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Title: University of North Dakota


1
University of North Dakota Nurse Anesthesia
Specialization Student Presentations
2
Spinal Hematoma Formation Following Neuraxial
Anesthesia in the Anticoagulated Patient
Lisa Bell, SRNA University of North Dakota
3
Introduction
  • The formation of a spinal hematoma is strongly
    correlated with the use of anticoagulation
    medications.
  • Incidence of epidural hematoma formation is
    1150,000.
  • Ratio of hematoma formation decreases slightly
    with spinal blocks, with a reported incidence of
    1220,000.
  • 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)

4
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.

5
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.

6
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.

7
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.

8
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)

9
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)

10
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)

11
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)

12
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)

13
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)

14
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)

15
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)

16
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 patients physical
    presentation, medical history, laboratory data,
    and current medication history prior to the
    administration of regional anesthesia.

17
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_Conferenc
    es
  • 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.o
    rg/pdf/neuraxial.pdf

18
Perioperative Myocardial Infarction
Lorrissa Bohlman, SRNA University of North Dakota
19
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.

20
Purpose
  • The purpose of this project is to examine the
    perioperative identification and management of
    surgical patients at risk for perioperative
    myocardial infarction.

21
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.

22
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

23
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

24
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.

25
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)

26
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?

27
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.

28
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.

29
Framework for Determining which Patients are
Candidates for Further Cardiac Testing
Fleisher, L. A. et al. Circulation
2007116e418-e499
30
Proposed approach to the management of patients
with previous percutaneous coronary intervention
(PCI) who require noncardiac surgery
Fleisher, L. A. et al. Circulation
2007116e418-e499
31
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.

32
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

33
Myocardial Infarction Management
  • Despite the classification of myocardial
    infarction management is dictated by the
    patients 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

34
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

35
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 patients
    level of hemodynamic stability

36
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/pt
    saftey/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

37
References
  • American Society of Anesthesiologists. (2005).
    Standards for basic anesthetic monitoring.
    Amended October 25, 2005 Approved House of
    Delegates October 21, 1986. Retrieved February
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  • Baxter, A. Kanji, S. (2007). Protocol
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  • Boersma, E., Poldermans, D., Bax, J.J.,
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38
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    (2004). Timing of high-risk vascular surgery
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39
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40
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41
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42
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43
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    Cardiovascular Therapy, 4(5), 731-734.
  • Sprung, J., Abdelmalak, B., Gottlieb, A., Mayhew,
    C., Hammel, J., Levy, P.J., et al. (2000).
    Analysis of risk factors for myocardial
    infarction and cardiac mortality after major
    vascular surgery. Anesthesiology, 93(1), 129-140.
  • Symons, J.A., Myles, P.S. (2006). Myocardial
    protection with volatile anaesthetic agents
    during coronary artery bypass surgery A
    meta-analysis. British Journal of Anaesthesia,
    97(2), 127-136.
  • Warltier, D.C., Pagel, P.S., Kersten, J.R.
    (2000). Approaches to the prevention of
    perioperative myocardial ischemia.
    Anesthesiology, 92(1), 253-259.
  • Wijeysundera, D.N., Beattie, W.S. (2003).
    Calcium channel blockers for reducing cardiac
    morbidity after noncardiac surgery A
    meta-analysis. Anesthesia and Analgesia, 97(3),
    634-641.
  • Wilson, S.H., Fasseas, P., Orford, J.L., Lennon,
    R.J., Horlocker, T., Charnoff, N.E., et al.
    (2003). Clinical outcome of patients undergoing
    non-cardiac surgery in the two months following
    coronary stenting. Journal of the American
    College of Cardiology, 42(2), 234-240.

44
Cerebral Oximetry Monitoring in Adult Cardiac
Surgery
  • Kate Busker, SRNA
  • University of North Dakota

45
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.

46
Goal
  • To optimize care of adult cardiac bypass
    patients.

47
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)

48
Cerebral Oximeter
  • Produced by Somanetics in Troy, MI

49
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.

50
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?

51
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)

52
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 gt concentration
    of dissolved substance can be measured
  • Same concept as pulse oximetry
  • The difference between oxyhemoglobin and
    deoxyhemoglobin
  • Shallow signal vs deep signal gt can eliminate
    extra-cerebral perfusion

53
How the Infrared Works
54
Review of Literature
  • Cerebral autoregulation remains intact when CPP
    is 70-90 mmHg.
  • A CPP change gt 30 mmHg results in severely
    compromised CBF
  • Oxygen levels directly affect perfusion
  • Hyperoxia has little effect
  • Hypoxia (PaO2 lt 60 mmHg) causes vasodilation
    leading to an increase in CBF

55
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 lt 25 mmHg
  • Temperature for every 1 degree decrease,
    cerebral metabolic rate decreases 6-7

56
Anesthetic Considerations
  • Normal venous sat. 58-82
  • Pediatric will be higher (70-92)- incr EBV
  • Intervention threshold anything lt 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 gt decreased perfusion gt unable to meet
    demand)

57
Anesthetic Considerations
  • Reasons for low cerebral sats
  • 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 (RBCs)
  • Incr. BP / CO
  • Incr. CO2 gt incr. CBF

58
Anesthetic Considerations
  • Anesthetic Interventions Decrease metabolism
  • Decrease temperature
  • Incr. volatile anesthetic
  • lt 1 MAC CMR decreased gt CBF increased
  • 1 MAC unchanged (both equal)
  • gt 1 MAC CBF increased gt CMR decreased
  • IV anesthetics (benzos, barbs, propofol,
    etomidate) will reduce CMR up to 30
  • But autoregulation sets in quickly d/t quick
    metabolism
  • Ketamine exception d/t SNS stimulation

59
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

60
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

61
Questions??
62
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.

63
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). Millers Anesthesia (6th ed).
    Philadelphia, PA Elsevier Churchill Livingstone.

64
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.

65
Twelve Lead ECG Interpretation
  • Christian Conner, SRNA
  • University of North Dakota

66
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

67
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

68
ECG and Anesthesia
  • Anesthetists routinely look at 12-lead 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

69
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?

70
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)

71
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)

72
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 cardio-electrophysiology
  • 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

73
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!

74
Physiological Framework
  • Includes
  • Cellular physiology
  • Electrophysiology
  • Anatomy
  • Gross physiology
  • Hemodynamic physiology

75
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?

76
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

77
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

78
References
  • Brady, W. J., Perron, A. D., Chan, T. (2001).
    Electrocardiographic ST-segment elevation
    correct identification of acute myocardial
    infarction (AMI) and non-AMI 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.

79
Teaching Regional Anesthesia to Nurse Anesthesia
Students
  • Garrel Kinzler, SRNA
  • UND Nurse Anesthesia

80
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

81
Teaching Regional Anesthesia
  • This demands more focus and more study/practice
    on regional methods from emerging practitioners
  • How is this being done?

82
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

83
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

84
Significance
  • SRNAs are expected to provide, under CRNA
    supervision, safe and effective regional
    anesthesia to patients undergoing surgery and
    painful procedures

85
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

86
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

87
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

88
Theoretical Framework
  • Six assumptions about adult learning including
  • need to know
  • self-concept
  • experience
  • preparedness
  • orientation
  • motivation

89
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

90
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

91
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

92
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

93
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

94
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

95
Application
96
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

97
Application
  • Preparation, including equipment for each block
  • Commonly used recipes and volumes for each block
  • Level of sedation along with proper positioning
    and technique

98
Application
99
Application
100
Application
  • Proper method
  • Adverse reactions discussed
  • hemidiaphragmatic paralysis
  • risk of epidural injection
  • Horners syndrome
  • Pick up injections identified

101
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

102
Application
  • Evaluation of learning will be done with pre- and
    post- testing
  • Results pending

103
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). Millers 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.

104
Clinical application of the LMA CTrach
  • Kent Moser,SRNA
  • University of North Dakota

105
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.

106
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.

107
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.

108
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.

109
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.

110
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.

111
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).

112
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.

113
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 (P0.110) or between the Cormack-Lehane
    grade and success of intubation (P0.38). (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)

114
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.

115
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.

116
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.

117
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.

118
Awake intubation case reports
  • Bilgin and Yylmaz (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.

119
Keys to Success for intubation
  • Prep CTrach
  • Prefocus, antifogging solution, lubricate
  • Prep patient
  • Antisialogogue, oral suction prior to insertion
  • Visualizing glottis
  • 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

120
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,
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