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VANA Lands End Logo Store!

office — 2011-09-24T20:00:03Z

Now you can promote your professional organization in many different ways. VANA has opened a company store through Lands End where you can order lots of different items all with the official VANA logo!

To visit the store, click here.

No Harm Found When Nurse Anesthetists Work Without Supervision By Physicians

office — 2011-02-02T16:20:00Z

Read about the care provided by CRNAs.

Click Here for Full Article that is downloaded via pdf file.

Myth Busters

office — 2011-02-02T15:00:00Z

Click Here for a great tool to educate individuals about CRNAs.

2012 District 5 Winter Workshop! Feb 11th - Register Today!

office — 2011-01-10T15:25:00Z

The Winter Workshop is set for February 11th. 8 CE's offered! Click Here for more information and to register online.

Anesthetic Management and Surgical Site Infections In Total Hip or Knee Replacement

admin — 2010-10-28T13:10:00Z

Anesthesiology 2010;113:279-284

Chang C-C, Lin H-C, Lin H-W, Lin H-C

Abstract

Purpose The purpose of this study was to determine if subarachnoid block and epidural block were associated with lower rates of Surgical Site Infections than general anesthesia in patients who had total joint replacements.

Background Surgical site infections (SSIs) have been estimated to occur after about 5% of surgeries overall in the USA. Often resulting in additional hospital inpatient days or hospital readmission, SSIs reportedly add four days following breast surgery and 32 days following cardiothoracic surgery. With increased inpatient days comes increased cost, an average of $1,157 per surgical infection. The cost of care following discharge may be even greater.

Surgical site infections develop during the initial hours immediately postoperatively. Risk factors for the development of SSIs include: smoking, obesity, surgical duration, and hyperglycemia. Tissue oxygenation and leukocyte tissue perfusion are thought to be critical factors in whether or not an SSI develops postoperatively. General anesthesia does not block the surgical stress response as completely as can regional anesthesia. Surgical pain also results in sympathetic activation. Sympathetic stimulation and increased circulating catecholamines result in vasoconstriction, reducing circulation to the wound. Reduced wound circulation results in reduced tissue oxygenation and locally reduced leukocyte activity. Furthermore, potent inhaled anesthetics and opioids have been shown to impair neutrophils and other cellular elements of the blood that defend against infection. Subarachnoid and epidural anesthesia typically block sympathetic activation more completely than does general anesthesia, improving tissue perfusion, oxygenation, and leukocyte perfusion. In patients who had major upper abdominal surgery, combined general - epidural anesthesia has been shown to increase tissue oxygenation with an associated reduction in SSIs compared to general anesthesia alone.

Methodology This was a retrospective study of a systematically collected “Longitudinal Health Insurance Database,” available to Taiwanese researchers. A randomly selected subset of the database was used for this study. The investigators identified 3,081 patients who had either total hip (n=951) or total knee (n=2,130) replacements during a five year period. Of these surgical patients, 1,191 received general anesthesia and 1,890 either subarachnoid block (n=1,281) or epidural block (n=609). A postoperative SSI included infections, cellulitis, and abscesses either during hospitalization or after discharge but within 30 days of hospital admission.

Result The mean age of all patients was 62.6 years. On average, patients who received regional anesthesia were about 2 years older than general anesthesia patients. Regional anesthesia patients were also more likely to have hypertension, diabetes, hyperlipidemia, and coronary artery disease. Those who received general anesthesia were more likely to have had surgery at a teaching hospital. Patients who had a general anesthetic for their total joint replacement were 2.21 times more likely (95% CI 1.25 – 3.90) to have an SSI compared to patients who had a subarachnoid block or epidural block. (Adjusted for comorbidities; the unadjusted risk for general anesthesia patients was 2.31.)

Surgical Site Infection	All Patients	General Anesthesia	Regional
Anesthesia
YES	1.8 %	2.8 %	1.2 %
NO	98.2 %	97.2%	98.8 %

Data from Anesthesiology 2010;113:279 table 2. * P = 0.002 compared to general anesthesia.

Comment

This very simple study has a lot to teach us. While it does have limitations, from a common sense point of view, they were unlikely to have blurred the overall outcome and the study was reasonably adjusted for many of them. This is a big picture sort of study, not a bunch of minutia. And the big picture is that a spinal or epidural alone for your total hip or knee replacement cuts your risk of a surgical site infection in half.

There are lots of reasons we donʼt do more total joints with regional anesthesia but, in my opinion, the reasons we donʼt arenʼt nearly as good as the reasons we should. Iʼm not going to address each one of them, but I am going to make my case for a patient care reason and a financial reason we should make regional anesthesia our first choice for total knee and total hip replacements. First, these patients have much better pain control and better surgical recovery when their total joint is done with a regional anesthetic. This is good patient care. Second, while regional anesthesia is often not used because “it takes too long” we must look at the total cost of care, not just the time to get the case started. In addition to the morbidity caused by postoperative infections, wound infections dramatically increase the cost of a total joint. If a regional anesthetic costs a little bit more for a few additional minutes of anesthesia time, it will, overall, be more than made up for by the lower cost of not having to treat twice as many infections. That is good financial management in a time of shrinking healthcare dollars (good patient care too).

While it would be easy to criticize this study for being retrospective, a prospective version would be hard to conduct for many reasons. One big reason is that most patients, and surgeons, have a strong idea of whether they want regional or general anesthesia and getting all to agree to have their anesthetic randomize might prove difficult.

This study is just one reason why all anesthesia providers need to be skilled in regional anesthesia and sedation techniques. And why anesthesia practice needs to be based upon evidence rather than simple surgeonʼs preference, anesthesia provider convenience, an OR that is behind schedule, or the inability to coordinate care between services.

Michael Fiedler, PhD, CRNA

2010 Rock N Roll 1/2 Marathon! CRNAs Rock!

office — 2010-09-02T14:25:00Z

Click Here for Details!

VANA's 2010 Fall Conference - Hilton Virginia Beach, October 16-17th!

office — 2010-08-02T19:30:00Z

For More Information Click Here

Risk of pulmonary aspiration with laryngeal mask airway and tracheal tube

sblanchard — 2010-03-06T04:20:00Z

Anaesthesia 2009;64:1289-1294

Bernardini A, Natalini G

Abstract

Purpose            The purpose of this study was to test the hypothesis that pulmonary aspiration of gastric contents was more likely when the airway was managed with an LMA than an endotracheal tube when patients were mechanically ventilated.

Background            The Laryngeal Mask Airway (LMA) has a number of advantages over an endotracheal tube and it can be useful in the management of a difficult airway when ventilation through a facemask is difficult. Nevertheless, the LMA does not seal the trachea against entry of gastric contents as well as an endotracheal tube (ETT). Positive pressure ventilation may result in gastric inflation and increase the risk of regurgitation and aspiration during LMA use. There is, however, little evidence about the actual risk of pulmonary aspiration with an LMA vs. an ETT during mechanical ventilation. Criteria considered to contraindicate the use of an LMA are based primarily on opinion and not on evidence.

The overall incidence of pulmonary aspiration (all types of airway management) has been reported to be between 1 in 3,216 and 1 in 14,139 general anesthetics.

Methodology            This retrospective study examined data in a preexisting quality improvement database. Data had been collected over a 10+ year period. Records were included in the analysis if either an LMA or ETT was used during a general anesthetic with mechanical ventilation. The selection of an LMA for airway management was driven by locally accepted contraindications to LMA use including: patients who were not NPO, intestinal obstruction, pregnancy, procedures involving the airway, and prone position. An LMA was occasionally used when one or more of these contraindications were present in a difficult airway situation.

Default volume controlled ventilator settings were tidal volume 8 – 10 mL / kg with respiratory rate adjusted according to the end tidal CO2. Surgical procedures included major abdominal, urologic, gynecologic, retroperitoneal, and laparoscopic surgery. Pulmonary aspiration of gastric contents was defined as the presence of gastric contents or bilious fluid in tracheal aspirate; bilious fluid on the LMA or in the oropharynx; or postoperative dyspnea, hypoxia, or “auscultatory abnormalities.” When a case of aspiration was identified in the quality improvement database the original chart was reviewed to verify the data.

Result            Slightly over 1,000,000 cases were contained in the database. Of those, 65,712 met the criteria for inclusion; general anesthesia and mechanical ventilation with either an LMA or ETT. Of those, 2,517 were major abdominal surgery or laparoscopy performed with an LMA. The airway was managed with an LMA in 1.7% of cases in which a contraindication to LMA use was present.

Aspiration occurred in 10 cases. Of these, 4 occurred during an elective procedure; 2 with an LMA and 2 with an ETT. The other 6 occurred during a non-elective procedure; 1 with an LMA. Only 2 of these patients were admitted to intensive care due to aspiration related problems; 1 of the ICU admissions was an LMA patient and 1 was an ETT patient. The occurrence of pulmonary aspiration in patients whose airway was managed with an LMA and mechanical ventilation was no different than those whose airway was managed with an ETT (odds ratio 95% confidence interval 0.09-1.4; P=0.141). The power of the study (the probability of rejecting the hypothesis when it is false) was calculated after the fact to be 0.69.

The primary factor associated with pulmonary aspiration was emergency surgery, not the airway management device. The overall incidence of aspiration was 1 in 6,571 anesthetics.

Conclusion            The incidence of pulmonary aspiration was no greater when an LMA was used than when an ETT was used during general anesthesia with mechanical ventilation. Institutional contraindications to LMA use may have influenced the results.

Comment

The focus of this study was the risk of aspiration when mechanical ventilation was used with an LMA. Accepted contraindications to LMA use were observed. The study was not about the risk of using an LMA for any and every case. It was about the added risk (if there is any) of using mechanical ventilation with an LMA. I’m glad to see this question addressed. Many of my colleagues are hesitant to use a ventilator with an LMA, yet manually bagging with an LMA is fine. Both are positive pressure ventilation. If our concern is insufflating the stomach with air it can happen with either method of ventilation. In my view, it is all about technique. I sometimes use mechanical ventilation with an LMA but I don’t use the ventilator the same way I’d use it with an ETT. I take care, for example, to keep peak pressures below 20 cm H2O. This study indicated that there may not be any increased risk of aspiration when mechanical ventilation is used with an LMA (see limitations in the following paragraphs). While I’m not ready to use an LMA as widely as this group apparently did, I do believe that with proper technique mechanical ventilation can safely be used with an LMA.

While the study is retrospective, it is unlikely it could have been conducted any other way, and, as such, it is probably nearly the best we are going to get. As retrospective studies go, this was a good one. Most retrospective studies are not based upon a detailed quality improvement database. The authors also took the wise step of reviewing the charts of all patients identified by the QI database as having experienced pulmonary aspiration. And, it has the advantage of including a large number of patients, especially important for a relatively low frequency event such as aspiration. Still, few aspirations were detected and there may have been a true difference in the aspiration rate that was undetectable as a result. Based upon the detailed statistical tests they reported and, in my judgment, one error in analysis, I believe there is a reasonable chance that the actual incidence of pulmonary aspiration may have been greater with the LMA than with an ETT (see note following).

The investigators rightly point out that the QI database may not have detected all cases of aspiration because complications were reported to the database by the anesthesiologist caring for the patient. Self reporting tends to underestimate the incidence of a complication because the clinician unconsciously gives themself the benefit of the doubt and because reporting can get put off until later and forgotten.

While it has a couple limitations, this study is important and enlightening because it is generally well done and encompasses a very large group of patients. The institution where this study was conducted does a great service by taking the time and effort to maintain a detailed quality improvement (QI) database for over a decade. Without it, this study would not have been possible.

Michael Fiedler, PhD, CRNA

NOTE: The upper boundary of the adjusted odds ratio 95% CI of the risk of aspiration with an LMA was 5.62 times greater than an ETT. A one sided test was used to calculate the power of the study.

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 12, December 31, 2009

Propofol Shortage Update

sblanchard — 2010-02-13T12:45:00Z

Click this link for Update

January 24-30th is National Nurse Anesthetists Week!

office — 2010-01-21T00:53:24Z

Celebrate YOUR profession! Plan to join your fellow CRNAs in Virginia for Lobby Day on Wednesday, January 27th.

For other ideas on how you can promote CRNAs at your place of work, click on the following link: http://www.aana.com/nnawpublic.aspx

Important Propofol Update!

sblanchard — 2009-11-19T03:44:39Z

For Immediate Release
November 17, 2009

FDA News on Propofol Injection Shortage

Dear Colleague,

As part of its efforts to resolve a critical shortage of propofol 1 percent injection products, FDA has authorized the importation of Fresenius Propoven 1 percent injection from the European Union, until such time that sources within the United States are capable of meeting local demand. View the Propofol Importation Statement.

A Dear Healthcare Professional letter from APP Pharmaceuticals, A Company of the Fresenius Kabi Group, is being distributed with the product and will be posted on the FDA website; a copy of the letter is attached.

Updated information can be obtained at the following FDA website.

Healthcare professionals may report serious adverse events (side effects) concerning drug products to the FDA's MedWatch Adverse Event Reporting program either online, by regular mail, fax or phone. Please include the name of the product, the manufacturer, and lot number (if known).

Online: MedWatch Online Voluntary Reporting Form (3500)
Regular Mail: Download postage-paid FDA Form 3500 and mail to MedWatch, 5600 Fishers Lane, Rockville, MD 20852-9787
Fax: (800) FDA-0178
Phone: (800) FDA-1088

Sincerely,

Beth Fritsch, RPh, MBA
Office of Special Health Issues
Food and Drug Administration
Beth.Fritsch@fda.hhs.gov

Anthem Reimbursement Issue Resolved!

sblanchard — 2009-11-09T02:18:54Z

VANA is working for you. This is an update on reimbursement issue affecting CRNAs all over the state. Click here to read more...

Contact information regarding Propofol Shortage

sblanchard — 2009-11-08T00:43:18Z

11/2/2009

APP (1-888-386-1300) and Teva Pharmaceuticals (1-800-545-8800) report a shortage of propofol injection 10 mg/mL, 20 mL vials (25s), 50 mL vials (20s), and 100 mL vials (10s) shortage due to increased demand. APP is allocating propofol supplies and currently hasDiprivan (propofol) 20, 50, and 100 mL vials and 20, 50, and 100 mL Novaplus vials available. Teva plans to have new propofol production available in December 2009. A recent recall of specific propofol lots manufactured by Hospira Pharmaceuticals (1-877-946-7747) has contributed to increased demand. Hospira has addressed this issue and expects to have new production available by mid-November 2009.

Propofol Shortage Hits Nationwide

sblanchard — 2009-11-08T00:05:00Z

Hospitals Hit with Propofol Shortage

Adam Marcus

Medical centers nationwide are feeling the pinch on propofol in the wake of recalls by two manufacturers of generic forms of the sedative.

The recalls involve propofol manufactured by Teva Pharmaceuticals and Hospira dating as far back as July. Although stemming from different reasons, the actions have led to a shortage of propofol that is forcing hospitals to ration their use of the drug and to use alternative medications for procedures ranging from surgery to sedation in the intensive care unit.

One hospital in Rochester, N.Y., for example, said its supply of propofol will run out in less than 10 days. The facility is calling on its anesthesiologists to cut back on their use of the drug by switching to an alternative induction agent such as methohexital (Brevital, JHP), etomidate or sevoflurane; avoiding propofol for “marginal indications” like general anesthesia, reducing postoperative nausea and for patients undergoing prolonged intubations; and by substituting other drugs—fentanyl, midazolam, dexmedetomidine (Precedex, Hospira)—for monitored anesthesia care.

The hospital also admonished its physicians to be parsimonious with the drug, which must be used or thrown out within six hours of the vial being opened: “Please do not draw it up until you are certain of use.”

At Thomas Jefferson University Hospital in Philadelphia on Wednesday, propofol was not to be found in the ICU, said Eugene Viscusi, MD, director of regional anesthesia and acute pain management at the institution. “Propofol is our most widely used sedation agent in the ICU setting,” Dr. Viscusi said. “Today on rounds I saw no propofol there so it has already impacted practice. Not too much effect in the OR here, at least yet,” he added.

Judith Jacobi, PharmD, a critical care pharmacist at Methodist Hospital/Clarian Health, in Indianapolis, and incoming president of the Society of Critical Care Medicine, said her facility is “soon to be in crisis on this. We have not made a definite plan, though,” Dr. Jacobi added. “We have alternatives and will need to use them.”

Double-Hit

The shortage is the result of a double-hit in the supply of propofol in the United States. Teva recalled approximately 57,000 vials of its propofol solution in mid-July, after at least 41 patients who received the drug fell ill with flu-like symptoms. The company announced that it had discovered high levels of endotoxin in vials of the sedative pulled from the affected lots. The company did not provide answers to questions about its recall by the time this article went to press.

The Hospira action was more recent. The company notified its customers on Oct. 16 that it was recalling batches of propofol and Liposyn, an IV fat emulsion with which propofol is administered, after discovering metal particles in the products.

Dan Rosenberg, a spokesman for the Lake Forest, Ill.-based company, said the recalled lots were manufactured between August and October. “We’ve identified the source as stainless steel equipment used in the manufacturing process,” added Mr. Rosenberg, who said the company has received no reports of harm to patients linked to the affected drugs. (Supplies of another Hospira anesthetic, thiopental [Pentothal], also are short because of manufacturing issues, according to the company, which expects to resume shipping the drug early next year. Mr. Rosenberg said the problems with the two agents are unrelated.)

Mr. Rosenberg said the company has taken “corrective action” to address the manufacturing flaw. “What we’re telling our customers is, we expect to have replacement product soon.”

That would be welcome news to Thomas Van Hassel, MS, RPh, director of pharmacy at Yuma Regional Medical Center, in Yuma, Ariz.

“This is a critical problem for us all,” Mr. Van Hassel said. “A shortage of this nature requires immediate attention by every pharmacy director or clinical staff to address work-around and to obtain adequate supplies of alternative agents. It seems drug shortages of this type are cropping into our normal workflows on a rather regular basis,” Mr. Van Hassel added. “The agent involved changes, but the grief it causes doesn’t seem to get any easier.”

Hospira may benefit from its propofol recall. Several experts interviewed for this article said they have been or would consider using dexmedetomidine instead of propofol for sedation. Dexmedetomidine costs roughly four to five times as much as propofol, Mr. Van Hassel said.

To see this article on the website click: Pharmacy Practice News

2009 District 5 Winter Workshop - Great Success

office — 2009-06-01T19:50:00Z

In February, District 5 hosted the annual Winter Workshop Conference at its new location, The Virginia Crossings Resort, located in Glenn Allen. About 153 CRNA’s and students attended the day conference and many stayed for a lovely wine and cheese reception that followed. Thank you to all that attended. I believe everyone enjoyed seeing old friends and the opportunity to reconnect. I can not say enough about the luxurious atmosphere at this incredible estate. The Virginia Crossings Resort offers golf, hiking, a spa and much more. Please check it out at www.wyndhamvirginiacrossings.com. You may want to stay all weekend for next year’s conference. Many thanks to our Winter Workshop committee members who faithfully and passionately choose dynamic speakers each year. Fun raffles and entertaining vendors are combined with great food and friends. Thanks to the committee members for an elegant and informative day.

Robin Blanchard, CRNA, MSNA

District 5 Director