Exploring Production Pressure and Normalization of Deviance and Their Relationship to Poor Patient Outcomes

Production pressure and/or normalization of deviance contribute to poor patient outcomes. The purpose of this study was to explore the relationship between production pressure and normalization of deviance to poor patient outcomes. A team of experienced qualitative researchers conducted a metasynthesis of all qualitative closed claims studies that used the American Association of Nurse Anesthetists (AANA) Foundation Closed Claims database and were accepted for publication at the time of the study. Three central concepts emerged from the analysis: (1) impaired culture of safety, (2) violations of standards of care, and (3) impaired patient safety and outcomes. It is imperative that anesthesia providers support a culture of safety and follow AANA Standards for Nurse Anesthesia Practice.

Identification of a Very High Cuff Pressure by Manual Palpation of the External Cuff Balloon on an Endotracheal Tube

The most common complication due to intubation is a high cuff pressure. A high cuff pressure can cause postanesthetic tracheal mucosal injuries in patients undergoing surgery. The aim of this cross-sectional study was to describe whether anesthetic nurses and anesthesiologists identified a very high cuff pressure by manual palpation of the external cuff balloon on an endotracheal tube. An airway device was intubated with an endotracheal tube cuffed to 95 cm H2O. Each participant palpated the external cuff balloon and then filled out a questionnaire, including estimation of the cuff pressure and user frequency of the cuff pressure manometer. The results showed that 89.1% estimated that the cuff pressure was high. Among the participants who rated the cuff pressure as high, 44.8% rated the pressure as quite high and 60.6% rated the pressure as very high. There was no significant relationship between profession and skill in identifying a very high cuff pressure (P = .843) or between work experience and skill in terms of identifying a very high cuff pressure (P = .816). These findings indicate that 10% of patients are at risk of tracheal erosion because of a high cuff pressure.

The preoperative anesthesia evaluation--revisited

This article discusses the importance of individualizing the preoperative anesthesia assessment. Establishing trust between the interviewer and patient results in a positive, calming effect from preoperative period through to PACU. An interviewing technique can eas- ily be developed to alleviate anxiety and still make patients aware of risks and potential outcomes.

Medication administration in the operating room: new standards and recommendations

Anesthesia is one of the few areas in healthcare with no secondary verification of medication administration, yet it also has the highest number of administered medications, most of which are high-alert medications. Anesthetists often prescribe, dispense, mix, relabel, administer, and document medications without secondary verification. To increase patient safety, vigilance is one of the basic principles of anesthesia delivery in addition to the other fundamentals of medication administration. The Anesthesia Patient Safety Foundation recommends implementing standardizations, barcode medication administration, and the use of prefilled or premixed syringes to assist in the safe delivery of anesthesia. It has been shown that adhering to the principles outlined by the Anesthesia Patient Safety Foundation reduces the number of adverse drug events and results in safer care of patients.

Reexamining traditional intraoperative fluid administration: evolving views in the age of goal-directed therapy

Intraoperative volume administration has long been a topic of debate in the field of anesthesia. Only recently, however, has the conversation shifted to a discussion of appropriate intraoperative volume. A thorough review of the literature explores the history of today's widely accepted fluid administration equation and discusses possible explanations and consequences of iatrogenically induced hypervolemia. Current studies exploring various volume administration techniques are reviewed, as are emerging technologies available to help guide anesthesia providers with intraoperative fluid management.

Emergency cesarean delivery in primigravida with portal hypertension, esophageal varices, and preeclampsia

The incidence of cirrhosis and advanced portal hypertension during pregnancy is very low, and the literature is scarce with regard to the anesthetic management of a parturient with this coexisting disease. We report the successful perioperative management of a parturi- ent with a history of cirrhosis and portal hypertension with esophageal varices and mild preeclampsia who presented at 38 weeks' gestation in active labor with a breech presentation requiring emergency cesarean delivery. She required endoscopic esophageal varices banding during the second trimester of pregnancy. After correction of her coagulopathy, she was administered subarachnoid block and cesarean delivery, which was conducted uneventfully. Anesthetic management of these patients depends on understanding and avoiding variceal hemorrhage, encephalopathy, renal failure, and careful fluid and electrolyte management.

[Anaesthesia in elderly people]

The "perioperative" period for elderly patients is prone to a significant level of morbidity and mortality. Chronological age and comorbidities are the main causes of mortality. Loco-regional anaesthesia is used in 50% of cases. When general anaesthesia is used, invasive monitoring is the rule, with titration of medication and pain treatment. Cognitive dysfunctions are related to age rather than the anaesthetic technique. The aim is for early rehabilitation perhaps through ambulatory care.

Ventricular assist devices and anesthetic implications for noncardiac procedures

Approximately 5 million Americans experience heart failure, which affects 10 in every 1000 people older than 65 years. Ventricular assist devices (VADs) are a type of mechanical circulatory support that aids in systemic perfusion by maintaining unidirectional flow while reducing the oxygen demand of the failing ventricle. There are 3 generations of VADs in circulation used as a bridge to transplantation, a bridge to recovery, or as destination therapy. Due to the increasing use of these devices, it is likely that anesthetists will encounter patients with these devices more frequently, which requires adequate preoperative discussion with the care team. Intraoperatively, it is important to realize that patients with VADs are at higher risk for aspiration, to recognize electromagnetic interference from surgical devices, to maintain hemodynamic stability, and to monitor coagulation status. With proper knowledge, and adequate preoperative preparation and intraoperative care, anesthetists should be able to achieve safe and successful patient outcomes through anesthesia care.

Bilateral tension pneumothoraces and subcutaneous emphysema following colonoscopic polypectomy: a case report and discussion of anesthesia considerations

A 78-year-old man presented preoperatively with severe abdominal pain, dyspnea, and subcutaneous emphysema in his face, neck, and chest approximately 8 hours after colonoscopy with a sigmoid polypectomy. A pneumoperitoneum, free air in the mesentery, pneumoretroperitoneum, pneumomediastinum, and bilateral pneumothoraces were diagnosed using radiography and computed axial tomography. He emergently underwent an exploratory laparotomy with colostomy following bilateral chest tube placement. At laparotomy, a perforation of the posterior sigmoid colon was identified at the site of earlier polypectomy. The patient remained intubated and mechanically ventilated for 3 days postoperatively. Perforations of the colon during colonoscopies are the most serious complication of the procedure. Continued insufflation of air or carbon dioxide into a perforated colon can result in extraluminal gas that can result in life-threatening tension pneumothoraces. This case examines the consequences of colonic perforation and the anesthetic management for the definitive surgical treatment of a posterior sigmoid wall perforation. Anesthesia providers' awareness of the risk factors for colonic perforation due to colonoscopy, early signs and symptoms of perforation, and knowledge of the surgical and anesthetic management of perforation could lead to early recognition and intervention and likely to improved patient outcomes.

The differences of anaesthetic care in paediatrics compared to adults

In the study of holistic perspectives in perioperative care the following article focuses on the care required for paediatric patients through the perioperative period. This incorporates an understanding of the anatomical, physiological and pharmacological differences from adult practice, acknowledging the most important principles of patient safety. The planning, implementation, equipment adaptations and psychological challenges associated with this group will be discussed in relation to improving the overall perioperative experience.

Cystic fibrosis: a systems review

Cystic fibrosis (CF) is a fatal genetic disorder that affects many organ systems in the body. Historically, few patients with CF lived beyond early childhood, but with continuous improvement in treatment modalities, quality of life and the life span of persons with CF has greatly improved. As the surviving population of people with CF increases, a greater chance of encountering them in anesthesia practice exists. Comorbidities associated with the disease, such as diabetes mellitus and osteopenia, may also contribute to an increased frequency of surgical and anesthetic encounters. An understanding of the pathophysiology of the disease, as well as anesthetic implications and management, is crucial to the safe administration of anesthesia in this population. Cystic fibrosis is traditionally thought of as a childhood disease affecting the lungs and pancreas, which does not accurately describe the disease in its entirety. Many organ systems are affected, from the heart and lungs to the reproductive system, and may warrant alterations in an anesthetic plan. This review highlights the pathologic conditions associated with multiple systems, therapy regimens, and potential complications and suggests anesthetic implications.

[Ambulatory anaesthesia, beneficial for children]

The advantages of ambulatory surgery and anaesthesia are widely recognised. Apart from their interest in terms of reducing hospital costs, they are overwhelmingly preferred by patients. Of all patients, it is children who can benefit the most.

A model for utilization of academic resources: the Philadelphia area nurse anesthesia educational programs' shared curriculum consortium

Educational consortiums possess significant academic and financial benefits. A faculty shortage has had an impact on subspecialty educational programs including nurse anesthesia. This column describes a collaborative "consortium" model of 3 individual nurse anesthesia educational programs located in the Philadelphia, Pennsylvania, area. The Philadelphia Area Nurse Anesthesia Educational Programs' Shared Curriculum Consortium provides high quality, didactic education; decreased overall program administrative costs; and offers each participating program the ability to explore opportunities for continued growth.

A survey of post anesthetic pain management in Thailand

OBJECTIVES

The Royal College of Anesthesiologists of Thailand aimed to study status of post anesthetic pain management to determine factors for quality improvement of anesthesia services in Thailand.

MATERIAL AND METHOD

A pre-planned structured questionnaire regarding demographic variables, early and late postoperative pain management, establishment of the post anesthesia care unit (PACU) was requested to be filled in by nurse anesthetists attending the refresher course lectures of the Royal College of Anesthesiologists of Thailand in August 2007.

RESULTS

Of 280 questionnaires, 261 respondents (93%) returned the questionnaires. Most of the respondents (94%) worked in government hospitals. One-third practiced in hospitals without an anesthesiologist. Twenty percent of respondents reported absence of PACU in their hospitals. Anesthesia personnel took responsibility of and prescribed pain medication in the PACU in 69% and 55% respectively. Intravenous route was the most frequent mode of pain medication administered Percentages of respondents who reported no post anesthetic pain management guidelines and no record of pain assessment in PACU were 39% and 49% respectively. At the surgical ward, surgeons played major roles for postoperative management (91%) and intramuscular injection was the most preferable route. Seventy-one percent of respondents reported no record of pain assessment.

CONCLUSION

Post anesthetic pain management continues to be undermanaged. Establishment of PACU, increasing the number of anesthesia personnel including MD anesthesiologists, providing clinical guidance for post anesthetic pain management are suggested corrective strategies. Establishment of acute pain service in big hospitals should be promoted

Telephone pre-anaesthesia assessment for ambulatory breast surgery

OBJECTIVE

To review the efficacy of telephone preoperative anaesthesia assessment in patients undergoing ambulatory breast surgery.

DESIGN

Retrospective study.

SETTING

Day Surgery Centre, Tung Wah Hospital, Hong Kong.

PATIENTS

Patients with breast lumps to be excised were seen by dedicated breast surgeons and informed of day procedures and preoperative anaesthesia assessment. Those who fulfilled the selection criteria of age (18-45 years) and American Society of Anesthesiologists grade I were recruited for telephone anaesthesia assessment preoperatively. The patients were contacted by senior day surgery nurses via telephone before the scheduled operation date, and information was retrieved using a standard assessment form. Prospective data from January 2002 to December 2007 were analysed.

MAIN OUTCOME MEASURES

Proportion of patients who successfully underwent day surgery after telephone preoperative anaesthesia assessment.

RESULTS

Of 482 patients receiving ambulatory surgery for breast lumps during the study period, 283 patients were selected for preoperative telephone anaesthesia assessment. Five (2%) patients with problems identified by this method underwent further assessment at the Day Surgery Centre; the remaining 278 (98%) required no further assessment and proceeded to have a successful day surgery procedure.

CONCLUSION

Preoperative anaesthesia assessment by telephone is an effective means of preoperative assessment in selected patients undergoing ambulatory breast surgery.

Semmelweis revisited: hand hygiene and nosocomial disease transmission in the anesthesia workstation

Hospital-acquired infections occur at an alarmingly high frequency, possibly affecting as many as 1 in 10 patients, resulting in a staggering morbidity and an annual mortality of many tens of thousands of patients. Appropriate hand hygiene is highly effective and represents the simplest approach that we have to preventing nosocomial infections. The Agency for Healthcare Research and Quality has targeted hand-washing compliance as a top research agenda item for patient safety. Recent research has identified inadequate hand washing and contaminated anesthesia workstation issues as likely contributors to nosocomial infections, finding aseptic practices highly variable among providers. It is vital that all healthcare providers, including anesthesia providers, appreciate the role of inadequate hand hygiene in nosocomial infection and meticulously follow the mandates of the American Association of Nurse Anesthetists and other professional healthcare organizations.

[Experience of an interdisciplinary anesthesiology and nursing team for providing anesthesia outside the operating room]

OBJECTIVE

To report on the creation and development of an interdisciplinary anesthesiology and nursing team to provide anesthesia outside the operating room.

MATERIAL AND METHODS

We describe the creation of an interdisciplinary team and preanesthesia evaluation protocols for using nurses specializing in anesthesia for procedures outside the operating room. We analyzed the anesthetic procedures performed outside the operating room, the rate of suspensions due to failure of the procedure, and their impact on the rate of associated complications, from October 2006 to October 2007.

RESULTS

Since the start of the project, 586 procedures outside the operating room have been performed. No suspensions or delays were observed that were due to comorbidity not detected in the preanesthesia evaluation carried out by the nurses. The incidences of complications and inadequate sedations were comparable to those reported for other similar interdisciplinary groups in this area.

CONCLUSIONS

The creation of an interdisciplinary team of anesthesiologists and specialized nurses for providing anesthesia outside the operating room optimizes resources and improves routine clinical practice. It has allowed for universal preanesthesia evaluation, improved the distribution of resources, and proven a stimulus to the care-giving process.

Anaesthetic assistant competencies: our experience

The purpose of this article is to share our findings since introducing the recently-developed anaesthetic assistant competencies (NHS Education for Scotland 2006). The term 'anaesthetic assistant' will be used throughout this article to refer to those who support the anaesthetist during anaesthesia. It is in no way meant to be derogatory to any person practising currently in this speciality.

Oxygen: the two-faced elixir of life

Take a moment and consider our planet without oxygen. Imagine the earth some 2.5 billion years ago when oxygen first appeared as a waste product of early anaerobes. Oxygen, as we know it today, is essential for life. Abundant and relatively inexpensive to manufacture, oxygen has widespread use in industry and healthcare. Anesthesia providers routinely administer oxygen in concentrations exceeding that in ambient air to ensure clinical safety and to offset the predictable sequelae associated with patient, drug-related, and procedural factors. Understanding the history of this unique element is critical in evaluating the often contentious body of contemporary research that has illuminated its efficacy (as elixir) and its attendant complications (its "two-faced" nature). Of particular interest is its role in free radical formation as etiogenic in developing complications. Oxygen is a mainstay in the perioperative management of patients, but its administration should be guided by thoughtful and rational goal-directed outcomes to maximize efficacy and minimize complications associated with its use.

Body piercing and airway management: photo guide to tongue jewelry removal techniques

Body modification has been practiced in cultures around the world for thousands of years. The ramifications of body piercing on anesthesia practice and airway management have become more evident in recent years. This article reviews the techniques for removal of tongue jewelry and options for maintaining oral piercing patency. To remove or not to remove...that is the question. In the emergency medicine and anesthesia literature, there are arguments both for and against the routine removal of oral jewelry for intubation. Some practitioners feel that if people can eat, drink, talk, and sleep with the jewelry in place, they probably can be intubated safely without removing it. Most case reports present the opinion that tongue jewelry should be removed before oral intubation to minimize jewelry aspiration, bleeding, and medical-legal risks to the anesthetist. This article's focus is to illustrate suggested tongue jewelry removal techniques for awake and unconscious patients from the health practitioner's and body piercer's perspectives.

CRNA performance using a handheld, computerized, decision-making aid during critical events in a simulated environment: a methodologic inquiry

Directives to improve patient outcomes and enhance safety within the healthcare system have led to development of technologies to assist practitioners in a variety of activities. The purpose of this study was to explore and evaluate a method for examining the effect of computer-assisted decision making (CADM) using a handheld device on the accuracy (ie, correct diagnosis and treatment) and speed of problem solving by Certified Registered Nurse Anesthetists (CRNAs) during simulated critical patient-care events. A randomized crossover design with matched-pair sampling was used. In a high-fidelity human simulation environment, 4 CRNAs participated in 2 plausible critical anesthesia case scenarios. CRNA performance with and without CADM technology, environmental authenticity, and reliability and validity of data collection tools and simulated case scenarios were evaluated. Time to correct diagnosis and treatment varied by scenario, taking less time with CADM for one but more with CADM for the other, likely due to differences in pace, intensity, and conduct of the 2 scenarios. We believe this study supports further exploration and application of CADM in complex patient scenarios involving anesthesia practitioners. Affirmation of environmental authenticity also validates the high-fidelity human simulation environment as an appropriate setting to conduct research in this area.

Care of the child undergoing an examination under anesthesia for retinoblastoma

In conclusion, the welfare of the child is of paramount importance in the detection and treatment ofretinoblastoma. It is important for the parents to feel comfortable with the care their child is receiving since they are facing a lengthy course of therapy. Consequently, the family will require the support of the entire ambulatory surgical daycare team for years to come.

Anaesthesia for day surgery

The Department of Health (DH) proposes that 75% of elective surgery should be performed as a day case procedure (NHS Plan 2000). To achieve this some modification of the traditional selection criteria may be required and careful thought given to the patient pathway, including the anaesthetic technique. Successful anaesthesia for day case surgery requires a balanced anaesthetic technique and multidisciplinary input which commences at booking, runs through preoperative assessment and continues to a nurse-led discharge. Suitable patients need to be selected (Digner 2007), prepared both physically and psychologically, undergo minimally invasive surgery with a suitable anaesthetic technique encompassing good pain relief and the avoidance of postoperative nausea and vomiting (PONV). Pain and PONV are the most common causes for a patient to require unplanned admission (Junger 2001).

Closed claims studies in anesthesia: a literature review and implications for practice

Historically, closed malpractice claims have been used to identify and examine potential causes for adverse anesthesia outcomes. In the United States, the American Association of Nurse Anesthetists and the American Society of Anesthesiologists have compiled and analyzed such data. In all claims filed, respiratory events were most common, and the most common outcome class was brain damage or death. These findings and others led to improved practice standards, including end-tidal carbon dioxide and pulse oximetry monitoring. Although some researchers have cited closed claims studies as evidence of anesthesia risk trends, the nature of the data makes it inappropriate for calculation or comparison of risk. Further work is needed to elucidate some mechanisms of injury and to develop interventions to maximize patient safety.

Anesthetic implications for surgical correction of scoliosis

Patients undergoing surgical correction of scoliosis present many challenges to anesthetists because of the pathophysiologic derangements caused by the disease and the demanding nature of the anesthetic care that is required. A thorough understanding of the pathophysiology of the disease, intraoperative concerns specific to the procedure, and the efficacy of various anesthetic management techniques is required by anesthetists to optimally care for patients undergoing surgical correction of scoliosis. This literature review focuses on key considerations for anesthetists, including common comorbidities in patients with scoliosis, the need for induced hypotension, large surgical blood loss, the need for transfusion of blood and blood products, possible autologous blood donation and acute normovolemic hemodilution, patient positioning, possible intraoperative wake-up testing to assess motor function, spinal cord monitoring, and hypothermia.

Update for nurse anesthetists--part 3--cyclodextrin introduction to anesthesia practice: form, function, and application

Cyclodextrins, some of the select molecules exhibiting properties that are beneficial across multiple industries, are naturally occurring cyclical oligosaccharides with a lipophilic inner cavity and a hydrophilic exterior. These characteristics enable cyclodextrins to surround and bind lipophilic molecules while maintaining aqueous solubility. Agrochemistry, analytical chemistry, food, nutraceutical, and pharmaceutical industries have benefited and continue to benefit from these unique molecular properties. Though known and studied for more than 100 years, cyclodextrins have only recently been explored for specific application to anesthesia. Numerous studies exploring cyclodextrin-improved anesthetic delivery are underway. This new class of enabling molecules will enter the anesthetic arena and will require an understanding of their form, function, and application. This knowledge will facilitate anesthesia providers' optimal use of these unique molecules and the safety and efficacy associated with them.

Update for nurse anesthetists. Anesthetic implications for cancer chemotherapy

Cancer is one of the most prevalent disease processes affecting people of all ages. Cancer is the second most common cause of death in the United States, exceeded only by heart disease. Cancer survival is dependent on treatment options that may include surgery, radiation, and chemotherapy. Chemotherapy, or systemic cancer therapy, is designed to promote cell death during different phases of cell growth and division. Unfortunately, chemotherapeutic agents cannot differentiate between malignant and normal cells. Therefore, the toxic effects of chemotherapy are also seen in healthy organs and tissues. In addition, chemotherapeutic agents can interact with other medications. The effects of chemotherapy may be acute and self-limiting or chronic and present long after treatment has been completed. Patients who have had chemotherapy often undergo surgery that may or may not be related to their cancer. Chemotherapy administration can have a profound influence on anesthetic management. Safe administration of anesthesia includes knowledge of chemotherapeutic agents and their toxic effects. This course discusses the anatomic and physiologic effects of cancer chemotherapeutic agents and how they specifically affect patients receiving anesthesia.

Checking the anaesthetic machine

Making sure that anaesthetic equipment is working correctly is an essential part of the anaesthetic practitioner's role. During induction of anaesthesia the patient is at one of the most vulnerable points in his or her perioperative care. This is the point at which equipment error may put the patient at high risk of harm, for example, through compromising the airway, causing circulatory problems, preventing satisfactory oxygenation or even causing death. Many writers have drawn comparisons between anaesthesia and aviation, with the suggestion that practitioners should check the anaesthetic machines using a 'cockpit drill' (Ranasinghe 2000). The purpose of this detailed check is to ensure the machine is safe to use. The careful attention to the check is a reflection of good practice which the practitioner's codes of professional practice demand (HPC 2004, NMC 2004). This article discusses the importance of following the anaesthetic checklist to the recommended standards for both the practitioner and the patient.

The perioperative implications of obstructive sleep apnea

Patients with obstructive sleep apnea provide significant challenges to the perioperative team. This disorder is often undiagnosed and coexists with other disease processes such as hypertension, congestive heart failure, and cor pulmonale. The prevalence of obesity in American society suggests that an increasing number of patients with sleep apnea will present for surgery. During the perioperative period, life-threatening problems can occur during anesthetic induction and emergence. The pathophysiology of obstructive sleep apnea is reviewed here along with the anesthesia implications of this disease process. Members of the perioperative team need to be aware of the implications of sleep apnea so that surgical outcomes can be optimized.

Update for nurse anesthetists--pt 4. Itching, the "little" big problem as an orphan symptom

The phenomenon of itching has received surprisingly little scientific scrutiny despite its commonality--hence its designation as a kind of neglected, "orphan symptom." Recent research and clinical understanding has shed light on itching, helping to illuminate its previously shaded landscape. This course reviews the nature of itching, its physiology, major triggers of particular interest to anesthetists (especially when using neuraxial agents), and interventions directed at its resolution. A variety of chemical mediators and modulators have important roles in the genesis and experience of itching. Although many medical comorbidities can cause itch, the ubiquitous use of neuraxial opioids in the perioperative care of patients has been attended by a dramatic increase in the number of patients experiencing, and complaining of, itching as a consequence of our management. Patient satisfaction inventories have placed the sensation of refractory itch among the most distressing, non-life-threatening complications that are experienced. Intractable itch can be so incapacitating that it deserves the same degree of clinical attention as pain.

Quality Review in Anesthesia: then, now, and the future

The Quality Review in Anesthesia (QRIA) newsletter is a significant, evolving resource to the Certified Registered Nurse Anesthetist (CRNA) in clinical practice. Since its inception in 1997, the newsletter has been modified to meet the changing needs of anesthesia practice. The goal of the newsletter is improvement in patient care and risk avoidance by keeping CRNAs abreast of the latest changes in risk management, quality assurance, and malpractice concerns. By incorporating reports of patient safety adverse events, it is anticipated CRNAs will better understand the need for compliance and adherence to the standards of care. A chronological history of the development of the QRIA newsletter is provided. The methodology of how an article is conceived, reviewed, and published is presented so the CRNA can appreciate the mechanisms involved in putting together each publication. The QRIA newsletter now has a chronological and alphabetical index on the AANA website. This electronic format allows the CRNA to access articles that might be of special interest to a certain aspects of practice. Each issue of QRIA is planned carefully to meet the needs of the CRNA and is offered as a valuable membership service.

Aortic stenosis: A review

The prevalence of aortic stenosis has been increasing in recent decades, and nurse anesthetists are more likely to encounter this problem as the population ages. Fortunately, the widespread use of echocardiography has expanded our understanding of valvular heart disease. The purpose of this course is to evaluate the current literature regarding aortic stenosis with a focus on anesthetic management. The 2 most common causes of aortic stenosis are calcific tricuspid disease and congenital bicuspid valves. An inflammatory, atherosclerotic disease process also has been identified in aortic stenosis. Patients with aortic stenosis are at high risk for perioperative cardiac complications. Anesthetic management often includes invasive hemodynamic monitoring and carefully tailored anesthetic techniques.

[Survey of nursing roles in anesthesiology, postoperative recovery care and pain management in Catalonia, Spain: analysis of the current situation]

OBJECTIVE

To determine nursing functions in anesthesiology, postoperative recovery care, and pain management in Catalan hospitals and to analyze the roles of nurses in this specialty.

METHODS

Development of a mail questionnaire sent to 70 public and private hospitals in Catalonia, to be filled in and returned separately by the nursing supervisor and by the anesthesiology department of each hospital. The survey included questions on whether tasks were or were not carried out by nurses.

RESULTS

Responses were received from 31% of nursing supervisors and 45% of anesthesiology departments. Only 22% of the hospitals employed nursing staff with duties exclusively in the anesthesiology department. Nurses took on more responsibilities in major outpatient surgery services and postanesthetic recovery care units than in other areas. Significant discrepancies were found between answers given by nursing supervisors and those returned by anesthesiology departments regarding tasks of nurses in this specialty. Items with the greatest agreement were those related to maintenance of material. Those with the lowest agreement were related to drug management.

CONCLUSIONS

Although responses came from only a third of the target population, the information obtained suggests a lack of definition in Spain of nursing tasks in the field of anesthesiology. This situation is different from that of most European countries and of the United States of America.

Update for nurse anesthetists. Eisenmenger syndrome: an anesthetic conundrum

Eisenmenger syndrome is an insidious disease entity. This disease is characterized by an unrepaired congenital heart defect and left-to-right cardiac shunting. After many years of increased blood flow through the pulmonary system as a result of the shunting, damage to the pulmonary vessels occurs, culminating in severe pulmonary hypertension. The pulmonary hypertension eventually causes the cardiac shunt to reverse direction. The right-to-left shunt results in a very debilitated patient. There is no known medical cure for this disease; the only curative option is heart-lung transplantation or bilateral lung transplantation with repair of the patent heart defect. Because of the great strides in medical care, more patients with Eisenmenger syndrome require anesthesia. Maintaining the patient's systemic vascular resistance at the preoperative level is of paramount importance. Choosing the best anesthesia technique is difficult, at best.

Implications of Obstructive Sleep Apnea Syndrome for the Perianesthesia Nurse

Perianesthesia nurses care for patients who receive anesthesia, sedation, and analgesia. Anesthesia, sedation, and analgesia can adversely affect the patient with obstructive sleep apnea syndrome (OSAS). Increased patient morbidity and mortality have been associated with the perianesthesia management of the patient with OSAS and can potentially impact every phase of the perianesthesia experience. Negative outcomes have been associated with respiratory arrest after the administration of opioid or sedative medications, difficult intubation or failure to intubate, and respiratory obstruction after extubation. It is important for the perianesthesia nurse to identify the implications of OSAS and respond with appropriate patient management strategies. The purpose of this article is to identify perianesthesia implications associated with the patient with formally diagnosed OSAS, patient characteristics that may imply undiagnosed OSAS, and considerations for the management of the patient with OSAS for each phase of the perianesthesia experience. The new ASA practice guidelines developed to assist the practitioner in the decision-making process for the management of this patient population have been incorporated.

Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy

BACKGROUND & AIMS

Propofol has advantages as a sedative for endoscopic procedures. Its administration by anesthesia specialists is associated with high cost. Administration by nonanesthesiologists is controversial because of concerns about safety, particularly respiratory depression.

METHODS

Three endoscopy units developed programs to train registered nurses supervised only by endoscopists in the administration of propofol for endoscopic procedures. The rate of adverse respiratory events was tracked from the inception of the programs. To estimate whether training nurses to give propofol on a widespread basis might be effective, we evaluated the individual safety records of all nurses and endoscopists involved in propofol delivery at the 3 centers.

RESULTS

Among a total of 36,743 cases of nurse-administered propofol sedation (NAPS) at the 3 centers, there were no cases requiring endotracheal intubation or resulting in death, neurologic sequelae, or other permanent injury. The rate of respiratory events requiring assisted ventilation was not significantly different among the 3 centers and ranged from just <1 per 500 cases to just <1 per 1000 cases among the 3 centers. There was no individual nurse or physician for whom the rate of respiratory events requiring assisted ventilation differed from the overall rate of events at the respective centers.

CONCLUSIONS

Trained nurses and endoscopists can administer propofol safely for endoscopic procedures. Nurse-administered propofol sedation is one potential solution to the high cost associated with anesthetist-delivered sedation for endoscopy.