses a grave risk to the patient, but transfusion is costly and associated with adverse outcomes. Antifibrinolytics, however, offer an economical and effective means of decreasing blood loss associated with surgical procedures. Tranexamic acid (TXA) is an antifibrinolytic that blocks lysine-binding sites of fibrinogen and fibrin, preventing the breakdown of existing clots. This journal course reviews extensive research demonstrating that antifibrinolytics such as TXA decrease blood loss and in some studies reduce allogeneic transfusion requirements. In addition, this journal course addresses concerns that use of antifibrinolytics increases embolic events, reviews research that demonstrates TXA does not increase the incidence of vascular occlusive events, and describes methods of TXA use in cardiac and orthopedic surgical procedures, neurosurgery, and obstetrics. The Certified Registered Nurse Anesthetist should consider the possibility, on a case-by-case basis, of using TXA in surgical procedures to reduce blood loss with minimal adverse effects.

Perianesthetic Considerations for the Breastfeeding Mother.

Breastfeeding has been shown to be beneficial in the development of infants, but sometimes, the breastfeeding mother may require anesthesia. It is important for perianesthesia caregivers to understand how the breastfed infant may be affected by the anesthetic medications received by the breastfeeding mother. This article reviews current literature on drug transfer into breast milk and specifically how anesthetic drugs may affect breastfed infants. The pharmacokinetics of drug transfer during lactation is described as well as considerations for perianesthesia providers when caring for breastfeeding patients. The results of this literature review provide evidence that there is little risk to the breastfed infant after the mother receives surgical anesthesia. However, the type of drug, the dosage, the timing of treatment, and the infant's age and health must be taken into consideration.

Thromboelastography: Clinical Application, Interpretation, and Transfusion Management.

The coagulation cascade is a dynamic process dependent on many factors. It involves interaction between primary hemostasis, platelet clot formation, secondary hemostasis, thrombin generation, and fibrinolysis. The assessment of this process is particularly important in the surgical patient to properly manage hemostatic issues. Traditionally, coagulation tests used to guide transfusion management have included platelet count, activated partial thromboplastin time, prothrombin time, international normalized ratio, and activated clotting time, among others. Although these tests provide the practitioner with valuable information, they lack the ability to measure platelet function. The ability to measure whole blood coagulation, including platelet function, and not just the number of platelets, can be critical when a healthcare provider is determining what products are appropriate for a particular patient during surgery. One possible solution to this deficit in traditional coagulation monitoring is thromboelastography. Thromboelastography provides a more complete picture of coagulation status, taking into account more factors involved in the clotting process, including platelet function and temperature.

Residual Neuromuscular Blockade.

This article provides an update on residual neuromuscular blockade for nurse anesthetists. The neuromuscular junction, pharmacology for producing and reversing neuromuscular blockade, monitoring sites and methods, and patient implications relating to incomplete reversal of neuromuscular blockade are reviewed. Overall recommendations include using multiple settings when employing a peripheral nerve stimulator for monitoring return of neuromuscular function and administering pharmacologic reversal when the train-of-four ratio is below 0.9.

Perioperative Vision Loss: Considerations and Management.

Perioperative vision loss (POVL) associated with routine surgical procedures is a rare but catastrophic event. Although no clear direct cause of POVL has been determined, it is theorized that decreased ocular perfusion pressure of the optic nerve is responsible for POVL. This article will investigate theories as to why POVL occurs, risk factors associated with POVL, anatomy related to POVL, preventive measures that may help to reduce risk of POVL, and interventions that the anesthesia provider can implement.

Infection Associated With Single-Dose Dexamethasone for Prevention of Postoperative Nausea and Vomiting: A Literature Review.

Postoperative nausea and vomiting is one of the most common complications affecting surgical patients. The glucocorticoid dexamethasone is often used for the prevention of postoperative nausea and vomiting. This literature review seeks to summarize research related to the use of a single perioperative dose of dexamethasone for prophylactic treatment of postoperative nausea and vomiting and its impact on surgical healing. Although the majority of the literature reviewed found no association between single-dose intraoperative dexamethasone and an increase in surgical site infections, the need for a large-scale randomized controlled trial is consistently mentioned. Prudent clinicians should always use the most current evidence with their best clinical judgment when making medication decisions for their patients.

Role of Esmolol in Perioperative Analgesia and Anesthesia: A Literature Review.

Use of opioids to provide adequate perioperative analgesia often leads to respiratory depression, nausea, vomiting, urinary retention, pruritus, and opioid-induced hyperalgesia, with the potential to increase length of stay in the hospital. In an effort to reduce perioperative opioid administration yet provide appropriate pain relief, researchers began to study the use of esmolol beyond its well-known cardiovascular effects. Perioperative esmolol has been shown to reduce anesthetic requirements, decrease perioperative opioid use, decrease the incidence of postoperative nausea and vomiting, lead to an earlier discharge, and increase patient satisfaction. This article provides a review of the literature on the use of esmolol as an adjunct for perioperative analgesia and anesthesia.

Cost-effectiveness of quantitative pretest probability intended to reduce unnecessary medical radiation exposure in emergency department patients with chest pain and dyspnea.

OBJECTIVES: Quantitative pretest probability (qPTP) incorporated into a decision support tool with advice can reduce unnecessary diagnostic testing among patients with symptoms suggestive of acute coronary syndrome (ACS) and pulmonary embolism (PE), reducing 30-day costs without an increase in 90-day adverse outcomes. This study estimates long-term (beyond 90-day) costs and outcomes associated with qPTP. The authors hypothesized that qPTP reduces lifetime costs and improves outcomes in low-risk patients with symptoms suggestive of ACS and PE. METHODS: This was a cost-effectiveness analysis of a multicenter, randomized controlled trial of adult emergency patients with dyspnea and chest pain, in which a clinician encountering a low-risk patient with symptoms suggestive of ACS or PE conducted either the intervention (qPTP for ACS and PE with advice) or the sham (no qPTP and no advice). Effect of the intervention over a patient's lifetime was assessed using a Markov microsimulation model. Short-term costs and outcomes were from the trial; long-term outcomes and costs were from the literature. Outcomes included lifetime transition to PE, ACS, and intracranial hemorrhage (ICH); mortality from cancer, ICH, PE, ACS, renal failure, and ischemic stroke; quality-adjusted life-years (QALYs); and total medical costs compared between simulated intervention and sham groups. RESULTS: Markov microsimulation for a 40-year-old patient receiving qPTP found lifetime cost savings of $497 for women and $528 for men, associated with small gains in QALYs (2 and 6 days, respectively) and lower rates of cancer mortality in both sexes, but a reduction in ICH only in males. Sensitivity analysis for patients aged 60 years predicted that qPTP would continue to save costs and also reduce mortality from both ICH and cancer. Use of qPTP significantly reduced the lifetime probability of PE diagnosis, with lower probability of death from PE in both sexes aged 40 to 60 years. However, use of qPTP reduced the rate of ACS diagnosis and death from ACS at age 40, but increased the death rate from ACS at age 60 for both sexes. CONCLUSIONS: Widespread use of a combined qPTP for both ACS and PE has the potential to decrease costs by reducing diagnostic testing, while improving most long-term outcomes in emergency patients with chest pain and dyspnea.

Cost of education and earning potential for non-physician anesthesia providers.

Potential non-physician anesthesia students gauge many different aspects of a graduate program prior to applying, but cost of education and earning potential are typically high priorities for students. Our analysis evaluated the cost of tuition for all certified registered nurse anesthetist (CRNA) and anesthesiologist assistant (AA) programs in the United States, as well as earning potential for both professions. We collected educational cost data from school websites and salary data from the Medical Group Management Association's Physician Compensation and Production Survey: 2012 Report in order to compare the two groups. We found that the median cost of public CRNA programs is $40,195 and the median cost of private programs is $60,941, with an overall median of $51,720. Mean compensation for CRNAs in 2011 was $156,642. The median cost of public AA programs is $68,210 compared with $77,155 for private AA education, and an overall median cost of $76,037. Average compensation for AAs in 2011 was $123,328. Considering these factors, nurse anesthesia school is a better choice for candidates who already possess a nursing license; however, for those prospective students who are not nurses, AA school may be a more economical choice, depending on the type and location of practice desired.

The impact of the Bologna process on nursing higher education in Europe: a review.

BACKGROUND: Changes are occurring in global higher education. Nursing is not exempt from these changes, and must adapt in order to be competitive in a global market. The Bologna process has been integral in the last decade in modernizing European higher education. However, modernization does not occur without challenges. This paper addresses the Bologna process and the challenges it presents to nursing higher education in Europe. OBJECTIVE: To describe the Bologna Process as it relates to European nursing education. DESIGN AND METHODOLOGY: Literature review via searches of the following electronic databases: Academic Search Premier, MEDLINE, PubMed, ERIC, and CINAHL. Search criteria included Bologna process, European higher education, nursing education, quality assurance, and ECTS. RESULTS: Twenty-four peer-reviewed articles were included as well as one peer-reviewed presentation, one commission report, and one book. CONCLUSION: Further investigation is required to address the complexities of the Bologna process and its evolutionary changes as it relates to nursing education in Europe. Change is not always easy, and is often complex, especially as it relates to cross-border education that involves governmental regulation. Bologna-member countries need to adapt to the ever-changing higher education environment or fall behind.

Anesthesia and critical care ventilator modes: past, present, and future.

Mechanical ventilators have evolved from basic machines to complicated, electronic, microprocessing engines. Over the last 2 decades, ventilator capabilities and options for critical care and anesthesia ventilators have rapidly advanced. These advances in ventilator modalities--in conjunction with a better understanding of patient physiology and the effects of positive pressure ventilation on the body--have revolutionized the mechanical ventilation process. Clinicians today have a vast array of mechanical ventilator mode options designed to match the pulmonary needs of the critically ill and anesthetized patient. Modes of mechanical ventilation continue to be based on 1 of 2 variances: volume-based or pressure-based. The wording describing the standard ventilatory modes on select present-day ventilators has changed, yet the basic principles of operation have not changed compared with older ventilators. Anesthesia providers need to understand these ventilator modes to best care for patients. This literature review encompasses a brief history of mechanical ventilation and current modes available for anesthesia and critical care ventilators, including definitions of each mode, definitions of the various descriptive labels given each mode, and techniques for optimizing and meeting the ventilator needs of the patient while avoiding complications in the surgical and critical care patient.