New Things You Want to Learn but Fall Asleep Reading About …
(aka Update! New Advances in Clinical Anesthesia Practice)
Let’s face it, we’re all interested in learning about the “latest and greatest” in clinical anesthesia, but after the long working day, afternoon errands, and family obligations, WE’RE EXHAUSTED! Just as you find that quiet moment to sit down and read, your eyelids simply Refuse. To. Stay. Open…zzzzz
So I’ll give you a brief rundown on what’s happening now with links to explore more details whenever your eyelids can cooperate!
The pure technical nature and number of syllables in these words immediately invoked in me the feeling of “you’re really going to have to focus for this one…” However, once my inner techie discovered that this involves a cool gadget for quantitative monitoring of neuromuscular blockade to more accurately determine residual neuromuscular weakness, I was sold on learning more!
The acceleromyograph is a device that measures muscle acceleration across a joint in response to nerve stimulation. That acceleration correlates with the force of muscle contraction therefore providing a quantitative, objective measure of residual muscle weakness beyond the traditional qualitative, subjective measures typically used.
This concept is not really new, but has been in the works for quite some time. Clinicians have been seeking more accurate ways of measuring residual neuromuscular blockade in an attempt to decrease adverse postoperative events that occur as a result. As with any new technology, it takes time for studies to prove its worthiness, describe its strengths and weaknesses, and produce a device that is affordable and safe for clinical use. For that reason, this device is just beginning to surface in many ORs. My experience with the acceleromyograph is a result of its integration into the newest anesthesia machine our department purchased, the GE Aisys. Other manufacturers are following suit as well.
To embrace your inner techie, you can read more here:
Brull, S. J. & Murphy, G. S. (2010). Residual neuromuscular block: Lessons unlearned. Part I: Definitions, incidence, & adverse physiologic effects of residual neuromuscular block. Anesthesia & Analgesia, 111(1), 120-128. doi: 10.1213/ANE.0b013e3181da832d
The above article is free & available online at http://www.anesthesia-analgesia.org/content/111/1/120.long
Brull, S. J. & Murphy, G. S. (2010). Residual neuromuscular block: Lessons unlearned. Part II: Methods to reduce the risk of residual weakness. Anesthesia & Analgesia, 111(1), 129-140. doi: 10.1213/ANE.0b013e3181da8312
This above article is free & available online at http://www.anesthesia-analgesia.org/content/111/1/129.long
Sandberg, W. S., Urman, R. D., & Ehrenfeld, J.M. (2011). The MGH textbook of anesthetic equipment. Philadelphia: Elsevier Saunders.
IV Ibuprofen – Caldolor
I recently received a visit from our area’s Cumberland Pharmaceuticals rep to hear his plug for IV ibuprofen (trade name Caldolor). I’m always a little skeptical about sales pitches in general but try to be open-minded about the potential of any new drug. Caldolor actually received FDA approval in 2009, but until recently I hadn’t really heard any buzz about it. This leaves me wondering if there is a new wave of sales promotions designed to ride the coat tails of IV acetaminophen’s (Ofirmev) success. Regardless, it seems rational to consider the possibilities. Here are the basics:
- • Indicated for pain and fever in adults
- • Administered pre-op, intra-op, or post-op
- • Dosing: 400mg q 4-6 hours or 800mg q 6 hours
- • Infuse over 30 minutes
- • Added anti-inflammatory benefits of other NSAIDs like ketorolac, but with fewer side effects related to bleeding, gastric upset, and renal issues
Unfortunately, this drug is not on my hospital’s formulary, so I don’t have any personal experience to comment upon. I would love to hear opinions from those who have!
Get the full details and prescribing information at www.caldolor.com.
Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
In healthcare, we all love the mystery of a new abbreviation. This time my curiosity was peaked when one of my students told me about a new “hi-tech” procedure she was involved in (but only briefly involved in because it was potentially dangerous for her, at a childbearing age, to be in the room…..THAT got my attention!).
HIPEC (not “hi-tech” as I thought I heard) is a procedure available to treat advanced abdominal cancers such as peritoneal mesothelioma, pseudomyxoma peritonei, colorectal cancer, and ovarian cancer. This procedure is new to my facility, but has been performed successfully at other leading medical centers across the country.
HIPEC involves surgical exploration, tumor debulking, and application of heated chemotherapy to the peritoneal cavity. The chemotherapy solution is left in the abdomen for 1.5 to 2 hours. This phase of the procedure is referred to as “shake and bake” where the surgeon ensures the chemotherapy solution is evenly distributed throughout the peritoneal space. Confining the chemotherapy to the peritoneal cavity allows for usage of higher concentrations of agents while minimizing systemic toxicity and side effects.
Patient and healthcare provider safety is of utmost concern during this procedure due to the potential exposure to cytotoxic agents. Routes of exposure include: inhalation, contact, ingestion and injection. Essential equipment that should be utilized and/or readily available includes: unpowdered latex gloves, impervious sterile gowns, protective eye wear, respirator mask (if a spill occurs), a spill kit, an impenetrable hazardous waste container, specially marked linen bags and appropriate cytotoxic agent labels.
With regard to providers’ repeated involvement with these cases, Stephens et al (2010) state, “Because the toxicities of low level cumulative exposure are not well defined, personnel who have specific medical concerns should be excluded from the chemotherapy environment. This includes, but is not limited to: pregnant or breastfeeding women, men or women who are planning a family in the near future, personnel with known blood dyscrasias or who are immunocompromised and personnel taking hematologically toxic medications.”
See the full article including anesthesia considerations from Stephens et al at http://www.surgicaloncology.com/hiicman.htm.
Cotte, E., Passot, G., Gilly, F.N. & Glehen, O. (2010). Selection of patients and staging
of peritoneal surface malignancies, World Journal of Gastrointestinal Oncology, 2(1),
31-35. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999158/.
What’s New With You?
I’ve outlined just a few new things I’ve heard about around East Tennessee. What’s new where you are? We’d love to hear your comments!
Julie N. Bonom, CRNA, DNP, APN serves as the TANA District V Director, an educator, and a staff CRNA. She resides just outside of Knoxville with her husband, 3 Doberman Pinschers, and one really old cat.