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UND Nurse Anesthesia

Student Presentations

2013 Fall Educational MeetingNorth Dakota Association of Nurse Anesthetists

Bismarck, ND

Herbal Medicines and their Effect on Anesthesia and Perioperative Care

Jenni Cross, SRNA

Introduction & Statement of Problem

• Since the 1990’s, the use of herbal medicines has increased dramatically with the number of people using these supplements growing at a rate of approximately 20% each year (Messina, 2006).

• It is estimated that 22-60% of adult surgical patients use some form of herbal medicine.

• Use of these medicines are not disclosed to medical providers up to 70% of the time (Gray & West, 2012).

• Some of the risks associated with herbal supplements include hypertension, prolonged bleeding and the potential for drug-herb interactions.

Purpose

• Examine some of the commonly used herbs that have the most potential for interactions and complications during the perioperative period.

• Review the surgical and anesthetic implications involved.

• Disseminate the information to CRNAs and SRNAs, increasing their knowledge regarding herbal medicines and how they can affect anesthesia.

Significance

• The use of herbal medicines is increasing significantly in the United States.

• Lack of regulation by the FDA, uneducated consumers and CRNAs, and failure to inform healthcare providers and anesthesia providers leads to possible risks perioperatively.

• Approximately 11% of surgical patients who use herbal supplements have had complications during surgery (Messina, 2006).

• A study by Temple, Fagerland and Saewyc (2005) found the mean knowledge score of adverse interactions of herbal supplements by CRNAs was 21% and only 17% of CRNAs indicated confidence in their familiarity with herbal-supplement anesthesia interactions.

Research Questions

• What effect do herbal medicines have on anesthesia and perioperative care?

• What are some of the most commonly used herbal medicines that would impact anesthesia and what are the risks involved?

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Framework

• Orem’s Self-Care Deficit Theory

– Describes how people care for themselves and encourages people to take good care of themselves and their families.

– A person's knowledge of potential health problems is needed for promoting self-care behaviors.

– By taking herbal supplements, people are performing self-care.

• People believe by using herbal supplements, they are enhancing their health.

Overview of Methods

• Electronic literature reviews were performed utilizing Cochrane Reviews and the Harley French Library.

• Harley French Online Library was used to access search engines including PubMed and CINAHL. – Once articles were identified as pertinent,

similar articles were reviewed for pertinence.

Problems with the Research

• Herbal medicines are not regulated by the FDA therefore, research studies and clinical trials are not required.– Due to this lack of regulation the quality,

potency, and active ingredients are not regulated which can lead to varying results and risks.

– There is also no standardized dosing.

• It was difficult to find good quality research studies.

Results: Echinacea

• Used for illnesses such as colds and respiratory infections.

• All the studies in my research indicate that echinacea does have immunostimulation properties.

• Anesthesia concern: that the immunostimulatory effects may antagonize immunosuppressants.

– There are currently no studies that address this specifically.

Results: Ephedra• Acts as a sympathomimetic and is used for weight loss

and energy.

– Ephedrine is the predominant component.

• Studies found that even with small doses, ephedrine will increase HR, BP, and CNS effects.

• Anesthesia concerns: hypertension and tachycardia that may result could lead to myocardial ischemia or stroke.

– Long-term use could potentially result in tachyphylaxis from depletion of endogenous catecholamine stores, therefore making indirect-acting sympathomimetics (ephedrine) less effective intraoperatively.

– No current studies

Results: Gingko Biloba

• Used for cognitive disorders, PVD, and energy.

• Primary studies found that ginkgolides provided antagonistic action of platelet-activating factor (PAF), thereby affecting plt function.

– These studies used large doses and were often performed ex vivo.

• Current clinical trials have found no significant alteration in the PAF function, bleeding time, or coagulation parameters.

• However, there have been case reports of intracranial bleeding, a spontaneous hymphema, and postop bleeding from a lap chole.

• Anesthesia concern: potential increased risk for bleeding.

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Results: Garlic

• Used for infection, HTN, hyperlipidemia, and atherosclerosis.

• Results are conflicting:

– For the most part the older studies found that garlic does inhibit plt function and the newer studies had more conflicting results.

• When smaller doses were used, the results indicated that garlic did not inhibit plt function.

• Anesthesia concern: potential increased risk for bleeding.

Results: Ginseng

• Used as a stimulant, immunomodulator, mood elevator, and to lower postprandial blood sugar .

• Primary studies claim that ginseng decreases plasma glucose levels and decreases insulin resistance.

– Mostly animal and in vitro studies.

• Several current studies found that ginseng may have some affect on acute plasma glucose levels but no changes were found to the HbA1c, therefore the long-term affects remain questionable.

– The results of one study showed no significant effect on HBA1c, fasting plasma insulin levels or finger-prick blood glucose levels.

• Anesthesia concern: risk of hypoglycemia perioperatively.

Results: Ginseng cont.

• Ginsenosides are inhibitors of cyclooxygenase and thromboxane A2 synthase, both of which are important enzymes for platelet function.

• Results were conflicting:

– Some found plt function was not affected.

– Others found plt aggregation was inhibited and there were prolonged aPTTs and PTs.

• These tended to be animal studies

• Anesthesia concern: increased risk of bleeding.

Results: St. John’s Wort

• Used for depression and anxiety.

• Induces the cytochrome P450 system.

– Causes medications metabolized by the cyt P450 system to be metabolized at a greater rate.

• One study found that high doses of SJW required a 65% increase in the dose of cyclosporine (immunosuppressant given to pts receiving a transplant).

• Another study found that the clearance of midazolam was significantly increased after SJW administration.

• Anesthesia concern: be aware of possible drug interactions with SJW.

– Immunosuppressants, some antineoplastic drugs, benzodiazepines, alfentanil, lidocaine, digoxin, and warfarin.

Conclusions

• Overall, not a lot of concrete evidence regarding these herbal medicines discussed.

• Ask your patients if they are on any herbal supplements.

• Be aware of the possible risks with herbal supplements.

• G’s- increased risk for bleeding so ask about concomitant use of ASA, NSAIDS, and anti-coagulants.

• The American Society of Anesthesiologists (ASA) recommends that all herbal medicines be stopped 2 weeks prior to surgery as a general guideline.

References• Ang-Lee, M.K., Moss, J., & Yuan, C.S. (2001). Herbal medicines and perioperative care. Journal of the

American Medical Association, 286(2), 208-216.

• Beckert, B.W., Concannon, M.J., Henry, S.L., Smith, D.S., & Puckett, C.L. (2007). The effect of herbal medicines on platelet function: An in vivo experiment and review of the literature. Plastic Reconstruction Surgery, 120(7), 2044-2050.

• Bone, K.M. (2008). Potential interaction of Ginkgo biloba leaf with antiplatelet or anticoagulant drugs: What is the evidence? Molecular and Nutrition Food Research, 52, 764-771.

• Bordia, A. (1978). Effects of garlic on human platelet aggregation in vitro. Atherosclerosis, 30, 355-360.

• Chaplin, R.L., Jedynak, J., Johnson, D., Heiter, D., Shovelton, L, & Garrett, M. (2007). The effects of valerian on the time course of emergence from general anesthesia in Sprague-Dawley rats (rattus norvegicus). AANA Journal, 75(6), 431-435.

• Denyes, M.J., Orem, D.E., & SozWiss, G.B. (2001). Self-care: A foundational science. Nursing Science Quarterly, 14(1), 48-54.

• Ferriera, A., Proenc, C., Serralheiro, M.L.M., & Araujo, M.E.M. (2006). The in vitro screening for acetylcholinesterase inhibition and antioxidant activity of medicinal plants from Portugal. Journal of Ethnopharmacology, 108, 31-37.

• Gray, S. & West, L.M. (2012). Herbal medicines – a cautionary tale. New Zealand Dental Journal, 108(2), 68-72.

• Guinot, P., Caffrey, E., Lambe, R., & Darragh, A. (1989). Tanakan inhibits platelet-activating-factor-induced platelet aggregation in healthy male volunteers. Haemostasis 19(4), 219-223.

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References• Haller, C.A., Jacob III, P., & Benowitz, N.L. (2002). Pharmacology of ephedra alkaloids and caffeine after

single-dose dietary supplement use. Clinical Pharmacology & Therapeutics, 71(6), 421-432.

• Hodges, P.J. & Kam, P.C. A. (2002). The peri-operative implications of herbal medicines. Anaesthesia, 57, 889-899.

• Imai, H., Kotegawa, T., Tsutsumi, K., Morimoto, T., Eshima, N., Nakano, S., & Ohashi, K. (2008). The recovery time-course of CYP3A after induction by St John’s wort administration. British Journal of Clinical Pharmacology, 65(5), 701-707.

• Jin, Y.R., Yu, J.Y., Lee, J.J., You, S.H., Chung, J.H., Noh, J.Y., Im, J.H., Han, X.H., Kim, T.J., Shin, K.S., Wee, J.J., Yun, Y.P. (2007). Antithrombotic and antiplatelet activities of Korean red ginseng extract. Basic & Clinical Pharmacology & Toxicology, 100, 170-175.

• Kaye, A.D., Kucera, I., & Sabar, R. (2004). Perioperative anesthesia clinical considerations of alternative medicines. Anesthesiology Clinics of North America, 22(1), 125-139.

• Kiesewetter, H., Jung, F., Jung, E.M., Mroweitz, C. Koscielny, J., & Wenzel, E. (1993). Effect of garlic on platelet aggregation in patients with increased risk of juvenile ischaemic attack. European Journal of Clinical Pharmacology, 45(4): 333-336.

• Kim, S., Shin, B.C., Lee, M.S., Lee, H, & Ernst, E. (2011). Red gingseng for type 2 diabetes mellitus: A systematic review of randomized controlled trials. Chinese Journal of Integrative Medicine, 17(12), 937-944.

• Koch, E. (2005). Inhibition of platelet activating factor (PAF)-indueced aggregation of human thrombocytes by gingkolides: considerations on possible bleeding complications after oral intake of Ginkgo biloba extracts. Phytomedicine 12, 10-16.

References• Leuschner, J., Muller, J., & Rudmann, M. (1993). Characterisation of the central nervous depressant

activity of a commercially available valerian root extract. Arzneimittelforschung, 43(6), 638-641.

• Lyons, T.R. (2002). Herbal medicines and possible anesthesia interactions. Association of periOperative Registered Nurses Journal, 70(1), 47-51.

• Mai, I., Bauer, S., Perloff, E.S., Johne, A., Uehleke, B., Frank, B., Budde, K., Roots, I. (2004). Hyperforin content determines the magnitude of the St. John’s wort-cyclosporine drug interaction. Clinical Pharmacology and Therapeutics, 76(4), 330-340.

• Merriam-Webster. (2013). Platelet-activating factor. Retrieved from http://www.merriam-webster.com/medical/platelet-activating%20factor

• Messina, B.A. (2006). Herbal supplements: facts and myths- talking to your patients about herbal supplements. Journal of Perianesthesia Nursing, 21(4), 268-278.

• Na, D.H., Ji, H.Y., Park, E.J., Kim, M.S., Liu, K.H., & Lee, H.S. (2011). Evaluation of metabolism-mediated herb-drug interactions. Archives of Pharmacology Research, 34(11), 1829-1842.

• National Center for Complimentary and Alternative Medicine (NCCAM) (2012, December 13). Using dietary supplements wisely. Retrieved from http://nccam.nih.gov/health/supplements/wiseuse.htm

• Norred, C.L. (2002). Complementary and alternative medicine use by surgical patients. Association of periOperative Registered Nurses Journal, 76(6), 1013-1021.

• O’Malley, P., Trimble, N., & Browning, M. (2004). Are herbal therapies worth the risks? The Nurse Practitioner, 29(10), 71-75.

• Pribitkin, E.D. (2005). Herbal medicine and surgery. Seminars in Integrative Medicine, 3, 17-23.

References• Raey, J.L., Scholey, A.B., Milne, A., Fenwick, J., & Kennedy, D.O. (2009). Panax ginseng has no effect

on indices of glucose regulation following acute or chronic ingestion in healthy volunteers. British Journal of Nutrition, 101, 1673-1678.

• Roesler, J., Emmendorffer, A., Steinmuller, C., Luettig, B., Wagner, H., Lohmann-Matthes, M.L. (1991). Application of purified polysaccharides from cell cultures of the plant Echinacea purpurea to test subjects mediates activation of the phagocyte system. International Journal of Immunopharmacology, 13(7), 931-941.

• Rosenblatt, M. & Mindel, J. (1997). Spontaneous hyphema associated with ingestion of ginkgo biloba extract. New England Journal of Medicine, 336(15), 1108.

• Rahman, K. & Billington, D. (2000). Dietary supplementation with aged garlic extract inhibits ADP-induced platelet aggregation in humans. The Journal of Nutrition, 130, 2662-2665.

• Sabar, R., Kaye, A.D., & Frost, E.A. (2001). Perioperative considerations for the patient on herbal medicines. Middle Eastern Journal of Anesthesiology, 16(3), 287-314.

• Scharbart, G., Kalb, M.L., Duris, M., Marschalek, C., & Kozek-Langenecker, S.A. (2007). Garlic at dietary doses does not impair platelet function. International Anesthesia Research Society, 105(5), 1214-1218.

• See, D.M., Broumand, M., Sahl, L., Tilles, J.G. (1997). In vitro effects of Echinacea and ginseng on natural killer and antibody-dependent cell cytotoxicity in healthy subjects and chronic fatigue syndrome or acquired immunodeficiency syndrome patients. Immunopharmacology, 35, 229-235.

• Shankland, W.E. (2009). Four common herbs seen in dental practice: properties and potential adverse effects. CRANIO: The Journal of Craniomandibular Practice, 27(2), 118-133.

References• Shergis, J.L., Zhang, A.L., Zhou, W., & Xue, C.C. (2012). Panax ginseng in randomized controlled trials:

A systematic review. Phytotherapy Research, DOI: 10.1002/ptr.4832.

• Sievenpiper, J.L., Sung, M.K., Buono, M.D., Lee, S.K., Nam, K.Y., Arnason, J.T., Leiter, L.A., & Vuksan, V. (2006). Korean red ginseng rootlets decrease acute postprandial glycemia: Results from sequential preparation and dose-finding studies. Journal of the American College of Nutrition, 25(2), 100-107.

• Steiner, M., & Li, W. (2001). Aged garlic extract, a modulator of cardiovascular risk factors: A dose-finding study on the effects of AGE on platelet functions. The Journal of Nutrtion, 131, 980-984.

• Stohs, S.J. & Dudrick, S.J. (2011). Nutritional supplements in the surgical patient. Surgical Clinics of North America, 91(4), 933-944.

• Temple, M.D., Fagerlund, K., & Saewyc, E. (2005). A national survey of certified registered nurse anesthetists’ knowledge, beliefs, and assessment of herbal supplements in the anesthesia setting. American Association of Nurse Anesthetists Journal, 73(5), 368-377.

• Teng, C.M., Ko, F.N., & Yu, S.M. (1994). Inventory of exogenous factors affecting platelet aggregation isolated from plant sources. Journal of Thrombosis and Haemostasis, 71, 517.

• Teng, C.M., Kuo, S.C., Ko, F.N., Lee, J.C., Lee, L.G., Chen, S.C., & Huang, T.F. (1989). Antiplatelet actions of panaxynol and ginsenosides isolated from ginseng. Biochimica et Biophysica Acta, 990(3), 315-320.

• Vale, S. (1998). Subarachnoid haemorrhage associated with ginkgo biloba. The Lancet, 352, 36.

• Yun, Y.P., Do, J.H., Ko, S.R., Ryu, S.Y, Kim, J.H., Song, H.C., Park, Y.D., Ahn, K.S., &Kim, S.H., (2001). Effects of Korean red ginseng and its mixed prescription on the high molecular weight dextran-induced blood stasis in rats and human platelet aggregation. Journal of Ethnopharmacology, 77, 259-264.

References

• Vuksan, V., Sung, M.K., Sievenpiper, J.L., Stavro, P.M., Jenkins, A.L., Buono, M.D., Lee, K.S., Leiter, L.A., Nam, K.Y., Arnason, J.T., Choi, M., & Naeem, A. (2008). Korean red ginseng (Panax ginseng) improves glucose and insulin regulation in well-controlled, type 2 diabetes: Results of a randomized, double-blind, placebo-controlled study of efficacy and safety. Nutrition, Metabolism & Cardiovascular Diseases, 18, 46-56.

• White, L.M., Gardner, S.F., Gurley, B.J., Marx, M.A., Wang, P.L., & Estes, M. (1997). Pharmacokinetics and cardiovascular effects of ma-huang (Ephedra sinica) in normotensive adults. Jounal of Clinical Pharacology, 37(2), 116-122.

• Wojcikowski, K., Myers, S., & Brooks, L. (2007). Effects of garlic oil on platelet aggregation: A double blind placebo controlled crossover study. Platelets, 18(1), 29-34.

• Yun, Y.P., Do, J.H., Ko, S.R., Ryu, S.Y., Kim, J.H., Song, H.C., Park, Y.D., Ahn, K.S., & Kim, S.H. (2001). Effects of Korean red ginseng and its mixed prescription on the high molecular weight dextran-induced blood stasis in rats and human platelet aggregation. Journal of Ethnopharmacology, 77(2), 259-264.

Thank YouAre There Any Questions?

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Use of Total Intravenous Anesthesia to Reduce Post-Operative Nausea Vomiting in Women

Undergoing Laparoscopic Gynecological Procedures

Myles Brandt, SRNA

Introduction

• Postoperative Nausea and Vomiting (PONV) is experienced by roughly 20-30% of surgical patients. (Apfel, et. al. 2012).

• Rates of PONV in young female patients undergoing gynecological laparoscopic procedures can be as high as 70%. (Lambert & Lambert 2009).

Statement of Problem

• Patients at high risk for PONV may be placed at increased risk with the use of inhalational anesthetics.

Purpose

• The purpose of this project is to examine current literature to determine if the use of a propofol based anesthetic is effective at reducing the rates of PONV in the selected patient population.

Significance

• PONV is a significant reason for delayed discharge from the PACU.

• Many patients rank PONV as a concern of receiving anesthetics.

• The delayed discharge from the PACU has the potential to generate considerable costs in the form of increased nursing care, more medications, etc.

• Many organizations are looking for ways to cut costs in the form of faster discharges and decreased time in the PACU.

Significance

• Delaying discharge can be especially problematic for patients undergoing same day surgical procedures.

• In addition, ineffective treatment of PONV in patients undergoing same day procedures can lead to unplanned, costly admissions.

• Other complications include wound dehiscence and potential for aspiration.

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Research Questions

• Is the use of a propofol based anesthetic effective at decreasing the overall incidence of PONV?

• Does using a TIVA technique decrease the overall incidence of PONV in a high risk patient population?

Framework

• A physiologic framework was selected for this project.

• The physiology of PONV is complex with multiple triggers.

• Multiple neurotransmitters including serotonin, dopamine, histamine and acetylcholine being the most important.

Overview of Methods

• A literature search was conducted utilizing the CINAHL and PubMed databases through the Harley French Library at the University of North Dakota.

• The following keywords were used in the search: PONV, TIVA, Propofol, Laparoscopic and Gynecological.

Population Selection

• Is your patient high risk for PONV?

• Risk factors:– Female sex

– History of PONV or motion sickness

– Non-smoker

– Surgery type

– Duration of surgery

– Anesthetic technique

– Anesthetic drugs

Apfel, 2002 Apfel, 2002

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Results

• White, et. al (2007):

– Compared two anesthetic groups undergoing day-case gynecological surgery. One with a propofol based technique and one with a sevoflurane based technique utilizing dolasetron.

– Results showed that the rates of PONV were similar in both groups. However, rates of post-discharge nausea and vomiting were higher in the propofol based group.

– Increased rates of PDNV in the propofol based group associated with propofol’s short term anti-emetic effects.

Results• Park & Cho (2011):

– Two groups of patients undergoing gynecological laparoscopic surgery greater than one hour duration were compared. One group received a propofol based technique and the other group received a sevoflurane technique with palonosetron.

– Results showed no significant differences in rates of PONV. PONV was decreased only in the early post-operative period.

– Authors did state that the use of a propofol based technique is just as powerful as a single anti-emetic agent.

Results

• Shinn, et. al. (2011):– Two groups of patients undergoing laparoscopic

gynecological surgery. One group maintained with propofol, one group maintained with sevoflurane.

– Results showed patients in the propofol group had significantly lower rates of PONV in the first hour postoperatively. Rates of PONV following the first hour showed no significant difference.

– Authors also pointed out the short duration of propofol’ s anti-emetic effects.

Results• Hofer, et. al. (2003):

– Compared two groups of patients to compare and assess patient well-being following inhalational and intravenous anesthesia. One group maintained with propofol, one group maintained with sevoflurane.

– Results of this study demonstrate that for gynecological procedures, the rates of PONV in the propofol group were significantly reduced 90 minutes post-operatively compared to inhalational techniques.

– Results also show that a TIVA technique is effective for decreasing PONV in patients undergoing gynecological procedures.

Results

• Eriksson & Korttila (1996):– Compared three groups of patients undergoing

outpatient gynecologic laparoscopic procedures. Two groups received desflurane for maintenance both with and without ondansetron, one group received propofol for maintenance.

– Results favor the use of propofol for day case gynecological day case procedures. Patients in the propofol based group showed the lowest rates of PONV.

Results• Jokela, et. al. (2000):

– Compared three different groups undergoing breast surgery. Sevoflurane both with and without ondansetron was compared to propofol for maintenance of anesthesia.

– Results of this study showed that the rates of PONV in the propofol group were similar to the rates in the sevoflurane-ondansetron group.

– Beyond two hours postoperatively, rates of PONV in the propofol group became greater than the rates in the sevoflurane-ondansetron group.

– Study also points out that the anti-emetic effects of propofol are short lived and does not cover the post-discharge period.

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Results

• Habib, et. al. (2004):– Study compares a variety of strategies to prevent PONV. One

such strategy is the use of a TIVA technique.

– Results of this study show that the use of a TIVA technique with no other anti-emetics is every bit as effective as effective as the use of an inhalational agent and two anti-emetics.

– This study also suggest the use of a TIVA technique with the use of longer acting anti-emetics is an effective way to treat high risk patients to provide coverage into the post-discharge period.

Conclusions

• The use of a propofol based technique is highly effective for reducing the incidence of PONV in high risk patients.

• The anti-emetic effects of propofol are as effective as an anti-emetic agent.

• The anti-emetic effects of propofol are effective for approximately 1-2 hours post-operatively, requiring longer lasting agents.

• Current recommendations for high risk patients is to utilize a TIVA technique with longer acting anti-emetic agents.

• Further research is required for this demographic group.

References• Apfel, C.C., Heidrich, F.M., Jukar-Rao, S., Jalota, L., Hornuss, C., Whelan, R.P., Zhang, K. Evidence-based

analysis of risk factors for postoperative nause and vomiting. British Journal of Anesthesia 2012; 109 (5): 742-53.

• Apfel, C.C., Kranke, P., Katz, M.H., Goepfert, C., Papenfuss, T., Rauch, S., Heineck, R., Greim, C.A. & Roewer, N. Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: a randomized controlled trial of factorial design. British Journal of Anaesthesia 2002; 88 (5): 659-68.

• Apfel, C.C., Stoecklein, K. & Lipfert, P. PONV: A problem of inhalational anaesthesia? Best Practice & Research Clinical Anaesthesiology 2005; 19 (3): 485-500

• Borgeat, A., Oliver, H., Wilder-Smith, G., Saiah, M., & Rifat, K. Subhypnotic Doses of Propofol Possess Direct Antiemetic Properties. Anesthesia & Analgesia 1992; 74: 539-41

• Buchh, V.N., Saleem, B., Reshi, F.A., Hashia, A.M., Gurcoo, S., Shora, A.N. & Qazi, S. A comparison of total intravenous anaesthesia (TIVA) to conventional general anesthesia for day care surgery. The Internet Journal of Anesthesiology 2009.

• Eriksson, H. & Korttila, K. Recovery Profile After Desflurane With or Without Ondansetron Compared With Propofol in Patients Undergoing Outpatient Gynecological Laparoscopy. Anesthesia & Analgesia 1996; 82: 533-8.

• Fredman, B., Nathanson, M.H., Smith, I., Wang, J., Klein, K. & White, P.F. Sevoflurane for Outpatient Anesthesia: A Comparison with Propofol. Anesthesia & Analgesia 1995; 81: 823-8

• Gan, T.J., Meyer, T., Apfel, C.C., Chung, F., Davis, P.J., Eubanks, S., Kovac, A., Philip, B.K., Sessler, D.I., Temo, J., Tramer, M.R., &Watcha, M. Consensus Guidelines for Managing Postoperative Nausea and Vomiting. Anesthesia & Analgesia 2003; 97: 62-71.

References• Gupta, A., Stierer, T., Zuckerman, R., Sakima, N., Parker, S.D. & Fleisher, L.A. Comparison of Recovery Profile

After Ambulatory Anesthesia with Propofol, Isoflurane, Sevoflurane, and Desflurane: A Systematic Review. Anesthesia & Analgesia 2004; 98: 632-41.

• Habib, A.S., White, W.D., Eubanks, S., Pappas, T.N. & Gan, T.J. A Randomized Comparison of a Multimodal Management Strategy Versus Combination Antiemetics for the Prevention of Postoperative Nausea and Vomiting. Anesthesia & Analgesia 2004; 99: 77-81.

• Hofer, C.K., Zollinger, A., Buchi, S., Klaghofer, R., Serafino, D., Buhlman, S., Buddeberg, C., Pasch, T & Spahn, D.R. Patient well-being after general anaesthesia: a prospective, randomized, controlled multi-centre trial comparing intravenous and inhalational anaesthesia. British Journal of Anaesthesia 2003; 91 (5): 631-7.

• Iqbal, I.M. & Spencer, R. Postoperative nausea and vomiting. Anaesthesia and Intensive Care Medicine 2012; 613-16.

• Jokela, R.M., Kangas-Saarela, T.A., Valanne, J.V.I., Koivuranta, M.K., Ranta, P.O. & Alahuhta, S.M. Postoperative Nause and Vomiting After Sevoflurane With or Without Ondansetron Compared with Propofol in Female Patients Undergoing Breast Surgery. Anesthesia & Analgesia 2000; 91: 1062-5.

• Lambert, K.G., Wakim, J.H. & Lambert, N.E. Preoperative Fluid Bolus and Reduction of Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Gynecologic Surgery. AANA Journal 2009; 77 (2): 110-14.

• Norred, C.L. Antiemetic prophylaxis: Pharmacology and therapeutics. AANA Journal 2003; 71 (2): 133-40.

• Park, S.K. & Cho, E.J. A Randomized Controlled Trial of Two Different Interventions for the Prevention of Postoperative Nausea and Vomiting: Total Intravenous Anaesthesia using Propofol and Remifentanil versus Prophylactic Palonosetron with Inhalational Anaesthesia using Sevoflurane-Nitrous Oxide. The Journal of International Medical Research 2011; 39: 1808-1815.

References• Rognas, L.K. & Elkjer, P. Anaesthesia in day case laparoscopic female sterilization: a comparison of two

anaesthetic methods. Acta Anaesthesiol Scand 2004; 48: 899-902.

• Shelley, B. & Sutcliffe, N. Total intravenous anaesthesia. Clinical Anaesthesia 2010; 11 (4): 144-46.

• Shinn, H.K., Lee, M.H., Moon, S.Y., Hwang, S.I., Lee, C.S., Lim, H.K. & Song, J.H. Post-operative nausea and vomiting after gynecological laparoscopic surgery: comparison between propofol and sevoflurane. Korean J Anesthesiol 2011; 60 (1): 36-40.

• Smith, I. & Thwaites, A.J. Target-controlled propofol vs. sevoflurane: a double-blind, randomized comparison in day case anesthesia. Anaesthesia 1999; 54: 745-752.

• Visser, K., Hassink, E.A., Bonsel, G.J., Moen, J., Kalkman, C.J. Randomized Controlled Trial of Total Intravenous Anesthesia with Propofol versus Inhalational Anesthesia with Isoflurane-Nitrous-Oxide. Anesthesiology 2001; 95(3): 616-26.

• Voigt, M., Frohlich, C.W., Waschke, K.F., Lenz, C., Gobel, U., Kerger, H. Prophylaxis of postoperative nausea and vomiting in elective breast surgery. Journal of Clinical Anesthesia 2011; 23: 461-468.

• White, H., Black, R.J., Jones, M. & Mar Fan, G.C. Randomized comparison of two anti-emetic strategies in high-risk patients undergoing day-case gynaecological surgery. British Journal of Anaesthesia 2007; 98 (4): 470-6.

Thank YouAre There Any Questions?

10/31/2013

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Neurodevelopmental Outcomes in Pediatric Patients Undergoing General

Anesthesia

Chelsea Boekelheide, SRNA

Introduction & Statement of Problem

• 4 million American children undergo general anesthesia per year.

• Growing concern: link between anesthesia and neurocognitive delay.

• Is there a real causal relationship, and what can we do about it?

Purpose

• Identify the effects of general anesthesia on the developing brain.

• Identify crucial periods of neurocognitive development that are significantly affected by anesthesia.

• Investigate practical alternatives to general anesthesia in pediatrics.

• Provide recommendations for clinical practice.

Definitions

• Pediatric population: birth to 36 months of age.

• Neurodevelopment: the time between the third trimester of pregnancy to the first 36 months of postnatal life, during which the critical period of cerebral plasticity and peak synaptogenesis occurs (when the brain is most vulnerable to insult).– Vutskits et al., 2012

Significance

• Developmental delays are being diagnosed more and more frequently.– ADHD, autism, learning disorders

• ADHD: increased over 25% in the last 10 years (CDC, 2011).

• Autism: increased 289.5% over past 12 years (Plizska, 2007).

• Unspecified developmental delay: increased by 17.1% (Plizska, 2007)

Significance

• No effect on life expectancy

• Effects continue into adulthood

• Multi-factorial etiologies– One theory: general anesthesia

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Significance

• General anesthesia in the pediatric population is reserved for completely necessary surgeries.

Research Questions

• Does general anesthesia in patients younger than 3 years significantly increase the risk of diagnosis of behavioral or developmental delay?

• What alternatives are available to decrease the risk on the developing brain?

Framework

• Physiologic framework– Physiologic biological mechanisms of the

developing brain

– Effects of NMDA-antagonists and GABA-agonists on neurodevelopment

– Exposure to anesthetic agents in critical periods of neurodevelopment

Overview of Methods

• Comprehensive review of literature using research databases from UND’s Harley E. French Library of Health Sciences– PubMed, CINAHL, Google Scholar

• Search terms:– Pediatric anesthesia, neurotoxicity,

developmental disorder OR behavioral disorder AND general anesthesia

• Jamie Sperle, CRNA, DNP, consulted as faculty advisor

Results• Does general anesthesia in patients younger

than 3 years significantly increase the risk of diagnosis of behavioral or developmental delay?– Preclinical data: Mammalian studies have tested

NMDA-antagonists and GABA-agonists, and have found unanimously that neuroapoptosisoccurs at an accelerated rate during periods of peak synaptogenesis (Slikker et al., 2007; Fredrikkson, Ponten, Gordh, & Eriksson, 2007; Jevtovic, Hartman, & Izumi, 2003).

Results Cont’d

– Clinical studies:• Wilder et al. (2009): Retrospective cohort study—

found multiple, but not single, exposures to general anesthesia resulted in an increased incidence of learning disability.

• DiMaggio et al. (2009): Exposure was defined as general anesthesia during an inguinal hernia repair; found 3.5-fold increase in incidence of behavioral or developmental disorder.

• Sprung et al. (2012): ADHD incidence increased almost 2.5-fold with multiple, but not single, exposures to general anesthesia.

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Results Cont’d

• Alternatives to general anesthesia– Xenon: rarely-used NMDA antagonist

• Ma et al. (2007) and Cattano et al. (2008)

• Significant protection against isoflurane injury.

• Limitations to use: exceedingly scarce, very expensive, MAC of 70%.

Results Cont’d

• Alternatives to general anesthesia– Dexmedetomidine

• Alpha-2 receptor agonist

• Trophic role during neurodevelopment and has neuroprotective effects.

• Sanders et al. (2009) and Tobias (2007)

• Limitations to use: No FDA recommendations for pediatrics at this time, very large amounts needed for sole anesthetic.

Summary

• Most important conclusion:– Multiple, but not single, exposure to general

anesthesia in children younger than 3 years of age significantly increases the risk of diagnosis of developmental disorders.

Recommendations

• Continued research into alternatives to general anesthesia.

• Care conferencing with parents/families so that they can make informed decisions.

• Continued exceptional, evidence-based care for all of our patients.

References• American Psychiatric Association (2002). Diagnostic and statistical manual of mental disorders

(revised 4th ed.). Washington, DC: Author.• American Society of Anesthesiologists (2009). Guidelines for Sedation and Analgesia. Retrieved

from http://www.asahq.org.• Bartels, M., Althoff, R.R., & Boomsma, D.I. (2009) Anesthesia and cognitive performance in

children: no evidence for causal relationship. Twin Research and Human Genetics, 12, 246-253.• Bosenberg, A. (2012). Benefits of regional anesthesia in children. Pediatric Anesthesia, 22, 10-18.• Cattano, D. Williamson, P., Fukui, K., Avidan, M., Evers, A.S., Olney, J.W., & Young, C. (2008).

Potential of xenon to induce or to protect against neuroapoptosis in the developing mouse brain. Canadian Journal of Anesthesiology, 55, 429-436.

• Cattano, D., Young, C., Straiko, M.M., & Olney, J.W. (2008). Subanesthetic doses of propofolinduce neuroapoptosis in the infant mouse brain. Anesthesia & Analgesia, 106, 1712-1714.

• Centers for Disease Control and Prevention (2011). Attention-deficit/hyperactivity disorder. Retrieved from http://www.cdc.gov/ncbddd/adhd/data.html.

• Creely, C.E., & Olney, J.W. (2010). The young: neuroapoptosis induced by anesthetics and what to do about it. Anesthesia & Analgesia, 110(2), 442-448.

• Culley, D.J., Maze, M., & Crosby, G. (2012). Reprogramming of the infant brain by surgery with general anesthesia. Mayo Clinic Proceedings, iu(2), 110-113.

• DiMaggio, C., Sun, L.S., Kakavouli, A., Byrne, M.W., & Li, G. (2009). A retrospective cohort study of the association of anesthesia and hernia repair surgery with behavioral and developmental disorders in young children. Journal of Neurosurgical Anesthesia, 21(4), 286-291.

References• DiMaggio, C., Sun, L.S., & Li, G. (2011). Early childhood exposure to anesthesia and risk of developmental and

behavioral disorders in a sibling birth cohort. Pediatric Neuroscience, 113(5), 1143-1151.• Flick, R.P., Katusic, S.K., Colligan, R.C., Wilder, R.T., Voigt, R.G., Olson, M.D., Sprung, J., Weaver, A.L.,

Schroeder, D.R., & Warner, D.O. (2011). Cognitive and behavioral outcomes after early exposure to anesthesia and surgery. Pediatrics, 128, 1053-1061.

• Fredriksson, A., Ponten, E., Gordh, T., & Eriksson, P. (2007). Neonatal exposure to a combination of N-methyl-D-aspartate and gamma-aminobutyric acid type A receptor anesthetic agents potentiates apoptotic neurodegeneration and persistent behavioral deficits. Anesthesiology, 234, 427-436.

• Holzki, J. (2011). Recent advances in pediatric anesthesia. Korean Journal of Anesthesiology, 60(5), 313-322.• Ikonomidou, C., Bosch, F., Miksa, M., Bittigau, P., Vockler, J., Dikranian, K., Tenkova, T.I., Stefovska, V., Turski,

L., & Olney, J.W. (1999). Blockade of NMDA receptors and apoptotic neurodegeneration in the developing brain. Science, 283, 70-74.

• Jevtovic-Todorovic, V., Hartman, R.E., Izumi, Y., Benshoff, N.D., Dikranian, K., Zorumski, C.F., Olney, J.W., & Wozniak, D.F. (2003). Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. Journal of Neuroscience, 23, 876-882.

• Kalkman, C.J., Peelen, L., Moons, K.G., Veenhuizen, M., Bruens, M., Sinnema, G., deJong, T.P. (2009). Behavior and development in children and age at the time of first anesthetic exposure. Anesthesiology, 110, 805-812.

• Loepke, A.W., & Soriano, S.G. (2008). An assessment of the effects of general anesthetics on developing brain structure and neurocognitive function. Anesthesia & Analgesia, 106, 1681-1707.

• Ma, D., Williamson, P., Januszewski, A., Nogaro, M.C., Hossain, M., Ong, L.P., Shu, Y., Franks, N.P., & Maze, M. (2007). Xenon mitigates isoflurane-induced neuronal apoptosis in the developing rodent brain. Anesthesiology, 106, 746-753.

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References• McCann, M.E., 2011). Anesthetic neurotoxicity in babies. Journal of AAPOS, 15, 515-517.• McCann, M.E., Bellinger, D.C., Davidson, A.J., Soriano, S.G. (2009). Clinical research

approaches to studying pediatric anesthetic neurotoxicity. NeuroToxicology, 30, 766-771.• McCann, M.E., & Soriano, S.G. (2009). Is anesthesia bad for the newborn brain? Anesthesiology

Clinics, 27, 269-284.• Perez-Castro, R., Patel, S., Garavito-Aguilar, Z.V., Rosenberg, A., Recio-Pinto, E., Zhang, J.,

Blanck, T.J.J., & Xu, F. (2009). Cytotoxicity of local anesthetics in human neuronal cells. Anesthesia & Analgesia, 108(3), 997-1007.

• Pliszka, S. (2007). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7), 894-921.

• Porth, C.M. (2005). Pathophysiology: Concepts of Altered Health States (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

• Sanders, R.D., Xu, J., Shu, Y., Januszewski, Al, Halder, S., Fidalgo, A.M., Sun, P., Hossain, M., Ma, D., & Maze, M. (2009). Dexmedetomidine attenuates isoflurane-induced neurocognitiveimpairment in neonatal rats. Anesthesiology, 110, 1077-1085.

• Scallet, A.C., Schmued, L.S., Slikker, W., Grunberg, N., Faustino, P.J., Davis, H., Lester, D., Pine, P.S. Sistare, F., & Hanig, D.P. (2004). Developmental neurotoxicity of ketamine: morphometricconfirmation, exposure parameters, and multiple fluorescent labeling of apoptotic neurons. Toxicological Sciences, 81, 364-370.

• Slikker, W., Zou, X., Hotchkiss, C.E., Divine, R.L., Sadovova, N., Twaddle, N.C., Doerge, D.R., Scallet, A.C., Patterson, T.A., Hanig, J.P., Paule, M.G., & Wang, C. (2007). Ketamine-induced neuronal cell death in the perinatal rhesus monkey. Toxicological Sciences, 98, 145-158.

References• Sprung, J., Flick, R.P., Katusic, S.K., Colligan, R.C., Barbaresi, W.J., Bojanic, K., Welch,

T.L., Olson, M.D., Hanson, A.C., Schroeder, D.R., Wilder, R.T., & Warner, D.O. (2012). Attention-deficit/hyperactivity disorder after early exposure to procedures requiring general anesthesia. Mayo Clinic Proceedings, 87(2), 120-129.

• Sun, L. (2010). Early childhood general anaesthesia exposure and neurocognitive development. British Journal of Anaesthesia, 105(51), 61-68.

• Tobias, J.D. (2007). Dexmedetomidine: Applications in pediatric critical care and pediatric anesthesiology. Pediatric Critical Care, 8, 115-131.

• Vutskits, L., Davis, P.J., & Hansen, T.G. (2012). Anesthetics and the developing brain: time for a change in practice? A pro/con debate. Pediatric Anesthesia, 22, 973-980.

• Wilder, R.T., Flick, R.P., Sprung, J., Katusic, S.K., Barbaresi, W.J., Mickelson, C., Gleich, S.J., Schroeder, D.R., Weaver, A.L., & Warner, D.O. (2009). Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology, 110, 544-553.

• Zhang, X., Xue, Z., & Sun, A. (2008). Subclinical concentration of sevoflurane potentiates neuronal apoptosis in the developing C57BL/6 mouse brain. Neuroscience Letters, 447, 109-114.

Thank YouAre There Any Questions? Lidocaine as an Adjunct in

Perioperative Pain Management

Nathan Opland, SRNA

Introduction• Intravenous lidocaine is an old strategy gaining

new interest (Gordon and Schroeder, 2008).

• Lidocaine was the first amide type localanesthetic utilized when its discoverers colleague injected it in himself in 1943.

• Lidocaine's history has since well-established its highly effective analgesia and quality of recovery following some but not all surgeries.

Statement of Problem

• Continued traditional use of opioids versus multimodal opioid-sparring analgesia is a contributing factor to adverse outcomes (Joshi andKehlet, 2013).

• Despite current literature's wealth of evidence-based knowledge, opioids continue to take precedence over multimodal analgesia therapies (Joshi and Kehlet, 2013).

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Purpose

The purpose of this independent project was to explore the efficacy in utilizing intravenous lidocaine as an adjunct in perioperative pain management for adult patients.

Significance

• Intravenous lidocaine is suitable in many surgical procedures.*

• Ample current research findings are associated with reductions in physiological, somatic, autonomic, and behavioral responses (Baral, Bhattarai, Rahman, Regmi, and Singh, 2010).

Research Questions

• When implemented in the perioperative analgesia plan, how does the utilization of intravenous lidocaine outcomes compare to those not treated with lidocaine in terms of:– Time to return of bowel and bladder function?

– Time to resumption of oral intake?

– Time to participation in post-operative exercises?

– Incidences of post-operative nausea and vomiting?

– Opioid requirements?

– Time to discharge from hospital?

Framework

• For this independent project, I chose to use Kolcaba`s Theory of Comfort to evaluate nurse anesthesia care and desirable outcomes.

• Anesthesia professionals relieve physical pain through the administration of many different pharmacological agents.

Framework(continued)

• Applicable to this independent project is anesthesia professionals relief of physical pain and behavioral changes to follow that moves them towards a holistic state of well being.

Framework (continued)Types of

comfort/in

context of

Relief Ease Transcen-dence

Physical

(pertaining to

bodily

sensations)

The state of a

recipient who

has had a

special need

met

The state of

calm or

contentment

The state in which an

individual rises above

his/her problems/

pain

Psycho-

spiritual

Social

Environ-

mental

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Overview of Methods

• A comprehensive review of the literature was performed using the PubMed and CINAHL databases as well as Google Scholar.

• Search terms included, but were not limited to lidocaine, infusion, intravascular, intravenous, intraoperative, postoperative, perioperative, surgery, analgesia, comfort, and pain.

Overview of Methods (continued)

• Limitations to English language, less than five years old, and peer reviewed were set in deeper CINAHL, PubMed, and Google Scholar searches.

• The Johns Hopkins Research Evidence Apprasial Tool and Stetler`s Evidence of Hierarchy were utilized to rank the strength of the articles.

Results

• The literature review demonstrated statistically significant outcomes for lidocaine groups when compared to the control groups.

• The following slides summarize the interpretation of the data.

Results (continued)

• A statistically significant reduction by 11.8% time in hours to first flatus was observed in those recieving lidocaine.

This image cannot currently be displayed.

Results (continued)

• Review of the literature revealed statisticallysignificant reductions by 10.4% time in hours to the first passage of feces in the lidocainegroups.

Results (continued)

• Statistically significant. Nausea and vomiting (a critical patient comfort and sense of well being marker) incidences were reduced by 13.7% in those treated with lidocaine.

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Results (continued)

• Patients whom recieved lidocaine infusions as a component of their anesthetic plan experienced less opioid consumption.*

Results (continued)

• Patients treated with intravenous lidocaine resumed oral intake and discontinuation of intravenous fluids earlier.*

Results (continued)

• The implementation of lidocaine on functional walking capacity yielded a statistically significant decrease in number of feet lost preoperatively to postoperatively.

Results (continued)

• Patients treated with lidocaine were discharged from the hospital on average one day earlier (Fitzgerald et al., 2012 and Cote et al., 2011).

Results (continued)

• The literature supports beneficial outcomes to multimodal analgesia in contrast to the deleterious effects when opioids are used solely.*

• In the pursuit of multimodal analgesic techniques the joint commission has since labeled pain as “the fifth vital sign.”

Results (continued)

• Recent evidence by Derry et al., 2012 and the American Society of Anestheologists(ASA) both send a strong message that there is room for improvement.*

• In contrast to less emphasis being placed on traditional measures**, patient reports of well-being and administrative markers*** are taking precedence.

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Results (continued)

• Dosing – Many of the individual pieces of literature’s

authors agreed that more research was needed to make recommendations about dosing for continuous lidocaine infusions.*

– A wide array of dosing ranges were employed in the trials observed for this project.**

– Contraindications:• Cardiac arrhythmias, history of seizures, allergy.

Results (continued)• Dosing (continued)

– Adverse events• Cote et al., (2011) found there to be no

significant difference between control and lidocaine groups with respect for neurological and cardiovascular events.*

• In planning utilization of intravenous lidocaine in the perioperative setting anesthesia professionals should consider the proposed procedure, contraindications, and benefits for its application.

Conclusion

• Opioids should not be the mainstay of analgesic plans.

• Although there are other options to primary pharmacology in perioperative pain management, lidocaine’s well established history promotes a safe, cost effective, and an efficacious adjunct in multimodal pain management.

References• Aduckathil, S., Gerbershagen, H.J., Kalkman, C.J., Meissner, W., Peelen, L.M., & Van Wijck,

A.J. (2013). Pain intensity on the first day after surgery: A prospective cohort study comparing 179 surgical procedures. Pain Medicine Anesthesiology, 118(4), 934-944.

• Alligood, M.R., & Tomey, A.M. (2002). Theory of Comfort. In T. Dowd (Ed.), Nursing Theorists and Their Work, (5th ed., pp. 430 – 442). St. Louis, MO: Mosby.

• American Academy of Family Physicians (2012). Levels of evidence in AFP. Retrieved fromhttp://www.aafp.org/online/en/home/publications/journals/afp/afplevels.html

• Annoni, J.M., Cahana, A., Carota, A., & Montadon, M. (2004). The long-term effect of repeated intravenous lidocaine on central pain and possible correlation in positron emission tomography measurements. Anesthesia and Analgesia, 98, 1581-1584. doi: 10.1213/01.ANE.0000113258.31039.C8

• Apfelbaum, J.L., Ashburn, M.A., Connis, R.T., Tong J.G., & Nickinovich, D.G. (2012). American society of anesthesiologists task force on acute pain management. An practice guidelines for acute pain management in the perioperative setting. Anesthesiology, 116(2), 248-273. Retrieved from http://www.asahq.org/~/media/For%20Members/ Practice%20Management/PracticeParameters/AcutePainManagementInThePerioperativeSetting.ashx

• Bach, F.W., Biering-Sorensen, F., Finnerup, N.B., Jensen, T.S., Johannesen, I.L., Juhl, G.I., Kristensen, A.D., Sindrup, S.H., & Terkelsen, A.J. (2005). Intravenous lidocaine relieves spinal cord injury pain. Anesthesiology, 102(5), 1023-1030.

References (continued)• Ballantyne, J.C., Ginsberg, B., Gordon, D.B., Liu, S.S., Perkins, F.M., Rathmell, J.P., Reuben, S.S., Rosenquist,

R.W., Sinatra, R.S., Viscusi, E.R., & Wu, C.L. (2006). Acute post-surgical pain management: A critical appraisal of current practice. Regional Anesthesia and Pain Medicine, 31(4), 1-42. doi: 10.1016/j.rapm.2006.05.002

• Baral, B.K., Bhattarai, B.K., Rahman, T.R., Regmi, R., & Singh, S.N. (2010). Perioperative intravenous lidocaine infusion on postoperative pain relief in patients undergoing upper abdominal surgery. Nepal Med Coll Journal, 12(4), 215-220.

• Bauer, H., Bottiger, B.W., Dijkgraaf, M.G., Durieux, M.E., Friess, H., Herroeder, S., Hollman, M.W., Kaulitz, G., Pecher, S., & Schonherr, M.E. (2007). Systemic lidocaine shortens length of hospital stay after colorectal surgery. Annals of Surgery, 246(2), 192-200. doi: 10.1097/SLA.0b013e31805dac11

• Beilin, B., Bessler, H., Levinson, Y., Mayburd, E., & Yardeni, I. Z. (2009). The effect of perioperative intravenous lidocaine on postoperative pain and immune function. International Anesthesia Research Society, 109(5), 1464-1469. doi: 10.1213/ANE.0b013e3181bab1bd

• Bernards, C.M., Butterworth, J.F., Di Gregorio, G., Drasner, K., Hejtmanck, M.R., Mulroy, M.F., Neal, J.M., Rosenquist, R.W., & Weinberg, G.L. (2012). Checklist for treatment of local anesthetic systemic toxicity. American Society of Regional Anesthesia and Pain Medicine, 35, 1-2. Retrieved from

• http://www.asra.com/checklist-for-local-anesthetic-toxicity-treatment-1-18-12.pdf

• Bryson, G.L., Charapov, I., Krolczyk, G., Reid, D., & Taljaard, M. (2010). Intravenous lidocaine does not reduce length of hospital stay following abdominal hysterectomy. Canadian Journal of Anesthesia, 57, 759-766. doi: 10.1007/s12630-010-9332-2

References (continued)• Carli, F., Feldman, L., Fried, G., Kim, D.J., Lauwick, S., Michealagnoli, G., & Mistraletti, G. (2008). Intraoperative infusion

of lidocaine reduces postoperative fentanyl requirements in patients undergoing laparoscopic cholecystectomy. Canadian Journal of Anesthesia, 55(11), 754-760.

• Carli, F., Kim, D.J., Lauwick, S., & Mistraletti, G. (2009). Functional walking capacity as an outcome measure of laparoscopic prostatectomy: the effect of lidocaine infusion. British Journal of Anesthesia, 103(2), 213-219. doi: 10.1093/bja/aep103

• Cassuto, J., Faxen, A., Hedner, T., Hogstrom, S., Linden, I., Rimback, G., & Wallin, G. (1987). Effects of lidocaine infusion on sympathetic response to abdominal surgery. Anesthesia and Analgesia, 66, 1008-1013.

• Chen, K.M., Jao, S.W., Kuo, C.P., Sheen, M.J., Wong, C.S., Su, C.T., & Yeh, C.C. (2006). Comparison of the effects of thoracic epidural analgesia and i.v. infusion with lidocaine on cytokine response, postoperative pain and bowel function in patients undergoing colonic surgery. British Journal of Anesthesia, 97(5), 640-646.

• Chen, L.L., & Mao, J. (2000). Systemic lidocaine for neuropathic pain relief. Pain, 87, 7-17.

• Clark, N., Grady, P., Hawkins, R., Lenahan, J., Nezat, G., Oudederk, C., & Pellegrini, J.E. (2012). Effect of intraoperative intravenous lidocaine on postoperative pain and return of bowel function after laparoscopic abdominal gynecologic procedures. AANA Journal, 80(4), 282-288.

• Cleland, H., Costello, V., Ferraro, F., Konstantatos, A., Paul, E., Spinks, A., Wasiak, J. (2011). Adjuvant use of intravenous lidocaine for procedural burn pain relief: A randomized double-blind, placebo-controlled, cross-over trial. Burns, 37, 951-957. doi: 10.1016/j.burns.2011.03.004

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References (continued)• Cote, D., Fergusson, D. A., Lauzier, F., McIntyre, L.A., Moore, L., Nicole, P. C., Turgeon, A.F., Vigneault, L., &

Zarychanski, R. (2011). Perioperative intravenous lidocaine infusion for postoperative pain control: A meta-analysis of randomized controlled trials. Canadian Journal of Anesthesia, 58, 22-37. doi: 10.1007/s12630-010-9407-0

• Derry, S., Eccleston, C., McQuay, H.J., Moore, R.A., & Wiffen, P.J. (2012). Evidence for

analgesic effect in acute pain-50 years on. Pain, 153, 1364-1367.

• Diab, D.G., Matter, M.K., Ramzy, E.A., Tahan, M.R., & Warda, O.M. (2009). A randomized study of the effects of perioperative i.v. lidocaine on hemodynamic and hormonal responses for cesarean section. Journal of Anesthesia, 23, 215-221. doi: 10.1007/s00540-009-0738-3

• Detroz, B.J., Durieux, M.E., Joris, J.L., Kaba, A., Lamy, M.L., Laurent, S.R., & Sessler, D.I. (2007). Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy. Anesthesiology, 106(1), 11-18.

• Durieux, M.E., Gottschalk, A., Groves, D.S., McKay, A., & Ploppa, A. (2009). Systemic lidocaine decreased the perioperative opioid analgesic requirements but failed to reduce discharge time after ambulatory surgery. Anesthesia & Analgesia, 109(6), 1805-1808. doi: 10.1213/ ANE.0b013e3181be371b

• Fisher, H.A., Groudine, S.B., Kaufman, Jr., R.P., Lumb, P.D., Mehta, S.A., Patel, M.K., & Wilkins, L.J. (1998). Intravenous lidocaine speeds the return of bowel function, decreased postoperative pain, and shortens hospital stay in patients undergoing radical retropubic prostatectomy. Anesthesia and Analgesia, 86, 235-239.

References (continued)• Fitzgerald, P., Marcus, R., McCarthy, R., Oliveira, G.S., & Streicher, L. F., (2012). Systemic lidocaine to improve

postoperative quality of recovery after ambulatory laparoscopic surgery. Society for Ambulatory Anesthesiology, 115(2), 262-267. doi: 10.1213/ANE.0b013e318257a380

• Gordon, D., & Schroeder, M. (2008). Intravenous lidocaine for postoperative analgesia: renewed interest in an old strategy, APS Bulletin, 18(3), 3-5.

• Habib, A.S., McCarthy, G.C., & Megalla, S.A. (2010). Impact of intravenous lidocaine infusion on postoperative analgesia and recovery from surgery. Drugs, 70(9), 1149-1163.

• Hering, W., Koppert, W., Neumann, F., Reinhard, S., Schmelz, M., Schuettler, J., & Weigand, M. (2004). Perioperative intravenous lidocaine has preventive effects on postoperative pain and morphine consumption after major abdominal surgery. Anesthesia and Analgesia, 98, 1050-1055. doi: 10.1213/01.ANE.0000104582.71710.EE

• Hospira (2010). Lidocaine drug insert. Lake Forest, IL: Hospira, Inc.

• Joshi, G.P., & Kehlet, H. (2013). Procedure-specific pain management the road to improve postsurgical pain management. Anesthesiology, 118(4), 1-3. doi: 10.1097/ALN.0b013e31828866e1

• Kang, H., & Kim, B.G. (2011). Intravenous lidocaine for effective pain relief after inguinal herniorrhaphy: A prospective, randomized, double-blind placebo-controlled study. The Journal of International Medical Research, 39, 435-445.

References (continued)• Kolcaba, K. (2001). Evolution of the mid-range theory of comfort for outcomes research. Nursing Outlook, 49(2),

86-92, doi: 10.1067/mno.2001.110268

• Kolcaba, K., & Wilson, L. (2004). Practical application of comfort theory in the perianesthesia setting. Journal of PeriAnesthesia Nursing, 19(3), 164-173. doi: 10.1016/j.jopan.2004.03.006

• Krenzischek, D.A., & Wilson, L. (2003). An introduction to the ASPAN pain and comfort clinical guideline. Journal of PeriAnesthesia Nursing, 18(4), 228-231. doi: 10.1016/S1089-9472(03)00128-X

• The Johns Hopkins Hospital/The Johns Hopkins University (2007). Johns Hopkins nursing evidence-based practice research evidence appraisal. Retrieved from

http://www.nursingworld.org/DocumentVault/NursingPractice/Research-Toolkit/JHNEBP-Research-Evidence-

Appraisal.pdf

Thank YouAre There Any Questions?

Anesthetic Considerations for Phantom Limb Pain

Robert Kari, SRNA

Introduction & Statement of Problem

• Phantom limb pain (PLP) is the perception of pain in a region of the body that is no longer present.

• Most common following limb amputation but has been described in other areas of the body including the eyes, breast, genitals, bowel and bladder.

• Concept was first introduced in mid 16th century by a French military surgeon.

• Silas Weir Mitchell, a famous civil war surgeon, provided an early and accurate description and coined the term “phantom pain.”

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Epidemiology and Statistics

• Studies indicate a wide variation in prevalence, symptoms and development suggesting complex interactions between physiological mechanisms.

• Estimated 1.7 million amputees in the United States.

• Demographic changes and higher rates of vascular disease , secondary to diabetes, may double this number by the year 2050.

• Some studies suggest PLP is rare but recent epidemiological studies indicate prevalence rates between 50% - 80%.

Purpose

• Educate anesthesia providers on possible mechanisms for the development of PLP.

• Investigate current recommendations supported by the literature for the prevention and treatment of PLP in terms of preemptive analgesia and anesthesia.

Significance

• Anesthesia providers are on the forefront of pain management.– Epidemiological studies and prevalence rates

indicate that PLP is a common problem following amputation.

– Is often underreported: Study of 2700 veteran amputees showed 69% were reluctant to talk to providers.

Research Questions

• What are the physiological mechanisms that contribute to the development of PLP?

• Is preemptive analgesia and anesthesia effective in preventing the development or lessening the severity of PLP?

Framework

• Physiological Framework– Pain is individual in nature, what may be a mild

nuisance to one person may be debilitating to another.

– Complex physical and emotional factors.

– PLP is a type of neurogenic pain that is typically chronic in nature.

– Abnormal processing or dysfunction of the nervous system.

– Neuropathic pain is difficult to diagnose and treat.

Overview of Methods

• Comprehensive literature review– Electronic databases: PubMed, CINHAL,

Scopus, Google Scholar.

– Keywords: phantom limb pain, anesthesia, analgesia, epidural, perineural, neuropathic, and neurogenic.

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Results

• Multiple theories for the development of PLP.

• No one specific pain theory can accurately describe PLP.

PLP Peripheral Theory• PLP originates at the nerves around the injury.

• Amputation causes neurogenic inflammation leading to a release of inflammatory mediators (bradykinin, histamine, arachadonic acid metabolites).

• Peripheral nociceptors become up-regulated.

• Neuromas form-hyperalgesia, allodynia.

• Non-nociceptive peripheral Aβ nerve fibers carry pain impulses into dorsal root.

• All these factors lead to peripheral sensitization.

PLP Spinal Cord Theory

• Changes in spinal cord contribute to development of PLP.

• Inhibitory GABA can be destroyed by massive ectopic discharge caused by neural damage.

• GABA neurons can actually change from inhibitory to excitable.

• Down regulation of opioid receptors.

• Increased glutamate activity leading to increased excitatory NMDA receptor activity.

• Substance P released from Aβ nerve fibers, non-noxious stimulus can cause pain.

• All factors lead to central sensitization.

PLP Central Theory

• Supraspinal areas: brainstem, thalamus and cortex.

• Theories revolve around reorganization of somatosensory cortex (remapping) and neurosignatures (pain memories) .

• Melzack proposed neuromatix theory: neurosignature or memory of each body part in the brain.

• Reorganization suggests that removal of a body part causes other areas of the brain to take over impulses from the missing body part.

Preemptive Epidural Anesthesia

• 6 main studies that investigated different epidural approaches:– Bach, Noreng and Tjelden (1988): lumbar epidural with

bupivacaine and morphine.

– Jahangiri, Jayatunga, Bradley and Clark (1994): lumbar epidural with bupivacaine, morphine and clonidine.

– Shug, Burrell, Payne and Tester (1995): epidural with bupivacaine and fentanyl.

– Nikolajsen, Ilkjaer, Christensen, Kroner and Jensen (1997): epidural with bupivacaine and morphine.

– Wilson, Nimmo, Fleetwood-Walker and Colvin (2008): epidural with bupivacaine and ketamine.

– Karanikolas, et, al (2011): epidural with bupivacaine and fentanyl alone compared to standard pain treatment modalities.

Preemptive Epidural Anesthesia

• Mixed results from studies– Not surprising considering complexity of PLP.

– Data suffered from lack of randomization and blinding, high attrition rates and limited sample sizes.

– Some researchers suggested promising results, but no strong statistical data to support preemptive epidural anesthesia.

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Preemptive Perineural Anesthesia

• 4 main studies investigating perineural anesthesia:– Fisher and Meller (1991): continuous infusion of

bupivacaine into transected nerve sheaths.

– Pinzur, Garla, Pluth and Vrbos (1996): same as above with larger sample and better control.

– Reuben, Raghunathan, and Rossing (2006): single perineural injection of bupivacaine and clonidine.

– Borghi, et al (2010): continuous infusion of ropivacaine intraoperatively and following discharge (observational study).

Preemptive Perineural Anesthesia

• Mixed results for these studies as well– Small sample sizes, lack of blinding, high attrition.

– Researchers concluded that perineural anesthesia is effective in some cases but lacks statistical significance.

– Borghi study: 84% of participants that were able to complete study had no PLP at one year followup.

Preemptive IV Ketamine

• 2 studies:

– Dertwinkle et al (2002): ketamine bolus with continuous infusion for 48 hours.

– Hayes, Armstrong-Brown and Burstal (2004): ketamine infusion.

• No statistical difference between study and control.

Conclusion• Complex nature of PLP

– Peripheral, spinal cord and supraspinal

• Anesthetic and analgesic techniques discussed are quality methods for relieving acute stump pain and phantom pain in the immediate postoperative period.

• Literature does not support preemptive anesthesia and analgesia for the prevention of chronic PLP.

• More research is needed for definitive treatment recommendations.– New pain research involving genetics and epi-genetics: i.e.,

peripheral and centrally expressed CACNG2 gene may be responsible for the development of neuropathic pain .

References

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• Bailey, A.A. & Moersch, F.P. (1992). Phantom limb, 1941. Canadian Medical Association Journal, 146(11), 1959-1965.

• Borghi, B., D’Addabbo, M.D., White, P.F., Gallerani, P., Toccaceli, L., Raffaeli, W., Tognu, A., Fabbri, N., & Mercuri, M. (2010). The use of prolonged peripheral neural blockade after lower extremity amputation: The effect on symptoms associated with phantom limb syndromes. Anesthesia & Analgesia, 111(5), 1308-1315.

• Chapman, S. (2010) Pain management in patients following limb amputation. Nursing Standard, 25(19), 35-40.

• Clark, M. & Treisman, G. (2004). Neurobiology of pain. Advances in Psychosomatic Medicine, 25, 78-88.

References• Department of Veterans Affairs/Department of Defense. (2007). VA/DoD

clinical practice guideline for rehabilitation of lower amputation. Washington, DC: Department of Veterans Affairs, Department of Defense. 1-55.

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• Fisher, A. & Meller, Y. (1991). Continuous postoperative regional analgesia by nerve sheath block for amputation surgery-a pilot study. Anesthesia and Analgesia, 72, 300-303.

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References• Hayes C., Armstrong-Brown, A. Burstal, R. (2004).Perioperative intravenous

ketamine infusion for the prevention of persistent post-amputation pain: a randomized, controlled trial. Anaesthesia and Intensive Care, 32(3), 330-338.

• Hill, A. (1999). Phantom limb pain: a review of the literature on attributes and potential mechanisms. Journal of Pain and Symptom Management, 17(2), 125-142.

• Huse, E., Larbig, W., Flor, H. & Birbaumer, N. (2001). The effect of opioids on phantom limb pain and cortical reorganization. Pain, 90, 47-55.

• Jahangiri, M., Jayatunga, A.P., Bradley, J.W.P. & Clark, C.H. (1994). Prevention of phantom pain after major lower limb amputation by epidural infusion of diamorphine, clonidine and bupivacaine. Annals of the Royal College of Surgeons of England, 76, 324-326.

• Johnson, L. (2004). The nursing role in recognizing and assessing neuropathic pain. British Journal of Nursing, 13(18), 1092-1097.

• Karanikolas, M., Aretha, D., Ioannis, I., Monantera, G., Kiekkas, P., Papadoulas, S., Swarm, R.A., & Filos, K.S. (2011). Optimized perioperative analgesia reduces chronic phantom limb pain intensity, prevalence and frequency. Anesthesiology, 114(5), 1144-1154.

References• Knotkova, H., Cruciani, R.A., Tronnier, V.M. & Rasche, D. (2012). Current

and future options for the management of phantom limb pain. Journal of Pain Research, 2012 (5), 39-49.

• Lambert, A.W., Dashfield, A.K., Cosgrove, C., Wilkins, D.C., Walker, A.J., & Ashley, S. (2001). Randomized prospective study comparing preoperative epidural and intraoperative perineural analgesia for the prevention of postoperative stump and phantom limb pain following major amputation. Regional Anesthesia and Pain Medicine, 26(4), 316-321.

• Lavand’homme, P.M. & Eisenach, J.C. (2003). Perioperative administration of the alpha-2 adrenoceptor agonist clonidine at the site of nerve injury reduces the development of mechanical hypersensitivity and modulated local cytokine expression. Pain, 105, 247-254.

• Lomen-Hoerth C., Messing R.O. (2010). Chapter 7. Nervous System Disorders. In S.J. McPhee, G.D. Hammer (Eds), Pathophysiology of Disease, 6e. Retrieved March 14, 2013 from http://www.accessmedicine.com.ezproxy.undmedlibrary.org/content.aspx?aID=5368376.

References• Madabhushi, L., Reuben, S.S., Steinberg, R.B. & Adesioye, J. (2007). The

efficacy of postoperative infusion of bupivacaine and clonidine after lower extremity amputation in preventing phantom pain and stump pain. Journal of Clinical Anesthesia, 19, 226-229.

• Mateo, M. A. & Kirchhoff, K.T. (2009). Research for Advanced Practice Nurses. New York: Springer.

• McQuay, H.J., Moore, R.A. & Kalso, E. (1998). Phantom limb pain. Lancet, 351(9102), 595.

• Melzack, R. (1990). Phantom limbs and the concept of a neuromatrix. Trends in Neurosciences, 13(3), 88-92.

• Melzack, R., Coderre, T. J., Katz, J. & Vaccarino, A.L. (2001). Central neuroplasticity and pathological pain. Annals of the New York Academy of Sciences, 933, 157-174. Doi: 10.1111/j.1749-6632.2001.tb05822.x

• Middleton, C. (2003.) The causes and treatments of phantom limb pain. Nursing Times, 99(35), 30-33.

• Morgan, G.E., Mikhail, M.S. & Murray, M.J. (2006). Clinical anesthesiology (4th ed.) New York, NY: McGraw-Hill Medical.

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References• Nikolajsen, L., Iikjaer, S., Christensen, J.H., Kroner, K. & Jensen, T.S.

(1997). Randomized trial of epidural bupivacaine and morphine in prevention of stump and phantom pain in lower limb amputation. Lancet, 350, 1353-1357.

• Nikolajsen, L., & Jensen, T.S. (2001). Phantom limb pain. British Journal of Anaesthesiology, 87, 107-116.

• Nociception. (n.d.) Dorland's Medical Dictionary for Health Consumers. (2007). Retrieved March 14, 2013 from http://medical-dictionary.thefreedictionary.com/nociception

• Perineural. (n.d.) Saunders Comprehensive Medical Dictionary, 3 ed. (2007). Retrieved March 14, 2013 from http://medical-dictionary.thefreedictionary.com/perineural

• Pinzur, M.S., Garla, P.G.N., Pluth, T. & Vrbos, L. (1996) Continuous postoperative infusion of a regional anesthetic after an amputation of the lower extremity. Journal of Bone and Joint Surgery, 78, 1501-1505.

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Management. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison's Principles of Internal Medicine, 18e. Retrieved March 10, 2013 from http://www.accessmedicine.com.ezproxy.undmedlibrary.org/content.aspx?aID=9094544.

• Reuben, S.S. Reghunathan, K. & Roissing, S. (2006). Evaluating the analgesic effect of the perioperative perineural infiltration of bupivacaine and clonidine at the site of injury following lower extremity amputation. Acute Pain, 8, 117-123.

• Richardson, C. (2008). Nursing aspects of phantom limb pain following amputation. British Journal of Nursing, 17(7), 422-426.

• Schug, S.A., Burrell, R., Payne, J. & Tester, P. (1995). Pre-emptive epidural analgesia may prevent phantom limb pain. Regional Anesthesia, 20, 256.

• Subedi, B. & Grossberg, G.T. (2011). Phantom limb pain: Mechanisms and treatment approaches. Pain Research and Treatment, 2011, 1-8 . doi:10.1155/2011/864605

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after amputation. British Journal of Nursing, 13(11), 664-667.

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• Wilson, J.A., Nimmo, A.F., Fleetwood-Walker, S.M., & Colvin, L.A. (2008). A randomized double blind trial of the effect of pre-emptive epidural ketamine on persistent pain after lower limb amputation. International Association for the Study of Pain, 135, 108-118.

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• Ypsilantis, E. & Tang. T.Y. (2010). Pre-emptive analgesia for chronic limb pain after amputation for peripheral vascular disease: A systematic review. Annals of Vascular Surgery, 24, 1139-1146. Doi:10.1016/j.avsg.2010.03.026

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References

• Ziegler-Graham, K., MacKenzie, P.L., Ephraim, P.L., Travison, T.G., & Brookmeyer, R. (2008). Estimating the prevalence of limb loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation,89(3), 422-42.

Thank YouAre There Any Questions?

Esophageal Doppler Monitoring in the Perioperative Setting

John Mikkelsen, SRNA

Introduction

• Over 27 million patients have surgery/year.

• 8 million have CAD or risk factors for CAD.

• 1 million have perioperative cardiac ischemia.

• Advanced hemodynamic monitoring is needed to limit morbidity and complications.

(Fleisher & Eagle, 2001) (Ersan, 2011)

• Cardiac output monitoring can help guide medical interventions.

Introduction• Using conventional Data alone (BP & HR)

can lead to subclinical hypovolemia.– Impaired tissue perfusion and O2 delivery

– morbidity and complications(Phan, Ismail, Heriot & Ho, 2008)

• Pulmonary Artery Catheters (PACs) used traditionally- up to 24% complication rate.

(Boyd, Thomas, Gold & Boyd, 1983)

Less Invasive Alternatives

• Esophageal Doppler monitors (EDMs)

• Pulse contour analysis technology (PCAs)

• Others

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Statement of Problem

• BP & HR can be normal while microcirculation and tissue oxygenation markedly decreased (compensation).

(Schober, Loer, & Schwarte, 2009)

• Low CO often caused by hypovolemia (fasting, anesthetic induced vasodilation, surgical blood loss, etc.) tissue perfusion leads to CO2, lactic acid

– Leads to morbidity and mortality(Gan et al., 2002)

Purpose• “Gold Standard” for CO is thermodilution via a PAC.

(Funk, Moretti, & Gan, 2009)

– Disadvantages: cost (equipment and time), health risks (arrhythmias, pulmonary infarct/embolus, infection, & pulmonary artery rupture).

(Domino et al., 2004)

• EDM a safe, quick, and less invasive.– Assess preload, afterload, contractility, and more

• PAC alternative to EDM but accuracy concern. (Meng et al., 2011) (Monnet et al., 2012) (Suehiro et al., 2013)

Significance

• age = prevalence of CV disease

• 50% of Americans 65+ will have surgery.– Equates to 20 million seniors (Ersan, 2011)

• PAC has relative high morbidity.– Complication rate 5-10% (Harvey et al., 2005) (Binanay et al., 2005)

– Must weigh risks and benefits

Significance

• EDMs can be used to optimize perfusion.– NO significant complications reported

– Reported to improve outcomes

– Reported to reduce length of stay

– First introduced in 1970s

– Used in 1,750 hospitals in 30+ countries

– 200+ clinical publications validating EDM(Keen, 2009)

Research Questions

• How does EDM compare to PAC in terms of accuracy, effectiveness on outcomes, ease of placement/use, and cost?

• How does EDM compare to PCA (i.e. FloTrac) in accuracy of CO in relation to the “gold standard” PAC?

Framework

• A physiologic framework was utilized.

• Key concepts– Cardiac Output: preload, afterload, cardiac

contractility, heart rate, Frank-Starling relationship, stroke volume.

– Hypovolemia: compensation, shock

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Overview of Methods

• Online literature search of PubMed, The Cochrane Library, and CINAHL.

• Terms: “esophageal Doppler” and “cardiac output” = 127 articles– Narrowed by adding “anesthesia” = 28 articles

and “critically ill” = 21 articles

• Additional articles acquired by links to similar articles on PubMed.

Results• Accuracy of EDMs

– Su et al. (2002): Primary CABG• “good agreement” for CO with thermodilution PAC.

– Dark & Singer (2004): meta-analysis of RCTs• “high validity” for monitoring changes in CO

compared to thermodilution PAC.

– Bein et al. (2004): CABG (EF<50%)• “clinically acceptable agreement” for continuous

CO comparing EDM, PAC, and PCA with femoral artery catheter.

Results cont.

– Chatti et al. (2009): EDM vs. FloTrac• Clinically unacceptable percentage error of SV in PCA (1st & 2nd

gen. FloTrac) compared to EDM.

• Led to development of current 3rd gen.

– Meng et al. (2011): EDM vs. FloTrac (3rd gen.)• Percentage error – ∆MAP/∆CO in response to intervention

(phenylephrine 23%, ephedrine 69%, and increased preload 96%).

• FloTrac affected with acute vasomotor change.– Accurate with increased preload,

– Less accurate with ephedrine,

– Poor with Neo (showed CO w/ FloTrac)

Results cont.

– Monnet et al. (2012): CI data- FloTrac vs. PAC• Volume expansion and norepinephrine administration

• FloTrac not reliable trending CI with Levo use – (higher the SVR = bias between FloTrac and PAC)

– Suehiro et al. (2013): FloTrac vs. PAC in CABG• CO and trend CO with SVR using phenylephrine

• Clinically acceptable for normal SVR only

Results cont.

• Effectiveness on outcomes– Gan et al. (2002): goal-directed fluid therapy

administration using EDM.• No significant change in HR or MAP between

control group and protocol group.

• Significant increase in SV, CO, and FTc (flow time corrected).

• Significant Results: shorter LOS, quicker toleration of oral solids, fewer incidences of PONV.

Results cont.

– Noblett et al. (2006): Colorectal resection• Fluid bolus given solely on EDM assessment.

• Significant for intervention group: “time to fitness for discharge”

time to “actual discharge”

- Earlier diet tolerance

intermediate or major complications

PONV

admissions to critical care unit.

• No sig diff in total volume given.

• Intervention group received fluid earlier in surgery.

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Results cont.

– Phan et al. (2008): meta-analysis of 58 RTCs • EDM to optimize intravascular volume (or SV).

• EDM guided Results: intraoperative fluid, hospital LOS, time to resume full oral diet, postop morbidity or complications.

– Figus et al. (2011): free perforator flap • EDM vs. CVP and arterial catheter.

• EDM results: return to OR, postop complications, flap survival, 1.9 days less LOS.

Results cont.

– Abbas & Hill (2008): systematic review, 5 RCTs,• EDM use during major abdominal surgery.

• EDM significant: LOS, complications, ICU admits, more rapid return of gut function.

• NO Sig Diffs: volume of crystalloid used, mean urine output, MAP after surgery, or CVP.

– Wang et al. (2008): Shock resuscitation in burns • Trending of hemodynamic parameters useful,

not absolute values of preload and CO.

Use

• Proficiency of placement in < 13 attempts

• Both conscious and anesthetized patients

• Oral or nasal (like gastric tube)

• Depth of probe at T5-6– Esophagus and descending aorta parallel

(Schober et al. 2009)

Cost

• Direct cost:– Variable in USA due to purchasing power etc.

• CMS reimbursement declared on May 22, 2007(Phurrough et al., 2007)

– In UK (Deltex medical, CardioQ EDM)• Probe- $93 for 6-hr probe to $188 for 10-day probe

• Monitor (5 year lifetime)- $12,457 – $8.75/patient if 500 patients/monitor/year

(NHS-CEP, 2008)

Cost Cont’d

• Indirect cost savings:Length of stay

• In UK, estimated at reduced LOS of 1.82 days with EDM use

– Per patient savings of:

» $4,863 for ICU

» $2,228 for step down unit

» $878 for floor bed

morbidities

time/training for insertion

Summary

• CO monitoring essential for indication of tissue perfusion in critical cases.

• EDM is safer, easier to place and use, as accurate, and possibly cheaper than Swan-Ganz.

• FloTrac is inaccurate with vasopressors.

• Use of EDM with goal-directed fluid therapy results in decreased M & M.

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