Controlled drug misuse by Certified Registered Nurse Anesthetists.

The primary purpose of this study was to determine the prevalence of controlled drug misuse among actively practicing Certified Registered Nurse Anesthetists (CRNAs). A second purpose was to determine variance in controlled drug misuse by the variables of age, sex, population and geographic area of residence, type of anesthesia position currently held, and number of years in anesthesia practice. The research data were obtained through self-administered surveys mailed to 2,500 actively practicing CRNAs throughout the United States. With a response rate of 68.4% (1,709 of 2,500), the survey instrument allowed for stratification according to admitted misuse of controlled drugs commonly used in the clinical practice of anesthesia. The established prevalence of controlled drug misuse in the target population was found to be 9.8% of the sample (167 of 1,709 respondents), with the majority indicating a distinct proclivity for polydrug misuse. The survey results were comparable with those of studies involving anesthesiologists and registered nurses with the notable exception of the preferred drugs for misuse. A strong relationship existed between sex, number of years in clinical anesthesia practice, and the likelihood for controlled drug misuse, thus indicating a potential predictor of which CRNAs may misuse controlled drugs. In addition, a significant relationship existed between recency of controlled drug misuse and drug(s) of choice (P = .05). Recommendations include specific tactics for strengthening drug misuse education and prevention. Also, modifications in research design and additional studies in the research area are suggested.

Acute pain management services: a comparison between Air Force and U.S. hospitals.

The purpose of this descriptive study was to assess the prevalence of acute pain management services (APMS) in Air Force medical facilities. There are no published reports on the current status of Air Force pain programs. This study used a telephone survey to all facilities worldwide that house an anesthesia department. Anesthesia providers in charge of pain services or department chiefs were interviewed from December 1996 to May 1997. Respondents were asked questions related to the initiation of a formal APMS, components, and familiarity with the Agency for Health Care Policy and Research guidelines on pain management. Data analysis described current practices and used chi 2 analysis to compare results with a national study of U.S. hospitals. Air Force anesthesia departments (45%) had established as many acute pain services as U.S. hospitals (42%). Formal pain programs are becoming more prevalent in Air Force hospitals. These findings suggest an increased awareness of the need for pain management and future establishment of pain programs.

The effect of intrathecal and epidural narcotic analgesia on the length of labor.

A number of studies have shown conflicting results on the effect of epidural (EPI) analgesia on the length of labor. Combined spinal-epidural (CSE) and intrathecal analgesia (ITA) techniques have been used to provide pain relief for parturients, but currently there are few studies comparing EPI, CSE, and ITA techniques and their effect on the length of labor. Intrathecal opioids provide immediate pain relief for the parturient without autonomic, sensory, or motor blockade. The purpose of this retrospective study is to identify the effects of ITA on the length of labor compared with other regional anesthesia techniques. A total of 213 uncomplicated obstetric charts were reviewed in a 70-bed Air Force hospital that provided EPI, CSE, and ITA for obstetrical patients. The study consisted of the following four groups: (1) CSE (n = 76), (2) EPI(n = 41), (3) ITA (n = 49), and (4) no regional analgesia (NR) (n = 47). The results showed that the length of first-stage labor was statistically significantly less for those who received ITA compared with those who received CSE, EPI, and NR (P < .001). Second-stage labor was statistically significantly shorter for the NR group compared with the CSE and EPI groups (P < .01). No statistically significant difference was found between the length of second stage for ITA and NR groups. ITA analgesia shortened the first stage significantly in both primipara and multipara patients (P < .01). These results imply that the use of intrathecal opioids in the obstetrical patient does not prolong labor and seems to shorten the first stage of labor in both the primipara and multipara patients.

A guide to understanding informed consent.

Anesthesia providers are expected to provide information to the patient during the preanesthesia interview that enables the patient to make informed choices. Adequate disclosure during the informed consent process ensures the equalization of the practitioner/patient relationship and the decision-making rights of the patient. Both certified registered nurse anesthetists (CRNAs) and anesthesiologists are not only legally required to provide information that will allow a patient to make an informed judgment about how to proceed with various anesthetic modalities but are also obligated by their standards of practice. This article informs the CRNA about the principles of informed consent so that they can better understand their role in the informed consent process.

Informed consent: an essential element of safe anesthesia practice.

Generally, health care providers have viewed safety in terms of prevention of patient accidents. However, with the growth of patient consumerism and stress on quality improvement, the concept of "safety" has been expanded. This article examines the legal concept of informed consent and offers practical suggestions on increasing both patient and provider safety and improving quality of care. For reasons dictated by statute, case law, and professional ethics, informed consent should be part of the practice of every CRNA. With proper informed consent, misinformation, dissatisfaction, and subsequent legal action can be diminished. Information should be offered to the patient and family and reinforced with written educational materials and instructions. These procedures should be documented in the medical record to provide verification that the patient was informed of the risks and benefits and agreed to the procedure contemplated. Failure to do so could expose the CRNA to legal actions under legal theories that include not only negligence, but battery, and contract as well.

Personality, addiction and anesthesia.

While substance abuse problems in the health care profession are not new, little documentation exists as to their prevalence among nurse anesthetists. There already exists considerable evidence that physician specialists in anesthesia are overrepresented in the population of physicians seeking treatment for drug and alcohol use. The purpose of this research was to explore factors related to personality and addictive tendencies that might predispose nurse anesthetists to substance abuse as well. Of the 150 graduate nursing students in the study, those specializing in anesthesia (n = 81) formed the study group while those pursuing general nursing graduate degrees (n = 69) comprised the control group. Differences in the personality facets of impulsiveness, assertiveness and excitement seeking were measured using the NEO Personality Inventory. The addictive tendencies of the subjects were measured using the MacAndrew Scale taken from the Minnesota Multiphasic Personality Inventory. In comparative analyses of the two groups, the anesthesia subjects exhibited a higher mean score for excitement seeking and a greater number of positive MacAndrew (addictive tendency) scores (22.2% versus 5.9%). The findings also showed that subjects with positive MacAndrew scores generally had higher excitement seeking scores. It may be possible that this higher level of excitement seeking predisposes future nurse anesthetists to the development of addictive disorders.

Covalent phosphorylation of the Mg2+-dependent ATPase of yeast plasma membranes.

Phosphorylation by [gamma-32P]ATP of proteins associated with the plasma membrane of Saccharomyces cerevisiae has been studied both in vivo and in vitro. Although at least nine proteins are labeled in vivo, there is only one major protein labeled in vitro. This species with an apparent molecular weight of 114,000 has been identified as the plasma membrane Mg2+-ATPase. Phosphorylation of this enzyme occurs exclusively on serine residues. This is the first report that the proton-translocating ATPase of fungal plasma membranes is subject to phosphorylation by a protein kinase.

Properties and possible functions of the adenylate cyclase in plasma membranes of Saccharomyces cerevisiae.

We have examined the possible role of adenosine 3',5'-phosphate (cAMP) in functions associated with the plasma membranes of Saccharomyces cerevisiae. Purified membranes from this source contained an adenylate cyclase which was insensitive to activation by fluoride or guanine nucleotides, only weakly responsive to changes of carbon source in the growth medium, and strongly stimulated by vanadate. They also contained at least two classes of receptor proteins for guanine nucleotides (as measured by binding of labeled 5'-guanylyl methylene diphosphate) with apparent dissociation constants equal to 1.0 x 10(-7) and 3 x 10(-6) M, a protein kinase capable of phosphorylating added histones, the activity of which was stimulated by cAMP, and cAMP receptors that may function as regulatory subunits for this kinase. Membrane proteins were also susceptible to phosphorylation by endogenous kinase(s), with polypeptides of apparent molecular weights equal to 160 x 10(3), 135 x 10(3), 114 x 10(3), and 58 x 10(3) as the major targets. Of these, the 114,000-molecular-weight polypeptide was probably identical to the proton-translocating ATPase of the membranes. However, the cAMP-dependent protein kinase did not appear to be involved in these reactions. Intact (rho+ or rho0) cells responded to dissipation of the proton electrochemical gradient across their plasma membranes by rapid and transient changes in their intracellular level of cAMP, as suggested earlier (J. M. Trevillyan and M. L. Pall, J. Bacteriol., 138:397-403, 1979). Thus, although yeast plasma membranes contain all the essential components of a stimulus-responsive adenylate cyclase system, the precise nature of the coupling device and the targets involved remain to be established.

Partial characterization of the plasma membrane ATPase from a rho0 petite strain of Saccharomyces cerevisiae.

Crude membrane preparations of a rho0 mutant of Saccharomyces cerevisiae exhibit Mg2+-dependent ATPase activity. Over the optimal pH range, 5.0-6.75, the apparent Vmax of the enzyme equals 590 nmoles of ATP hydrolyzed per minute per milligram protein, with an apparent Km for ATP of 1.3 mM. ATP hydrolysis is insensitive to ouabain, venturicidin, aurovertin, and the protein inhibitor described by Pullman and Monroy; inhibited by oligomycin (at high concentrations) and sodium orthovanadate, and it is sensitive to dicyclohexylcarbodiimide, p-hydroxymercuribenzoate, hydroxylamine, sodium fluoride, and sodium iodoacetate. The pH optimum and the inhibitor pattern distinguish the plasma membrane enzyme from the mitochondrial F1 ATPase still present in these cells (this activity is sensitive to efrapeptin, aurovertin, and the protein inhibitor, but resistant to DCCD). In addition, the activity of the plasma membrane enzyme and its affinity for ATP are responsive to changes in the composition of the growth medium, with the highest activity observed in cells grown on methyl-alpha-D-glucoside, a sugar which results not only in partial release from catabolite repression but also requires the induction of an active transport system for growth.