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Portfolio Project
A Course Paper Submitted In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice-­‐Anesthesia School of Nurse Anesthesia Harris College of Nursing and Health Sciences Texas Christian University By Michelle Freshcoln RN, BSN Fort Worth, Texas September 27, 2013
1 Fall 08 Table of Contents
Portfolio Project ........................................................................................................... 1 Table of Contents ......................................................................................................... 2 Introduction ................................................................................................................. 3 Fall 2011 ...................................................................................................................... 4 Concept Map – Glucometers as Disruptive Innovators ............................................................................. 5 Concept Map – Multifactoral Considerations for Cardiac Code Situation ......................................... 6 Decision Analysis – Optimal Level of Fraction Inspired Oxygen ........................................................... 7 Cost Effectiveness Analysis -­‐ Comparison of Anesthesia Provider Models ................................... 17 Reflective Self Evaluation Fall 2011 ............................................................................................................... 22 Spring 2012 ................................................................................................................ 27 Research Proposal – Massive Blood Transfusion Protocol .................................................................. 28 Narrative Review .................................................................................................................................................... 43 Additional Work -­‐ 2011 TANA Annual Convention Reflection ........................................................... 54 Reflective Self Evaluation Spring 2012 ......................................................................................................... 60 Summer 2012 ............................................................................................................. 64 Tutorial PowerPoint Audio Imbedded .......................................................................................................... 65 Research Article Critique – Chreode Theory of Molecule Diffusion ................................................. 67 Research Article Critique – CRNA Prescribing Practices ....................................................................... 71 Additional Works – Malignant Hyperthermia Worksheet/Presentation ....................................... 85 Reflective Self Evaluation Summer 2012 ..................................................................................................... 89 Fall 2012 .................................................................................................................... 93 Clinical Case Report – Carbon Dioxide Embolism .................................................................................... 94 Additional Work – Medical Mission Trip .................................................................................................... 102 Clinical Log ............................................................................................................................................................... 104 Reflective Self Evaluation Fall 2012 ............................................................................................................. 107 Spring 2013 .............................................................................................................. 110 Clinical Case Report – OLV inability to tolerate ....................................................................................... 111 Narrative Review – POVL following Robotic Procedures ................................................................... 120 Reflective Self Evaluation Spring 2013 ....................................................................................................... 136 Additional Works – Washington DC Mid-­‐Year Assembly .................................................................... 138 Research Poster – POVL in Steep Trendelenburg ................................................................................... 142 DNP Project PowerPoint Presentation ........................................................................................................ 143 Summer 2013 ........................................................................................................... 145 Case Report-­‐ Epidural Placement and Thrombocytopenia ................................................................ 146 Professional Leadership Policy Paper – Timing Perioperative Antibiotics ................................. 151 Evidence of Oral Professional Presentation .............................................................................................. 157 Evidence of Peer-­‐Reviewed Publication Submission ............................................................................ 158 Reflective Self Evaluation: Summer 2013 .................................................................................................. 159 2 Introduction
This portfolio displays a collection of scholarly activities complied to capture the
education and professional growth progression throughout the TCU nurse anesthesia
curricula. Each submission within the portfolio demonstrates evidence of learning in one
or more of the competencies outlined for the certified registered nurse anesthetist
(CRNA) practitioner at the doctorate level. The Core Competencies, according to the
TCU handbook are as follows:
3 Fall 2011
4 Concept Map – Glucometers as Disruptive Innovators
Core Competency: Technology and Informatics
Description: Through visual imagery, this concept map exists as evidence of ability to
convey a message with various techniques. This specific concept map describes how
glucometers are an example of a technological innovation that has changed a now outdated process.
5 Concept Map – Multifactoral Considerations for Cardiac Code Situation
Core Competency: Professional Role
Description: This concept map visually depicts an aspect of the advanced cardiac life
support (ACLS) protocol while also showing extraneous factors that influence this
process. 6 Decision Analysis – Optimal Level of Fraction Inspired Oxygen
Core Competency: Health Systems Management
Description: This assignment comparison varying levels of fraction inspired oxygen
(FiO2) in order to determine the optimal level to deliver to a patient during general
anesthesia. The student evaluated various research articles and evaluated data to arrive at
a conclusion.
Decision Analysis - Optimal Level of Fraction Inspired Oxygen During General
Anesthesia
Michelle Freshcoln, BSN
Texas Christian University – Doctorate of Nurse Practice in Nurse Anesthesia
May 1, 2011
7 Introduction
Oxygen is an essential component of life, and during general anesthesia, it is up to
the anesthesia provider to not only monitor the patient’s oxygen levels, but also to
determine the ideal amount of fraction of inspired oxygen (FiO2) to administer to the
patient. The anesthetist ensures that the patient receives enough oxygen, however
research suggests that too much oxygen may in fact hinder the wellbeing of the patient.
Therefore, researchers have been striving to find an optimal level of FiO2 for patients to
receive during routine general anesthesia. The purpose of this decision analysis paper is
to explore optimal FiO2 delivery.
Both Sides of the Dilemma
In determining the optimal level of FiO2 to be administered during general
anesthesia, the anesthetist’s first priority is the patient’s safety. There are several reasons
an anesthetist may consider using high levels of oxygen. One benefit of using a high
amount of FiO2 is the delay time before life-threatening hypoxemia develops during
endotracheal intubation.1 Researchers have also attempted to link high levels of FiO2 with
a decrease in postoperative nausea and vomiting (PONV) as well as decreased prevalence
of surgical site infection.2 However, using FiO2 1.0 actually causes small distal airway
closure within five minutes and often leads to atelectasis.3 In order for the anesthetist to
provide the most optimal outcome for the patient undergoing routine general anesthesia,
researchers compare the affects of differing levels of moderate hyperoxia, a level of FiO2
ranging from 0.21 to 0.5, to FiO2 of 1.0.
8 Review of Literature
A review of literature reveals research pertaining to both sides of the dilemma.
Rothen examines and refutes the theories of high levels of FiO2 reducing PONV and
surgical site infection.2 He establishes that while two studies have confirmed a reduction
of PONV, subsequent studies fail to reproduce the same results.2 Out of three metaanalyses, two showed an ability of high levels of FiO2 to prevent surgical site infection,
and the third was unable to confirm a reduction of infection rates.2 The literature review
also reports findings of a more recent randomized trial involving 1400 patients not
included in the meta-analyses that showed no difference in the presence of surgical site
infection related to varying levels of FiO2.2 This finding would have the capacity to
change the results of the first two studies, which showed a reduction of infection rates.
The researchers findings show FiO2 1.0 causes airway closure within five minutes
and often leads to atelectasis.3 In addition to this finding, the literature shows a lower
level of FiO2 results in a more ideal PaO2/FiO2 ratio.1 Unanimously, researchers agree
FiO2 of 1.0 harms the health of the patients far more than it benefits them.
The EBSCO (MEDLINE with Full Text) database was used to obtain these
articles.4 A five year timeline and a search of, "FiO2 and general anesthesia" produced
one result. It was necessary to expand the search to ten years back from the current date
and change the search criteria to “oxygen administration fraction inspired oxygen in
general anesthesia." SmartText Searching option was used to weigh the importance of
each word to find relevant articles.4 This method located the additional articles.
Eight-step process
9 The Alemi 8-step process is a cyclical approach which allows the review of the
data and thorough exploration of all options.5 It provides a template to organize and
compile data in a clearly defined manner by guiding the researcher to divulge further into
the topic. The process provides an outline for the problem− it identifies the people the
problem influences, elements already known, areas for further research, and requires a
sensitivity analysis and explanation of the results. This process helps to explore the issue
of ideal oxygenation.
1. Identify the Decision Makers, Constituents, Perspectives, and Timeframes
The decision maker is the anesthetist who selects the level of FiO2 to
administer. The constituents are the patients. The perspectives are of the
patient, the anesthetist, and physicians.
2. Explore the Problem and the Role of the Model
The researchers aim to address how much supplemental oxygen is ideal to
administer to the patient undergoing routine general anesthesia. Research
suggests the human body responds differently to varying levels of oxygen,
and may influence post operative nausea and vomiting, surgical site
infection, atelectasis, and airway collapse. 1,2,3 It is important to know
which of these claims are valid and how the anesthesia provider can aid in
ensuring the best possible outcome.
3. Structure the Problem
The options for varying levels of FiO2 range from room air, 0.21, to full
oxygen administration, 1.0. Research compares the physiologic responses
of patients who receive high and low levels of FiO2.
10 4.
Quantify the Values
Outcomes of utilizing low to moderate FiO2
- Improves PaO2/FiO2 ratio during anesthesia1
- Applied over 2 hours exacerbates lung injury2
- Allows for a longer amount of time before airway closure3
Outcomes of utilizing high FiO2 of 1.0
- Allows more time before hypoxemia develops
- Decreases post operative nausea and vomiting2
- Increases arterial vasoconstriction3
- Decreases coronary blood flow3
- Decreases functional residual capacity2
5. Quantify the Uncertainties
- Patients with preexisting lung disease
- Length of procedure
- The use of FiO2 in conjunction with positive end-expiratory
pressure3
- Research for specific types of procedures as related to FiO2
administration
6. Analyze the Data and Recommend a Course of Action
The study by Agarwal et al. found 0.4 FiO2 in air significantly improved
PaO2/FiO2 ratio during anesthesia.1 However, for safety reasons they
suggest that anesthetist continue using 1.0 O2 during preoxygenation and
11 induction of anesthesia should be continued.1 Further studies are necessary
to compare the results of using varying levels of lower FiO2.1
7. Conduct a Sensitivity Analysis
This step is important to identify how various assumptions affect the
conclusion.
8. Document and Report Findings.
The Bayesian Approach
The Bayesian approach is beneficial because it measures risks and allows for
hypothetical questions. The approach “focuses on observable quantities: the actual
population and the knowledge available.”6(p2) Research has already shown FiO2 of 1.0
causes airway closure after five minutes so this does not need to be retested because of
the detrimental side effects it has on the patient. Depriving a patient of oxygen is also an
unacceptable practice, so researchers can evaluate these scenarios through the risk
assessment tree. This approach also allows the anesthetist to consider the individual
aspects of each case.
A decision analysis tree for this topic can be lengthy with all the possibilities. As
research progresses, more branches can be added, and researchers will propose FiO2
suggestions based on evidence. One example of a decision analysis tree related to this
topic is as follows:
12 Event Tree – Choosing the optimal FiO2 level General
Complications
Anesthesia?
Expected?
Cardio-pulmoary
Disease?
PEEP
Available?
Procedure-specific
FiO2 Research available?
Level? yes low, varies (see research) yes no no low no low no FiO2 yes yes varies (see research) start high adjust as tolerated yes Article Review
In the randomized control study “Oxygen in Air (FiO2 0.4) Improves Gas
Exchange in Young Healthy Patients During General Anesthesia,” Agarwal et al.
compares the use of FiO2 of 1.0 to FiO2 of 0.4 in 27 patients undergoing elective
laparoscopic cholecystectomy. 1 The author uses a random approach and evaluates the
PaO2/FiO2 ratios after treatment with both levels of oxygen. The sample size is small.
The authors provide the reader with enough information to replicate the study. The study “The Impact of Positive End-Expiratory Pressure on Functional
Residual Capacity and Ventilation Homogeneity Impairment in Anesthetized Children
13 Exposed to High Levels of Inspired Oxygen” was published by Ungern-Sternberg et al.3
The article compares FiO2 of 1.0 to FiO2 of 0.3 and provides the anesthetist with the
option of positive-end-expiratory pressure (PEEP). This study evaluates 46 children
undergoing routine general anesthesia for combinations of PEEP with the varying levels
of FiO2 and measures functional residual capacity, dead-space volume, lung clearance
index, mean dilution number, and tidal volume. In this report authors go into great depth
to describe all techniques and cite references appropriately. The final article, “Oxygen: Avoid too Much of a Good Thing!” by Rothen
systematically reviews and summarizes the findings of seven studies related to optimal
amounts of FiO2 in general anesthesia. The article gives insight on the reasons higher
levels of oxygen had been considered in the past. The author properly cites and explains
each study, but he merely presents the results rather than critical details readers need to
properly evaluate the quality of each study. This requires the researcher to review each
article individually before including the results in scientific data. It is impossible to
ensure the reliability of each survey from this article alone, so the researcher must review
each article individually before incorporating the results into scientific data. The article
benefits research by providing insight on the topic and an understanding of the various
opinions, however, additional research is necessary to verify the validity of each study.
Summary
Researchers agree lower oxygen levels are more beneficial than FiO2 of 1.0.
Agarwal suggests FiO2 of 0.4 and Ungern-Sternberg et al suggests FiO2 of 0.3 with the
addition of PEEP.1,3 There may be no optimal FiO2 that works for all patients, but either
14 of these suggestions are justifiable. Further research is still required on the subject of
optimal FiO2 during general anesthesia. Future research should evaluate factors such as
type of surgery, age, co-morbidities, gender, length of procedure, and other ventilation
options such as PEEP. The anesthetist takes these factors into consideration, forms the
plan of care for each individual patient, and uses clinical judgment to modify that care in
order to maintain an optimal oxygen saturation level in order provide the ideal level of
FiO2 to their patients.
As a result of the data analyzed it remains inconclusive exactly the optimal level
of FiO2. The decision to titrate FiO2 should be formulated on an individualized basis,
using clinical judgment to maintain optimal perioperative oxygenation.
References 1. Agarwal A, Singh P, Dhiraj S, Pandey C, Singh U. Oxygen in air (FiO2 0.4)
improves gas exchange in young healthy patients during general anesthesia. Can J
Anesth [serial online]. December 2002;49(10):1040-1043. Available from:
MEDLINE with Full Text, Ipswich, MA. Accessed February 15, 2011. 2. Rothen HU. Oxygen: avoid too much of a good thing! EJA. 2010;27(6):493-494.
doi: 10.1097/EJA.0b013e3283396360 3. Ungern-Sternberg BS, Regli A, Schibler A, Hammer J, Frei F, Erb TO. The
impact of positive end-expiratory pressure on functional residual capacity and
ventilation homogeneity impairment in anesthetized children exposed to high
levels of inspired oxygen. ANESTH ANALG. 2007;104(6):1364-8. doi:
10.1213/01.ane.0000261503.29619.9 15 4. EBSCOhost - MEDLINE with Full Text Database. Ipswich, MA: EBSCO
Publishing 2011. Updated December 30, 2010. Accessed April 23, 2011.
5. Alemi F, Gustafson DH. Decision Analysis for Healthcare Managers. Chicago,
IL: Health Administration Press; 2007.
6. Sollid SJ, Lossius HM, Nakstad AR, Aven T, Soreide E. Risk assessment of pre-
hospital trauma airway management by anaesthesiologists using the predictive
Bayesian approach. Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine. 2010; 18 (22), 2 - 10. Accessed April 23, 2011. 16 Cost Effectiveness Analysis - Comparison of Anesthesia Provider Models
Core Competency: Healthcare Improvement and Health Systems Management
Description: This assignment two articles discussing comparing anesthesia delivered by
an anesthesiologist to that which is delivered by a CRNA. The articles were evaluated for
content and validity. It was up to the student to determine whether the articles were
reliable.
What is the purpose of each article? Be specific. How are the purposes different
from each other?
The purpose of the study by Glance is “to evaluate the incremental cost
effectiveness of anesthesia workforce staffing scenarios, as a function of skill mix, by
using the technique of decision analysis” in order to determine the level at which
physician supervision is no longer costs effective.1(p584)
The purpose of the study by Hogan et al. is to inform payers, employers,
legislators, and investors “regarding the cost, quality, and access implications of alternate
delivery models.”2(p160)
The first article aims determine at what point the benefits of having a physician no
longer are outweighing the costs. It is assumed in this article that a physician provides
superior care to that of a nurse anesthetist.1(p585) This differs from the second model
which relies on the assumption that the different provider types result in the same quality
of care.2(p160)
What factors were included in each article's decision-analysis model? Which of
these were based on assumption? How do these assumptions affect the CEA?
17 The article by Glance used the decision tree model to compare five different
staffing scenario models including physician only, nurse only, and doctor to nurse ratios
of 1:2, 1:4, and 1:8. In each scenario, doctors provided anesthesia for all high-risk
cases.1(p584) Other factors include cost per anesthetic unit, cost per provider, and mortality
rate divided into primary or secondary classifications.1(p586)
Glance states “Medicare rules mandate an anesthesia provider mix neutral
approach to billing.”1(p585) Reimbursement is the same regardless of the provider type
within the Medicare structure, but outside of it, “there is no consistent reimbursement
formula for CRNAs.1(p585) This fact leads to the assumption that policy-makers may
change this policy in attempt to lower costs.1(p585)
As previously stated, this article is also based on the assumption that
“anesthesiologists working alone result in better patient outcomes than CRNAs working
either alone or with minimal medical direction.”1(p585) Other factors considered in the first
article include success measured by years of life saved, insurance types, and primary and
secondary mortality rates.1(p586)
In contrast, the second article’s assumption uses a reliance on literature “to
establish that there is no evidence to suggest that the quality of services or the outcomes
will vary across the delivery models.”2(p160) Since no literature was found to disprove the
theory, it is assumed quality of care between CRNAs and anesthesiologist are equal.2(p161)
Other factors considered include the cost of providing service and the cost of
educating each type of provider.
These assumptions are opposite and seen in the approaches to the study. Because
the first article felt that the physicians provide better quality of care, they included the
18 measures of quality such as the mortality rates. Because the second article felt no
difference existed, it was not closely measured as a contributing factor in the study.
Why should a CEA conduct a sensitivity analysis? Why do you think these articles
did not conduct one?
A sensitivity analysis is a “technique used to determine how different values of an
independent variable will impact a particular dependent variable under a given set of
assumptions.”3 This is appropriate for a CEA because when analyzing costs, many times
single contributing factors are able to be manipulated each having varying effects on the
overall outcome.
The first study partially used a sensitivity analysis. “By using one-way sensitivity
analysis, the effect of varying the estimates for the model variable through a range of
plausible values was investigated.” 1(p588)
The second article is based on an assumption deducted from their findings in
literature. The authors concluded “there is no evidence to suggest that the quality of
services or the outcomes will vary across the delivery models was considered.”2(p160)
Neither of the studies used a complete sensitivity analysis because of the lack of a
measureable dependent variable. According to Glance, to demonstrate smaller differences
in outcome more than 18,000 patients are needed. To investigate the primary mortality
only, more than 2,000,000 participants are required. According to the authors this type of
analysis may not be possible.1(p591) The second study was based on assumptions made
from a lack of evidence. This is also due to the same dependent variable that is unable to
be measured.
19 If you were making a decision related to an anesthesia delivery model and you were
presenting an argument for a certain type of provider/mix to your institution's
CEO, which one of these articles would you cite? Convey the basis of your decision
with appropriate citations.
I would cite the article by Glance. This article attempts to determine the safety of
the patients per varying model type. I think this is an important factor. If the patients are
not safe, the cost is irrelevant. There is a small improvement in patient outcome when the
physician to CRNA ratio is increased from 1:8 to 1:4.1(p584)
Another point Glance bring up is that the “independence of NPCs may allow them
to replace, rather than complement, their physician counterparts in certain settings
(5)”1(p584) I think this brings up a valid point. Anesthesiologist have educational
requirements twice as long as their complementing CRNAs. Although professional
experience has its place, classroom education is noteworthy. Anesthesiologist can be
good points of reference for nurse anesthetists.
Finally, I feel this article has less bias. Glance proposes several different options
and their benefits. The 1:4 ratio is preferred for patient safety where as the 1:8 ratio is
preferred for cost management. These proposals leave room for both CRNAs and
Anesthesiologists.
Reference List
1. Glance, LG. The cost effectiveness of anesthesia workforce models: A simulation
approach using decision analysis modeling. Anesthesia Analgesia. 2000;90:584 - 592.
2. Hogan, PF, Siefert, RF, Moore, C S, Simonson, BE. Cost effectiveness analysis of
anesthesia providers. Nursing Economics. 2010;28(3):159 - 169.
20 3. Investopedia. Sensitivity analysis. Available at:
http://www.investopedia.com/terms/s/sensitivityanalysis.asp. Accessed March 25, 2011.
21 Reflective Self Evaluation Fall 2011
Core Competency: Professional Role
Description: A reflective self-evaluation allows the course work and performance to be
evaluated for constructed criticism. It also recalls major events during the semester and
serves as a marker for personal growth in the profession.
Ever since the beginning years of life I have heard the phrase “It won’t be this
easy when you get to” followed by the next major step in my life. I remember hearing
that from the elementary school teachers in reference to middle school and the middle
school teachers about being in high school. I adapt well to change and like to think I
easily breezed through these years of my life while excelling at all I set to accomplish.
My ability to adapt also made my transitions to college and even my first job seem only
slightly more than effortless. The long history weaved with empty promises of trying
challenges to come left me with a reasonable amount of doubt that anesthesia school
would come with anymore difficultly than I had previously faced when presented with
the same promise. In fact, I was so used to the typical outcome that no conversation
would have changed my mind prior to my first semester in the Texas Christian University
(TCU) School of Nurse Anesthesia in the Doctorate of Nursing Practice (DNP) program.
My first fully loaded semester was packed with more details than I knew existed
about the human body, foreign concepts in chemistry, an extensive list of pharmacologic
agents, and a doctoral-specific translational research class. I had papers and research, and
for the first time found a need for and utilized a study group. Outside of school, life was
a rollercoaster. A few unexpected deaths, a couple much-anticipated weddings and the
22 time it took to accommodate these events contributed to making this transitional semester
the challenge it was.
Though each class required meticulous studying and preparation, there was only
one class in which I felt I was fighting an uphill battle with. I gave more time to the
advanced pharmacology class then I have ever dedicated to any other commitment in my
life. I can say without hesitation this class was the biggest scholastic challenge of my
academic career. Following each test I talked with the professor or another faculty
member and altered my study methods. I learned to prepare ahead of time for the
unexpected. A twelve-hour study day became common for me. I do not have the
responsibility of supporting a family at this time, so fortunately my schedule allowed me
to do this. Each test left me slightly disappointed, but not defeated. Anesthesia has been a
dream of mine for years and so I fought on. By the end of the semester I still do not have
all the kinks worked out, but I am refreshed for the new semester with an unrelenting
persistence.
The biggest weakness of mine throughout the academic challenge is the presence
of a mental block that tries to take root in my mind. At times merely thinking of the next
exam in this class gave me anxiety. I perceive anxiety as a futile emotion which causes
more detriment than benefit. At times I still must talk myself out of this one in order to
reach my goal of success both scholastically and in my future practice as a certified
registered nurse anesthetist.
The translational research course paved the way towards thinking as a DNP. It
taught me how to analyze research and to then convert all of my new found knowledge
23 into emerging, evidenced-based practice. Each large assignment played a particularly
important role in my doctoral education process.
The first task in the class was to choose a topic for further research. Prior to the
first assignment I struggled largely with knowing how to find a topic of interest. I looked
at suggested ideas, talked to friends, and searched databases and journals with little
success. After a little guidance from my professors and advisors, I finally settled on the
topic of massive blood transfusion protocols (MTP).
It was not until I received my graded first assignment that I realized that it is okay
to choose a topic before fully understanding all the complexities of it. I had been going
about the process backwards. I attempted to find literature to support a conclusion I
imagined instead of using literature to formulate a conclusion. Once I gained this
understanding I was able to narrow my topic down further to a more focused and
applicable study topic which I was then able to use for the remainder of the semester.
The second assignment, a synthesis of literature, taught me the essence of
translational research. After receiving my second synthesis back, I realized I had been
thinking about the intervention wrong as well. Originally, I thought the purpose of the
intervention was to demonstrate that the newly implemented intervention worked how
literature predicted it would. In my case, I thought the intervention of a MTP needed to
have outcomes that showed decreased mortality rates following MTP implementation.
With guidance, I learned that the point of translational research is to use what has already
been researched to improve clinical practice. Research has already shown MTPs to be
beneficial. Therefore, the evaluation measures how well the facility responds to the
24 transition process in the areas of education of the staff to maintenance of the new
intervention.
It was the last and final large assignment of the class that I value most. I learned
to compile all the research and information I have and present it in a quick and practical,
one-page form. This will be very useful in clinical settings when it is important to make a
point quickly and clearly without compromising the value of the project. This step is the
call to action. Through these assignments, I understand that my role as a DNP is to
become a leader and an initiator of change. My understanding of the translational
research process has been strengthened, and I have developed the tools necessary to
continue building this skill.
This semester I had the interesting experience of attending a Texas Association of
Nurse Anesthesia conference. It was exciting to interact with the many individuals who
have already accomplished what I am now striving for. The lectures attended were
informative in many aspects of the profession. I was able to gain more understanding in
both the clinical and political side of nurse anesthesia. I learned about current issues that
affect anesthesia and also about emerging practices not yet available in all facilities. The
most pleasant surprise of this meeting was seeing the pride current anesthetist have for
their profession, and their desire to continue to improve it. It was encouraging to see
nurse anesthetist of all ages and levels of experience enjoying their profession.
To sum it up, my first fall semester of the DNP program was anything but easy. I
faced more challenges than I anticipated, and I expect to encounter more challenges as
25 the program persists. Each challenge presents opportunities to learn and thrive, and that is
exactly what I plan to do for the next semester and the remainder of my career.
26 Spring 2012
27 Research Proposal – Massive Blood Transfusion Protocol
Core Competency: Biological Systems, Homeostasis and Pathogenesis
Description: This assignment utilized various techniques to evaluate research and present
the findings.
Massive Blood Transfusion Protocol: A Narrative of Proposal
Michelle Freshcoln RN, BSN
Harris College of Nursing and Health Sciences
Texas Christian University
November 21, 2011
NRAN 73195: Narrative Proposal Paper
Instructor: Dr. Welliver CRNA, DNP, ARNP
28 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
Introduction
Hemorrhage is the leading cause of preventable death in trauma patients.1-4 The
universally accepted treatment for massive hemorrhage includes replacement of blood
products; however, there is no standard recommendation for how to execute massive
blood transfusions.5 Literature defines massive transfusion as the transfusion of greater
than 10 units of packed red blood cells (PRBC) in 24 hours.2-8
Researchers first discussed the issue of massive blood transfusions in the 1970s
with an associated mortality rate of greater than 90% of patients. 2(p198) A review of
literature performed for adult trauma patients, 18 years and older, shows mortality rates
for those who require a massive blood transfusion still remain high today at near 50%.1,3,4
Massive transfusion protocols (MTPs) are among various interventions that healthcare
facilities have developed in order to decrease the high mortality rates of the
hemorrhaging patient.2-4
Intervention
A review of literature shows massive blood transfusion protocols provide for
efficient administration of massive amounts of blood products and lead to a decrease in
the prevalence of patient mortality.2-4,6-8 For this reason researchers recommend
institutions utilize MTPs based on best practice recommendations from current literature.
The following includes a sample protocol, an analysis of the facility, the internal and
external changes required, and the effects of implementation analyzed in the format of
strengths, weaknesses, opportunities, and threats (SWOT). The sample protocol was
obtained from Rossaint et al. who published updated evidenced-based guidelines to
structure the acute management of the hemorrhaging trauma patient.9
29 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
30 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
Type of Facility for Implementation
The implementation of a massive blood transfusion protocol may benefit any
hospital, but is most applicable to designated trauma centers. Collaborative care is
necessary for the treatment of trauma patients within the facility. The departments
involved include the emergency room (ER), the operating room (OR), and the intensive
care unit (ICU), blood bank, and the laboratory. The ER personnel conduct initial
assessments and care for patients upon arrival to the facility. Physicians in the ER will be
responsible for initiating the care sequence. Healthcare providers in the OR are
responsible for surgical management of severe injuries sustained from trauma, for replace
blood lost, and for the prevention of further exsanguination. The ICU receives the
patients postoperatively, and the staff monitor the patients and continue blood
replacement therapy if necessary. Blood bank staff must be prepared to administer blood
at a rapid
External and Internal Situational Analysis Factors
External
Situational
Analysis
Factors
Demographic
Trauma is the leading cause of death for the 1-44
years age group. Hemorrhage is responsible for
80% of deaths while in the OR and 50% of
deaths in the first 24 hours following injury.4
The prevalence of trauma is unrelated to gender
or race. The patient population will differ for
each facility.
Economic
Patients’ ability to pay will be an unrelated issue
due to the emergent nature of trauma. Funding of
hospitals will be individualized per facility.
Legal
The legal considerations involved in the
implementation of a MTP align with standard
considerations in the treatment of patients in a
healthcare facility. Additional legal conflicts are
not anticipated.
31 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
Policy
The universally accepted treatment for massive
hemorrhage includes replacement of blood
products; however, there are no standard
recommendations for how to execute massive
blood transfusions. 5 Therefore, a conflict of
policy with MTP implementation should not
occur.
A review of literature supports the use of rFVIIa.
The FDA has approved rFVIIa for treatment of
hemophilia and congenital disease, but it is not a
first line drug for bleeding.9 The use of rFVIIa
for treatment of hemorrhage is an off-label use
not supported by FDA. The use of a drug for offlabel use may conflict with the policy of the
facility.
Social
Literature does not suggest external social
conflicts to arise with MTP implementation.
Research suggests the best results of MTPs occur
when all members think and act like a team.4
Technological
Information
The change does not have technology
requirements. If the technology already exists,
the protocol may be converted into electronic
form for easy transmission of data.
Costs to implement
the project
The monetary costs to implement massive blood
transfusion protocol changes include the cost for
additional recommended material and staff.
Recommended materials that trauma centers
may or may not already have include blood
warmers, tourniquets, and bedside serum lactate
analyzers. 9 Hemorrhaging patients require
immediate care for optimal outcomes. 9 Adequate
staffing of the trauma center includes surgeons,
intensivists, nurses, radiology personnel, and
adequate lab staff. 9 Literature considers the use
of adjunct therapies, such as rFVIIa, which may
be an additional cost. 9 The staff of each involved
departments will need to take time to be
educated.
Human resources
necessary
The facility will require sufficient personnel in
order to obtain optimal patient outcomes. Staff
recommended for the treatment of trauma
Internal
Situational
Analysis
Factors
32 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
Marketing
Operations analysis
patients includes surgeons, intensivists, nurses,
lab personnel, radiology personnel, and
anesthesia providers.
Internal marketing is directed towards staff
education. An education coordinator will need
to provide education material to prepare the staff
to provide optimal levels of care.
The staff must be properly educated for the
implementation process to take effect. It is
reasonable to think any modifications should be
an easy transition from current practices. Many
recommendations suggest quickly obtaining lab
results, blood products, and immediate OR
access which can occur through improvements in
existing systems.
Identified Factor in SWOT Format
•
Strengths – The MTP will provide an algorithm for clear, organized, and directed
care. The authors include suggestions for implementation based on current
literature.
•
Weaknesses – All patients are different and may require interventions not
addressed in the protocol. In these situations clinical judgment will take priority.
Trauma cases are highly unpredictable, and optimal treatment requires staffing a
hospital for the unknown. The type of physicians and materials required for
treatment will be unknown until a patient presents.
•
Opportunities – Protocols have led to reductions in mortality rates, blood product
use, and time to receiving care. 4 The implementation of planned care through a
protocol provides opportunity for studies to further explore the effects of
structured treatment.
33 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
•
Threats – Implementation of a protocol will require the participation and
cooperation of many departments. 4 The facility must dedicate sufficient time,
money, and commitment in order to obtain the most optimal results.
Model
The Rosswurm and Larrabee model provides structure to facilitate this change
using evidenced based practice.10 The six-step model incorporates quantitative data,
qualitative data, clinical expertise and contextual evidence to systematically guide
healthcare professionals through a process to change to evidence-based practice. It
begins with problem assessment and ends with integration of an evidenced-based
protocol. This model is useful in describing the change that will occur in a facility
implementing an evidenced-based MTP.
34 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
Step 1 – Assess Need for Change in Practice
The process begins when stakeholders realize an area of dissatisfaction.
Stakeholders include administrators, ER physicians, surgeons, nurses in each of the
involved unit, blood bank and laboratory staff, and patients.10 The researcher performed a
review of literature to assess the need for an improvement in practice. The area of
dissatisfaction is the high mortality rate, near 50%, of patients requiring a massive blood
transfusion.1,3,4 Facility administrators must evaluate current practices and outcomes at
their facility and compare the results to external, evidenced- based data. Assessing the
mortality rate for the year prior to MTP implementation establishes a baseline, which is a
necessary comparator to the outcomes resulting from the change.
In addition to comparing the mortality rate, the procedure for massive blood
transfusion should be evaluated. Literature has shown administration of massive amounts
of blood products works best in a predefined, protocol driven system.4 If a protocol is not
being utilized at the facility, it is likely that care provided is slower and more inconsistent
than what could be achieved with the use of a protocol. The review of literature has
shown MTPs to lead to a decreased time to transfusion, decreased amount of blood
products used, and decreased mortality rate following implementation.2-8
Step 2 – Link Problem with Interventions
The problem of high mortality rates in trauma patients requiring massive blood
transfusion is linked to the intervention of implementing an evidenced based MTP. The
MTP will require a doctor’s order, most commonly from the ER physician, and will be
utilized for any patient foreseen to require greater than 10 units of PRBC. The
35 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
coordinator will measure the outcome of patient mortality rates after the facility has
implemented the protocol, and compare the results to the baseline rates.
The coordinator should encourage communication between those involved in the
change and direct attention towards identifying resources and standards for cost and
effectiveness of care.10 These factors are addressed in the external and internal situational
analysis.
Step 3 – Synthesize Best Evidence
The researcher performed a review of literature and a synthesis of literature to
evaluate the strength of evidence. Researchers suggest the implementation of a MTP
leads to a well coordinated process that results in decreased mortality, decreased time to
transfusion, and decreased amount of blood products used.2-8 The included protocol by
Rossaint et al. reflects best practice based on current literature.
Step 4 – Design a Change in Practice
In order to facilitate a change, staff must be involved education on the new
protocol and actively participate to maintain the change.10 The facility should appoint a
coordinator to aide in education and maintenance of the MTP implementation. The
coordinator will direct the education process and the staff of all units involved including
the ER, OR, ICU, blood bank, and the laboratory. All staff involved should attend
educational staff meetings in which the new protocol is presented, with rational, in a
variety of formats such as paper handouts and PowerPoint presentations, and posters. The
coordinator should provide the staff with opportunities to ask questions at the time the
material is presented and as they come up in the first few months after MTP
36 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
implementation. Once education has been completed, the coordinator should prepare the
staff for a pilot study. The pilot study allows practitioners to influence adaptation of the
change to fit their practice needs. 10
Step 5 – Implementing and Evaluating Change
Upon implementation of the pilot study, the coordinator should be available to
answer questions and actively communicate with staff. The pilot study is more
successful if the coordinator of the study closely monitors the process and is available to
the staff, and this will ease the process of change.10 The facility should make the new
protocol readily available through online access or paper forms for the staff to review as
needed. The facility will evaluate the change for compliance to the protocol and the
effects the protocol has on mortality rates through a chart review method. The
coordinator should perform mortality rate evaluations at the one month, six month, and
one year time markers from the time of MTP implementation and compared to baseline.
The coordinator must remember that numerous factors other than the intervention,
including characteristics of patients, staff, interpersonal aspect of care, and the setting,
can affect the results and should be taken into consideration upon evaluation. 10 Table 1,
provided by Dente et al. is useful in organizing many of the various factors to consider.
Step 6 – Integrate and Maintain Change
37 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
The coordinator needs to consider the culture climate of the organization as he or
she integrates practice innovations.10 The staff are more likely to accept the change when
they participate in the change.10 To create participation, the coordinator should inform
staff of the compliance and mortality rate outcomes each time they are measured. In the
final steps, the coordinator should reevaluate the protocol based on results from the pilot
study. Adjustments may be made if necessary, and the facility should adopt the protocol
as the new standard practice. Adherence to details of the organization’s operations and
approval processes ensures a smooth and speedy integration of the change. 10
Step 1
Step 2
Step 3
• Assess Need for Change in Practice
• The area of dissatisfaction is the high mortality rate, near 50%, of patients requiring a massive blood transfusion.1,3,4
• Link Problem with Interventions
• The intervention is a standard MTP based on evidence.
• Synthesize Best Evidence
• A review and synthesis of literature supports MTP recommendations.
Step 4
•  Design a Change in Practice
•  A MTP is recommended. A pilot test is necessary to allow practitioners to indluence adaptation of the change to dit their practice needs. 10
Step 5
•  Implementing and Evaluating Change
•  After implementation, outcomes should be measured after one month, six
months, and one year.
Step 6
•  Integrate and Maintain Change
•  Inform staff of the outcomes each time they are measured to encourage participation in the new change.
38 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
Outcomes to be Evaluated
The facility should evaluated the mortality rate following MTP implementation,
and compare the results to the rate prior to MTP implementation. The coordinator should
also evaluate staff compliance with the protocol. The coordinator should perform chartreview evaluations at one month, six months, and one-year intervals from the time of
implementation in order to monitor the progression of change over time. The following
figures show two standard tools of measurement
that may be utilized to ensure organized comparison
of the data.
Baseline Mortality Rate -­‐ • Number of Patients _____ meaured from one year • Number of Deaths ______ prior to protocol • Percentage of Mortality _____ implementation One month after MTP implementation • Number of Patients _____ • Number of Deaths ______ • Percentage of Mortality _____ Six months after MTP implementation • Number of Patients _____ • Number of Deaths ______ • Percentage of Mortality _____ One year after MTP implementation • Number of Patients _____ • Number of Deaths ______ • Percentage of Mortality _____ Table 1 Data Collected
Clinical data
Age
Gender
History of anticoagulant use
Mechanism of injury
Anatomic injury, type and severity
Injury severity score
Vital signs on admission
Initial base deficit
Time to and length of 1st operation
Use of damage control procedure
Crystalloid infusion, 1st 6 and 1st 24 h
Outcome data
24 Hour mortality
30 Day mortality
Hospital mortality
Hospital length of stay
ICU length of stay
Ventilator days
Laboratory data
Emergency department
Blood counts (hemoglobin, hematocrit)
Platelet counts
Coagulation parameters (PT, INR, aPTT)
Fibrinogen level
ICU admission
Blood counts (hemoglobin, hematocrit)
Platelet counts
Coagulation parameters (PT, INR, aPTT)
Fibrinogen level
24 Hours after ICU admission
Blood counts (hemoglobin, hematocrit)
Platelet counts
Coagulation parameters (PT, INR, aPTT)
Fibrinogen level
Transfusion data *
1st 6 h
1st 24 h
Hospital stay
PT = Prothrombin Time; INR = International Naturalized
ratio aPTT = activated Partial Thromboplastin Time
Table provided by Dente et al.6
39 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
Conclusion
The implementation of planned care through an evidenced-based protocol
provides an organized approach which leads to numerous benefits including reductions in
mortality rates, blood product use, and time to receiving care.4 The SWOT analysis and
review of external and internal factors demonstrate that the benefits of MTP
implementation outweigh the risks. Once a facility makes the decision to implement an
MTP, the facility should facilitate the change in the least complicated manner. A
coordinator will provide education and guidance during the process and ensure
progression of change. The coordinator will assess the outcomes and encourage
participation after implementing the MTP in order to maintain the change. The
coordinator should make adjustments to best fit the needs of the facility while adhering to
evidence based on the most current literature.
Reference List
1. Curry N, Hopewell S, Dorée C, Hyde C, Brohi K, Stanworth S. The acute
management of trauma hemorrhage: a systematic review of randomized
controlled trials. Critical Care [serial online]. April 2011;15(2):R92. Available
from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 19, 2011.
2. Riskin D, et al. Massive transfusion protocols: the role of aggressive resuscitation
versus product ratio in mortality reduction. Journal of The American College of
Surgeons [serial online]. August 2009;209(2):198-205. Available from:
MEDLINE with Full Text, Ipswich, MA. Accessed November 19, 2011.
40 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
3. Cotton B, et al. Damage control hematology: the impact of a trauma
exsanguination protocol on survival and blood product utilization. Journal of
Trauma [serial online]. May 2008;64(5):1177-1183. Available from: CINAHL
Plus with Full Text, Ipswich, MA. Accessed November 19, 2011
4. Nunez T, Young P, Holcomb J, Cotton B. Creation, implementation, and
maturation of a massive transfusion protocol for the exsanguinating trauma
patient. J Trauma [serial online]. June 2010;68(6):1498-1505. Available from:
CINAHL Plus with Full Text, Ipswich, MA. Accessed November 19, 2011.
5. Schuster K, Davis K, Lui F, Maerz L, Kaplan L. The status of massive transfusion
protocols in United States trauma centers: massive transfusion or massive
confusion? Transfusion [serial online]. July 2010;50(7):1545-1551. Available
from: MEDLINE with Full Text, Ipswich, MA. Accessed November 19, 2011.
6. Dente C, et al. Improvements in early mortality and coagulopathy are sustained
better in patients with blunt trauma after institution of a massive transfusion
protocol in a civilian level I trauma center. J Trauma [serial online]. June
2009;66(6):1616-1624. Available from: CINAHL Plus with Full Text, Ipswich,
MA. Accessed November 19, 2011.
7. Mohan D, Milbrandt EB, Alarcon LH. Black hawk down: the evolution of
resuscitation strategies in massive traumatic hemorrhage. EBM Journal [serial
online]. July 2008:12:305. Available from: MEDLINE with Full Text, Ipswich,
MA. November 19, 2011.
41 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
8. Malon DL, Hess JR, Fingerhut A. Massive transfusion practices around the globe
and a suggestion for a common massive transfusion protocol. J Trauma [serial
online]. June 2006.
9. Rossaint R, Bouillon B, Spahn D, et al. Management of bleeding following major
trauma: an updated European guidline. Critical Care [serial online]. April
2010;14(2):R52. Available from: CINAHL Plus with Full Text, Ipswich, MA.
Accessed November 19, 2011.
10. Rosswurm M, Larrabee J. Clinical scholarship. A model for change to evidencebased practice. Image: Journal of Nursing Scholarship [serial online]. October
1999;31(4):317-322. Available from: CINAHL Plus with Full Text, Ipswich, MA.
Accessed November 19, 2011.
42 THE IMPACT OF MASSIVE BLOOD TRANSFUSION PROTOCOLS
Narrative Review
Core Competency: Biological Systems, Homeostasis and Pathogenesis
Description: This synthesis of literature compiles research and translates it into useable
information to advance evidence based practice.
The Impact of Massive Blood Transfusion Protocols: A Synthesis of Literature
Michelle Freshcoln RN, BSN
Harris College of Nursing and Health Sciences
Texas Christian University
October 24, 2011
NRAN 73195: Synthesis Project
Instructor: Dr. Welliver CRNA, DNP, ARNP
43 The Impact of Massive Blood Transfusion Protocols on Patient Mortality
Background
Hemorrhage is the leading cause of preventable death in trauma patients. 1-4 The
issue of massive blood transfusions was first discussed in the 1970s with an associated
mortality rate of greater than 90% of patients. 2(p198) Although healthcare has seen many
beneficial changes since the 1970s, a relatively high level of mortality related to
exsanguination remains.1-3 Research to improve outcomes on patient mortality has led to
a number of suggested interventions. No universal recommendations currently guide the
care of the hemorrhaging patient. 5(p1550)
Massive transfusion is most commonly defined as the transfusion of greater than
10 units of packed red blood cells (PRBC) in 24 hours, although a variety of definitions
exist.2-8 Massive transfusion protocols (MTPs) are among various interventions that have
developed in response to high mortality rates of the hemorrhaging patient.2-4 The use of
MTPs has become more frequent over the past few years. 4, 5 The outcomes of
implementing such protocols remain a relatively new topic, and the effects on patient
mortality are still being debated.4,5,8
It is known that the mortality rate of patients requiring massive blood transfusions
remains relatively high, current treatment provided to these patients is not standardized,
and that protocols are emerging in response to this issue. In regards to massive blood
transfusions, it is still uncertain what role protocols have in reducing patient mortality,
what the impact is of varying interventions within the protocols, such as blood product
ratios and adjunct therapies, and how commonly MTPs are used.
44 Synthesis of Literature
The prevalence of mortality related to massive blood transfusions is well
documented.1-8 A review of literature shows mortality rate in patients who require a
massive blood transfusion has declined to near 50%.1,3,4 Researchers identify that only
3%-5% of civilian trauma cases will require a massive transfusion, however, this small
population consumes 75% of all blood products at urban trauma centers. 4(p2) Traumaassociated coagulopathy is a complication closely related to trauma induced
hemorrhage.4(p1) It is reported in at least 25% of patients upon arrival to the trauma unit
and is a contributing factor to high mortality rate.4(p1)
Though the goals for massive transfusion are similar, the methods for executing
this process vary significantly.1,5 A common goal in gross blood replacement is to have
the required blood products readily available and to administer the proper amount
required by the patient.4(p1) A recent systematic review of 35 randomized control trials
found interventions for the care of hemorrhage are largely heterogeneous and
recommends a coordinated strategy for administering care to the hemorrhaging
patient.1(p7)
Protocols are among the suggested interventions for improving mortality rates. 2-4
Protocols provide an algorithm to standardize care within a facility.4(p1) It is rational to
believe trauma institutions share the common goal of decreasing the amount of time
between patient presentation and initiation of blood transfusion while optimizing patient
outcomes. However, the reality of the situation is that facilities’ goals for MTPs are
45 multifold and strive to improve on factors such as cost effectiveness of care, amount of
blood products used, the type of blood products used, time from request for blood
products to time of delivery of blood products, time to hemostasis, and mortality rates.1-8
This multifold goal has led to numerous studies on the use of MTPs.
It is certain that protocols produce a wide range of results.2-8 The review of
literature suggests the most common benefit of using MTPs is the reduction of time until
blood products are obtained.2-4 A retrospective study by Cotton et al. reported the use of
an MTP allowed blood products to be obtained at an early and continuous rate. 3 This
change contributed to a 74% reduction in mortality in the group treated with the protocol
as compared to treatment without the protocol. 3(p1180) The researches credit the success of
the protocol to an earlier time to treatment, and an aggressive and predefined manner of
care.3(p1181) This is a valuable study, however the review of literature revealed few other
studies with results as reliable.
As previously mentioned, it is uncertain what impact protocols have in decreasing
patient mortality. The strong inconsistencies that exist in current management of blood
transfusions contribute to this uncertainty.1,5 Various studies address the issue of patient
mortality, but at the time of protocol implementation, other changes in care are made.
Riskin et al. performed a study over the course of four years surrounding the time of
MTP implementation. 2(p198) The study included 77 subjects and measured time from
patient presentation to documentation of the first patient-specific blood product
administered. Observations of blood product types transfused were documented. There
was a decrease in mortality rate from 45% pre-transfusion protocol to 19% post-protocol
implementation.2 Though a reduction of mortality is clear, findings are complicated by
46 the fact that the protocol also altered the ratio at which blood products were administered.
It is unclear whether the reduction of mortality can be credited to the protocol or the
altered ratio.
One of the complications encountered when assessing the outcome of MTPs is
that researchers are unable to agree on what best practice is for the hemorrhaging patient,
and therefore, cannot agree on what needs to be included in the protocols.1,5 Topics such
as administering varying blood product ratios and using adjunct therapies are highly
intertwined with the implementation of MTPs.2,4,5 Two studies reviewed focused protocol
implementation on reduction of mortality and control of coagulopathy.6, 7 The studies
both show decreased mortality following protocol implementation. 6, 7 Increased survival
rates were reported in correlation with implementation of new protocols which ordered
high plasma to RBC ratio. Because the high plasma to RBC ratio and the protocol were
new interventions, the reason behind the improvements is unclear.
The use of adjunct therapies within protocols has been suggested to lead to
improvements in patient outcomes.2(p199) These interventions include
thromboelastography (TEG) and recombinant human activated factor VIIa.2,4,5 A review
of literature shows studies involving recombinant-activated factor VIIa and cell-saver
devices were unable to confirm an improvement in mortality rates. 1,2,4,5
Protocol algorithms vary significantly due to the fact that many best practice
suggestions are not supported by consistent, reliable evidence.4,5 Some facilities report a
decrease in mortality after implementing a protocol, but the studies are unable to be
repeated in order to verify results. Furthermore, researchers are unable to give credit to
47 the ratios of blood products administered or the rapid provision of care for the improved
outcomes.5
The review of literature suggests MTPs are being used more frequently. It is
unclear what percentages of hospitals currently utilize MTPs. Attempts have been made
to gather information on the prevalence of MTPs and the contents of the protocols. Two
survey studies were conducted in order to evaluate current use of massive blood
transfusion protocols. The first survey reviewed was conducted in 2005 by Malone et al.
The authors found “relatively few institutions with MTPs” despite an extensive search.8
Though survey responses were analyzed, the percentage of hospitals that use protocols
verses those that do not is not included in the article. Additional literature also suggests
that the use of MTP is a relatively new practice that has grown significantly in the past
five years.5 At the time the first study was conducted, the topic of massive blood
transfusion protocols was gaining interest.
A second set of surveys sent out in 2009 cultivated a total of 245 responses. 5(p1545)
Researchers created the survey to gain information pertaining to utilization and content of
MTPs. Researchers found that 85% of the institutions surveyed employ a MTP. 5(p1545) In
comparing the two surveys it appears that protocols are being utilized at a growing
number of facilities. This conclusion is limited by the fact that only two individual
surveys were obtained, and one survey lacked the statistical evidence needed to verify
this assumption.
A synthesis of literature shows a need to improve the mortality rate in patients
requiring massive blood transfusions. Many suggestions exist, and some, such as massive
48 blood transfusion protocols, are being implemented. MTPs have been reported to have
various beneficial results. At this time a standard recommendation is not possible due to
the heterogeneous nature of the protocols and the lack of best practice guidelines to direct
massive blood transfusions.
Intervention
Implementation of studies producing higher levels of evidence is recommended so
the impact MTPs have on reducing patient mortality can subsequently be determined.
Literature search
A search of literature was performed in the CINAHL and Medline databases using
“massive transfusion protocol” as a search term between September 2011 and October
2011. An initial search of CINAHL database provided 14 results, and MEDLINE
provided 26 results. Only full text articles were considered. Studies which specifically
investigated non-trauma related patients, pediatric patients, and patients that did not
qualify as requiring a massive blood transfusion were excluded from the review of
literature. A majority of published studies found are retrospective cohort studies which
compare outcomes of newly implemented protocols to previous practice.2,3,6,7 One
systematic review of 35 randomized control trials (RCT) for the acute management of
trauma hemorrhage was obtained.1 Other significant literature includes literature reviews
and surveys which provide insight on the current status of massive blood transfusion
protocols in various hospital settings.4,5 A 2010 article by Nunez et al. provided an
extensive review of literature in order to guide trauma facilities in planning and
implementing a MTP. Numerous references are made to studies which relate to the
49 implementation of a MTP.4 Unfortunately, this recent and extensive review of literature
also noted a strong absence of high levels of evidence.4
Levels of Evidence
Reviewed articles were assigned a level of evidence using an adapted version of
the Oxford Centre for Evidence-Based Medicine Levels of Evidence (LOE) document.9
Levels range from Level I, the strongest level which includes systematic reviews, through
Level VII, the lowest level which includes expert opinions. A review of literature shows a
significant lack of level I and level II evidence evaluating mortality rates associated with
massive blood transfusion protocols. Most studies retrieved are retrospective cohort
studies with some prospective aspects. The following table lists studies in descending
order of levels of evidence.
Table 1: Levels of Evidence
Article
Year
Article Type
Level of
Evidence
Subject Number Major Findings
Curry et al.
2010
Systematic
review of
RCT
Level I
35 RCT
No significant
improvement in mortality
rates related to trauma
hemorrhage have resulted
in the past decade.1(p1)
Cotton et al.
2008
Retrospectiv
e study
Level IV
211
117 pre TEP
The use of a protocol
decreases mortality and
blood product
consumption.3(p1177)
94 TEP
-pre TEP group
was selected as
those how
would be most
comparative
50 Dente et al.
2009
Prospective
and
retrospective
cohort study
Level IV
157
84 – pre- MTP
73-MTP
The use of the protocol
with aggressive use of
FFPs decreased the 24hour mortality rate.
Blunt trauma patients
showed a decrease in 30
day mortality rate.6(p1616)
Mohan et al.
2008
Retrospectiv
e study
Level IV
246
Protocols utilizing a 1:1
ratio of plasma to RBC
decreases mortality.7
Riskin et al.
2009
Retrospectiv
e cohort
study
Level IV
77
Researchers found a
reduction in mortality:
40 – preprotocol
37 – MTP
18 deaths of 40 patients
studied pre MTP as
compared to 7 deaths of
37 patients studied with a
MTP. Results may be
related to time to first
transfusion which also
significantly decreased.
2(p198)
Increased units of
platelets transfused were
associated with decreased
mortality. 2(p198)
Researchers suggest the
use of protocols is more
important for timing than
the ratios used.
Conclusion
Numerous studies report decreased mortality rates and other beneficial results
after implementing protocols. It is unclear as to which interventions during many
protocol initiations led to these findings. It appears that an organized approach to patient
care will likely lead to improved results. MTPs may provide the organization necessary to
result in aggressive, rapid and improved treatment of the hemorrhaging patient. It is on
51 this premise that further research of protocol use in relation to decreasing mortality rate is
encouraged.
Reference List
1. Curry N, Hopewell S, Dorée C, Hyde C, Brohi K, Stanworth S. The acute
management of trauma hemorrhage: a systematic review of randomized
controlled trials. Critical Care [serial online]. April 2011;15(2):R92. Available
from: CINAHL Plus with Full Text, Ipswich, MA. Accessed October 7, 2011
2. Riskin D, et al. Massive transfusion protocols: the role of aggressive resuscitation
versus product ratio in mortality reduction. Journal Of The American College Of
Surgeons [serial online]. August 2009;209(2):198-205. Available from:
MEDLINE with Full Text, Ipswich, MA. Accessed October 6, 2011.
3. Cotton B, et al. Damage control hematology: the impact of a trauma
exsanguination protocol on survival and blood product utilization. Journal of
Trauma [serial online]. May 2008;64(5):1177-1183. Available from: CINAHL
Plus with Full Text, Ipswich, MA. Accessed October 7, 2011
4. Nunez T, Young P, Holcomb J, Cotton B. Creation, implementation, and
maturation of a massive transfusion protocol for the exsanguinating trauma
patient. J Trauma [serial online]. June 2010;68(6):1498-1505. Available from:
CINAHL Plus with Full Text, Ipswich, MA. Accessed October 7, 2011.
5. Schuster K, Davis K, Lui F, Maerz L, Kaplan L. The status of massive transfusion
protocols in United States trauma centers: massive transfusion or massive
confusion?. Transfusion [serial online]. July 2010;50(7):1545-1551. Available
from: MEDLINE with Full Text, Ipswich, MA. Accessed October 6, 2011.
52 6. Dente C, et al. Improvements in early mortality and coagulopathy are sustained
better in patients with blunt trauma after institution of a massive transfusion
protocol in a civilian level I trauma center. J Trauma [serial online]. June
2009;66(6):1616-1624. Available from: CINAHL Plus with Full Text, Ipswich,
MA. Accessed October 7, 2011.
7. Mohan D, Milbrandt EB, Alarcon LH. Black hawk down: the evolution of
resuscitation strategies in massive traumatic hemorrhage. EBM Journal [serial
online]. July 2008:12:305. Available from: MEDLINE with Full Text, Ipswich,
MA. Accessed October 7, 2011.
8. Malon DL, Hess JR, Fingerhut A. Massive transfusion practices around the globe
and a suggestion for a common massive transfusion protocol. J Trauma [serial
online]. June 2006.
9. Melnyk, B., Fineout-Overholt, E. Evidence-based practice in nursing and
healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, and
Wilkins. 2005: 10
53 Additional Work - 2011 TANA Annual Convention Reflection
Core Competency: Professional Role
Description: This submission summarizes each session attended at the Texas Association
of Nurse Anesthetist convention. Attending professional meetings helps to ensure based
practice based on current literature, and promotes the profession through collaboration
with other professionals.
2011 TANA Fall Annual Convention
September 23-24, 2011
Plano, TX
Friday September 23
0700-0800
Reversing Inhaled Anesthetics: Returning Patients Quickly to Baseline –
Derek Sakata, MD
I have not yet had any clinical experiences of my own, therefore I did not realize that this
was a problem that could go on for an extended length of time. During this lectured I
learned that increased ventilation will help remove the anesthetic agent since exhalation
helps to eliminate the drug from the body. I also learned that a decrease in CO2 will
decrease the blood flow to the brain and will therefore slow recovery.
0800-0900
Ethics for Certified Registered Nurse Anesthetists – James R. Walker,
CRNA, DNP; Susan Willis, CRNA; and Trey Blocker, JD
54 This lecture was a review of the ethics class I took as an undergraduate student. I feel
like the speaker said, there are many ways to view a situation. Even though most of the
lecture was a refresher, I had never seen the “How to Live Ethically” set of rules by Tao
Te Ching which was written 7-4 BC. I thought it was very interesting and I honestly find
it easier to relate to these set of rules rather than one specific ethical principle.
0930-1030
Anesthetic Considerations for Major Orthopedic Procedures for the Pelvis:
The Hemipelvectomy Paul Myers, CRNA, MS
This lecture discussed high amounts of blood loss and replacement specifically during
pelvic tumor resection. I knew this was an area that bled significantly, but I never knew
it was this significant. The speaker gave valuable suggestions such as have 8-12 units
PRBCs and 4 FFP ready prior to the surgery. Another suggestion I took from this lecture
was the importance of staying in front of blood replacement. Even though frequent labs
are being sent, begin to replace blood when you see significant blood loss even if the
results have not yet returned.
1030-1130
Robotic Surgery: Innovations in Anesthesia Melissa Morris, CRNA, MS
This discussion was informative on the history and the future of robotic technology in the
operating room. I have never seen this type of procedure and before this lecture I knew
little about it. It seems there is still much work to be done in this field before it becomes
a feasible option for common procedures.
55 1300-1400
Fluid Management – A Paradigm Shift – Sarah Goss, CRNA
This lecture discussed fluid management. I thought it was interesting to that the CVP is
not necessarily the best indicator of fluid volume. Instead it was recommended to
evaluate the SVV in some patients. I also found it interesting that the speaker suggested
fluid volume replacement may be overestimated for reasons such as stress induced from
surgery will lead to renal conservation of water. These are good points to consider for
the future.
1400-1500
Advances in Intraperitoneal Hyperthermic Perfusions (IPHP) Darline
Hurst, CRNA
I have not had much experience with oncology or pediatric patients. I had not heard of
this type of treatment prior to this nor have I heard of other more commonly used
comparative treatments. Much of this lecture I could not relate to, however I did find it
interesting that this treatment comes with a 6-8 month estimate for time to recover back
to a preoperative quality of life. This is a serious point to consider and to convey to the
patient.
1530 – 1630 Recombinant Factor VII Use in Trauma Patients Kirk Evans, CRNA,
MSNA
I enjoyed this lecture on Factor VII use. I was not aware before this that the FDA needed
to not only approve the drug, but also which uses it was able to be promoted for. I think
it is also interesting the military used this drug so extensively. The positive and negative
56 aspects of this drug were discussed, but at the moment the cost of treatment seems
excessive for prolonged treatment. It will be interesting to see the future of this drug.
1630 – 1730 Amniotic Fluid Embolus: The Bad, The Ugly, and The Really Bad Donovan
Earley, CRNA, MS
I had no idea so little was known about this condition before this lecture. I think it is
interesting that not much research has been made in this area in the past 10 years, yet
there is so much to learn on this topic. This situation seems like it would best be handled
like many crisis situations and at the moment there is very little that will foreshadow this
often fatal event. From this lecture I gathered that much more research is needed in this
area.
Saturday
September 25
0700-0900
Intraoperative Transesophageal Echocardiography
I have been present for TEEs before and have even had the pictures explained to me
while the procedure was occurring. Although I understood the basics, this lecture
explained in detail what things were really being looked for. This was a good lecture. I
don’t think I took in all the information that I will need to know for the future, but this
was a good introduction for me and will need follow up as my education continues.
0930-1030
Pediatric Burns and Traumatic Airways – Mark Talon, CRNA, DNP
I really liked this lecture. I have never worked at a hospital with a burn unit so some of
this pictures really came across as shocking to me. Burn and traumatic airways will take
57 a lot of skill to master. There seem to be many tricks and a lot to know. Seeing as how I
can’t establish any airways yet it all seems complicated. I look forward to these
challenges in the future.
1030-1130
Non-traditional Hemodynamic Monitoring - Mark Talon, CRNA, DNP
Some of this technology was beginning to be introduced to the first hospital I worked at
just before I left. I had some training with similar technology and very little practice. It
was a good review of the information I had already known, but there was also a lot that
was new to me. I feel this will become increasingly common and more often seen by the
time I get into practice.
1130–1230
Region 7 AANA Update – John McFadden, CRNA, PhD
This discussion was very informative on the current status of CRNAs in the united states
and Texas. It was interesting to see things such as expected retirement dates of current
CRNAs. This directly impacts us and our future ability to find jobs. It was nice to see a
sense of community between CRNAs.
1230-1430
TANA Annual Business Meeting and Luncheon
This was a very nice lunch. During the meeting nominations and elections for new
offices were conducted. The discussions were governed by strict parliamentary
procedure, which I am now glad I learned during my undergraduate years. Those
directing the meeting were very excited to see students present at the meetings and
58 encouraged us to return. Overall it was a nice and informative lunch. It showed the more
political and governing side of TANA.
1430-1530
Student Session – Difficult Airways – Noah Reese, CRNA
I absolutely loved listening to this many talk. Some of the techniques for manipulating
difficult airways mimicked what had previously been suggested in the other sessions
however this was more geared towards students, which helped. The part I enjoyed most
was hearing the stories from the military and seeing his pictures. I have tossed around
the idea of this before and everything he showed looked so exciting.
Attended:
13 educational hours
Attended:
2 business meeting hours
Attended:
1 student session hour
Michelle Freshcoln
Clinical site: Tampa, Fl
59 Reflective Self Evaluation Spring 2012
Core Competency: Professional Role
Description: This self-evaluation of Spring 2012 helps to document progress through the
program. It provides opportunity to reflect on strengths, weaknesses, and professional
growth.
Self-Reflection: Spring 2012
Michelle Freshcoln BSN, RN
Texas Christian University – Doctorate of Nurse Practice in Nurse Anesthesia
May 3, 2012
60 Introduction
The second semester ending, and I can see the sigh of relief in the near future. The
end of a semester brings a glimmer of encouragement that I have survived another
semester and four months closer to accomplishing my dream from so long ago. The final
weeks of a semester also carry the burden of realizing all that remains to be accomplished
and preparing for stepping into the impending unknown. Rumors float around the
classroom of horrors of the next round of classes, and of bad experiences from previous
student resident nurse anesthetist (SRNA) students. As the week of finals approaches, it
is easy to feel all the stressors of the semester magnify.
I was recently asked by a friend, “What is it that makes anesthesia school
so difficult.” At the time I was at a loss for words. This semester is no exception to my
previous semesters where stress seems to accumulate despite my best resolutions from
the first day of class. The sources of stress this semester include working relationships
with peers and faculty, financial burdens, and balancing home-life with heavy workload
of learning what seems to be endless information. Of this list, the last issue of time
management has been the most prevalent issue, and also the most beneficial, for a
professional future, to conquer while still in the classroom.
Reflection
The demands of this program provide its due amount of stress. There are 5 tests
scheduled for the final two weeks of the first spring semester. Each test holds the promise
of dismissal from school if the student is unable to demonstrate competence in the
subject. In accordance with the second DNP competency of developing a professional
61 Freshcoln role, these stressful conditions oblige the students to adapt in order to experience
successes. Through adaptation to the high demands, the professional skills of time
management first learned in nursing school, and later the intensive care unit, become
refined.
One particular manifestation of the honing of this skill was my improved plan for
studying. I found myself preparing to study so much that a few days before the test I had
made enough flashcards to fill a library, yet the material still felt foreign. So much of my
time had been spent making flashcards, and organizing information into neat, color-coded
charts, that I left no time to learn the contents. I felt the need for crash study sessions to
cram as much information as possible into my already congested memory bank. Upon
this realization I determined I needed to not only allot time for each class, but I also need
to schedule in advance how that time needed to be spent. For example, if I had 8 hours to
study, for each class I could spend one hour creating study materials and the following
hour reviewing what I had just prepared.
According to a 2010 online article from the American Association of Nurse
Anesthetists, nurse anesthesia students cope with school in stages.1 Students fully realize
the importance of and refine time-management between 10 and 18 months into the
program. This is in accordance with the student understanding expectations of the faculty
and taking responsibility for their own education.1 Although it was clear time
management was essential upon acceptance into the program, I can see myself taking
even more responsibility for all that is required and transitioning thought into what will
be expected upon commencement of the clinical portion of my education.
62 62 Freshcoln Conclusion
Based on one of my previous listed stressors, rumors, I anticipate the program
intensity continually increasing with each upcoming semester. The improvement of stress
and time-management is the foundation for success. Stress is an inevitable part of any
challenge. It is a positive response to that stress that will develop students into adaptable
and valuable professionals.
References
1. Phillips J. Exploring student nurse anesthetist stressors and coping using grounded
theory methodology. AANA Journal [serial online]. December 2010;78(6):474-482.
Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 2, 2012
63 63 Freshcoln Summer 2012
64 64 Freshcoln Tutorial PowerPoint Audio Imbedded
Core Competency: Healthcare Improvement and Practice Inquiry
Description: This presentation describes a framework for evidenced based practice. The
ability to add sound to a presentation shows an addition manner in which inform can be
presented to others.
65 65 Freshcoln 66 66 Freshcoln Research Article Critique – Chreode Theory of Molecule Diffusion
Core Competency: Technology and Informatics
Description: This assignment enhanced the ability to evaluate research by providing a
step-by-step method for article evaluation.
Element of critique
Comments by critics
What are the theoretical
-
foundations for this theory?
Chreode Theory of Molecule Diffusion – chreodes,
pathways, created through the water near the protein
surface permit rapid diffusion of molecules to the
receptors1(p109)
-
Nonspecific Volatile Anesthetic Activity – Weak binding
occurs to produce the anesthetic effect with volatile,
nonspecific drugs. The non-specific agent acts at
multiple receptor landscapes.1(p110)
-
Relation Between General Anesthesia and Sleep –
anesthesia and sleep are related and “the mechanism of
both sleep and anesthesia is the inhibition located in
neurotransmission systems.”1(p110)
-
A Theory of Sleep – Nitrogen is the exogenous substance
leading to sleep. Various levels of nitrogen in the body
results in different levels of the elimination of
wakefulness.1(p110)
Provide an overview of the
The theory suggests that pathways are created to assist in the
67 67 Freshcoln theory in clear language.
rapid transmission of molecules to many receptors.
Anesthesia is produced by a decline in many receptor
functions.1(p110) Nitrogen acts as a nonspecific drug, meaning
it bonds to many sites and produces the anesthesia effect.
Sleep and anesthesia share similar properties which suggest
that the principles for one may be applied to the other.
Nitrogen may induce normal sleeping and waking patterns
due to the fluctuation of the levels in the body at different
times. Since nitrogen may produce regular sleep, it explains
why higher levels of nitrogen produce anesthesia.
How is this theory
Explanatory – “Explanatory theories expand the knowledge
classified? (practice,
base by delineating the relationships between characteristics
prescriptive, descriptive,
of the phenomenon, clarifying why it is happening.” 2(p26)
etc)
What are the major
-
concepts of this theory?
Water properties and molecular bonding – the making
and breaking of hydrogen bonds, diffusion of a substance
through water, hydrophobic and hydrophilic
properties1(p109)
-
Receptor site binding – “The proposed molecular
mechanism of anesthesia is based on small encounters at
many sites on a protein, not at the receptor on its
surface.” 1(p110)
-
An agreement of the desired goal – “reversible
68 68 Freshcoln characteristics including analgesia, amnesia,
unconsciousness, and skeletal muscle relaxation.”1(p110)
-
Fluctuations of levels of Nitrogen in the body result in
varying levels of consciousness. 1(p111)
What are the relationships
It is proposed that higher levels of the inhaled agent,
among the concepts?
Nitrogen, influence the structure of the passageways,
chreodes, which alters their function leading to the desired
goal of anesthesia.
How can this theory be used
It is proposed that Nitrogen levels naturally and predictably
in practice?
fluctuate. If there is a target level of Nitrogen needed to
induce anesthesia, then the characteristics which may predict
levels of nitrogen in the body, due to variables such as
normal sleep patterns, should be taken into consideration
when calculating the amount of anesthesia needed for each
patient.
Is this theory structured to
To measure this theory, it would be necessary to be able to
reflect evidence from
measure the amount of nitrogen in the body over extended
measurement or is this
periods of time to see the fluctuations in levels during daily
theory too esoteric to invite
functioning and various levels of consciousness. Although
measurement?
this is not currently possible, I do not believe technology is
too far off from this, and it may be a possibility in the future.
69 69 Freshcoln References
1. Kier, LB. A Review of Recent Studies Relating Ligand Diffusion, General
Anesthesia, and Sleep. AANA Journal. 2008 April;76(2):109-12
2. Peterson, SJ, Bredow, TS. Middle Range Theories: Application to nursing
research. 2nd ed. Philidelphia, PA. Lippincot Williams & Wilkins. 2009:26.
70 70 Freshcoln Research Article Critique – CRNA Prescribing Practices
Core Competency: Technology and Informatics
Description: This research article critique essay demonstrates the ability to assess
research and present the material as a scholastically written, and evidence supported
evaluation.
Quantitative Article Critique
CRNA Prescribing Practices: The Washington State Experience
Louise Kaplan, Marie-Annette Brown, Dan Simonson
Critiqued by
Michelle Freshcoln RN, BSN
Texas Christian University
71 71 Freshcoln Introduction
In 2005 the state of Washington granted authority to certified registered nurse
anesthetists (CRNAs) to prescribe schedule II through IV controlled substances to their
scope of practice. A 2011 AANA Journal article presented a study conducted by Dr.
Louis Kaplan, Dr. Marie-Annette Brown, and Dan Simonson, a CRNA, to evaluate how
the recently extended scope of practice is being utilized by those affected by the change.
This was a descriptive study. Information was gathered through a survey method. This
critique will review the ethical aspects, research problems, literature reviews, conceptual
and theoretical frameworks, research design, quantitative sampling designs, data
collection procedures, data quality, quantitative analyses, and the discussion Kaplan et al
presented in their study.
Ethical Aspects
The researches did not need to take extra steps to prevent harm to the participants
because the participants were not subjected to any physical harm or psychological
distress. The participants in this study were mailed a questionnaire and therefore
received the benefit of the results without any potential risk or discomforts experienced.
Both society and the participants benefited from the study without any cost to the
participants other than their time to fill out the questionnaire. No type of coercion or
influence was used to recruit participants. The questionnaire used “was mailed in 2006 to
CRNAs licensed in Washington with addresses in Washington, Oregon, and Idaho.” 1
(p24)
The participants were also not deceived in any way. Consideration of vulnerable
subjects is not applicable to this study due to the fact that participants were not put at risk
72 72 Freshcoln in anyway. The participants’ privacy was protected in that only demographic data was
used such as gender, education and age. The study received “institutional review board
approval.” 1 (p 26)
Research Problems, Research Questions, and Hypotheses
The research problem presented is what extent are CRNAs with the option to
prescribe scheduled II through IV controlled substances using the increased scope of
practice. This can contribute to CRNA practice in that it can give them a fully
autonomous scope of practice. 1 (p 24) There is a good match between the research problem
and paradigm in that in this case the researchers are seeking to see how CRNAs with
prescriptive authority are “limited by law adapt their practice to prescribing constraints
and then transition to a new scope of practice when the law changes.” 1 (p 24) The problem
is addressed as a statement of purpose, as previously mentioned. The purpose is located
in a separate paragraph title “Study Purpose” making it clear and concise. The wording of
the purpose of the study could have been slightly better in that it could’ve have included
what factors were analyzed in relation to the adoption of prescriptive authority. However
the study group was identified as CRNAs within Washington, Oregon, and Idaho. 1 (p 26)
This is a descriptive study; the researchers are attempting to “describe a group of
individuals on a set of variables, to document their characteristics. Descriptive data allow
researchers to classify and understand the scope of clinical phenomena, often providing
the basis for further investigation.” 2 (p. 22) Because this is a descriptive study, there is not a
defined hypothesis but rather a purpose of the study. This study has two purposes the first
being to describe Washington State CRNA prescribing practices and workforce and
practice characteristics. A secondary purpose of the study was to analyze factors related
73 73 Freshcoln to Washington State CRNAs’ adoption of prescriptive authority. As previously
mentioned this study does not state a hypothesis and therefore is non-directional because
the researchers are not seeking to either to predict or not predict the relationship between
to variables. 2 (p 867-868 The study also does not have a research hypothesis because the
researchers are not stating their true expectations of the results. 2 (p 135) However, it is
possible to say that that the purpose of the study could be a null hypothesis in that there
may be no relationship or difference between the dependent and independent variables
(having prescriptive authority or not have the prescriptive authority.) 2 (p 135)
Research Literature Reviews
A figure within the article is presented that summarizes the status of CRNA
prescribing across the nation. As per the article “this figure is the result of a review of
the statues and rules of each state, consultation with boards of nursing staff when
clarification was necessary, and review by interested participants in several CRNA
electronic mailing list.”1 (p 25) The most recent research reports cited is, “Recommended
Scope of Practice of Nurse Anesthetist and Anesthesiologist Assistants” from American
Society of Anesthesiologist in 2010. The review of literature relies mainly on research
reports ranging from 1988 to 2010. The content within in the reports comes from CRNA
and Anesthesiologist sources.
The review supports the need for new research in that this study only looks at a
section of an entire country and profession. In order to fully understand if having the
ability the prescribe schedule II through IV controlled substances impacts the CRNA
practice a study on a larger and more depth scale would need to be performed. The
review of literature is divided up into two sections, the first being CRNA Prescriptive
74 74 Freshcoln Authority and the second Prescribing Medications. The review is concluded with the
statement, “limitations in CRNA prescriptive authority are in part a result of
interprofessional challenges between CRNAs and anesthesiologist. To confront practice
barriers, nurse anesthetist and others need data about CRNA prescribing practices.” 1 (p 25)
The style of the review is appropriate, it does not rely heavily on quotes but rather
paraphrases the literature reviewed. The researchers present a lot of facts regarding
current CRNA practice and the requirements for prescribing medications. However, it
could be construed as bias by not presenting why CRNAs do have limits on their
prescriptive authority. The reviewer uses appropriate language. The review of literature is
well written and easy for the reader to understand why the research is being conducted
based on the literature reviewed and the current lack of literature on the specific topic.
Conceptual and Theoretical Framework
The theoretical framework for this research is based on that “there is little
literature regarding CRNAs and prescriptive authority. No research about prescriptive
authority for CRNAs was located in PubMed, CINAHL, the Cochrane Library Clinical
Evidence, the National Guideline Clearinghouse, and the American Association of Nurse
Anesthetist (AANA) website.” 1 (p 24)
Conceptual framework is an organized way of thinking about how and why a
project takes place. 3 The major concepts of this framework are expressed opinions of
CRNAs that have the ability to or have obtained prescriptive authority and how this
adaptation affects the autonomy and prescribing practices of CRNAs. The framework is
consistent with the paradigm, which is “a set of concepts that constitute a way of viewing
75 75 Freshcoln reality in an intellectual community.” 1 (p 873) The paradigm is “CRNAS who are limited,
by law, adapt their practice to prescribing constraints.” 1 (p 24) This is consistent with the
framework that seeks to understand whether this restraint affects autonomy and practices
of CRNAs. The research purpose and framework does flow naturally between the two.
The conceptual framework is addressed in the purpose of the study, the study seeks to
“describe Washington State CRNA prescribing practices and workforce and practice
characteristics.” 1 (p 26)
Conceptual definitions are not spelled out for the reader however, an
understanding of the conceptual framework can be found in the literature review section.
It provides a view of how the country as a whole stands on CRNA prescriptive authority,
prescribing medications, as well as background on the prescriptive authority in
Washington State. These sections help the reader know how and why the study is taking
place. The conceptual framework does guide the study methods in that the questionnaire
covered demographic characteristics, practice setting characteristics, and prescriptive
authority. 1 (p 26) The research findings are tied back into the conceptual framework, the
study found that “most CRNAs were aware of the new option of full prescriptive
authority with schedule II through IV medications. However, only 30% took advantage of
this option. Most respondents without prescriptive authority considered the Nurse
Practice Act provision to ‘select, order, and administer’ as the foundation of their
practice.” 1 (p 28)
Research Designs in Quantitative Studies
76 76 Freshcoln The design used in this study is descriptive, or more specifically developmental
research. Descriptive research “attempts to describe a group of individuals on a set of
variables. Descriptive data allow researchers to classify and understand the scope of
clinical phenomena, often providing the basis for further investigation.” 2 (p 22) This study
falls under the descriptive definition because little research has been done in this area
and, through this survey, a basis is established for future research. No intervention was
used in this research therefore it does not fall under experimental, quasi-experimental, or
preexperimental design. Because “adoption of changes in scope of practice among
advance practice nurses is often slow and uneven” the researchers did not seek to
manipulate the independent variable (the CRNAs being surveyed) due to lack of literature
regarding this issue and instead was seeking to establish a basis for further research. This
is a cross-sectional study that is “based on observations of different age or developmental
groups at one point in time, providing the basis for inferring trends over time.” 2 (p280)
“The typical respondent was 51 years of age, white, and equally likely to be male or
female.” 1 (p 26) It was also noted that “respondents were highly experienced, with an
average of 19 years as a CRNA…only 12.5% had practiced 5 or fewer years.” 1 (p 26)
The comparisons within this study were between subjects. The researchers were
surveying various CRNAs in order to see how prescriptive authority of schedule II
through IV controlled substances affected their practice. This type of comparison is the
most appropriate for demonstrating the relationship of how of prescriptive authority
affects the autonomy of the CRNA practice. This study is described as survey or
questionnaire that was first mailed in late 2006 to CRNAs licensed in Washington,
Oregon, and Idaho. 1 (p 26) The researchers did not seek to control external or intrinsic
77 77 Freshcoln factors because the results of this study more or less laid a baseline or foundation for
future research in this area. By not seeking to control internal or external factors there is
more room to improve in future research that may seek to answer more specific questions
such as does prescriptive authority in experienced versus less experience CRNAs affect
patient outcomes. This type of study and question would need control of external and
internal factors.
The interval validity or degree to which the relationship between the independent
and dependent variables is free from the effects of extraneous factors, is not well
accounted for. 2 (p 869) This is concluded based on the fact that the questionnaire was
mailed to the CRNAs with no documentation within the article about the direction they
were given when asked to fill it out. It possible that some the subjects that responded,
answered the questionnaire together and thus is not actually reflective of their own
personal opinion making this a threat to the internal validity. The inferences about the
relationship among the study variables are perplexing. After looking at table 2 within the
article 44.4% of the participants that responded said that they use the “select, order, and
administer” provision of the Nurse Practice Act and that 35% do not want to prescribe
medications. 1 (p 27)
Because there was no discrimination in the criteria of those that participated in the
study the external valid, or degree to which the results of this study can be generalized,
seems like it could be applicable to a larger group of people. However, on closer
examination the study may be too generalized and did not have a large enough sample
size to really generalize the findings. The questionnaire was only mailed to CRNAs
within the Washington, Oregon, and Idaho area that included about 436 CRNAs. The
78 78 Freshcoln researchers also only received a 65% response to the questionnaires mailed out. 1 (p 26)
While no discrimination of participants usually leads to a wide variety of participants and
thus makes the finds more applicable. However, the sample size and location really
hinder the externally validity of this study. With only 283.4 responses that only makes up
about 0.78% of the total number of CRNAs in the United States today, it’s hard to say
these finds could really be used on a larger scale. Limitations of the study include the
need for “additional information about physician supervision of CRNA prescribing [to]
provide the basis for recommendations for change in professional and public policy.”
29)
1 (p
Another limitation is “what barriers limit CRNAs from practicing to the full scope of
their ability.” 1 (p 29) The researchers address the limitation as implications for further
research.
Quantitative Sampling Designs
The target population for the study is CRNAs. CRNAs with a Washington license
living in the states of Washington, Oregon, and Idaho were eligible to participate in this
study.1(p26) Results were only printed of those who were licensed and practicing in
Washington, therefore this study can only truly be generalized to states with similar laws
regarding prescriptive authority.
The sampling selection procedure is described in terms of who was eligible to
receive the survey, however it is not mentioned how many surveys were sent out. It is
unknown whether every CRNA received a survey or if there was a selection process.
The sample plan yielded a response of 436 responders. Due to specific criteria
only 203 surveys were used for the study.1(p26) The factor which contributed to less than
79 79 Freshcoln half of the responses being used was the authors limited the study to only those that
practiced in the state of Washington, this leads to a potential bias. If the results could be
affected by varying opinions in relation to geographic location, it could not be accounted
for in this study.
The sample size of 203 appears to be sufficient. CRNAs from a variety of work
environments are surveyed, however, there is no power analysis or other rational to
justify the sample size or to suggest what size population they find the results sufficient
to represent.
Data Collection Procedures
The research data was collected by use of a questionnaire. The questionnaire was
refined by investigators and validated by content and clinical experts.1(p26) There does not
appear to be a bias interfering with the accuracy of data collection. The data collectors
were evaluators of previous Washington State Surveys and are considered to be content
experts.1(p26) The surveys were mailed to the CRNAs. There is no standardization of the
conditions the CRNAs were in at the time of completing the survey, but due to the nature
of the study this factor is unlikely to affect the results.
The burden of this study on the participants was in the form of time used to
respond to the survey. A lengthy survey will affect the number of people to respond.
This may also have an effect on the quality of answers provided on open-ended
questions.
Data Quality in Quantitative Studies
80 80 Freshcoln There is a strong congruence of data between variables conceptualized in the
introduction and operationalized in the methods sections. The method section presents the
same material found in the introduction and proceeds to elaborate on it. Data was
collected by content and clinical experts with previous experience in state wide surveys.
The results came in the form of a survey.1(p26) Having a hard copy of the responses, and
the expertise of the committee chosen to evaluate those responses, minimized the chance
of measurement errors.
There is a minimal amount of literature available regarding prescriptive authority
for CRNAs.1(p24) All results generated from the study come from evidence found within
this study. Therefore this study is found to be both reliable and valid. The only data
presented in the report that did not come from survey results is given to show which
states have what type of prescriptive authority and the facts of how many CRNAs are
using this authority. “For example, in December 2008, only 1 of 1,282 CRNAs in
Louisiana had applied for prescriptive authority.”1(p24) The data is referenced
appropriately, and there is no reason to believe that this information is unreliable.
Quantitative Analyses
All data is represented in the form of descriptive statistics and sufficiently reflect
the major characteristics of the researcher’s data set. The descriptive statistics are used
appropriately and properly convey the information it is aimed to convey. Inferential
statistics were not used nor would it be appropriate for this study. No hypotheses were
presented for this research study for statistical test to be performed on.
81 81 Freshcoln Data was reported in a statistical manner to reflect the responses of the surveys.
Tests were not performed to manipulate the statistics. Multivariate procedures were not
used in this study. Variables were presented independently of other variables. This does
not affect the validity of this type of study.
The statistical data presented reflects the purpose of the paper which is to describe
prescribing practices of CRNAs in Washington State.1(p24) The results are aimed to
further knowledge on current practices. There was no hypothesis for this study.
The statistical information presented in this study is complete. No needed
information is omitted from the study. Tables are clear, appropriately titled and labeled.
The information supports the data presented in the study and helps clarify the results
rather than seeming redundant. All results are objectively reported. No bias is seen in the
data reports.
Discussion
The objectives of the study are met. Demographic knowledge and reasons
surrounding prescriptive authority practice decisions are clearly reported. The results
accurately reflect the information gathered from the study.
A minimal amount of speculation, such as the statement, “Possibly, CRNAs are
reluctant to promote prescribing legislation because of a concern that physicians might
respond by withdrawing from collaborative arrangement,” is included in suggesting
possible reasons for study results, however excessive, needless speculation is not
included.1(p28) The results remain objective. The statistical results are significant because
82 82 Freshcoln they reflect the demographics for the CRNAs that participated in the study. This is a
needed aspect of the report.
All objectives of the study are met. Data is reported clearly, supported by tables,
and interpreted appropriately. Specific limitations of the study include further research
“needed to determine what barriers limit CRNAs from practicing to the full scope of their
ability.”1(p29) The data presented is the data discussed. There is only a small amount of
literature previously published on this subject, therefore the majority of data presented
comes from the results of this study.
Conclusion
Overall, this study was well executed and well presented. Ethical aspects were not an
issue, the research problem is significant and is consistently addressed through the study,
the literature review is appropriate, and the theoretical framework supports the study.
The research design and the quantitative sampling designs are addressed. The data
collection procedures, data quality, and quantitative analyses are justified for this type of
research. This study benefits the field of nurse anesthesia and encourages room for
further research.
83 83 Freshcoln Reference List
1. Kaplan L, Brown MA, Simonson D. CRNA prescribing practices: the Washington
state experience. AANA Journal. 2011;79(1):24-29
2. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice.
3rd ed. Upper Saddle River: Pearson Education, Inc; 2009.
3. Heathly Women. http://www.lazogroup.ca/msproject/framework1-e.php. Updated
2003. Accessed March 31, 2011.
84 84 Freshcoln Additional Works – Malignant Hyperthermia Worksheet/Presentation
Core Competency: Professional Role, Healthcare Improvement, and Practice Inquiry
Description: The student registered nurse anesthetists were responsible for educating
perioperative employees about malignant hyperthermia (MH) and the protocol for
treatment of an MH crisis. This additional work is a flyer created as a supplemental tool
for education that was passed out to those who attended the MH presentation.
Treatment Protocol for MH Crisis
Dosage or Action
Dosage or Action
1. Immediately discontinue
Life-threatening surgery will be continued, but with the use of a
anesthesia, including
different anesthetic agent and machine to prevent residual inhalation
succinylcholine.
agent from triggering a second episode.2
100% oxygen at a high flow rate of 10L/min. to treat effects of
2. Hyperventilate
hypercapnia, metabolic acidosis, and increased oxygen consumption
2.5mg/kg IV as soon as possible; given every five minutes until
3. Dantrolene
symptoms subside.3 Maximum dose 10mg/kg
Some anesthesia providers may still perform this action, but research
4. Change ventilator tubing and
has shown that it is not necessary to change the breathing circuit and
soda lime canister.
anesthesia machine since the oxygen delivery rapidly clears the
machine of the anesthetic gases.4
1-2 mEq/kg IV to combat metabolic acidosis due to increase of lactate
5. Sodium bicarbonate
in the circulatory system
Apply to groin area, axillary regions, and sides of neck – where major
6. Ice packs
arteries are located.
85 85 Freshcoln Lavage the stomach and rectum with cold fluids to lower temperature.
It is recommended not to lavage the bladder since the fluids can alter
7. Iced lavage
the true amount of urine being excreted by the patient and alter
measurement of output. Avoid causing hypothermia; cooling should be
discontinued when the core body temperature reaches 38o C.
Muscle cells are destroyed during an MH crisis and the myoglobin that
is released accumulates in the kidneys, obstructing urinary flow,
referred to as myoglobinuria. Diuretics are given IV to promote and
8. Mannitol or furosemide
maintain urinary flow in order prevent renal damage: mannitol 0.25g/kg
IV; furosemide 1mg/kg IV; up to four doses each. Urinary output of
2ml/kg/hr or higher must be maintained to prevent renal failure.4
9. Procainamide
200 mg IV to treat arrhythmias secondary to electrolyte imbalances.
Treat hyperkalemia due to the release of potassium into the circulatory
10. Dextrose and insulin
system as muscle cells are destroyed. Dextrose 25-50g IV; regular
insulin 10 units in 50ml of 50% dextrose in water given IV.
11. Monitor urine output
Insert foley catheter if one is not in place
Blood samples taken every 10 minutes to measure sodium, potassium,
12. Monitor electrolyte levels
chloride, calcium, phosphate, and magnesium levels.
13. Perform clotting studies
14. ABG
Every five to 10 minutes
15. Arterial blood pressure
Insert line if one is not in place
16. Central venous pressure
Insert line if one is not in place
Instrument used to produce a capnogram, a tracing that measures the
17. Capnograph
proportion of carbon dioxide in exhaled air.
86 86 Freshcoln Malignant Hyperthermia
What is Malignant Hyperthemia?
Malignant Hyperthemia (MH) is a fulminant hypermetabolic crisis triggered by certain
anesthetic agents and is characterized by an uncontrolled increase in skeletal muscle
metabolism.
How is it recognized?
Early Signs
• ↑ EtCO2
• Tachycardia
• Tachypnea
• Masseter muscle rigidity (trismus) (may be seen in pediatric patients without MH)
Late Signs
• Unstable blood pressure
• cyanotic/mottled skin
• Diaphoresis
• Cardiac dysrhythmias
• Dramatic increase in body temperature (Pyrexia) – 1-2O C every 5 minutes
What non-anesthesia personnel can do:
• Grab MH cart
• Prepare ice packs and ice lavage
87 87 Freshcoln • Ensure the following are present: dantrolene, sodium bicarbonate,
mannitol/furosemide, procainamide, dextrose and insulin
• Grab crash cart
• Ensure foley catheter is in place
• Send and check labs frequently
Malignant Hyperthermia Hotline: 800-644-9739
MHAUS has established a hotline to assist a surgical team in the immediate treatment of
a patient. The hotline is staffed by anesthesiologist volunteers who are experts in the
treatment of MH.1
References
1. Association of Surgical Technologists. Guideline statement for malignant
hyperthermia in the perioperative environment. 2005. Available at
http://www.ast.org/pdf/Standards_of_Practice/Guideline_Malignant_Hyperthermi
a.pdf
2. Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed. New York:
McGraw Hill; 2006.
3. Phillips N. Berry & Kohn’s Operating Room Technique. 10th ed. St Louis, MO:
Mosby; 2004.
4. Malignant Hyperthermia Association of the United States (MHAUS). Managing
an MH crisis. Available at http://www.mhaus.org. Accessed March 14, 2013.
88 88 Freshcoln Reflective Self Evaluation Summer 2012
Core Competency: Professional Role
Description: This reflective self evaluation documents reflection on personal growth
through the primarily didactic portion of the anesthesia program. It also looks towards the
beginning of the first clinical semester.
Self-Reflection: Summer 2012
Michelle Freshcoln BSN, RN
Texas Christian University – Doctorate of Nurse Practice in Nurse Anesthesia
July 28, 2012
89 89 Freshcoln Introduction
The conclusion of the Summer 2012 semester also brings to an end the solely
didactic portion of my anesthesia education. It is the precursor to an adventure in a new
city, in which my days will be filled with applying the knowledge I have gained in these
months prior. I can not help but feel half the fight has been won, but the battles that will
be encountered between now and the finish line will not be easy and will definitely not be
like any I have encountered this far in my anesthesia student career.
Reflection
As I had expected, the summer classes required just as much effort and dedication
as I had put in previously. By this point in my didactic education I had well prepared to
eat, breathe, and sleep anesthesia as long as there was material presented and tests ahead.
Fortunately, since it was summer, I did manage to spend a day or two at pool-side
barbeques with other classmates who were excited to have passed yet another test, and
craved a moment of normalcy.
As the lectures and labs progress, I am beginning to pull together the previous
information taught with the current lessons of how it will be applied. We have learned
things about pediatric patients, and obstetrical patients. We have simulations, in the form
of competencies, in which we performed preoperative interviews, history assessments,
setting up our anesthesia machines from memory, and inductions on mannequins that,
through instructor control, “responds” to the medications we administer and the actions
we take.
90 90 Freshcoln This competency check-off was a personal accomplishment for me this semester.
We had one practice competency, which was to be followed by the real-deal competency.
I studied, typed up cliff notes, and practiced putting pillows to sleep in my living room.
None-the-less, I struggled with confidence going into the competency. The fear steamed
more from the fear of being judged than for the fear of failing. I had prepared well, but I
also knew a faculty member, but more importantly a CRNA, would be watching my
every action. It was the duty of that CRNA to judge if I had was it take to provide a safe
anesthetic. It was his job to ensure I could provide safe and acceptable before he turned
me lose to work side-by-side with his colleges. My nerves screamed reminders at me to
not forget something vital to patient safety. One slip could be costly for the competency,
but more importantly, the life of my silicon mannequin friend.
I showed up to the first, practice competency an hour earlier than the
recommended early arrival time. I poured over the sheet revealing the patient’s history. I
scrutinized each line as if I could always seep out one more drop of insight. I converted
my patient’s weight to kg and calculated my drug dosages. Then, I rechecked my
dosages. Then, I probably checked them one more time, just to be sure. I gathered my
supplies and entered the room more diffidently than I’d typically like to admit. The mood
in the room was airy and light. I progressed through the steps of the competency as
rehearsed. I feel as if I held my breath until the moment I knew my scenario had
concluded. “How do you think you did?” That was the response I received when I
prodded for feedback. I was taken about, once again quit breathing, and muttered the
steps critical for patient safety that I knew I had done. I paused, and said, “I must have
missed one. I must have forgotten something that I can’t remember right now. I did
91 91 Freshcoln everything correct that I can think of. I don’t know what I missed.” My CRNA and
faculty member then passed along the affirmative statement that I had almost given up
on, “You missed nothing.”
I followed up an excellently executed practice competency, with a second
performance of the same caliber. I was tried, tested and deemed worthy of being sent to
the clinical portion of my doctoral education. For the first time, I saw myself as being on
deck, and next in line to step up to the plate, and try my shot at becoming a true CRNA.
Conclusion
My car is crowded with boxes, my house is empty, and I find myself in the middle
of a transition that I find oddly symbolic. I’m leaving a city, a state, and a family of
classmates. I have poured my sweat and tears into this city for the sake of education. I
look back and see how much I have given and how far I have come. As I embark on the
next step of my journey, I feel very green in my clinical experience. I have a long drive
ahead of me to Baton Rouge, Louisiana, and an even longer road ahead of me as I begin
the clinical portion of my education.
92 92 Freshcoln Fall 2012
93 93 Freshcoln Clinical Case Report – Carbon Dioxide Embolism
Core Competency: Healthcare Improvement and Practice Inquiry
Description: The clinical case report documents aspects of a clinical case that were
analyzed and compared with research for the purposes of evaluation and improvement.
Carbon Dioxide Embolism During Laparoscopic Procedure: A Case Report
Michelle L. Freshcoln, BSN
Texas Christian University School of Nurse Anesthesia
94 94 Freshcoln Introduction
Laparoscopy is a minimally invasive approach for abdominal exploration. The
procedure requires the surgeon to inflate the peritoneal cavity with CO2. Surgeons and
patients often prefer a laparoscopic approach to repair recurrent and bilateral inguinal
hernias.1 Laparoscopic procedures may lead to a complication called a CO2 embolism. A
CO2 embolism occurs when CO2 enters the vascular system. The patients’ potential
responses include a decrease in blood pressure, dysrhythmias, and cardiovascular
collapse.1 Ideally, an informed anesthesia provider will correctly identify the
physiological changes early and implement an appropriate and effective plan of care.
This case report describes a 48-year-old male undergoing laparoscopic bilateral
hernia repair with the complication of a CO2 embolism.
Case Presentation
The patient presented as follows: 48-year-old male, height 170 cm, and weighed
59.5 kg with a primary diagnosis of bilateral inguinal hernia. The patient did not have any
allergies, coexisting medical conditions, previous problems with anesthesia, or take
current medications. Clinicians did not find abnormal lab results or the need for
additional diagnostic testing. The patient was classified as an American Society of
Anesthesiologist I. A general anesthetic was chosen.
Preoperatively, the anesthesia professional administered 2 mg midazolam
intravenously (IV). The healthcare professionals brought the patient to the operating
room and transferred the patient to the operating table. The anesthesia professional
applied a blood pressure cuff, a pulse oximeter, a continuous five-lead electrocardiogram
(ECG), and 12 L O2 per facemask with an attached end-tidal CO2 (EtCO2) monitor. The
95 95 Freshcoln monitors reported initial vital signs: blood pressure (BP) 118/69 mm Hg, pulse 72 beats
per minute (BPM) in normal sinus rhythm (NSR), respiratory rate 16, and EtCO2 33 mm
Hg. Fentanyl 100 mcg IV was administered.
The patient breathed 12 L O2 for 5 minutes. The anesthesia professionals induced
general anesthesia and intubation conditions with 50 mg lidocaine IV, 5 mg rocuronium
IV, 200 mg propofol IV, and 30 mg rocuronium IV. The anesthesia professional
intubated the patient without complications, then confirmed and secured the airway. The
anesthesia professional set the ventilator to control respirations at a rate of 10 breaths per
minute, with 2 L of O2 and 3% sevoflurane added to the gas. The monitors recorded vital
signs after induction as BP 101/57 mm Hg, pulse 69 BPM, NSR, and EtCO2 of 33 mm
Hg.
The vital signs remained relatively unchanged until insufflation. Approximately
two minutes after insufflation, the heart rate rapidly dropped to 46 BPM. Blood pressure
decreased to 54/38 mm Hg, and EtCO2 decreased to 10 mm Hg. The anesthesia
professional administered 0.2 mg glycopyrolate IV. The heart rate continued to decrease.
The ECG showed a new onset of an inverted, and occasionally absent, p wave. The
following blood pressure was 52/34 mm Hg, and the pulse 42 BPM. The anesthesia
professional responded by administering two boluses of 25 mcg epinephrine IV. A
subsequent vital sign reading showed no change. The anesthesia professional
administered boluses of epinephrine 50 mcg to a total of 200 mcg epinephrine IV over
two minutes. The heart rate increased to 71 BPM, BP increased to 154/78 mm Hg, and
EtCO2 increased to 41mm Hg. The patient returned to NSR. The anesthesia professional
informed the surgeon of the event. The surgeon and the anesthesia provider determined
96 96 Freshcoln no surgical changes needed to be made at that time. Vital signs returned to baseline
within 5 minutes.
The patient’s vital signs remained stable for the remainder of the case. The
anesthesia professional extubated the patient in the operating room and transferred to post
anesthesia care unit (PACU). Vital signs upon arrival to PACU were blood pressure
99/59 mmHg, pulse 97, respiratory rate 18. The anesthesia professional discharged the
patient as planned preoperatively.
Discussion
Laparoscopic procedures rarely cause CO2 embolisms. A recent meta-analysis
reports 7 cases of CO2 embolism out of nearly 500,000 cases.2 Clinicians prefer CO2 for
insufflation because it has ideal chemical properties, is inexpensive, readily available, and
highly soluble in blood.2 Misplacement of the Veres needle into a vein or an organ causes
CO2 to enter the vascular system. The patient will experience complications shortly after
insufflation of the peritoneal cavity.2,3
Symptoms
A CO2 embolism may manifest as asymptomatic to severe. A direct relationship
exists between the amount of CO2 entering the circulatory system and the severity of
symptoms the patient experiences.2,4 Symptoms may include dyspnea, systemic
hypotension, neurologic injury, tachycardia, bradycardia, dysrhythmias, asystole, and
circulatory collapse.1,2 Researchers believe a “gas lock” effect causes the hemodynamic
compromise. 2,4 The gas lock travels through the vena cava to the right atrium where it
causes decreased venous return and reduced cardiac output.2,4
97 97 Freshcoln Diagnosis
Researchers suggest the following monitors may provide confirmation of a CO2
embolism: EtCO2 and pulmonary artery pressure (PAP), precordial and esophageal
stethoscope, transesophageal echocardiogram (TEE), and transesophageal and precordial
Dopplers. Monitors for a standard laparoscopic procedure include EtCO2 and, in some
cases, precordial or esophageal stethescope. The EtCO2 recording is a readily available,
sensitive, and non-invasive monitor. However, the diagnostic picture with EtCO2 may not
be definitive. Various studies of CO2 embolisms have reported finding both increases and
decreases in EtCO2 during an embolism.2 Researchers generally accept emboli obstruct
the pulmonary vasculature causing an increase in ventilatory dead space and cause an
initial decrease in EtCO2.2
Precordial and esophageal stethescopes are readily available and non-invasive.
Several studies report auscultation of a precordial “mill-wheel murmur” during an
embolic event. A mill-wheel murmur is a loud, harsh, churning, metallic sound.
However, these murmurs are reported in less than half of the cases.2
Other methods for diagnosis are not considered routine patient management.
Researchers consider the TEE and the transesophageal Doppler highly sensitive for
detecting intravenous CO2.2 Both monitors have a high incidence of false negatives due
to improper probe positioning and a lack of quantitative results to aide diagnosis. The
monitoring of pulmonary artery pressure will only identify CO2 when introduced in large
amounts, over 100 mL.2
98 98 Freshcoln Treatment
Corrective measures and supportive care should commence immediately when a
CO2 embolism is suspected. Suggested treatment includes discontinuation of insufflation
and release of the pneumoperitoneum. The patient should be ventilated with 100% O2 to
decrease the ventilation- perfusion mismatch.5 An increase in central venous pressure
with volume expansion will prevent further gas entrainment. Air should be directed to
the apex of the right atrium via a steep head-down, left-lateral decubitus position to
discourage the air from entering the pulmonary artery or traveling to the brain. If present,
a central venous catheter may be used to withdraw gas from the right atrium and
ventricle, assist in diagnosis, and be utilized to release a gas lock if present. Supportive
care should be initiated as needed to maintain vital signs stability and to optimize
oxygenation and perfusion. For severe cases of CO2 embolisms, cardiopulmonary bypass
and hyperbaric oxygen therapy has proved useful.
Case Evaluation
For this case, the anesthesia professional suspects that a small amount of CO2 was
entrained into venous circulation shortly after insufflation as evidenced by a reduction in
heart rate, blood pressure, and EtCO2, with a change in cardiac rhythm. Initial actions
were directed at treating the hemodynamic changes, and restoring cardiac stability. In
total, about three minutes of hemodynamic compromise occurred with sufficient, but
diminished response to the vasoactive drugs. The return to hemodynamic stability may be
credited to the highly soluble property of CO2 in blood and a small sized CO2 embolism.
At the time of the event, the possibility of a CO2 embolism remained unrecognized.
Therefore, release of the pneumoperitoneum was not considered. The anesthesia provider
99 99 Freshcoln utilized the EtCO2 monitor. Other diagnostic monitors were not indicated for the
procedure and were unavailable at the time of the incident.
In accordance with recommended interventions, the anesthesia provider
administered medications to establish hemodynamic stability. The patient was also placed
on 100% O2. In addition to actions taken, the anesthesia provider could have informed the
surgeon of the patient’s condition at the initial change of status, with a request to deflate
the pneumoperitoneum. Deflating the peritoneum may have reduced the hemodynamic
changes and decreased the amount of CO2 able to enter.
CO2 embolism is a potentially life threatening event. Recommended monitors
would have been indicated had the symptoms persisted. A change in surgical procedure
and post-operative care would have been necessary.
References
1. Jaffe RA, Samuels SA. Anesthesiologist’s Manual of Surgical Procedures. 4th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2009:595-7
2. Park EY, Kwon J, Kim KJ. Carbon dioxide embolism during laparoscopic
surgery. Yonsei Med J. 2012; 53(3):459-466.
3. Abut Y, Erylimaz R, Okan I, Erkalp K. Venous air embolism during laparoscopic
cholecystectomy. Minimally Invasive Therapy & Allie Technologies [serial
online]. 2009;18(6):366-368. Available from CINAHL Plus with Full Text,
Ipswich, MA. Accessed October 17, 2012.
4. Zhu Q, Mao Z, Yu Buwei, Jin J, Zheng M, Li J. Effects of persistent CO(2)
insufflation during different laparoscopic inguinal hernioplasty: a prospective,
100 100 Freshcoln randomized, controlled study. J Laparoendosc Adv Surg Tech A. 2009:19(5):6114.
5. Smith HJ. Carbon dioxide embolism during pneumoperitoneum for laparoscopic
surgery: a case report. AANA J. [serial online]. 2011;79(5):371-3. Available from:
CINAHL Plus with Full Text, Ipswich, MA. Accessed October 14, 2012.
101 101 Freshcoln Additional Work – Medical Mission Trip
Core Competency: Professional Role and Healthcare Improvement
Description: As an additional work, a PowerPoint presentation was created to document a
medical-surgical mission trip to the Philippines. The presentation shows other anesthetist
what to expect for a mission trip. The mission trip shows an ability to provide safe and
effective care in settings outside of the traditional operating room. Other aspects of
healthcare were considered in the mission trip such as cost-conscious care, effective
utilization of resources, cultural competence and sensitivity, and overcoming language
barriers. 102 102 Freshcoln 103 103 Freshcoln Clinical Log
Core Competency: Technology and Informatics
Description: The typhoon case log is a database to document clinical cases. It is an
example of how technology has been integrated into education to provide effective
documentation of clinical progress and evidence of completion of program requirements
needed for graduation.
104 104 Freshcoln 105 105 Freshcoln 106 106 Freshcoln Reflective Self Evaluation Fall 2012
Core Competency: Professional Role
Description: The Fall 2012 reflective evaluation documents the progress through the first
clinical semester. It provides a facilitates achieving a healthy level of self-awareness that
is necessary part of professional development.
Self-Reflection: Fall 2012
Michelle Freshcoln BSN, RN
Texas Christian University – Doctorate of Nurse Practice in Nurse Anesthesia
December 30, 2012
107 107 Freshcoln Self-Reflection: Fall 2012
Reflection
I strolled into the operating room day one of my clinical rotation proudly donned
with a name badge, a stethoscope, a nerve stimulator, a pen variety in my front pocket,
and a blue and white striped folder containing all my notes from my classes and my
research for any situation I thought I might be faced with that day. It was a matter of days
before my clinical coordinator finally told me “you’re going to have to lose the folder.” It
was that moment that I realized there was a long road ahead of me before this newbie
became a comfortable and confident CRNA.
Looking back to my first day of clinicals, I see hard-work, dedication, frustration,
and endless hours of preparation. I remember nights that cost precious amounts of sleep
due to reviewing exactly how to do in bier block and showing up bright and early the
next day only to find out we, in fact, rarely do bier blocks, and would instead be putting
the patient to sleep. I still cringe at certain memories of fumbling around the OR in a
manner that was sure to not win me any “style points” in the eyes of the CRNAs, the
surgeon, nor the OR staff. In another instant I can recall specific moments of subtle hints
from my CRNA mentor leading to a beautiful emergence from anesthesia, only to be
followed up with bragging to the surgeon about the kind of anesthesia I could provide.
As with starting any new endeavor, the first semester of practicing anesthesia in
the clinical setting came with an adjustment period accompanied by a steep learning
curve. The first few months we were assigned cases appropriate for our experience level,
and to be partnered with CRNAs who facilitate my learning. I would spend nights at
home with open textbooks and an Internet that would help me search all corners of the
108 108 Freshcoln world in preparation for my tasks the next day. I quickly learned what was important, and
how the cases would most likely be run. I was able to adapt routines, and apply
knowledge that soon alleviated a generous amount of preparation time.
As my class of four neared the winter holidays, we were granted with a new,
awaited privilege of choosing our own cases. This allowed us to challenge ourselves in
ways we saw fit. We could choose to push ourselves with difficult case we had yet to try,
or by working with CRNAs who offered more guidance, or more independence, or a
technique used by none other. I saw personalities form within administering anesthetics. I
observed the finesse that come to anesthesia, and noted each technique to be as unique as
a fingerprint.
At the end of this first semester in clinicals, I can say I have enjoyed being
acquainted to the clinicals setting. I have good days and rough days. I have some days
when I feel I can do nothing right, and other days where I feel I have done no wrong. On
both days I am fully aware that may career as a CRNA is in its infancy. I have much to
keep learning. I look towards this new year and new semester to continuing fine tuning
skills and acquiring new ones. I can’t help but celebrate the little victory of making it this
far and having survived my first semester in the clinical setting.
109 109 Freshcoln Spring 2013
110 110 Freshcoln Clinical Case Report – OLV inability to tolerate
Core Competency: Practice Inquiry and Technology and Informatics
Description: This clinical case report evaluates the outcomes of a one-lung ventilation
(OLV) case that was cancelled after the initiation of surgery. A database search was used
to find articles on current literature. Anesthesia actions from the case were compared to
literature to evaluate if the patient was provided care in an evidence-supported manner.
This evaluation facilitates professional growth.
Optimizing One-Lung Ventilation: A Case Report
Michelle Freshcoln, BSN, RN
School of Nurse Anesthesia
Texas Christian University
111 111 Freshcoln Case Presentation
The patient presented as a 54 year old female height 5’5 and weighed 56kg,
American Society of Anesthesia (ASA) classification IV. The patient’s had a history of
smoking for 57 pack years. Comorbidities included chronic obstructive pulmonary
disease, lung cancer and reflux. The patient had poor exercise tolerance and experienced
shortness of breath with minimal exertion. The operative plan was a right lung lobectomy
for treatment of lung nodules. The anesthetic plan was to administer general anesthesia
and intubation with a double lumen tube. One-lung ventilation would be performed as
tolerated to facilitate the surgeon during the surgical procedure. A thoracic epidural
would be performed preoperatively and left in place for postoperative pain management.
Prior to surgery the patient was brought to a preoperative monitoring area where
the patient was placed on three liters of oxygen per nasal cannula. The patient’s oxygen
saturation level was 94%. Immediately prior to surgery, the patient was administered
midazolam 2 mg IV for an anxiolytic. The anesthesiologist performed a thoracic epidural.
Vital signs remained stable, oxygen saturation remained at 94%. The patient was
transferred into the operating room and was assisted onto the operating table. 100%
oxygen was delivered to the patient via facemask, and all ASA required monitors were
applied. A smooth IV induction and an atraumatic intubation with a left double lumen
tube was performed. There were no complications with induction and vital signs
remained stable. The patient was maintained with isoflurane and 100% oxygen. Oxygen
saturation increased to 96%. Double lumen tube placement was confirmed with a
fiberoptic bronchoscopy. The surgeon required the operative lung to be deflated. Tidal
volumes were decreased, and a clamp was placed on the tracheal lumen of the double
112 112 Freshcoln lumen tube. The right lung successfully deflated. The oxygen saturation decreased within
two minutes to 87% and continued to fall. Continuous positive airway pressure (CPAP)
was placed on the non-ventilated lung. Oxygen saturation continued to fall to 83% over
the next minute. The surgeon was informed and surgery was held. The non-dependent
lung was reinflated. With two-lung ventilation for three minutes the oxygen saturation
increased to 96%. The non-dependent lung was again deflated. The non-dependent lung
was again placed on CPAP with low flow oxygen passing through the collapsed lung.
The dependent lung was placed on 5 cm H20 of positive end expiratory pressure (PEEP).
The oxygen saturation fell to 84% within 4 minutes.
After multiple attempts of repeating the process of deflating the lung and inflating
the lung to oxygenate the patient, the surgeon concluded he was unable to proceed with
the case if the patient could not tolerate one-lung ventilation for near 10 minutes
intervals. The patient was unable to tolerate one-lung ventilation due to rapidly
decreasing oxygen saturation levels. The surgery was cancelled. The patient’s muscle
relaxant was reversed. The patient had an uneventful emergence, and was able to be
extubated in the operating room prior to being transferred to the postoperative care unit
(PACU).
Discussion
Indications
One-lung anesthesia may be indicated for lung, esophageal, mediastinal, or spinal
procedures. One-lung ventilation (OLV) is when one lung is ventilated as normal, and the
other lung is deflated and does not participate in normal respirations. Originally OLV was
113 113 Freshcoln performed to prevent spillage of infectious lung contents from one lung to the other
during thoracic or bronchial procedures. 1 Preventing the spread of massive
contamination from one lung to the other remains the only absolute indication for OLV. 1
OLV is most commonly performed for relative indications such as “aortic aneurysm
repair, thoracoscopy, pneumonectomy, lobectomy, esophageal surgery, thoracic spine
procedures, and mitral valve repair.” 1 The deflated lung serves as a still surgical site for
the surgeon, while maintaining the patient’s respiratory requirements through the use of
one functional lung.
To accomplish one lung anesthesia, a bronchial blocker (BB) or a double lumen
tube (DLT) is used. The device will isolate each lung to allow ventilation of both lungs
together as a unit or as separate entities in which different care may be provided to each
lung.
Physiology
The patient is typically positioned laterally for procedures that require OLV. The
upper lung is referred to as the “up” lung or the “non-dependent” lung. The lower lung is
referred to as the “down” lung or the “dependent” lung. The up lung will be deflated and
the down lung will be ventilated by means of a BB or a DLT. The lateral position and a
deflated lung stress the respiratory system. Additionally, the mediastinum, abdominal
contents, and positioning aides, such as axillary rolls, compress the down lung once the
patient is positioned. 1
Ventilation and perfusion must be matched in the lungs to maintain adequate
oxygenation and carbon dioxide removal. 1 The lungs have an intrinsic method of
114 114 Freshcoln redirecting blood to the better-ventilated alveoli termed hypoxic pulmonary
vasoconstriction (HPV). 1 During OLV, 30%-70% of lung may be hypoxic. HPV, though
attenuated by inhalation agents, may result in a 50% reduction of the expected shunt.
1,2
This intrinsic mechanism aides the patient in maintaining an adequate match of
ventilation and perfusion and normalizing oxygenation and carbon dioxide removal.
In comparison to the supine position, the lateral decubitus position is actually
associated with better ventilation and perfusion (V/Q) matching. 2 The better V/Q match
should suggest improved oxygenation. The better match can be attributed to improved
perfusion to the dependent, ventilated lung coupled with hypoxic pulmonary
vasoconstriction (HPV) of the collapsed lung. 2 However, when the lateral decubitus
position is coupled with inhalation agents, which attenuate the HPV intrinsic response,
significant mismatching of oxygenation to lung perfusion occurs.
Additionally, when the patient is sedated and paralyzed in the lateral decubitus
position, the dependent lung experiences a reduction in functional residual capacity
(FRC) due to compression and limited excursion. 1 The non-dependent lung experiences
improved compliance. 1 In the non-dependent lung of an anesthetized patient in lateral
position may increase, the FRC may increase 1.5 that of the dependent lung. 1 The
surgeon will perform the procedure by opening the nondependent hemithorax. This
opening increases the compliance and FRC in the nondependent and decreases the
compliance and FRC of the dependent lung. These changes further worsen the V/Q
mismatch. 1
Complications and Management
115 115 Freshcoln Thoracic surgery patients often have underlying lung pathologies that predispose
the patient to complications during thoracic surgery. OLV further complicates the
respiratory efforts by causing a large shunt that often results in hypoxia. 3 Hypoxia
increases the risk for postoperative complications including cardiac arrhythmias,
cognitive dysfunction, renal failure, and pulmonary hypertension. 2 Preventative
measures against and treatment of hypoxia must be a priority for anesthesia providers.
Shunts are caused by the mismatching of ventilation and perfusion. Improving either
factor may reduce the shunt and treat the hypoxia.
The accepted first intervention for combating hypoxia in OLV is the application
of CPAP to the non-ventilated lung. 3 If necessary, the next intervention is to apply PEEP
to the ventilated lung. 3 It is accepted that this method provides may reduce atelectasis,
decrease the shunt, and improve oxygenation while maintaining an optimal level of
surgical exposure for the surgeon. 2,3 It has also been suggested that the technique of
PEEP may be harmful in patients with hyperinflated lungs if a recruitment maneuver is
not first used. 2
The recruiment maneuver is a technique to reinflate collapsed alveoli. Every time
a patient is disconnected from the ventilator, segments of the lung will collapse, and
alveoli will derecruit. 4 Collapsed alveoli provide less surface area for gas exchange and,
therefore, increase the shunt and contribute to hypoxia.
Additionally, small tidal volumes should be used during OLV. Large tidal
volumes, 8-12 ml/kg cause pulmonary hyperinflation and increased inflammatory
markers may lead to pulmonary edema and acute lung injuries. 3 Smaller tidal volumes
116 116 Freshcoln will reduce the incidence of acute lung injury. Research supports the following six steps
for performing a recruitment maneuver 4,5 :
1. Establish hemodynamic stability
2. Deliver FiO2 of 1.0 for a minimum of seven minutes
3. Attempt recruitment with 30 cmH2O CPAP for 30-40 seconds (or 10 cm H2O
about the plateau level)
4. If unresponsive, wait 15 minutes and then attempt recruitment with 35 cm H2O
for 30-40 seconds.
5. If unresponsive, wait 15 minutes and then attempt recruitment with 40 cm H2O
for 30-40 seconds.
6. If unresponsive, wait 15 minutes and then attempt recruitment with 20 cm H2O
pressure control and 40 cm H2O CPAP for two minutes.
These steps were originally designed for the intensive care unit, however similar
concepts can be applied to patients acutely ventilated during surgery. A successful
intervention will result in improved oxygenation, reduced end-tidal CO2, and improved
compliance. 4
Improving lung perfusion may also reduce the shunt. Perfusion may be maximized by
using low concentration of local anesthetics in thoracic epidurals, maintenance of cardiac
output, and avoidance of excessive hemodilution in patients with compromised lung
function. 2
When suggested measures fail to improve oxygenation, two-lung ventilation should
be resumed until the hypoxia resolves. Some patients may require intermittent reinflation
117 117 Freshcoln of the nondependent lung with small tidal volumes in order to maintain adequate
oxygenation. 2 In restrictive lung disease (preoperative FRC < 77%) hypoxia has been
shown to respond superiorly to pressure controlled ventilation when compared to volume
controlled ventilation. 2 Finally, when applicable in persistently hypoxic patients, the
surgeon may clamp the pulmonary artery of the nonventilated lung in order to divert
blood flow to the ventilated lung.
It is the goal of these interventions to maintain OLV and adequate oxygenation to the
patient for the duration of the procedure through the manipulation of ventilation and
perfusion factors. CPAP to the nondependent lung, proper alveolar recruitment, the
application of PEEP to the dependent lung, and intermittent return to two-lung ventilation
are interventions to improve the quality of ventilation. Maintaining cardiac output and
hemodynamic status improve the quality of perfusion to the lungs. Ideally, the shunt will
be minimized and the adequate oxygenation will ensue.
Case Evaluation
The initial interventions in this case accurately followed the recommendations for
the management of a patient experiencing hypoxia during one-lung ventilation. CPAP
and PEEP were applied in the proper order when indicated. Additionally, low flow
oxygen was administered to the non-ventilated lung. These maneuvers failed to correct
the hypoxia. Other interventions may have included alveolar recruitment attempts, and
the surgeon could have clamped the pulmonary artery of the nonventilated lung in an
attempt to increase the blood flow to the ventilated lung.
118 118 Freshcoln References
1. Dunn P. Physiology of the lateral decubitus position and one-lung ventilation. Int
Anesthesiol Clin. 2000;38(1):25-53.
2. Ng A, Swanevelder J. Hypoxaemia associated with one-lung anaesthesia: New
discoveries in ventilation and perfusion. Br J Anaesth. 2011;106(6):761-763.
3. Badner NH, Goure C, Bennett KE, Nicolaou G. Role of continuous positive airway
pressure to the non-ventilated lung during one-lung ventilation with low tidal volumes.
HSR Proc Intensive Care Cardiovasc Anesth. 2011;3(3):189-194.
4. Neligan P. Mechanics of breathing and PEEP. Critical Care Medicine Tutorials. 2002.
5. Kacmarek RM. Lung recruitment. Respir Care Clin N Am. 2000;6:597-623.
119 119 Freshcoln Narrative Review – POVL following Robotic Procedures
Core Competency: Practice Inquiry and Technology and Informatics
Description: This narrative review evaluates literature on a topic highly relevant to
current practice in anesthesia. From the literature evaluation, recommendations for
practice were made. Repositioning During Robotic Procedures to Prevent Post Operative Vision Loss
Michelle Freshcoln, BSN, RN
School of Nurse Anesthesia
Texas Christian University
March 2013
120 120 Freshcoln Abstract
Statement of the Practice Problem
The number of surgical procedures performed in steep Trendelenburg (ST) is
increasing due to the growing popularity of robotic procedures often requiring this
position.1 Researchers have found that a patient under general anesthesia in ST for a
sustained period of time loses normal autoregulation of ocular pressures. The loss of
normal autoregulation predisposes the patient to risk factors of postoperative visual loss
(POVL).2
Proposed Solution
The proposed solution is to relieve the ocular pressures by interrupting procedures
in ST of longer than six-hour duration with a level supine intervention (LSI).
Methodology
The Rosswurm and Larrabee six-step model for change to evidence based practice
was used to guide the process.3 A review of literature was performed in CINAHL and
Google Scholar to include 2008-2013. Search terms included “robotic surgery,” “steep
Trendelenburg,” “POVL,” and “Intraocular pressure.” After reviewing initial findings,
the range of dates was expanded to 2007-2013 in order to include two case studies
reviewed by an article published in 2012.
Findings
Robotic cases have been documented to last as long as 9.9 hours.4 Two case
reports were found in which patients have experienced POVL following cases with the
patient placed in ST for an extended period of time.5 Several small studies have been
121 121 Freshcoln performed evaluating ocular pressures in ST and one study has evaluated effects of a LSI
on ocular pressures.6 Researchers agree ocular pressures autoregulation is lost in the
patient under general anesthesia.2,6 Intraocular pressure (IOP) relates directly and ocular
perfusion pressure(OPP) inversely with the duration of the procedure.7 A LSI performed
after an hour has been show to decrease IOP and facilitate an earlier return to baseline
once the patient is returned to level position.6 A tool has been created to help providers
identify critical ocular pressure levels attempting to minimize equipment and provider
education, however, a baseline IOP reading remains to be a significant identifying factor
in determining the probability of a patient reaching critical IOP levels prior to the end of
surgery.8
Conclusions
An LSI of 5-minutes after one hour of ST is an effective way to decrease the risk
of POVL while undergoing a surgical procedure in the ST position. 8 It would be prudent
to perform an LSI prior to 6-hours of ST. Further research is needed to identify the most
optimal time and frequency to perform an LSI for cases of a duration greater than 120
minutes.
Introduction
Robotic surgery refers to surgical procedures performed by a surgeon-controlled
robot. The procedures are performed under general anesthesia in a manner similar to
laparoscopic procedures in which the abdomen is insufflated with CO2 to optimize the
view and access of the surgical field. 1 The procedure often requires ST positioning to
using gravity to push abdominal contents out of the surgical field. Benefits of robotic
122 122 Freshcoln procedures include improved range of motion, improved surgical access, smaller surgical
incisions, improved three-dimensional visualization in real time, reduced pain, and
quicker recovery. 1,9 Disadvantages of robotic procedures include potential increased
length of surgical time due to robot set-up and surgeon skill level, increased cost, limited
tactile feedback to the surgeon, the need for trained medical personnel, limited
availability of robots in many facilities, and positioning considerations.9
Common positioning for robotic procedures indicate the patient is placed in
lithotomy position in ST for many hours. 1 Once the robot cart is locked in place and the
robotic arms are inserted into the body cavity, any movement of the patient could be
catastrophic.1 The inability to reposition the patient during robotic cases has illuminated a
number of positioning concerns.
An arising concern is the incidence of postoperative vision loss in non-opthalmic
procedures related to ST.8 Eyelid, and corneal/conjunctival edema (chemosis),
ecchymosis, and facial edema are characteristic changes shared by both prolonged ST
positioned patients and patients experiencing POVL.2, 10 This complication is a risk
compounded by the inability to reposition patients during the length of the robotic
procedure. Cases often last 4-6 hours and have been documented to last as long as 9.9
hours.4 Two case reports were found in patients experiencing POVL following two ST
cases, one robotic and one non-robotic.5 A suggested intervention is to alleviate the
physiologic complications of ST by periodically pausing the robotic procedure and
disengaging the robot arms to allow an intermission of supine position as a preventative
measure to decrease the risk of POVL. This periodic supine intervention is known as a
LSI.
123 123 Freshcoln Methodology
The systemic process used to guide this transitional research is the Rosswurm and
Larrabee six-step model for change to evidence-based practice.4
The guidelines provide the researcher with a concise plan to navigate from
problem assessment through integration of an evidenced based protocol if indicated. The
six steps help the researcher to incorporate quantitative and qualitative data, clinical
expertise, and contextual evidence to systematically evaluate current practice and guide
the professional through a process to change systems to a practice supported by best
evidence.
Table A – Applied Rosswurm and Larrabee Six-step Model4
Step
Step 1: Assess Need for
Change in Practice
Applied
• Cite incidence of POVL in ST
• Identify usage frequency of robotics and ST
• Describe the need for increased knowledge on the
subject
• Discuss the uncommon practice of repositioning
during robotics cases
Step 2: Link Problem with
• Discuss the pathophysiology surrounding POVL
Interventions
• Describe methods to decrease risk factors of POVL
in ST
Step 3: Synthesize Best
• Cite specific time to reposition the patient
Evidence
• Identify best evidence to prevent POVL
Step 4: Design a Change in
• Educate all professionals involved in robotics cases
Practice
on current literature
• Develop a standard duration of time for which ST is
considered safe
Step 5: Implementing and
• Educate clinicians prior to cases on best practice to
124 124 Freshcoln Evaluating Change
prevent POVL
• Consistently document position interventions
Step 6: Integrate and Maintain
Change
• Standardize documentation related to position
changes on patient record.
• Evaluate documentation and POVL incidence using a
retrospective chart review in 2 months and 6 months.
Search Method
In accordance with Rosswurm & Larrabee model, the initial literature review is
aimed to assess the incidence of the problem of POVL related to ST positioning, and
identify current practices of robotic surgery including length of procedures and standard
positioning methods. Research must show that duration of ST positioning is reasonably
associated with POVL.
The second part of the literature review is aimed to evaluate interventions,
outcomes, and terms of measurement. It is the goal to identify a safe measure of time for
an anesthetized patient to remain in ST and at which period in which the patient should
be returned to horizontal position. It is also necessary to identify the optimal duration of
time for a patient to remain in a level, horizontal position before return the patient to ST.
It will be necessary to consider patient safety while keeping a realistic view on the length
of time for the surgical procedures and physician time management.
Search terms were placed in the CINAHL database and Google Scholar and
included “robotic surgery,” “steep Trendelenburg,” “POVL,” and “intraocular pressure.”
Exclusion criteria included: pediatric populations, studies in a position other than ST and
optic surgery. Optic surgery was excluded to eliminate the possibility of direct surgical
125 125 Freshcoln complications and preexisting optic pathophysiology to alter findings. Initially, only
literature published between 2008-2013 was considered. Studies published before 2008
were evaluated when referenced by literature published after 2008 to verify the
information. The case studies published by Weber in 2007 were included after found in
the 2012 article by Lee et al.
Critique of the Evidence
Table B outlines the research examined. Only studies conducted in ST were
examined. Studies initially were evaluated from 2013-2008 in attempts to keep the results
recent. Few studies were published between these dates. An additional study was
included from 2007 because of relative evidence and a reference from a 2012 article.
Table B – Levels of Evidence
Article
Year
Article Type
Level of Sample Size
Evidence (N)
Level III n = 37 ST
n = 29 LSI
Molloy et
al.
2010
Prospective
study – Quasi
experimental
Awad et
al.
2009
Prospective
study
Level III
N = 33
Molloy
2012
Prospective
study
Level III
N = 111
patients
377 observation
time points
126 126 Major Findings
Level supine intervention
(LSI) of 5 minutes during
ST cases of at least 120
minutes can minimize
increases in IOP and
facilitate a return of IOP
to baseline at the end of
the case.
IOP peaks at conclusion
of ST position on average
13 mm Hg higher than
baseline. Surgical
duration and EtCO2 were
directly related to IOP
Predictors of IOP > 40
mm Hg: chemosis and
elevated baseline IOP.
Created observation scale
for assessing need and
timing for IOPnormalizing
Freshcoln Molloy
2011
Nonexperimental
Level IV
N = 37
Weber
2007
Case Studies
Level III
N=2
interventions.
After 120 minutes in ST,
compared to baseline,
IOP range increased from
9-28 mm Hg to 25-54
mm Hg, and OPP fell
from 50-82 mm Hg to
21-75 mm Hg. These
findings challenged
accepted views of
cerebral and ophthalmic
circulatory
autoregulation during
general anesthesia.
Two cases of permanent
POVL. One procedure
was robotic and lasted 6
hours 35 minutes. One
procedure non-robotic
lasting approximately 9
hours.
Two prospective studies were found. Both studies were conducted at a single
hospital with a small population. Both studies reported using similar exclusion criteria of
patients, definitions of ST, methods of IOP measurements, data collection, and intervals
for measurements.
Molloy 2010 studied IOP of patients in continuous ST with those in ST but
temporarily relieved from ST with a LSI for a duration of 5 minutes. IOP in patients
without an LSI at 120 minutes ranged 25-54 mm Hg. The IOP of the group who received
the LSI ranged 10 – 33 mm Hg. When the patients were returned to level supine
following the conclusion of the procedure 11% of the non-LSI returned to baseline IOP.
A return to baseline IOP was seen in 75% of the patients who received the LSI.6 The
patients undergoing a LSI showed a decreased IOP following the LSI and a quicker
127 127 Freshcoln return to baseline as compared to those who did not receive the LSI. The findings in the
ST patients reflected those findings of the Awad et al. study.
In 2009, Awad et al. studied a total of 33 patients undergoing general anesthesia for
robot-assisted prostatectomy performed in ST.7 Findings showed that increased duration
in continuous ST directly correlates with an increase in IOP. The highest ranges of IOP
were found at the end of the case, suggesting a constant rise in IOP for the duration of ST
positioning. 7 Both findings support a direct correlation between length of procedure and
increases in IOP. 6,7, Awad et al. also found that an increase in IOP directly correlates
with and increase in EtCO2.7
Molloy continues to review literature in 2011 and 2012. Findings further evaluate
the loss of cerebral and ophthalmic autoregulation during general anesthesia and
predictors of IOP at critical levels respectively. Molloy’s 2011 study showed
inadvertently that 6 patients who were removed from the study, due to a procedure need
to reposition the patient level, experienced a decrease in IOP.
Molloy 2012 defines critical IOP at 40 mm Hg and sought to create a tool to
determine when critical IOP is reached. Molloy named the tool Molloy/Bridgeport
Anesthesia Observation Scale (MBOS). It evaluates the presence or absence of: (1) eyelid
edema, (2) corneal/conjunctival edema, (3) ecchymosis. Findings were assigned – absent
(0) or present (1). Molloy evaluated 111 patients with 377 observation time points and
found that the observations could be made to predict patients who would reach an IOP of
critical level. Ecchymosis was not found to be a significant predictor. The most predictive
factor for reaching critical IOP threshold was baseline IOP and chemosis. Chemosis can
128 128 Freshcoln be measured with minimal care-provider training. To measure baseline IOP a tonometer
must be used. The requirement for a tonometer to be used to establish a baseline IOP
seems to negate the need for the MBOS tool. If the facility has a tonometer, the
tonometer can give an exact IOP reading and should be used when available. Further
studies should be performed to continue evaluating the ability to determine IOP when a
tonometer is not available.
An article by Weber reviews two cases in which patients experienced permanent
post operative visual loss following ST positioning for > 6 hours.5 The first patient is a
62-year-old male under general anesthesia for a robotic assisted laparoscopic
prostatectomy. History is negative for hypertension. No mention is made of ocular
history. A period of hypotension (90/45 mm Hg) for one hour was experienced. The
patient received one unit of PRBC, 4,300 of lactated ringers, and a total blood loss of
1,200 ml. Postoperative the patient experienced purple vision and loss of inferior visual
fields in both eyes which worsened when positioned upright. A 3-month follow
examination revealed minimal improvements in vision with stable loss of bilateral
inferior fields, and bilateral superotemporal optic disc pallor.5
The second case study in the article describes a 64-year-old man placed in ST for
approximately 9 hours for a non-robotic laparoscopic prostatectomy. The patient had a
history of medication-controlled hypertension. The patient’s blood pressure ranged from
100/50 to 165/70 for the duration of the procedure. He received 6,500 ml of crystalloids
and had a total blood loss of 500 ml. Postoperatively the patient experience no light
perception vision in both eyes. Twelve days after surgery the patient had regained light
perception vision in the right eye with mild-temporal pallor. The left eye showed no
129 129 Freshcoln improvement to light perception and notable temporal disc pallor. Neither pupil
constricted to direct light.5
Of these two cases, only the patient in the second case experienced facial edema.
It is difficult to identify the degree of influence the position had in relation to the amount
of fluids the patients received, and the range of blood pressures. When compared to
previous research, it seems likely that the extended period of time the patients were in ST
contributed greatly to the end complication of POVL.
Discussion
The aim of this research was to evaluate the intervention of interrupting lengthy
cases in ST to position the patient level for a duration of time before replacing the patient
to ST is to decrease the risk of POVL. The topic of POVL is not a new or foreign issue in
the field of anesthesia with the highest incidence in spine (0.03%) and cardiac (0.08%)
procedures.11,12 A large number of researchers study the prevalence of POVL in supine
cases and fail to address the prevalence of POVL in ST. Although exact causes of POVL
are uncertain, the pathology of POVL has been contributed to compromised blood flow to
the optic nerve, from either increased pressure or decreased blood and oxygen supply,
leading to ischemia and vision loss. Increased pressure on the globe of the eye leads to
retinal vascular neuropathy from retinal vascular occlusion (RVO). Decreased blood and
oxygen supply to the optic nerve results in ischemic optic neuropathy (ION).12
A review of evidence supports the intervention to perform a LSI of about 5-7
minutes duration during lengthy ST procedures.6,7 Returning the patient to supine, or a
position in which the ocular level is above the heart, will reduce intraocular pressure to
130 130 Freshcoln below critical level and facilitate an earlier return to baseline upon repositioning to level
at the end of the case.6 Elevated IOP is an accepted risk factor for ischemic optic
neuropathy and POVL however there is no one specific cause for POVL. This
intervention has the potential to decrease a contributing cause of POVL.
There is a severe lack of research on POVL in relation to ST. The two research
articles evaluating both found a direct correlation with increasing IOP and length of
procedure.6,7 Molloy found a correlation with baseline IOP and chemosis being
significant predictors of the patient reaching critical IOP levels during the surgical
procedure.8 While the tested populations are small, there is reason to believe that similar
findings would occur in larger populations. Only one study directly tested LSI.6 For all
patients in the experimental group, the LSI was performed at 60 minutes for a duration of
5 minutes.6 Research evaluating different timing of LSI and duration of LSI are not
available.
The evidence found supports an LSI of 5 minutes duration at 60 minutes of ST is
effective in reducing IOP and alleviating a potential risk of POVL. Robotics cases often
last multiple hours.4 Current practice is not to reposition the patient for the entirety of the
case. Ideally, the intervention will balance patient safety with the needs of the physician
for the procedure.
Researchers agree IOP continues to increase throughout the duration of ST.6,7
Studies have showed that at a 2 hour elapsed period of ST the IOP would increase from 9
to 28 mm Hg baseline to 25 to 54 mm Hg.2 Molloy 2012 found at a period of 2 hours
21% patients had already reached critical IOP.8 Standard practice is no LSI during the
131 131 Freshcoln procedure regardless of the duration. It is logical to believe these patients would benefit
from an LSI at a two-hour increment for a duration of five minutes similar to the Malloy
study. However, the current practice of not repositioning a patient for the duration of the
case, and the time requirements it takes to un-dock the robot for repositioning make it
unlikely that physicians would be willing to reposition patients at a frequency of every
two hours with the lack of research to support this practice.
Conclusion
An LSI of 5-minutes after one hour of ST is an effective way to decrease the risk
of POVL while undergoing a surgical procedure in the ST position. It would be prudent
to perform an LSI prior to 6-hours of ST. Further research is needed to identify the most
optimal time and frequency to perform an LSI for cases lasting greater than 120 minutes.
Patients known to have an increased baseline IOP should be considered higher risk for
postoperative visual complications when ST position is required under general
anesthesia. When equipment and trained personnel are available, the decision to perform
and LSI should be based on tonometer readings to keep IOP below the critical level of 40
mm Hg.
Research supports the LSI after one hour of ST under general anesthesia.6
Researchers have not yet evaluated when a repeat LSI should be performed. It would be
beneficial to evaluate when subsequent LSIs should be performed. Only one research
article has attempted to create a tool to evaluate IOP in a manner that requires minimal
training and equipment for anesthesia providers.8 Future research should be aimed at
creating a tool that the anesthesia personnel can use to identify critical IOP levels and
when an LSI should be performed without assistance of a tonometer. A future study
132 132 Freshcoln should evaluate the time required to perform an LSI in a robotics case.
A change in practice to implement an LSI would require education of all OR
personnel involved in cases requiring ST. Education would be focused on explaining the
pathophysiology of ST and IOP as the reason for change. Education could be performed
in the manner that best fits the institution and include, but not be limited to, presentations,
posters, handouts, and training as deemed necessary. The cost of this change in practice
primarily would include educational material. Additional cost may be the additional time
required in the operating room caused from the LSIs. It would be necessary to confirm
the plan with the surgeon for a LSI every two hours of the procedure before the procedure
begins. A tonometer would be an additional expense should the hospital decide to utilize
one. A tonometer would give an exact IOP measurement, but the financial cost required
for this may surpass the level of research that supports its benefits at this current time.
Research is in the early stages as related to the issue of ocular complications
related to ST. Additional studies should be performed before a standard change of
practice should be recommended without the understanding that more research should be
performed. It is obvious that the potential complications of not intervening with an LSI
for long-duration procedures under general anesthesia in ST can be devastating.
133 133 Freshcoln References
1. Irvine M, Patil V. Anesthesia for robot-assisted laparoscopic surgery. Continuing
education in anaesthesia, Critical Care & Pain [serial online]. August 2009;9(4):125-129.
Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed March 4, 2013.
2. Molloy B. Implications for Postoperative Visual Loss: Steep trendelenburg position and
effects on intraocular pressure. AANA Journal [serial online]. April 2011;79(2):115-121.
Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed March 4, 2013.
3. Rosswurm M, Larrabee J. Clinical scholarship. A model for change to evidence-based
practice. Image: J Nurs Sch [serial online]. October 1999;31(4):317-322. Available from:
CINAHL Plus with Full Text, Ipswich, MA. Accessed April 15, 2011.
4. Lee LA, Roth S, Todd MM, Posner KL, Polissar NL, Neradilek MB, et al. The
postoperative visual loss study group. J Anes [serial online]. August 2012;117(2):434–
436.
5. Weber ED, Colyer MH, Lesser RL, Subramanian PS. Posterior ischemic optic
neuropathy after minimally invasive prostatectomy. J Clin Neuro Ophthamol. December
2007;27(4):285-287. Accessed March 24, 2013.
6. Molloy BL. A comparative assessment of intraocular pressure in prolonged steep
trendelenburg position vs. supine position intervention. Poster presented at the
PostGraduate Assembly in Anesthesiology; December 2010. New York, NY.
7. Awad H, Santilli S, Ohr M, et al. The effects of steep Trendelenburg positioning on
intraocular pressure during robotic radical prostatectomy. Anesth Analg.
2009;109(2):473-478.
134 134 Freshcoln 8. Molloy B. A Preventive Intervention for Rising Intraocular Pressure: Development of the
Molloy/Bridgeport Anesthesia Associates Observation Scale. AANA Journal [serial
online]. June 2012;80(3):213-222. Available from: CINAHL Plus with Full Text,
Ipswich, MA. Accessed March 4, 2013.
9. MedlinePlus web site. Robotic Surgery.
http://www.nlm.nih.gov/medlineplus/ency/article/007339.htm. Accessed March 4, 2013.
10. Delattre O, Thoreux P, Liverneaux P, et al. Spinal surgery and ophthalmic complications:
a French survey with review of 17 cases. J Spinal Disord Tech. 2007;20(4):302-307.
11. Shen Y, Drum M, Roth S. The prevalence of perioperative visual loss in the United
States: A 10-year study from 1996 to 2005 of spinal, orthopedic, cardiac and general
surgery. J Anesth Analg. Publish ahead of print August 27,2009.
12. Roth S. Perioperative visual loss: what do we know, what can we do? Br. J. Anaesth.
2009;103(1):31-40. doi:10.1093/bja/aep295.
135 135 Freshcoln Reflective Self Evaluation Spring 2013
Core Competency: Professional Role
Description: The 2013 spring semester evaluation shows reflection on the learning
process through the second clinical semester. It serves as a reference tool for professional
growth. Self-evaluation allows the anesthetist to see areas needing improvement as well
as those that have already been improved upon.
Self-Reflection: Spring 2013
Michelle Freshcoln BSN, RN
Texas Christian University – Doctorate of Nurse Practice in Nurse Anesthesia
May 18, 2013
136 136 Freshcoln Self-Reflection: Spring 2013
Reflection
Another semester spent in the clinical setting has come to an end. The second
semester of clinicals has again brought many early mornings, and long days of studying.
As compared to the first semester, I have started to establish routines. Each day brings a
little more confidence.
This semester I went on my first rotation to San Antonio for a rotation
specializing in placement of spinals and epidurals. This rotation provided a new skill and
introduced a new routine presented by a different group of anesthesiologist. It took me
out of my comfort zone and challenged me to continue to grow and learn. As a nurse, I
rotated often to different hospitals. I found I easily adapted to the new routine. My skills
and confidence progressively grew oven the month I spent at my San Antonio rotation
site.
I completed my pediatric rotation this semester. This rotation helped me work on
mask and airway skills. I improved on my inhalation inductions. The challenge I faced
during my pediatric rotation was managing timing of emergence. This is a skill I will
continue to work on as I progress through my training.
The second semester of my clinical experience I could tell I had gained confidence and abilities. I look forward to my upcoming semesters to begin to fine-­‐
tune my skills. I look forward to the independence that steadily increases with experience, and to really begin establishing routines of my own.
137 137 Freshcoln Additional Works – Washington DC Mid-Year Assembly
Core Competency: Public and Social Policy and Ethics
Description: This additional work was a letter showing an interest to attend the AANA
mid-year assembly held in Washington – DC. Through this letter, it is evident that the
anesthesia student understands the importance of understanding political influence on the
profession and the importance of taking an active role to ensure the well-being of our
profession.
AANA Mid-Year Assembly: Interest to Attend
Michelle Freshcoln
January 22, 2013
138 138 AANA Mid-Year Assembly: Interest to Attend
“Be independent, self-sufficient, and do not rely on others to get you what you
want.” I remember exactly where I stood in the kitchen when my dad etched those words
into my mind when I, as a child, made a half-hearted joke about marrying rich to solve
life’s problems. It was those words that pushed me to pursue a career in nursing and to
further my education in the field of nurse anesthesia. I believe those words are not only
important for accomplishing goals, but also ideal principles for governing those
accomplishments. Nurse anesthetists regard their profession with pride. It is not enough
to merely belong to the American Association of Nurse Anesthetist. As members we
must take responsibility for acquiring knowledge about current events and to apply that
knowledge to the profession of nurse anesthesia.
The recent presidential election brought light to the reality that politics highly
influences many aspects of healthcare. I believe the biggest current political issue facing
nurse anesthesia practice today is the dark, mysterious cloud of the Patient Protection and
Affordable Care Act (PPACA), more commonly known as “Obamacare.”1 The PPACA
“is the biggest overhaul of the $2.6 trillion healthcare system since the 1960’s.”1 Rumors
swirled around the perioperative care units around election time. I heard speculations of
expect pay cuts, fewer available jobs, and certified registered nurse anesthetists will be
run out of the profession and replaced by the cheaper alternative of anesthesia assistants.
I will be the first to admit that I am currently under-educated on the actual impact
PPACA will have on the profession of nurse anesthesia. I also believe that every
professional in the industry has a direct responsibility to gain an accurate understanding
of this political issue, amongst many more. As members of the profession we need an
139 accurate overview of the law in order to respond in a manner that may best further the
profession of nurse anesthesia.
My attendance at this meeting will help me gain a factual base for political issues
as they affect future of nurse anesthesia. A better understanding of the issues will enable
me to educate others by presenting facts in conversations, provide a foundation for my
continuing education on political issues impacting healthcare, and empower me to get
involved in future policy making as an informed individual. Specifically from this
meeting, I would like to gain a broader understanding of what other political issues the
profession is faced with, and how I can get involved with where I am now in my
education and future career.
It is my personal experience that word-of-mouth is the most influential way to
pass along any type of information. I would be much more likely to try a restaurant or a
product if a friend recommended it. Likewise, if a friend emphasized the importance of
political issues in nurse anesthesia, I would be more likely to take action, than had I been
given an article. The knowledge I gain from attending this meeting, I will pass on by
word of mouth to my classmates and to other anesthesia providers. I do plan to take notes
to ensure the information I share is accurate. One of the most helpful tools mailed to my
house before the presidential election was a pamphlet that outlined all the issues of the
election. It reported what a vote yes or a vote no would actually mean. If the information
I receive can be compiled in this manner, it would be an ideal way to encourage others to
read about the issues and make their own decisions about pertinent matters.
140 140 As a future nurse anesthetist, it is my responsibility to be independent, selfsufficient, and to not rely on others to learn about the influence of politics on my
profession. I see this meeting as an awesome opportunity. I am grateful that faculty and
staff encourage us to get involved in the bigger picture of anesthesia. I can not express
enough how elated I would be to represent the students of Texas Christian University on
this trip. I appreciate your consideration, and assure you that I would represent the school
well. I will pass along my knowledge and excitement about the experience to my peers to
the best of my ability.
References
1. Vincini J, Stempel J. Wrapup 4-US top court upholds healthcare law in Obama
triumph. Januaray 28, 2012. Available from:
http://www.reuters.com/article/2012/06/28/usa-healthcare-courtidUSL2E8HS4WG20120628 Accessed January 20, 2013.
141 141 Research Poster – POVL in Steep Trendelenburg
Core Competency: Healthcare Improvement
Description: This poster is a visual presentation of the research process and the relevant
findings. This serves as an efficient method of sharing results to others in the profession.
142 142 DNP Project PowerPoint Presentation
Core Competency: Professional Role
Description: This PowerPoint serves as a visual aide to facilitate the presentation of my
completed and final work in becoming a doctoral prepared advanced practice nurse. It
shows professional growth and completion of all requirements for the doctoral degree of
nurse practice.
143 143 144 144 Summer 2013
145 145 Case Report- Epidural Placement and Thrombocytopenia
Core Competency: Practice Inquiry
Description: This case report shows two similar cases in which different case
management resulted in different patient outcomes. Though neither approach was
considered incorrect, an evaluation of research would allow more informed decisions for
future similar cases.
Case Study: Epidural Placement and Thrombocytopenia Michelle Freshcoln Texas Christian University School of Nurse Anesthesia August 3, 2013 146 146 Introduction A relative contraindication to receiving an epidural is a platelet count of less than 100,000 /µL. In cases of thrombocytopenia, the nurse anesthetist must be an advocate for the patient to facilitate the patient to make the best-­‐informed decision for their care. This case study describes two cases of laboring women who requested to receive an epidural with a platelet count of less than 100,000/µL. The patients were under the care of different nurse anesthetist. The nurse anesthetists had varying opinions and gave the patients advice accordingly. In one case, the laboring women chose to forgo the epidural, and the second laboring women chose to receive an epidural. This case study seeks to examine current literature regarding thrombocytopenia in order to give the best possible recommendations for practice. Case Presentation Case 1 The patient was a 19 year-­‐old gravida 2 prima 1 parturient in active labor with a plan for a vaginal delivery. The patient’s medications included prenatal vitamins. The patient did not receive routine prenatal care. Serial labs were not available. Morning labs showed a platelet count of 89,000 µL. The patient reported occasional bleeding when brushing her teeth. The nurse anesthetist explained the risks associated with administering an epidural with a low platelet count. The patient chose not to receive an epidural for labor. Case 2 147 147 The patient was an 16 year old gravida 1 prima 1 parturient in active labor planning for a vaginal delivery. The patient received routine prenatal care. Serial labs showed a progressive drop in platelets. The platelets the morning the patient requested the epidural were 67,000 /µL. One day prior the platelet count was 93,000 /µL. A week prior, the platelet count was 121 /µL. The anesthetist collaborated with the obstetric physician and informed the patient of the risks of administering an epidural with a platelet count of less than 100,000 /µL and proceeded to describe the options available. The patient was administered two units of platelets. Thirty minutes after the infusion of the last unit of platelets, the anesthetist administered an epidural without complications. Discussion When an anesthesia provider evaluates a patient to receive regional anesthesia, the platelet count is an important part of the assessment. Thrombocytopenia is considered to be a relative contraindication to regional anesthesia. Typically, it is recommended to avoid regional anesthesia for a platelet count of less than 100,000 mm/µL, although an absolute minimum level remains unknown. 1 A patient with a low platelet count has an increased risk of bleeding which could result in the rare, but serious complication of a hematoma that compresses and damages the spinal cord. 1 The complication occurs from spontaneous or needle included hemorrhage into the spinal canal. 2 Most often the epidural space is affected because of the prominent venous plexus. 2 148 148 Despite the concerns of serious complications, documentation shows the successful placement of numerous epidurals in patients with platelet counts far less than 100,000 mm/µL the recommended minimum. One case study reports safely administering an epidural to a patient with a platelet count as low as 2,000 mm/µL without complications. 1 Numerous other case studies, show the administration of epidurals without complications to patients with platelet counts ranging from 26,000 mm/µL to 50,000 mm/µL. 1 On discovery of a low platelet count, the patient should be questioned about bleeding abnormalities, especially excessive bleeding with cuts and bleeding gums with routine oral care. The patient should be evaluated for ecchymosis or petechiae, a warning sing for increased risk of bleeding. 1 A rapidly decreasing platelet value is thought to be more concerning than a chronically low platelet value. Prior to receiving an epidural, the patient should be explained the risks of a low platelet count and regional anesthesia. The patients’ likelihood to bleed should be assessed through questioning typical bleeding patterns. Serial platelet counts should be evaluated if applicable. 1 If the decision is made to proceed with a regional anesthetic, it is recommended to use a short duration local anesthetic with the lowest possible concentration. 1 Signs and symptoms of an epidural hematoma include localized, sharp or radiating lower back pain followed by progressive motor and sensory deficits. 2 Following the placement of the regional anesthetic, the patient should be evaluated every two hours for sensory and motor skills for comparison to baseline. Should any deficits be found, neurosurgery should be 149 149 consulted. Diagnosis can be made with magnetic resonance imaging and the recommended treatment of emergent laminectomy and decompression within 6-­‐12 hours in order to preserve neurologic function. 1,2 Each patient should be considered individually. Anesthesia providers and obstetricians should collaborate in order to provide the safest and ideal care for the mother and fetus. Anesthetists should be aware of the indications for patients at an increased risk for bleeding, while keeping in mind that patients have safely received regional anesthesia on numerous occasions with platelet counts less than the recommended minimum. References 1. Shaw MB. Regional anesthesia in the parturient with idiopathic thrombocytopenia purpura. Int Student J Nurs Anesth. 2009;8(2):46-­‐49. 2. Claerhout AJ, Johnson M, Radtke JD, Zaglaniczny KL. AANA journal course 2: Update for nurse anesthetists: Anticoagulation and spinal and epidural anesthesia. AANA J. 2004;72(3):225-­‐231. 150 150 Professional Leadership Policy Paper – Timing Perioperative Antibiotics
Core Competency: Professional Role and Health Systems Management and Public Policy
and Social Policy
Description: This assignment discusses a policy that applies to anesthesia care and
evaluates related research. This empowers the anesthesia provider to take an active part in
evaluating care practices.
Policy Review: Timing Perioperative Antibiotics
Michelle Freshcoln
School of Nurse Anesthesia
Texas Christian University
June 30, 2013
151 151 Issue Statement
The incidence of surgical site infection (SSI), the most common healthcare
associated infection in surgical patients, can be significantly reduced when prophylactic
antibiotics are administered in an evidenced based manner in the perioperative time. 1
Background
Prophylactic antibiotic administration prior to surgical incision is a universally
accepted method for reduction of SSI. A 2009 meta-analysis of 4,809 patients showed a
reduction of rate of infection by one-half for the patients who received prophylatic
antibiotics compared to those who did not receive prophylactic treatment. 2,3 Reduction of
infection was reported in 23 different types of cases including clean, elective cases
including hernia and breast procedures, obstetric cases, and colorectal procedures. 2
Despite these benefits, the use of prophylactic antibiotics does not come without
risk. These risks cause practitioners to occasionally forgo ordering prophylactic
antibiotics for clean cases. The risks of use include adverse effects, acquired antibiotic
resistant pathogens, C. difficile colitis, and significant increase in treatment costs. 2
According to the 2009 meta-analysis, correct timing of the administration of
antibiotics is crucial for reducing the incidence of SSI. 3 Early studies recommended
administering antibiotics within the first two hours before surgery. 2 This time was
referred to as the “golden period.” 2 Numerous studies have since reported varying
optimal time ranges for administration of antibiotics including 30-60 minutes prior to
incision, 10-20 minutes prior to incision, and 1-30 minutes prior to incision. 2 Evidence
152 152 supports the administration of longer acting antibiotics, such as vancomycin and
fluoroquinolones, 1-2 hours prior to incision. Benefits of prophylactic antibiotics are lost
when antibiotics are initiated more than 12 hours before surgical incision. 2
Various studies have examined the use of single dose antibiotics versus multiple
dose antibiotics. These studies indicate a single dose is as effective in as multiple doses of
antibiotics in reducing SSI. This result is not reproducible in all studies. One study found
a reduction in SSI of 14.2% to 4.3% in colorectal surgery when 3 doses of cefmetazole
were administered as opposed to one dose. A similar reduction was evident in a
prospective randomized study of patients undergoing coronary artery bypass grafting.
Researchers speculate the decreased incidence of SSI with multiple doses of
antibiotics may be attributed to a therapeutic concentration of antibiotic being present at
the time of surgical site closure. 2 Renal function, body weight, half-life of the antibiotic,
age, and rate of administration in combination with the use of any fluid resuscitation,
blood transfusions, or cardiopulmonary bypass must all be taken into consideration when
considering therapeutic concentrations of antibiotics. 2
Modifying Factors
Excretion of antibiotics usually directly correlates with renal function. Renal
impairment prolongs the rate of excretion. Hypotension decreases renal function and,
consequently, will also decrease the rate of excretion. Obese patients require a higher
dose of antibiotics to achieve tissue and serum concentrations adequate to reduce SSI. 2 A
single dose of a drug with a short half-life, such as cefazolin, will not sustain therapeutic
levels for the duration of a long procedure. Either redosing an antibiotic with a short half-
153 153 life, or administering an antibiotic possessing a long half-life, such as fluoroquinolones,
may maintain the prophylactic effect of the antibiotic. Table 1 from Wesley et al. shows
recommendations for redosing antibiotics based on creatinine clearance rates. 2
Table 1. Intraoperative Dosing Intervals (hours) for Selected
Antibiotics Based on Renal Function
CrCl > 50
m L/m in
3–4
3
8
CrCl 20 – 50
m L/m in
8
6
12
CrCl < 20
m L/m in
16
12
None
3
6
12
6
6
6
Gentamicin
5
Call Pharmacy
None
M etronidazole (Flagyl)
Vancomycin
8
8
8
16
8
None
Antibiotic
Cefazolin
Cefuroxime
Ciprofloxacin
Ampicillin/sulbactam
(Unasyn)
Clindamycin
Numerous studies have shown administration of prophylactic antibiotics
exceeding 24 hours add no benefit in reducing SSI in a variety of surgical cases.
Prolonged antibiotic use increases the risk of acquired antibiotic resistance and directly
increases the cost of care. 2
Policy
Centers for Medicare and Medicaid Services (CMS) have outlined certain policies
through the Surgical Care Improvement Project (SCIP) that aim to improve surgical care
by reducing surgical complications. SCIP recommends administering preoperative
prophylactic antibiotics within one hour prior to surgical incision and two hours prior for
154 154 vancomycin or fluroquinolones. Prophylactic antibiotics should be discontinued within
24 hours of surgical end time, 48 hours for cardiovascular surgery.
Goals
The goal of the prophylactic antibiotic policy is to provide effective and
evidenced-based care to surgical patients through clear recommendations for the
administration of antibiotics in order to prevent the complication of SSI.
Policy Options for Practice
1. Adhere to CMS recommended policy as currently stated: Antibiotics will be
administered within one hour of surgical incision, within two hours for
vancomycin and fluroquinolones, and discontinued within 24 hours of surgical
end time, and within 48 hours from surgical end time for cardiovascular surgery.
2. Reduce the window of time for the delivery of antibiotics to 30 minutes prior to
surgical incision, and maintain the time for discontinuation of antibiotics.
3. Amend the policy to require dosing and redosing antibiotics based on modifying
factors and creatinine clearance as recommended in Table 1.
4. Modify the policy to discontinue antibiotics once the surgical incision has been
closed.
Recommended Policy
Current literature suggests the most effective method for reducing SSI is to
administer prophylactic antibiotics within 30 minutes before the surgical incision. It is
imperative to maintain a therapeutic level of antibiotics in the tissue from first surgical
155 155 incision to surgical closure. Therefore, a standard timing and method for redosing should
be added to the current policy. Redosing should be approximately 3 hours after an initial
dose of short-acting antibiotics. Table 1 may also be adopted into the policy for a more
specific method of redosing antibiotics. Evidence shows no benefit of prophylactic
antibiotic administration once the surgical wound has been closed. The policy should be
changed to discontinue antibiotics, in the absence of vast contamination, at surgical end
time.
2,3
Since the length of time necessary to prepare for a case varies with each
procedure, a recommendation is to commence antibiotic dosing when the scrubbed-in
surgeon enters the room in immediate preparation for surgery. In addition to utilizing the
table for redosing, additional considerations, such as body mass, is to be taken into
consideration when deciding the proper dose for the patient.
References
1. Grose S, Schub T. Infections, surgical site: prevention. Cinahl Information Systems.
2013.
2. Wesley JA, Solomkin J, Edwards MJ. Updated recommendations for control of
surgical site infections. Annals of Surgery. 2011;253(6):1082-1093.
3. Bowater RJ, Stirling SA, Lilford RJ. Is antibiotic prophylaxis in surgery a generally
effective intervention? testing a generic hypothesis over a set of meta-analyses.<br />.
Ann Surg. 2009;49:551–556.
156 156 Evidence of Oral Professional Presentation
Core Competency: Professional Role, Healthcare Improvement, and Practice Inquiry
Description: The TCU students at the clinical site of Baton Rouge were responsible for
educating the PACU, OR , ICU, and endoscopy nurses about malignant hyperthermia and
how to be prepared to respond to a crisis. We prepared a PowerPoint presentation and a
skit and over two days at two hospitals gave nearly ten presentations which were
recorded and will be used by the education department in the future.
157 157 Evidence of Peer-Reviewed Publication Submission
Core Competency: Healthcare Improvement
Description: The postoperative vision loss in steep Trendelenburg was submitted and
accepted for presentation at various events. The poster was presented at the TCU Harris
College Research Symposium, the TCU School of Nurse Anesthesia research symposium
and dinner, and the AANA Annual Meeting.
158 158 Reflective Self Evaluation: Summer 2013
Core Competency: Professional Role
Description: The final self evaluation reflects on the comprehensive educational process.
It examines strengths and weaknesses as well as evaluated the completion of the program
goals and requirements.
Self-Reflection: Summer 2013
Michelle Freshcoln BSN, RN
Texas Christian University – Doctorate of Nurse Practice in Nurse Anesthesia
July 21, 2013
159 159 Cumulative Summary Self-Reflection: Summer 2013
Summer semester is coming to an end. I have one more test between left in the
summer semester before I begin the last school semester before graduation. As I write
this reflection, I am in the process of reviewing this portfolio. I have started preparing for
the boards and begun considering jobs to apply for. The end of my journey through nurse
anesthesia school is in sight.
This summer I rotated to a hospital in Dallas for a month. I really enjoyed this
experience. I feel my skills and knowledge grew tremendously in just one month. I
encountered many different techniques and drugs that I had rarely, and even never in
some instances, had the opportunity to use prior to that rotation. I managed patients with
opioid infusions of remifentanil and sufentanil. I utilized the anesthetic gas desflurane
more times in one month than I had in my whole anesthesia clinical experience up to this
point. It took some time for me to become comfortable with the new technique, but by the
time I left, I had acquired a better knowledge of the patient response to opioids and how
to balance that with anesthetic gases. I provided anesthesia for cases I would not have
encountered had I not been afforded the opportunity to rotate to Dallas. I truly benefited
from that experience.
Coming back to Baton Rouge after my rotation felt like coming home. I was able
to fall back into a comfortable routine. It didn’t take me long to switch back to the
techniques I had been trained on. I was able to bring back my technique and was even
able to share some of my Dallas experience with the CRNAs I worked with in Baton
Rouge.
160 160 Next week I will begin my last rotation to Crowley, Louisiana. I am looking
forward to yet another opportunity to expound my anesthetic techniques and knowledge
of the profession. I see board preparation, doctoral project presentation, job searching,
and finally graduation in my near future.
As my school career nears completion, so does my portfolio. I feel fortunate to be
able to look at my progress through school compiled into one document. It serves as a
reminder of all that I have learned. I have documents from the beginning through which I
learned to form simple questions of practice and translate that question into a plan to
provide evidenced-based, quality care, and a format to pass that on to other professionals.
By the end of my scholastic training, the questions came almost second-nature. I was able
to spend more time evaluating and translating the research into knowledge and
suggestions, which I could pass onto other professionals.
I compare each work I add to my portfolio against the expected competencies for
a CRNA at the doctorate level. It is reassuring to see that I really have met and surpassed
the expectations set by TCU Harris College School of Nurse Anesthesia, American
Association of Colleges of Nursing, and the Council of Accreditation of Nurse
Anesthesia Educational Programs. I feel well prepared to begin my professional career of
nurse anesthesia.
161 161