Download Venous Thromboembolism Prophylaxis in Plastic Surgery: A

Venous Thromboembolism Prophylaxis in
Plastic Surgery: A Literature Review
Sergio Hernandez, DNP, CRNA
Jorge Valdes, DNP, CRNA
Moises Salama, MD
Venous thromboembolism (VTE) is a major health
concern because it increases morbidity and mortality
after a surgical procedure. A number of well-defined,
evidence-based guidelines are available delineating
suitable use of prophylaxis to prevent deep vein
thrombosis and pulmonary embolism. Despite the
available literature, there are clear gaps between
recommendations and clinical practice, affecting the
incidence of VTE. Plastic surgeons underuse the substantiated literature and risk stratification tools that
are available to decrease the incidence of VTE in
the office-based surgical setting because of fear of
V
enous thromboembolism (VTE) refers to
a continuum of disease ranging from deep
venous thrombosis (DVT) to pulmonary
embolus (PE). According to the American College of Chest Physicians (ACCP),
approximately one-third of the 150,000 to 200,000 VTErelated deaths per year in the United States occur following surgery.1 In 2001, the American Society of Plastic
Surgeons (ASPS) estimated 18,000 cases of DVT occur
in plastic surgery annually, with an overall incidence of
VTE in plastic surgery varying between 0.5% and 2%.2
Although the incidence rate in plastic surgery may seem
low, it is postulated these numbers represent only patients
who are symptomatic.3 Up to two-thirds of patients with
VTE are clinically silent, leading to a substantial delay in
diagnosis and treatment.4
Plastic surgery as a specialty stands to benefit from prevention of VTE because some authors have suggested that
patients undergoing plastic surgery are at higher risk of
VTE than typically perceived.5 Despite the data regarding
the incidence of VTE and available risk stratification tools
for prevention, the use of chemoprophylaxis in high-risk
patients remains controversial in the plastic surgery community because of fear of postoperative bleeding or hematoma complications.3,6,7 Plastic surgeons traditionally rely
on early ambulation and pneumatic compression devices
to protect against DVT.8 The underutilization of VTE prophylaxis in outpatient plastic surgery centers is a public
safety concern, predisposing patients to a greater incidence
of VTE events. As a result, these patients would benefit
from the implementation of a VTE prophylaxis regimen.
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bleeding or hematoma complications postoperatively.
Venous thromboembolism creates an economic burden on both the patient and the healthcare system. The
intent of this literature review is to determine existing
VTE risk using assessment models available to aid in
the implementation of protocols for VTE prevention,
specifically for high-risk cosmetic surgical patients in
office-based settings.
Keywords: Chemoprophylaxis, deep vein thrombosis,
low-molecular-weight heparin, venous thromboembolism, plastic surgery.
Thrombosis can occur at any point during the perioperative course; therefore, anesthesia providers play a
major role in the process of risk stratification for VTE.9
Anesthesia and immobilization cause venous stasis, as
do the supine and flexed positions required for surgery.2
The enactment of a successful VTE prophylaxis protocol
requires a multidisciplinary effort. It is crucial for surgeons, anesthesia providers, and ancillary surgical staff
to be aware of the risks of VTE and to formulate a treatment plan before surgery, which would include choice of
chemoprophylaxis medication, timing of initial dose, and
duration of treatment.
Venous thromboembolism is a costly complication,
affecting the healthcare system economically, creating a
financial burden to patients, affecting potential payouts
of lawsuit settlements, and increasing liability for plastic
surgery centers. Venous thromboembolism continues to
be a leading cause of morbidity and mortality in patients
during the perioperative process, representing a $500
million burden on the US healthcare system.10 Following
an initial VTE event, the rate of recurrence is estimated to
be 5% to 14% within 90 days, further increasing healthcare expenditures.11 Prophylaxis is more cost-effective
than treating an acute event of VTE and risking a potentially fatal outcome.12
Little evidence explores risk stratification and the management of patients with thromboembolic disease and
associated complications.13 The need for safety measures
and opportunities for protocol development in officebased surgery must be evaluated. The VTE prophylaxis
recommendations and guidelines can be implemented
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167
easily, improving patient safety and outcomes. The success
of these strategies relies on continuous awareness of preexisting risk factors, use of available resources, and practice
of protocols by all members of the surgical team through
the perioperative process. This review will analyze current
recommendations for VTE risk assessment and prophylaxis regimen available to aid in the implementation of
protocols for VTE prevention. Specifically, this review will
examine recommendations for high-risk cosmetic surgical
patients in office-based settings.
Methods
An electronic search was performed using Cumulative
Nursing & Allied Health Literature (CINAHL), PubMed,
MEDLINE, and Scopus. Search results were limited to the
English language and a publication date within the last 10
years. The following search terms were applied in all individual database searches: venous thromboembolism, deep
vein thrombosis, plastic surgery, chemoprophylaxis, and
low-molecular weight heparin. Qualitative and quantitative studies were used, and duplicate titles were removed.
Titles with abstracts not deemed relevant were eliminated.
Inclusion criteria consisted of studies of human subjects
whose interventions evaluated the efficacy of chemoprophylaxis in high-risk patients undergoing plastic surgery
procedures. Studies not focused on the plastic surgery
population were excluded. Study designs involved retrospective and prospective data consisting of participants
undergoing elective cosmetic or reconstructive surgical
procedures. Published guidelines and current recommendations regarding VTE risk assessment and prophylaxis
were also included in this literature review.
The search yielded 66 articles related to the previously
mentioned criteria. Of the 66 articles, 13 were found to
be relevant and subsequently included for this literature
review. Accompanying literature also included data and
recommendations from the ACCP and the ASPS.
Review of the Literature
Rudolf Ludwig Karl Virchow in 1859 was the first physician to demonstrate that thrombosis formation was
caused by a triad of factors: hypercoagulability of blood,
venous stasis, and endothelial damage.2 Perioperative
thrombosis and hemostasis management have changed
considerably over the past 50 years to include the breakthrough discovery of heparin and other anticoagulants.14
Since the late 1990s, the medical and surgical literature
has experienced a large number of reviews, clinical
studies, and meta-analyses of the issues pertaining to
VTE in the United States.2 Proximal DVT carries a 90-day
risk of PE in 50% of the affected population when untreated. Symptomatic PE has a 10% mortality rate within
the first hour of onset of symptoms.2,7,15 Many VTErelated events are considered potentially preventable.
Effective methods of VTE prevention have been iden-
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tified and are updated every 4 years by the ACCP, but
VTE as a public health concern and patient safety issue
remains largely unrecognized in office-based surgery
practices. Patients undergoing plastic surgery were first
included in the ACCP recommendations for VTE chemoprophylaxis in 2012 because of the increased volume
in plastic surgery.1,9 Of all cosmetic surgery procedures,
71% were performed in physicians’ offices in 2013, according to the ASPS.16 Debate among healthcare professionals exists regarding the appropriate VTE treatment
regimen in high-risk patients presenting for elective
plastic surgery in an office-based setting. The exact incidence of VTE is unknown because screening and prophylactic practices are often lacking in the plastic surgery
patient population.2,12
Risk assessment serves as an important tool to identify
patients who have a high probability for the development
of VTE. The most widely used risk stratification tool is
the Caprini model.3 In the Caprini model, preventive
measures first include identification of patient-related
risk factors such as a previous history of VTE, hormone
replacement therapy, obesity, use of oral contraceptives,
advanced age, pregnancy, immobility, smoking, cancer,
and hypercoagulable blood disorders (Table).17
The type of procedure being performed may also
augment patient-related risk factors. Procedural risk
factors specific to plastic surgery include large-volume
liposuction above 5 L, use of general anesthesia, abdominoplasty, and longer procedures or those in combination
lasting more than 4 hours (which include mastopexy and
abdominoplasty combined).2,5,6,12 A VTE prevention plan
should be created in accordance with patient and procedural risk factors. Despite the known risks of VTE, fewer
than 50% of plastic surgeons are believed to consistently
use chemoprophylaxis for high-risk patients.5
•Risk Factors. Independent patient-related factors
increasing the risk of VTE not included in the Caprini
model are ethnicity and travel. Ethnicity is a contributing factor for hypercoagulable disease. White females,
which account for 70% of all cosmetic surgical patients,
are most likely to carry the hereditary gene for the hypercoagulable disorder, factor V Leiden. The gene in this
disorder presents as a heterozygous mutation in 3% to
7% of white females, resulting in a sixfold increase in the
risk of VTE.2,5,14,16
Another important risk factor to also consider is
travel. People are more likely to travel in conjunction
with plastic surgical procedures than any other surgical
procedure.5 This population may also include patients
who travel for breast reconstructive surgery after previous malignancy of the breast. Prolonged air travel carries
the greatest risk of DVT or PE compared with other
modalities of travel. Traveling compounded with obesity,
oral contraception use, and factor V Leiden will increase
rate of VTE events even further.2
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Number
of points
5
Risk
Factorsa
• Elective major lower extremity arthroplasty
• Hip, pelvis, or leg fracture (< 1 mo)
• Multiple trauma (< 1 mo)
• Acute spinal cord injury (paralysis, < 1 mo)
• Stroke (< 1 mo)
• Age > 75 y
3
• History of DVT or PE
• Positive factor V Leiden
• Positive for prothrombin 20210A mutation
• Elevated serum homocysteine level
• Positive lupus anticoagulant test
• Elevated levels of anticardiolipin antibodies
• Heparin-induced thrombocytopenia
• Other congenital or acquired thrombophilia
• Family history of thrombosis
• Age 60-74 y
2
• Arthroscopic surgery
• Malignancy (present or previous)
• Major surgery (> 45 min)
• Laparoscopic surgery (> 45 min)
• Prolonged bedrest (> 72 h)
• Immobilizing plaster cast of the leg or foot (< 1 mo)
• Central venous access
• Age 41-60 y
1
• Minor surgery planned
• History of major surgery (< 1 mo)
• History of inflammatory bowel disease
• Obesity (BMI > 25 kg/m2)
• Acute myocardial infarction
• Congestive heart failure (< 1 mo)
• Sepsis (< 1 mo)
• Serious lung disease
• Abnormal pulmonary function
• Varicose veins
• Swollen legs (current)
• Medical patient currently at bedrest
1 (women only)
• Oral contraceptive or hormone replacement therapy
•U
nexplained stillborn infant or spontaneous
abortion
• Pregnancy or post partum (< 1 mo)
•P
remature birth with toxemia or growth-restricted
infant
Table. Risk Assessment Score for Venous
Thromboembolism
Abbreviations: BMI, body mass index; DVT, deep vein thrombosis;
PE, pulmonary embolism.
aEach risk factor represents the specified number of points.
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Cancer and obesity are considered major risk factors
contributing to VTE risk included in the Caprini model.
Patients undergoing reconstructive procedures due to
breast cancer fall into a high-risk classification for VTE.
Breast cancer treatment promotes a twofold to fivefold
increase in the risk of VTE because of estrogen receptor
modulator medications and malignancy causing a procoagulant state with abnormal blood flow, blood composition, and vessel walls.5,18 The presence of malignancies,
prolonged complex surgical procedures, and postoperative immobilization also contribute to the development
of VTE.19
Obesity has continuously been recognized as a major
risk factor to the development of VTE.2 Because of an
increase in the number of bariatric procedures, patients
experiencing massive weight loss are more prevalent
than ever. With these procedures comes the demand
for body contouring procedures, thus prompting plastic
surgeons to reconsider their views on VTE prophylaxis.20
Prolonged intraoperative time, increased intra-abdominal
pressure with tightening of abdominal fascia, and improper postoperative abdominal binder placement have
all been postulated as increasing the risk of VTE in plastic
surgery, which is the reason why body contouring and
abdominoplasty procedures have the highest probability
of VTE compared with other procedures in this specialty.
Moreover, abdominoplasty and belt lipectomy procedures are the most sought-after procedures for massive
weight loss patients, and these procedures result in VTE
complications ranging from 2% to 9% for symptomatic
DVT or PE.2,3,21
•Chemoprophylaxis. Patient-related and proceduralrelated factors must be weighed against the likelihood
of bleeding before chemoprophylaxis can be initiated.5
Timing of administration for chemoprophylaxis continues to be examined. No current consensus in the plastic
surgery literature exists regarding the most appropriate
time to initiate chemoprophylaxis therapy in high-risk
patients. The critical period for thrombosis formation begins at the induction of anesthesia, thus being a
concern for the anesthesia provider.2,5,6 Current recommendations suggest for pneumatic compression devices
to be applied to lower extremities before the induction
of anesthesia to prevent venous stasis due to decreases
in peripheral vascular resistance secondary to induction.13 Additional anesthesia-related factors contributing
to venous stasis and stimulation of coagulation include
prolonged operative/anesthetic exposure time, vasodilatory effects of anesthesia medications, muscle relaxation,
and decreases in core body temperature.22
Proper perioperative patient positioning and aggressive early postoperative ambulation are mandatory for all
patients undergoing surgery, according to the ACCP.5 Not
all patients can be fully ambulatory after plastic surgery,
requiring additional measures of prophylaxis. Prophylaxis
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for the prevention of VTE is broken down into 2
categories: mechanical and pharmacologic. Mechanical
prophylaxis refers to devices worn by the patient,
which reduces venous stasis, therefore preventing VTE.
Chemoprophylaxis refers to anticoagulant medications
used systemically to prevent VTE.5 Chemoprophylactic
therapy in combination with mechanical modalities continues to be superior to single-modality therapy alone for
VTE prevention in patients at highest risk.13 Hesitation
to use chemoprophylaxis exists among some plastic surgeons because of concerns about increased postoperative
bleeding; however, this fear is not validated in the plastic
surgery literature.2 Plastic surgeons cite lack of evidence
as a major driver of the decision to not use chemoprophylaxis.7
This literature review highlighted issues with pharmacologic prophylaxis, which include efficacy, safety, and
cost-effectiveness. The most effective methods of prophylaxis are low-dose unfractionated heparin and low-molecular-weight heparin (LMWH), reducing the risk of DVT
by 68% to 76%.12 Reportedly, LMWH reduced bleeding
and the risk of VTE as effectively as heparin, with increased bioavailability and longer plasma half-life.22 The
evidence is controversial regarding whether either of the
2 medications reduces the risk of bleeding and hematoma.
The decision to provide chemoprophylaxis raises
another question, which is when to administer the medication and duration of treatment. Clot formation mostly
occurs intraoperatively; therefore, most general, orthopedic, and bariatric surgeons administer chemoprophylaxis
preoperatively.21 Preoperative subcutaneous heparin has
been shown to be safe in other surgical groups; however,
the large surface areas and dissection involved in abdominoplasty, belt lipectomy, and transverse rectus abdominis
myocutaneous (TRAM) flap reconstructions have been
considered by many plastic surgeons as a relative contraindication to preoperative chemoprophylaxis. Campbell
et al3 retrospectively examined patients undergoing abdominoplasty; their results suggested safety and efficacy
with preoperative administration and continuation of
LMWH for 2 days postoperatively to cover the period of
maximum immobility, without any bleeding complications requiring surgical intervention or blood transfusion.
Keith and colleagues9 also retrospectively studied preoperative chemoprophylaxis in patients undergoing breast
reconstruction and reported an acceptable rate of postoperative bleeding complications managed conservatively.
Reish et al21 retrospectively reviewed a single surgeon’s experience of truncal contouring cases that were
at high risk of VTE. The findings of the study showed
the combination of preoperative and postoperative chemoprophylaxis with unfractionated heparin did not
significantly increase the incidence of bleeding. Seruya
et al4 also retrospectively reviewed a single surgeon’s
experience; results proved that mechanical prophylaxis
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plus subcutaneous heparin (unfractionated or LMWH)
postoperatively conferred a statistically significant reduction in the rate of VTE without a significant increase in
bleeding vs mechanical prophylaxis alone. Limitations to
these studies included a small sample size and a single
surgeon’s experience, but they had the advantage of enabling a strict adherence to a chemoprophylaxis protocol
to study efficacy.
Colwell et al8 prospectively analyzed patients undergoing abdominal contouring procedures. They noted that
the increase in intraoperative thrombin generation was
significantly less in patients receiving chemoprophylaxis
compared with those who received no prophylaxis (75 vs
997 nM, P = .019). The increase in postoperative thrombin generation was significantly less in patients receiving
chemoprophylaxis compared with those who received no
prophylaxis (186 vs 1404 nM, P = .004), with no thromboembolic events or bleeding complications reported in
the immediate postoperative period and in the 6-month
follow-up after receiving chemoprophylaxis for 7 days in
the treatment group. This study demonstrates a significant
intraoperative increase in thrombin generation in patients
undergoing body contouring procedures, thus supporting
the efficacy of preoperative chemoprophylaxis.
In a prospective, nonrandomized assessment, Kim et
al18 compared 2 groups of patients undergoing immediate pedicled TRAM flap breast reconstruction. One group
received no chemoprophylaxis, and the other received 7
days of enoxaparin starting 1 hour preoperatively. They
found no difference in transfusion rates or hematoma.
There was a significant difference in the incidence of
asymptomatic PE, 16.7% in the group without chemoprophylaxis vs 0% in the group receiving preoperative
and postoperative chemoprophylaxis. Michaels et al6 also
prospectively reviewed a cohort of patients undergoing
body contouring procedures after massive weight loss.
In a nonrandomized fashion, the control group received
mechanical prophylaxis alone, and the experimental
group received mechanical prophylaxis plus LMWH 6
hours postoperatively. The experimental group demonstrated no increased risk of transfusion or hematoma
after implementing a chemoprophylaxis regimen.
Hatef et al13 showed that enoxaparin administration
was associated with a statistically significant decrease
(P = .0064) in DVT among patients undergoing circumferential abdominoplasty. Data from this retrospective
analysis demonstrated that a risk-assessment tool such
as the Davison-Caprini risk assessment model should be
applied preoperatively to risk-stratify all patients undergoing excisional body contouring. The authors examined
the relationship between body contouring surgery and
enoxaparin administration. They compared enoxaparin
treatment timing: 2 hours preoperatively vs intraoperatively or immediately postoperatively. There was no
statistically significant difference in bleeding requiring
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transfusions, intraoperative blood loss, or VTE events. It
was noted that patients who received LMWH for 3 days
or longer had statistically significant increases in postoperative bleeding requiring transfusion, but they did not
have increased risk of hematoma formation.
Pannuci et al7,15 retrospectively collected and applied
a Venous Thromboembolism Prevention Study protocol
in a multicenter analysis of various plastic surgery procedures. The goal of this study was to risk-stratify and
provide chemoprophylaxis to high-risk plastic surgery
patients. The authors noted that postoperative LMWH
was protective against 60-day VTE in high-risk patients
and did not produce clinically relevant increases in observed rates of reoperative hematoma.
Newall et al22 retrospectively studied high-risk patients undergoing liposuction and body contouring procedures and the effect of chemoprophylaxis. The study
noted no incidence of VTE following chemoprophylaxis
administration 1 hour after surgery without provoking
hemorrhage or bleeding complications postoperatively.
Lemaine and colleagues19 studied LMWH chemoprophylaxis in women who had free-flap autologous breast
reconstruction; 5.3% of the study sample had a reoperative hematoma. The authors noted that most of the reoperative hematomas were attributed to flap congestion
and considered having a low threshold for reoperation
considering the nature of the procedure and concerns
of flap necrosis. The authors’ findings support the use
of chemoprophylaxis and demonstrated that LMWH is a
safe and effective method for prevention of VTE.
Implications for Future Studies
Gaps exist in the evidence to guide the choice among
available anticoagulants, dosing, optimal timing of initiation, and duration of therapy for VTE prevention.21 No
prospective randomized controlled trials exist on preoperative chemoprophylaxis for VTE in plastic and reconstructive surgery. However, retrospective reviews present
a decrease in the incidence of VTE in patients undergoing circumferential abdominoplasty and in patients with
massive weight loss following bariatric surgery when
postoperative chemoprophylaxis is used.3
The literature demonstrates the need for large multicenter, prospective, randomized studies to examine
various thromboembolic therapies and associated complications in these patients.13 Additionally, Seruya et al4
suggest that a Doppler analysis of the lower extremities
should be included in all future VTE studies of patients
preoperatively and on postoperative days 5 and 7 to
document the true incidence of VTE and more accurately
quantify risk reduction with thromboprophylaxis.4
Conclusion
Prophylactic modalities to prevent VTE are underutilized
by health professionals, particularly in office-based plastic
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surgery despite all the data to support thromboprophylaxis for prevention in high-risk patients. Events of VTE
significantly contribute to increased morbidity and mortality along with a steady rise in healthcare expenditures.
Patient education is paramount and should include information as to their individual risk factors, symptoms of
DVT or PE, and an explanation of the risk-to-benefit ratio
in using anticoagulants as prophylaxis.2 The Caprini risk
assessment tool has proved to be clinically valuable when
one assesses patients for VTE and should be included in
the patient’s chart in all office-based plastic surgery settings. Ethnicity, travel, malignancy, and obesity are some
of the patient-related factors contributing to increased
risk and must be considered clinically relevant.
Collectively, numerous retrospective studies demonstrate promising results in prevention, and these results
can be used to formulate an individualized treatment
plan for VTE prophylaxis in high-risk patients undergoing plastic surgery. Evidence suggests chemoprophylaxis
should be included during the perioperative period and/
or postoperatively to cover the period of maximum immobility in high-risk patients. Physician attitudes vary regarding adding chemoprophylaxis as part of multimodal
therapy because of concerns of increased surgical blood
loss and postoperative hematoma formation, although
some literature exists that refutes the notion. Focusing
on prophylactic efforts is of utmost value in VTE prevention. Multimodal therapy for VTE prophylaxis compared
with single-modality therapy or no therapy has shown
to be superior in improving patient outcomes.4 This
literature review supports the implementation of a VTE
screening protocol to assess and recommend prophylaxis
for all patients undergoing elective plastic surgery outside
a hospital environment. It is paramount to include VTE
prophylaxis in office-based plastic surgery settings to
increase patient safety, to promote evidence-based practices, and to improve cost-effectiveness through preventive measures.
REFERENCES
1. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e227Se277S.
2. Young VL, Watson ME. The need for venous thromboembolism (VTE)
prophylaxis in plastic surgery. Aesthet Surg J. 2006;26(2):157-175.
3. Campbell W, Pierson J, Cohen-Shohet R, Mast BA. Maximizing chemoprophylaxis against venous thromboembolism in abdominoplasty
patients with the use of preoperative heparin administration. Ann
Plast Surg. 2014;72(6):S94-S96.
4. Seruya M, Venturi ML, Iorio ML, Davison SP. Efficacy and safety of
venous thromboembolism prophylaxis in highest risk plastic surgery
patients. Plast Reconstr Surg. 2008;122(6):1701-1708.
5. Venturi ML, Davison SP, Caprini JA. Prevention of venous thromboembolism in the plastic surgery patient: current guidelines and
recommendations. Aesthet Surg J. 2009;29(5):421-428.
6. Michaels J, Coon D, Mulvey CL, Rubin JP. Venous thromboembolism
prophylaxis in the massive weight loss patient: relative risk of bleed-
AANA Journal

June 2016

Vol. 84, No. 3
171
ing. Ann Plast Surg. 2015;74(6):699-702.
7. Pannucci CJ, Wachtman CF, Dreszer G, et al. The effect of postoperative enoxaparin on risk for reoperative hematoma. Plast Reconstr Surg.
2012;129(1):160-168.
8. Colwell AS, Reish RG, Kuter DJ, Damjanovic B, Austen WG Jr,
Fogerty AE. Abdominal contouring procedures increase activity of the
coagulation cascade. Ann Plast Surg. 2012;69(2):129-133.
9.Keith JN, Chong TW, Davar D, Moore AG, Morris A, Gimbel
ML. The timing of preoperative prophylactic low-molecular-weight
heparin administration in breast reconstruction. Plast Reconstr Surg.
2013;132(2):279-284.
10. Hawkins D. Pharmacoeconomics of thrombosis management. Pharmacotherapy. 2004;24(7 pt 2):95S-99S.
11. Spyropoulos AC, Lin J. Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative
claims analysis from 30 managed care organizations. J Manag Care
Pharm. 2007;13(6):475-486.
12. Miszkiewicz K, Perreault I, Landes G, et al. Venous thromboembolism
in plastic surgery: incidence, current practice and recommendations.
J Plast Reconstr Aesthet Surg. 2009;62(5):580-588.
13.Hatef DA, Kenkel JM, Nguyen MQ, et al. Thromboembolic risk
assessment and the efficacy of enoxaparin prophylaxis in excisional
body contouring surgery. Plast Reconstr Surg. 2008;122(1):269-279.
14. Valsami S, Asmis LM. A brief review of 50 years of perioperative thrombosis and hemostasis management. Semin Hematol. 2013;50(2):79-87.
15. Pannucci CJ, Dreszer G, Wachtman CF, et al. Postoperative enoxaparin prevents symptomatic venous thromboembolism in high-risk
plastic surgery patients. Plast Reconstr Surg. 2011;128(5):1093-1103.
16. American Society of Plastic Surgery. 2013 Plastic surgery statistics
report. http://www.plasticsurgery.org/Documents/news-resources/
statistics/2013-statistics/plastic-surgery-statistics-full-report-2013.
pdf. Published 2013. Accessed September 26, 2014.
17. Caprini JA, Arcelus JI, Reyna JJ. Effective risk stratification of surgical
and nonsurgical patients for venous thromboembolic disease. Semin
Hematol. 2001;38(2 suppl 5):12-19.
18. Kim EK, Eom JS, Ahn SH, Son BH, Lee TJ. The efficacy of prophylac-
172
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
June 2016

Vol. 84, No. 3
tic low-molecular-weight heparin to prevent pulmonary thromboembolism in immediate breast reconstruction using the TRAM flap. Plast
Reconstr Surg. 2009;123(1):9-12.
19. Lemaine V, McCarthy C, Kaplan K, et al. Venous thromboembolism
following microsurgical breast reconstruction: an objective analysis
in 225 consecutive patients using low-molecular-weight heparin prophylaxis. Plast Reconstr Surg. 2011;127(4):1399-1406.
20. Colwell AS, Borud LJ. Optimization of patient safety in postbariatric
body contouring: a current review. Aesthet Surg J. 2008;28(4):437-442.
21. Reish RG, Damjanovic B, Colwell AS. Deep venous thrombosis prophylaxis in body contouring: 105 consecutive patients. Ann Plast Surg.
2012;69(4):412-414.
22. Newall G, Ruiz-Razura A, Mentz HA, Patronella CK, Ibarra FR, Zarak
A. A retrospective study on the use of a low-molecular-weight heparin
for thromboembolism prophylaxis in large-volume liposuction and
body contouring procedures. Aesthetic Plast Surg. 2006;30(1):86-95;
discussion 96-97.
AUTHORS
Sergio Hernandez, DNP, CRNA, was a DNP-anesthesiology candidate at
Barry University in the College of Health Sciences DNP Anesthesiology
Program, Hollywood, Florida, at the time this research was completed. He
is a nurse anesthetist employed by Elite Plastic Surgery, Aventura, Florida.
Email: [email protected].
Jorge Valdes, DNP, CRNA, ARNP, is a faculty member at Barry University in the College of Health Sciences DNP Anesthesiology Program,
Hollywood, Florida. Email: [email protected].
Moises Salama, MD, is chief of Surgery at Elite Plastic Surgery and a
staff plastic surgeon at Aventura Hospital and Medical Center, Aventura,
Florida. Email: [email protected].
DISCLOSURES
The authors have declared they have no financial relationships with any
commercial interest related to the content of this activity. The authors did
not discuss off-label use within the article.
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The Jehovah’s Witness Population:
Considerations for Preoperative Optimization
of Hemoglobin
Yasmine N. Campbell, DNP, CRNA
Melissa D. Machan, DNP, CRNA
Marquessa D. Fisher, DNP, CRNA
Most members of the Jehovah’s Witness community
refuse blood transfusions, and there are variations in
what alternatives they will accept depending on their
personal decisions. To provide culturally competent
care, healthcare providers need to be knowledgeable
about substitutions for blood administration as well
as the risks and benefits of available alternatives so
that they can inform their patients. It has been recognized in the literature that preoperative optimization of hemoglobin levels with alternative treatment
modalities through a multidisciplinary approach can
improve clinical outcomes in patients who refuse blood
J
ehovah’s Witnesses are a vulnerable patient
population that presents unique ethical and
legal dilemmas for anesthesia professionals.
Comprising approximately 1.2 million of the
US population, Jehovah’s Witnesses have religious beliefs that deter them from receiving blood transfusions, which can lead to adverse reactions from the
refusal of treatment.1 Surgical procedures that have the
potential for large amounts of blood loss for any patient
can be challenging for the nurse anesthetist, but when
combined with the patient who refuses to receive blood
products, the intraoperative fluid hemodynamic management strategies can become critical. Regardless of the
patient’s reasons for declining blood products, healthcare
providers should provide culturally competent care and
therefore must be knowledgeable about substitutions for
blood product administration as well as the risks and benefits of such treatments.
Inconsistencies exist in what alternatives a Jehovah’s
Witness patient will accept, depending on his or her religious sect. The responsibility of the nurse anesthetist is to
ensure that this unique patient population makes informed
decisions established on evidence-based transfusion alternatives, as such treatments relate to their religious practices. Furthermore, failure to optimize hemoglobin (Hgb)
status and provide culturally competent patient education
on transfusion alternatives before the day of surgery could
have financial implications for the institution and may
result in cancellation or delay of the surgery.
www.aana.com/aanajournalonline
products. The purpose of this article is to illuminate
the current beliefs of Jehovah’s Witnesses regarding
receiving blood products, discuss ethical and legal
considerations for the nurse anesthetist, discuss the
risks of blood transfusions, and examine transfusion
alternatives. Finally, this article considers a multidisciplinary approach to the optimization of preoperative
hemoglobin levels.
Keywords: Bloodless surgery, elective surgery, Jehovah’s Witnesses, transfusion alternatives.
A multidisciplinary approach to the care of the
Jehovah’s Witness population to optimize preoperative
Hgb status must be considered when preparing these
patients for surgery, and education of the nurse anesthetist and patient on transfusion alternatives is important
during the preoperative plan of care.
The aim of this article is to illuminate the current
beliefs of Jehovah’s Witnesses regarding receiving blood
products, discuss ethical and legal considerations for
the nurse anesthetist, discuss the risks of blood transfusions and examine transfusion alternatives, and, finally,
consider a multidisciplinary approach to optimization of
preoperative Hgb levels.
Review of the Literature
•Jehovah’s Witness Beliefs. Jehovah’s Witness is a
Christian religion founded by Charles Taze Russell in
Pennsylvania during the 1870s.2 In 1945, the governing body of the Jehovah’s Witnesses, The Watch Tower
Society, interpreted the scriptures to proclaim that
taking blood into the body would have loss of eternal
life and decided that members would be shunned by the
congregation and denied the church’s sacraments (“disfellowshipped”) for accepting blood.3 Citing the literal
translation of the book of Acts (Acts 15:19-20) from The
New World Translation of the Holy Scriptures, affiliates of
this faith believe the abstinence of whole blood products
will bring good health.4
In 2000, The Watch Tower Society revised its policies
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on blood transfusions to include that the acceptance of
blood products is to be based on personal decision and
conscience.5 Interestingly, if blood is given to a Jehovah’s
Witness by force or coercion, or accepted by personal
choice, the member can voluntarily disassociate himself
or herself from the church and repent to remain in the
religion thereafter.3 Under the new doctrine, members
of this religion are allowed medical confidentiality from
the church, and dissociation is voluntary unless medical
concealment is breached. In this instance, the member is
“disfellowshipped” by the church.5 Thus, to provide culturally competent care to the Jehovah’s Witness patient,
it is important for the healthcare provider to interview
these patients privately and allow them an opportunity
to make informed decisions about their medical care.
Once a patient is identified as a Jehovah’s Witness, staff
involved in the medical care of the patient should be informed and confidentiality regarding medical decisions
should be strictly maintained.
•Ethical Issues. The care of the Jehovah’s Witness
patient can present various ethical and legal dilemmas
for the nurse anesthetist. Adult patients and emancipated
minors, under the Patient Self-Determination Act, have
the right to decline medical care, even if the result is
death.6 The Jehovah’s Witness population is extremely
educated about legal rights of refusal, advance directives,
and living wills. Additionally, Jehovah’s Witnesses have
a standardized advance directive form that they carry at
all times and that provides specific instructions regarding
their care in the event of an emergency.
It is important for the nurse anesthetist to respect
the right to refuse the acceptance of blood products.
The refusal of blood products by the Jehovah’s Witness
patient is not a refusal of medical treatment, nor should
it ever be considered as such.7 Patient care strategies
include establishing a rapport as early as possible to
ensure the patient is informed about available alternatives to the administration of blood products. Second,
Jehovah’s Witness patients should be interviewed privately to maintain the integrity of their personal choice
to accept or deny blood fractions or allogeneic blood
transfusions. Their decisions should remain private and
should not be discussed in front of friends or family
members. Finally, exclusive perils should be added to
the anesthesia consent in relation to the procedure and
excessive blood loss. Blood fractions and other accepted
treatment modalities by the patient should be clearly
indicated in the patient’s medical record and on the anesthesia preoperative assessment.8
•Transfusion Risks. Although many treatment
options for anemia exist, the transfusion of blood products remains one of the most commonly used lifesaving
treatments. However, receiving blood products is not
without inherent risks. Adverse reactions such as infection, transfusion-related acute lung injury (TRALI), fatal
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anaphylaxis, blood incompatibility, and immunologic
reactions are the most life-threatening reactions of blood
transfusions.9,10 Between 2001 and 2006, TRALI was responsible for greater than 50% of the deaths in the United
States of patients transfused with allogeneic blood.11
Moreover, blood transfusions are also known to increase
hospital length of stay and contribute to poor clinical
outcomes postoperatively.9,12
•Erythropoietin and Iron Therapy. Recombinant
human erythropoietin (EPO) is an endogenous glycoprotein hormone whose function is to increase the production of red blood cells and subsequently increase Hgb
levels as the result of tissue hypoxia.13,14 Comparatively,
intravenous (IV) iron therapy has also been shown to
significantly increase Hgb levels in patients with preoperative iron-deficiency anemia.12,15 Although iron
therapy as a primary treatment of preoperative anemia
is not recommended, studies have indicated that administration of EPO, in conjunction with iron therapy
preoperatively, can prevent blood transfusions in a wide
variety of operations.9,11,14,16,17 In their study, Harwin
and colleagues9 found that there was decreased mortality
and no morbidity after adequate preoperative optimization with EPO combined with iron therapy for anemic
Jehovah’s Witness patients undergoing total hip replacement surgery. Furthermore, other authors reported an
increase in Hgb levels after successful treatment of EPO
and iron therapy.10,16 Similarly, EPO has been successfully used for the preoperative optimization of Hgb status
in patients who were anemic before cardiac surgery, resulting in decreased mortality rates of Jehovah’s Witness
patients compared with patients who did not receive EPO
preoperatively.11
•Bloodless Surgery. Current literature has indicated
that blood transfusions can be avoided by exploring
alternative bloodless treatment modalities.11 “Bloodless
surgery” is an innovative phenomenon that medical
centers are adopting for patients who refuse blood
transfusions. Bloodless surgery protocols are essential to
minimize risks and to offer patients who decline blood
transfusions the same quality of care accessible to patients who do accept blood transfusions.13
Moreover, evidence suggests that mortality rates
may be lowered in patients receiving bloodless surgery.
Several studies found that the Jehovah’s Witness patients enrolled in a bloodless surgery program had a
decreased incidence of in-hospital death, decreased
5-year mortality rates, and shorter lengths of hospital
stay compared with non-Jehovah’s Witnesses postoperatively.1,18,19 Interestingly, the Jehovah’s Witness patients
studied had a statistically significant lower occurrence
of renal failure, sepsis, and bleeding postoperatively.
Furthermore, the authors argue that bloodless surgery
is considered a safe practice for patients who do not
accept blood.1,18,19 In a similar study, Moskowitz and
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Position
Allogeneic blood
Refused
Potentially
acceptable
Whole blood
Red cells
White cells
Platelets
Plasma
Fractions from
red cells
Fractions from
white cells
Fractions from
platelets
Fractions from
plasma
• Hemin
• Hemoglobin
Autologous blood
• Albumin
• Clotting factors
• Fibrinogen
• Immunoglobins
• Preoperative autologous
blood collection and storage for later reinfusion
• Acute normovolemic
hemodilution
• Dialysis
• Cardiopulmonary
bypass
• Blood salvage
Witnesses make personal decisions on what they can accept in good conscience. It is important
to discuss in advance what products or procedures are acceptable to each patient.
Figure 1. Jehovah’s Witnesses’ Position on Allogeneic and Autologous Blood
Abbreviations: Blood salvage, blood cell salvage.
colleagues20 emphasized that restrictive transfusion
practices do not adversely affect clinical outcomes and,
in fact, can improve clinical outcomes because of blood
conservation strategies that minimize complications that
are inherent to blood transfusions.
•Guidelines for Jehovah’s Witnesses on Blood
Products. Before 1945, Jehovah’s Witnesses were permitted to donate and accept blood.21 Current transfusion
guidelines by the Watch Tower Society do not allow
the acceptance of whole blood or major blood fractions,
specifically red blood cells, white blood cells, platelets,
and plasma, to be infused despite a life-or-death health
situation.21 Jehovah’s Witnesses do not dispute the fact
that blood transfusions have saved lives; nevertheless,
because of religious beliefs and sanctions, most Jehovah’s
Witnesses do not accept blood products.21,22 Conversely,
minor fractions of primary components of blood are
acceptable for lifesaving measures through personal
decision, careful prayer, and consideration.5,21,22 These
minor fractions include albumin up to 4% of plasma,
immunoglobulins up to 3% of plasma, clotting factors
less than 1% of plasma, Hgb 33% of blood cells, hemin
less than 2% of red blood cells, and small fraction of
white blood cells known as interferons.21 Acceptable
fluid replacement for the Jehovah’s Witness includes
crystalloid and other colloid hemostatic agents such
as desmopressin, recombinant factor VIIa, aprotinin,
ε-aminocaproic acid, and tranexamic acid.21,22 Although
these are recommendations made by the Watch Tower
Society, nurse anesthetists should be aware that every
Jehovah’s Witness has different beliefs, and his or her
willingness to accept transfusion therapy varies among
members (Figure 1).23
•Multidisciplinary Approach. Preoperative considerations are enormously challenging when caring for the
Jehovah’s Witness patient, especially those patients undergoing procedures that carry a risk of large amounts of
blood loss. Evidence suggests that clinical outcomes can
be improved when there is a multidisciplinary approach
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to preoperative care, along with extensive preoperative
treatment of anemia in the Jehovah’s Witness patient.24
In a retrospective study, Moraca and colleagues24 found
that the use of a multidisciplinary approach that included
a screening for transfusion risk and the administration
of erythropoiesis-stimulated agents can minimize the
risk of morbidity and mortality in Jehovah’s Witness patients undergoing cardiac surgery. Surgery was delayed
for approximately 3.7 weeks for preoperative treatment
with oral iron and EPO, but the study participants had a
mortality rate of only 5%.24 Thus, early referral to facilities that provide bloodless procedures and preoperative
clinics may provide for optimization of Hgb status preoperatively in this patient population.
Routine screening for anemia in patients with voluntary major surgeries can be completed as early as 4 weeks
preoperatively to optimize treatment modalities.7,25 The
multidisciplinary team should consist of the surgeon, anesthesia, hematology, and a hospital liaison if available.25
The Jehovah’s Witness patient should have a comprehensive bleeding history taken consisting of previous surgeries, trauma history, and the use of anticoagulant medications.26 Moreover, a thorough history and physical is
a necessity. Family history of bleeding complications
should be noted because of the risk of possible hereditary bleeding disorders such as von Willebrand disease
and hemophilia. Medication lists should be reviewed
for anticoagulants, including platelet inhibitors, aspirincontaining agents, nonsteroidal anti-inflammatory drugs,
and herbal medications, and these should be discontinued before surgery if clinically possible.27 In Jehovah’s
Witness patients with anemia, symptoms should be
assessed, as well as comorbidities and the timing of
surgery, and improved hematopoiesis without allogeneic
transfusion is necessary in preparation for surgeries with
suspected large losses of blood.25 A specialized checklist
and algorithm for preassessment of Jehovah’s Witness patients are advantageous tools when preparing for elective
surgery (Tables 1 and 2; Figure 2).
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Unacceptable to
Jehovah’s Witnesses: Your personal decision
whole blood
Fractions
Choices you need to make
Plasma
Albumin up to 4% of plasma
____ I accept albumin
Or
____ I refuse albumin
Immunoglobulins up to 3% of plasma
____ I accept immunoglobulins
Or
____ I refuse immunoglobulins
Clotting factors less than 1% of plasma ____ I accept blood-derived clotting factors
Or
____ I refuse blood-derived clotting factors
Red blood cells
Hemoglobin 33% of red blood cells
____ I accept hemoglobin
Or
____ I refuse hemoglobin
Hemin less than 2% of red blood cells
____ I accept hemin
Or
____ I refuse hemin
White blood cells
Interferons: a tiny fraction of white blood cells
____ I accept blood-derived interferons
Or
____ I refuse blood-derived interferons
Platelets
At present, no fractions from platelets are being
isolated for direct medical use
Equipment and procedures
Blood cell salvage
Acute normovolemic hemodilution Cardiopulmonary bypass
Dialysis
____ I accept blood cell salvage
____ I accept acute normovolemic
hemodilution
____ I accept cardiopulmonary bypass
____ I accept dialysis
Patient signature________________________________________________________________ Date_______________________
Table 1. Preoperative Consent for Jehovah’s Witnesses for Transfusion Alternatives
Implications for Practice
• Do you have advanced directives? Yes or No
For the Jehovah’s Witness patient, there are many options
available as an alternative to blood transfusions. The use
of a multidisciplinary approach, one that is culturally
competent and meets specific patient needs, can be essential to optimize preoperative Hgb levels before elective
surgery. Indeed, the preoperative period is the best time
to optimize the Jehovah’s Witness patient and prepare
for any known challenges related to blood loss during
the procedure; such optimization should begin at least 4
weeks before the day of surgery.7,25 Likewise, the preoperative period can be used to develop strategies to minimize
blood loss during the procedure, including the use of less
invasive surgical techniques, controlled hypotension, or
the use of a blood cell salvage system. However, such
strategies are beyond the scope of this article.
Despite the evidence suggesting the effectiveness of
a multidisciplinary strategy to optimize the Jehovah’s
Witness patient preoperatively, there is no evidence
in the literature that compares Jehovah’s Witness patients who receive early care with those who do not.
Certainly, future research should expand in this area.
Equally important is the need to determine whether
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• Do you have a living will? Yes or No
•Is your surgeon aware that you are Jehovah’s Witness?
Yes or No
•Do you or your family have a history of bleeding disorders?
Yes or No
•Do you bruise easily or have excessive bleeding when you
shave or experience frequent nosebleeds? Yes or No
•Do you take blood thinners such as aspirin, anticoagulants,
NSAIDs, or herbal medications? Yes or No
• Have you had surgery before? Yes or No
•Have you had bleeding complications with any of your
surgeries? Yes or No
•In a life-or-death situation would you accept a blood
transfusion? Yes or No
Table 2. Preoperative Checklist for Jehovah’s
Witnesses
Abbreviation: NSAIDs, nonsteroidal anti-inflammatory drugs.
facilities located in regions that are heavily populated
with Jehovah’s Witnesses have the necessary alternative
treatment modalities, such as accepted blood products, to
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! Surgical consult and complete history and physical examination
inclusive of bleeding risk assessment and evaluation management of
anticoagulation and antiplatelet medications
! Surgeon consults anesthesia, hematology, and Hospital Liaison
Committee if available as early as 4 weeks before surgery to begin
preoperative optimization
! CBC, PT, PTT, and iron in blood samples evaluated
! Surgical consent, advance directives, blood refusal, and signed
statement of acceptable transfusion alternatives completed and faxed to
hematology and anesthesia care team
! Multidisciplinary care plan developed by surgical, anesthesia, and
hematology teams
No Yes Hgb < 13 g/dL in males Consult hematology Hgb < 12 g/dL in females ! Consider EPO/iron
therapy
! If Hgb < 10g/dL or
surgery < 2 weeks
away, consider IV
iron therapy
No further Hgb optimization needed ! Maintain autonomy and ensure
culturally competent care
! Refer patient to Hospital Liaison
Committee or local Jehovah’s
Witness Hospital Information
Services for guidance
Figure 2. Preoperative
Care Pathway for Adults Refusing Blood and Jehovah’s Witnesses Requiring Elective Surgery
Abbreviations: CBC, complete blood cell count; EPO, recombinant human erythropoietin; Hgb, hemoglobin; PT, prothrombin time; PTT,
partial thromboplastin
time.
care for these patients. Preventing patient morbidity and
mortality begins with a good plan of care and adequate
preparedness for any challenge that may arise. Indeed, by
using a multidisciplinary approach for the preoperative
care of the Jehovah’s Witness patient, the paradigm shifts
the administration of blood products to a more patientcentered approach. Rather than care that is driven by the
administration of products, the goal becomes the provision of culturally competent care that adheres to patient
beliefs, improves patient outcomes through risk minimization, and reduces costs.7,25
REFERENCES
1. Frank SM, Wick EC, Dezern AE, et al. Risk-adjusted clinical outcomes in patients enrolled in a bloodless program. Transfusion.
2014;54(10 pt 2): 2668-2677.
2. Knox Z. Writing Witness history: the historiography of the Jehovah’s
Witnesses and the Watch Tower Bible and Tract Society of Pennsyl-
www.aana.com/aanajournalonline
vania. J Religious Hist. 2011;35(2):157-180.
3. West JM. Ethical issues in the care of Jehovah’s Witnesses. Curr Opin
Anaesthesiol. 2014;27(2):170-176.
4. New World Bible Translation Committee. New World Translation of
the Holy Scriptures. Brooklyn, NY: Watchtower Bible and Tract Society of New York; 2013. www.jw.org/en/publications/bible/. Accessed
October 20, 2014.
5. Muramoto O. Bioethical aspects of the recent changes in the policy of
refusal of blood by Jehovah’s witnesses. BMJ. 2001;322(7277):37-39.
6. Gaddie K, Montgomery C, Murphy S, et al. Management of bloodless surgery in a trauma setting. Balancing patient wishes with safety.
Minn Med. 2013;96(6):49-51.
7.Shander A, Javidroozi M, Perelman S, Puzio T, Lobel G. From
bloodless surgery to patient blood management. Mt Sinai J Med.
2012;79(1):56-65.
8. Rogers DM, Crookston KP. The approach to the patient who refuses
blood transfusion. Transfusion. 2006;46(9):1471-1477.
9. Harwin SF, Pivec R, Naziri Q, Issa K, Mont MA. Is total hip arthroplasty a successful and safe procedure in Jehovah’s Witnesses? Mean
five-year results. Hip Int. 2014;24(1):69-76.
10. El Azab SR, Vrakking R, Verhage G, Rosseel PM. Safety of cardiac
AANA Journal

June 2016

Vol. 84, No. 3
177
surgery without blood transfusion: a retrospective study in Jehovah’s
Witness patients. Anaesthesia. 2010;65(4):348-352.
11. Vaislic CD, Dalibon N, Ponzio O, et al. Outcomes in cardiac surgery
in 500 consecutive Jehovah’s Witness patients: 21 year experience. J
Cardiothorac Surg. 2012;7:95-102.
12. Price E, Artz AS, Barnhart H, et al. A prospective randomized wait list
control trial of intravenous iron sucrose in older adults with unexplained anemia and serum ferritin 20–200 ng/mL. Blood Cells Mol Dis.
2014(4):221-230.
13. Guarino S, Di Matteo F, Sorrenti S, et al. Bloodless surgery in geriatric
surgery. Int J Surg. 2014:S82-85.
14. Ferraris VA, Brown JR, Despotis GJ, et al. 2011 update to the Society
of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg.
2011;91(3):944-982.
15. Kim YH, Chung HH, Kang SB, Kim SC, Kim YT. Safety and usefulness
of intravenous iron sucrose in the management of preoperative anemia in patients with menorrhagia: a phase IV, open-label, prospective,
randomized study. Acta Haematol. 2009;121(1):37-41.
16. McCartney S, Guinn N, Roberson R, Broomer B, White W, Hill S.
Jehovah’s Witnesses and cardiac surgery: a single institution’s experience. Transfusion. 2014;54(10 pt 2):2745-2752.
17. Bacuzzi A, Dionigi G, Piffaretti G, et al. Preoperative methods to
improve erythropoiesis. Transplant Proc. 2011;43(1):324-326.
18. Ramanan B, Burns TL, Sugimoto JT, Forse RA. Impact of a blood
conservation program on 30-day morbidity and mortality: a cohort
study. J Surg Res. 2014;187(1):343-349.
19. Pattakos G, Koch CG, Brizzio ME, et al. Outcome of patients who
refuse transfusion after cardiac surgery: a natural experiment with
severe blood conservation. Arch Intern Med. 2012;172(15):1154-1160.
20. Moskowitz DM, McCullough JN, Shander A, et al. The impact of
blood conservation on outcomes in cardiac surgery: is it safe and
effective? Ann Thorac Surg. 2010;90(2):451-458.
21. Grundy P. Jehovah’s Witnesses and blood transfusions. Facts About
Jehovah’s Witnesses website. 2014. http://www.jwfacts.com/watchtower/blood-transfusions.php. Accessed September 20, 2014.
22. Hua M, Munson R, Lucas A, Rovelstad S, Klingensmith M, Kodner IJ.
Medical treatment of Jehovah’s witnesses. Surgery. 2008;143(4):463-465.
23. Watchtower Tower Bible and Tract Society of Pennsylvania. Jehovah’s
178
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Witnesses’ position on allogeneic and autologous blood. In: Hospital
Information Services for Jehovah’s Witnesses. Pennsylvania, PA: Watch
Tower Bible and Tract Society of Pennsylvania; 2012.
24. Moraca RJ, Wanamaker KM, Bailey SH, et al. Strategies and outcomes of cardiac surgery in Jehovah’s Witnesses. J Card Surg.
2011;26(2):135-143.
25. Shander A, Javidroozi M. The approach to patients with bleeding
disorders who do not accept blood-derived products. Semin Thromb
Hemost. 2013;39(2):182-190.
26. Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the
assessment of bleeding risk prior to surgery or invasive procedures.
British Committee for Standards in Haematology. Br J Haematol.
2008;140(5):496-504.
27.Nuttall GA, Brost BC, Connis RT, et al. Practice guidelines for
perioperative blood transfusion and adjuvant therapies: an updated
report by the American Society of Anesthesiologists Task Force on
Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology. 2006;105(1):198-208. http://search.ebscohost.com.ezproxy.
barry.edu/login.aspx?direct=true&db=ccm&AN=2009227342&site=
ehost-live Accessed October 17, 2014.
AUTHORS
Yasmine N. Campbell, DNP, CRNA, is the lead CRNA at University of
Miami Hospital, Miami, Florida. Research for this article was conducted
while she was a doctoral candidate at Barry University in Hollywood,
Florida. Email: [email protected].
Melissa D. Machan, DNP, CRNA, is a full-time nurse anesthetist at
Plantation General Hospital, Plantation, Florida, as well as adjunct faculty
member at Barry University College of Health Sciences DNP anesthesiology program in Hollywood, FL. Email: [email protected].
Marquessa D. Fisher, DNP, CRNA, is an assistant professor of clinical in the nurse anesthesia program at the University of Miami School of
Nursing and Health Sciences in Coral Gables, Florida. Email: m.fisher@
med.miami.edu.
DISCLOSURES
The authors have declared they have no financial relationships with any
commercial interest related to the content of this activity. The authors did
not discuss off-label use within the article.
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Anesthetic Considerations of Stiff-Person
Syndrome: A Case Report
Kristi Hylan, DNP, CRNA
An-Duyen Nguyen Vu, CRNA
Katherine Stammen, MD
Stiff-person syndrome (SPS) is a neurologic disorder
characterized by painful involuntary episodes of severe
muscle rigidity affecting the axial muscles and extremities. Although the etiology of SPS is unknown, it is suspected to involve the synthesis of γ-aminobutyric acid
(GABA). Symptoms of SPS are precipitated by sudden
unexpected movements, noises, and stress. Additionally, SPS has been linked with various autoimmune
disorders, including diabetes mellitus, thyroid disease,
pernicious anemia, and certain cancers. Because of
the effect of SPS and SPS medications, inhalational
agents and neuromuscular blockers have the potential
to cause prolonged hypotonia following anesthesia,
S
tiff-person syndrome (SPS) is a rare and
debilitating neurologic disease that affects
the muscles of the extremities and trunk.
This syndrome is progressive and described
as involuntary activation of the motor unit of
the axial muscles and muscles of the extremities, causing continuous muscle spasms and rigidity.1 The central
muscles are affected first, but the disease can progress to
affect muscles of the back and extremities,2 particularly
the thighs. Clinical presentations range from mild muscle
spasms to bone fractures resulting from violent severe
muscle spasms.3 The disease occurs more often in women
ranging from 20 to 50 years of age.4 No prevalence of SPS
exists in any race or ethnic group, and there is no indication in previous studies that it is hereditary.
This syndrome was first documented by neurologists
Moersch and Woltman5 in 1956 as stiff-man syndrome
after treating 14 cases over a span of 32 years. In 1924,
the first reported encounter was a 49-year-old male
farmer from Iowa presenting with muscle stiffness and
difficultly walking. Before age 34, the patient experienced frequent migraines and occasionally cramps in his
leg muscles. His condition progressively worsened over
4 years and eventually advanced to his neck, shoulders,
upper back, abdominal muscles, lower back, and thighs.
His gait was “slow and awkward.” In addition to the rigidity, intermittent spasms developed and caused him to
fall like “a wooden man.” By 1932, he was unable to walk
unassisted.5 In 1958 the first case of SPS in a woman was
diagnosed by Dr Richard Asher, and in 1960 Dr David
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resulting in respiratory failure despite full reversal of
neuromuscular blockade. In documented case reports,
the outcomes of using general anesthesia with inhalational agents and neuromuscular blockers in patients
with SPS varied. This case report highlights the anesthetic management of a 56-year-old woman with diagnosed SPS undergoing a hemicolectomy for a colon
mass using total intravenous anesthesia.
Keywords: Moersch-Woltman syndrome, stiff-man
syndrome, stiff-person syndrome, stiff-limb syndrome,
total intravenous anesthesia.
Bowler published a case report on a 7-year-old child with
SPS.6,7 The term stiff-man syndrome was changed to stiffperson syndrome in 1991.8
The incidence of SPS is rare, estimated at approximately 1 in 1 million, and the etiology of SPS is still
unknown.4 Stiff-person syndrome is associated with
autoimmune disorders based on high titers of glutamate
decarboxylase (GAD) antibodies, particularly the 65-kD
isoform in the serum and cerebral spinal fluid. GAD is
an enzyme responsible for synthesis of γ-aminobutyric
acid (GABA) and a decrease of GAD has been found in
the brain of patients with SPS. These GAD antibodies
have been associated with other neurologic conditions
including seizures, cerebellar dysfunction, cortical dysfunction, and myelopathy.9 Raju et al10 found that the
antibodies decrease GABAA receptor–associated protein,
which is responsible for the stability and surface expression of the GABAA receptor. As the primary inhibiting
neurotransmitter in the brain and the spinal cord, GABA
contributes to motor control and many other cortical
functions. Muscle spasms and rigidity result from the
lack of inhibition via GABA causing motor neurons to
become excitable. Patients with SPS often have other
autoimmune diseases, such as diabetes mellitus, thyroid
disease, pernicious anemia, and certain cancers, particularly breast and lung cancers.11,12 A notable variation of the disease is called paraneoplastic or stiff-limb
syndrome, in which the patient exhibits symptoms in a
single limb. Progressive encephalomyelitis with rigidity
and myoclonus is another severe form of SPS that rapidly
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affects the central nervous system. In some variants of
SPS it is hypothesized the syndrome manifests from
the body’s immune response to eliminate cancer cells.
Because of the similarities between the tumor antigen
and central nervous system (CNS) antigens, high levels
of GAD antibodies attack the CNS.12 High levels of GAD
antibodies are found in a variety of other neurologic
disorders such as cerebellar ataxia, epilepsy, idiopathic
limbic encephalitis, and myasthenia gravis.13 However,
Newton et al3 mentioned that antibodies to GAD alone
do not indicate a definitive diagnosis of SPS. Patients can
test GAD negative but still exhibit symptoms of SPS.3
The clinical manifestations of SPS can occur randomly
or be triggered by emotional stress and noxious stimuli
such as noise and sudden touch. The diagnosis is made
in the presence of episodes of muscle spasms and stiffness of axial muscles slowly progressing to extremities
and deformity of the spinal column (severe lordotic
curve).14 Patients often present with a wide stance and
an unsteady gait. The gait resembles waddling and has
been referred to as tin man like.8 Patients with SPS also
have a hunched-over posture and abnormal eye movements, experience frequent falls, and are often bedridden.
Moersch and Woltman5 described that SPS may be mistaken for chronic tetanus, but it can also be misdiagnosed
as anxiety disorder, multiple sclerosis, Parkinson disease,
and somatic disorders.15 Misdiagnosis is common and a
correct diagnosis takes an average of 6.2 years from the
onset of SPS symptoms.15
Presently no cure for SPS exists, but the primary treatment is to enhance GABA receptors by targeting GABAB
with baclofen therapy, a GABAergic agonist, and targeting GABAA with benzodiazepine agents such as diazepam.16 Patients requiring higher doses of baclofen may
be treated via intrathecal baclofen pumps.3 Spinal cord
stimulation may relieve pain associated with spasms.
Intravenous (IV) opiates can relieve severe pain episodes and botulinum toxin A injections into the muscles
can mitigate severe muscle rigidity.12 Intravenous immunotherapy such as IV immunoglobulin (IVIG) can
modulate the immune response. Corticosteroids and
plasmapheresis are also recommended to suppress the
antibody response and remove the antibodies respectively.4 Furthermore, in a recent case report by Vicente-Valor
et al,17 an alternative treatment with cannabis derivatives,
tetrahydrocannabinol and cannabidiol oromucosal spray,
was successfully used to treat the spasticity symptoms
related to SPS.
Case Summary
A 56-year-old African American woman with a diagnosis of SPS was scheduled for a left hemicolectomy for
removal of a colon mass. She presented with a body mass
index of 16.9 kg/m2 (height of 1.753 m and weight of
51.71 kg) after a recent weight loss of 15.75 kg. Her SPS
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was diagnosed 17 years before her surgery and initially
presented with severe abdominal spasms and gagging
episodes. At the time of diagnosis, GAD antibodies were
elevated to more than 600 U/mL (normal, < 1 U/mL).
Her reported activity was limited, as she was wheelchair
bound with a severe lordotic curve, but she remained
fairly independent. Her symptoms were managed pharmacologically with diazepam, 10 mg 3 times a day; baclofen, 20 mg 4 times a day; tizanidine, 2 mg 3 times a
day; and IVIG infusions for flare-ups as needed. Her last
infusion was 1 month before surgery.
The patient’s medical history also included asthma,
osteoporosis, hyperlipidemia, gastroesophageal reflux
disease (GERD), uncontrolled type 1 diabetes with hypoglycemic episodes (last glycated hemoglobin, or HbA1C,
was 11.3%), hypothyroidism, pernicious anemia, controlled seizures, and rheumatoid arthritis.
An echocardiogram completed 1 month before the
scheduled hemicolectomy showed an ejection fraction of
60% to 65% with normal diastolic function, but left ventricular hypertrophy was apparent. An electrocardiogram
(ECG) showed a prolonged QT interval with a T-wave
abnormality in the inferior leads, a new finding from the
prior ECG 2 years before the scheduled hemicolectomy.
On preoperative interview she denied any recent chest
pain, shortness of breath, palpitations, dizziness, new
symptoms of spasticity, gagging movements, or abdominal
cramping. Specifically, she denied spasticity since a prior
admission 5 weeks earlier when she received IVIG. She
also conveyed that she commonly has a spastic episode
when she discontinues her SPS medications. Before the
scheduled hemicolectomy the patient had several episodes
of severe hypoglycemia, which required hospitalization
and treatment with 50% dextrose, with the last admission
being 3 weeks before the scheduled procedure. In the
preoperative clinic she was advised to continue her SPS
medications, but despite this recommendation she withheld her SPS medications the day of surgery.
The morning of surgery, the patient was asymptomatically hypoglycemic with a blood glucose level of 70 mg/
dL. Her regimen consisted of metformin at 1 g/d and an
insulin glargine injection (Lantus) of 20 U nightly. Her
last dose of insulin was the evening before surgery. She
was treated with 1.5 ampules of 50% dextrose, which
increased her glucose level to 160 mg/dL preoperatively.
The patient’s surgical history included cholecystectomy,
hernia repair, and multiple colonoscopies managed with
inhalational anesthesia and monitored anesthesia care
(MAC) techniques that yielded no adverse outcomes.
Airway assessment showed Mallampati classification 2,
thyromental distance greater than 3 fingerbreadths, mouth
opening greater than 3 cm, and limited neck extension.
After preoperative assessment was reviewed and informed consent was obtained, the patient was given
midazolam, 2 mg IV, before proceeding into the operat-
www.aana.com/aanajournalonline
ing room. The operating room was quiet and warmed
before the patient’s arrival. Standard ASA monitors were
applied, and the patient was given 100% oxygen via
face mask. Cricoid pressure was applied to the patient
throughout induction and intubation given her history
of uncontrolled GERD. Induction agents consisted of a titration of fentanyl, 100 μg; lidocaine, 100 mg; and propofol, 200 mg, IV. Tracheal intubation with a 7.0-mm oral
standard endotracheal tube was easily achieved without
the use of a muscle relaxant via a size 3 Macintosh laryngoscope blade providing a grade 1 view. A 20-gauge arterial line was placed in the right radial artery. An 18-gauge
peripheral IV was placed to the left forearm. A peripheral
nerve stimulator was applied over the ulnar nerve. The
patient’s severe lordotic curve was padded along with
other pressure points. General anesthesia was maintained
with an oxygen and air mixture, propofol infusion was
titrated between 120 and 200 μg/kg/min, and a remifentanil infusion was titrated between 0.1 and 0.25 μg/kg/min
to achieve a bispectral index of 40 to 60.
The initial anesthesia plan was to use a paralytic agent
throughout the case as needed to facilitate adequate
surgical conditions. Vecuronium, 2 mg, was chosen for
its intermediate action and predictability. This agent
provided adequate muscle relaxation for approximately
20 minutes to achieve a train-of-four (TOF) of 2/4 for a
midline incision of the abdominal muscles and surgical
exposure. The patient returned to a TOF of 4/4, and after
discussion with the surgeon who believed that operative
conditions were adequate, the decision was made to forgo
additional paralytics. Propofol, administered as a 100-mg
bolus in addition to the propofol and remifentanil infusions, provided adequate surgical conditions for closure
of the abdominal muscles. In addition to 2 L of balanced
electrolytes (Normosol-R), 500 mL of 5% dextrose in
water was infused at 170 mL/h throughout the case (3
hours), and the blood glucose level was checked every
hour to monitor for hypoglycemia. The patient’s glucose
levels ranged from 70 to 160 mg/dL throughout the perioperative period. The total blood loss was 250 mL and
urine output was 300 mL. Ondansetron, 4 mg, was given
IV before emergence.
Before extubation the patient had a TOF of 4/4 with
sustained tetany for 5 seconds showing no fade, a tidal
volume of 350 to 400 mL (6-8 mL/kg), and a sustained
head lift greater than 3 seconds with eye opening. The
patient was not administered neuromuscular blockade reversal because sustained tetany showed no fade
and she did not exhibit signs of muscle weakness. The
patient was extubated to 100% oxygen via face mask 10
minutes after the remifentanil and propofol infusions
were stopped. Hydromorphone, 6 mg IV, was titrated for
pain management, and promethazine (Phenergan), 18.7
mg IV, was titrated for control of nausea.
She was transferred to the surgical intensive care unit
www.aana.com/aanajournalonline
(SICU) on room air for close postoperative monitoring
without any complications. Vital signs on SICU admission were blood pressure of 123/72 mm Hg, pulse of 90/
min, temperature of 36.6oC, respirations of 18/min; pulse
oximetry was 98%, and the glucose level was 150 mg/dL.
Postoperatively the patient was managed by the
colorectal surgery service with consultation to both neurology and internal medicine. She received morphine,
5 mg IV, as needed for pain and was restarted on her
home medication regimen for SPS, including diazepam,
10 mg 3 times a day; baclofen, 20 mg 4 times daily; tizanidine, 2 mg 3 times a day; and hyoscyamine, 0.125 mg
every 4 hours as needed for cramping. Her antiepileptic
regimen also was restarted, which included levetiracetam
(Keppra), 500 mg twice a day, and phenytoin, 200 mg
twice daily (dosage decreased from 300 mg twice a day
as her serum phenytoin level was elevated). She was also
continued on a regimen of 5% dextrose with half normal
saline with 20 mEq of potassium chloride at 100 mL/h
because of concerns for recurrent hypoglycemia and mild
hypokalemia.
On postoperative day 2 the patient transitioned from
clear liquids to a regular diabetic diet, at which time she
moved to the general surgical unit. She did have a decrease
in her hemoglobin level to 7.5 g/dL on postoperative day
2, which required transfusion of 1 U of packed red blood
cells with adequate response. Internal medicine was consulted for diabetes management and recommended that
after discharge she be continued on a regimen of insulin
glargine, 10 U at bedtime, and metformin, 1 g twice daily.
She was able to tolerate a regular diet and did not have
any new symptoms of spasticity or rigidity.
She remained stable and was discharged home without
any incident on postoperative day 4. The patient was followed up in the colorectal surgery clinic 3 weeks after the
procedure and did not have any complaints at that visit.
Discussion
In our case we successfully used propofol and remifentanil infusions with minimal paralytics, resulting in no hypotonia at the end of the case. The patient did not report
any adverse events with her previous surgery, for which
an inhalational agent was used; however, the records
were unavailable, and the patient did not know the dates
of the surgeries. Since the time of her previous surgeries,
it was unclear whether her symptoms had progressed and
SPS treatments could have been increased substantially.
Although regional anesthesia is an appropriate option,
we elected not to use this method because of the patient’s
severe spinal deformity, anxiety, failure to take her SPS
medications the day of surgery, and the risk of initiating a
spasm while placing the epidural/spinal anesthetic.
In a search of the medical literature, only a small
number of published case studies were available. The outcomes of using general anesthesia with inhalational agents
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183
Author/patient
sex/age, y
SPS medications
and dosage
Surgical
procedure
Drugs
administered
Postoperative
outcome
General anesthesia with inhalation agent
Bouw19/F/62
Diazepam, 7.5 mg twice a
Colon resection
day; baclofen, 12.5 mg twice
a day; prednisone, 20 mg/d
Isoflurane,
propofol,
sufentanil,
atracurium,
morphine,
neostigmine,
glycopyrrolate
Prolong intubation 3 hours
into the postoperative period
Johnson20/F/46
Diazepam 100 mg/d; intrathe- Baclofen pump
cal baclofen pumpa
Propofol,
succinylcholine,
desflurane
Isoflurane,
nitrous oxide,
sufentanil,
thiopental, vecuronium,
neostigmine,
glycopyrrolate
Midazolam,
halothane,
isoflurane,
nitrous oxide
Weakness 2 days
postoperatively
Fentanyl,
thiopental,
vecuronium,
isoflurane,
nitrous oxide
Diazepam,
fentanyl,
thiopental, vecuronium,
isoflurane,
nitrous oxide
No exacerbation of symptoms
present
Baclofen pump repair 1
Baclofen pump repair 2
Obara18/F/40
Not given
Thymectomy
Appendectomy
Qin21/M/58
Diazepam, 5 mg twice a day; Thymectomy
baclofen, 10 mg 3 times a
day
Yamamoto22/M/76
Diazepam, 5 mg/d; baclofen, Thymectomy
30 mg/d; clonazepam, 1 mg/d
Muscle weakness and
hypotonia present; patient was
intubated overnight in ICU
No exacerbation of symptoms
present
No exacerbation of symptoms
present
Midazolam,
No exacerbation of symptoms
propofol, remifentanil, present
rocuronium, isoflurane,
nitrous oxide
Combined general/regional (epidural) anesthesia
Sevoflurane,
No exacerbation of symptoms
fentanyl,
present
propofol,
ropivacaine, 0.25%
infusion 24 hours postoperatively
Table 1. Case Studies of Stiff-Person Syndrome Receiving Either General Anesthesia or Regional Anesthesia
Combined With General Anesthesia
Abbreviations: ICU, intensive care unit; SPS, stiff-person syndrome.
aThe dose was not provided in the case report.
(From Ferrandis et al1 and Sidransky, Tran, Kaye24)
in patients with SPS are varied (Table 1).18-22 Of the 17
cases we reviewed related to SPS, 7 cases used inhalational
anesthesia, 2 cases used regional anesthesia combined
with MAC, and 2 cases used a sole MAC technique (Table
22,11,23,24). Five case reports we found used a total intravenous anesthesia (TIVA) technique (Table 3).1,16,18,25,26
•Preoperative Considerations. Preoperatively, patients
should continue their immunotherapy, benzodiazepine,
and baclofen to optimize the suppression of their SPS
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symptoms. Baclofen, if stopped abruptly, can cause
withdrawal symptoms and may require oral baclofen.
Baclofen withdrawal symptoms mimic alcohol withdrawal
and neuroleptic malignant syndrome. The symptoms associated with withdrawal include, but are not limited to,
seizures, hallucinations, sweating, confusion, labile heart
rate and blood pressure, fever, and increased spasticity.27
Although there is no association with any cardiorespiratory disorders, it is recommended to perform a pulmonary
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SPS
medications
and dosage
Method of
anesthesia
Author/ patient
sex/age, y
Surgical
procedure
Regional
anesthesia
(paravertebral
block) and MAC
Elkassabany11/M/65
Intrathecal baclofen Inguinal hernia
pumpa
Bupivacaine 0.5%
Midazolam
Fentanyl
Propofol
Patient reported
improvement of spasticity
symptoms during procedure
and 1 hour postoperatively
Regional
anesthesia (spinal/
epidural)
23
Shanthanna /F/55
Baclofen,
clonazepam,
gabapentina
Bupivacaine 0.5%
Midazolam
Fentanyl
Patient did not experience
exacerbation of symptoms;
however, anesthesia provider
was unable to achieve an
appropriate anesthesia level
without supplementing with
epidural
MAC
Sidransky24/M/34
Carisoprodol, 250
Permanent
mg/d; diazepam,
catheter
10 mg twice a day; placement
gabapentin, 600
mg 3 times a day;
baclofen, 30 mg/d
Lidocaine
Propofol
No exacerbation of
symptoms present
Neubert2/M/55
Not given
Bilateral
amputation
of lower
extremities
Drugs
administered
Left ilioinguinal Midazolam
nerve block
Ketamine
Postoperative
outcome
No exacerbation of
symptoms present
Table 2. Case Studies of Stiff-Person Syndrome Receiving Regional Anesthesia or Monitored Anesthesia Care
Abbreviations: MAC, monitored anesthesia care; SPS, stiff-person syndrome.
aThe dose was not provided in the case report.
(From Ferrandis et al1 and Sidransky, Tran, Kaye24)
Author/patient
sex/age, y
SPS medications
and dosage
Surgical
procedure
Drugs
administered
Postoperative outcome
Ferrandis1/F/44
Diazepam, 50 mg 3 times
daily; tizanidine, 4 mg/d
Double heart-valve
replacement
Midazolam, diazepam,
fentanyl, etomidate,
pancuronium, propofol,
remifentanil
Hypotonia was not prolonged;
however, pain and stiffness with
mild contractions in bilateral
upper and lower extremities was
present 7 hours postoperatively
Ledowski25/M/74
Clonazepam, quinine,
baclofena
ENT
Remifentanil, propofol
No exacerbation of symptoms
present
Toscano16/F/47
Diazepama
Incision and drain of
breast abscess
Midazolam, fentanyl,
propofol, morphine
No exacerbation of symptoms
present
Yagan26/M/46
Diazepam, 15 mg/d;
baclofen, 30 mg/d;
prednisolone, 20 mg/d
Lumbar vertebral
compression fracture
repair
Midazolam, lidocaine,
propofol, remifentanil
No exacerbation of symptoms
present
Obara18/F/40
Not given
Endoscopic nasal sinus
surgery
Propofol, fentanyl,
vecuronium,nitrous
oxide
No exacerbation of symptoms
present
Table 3. Case Studies of Stiff-Person Syndrome Receiving Total Intravenous Anesthesia
Abbreviations: ENT, ear, nose, and throat; SPS, stiff-person syndrome.
aThe dose was not provided in the case report.
(From Ferrandis et al1 and Sidransky, Tran, Kaye24)
function test to determine if respiratory insufficiencies are
present and to aid in determining a postoperative plan for
possible respiratory support. Laboratory results, including
electrolytes, coagulation panel, and GAD antibody levels,
should be checked before surgery. Levels of GAD antibodies may indicate the severity of the disease and predict response to medications and immunotherapy. Coagulation
laboratory findings will aid in deciding if spinal or epidural anesthesia is an option for the anesthetic plan. It is
optimal to schedule IVIG therapy close to the surgery date
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to decrease the levels of GAD antibodies, thus decreasing
the chance of a spasm occurring.27
•Intraoperative Considerations. The operating room
should be warmed and quiet. Any loud noises should
be diminished as much as possible because it can elicit
a spastic episode.27 In the case studies we reviewed, patients with SPS are not characterized by having difficult
airways. As a result of muscle rigidity, patient positioning can present a challenge from difficulty flexing and
extending muscles. The patient’s lordotic curve and other
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185
pressure points should be padded.
According to the anesthesia recommendations for patients with SPS made by Shanthanna et al,27 there are no
contraindications to any anesthetic agents or procedures
and no particular anesthetic technique has been shown to
be safer and more effective than another. When weighing
the risks and benefits of general anesthesia vs regional
anesthesia, the appropriate anesthetic plan should be
chosen based on the provider’s comfort level, location
and type of surgery, patient preference, and severity of
disease. However, it is hypothesized that inhalational
agents exert their effect through GABA inhibition,18 and
they have been reported to potentiate the hypotonia
caused by SPS medications, particularly baclofen.28 In a
case unrelated to SPS, a 49-year-old man with a spinal
cord injury was scheduled to have a penile implant.28
The patient was prescribed baclofen, 25 mg 3 times a
day, for muscle spasms. On induction, the patient was
given fentanyl, thiopental, and atracurium. Anesthesia
was maintained with isoflurane and nitrous oxide. At the
completion of the surgery, the muscle relaxant was reversed; however, the patient remained intubated because
of the presence of muscle hypotonia for 6 hours following
the case.28 It was discovered in the postoperative period
that the patient was taking the recommended dose of
baclofen and additional doses when muscle spasms were
not controlled. Inhalation agents should be avoided if
possible. In the event that inhalational agents are used in
patients with SPS, hypotonia should be monitored closely
before extubation.
In the case report by Bouw et al,19 a 62-year-old
woman was scheduled for resection of a colon mass. Her
SPS symptoms were managed with diazepam, 7.5 mg
twice a day; baclofen, 12.5 mg twice a day; and prednisone, 20 mg daily. On induction, she was given propofol,
sufentanil (Sufenta), and atracurium. Her anesthesia
was managed with isoflurane, and despite a TOF of 4/4
and full muscle relaxant reversal, the patient remained
intubated 3 hours in the postoperative period because
of prolonged hypotonia and respiratory failure. It was
hypothesized by the authors that the inhalational agent
used furthered the hypotonia by potentiating the effect
baclofen has on GABAB receptors.
Although the mechanism in unclear, it has also been
reported that neuromuscular blockers potentiate the
hypotonia caused by SPS medications.20 In the Johnson
and Miller20 case report, a 46-year-old woman was
scheduled for repair of a baclofen pump. Her surgical
history included postoperative weakness 2 days following her initial baclofen pump placement. Her SPS
symptoms had been managed with diazepam, 100 mg
daily, and an intrathecal baclofen pump, in which the
dose was not reported. During the follow-up baclofen
pump repair surgery, isoflurane and vecuronium were
used and resulted in muscle weakness and hypotonia.20
The patient was intubated and admitted to the intensive
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care unit (ICU) overnight. When the patient returned to
have a baclofen pump repaired 5 months later, inhalation anesthesia without muscle relaxants was used. The
patient did not exhibit an exacerbation of symptoms
or prolonged hypotonia in the postoperative period.
Although it has not been shown that muscle relaxants
are prolonged in patients with SPS, it has been recommended that muscle relaxants should be avoided if possible.20 If muscle relaxants must be used, small doses
of short-acting relaxants along with TOF monitoring
are recommended.27 Although no relationship has been
found between the depth of muscle relaxation and hypotonia in patients with SPS, it is recommended for muscle
relaxants to be reversed. Currently, there is insufficient
information on the use of succinylcholine in adults with
diagnosed SPS.11,27
Propofol is the recommended drug for the induction
and maintenance phase of anesthesia. In previous studies
of propofol, it is shown to be beneficial for managing
acute muscle spasms associated with SPS and it can also
enhance GABA receptors in GABA-deficient patients.16
In 2 separate studies conducted in rodents, propofol was
shown to enhance the GABAA receptor activity by shortening the phase of the GABAA receptor channel closure
and potentiating the GABAA receptor–mediated inhibitory postsynaptic currents.10,29
Regional anesthesia is an appropriate option in patients with SPS but can present a challenge to the anesthesia provider. In the Shanthanna23 case report in which
a 55-year-old woman was scheduled for bilateral amputation of the lower extremities, the provider was unable to
achieve an appropriate anesthetic level for surgery after a
spinal block without supplementing with an epidural. It is
noted that the deformity of the spine can cause an unpredictable spinal block, and the rigidity of the muscles can
make it difficult to position the patient.27 Shanthanna23
mentioned the successful use of regional anesthesia as
the safest mode of anesthesia (see Table 2). However,
loud noises and emotional stress, such as anxiety can
exacerbate spasms. Conscious sedation should be derived
in a manner adequate to keep the patient calm before
placing the epidural/spinal anesthetic.23 In the case of
a 65-year-old man with SPS undergoing a hernia repair,
the anesthesia provider performed regional anesthesia
using a paravertebral block, supplementing with a MAC
technique.11 The patient reported improvement of spasticity symptoms during the procedure and 1 hour into the
postoperative period.11
•Postoperative Considerations. Postoperatively the
patient should be monitored closely for muscle spasms
and weakness that could lead to respiratory failure
because of drug interactions between baclofen, diazepam,
and anesthetic drugs. All SPS medications should be
continued in the postoperative period to prevent muscle
rigidity from reoccurring. Patients may require supplementation with benzodiazepines to alleviate postoperawww.aana.com/aanajournalonline
tive symptoms. In the case study by Ferrandis et al,1 a
44-year-old woman scheduled for a double heart valve replacement was induced with fentanyl, midazolam, etomidate, and pancuronium. Anesthesia was maintained using
TIVA with propofol and remifentanil. Postoperatively she
experienced pain in her arms and legs with muscle rigidity in her forearm and lower limbs without spasms. She required a dose of diazepam, 5 mg IV, and morphine, 3 mg
IV, in addition to her continuous infusion of midazolam
(Versed). Four hours later she exhibited symptoms again
and was started on a regimen of diazepam, 50 mg every
8 hours, for pain and stiffness in her legs that eventually
subsided. She was discharged from the unit 3 days later
without SPS symptoms.1
Conclusion
Because of the unique effect that SPS has on GABA and
the possible interaction of inhalational agents and muscle
relaxants with SPS medications, anesthetic management
of a patient with SPS can be challenging for the anesthesia provider. In documented case studies TIVA has been
used successfully in patients with SPS without causing
postoperative hypotonia (see Table 3). The patient’s
comfort and safety were achieved without any residual
weakness before and following emergence and extubation. There were no undesirable symptoms related to
SPS noted, suggesting that in our case the use of minimal
paralytics, propofol, and opioids can be an appropriate
and safe choice to manage patients with SPS.
REFERENCES
1. Ferrandis R, Belda J, Llau JV, Belda C, Bahamonde JA. Anesthesia for
cardiac surgery on a patient with stiff person syndrome. J Cardiothorac
Vasc Anesth. 2005;19(3):370-372.
2. Neubert L, Green P, Green MS. Anesthetic care of stiff person syndrome in the outpatient setting. J Anesthesiol Clin Sci. 2013;2(1):5.
3. Newton JC, Harned ME, Sloan PA, Salles SS. Trialing of intrathecal
baclofen therapy for refractory stiff-person syndrome. Reg Anesth Pain
Med. 2013;38(3):248-250.
4.Baizabal-Carvallo JF, Jankovic J. Stiff-person syndrome: insights
into a complex autoimmune disorder. J Neurol Neurosurg Psychiatr.
2015;86(8):840-848.
5. Moersch FP, Woltman HW. Progressive fluctuating muscular rigidity
and spasm (“stiff-man” syndrome); report of a case and some observations in 13 other cases. Proc Staff Meet Mayo Clin. 1956;31(15):421-427.
6. Asher R. A woman with the stiff-man syndrome. Br Med J. 1958;
1(5065):265-266.
7. Bowler D. The ‘stiff man syndrome’ in a boy. Arch Dis Child. 1960;
35(181):289-292.
8. Ali F, Rowley M, Jayakrishnan B, Teuber S, Gershwin ME, Mackay
IR. Stiff-person syndrome (SPS) and anti-GAD-related CNS degenerations: protean additions to the autoimmune central neuropathies. J
Autoimmun. 2011;37(2):79-87.
9. Geis C, Beck M, Jablonka S, et al. Stiff person syndrome associated
anti-amphiphysin antibodies reduce GABA associated [Ca(2+)]i rise
in embryonic motoneurons. Neurobiol Dis. 2009; 36(1):191-199.
10. Raju R, Rakocevic G, Chen Z, et al. Autoimmunity to GABAA-receptor-associated protein in stiff-person syndrome. Brain. 2006; 129(12):
3270-3276.
www.aana.com/aanajournalonline
11. Elkassabany N, Tetzlaff JE, Argalious M. Anesthetic management of a
patient with stiff person syndrome. J Clin Anesth. 2006;18(3):218-20.
12. Kelly PA, Kuberski C. Stiff person syndrome: a case report. Clin J
Oncol Nurs. 2014;18(4):465-467.
13. Saiz A, Blanco Y, Sabater L, et al. Spectrum of neurological syndromes
associated with glutamic acid decarboxylase antibodies: diagnostic
clues for this association. Brain. 2008;131(10):2553-2563.
14.Lorish TR, Thorsteinsson G, Howard FM Jr. Stiff-man syndrome
updated. Mayo Clin Proc. 1989;64(6):629-636.
15. Dalakas MC, Fujii M, Li M, McElroy B. The clinical spectrum of antiGAD antibody-positive patients with stiff-person syndrome. Neurology.
2000;55(10):1531-1535.
16. Toscano F, Vick A, Shay H, Delphin E. Total intravenous anesthesia
(TIVA) for stiff-person syndrome. Open J Anesthesiol. 2012;2(4):185-187.
17. Vicente-Valor MI, Garcia-Llopis P, Mejia Andujar L, et al. Cannabis
derivatives therapy for a seronegative stiff-person syndrome: a case
report. J Clin Pharm Ther. 2013;38(1):71-73.
18. Obara M, Sawamura S, Chinzei M, Komatsu, Hanaoka K. Anaesthetic
management of a patient with stiff person syndrome. Anaesthesia.
2002;57(5):511.
19. Bouw J, Leendertse K, Tijssen MA, Dzoljic M. Stiff person syndrome
and anesthesia: case report. Anesth Analg. 2003;97(2):486-487.
20. Johnson JO, Miller KA. Anesthetic implications in stiff-person syndrome. Anesth Analg. 1995;80(3):612-613.
21. Qin X, Wang D-X, Wu X-M. Anesthetic management of a patient
with stiff-person syndrome and thymoma: a case report. Chin Med J.
2006;119(11) 963-965.
22. Yamamoto K, Hara K, Horishita T, Sata T. Considerations for general
anesthesia combined with epidural anesthesia in a patient with stiffperson syndrome. J Anesth. 2007;21(4):490-492.
23. Shanthanna H. Stiff man syndrome and anaesthetic considerations:
successful management using combined spinal epidural anaesthesia. J
Anaesthesiol Clin Pharmacol. 2010;26(4):547-548.
24. Sidransky MA, Tran NV, Kaye AD. Anesthesia considerations in stiff
person syndrome. Middle East J Anaesthesiol. 2013;22(2):217-221.
25. Ledowski T, Russell P. Anaesthesia for stiff person syndrome: successful use of total intravenous anaesthesia. Anesthesia. 2006;61(7):725.
26. Yagan O, Ozyilmaz K, Ozmaden A, Sayin O, Hanci V. Anesthesia in a
patient with Stiff Person Syndrome. Rev Brasil Anestesiol. In press.
27. Shanthanna H, Ferrandis R, Goldkamp J. Anesthesia recommendations
for patients suffering from stiff man syndrome. Orphan Anesth. 2014;
1-8. https://www.orpha.net/data/patho/Pro/en/Stiff_Man_EN.pdf.
Accessed March 21, 2016.
28. Gomar C, Carrero EJ. Delayed arousal after general anesthesia associated with baclofen. Anesthesiology. 1994;81(5):1306-1307.
29. Ying SW, Goldstein PA. Propofol suppresses synaptic responsiveness
of somatosensory relay neurons to excitatory input by potentiating
GABA(A) receptor chloride channels. Mol Pain. 2005;1(2):1-14.
AUTHORS
Kristi Hylan, DNP, CRNA, is a staff nurse anesthetist at University Health
in Shreveport, Louisiana. She is a graduate of Our Lady of the Lake College, Baton Rouge, and Louisiana State University Health Sciences Center,
New Orleans. Email: [email protected].
An-Duyen Nguyen Vu, CRNA, was a student registered nurse anesthetist at Texas Wesleyan University in Fort Worth, Texas, at the time
this manuscript was submitted. She graduated in December 2015. Email:
[email protected].
Katherine Stammen, MD, is a staff anesthesiologist and medical student clerkship director at LSU Health Sciences Center–Shreveport, Department of Anesthesia. Email: [email protected].
DISCLOSURES
The authors have declared they have no financial relationships with any
commercial interest related to the content of this activity. The authors did
not discuss off-label use within the article.
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187
Preventive Dorzolamide-Timolol for
Rising Intraocular Pressure During Steep
Trendelenburg Position Surgery
Bonnie Lee Molloy, PhD, CRNA
Xiamei Cong, PhD, RN
Charles Watson, MD, FCCM
The study purpose was to evaluate preventive use
of dorzolamide-timolol ophthalmic solution (Cosopt)
during laparoscopic surgery with the patient in steep
Trendelenburg (ST) position. Periorbital swelling,
venous congestion, and elevated intraocular pressure (IOP) may produce low ocular perfusion. Prompt
IOP reduction is important because 30- to 40-minute
episodes of acute IOP elevations can result in retinal
ganglion cell dysfunction. Dorzolamide-timolol ophthalmic drops reduce IOP and may ameliorate this
effect. A double-blind randomized experimental study
was conducted to test the effect of dorzolamidetimolol on IOP elevation during laparoscopic surgeries in ST position. Patients were randomly assigned
to receive dorzolamide-timolol treatment or balanced
salt solution following anesthesia induction. The
IOP levels were measured at baseline and 30-min-
T
his study was undertaken following a patient’s
blindness due to ischemic optic neuropathy
after lengthy laparoscopic prostate surgery in
the steep Trendelenburg (ST) position. The
anesthesia team became concerned about timedependent changes in ocular perfusion, periophthalmic
pressure, and intraocular pressure (IOP) during laparoscopic surgery with ST positioning. Within the confined
orbit, ocular perfusion pressure (OPP) is defined as the
mean arterial pressure (MAP) minus the IOP, when IOP
exceeds jugular venous pressure. Intraocular pressure is
the pressure exerted by the fluids (aqueous humor) in
the eye and is regulated by the resistance to outflow and
orthostatic pressure variations that may obstruct outflow.
Postoperative visual loss (POVL) due to posterior
ischemic optic neuropathy is a rare but life-changing
event. During laparoscopic abominal surgery, the ST
position (> 30-degree head-down tilt of the operating
room bed) is required because it enables the surgeon’s
visualization of pelvic structures by displacing the bowel
cephalad. However, facial engorgement and edema can
be substantial in this position. Progressive periorbital
edema together with elevated IOP during these procedures led to the hypothesis that cerebrovascular and
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utes intervals throughout surgery. The generalized
estimating equations model was used to analyze
treatment and time effects and treatment by time
interactions. Ninety patients were recruited, with
46 receiving dorzolamide-timolol treatment and 44
receiving balanced salt solution. Statistical analysis
revealed significant treatment and time effects and
treatment-time interactions on IOP. Patients’ IOP
was significantly lower in the treatment group than
controls (P < .05 to P < .001). Treatment effects were
medium to strong. Prophylactic therapy with dorzolamide-timolol significantly reduced IOP of surgical
patients during ST positioning.
Keywords: Chemosis, intraocular pressure, ischemic
optic neuropathy, ocular perfusion pressure, postoperative visual loss.
ophthalmic circulatory autoregulation is impaired during
anesthesia administered to the patient in ST position.
Increased periorbital swelling and venous congestion
could contribute to potential periophthalmic hypoperfusion and play a primary role in the increasingly reported
phenomenon of ischemic optic neuropathy following
lengthy laparoscopic procedures in ST position.
Literature Review
Lee and her colleagues1 hypothesized that hypotensive
ischemic optic neuropathy may be caused by a “compartment syndrome of the optic nerve” suggesting that “high
venous pressure and interstitial tissue edema may compromise blood flow”. This is possible because the orbit is
a relatively confined space, as described by Dunker and
colleagues.2 The eye and anterior optic sensing system
is in the orbit. The posterior optic nerve passes through
the bony optic canal from the orbit to the optic chiasm
toward the brain. The authors suggest that swelling in
this inelastic space can cause compression and exacerbate
ischemia, thus perpetuating a cycle of injury.
Bui et al3 developed a rodent model that showed
alterations in ganglion cell-related electroretinogram potentials during brief increases in IOP (30-40 minutes at
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189
> 50 mm Hg). Peak IOP was a principal determinant of
functional loss in these studies. Rhee et al4 demonstrated
that trabecular meshwork-dysregulated, pressure-dependant outflow caused increased periorbital swelling and
venous congestion, leading to a low flow state in the eye.
Johnstone and Grant5 studied this phenomenom and
concur that with increased IOP, there is dysregulation of
the orbital aqueous outflow. They showed that dependent
orthostatis increased this effect and resulted in a collapse
and occlusion of the lumen of the Schlemm canal. These
pressure-responsive aqueous outflow changes caused
reflux of blood into the anterior chamber, reversing flow.
Increased IOP and impaired orbital outflow can compress the pial vessels in the posterior segment.1,2 Thus,
ocular perfusion is impaired through a progressive series
of changes. Regional ischemia and death of optic nerve
cells both in the anterior and posterior segments can be
explained, potentially resulting in POVL. When patients
have prolonged laparoscopic surgery in ST position, the
physiologic result is analagous to acute glaucoma.
The purpose of this study was to evaluate preventive
use of dorzolamide-timolol (Cosopt) as a measure to
limit IOP increase during lower abdominal laparoscopic
procedures using ST position. This fixed combination of
topical dorzolamide hydrochloride and timolol maleate
is widely used by ophthalmologists to control elevated
IOP. Dorzolamide hydrochloride is a carbonic anhydrase
II inhibitor, and timolol maleate is a topical β-adrenergic
receptor blocking agent. Dorzolamide-timolol reduces
IOP by decreasing the production of aqueous humor and
a direct action on β2-adrenergic receptors in the ciliary
processes.6 In a previous study,7 dorzolamide-timolol
was administered intraoperatively to 63 of 194 subjects
at 3 separate institutions when their IOP reached 40
mm Hg. A nontreatment group did not receive medication because their IOP remained below 35 mm Hg.
Interventional dorzolamide-timolol decreased IOP and
maintained near-normal pressures while the subjects
were in the ST position for 3-hour durations.7
The hypothesis of this current study is that preventive treatment with dorzolamide-timolol would maintain
near-normal IOP during laparoscopic surgery with ST
positioning, while reducing orbital edema and preventing
orbital outflow dysregulation.
Materials and Methods
•Study Design. A randomized, double-blind, experimental design was used to test the effect of preventive
use of dorzolamide-timolol vs balanced salt solution
(BSS) on maintaining IOP levels during a laparoscopic
procedure in ST position. Subjects were randomly assigned to 2 groups: the dorzolamide-timolol treatment
group and the control group (BSS). One drop of topical
dorzolamide-timolol (containing 20 mg of dorzolamide
and 5 mg of timolol) or BSS was administered topically
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to both eyes immediately following induction of anesthesia. Patients in both groups received standard anesthesia
care throughout the surgery. This included dorzolamidetimolol administration when IOP reached 40 mm Hg
during surgery as a standard treatment for all STpositioned procedures at our institutions. We measured
each subject’s IOP at 30-minute intervals throughout the
surgery after an anesthetized baseline measurement in
the supine position. A final postprocedure measurement
in the supine position was obtained after termination of
laparoscopy.
•Setting and Samples. All patients planned for prolonged ST procedures at the medical center were eligible
for the study. They were recruited from a population
scheduled for robotic-assisted laparoscopic prostate and
gynecologic procedures projected to require the ST position for at least 120 minutes. Full institutional review
board approvals were obtained from the regional medical
center for the July 2012 to July 2014 timeframe. With
no exclusions, informed consent was obtained from each
participant before surgery. The sample size estimate
was calculated in the Power Analysis and Sample Size
(PASS) software package (version 8.0.6, NCSS Statistical
Software). Based on our previous findings7 of a medium
to strong effect size (d = 0.60) of dorzolamide-timolol
intervention compared with the standard care on IOP
reduction during ST position, 45 subjects were needed in
each group with α = .05 and power .80.
•Instruments and Measures.
•Demographics. Age, sex, height, weight, body mass
index (BMI), and ASA physical status (classes 1-5) were
documented, along with surgical procedure, medically
indicated tests, fluid maintenance, and vital signs.
•Intraocular Pressure. An applanation tonometer
was used for IOP monitoring (Reichert Tono-Pen XL,
Reichert Technologies). This applanation tonometer is
accepted as the most reliable IOP monitor in both awake
and anesthetized patients.8,9 This device was determined
to be the most accurate instrument for IOP measurement
in a comparison study with other minimally invasive applanation devices.10
•Mean Arterial Pressure. The MAP was measured
by an arterial catheter or noninvasive blood pressure
cuff (NIBP). For direct arterial measurement, MAP
was measured after calibrating the transducer at heart
level (midaxillary line) when the patients were supine.
For measurements in ST position, mean direct arterial
pressures were measured with the transducer zeroed to
the level of carotid artery. In each case, the MAP was
determined as the direct mean carotid level or NIBP determinations. The OPP was calculated as the difference
between MAP and IOP in all positions.11
•Procedures.
•Training. Five anesthesia providers who served as
research assistants were credentialed to monitor IOP
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with the patient under anesthesia in ST position during
laparoscopic urologic and gynecologic procedures.
Credentialed individuals took a video course, and the
technique was demonstrated with volunteers. Calibration
of the applanation tonometer was performed as outlined
in the Reichert Tono-Pen XL manual (black button
tapped twice and inverted upside down when “UP” is
visualized in the chamber; “GOOD” is visualized when
calibrated). This maneuver took place before each patient’s data collection. The principal investigator (BLM)
then observed each of the 5 research assistants’ technique
and measurements with 10 subjects to determine interrater reliability (IRR). The principal investigator’s rating
and the calibrated reading displayed in the applanation
tonometer’s window were the determinants of the correct
measure. Trochim’s12 IRR correlation method was used
for 60 observations and established a 98% IRR value.
•Preoperative Procedures. A sterile cover was used on
the head of the tonometer for each patient in preparation for IOP monitoring. Four vials of solution were
contained in our case; 2 were marked A and B (explained
in the section “Tonometry Measurement”), the third was
BSS, and the fourth was dorzolamide-timolol. Physiologic
anesthesia monitors included a 5-lead electrocardiogram
(ECG), NIBP and digital pulse oximetry. Inspired and
exhaled gases were monitored by side-stream infrared gas
analysis (Dräger/Fabius GS).
•Intraoperative Procedures. Anesthesia protocol was
standardized for all patients. Midazolam, 1 to 2 mg, was
given in the preoperative holding room. Anesthesia induction consisted of administration of fentanyl (1-2 μg/kg),
propofol (2-3 mg/kg), and rocuronium (0.07 mg/kg) or
vecuronium (0.01 mg-0.015/kg) to facilitate endotracheal
intubation. Additional muscle relaxant use was left to the
anesthesia provider’s discretion. Abdominal insufflation
pressure was maintained at 14 to 15 mm Hg throughout
the procedures. General anesthesia was maintained with
a volatile inhalation agent (sevoflurane or desflurane) in
100% oxygen. Supplemental fentanyl was administered as
needed. Bispectral index monitoring was used to assess
the depth of anesthesia. Minute ventilation was adjusted
with volume- or pressure-controlled ventilation to keep
end-tidal carbon dioxide in the range of 30 to 39 mm Hg
during the intraoperative period. Peak airway pressures
were maintained at less than 40 cm H20 and positive endexpiratory pressure ranged from 0 to 5 cm H20.
•Tonometry Measurement. Baseline IOP was determined by applanation tonometry after induction of anesthesia with the patient in the supine position. A sterile
cover was placed on the head of the tonometer, and
sterile BSS eyedrops were applied before each measurement to prevent dryness. The applanation tonometer was
placed above the pupil of each eye, and the black button
was pressed once. Following 3 beeps a mean value is displayed in the window, combining measures of 3 readings.
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One drop of either vial A or vial B (dorzolamidetimolol or BSS) was administered in each eye following
induction of anesthesia. Vial A or vial B was the only
marking on the vials, and anesthesia research assistants
were blinded as to which solution was administered.
The BSS eyedrops were applied before each reading, and
ocular tonometry was repeated every 30 minutes during
the surgery while the patient was in ST position. The
patient’s eyes were taped to prevent drying between measurements. Protective foam was placed over the patient’s
face to prevent injury. If the IOP measurement surpassed
40 mm Hg in either group, the surgeon was made aware of
the elevated IOP and 1 drop of dorzolamide-timolol was
then administered to each eye as a protective measure. If
IOP continued to rise in this subset of patients, a timeout occurred and all anesthesia, surgery and operating
room personnel were involved in determining the additional surgical time needed. A reverse ST positioning
took place for a 10-minute interval at that time if the
surgeon was not nearing completion of the procedure. A
return to ST then took place and tonometry monitoring
continued, but these participants were removed from the
study thereafter because escalating trends of IOP were affected by the interventions. There was no variation in the
anesthetic treatment.
A protractor at the bedside determined the degree of
ST, which ranged from 32 to 40 degrees. Fluid administration was limited to 200 mL/h unless blood loss, hemoconcentration noted by laboratory findings, metabolic
acidemia, or hypotension was noted.13 Arterial or venous
blood was drawn to assess acid-base status at periodic
intervals during the procedures if blood loss or respiratory status warranted. When the patient was returned
to the supine position, a final IOP measurement was
obtained before emergence from anesthesia. The MAP
was obtained for determination of OPP at the time of
IOP reading.
•Statistical Analysis. The IBM SPSS Statistics software
version 20 was used for data analysis. Descriptive statistics including means, standard deviations, and frequencies were used to describe the demographic data and IOP,
MAP, and OPP patterns over time. To address the treatment effect (dorzolamide-timolol vs control) on repeated
measures of outcomes (IOP, MAP, or OPP) throughout
the surgery, the generalized estimating equations (GEE)
model was used to analyze treatment and time effects and
treatment by time interactions. In all GEE models, the
baseline values were used as covariates. An a priori level
of significance was set at P < .05.
Results
A total of 90 patients, 42 (47%) men and 48 women
(53%), were recruited for the study. Forty-six patients
were randomly assigned to the dorzolamide-timolol treatment group and 44 patients were assigned to the control
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Characteristic
Dorzolamide-timolol group
Control group
Gender, No. (%)
Mean
SD
Mean
SD
Total sample
Mean
SD
M
19 (45.23)
23 (54.76)
42 (46.67)
F
27 (56.25)
21 (43.75)
48 (53.33)
Age (y)
56.98
BMI
30.85 9.13
9.52
CO2 (L/min)
34.49
PIP (cm H2O)
32.42 5.14
EBL (mL)
3.49
57.43
10.68
57.20
29.88
6.72
30.378.00
10.04
34.74
3.79
34.61
32.71
5.10
32.565.08
3.62
145.65
113.09
156.25
80.24
150.58
98.19
2,600.00
678.97
2,381.48
452.38
2,488.68
579.76
ASA class
2.38
0.58
2.30
0.60
2.34
0.59
Hematocrit (%)
39.04
3.92
40.85
4.22
39.94
4.14
Fluids (mL)
Table 1. Demographic Characteristics, and Health and Surgical Procedure Statusa
Abbreviations: BMI, body mass index; CO2, carbon dioxide; EBL = estimated blood loss; fluids, fluid maintenance; PIP, peak inspiratory
pressure.
a Data are shown as mean and standard deviation except for gender, which is number and percentage. There were no significant
differences in demographic characteristics between the 2 groups.
group. There were no significant differences in demographic characteristics between the 2 groups (Table 1).
•Intraocular Pressure. There was no difference in
the baseline IOP levels between the 2 groups. The GEE
analysis revealed significant treatment effect (Wald χ2(1)
= 21.85, P < .001) and time effect (Wald χ2(6) = 284.74,
P < .001) and treatment by time interactions (Wald χ2(6)
= 22.81, P < .01). Throughout the surgery, patients’ IOP
levels were significantly lower in the dorzolamide-timolol
group than in the control group at 60-minute, 90-minute,
120-minute, 150-minute, and 180-minute points (P < .05
to P < .001; Table 2, Figure 1). In the final flat position,
no significant differences in IOP were found between
the 2 groups. The effect size of the dorzolamide-timolol
treatment on IOP reduction compared with the control
during the ST position was medium to large (Cohen d =
0.57 to 0.9214).
•Mean Arterial and Ocular Perfusion Pressures.
There was a significant time effect on MAP values (Wald
χ2(6) = 47.74, P < .001) throughout the surgery, but there
were no treatment effect and interaction of treatment by
time on MAP values (Table 3). The OPP values were significantly affected by the treatment (Wald χ2(1) = 4.93, P
< .05) and time (Wald χ2(6) = 113.37, P < .001) and the
interaction of treatment by time (Wald χ2(6) = 12.81, P
< .05). At 120 and 180 minutes, OPP values were calculated to be higher in the treatment group than in the
control group (P < .05, respectively), but no differences
were found at other data points (Table 4).
Discussion
To the best of our knowledge, the present double-blind
randomized experimental study is the first to examine
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prophylactic therapy with Cosopt eyedrops on reducing IOP of patients who undergo laparoscopic surgery
in ST position. The results suggest that throughout the
surgery, the IOP was significantly lower in the treatment group compared with the control group and that
treatment effects were medium to strong across different
time points. The current findings are consistent with our
previous study in which dorzolamide-timolol was used
as a perioperative intervention when IOP approached
40 mm Hg and was shown to be beneficial; in the prior
study, dorzolamide-timolol reduced the IOP by a mean
of 26%, providing a statistically significant decrease at
all time points.7 That study was conducted at 3 different
institutions, with results and conclusions being the same
at all sites and providing a strong basis for conducting the
present research. The highest risk population included
patients with a BMI greater than 35 kg/m2 and age above
62 years.7 In addition, diabetes, vascular disease, and
history of glaucoma were cited as increasing the risk of
elevated IOP regardless of surgical position.1,3,6 Patients
with glaucoma are asked to take their medications before
laparoscopic surgery in ST position and their IOP is routinely monitored at our institution.
Gilbert15 reviewed the literature and concluded that
any interruption to blood flow autoregulation can lead
to POVL. The IOP must remain within normal ranges
to maintain optimum anatomical conditions for refraction and thus vision.16 Harris et al17 studied human
autoregulation and found that retinal blood flow in
response to increased IOP varied markedly. An IOP of
47 mm Hg, in one subject, reduced flow to one-third
of normal, suggesting that human autoregulation may
fail if IOP approaches within 40 to 45 mm Hg of the
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Time point
n
(patient position)a
Group
IOP (mm Hg)
Mean
SD
Initial (flat)
Control
44
12.00
4.05
Dorzolamide-timolol 46
12.61
5.32
30 min (ST)
Control
44
22.80
5.51
Dorzolamide-timolol
4619.83
27.41
P Valueb
> .05
> .05
5.50
60 min (ST)
Control
44
Dorzolamide-timolol
4623.15
5.48
6.47
< .05
90 min (ST)
Control
44
28.30
6.08
Dorzolamide-timolol 46
22.89
5.14
120 min (ST)
Control
43
30.88
Dorzolamide-timolol
4524.11
150 min (ST)
Control
24
dorzolamide-timolol
3125.00
7.50
180 min (ST)
Control
8
8.80
Dorzolamide-timolol
1626.06
8.06
Final (flat)
Control
44
5.48
Dorzolamide-timolol
4616.91
7.48
31.21
18.30
< .001
6.53
7.76
35.00
< .01
< .001
< .01
> .05
6.19
Table 2. Intraocular Pressure (IOP) Measures During Surgery
aIntraocular pressures were measured at baseline supine position (initial, flat), during every 30-minute interval throughout the surgery in
steep Trendelenburg (ST) position, and at a final postprocedure in the supine position (final, flat).
bTreatment by time interaction effects in the generalized estimating equations model. Boldface indicates statistically significant.
Figure 1. Profile Plot: Preventive Dorzolamide-Timolol (Cosopt) versus Control Group at Surgical Time Points
Abbreviation: IOP, intraocular pressure.
MAP (a critical threshold). The authors suggest that
response to an autoregulatory plateau may vary with
age, individual anatomy, atherosclerosis, and/or arterial
hypotension. Indeed, preexisting pathophysiology, drug
therapy, and existing disease entities, such as glaucoma,
will disrupt an individual’s response mechanism as seen
in the studies by Evans et al.18 In their research, 20 patients with open-angle glaucoma were placed in the ST
position, and results were compared with those of 20
healthy subjects in ST position; the results showed that
all 20 patients with glaucoma exhibited faulty autoregu-
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lation of central retinal artery blood flow measured by
Doppler flow imaging. Such variation in patient history
may explain why ophthalmic compartment syndrome,
unlike intracranial or tissue compartment syndrome, is
not uniformly observed at or below a range of OPPs. A
compartment syndrome occurs when increased pressure
in a closed tissue compartment crosses a critical perfusion threshold beyond which blood flow to tissues in the
compartment is compromised.
Studies performed by Molloy19 and Awad et al20 noted
a marked increase in IOP on ST positioning during
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193
Time point
n
(patient position)a
Group
MAP (mm Hg)
Mean
SD
89.02
15.10
P Valueb
Initial (flat)
Control
44
Dorzolamide-timolol
4686.20 14.83
30 min (ST)
Control
44
Dorzolamide-timolol
4693.15 13.29
60 min (ST)
Control
44
Dorzolamide-timolol
4691.70 12.42
90 min (ST)
Control
44
Dorzolamide-timolol
4688.28 11.28
96.05
94.74
89.70
89.45
> .05
13.19
> .05
10.26
> .05
11.55
> .05
120 min (ST)
Control
43
Dorzolamide-timolol
4587.69 12.00
150 min (ST)
Control
25
Dorzolamide-timolol
3087.53 10.46
87.00
83.75
12.04
> .05
10.46
> .05
180 min (ST)
Control
8
Dorzolamide-timolol
1689.44 11.45
Final (flat)
Control
44
Dorzolamide-timolol
4686.59 11.48
85.55
8.70
> .05
11.62
> .05
Table 3. Mean Arterial Blood Pressure (MAP) Measures During Surgery
aMean arterial pressures were measured at baseline supine position (initial, flat), during every 30-minute interval throughout the surgery
in steep Trendelenburg (ST) position, and at a final postprocedure in the supine position (final, flat).
b Treatment by time interaction effects in the generalized estimating equations model.
Time point
n
(patient position)a
Group
MAP (mm Hg)
Mean
SD
77.16
15.51
P Valueb
Initial (flat)
Control
44
Dorzolamide-timolol
4674.09 14.05
30 min (ST)
Control
44
Dorzolamide-timolol
4673.98 14.13
60 min (ST)
Control
44
Dorzolamide-timolol
4668.63 11.72
73.89
68.20
61.37
14.30
12.34
90 min (ST)
Control
44
Dorzolamide-timolol
4664.93 12.03
120 min (ST)
Control
43
Dorzolamide-timolol
4564.42 10.70
150 min (ST)
Control
25
Dorzolamide-timolol
3062.20 9.96
180 min (ST)
Control
8
Dorzolamide-timolol
1663.13 9.87
Final (ST)
Control
44
Dorzolamide-timolol
4668.41 11.36
58.69
56.40
49.75
66.42
13.22
12.93
3.23
11.35
11.31
> .05
> .05
> .05
> .05
< .05
> .05
< .05
> .05
Table 4. Ophthalmic Perfusion Pressure (OPP) Measures During Surgery
aOcular perfusion pressures were measured at baseline supine position (initial, flat), during every 30-minute interval throughout the
surgery in steep Trendelenburg (ST) position, and at a final postprocedure in the supine position (final, flat).
b Treatment by time interaction effects in the generalized estimating equations (GEE) model. Boldface indicates statistically significant.
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Figure 2. Chemosis Effects After 2.5 hours of Steep
Trendelenburg Positiona
aChemosis correlated to 3.4 times baseline intraocular pressure
(> 35-40 mm Hg).
robotic procedures in higher risk populations. Recent
recommendations from the Anesthesia Patient Safety
Foundation (APSF) propose that preoperative consent
include informing such patients of their risk of visual
impairment and that this information be given by both
surgical and anesthesia providers. The APSF held a POVL
multidisciplinary conference in 2013 with anesthesia,
surgery, and ophthalmology researchers and clinicians. A
consensus recommendation was to elevate the head of ST
position procedures at intervals to relieve venous congestion and to stage long prone procedures.21
Because most anesthesia providers rarely measure
IOP, a visual observation scale was developed by Molloy/
Bridgeport Anesthesia Associates for patients undergoing
laparoscopic procedures in ST position. This measurement scale correlates ocular signs to IOP levels.22 Eyelid
edema warns the practitioner that IOP is rising. In the
study by Molloy,22 there was a correlation of eyelid
edema with 2.5 times the baseline IOP. Conjunctival
edema, known as chemosis, proved a valuable predictor
of IOP above 40 mm Hg (area under the curve of the
receiver operator curve, 0.79 ± SD 0.718), the critical
threshold at which point ophthalmologists suggest intervention. Chemosis correlated with IOP 3.4 times the
baseline via a logistic regression analysis. In most cases
this approaches an IOP of 40 mm Hg since the normal
IOP is 10 to 15 mm Hg. Because chemosis has reliably
predicted IOP elevation above 35 mm Hg, we recommend
treatment whenever chemosis is observed (Figure 2).
With the preventive dorzolamide-timolol therapy, visual
signs of periorbital edema and chemosis together with
IOP decreased.
•Alternative Interventions. Porciatti and Nagaraju23
cited a benefit in reverse Trendelenburg positioning
(head-up tilt) and illustrated both a decrease in IOP and
an improvement in retinal ganglion cell function with
this intervention. Linder et al24 also proposed that elevation of the head above the level of the heart may reverse
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the effects of the gravity-induced, orthostatic venous
pressure gradient, resulting in a decreased IOP. A trial
of flat supine rest stop was investigated by Molloy and
Watson25 at the 60-minute point of ST positioning. This
intervention requires undocking and redocking the robot
for only 7 to 10 minutes during robotic cases, removing
instrumentation, then replacing and returning to ST position. The IOP decreased toward normal when tonometry
was measured within 30 minutes of the flat supine intervention. By the second hour the mean IOP for the supine
intervention group was 18.4 mm Hg, whereas it was
31.6 mm Hg in the control group. The findings support
the contention that a flat supine interval minimizes the
impact on IOP and OPP of lengthy laparoscopic surgery
in ST position. The beneficial effect was demonstrable
after an additional 2 hours’ return to the ST position.
Johnstone and Grant5 also found that outflow improved
on inversion. They showed that the orthostatic pressure
change unloaded the trabecular meshwork drainage
system and reopened the lumen of the Schlemm canal.
Surgeons may be resistant to modifying position once
surgery is under way. Therefore, preventive measures
that directly limit escalating IOP without disruption of
surgery should be considered.
•Practice Implications. Both preventive and interventional dorzolamide-timolol may be employed to control
IOP during laparoscopic procedures involving ST position. Shamesh et al26 identified the benefits of a second
daily dose. Subsequent dosing lowers IOP 25.9%. As a
result, we employ preventive dorzolamide-timolol in the
high-risk population (diabetes, vascular disease, glaucoma history, high BMI, and age above 62 years). Also,
when patients present with a history of glaucoma or high
IOP, their scheduled therapy is administered before they
enter the operating room, as a preventive measure. A
subsequent dorzolamide-timolol intervention should be
considered if IOP levels approach 40 mm Hg or if chemosis is observed.
Pinkney and colleagues27 reviewed the relationship of
patient positioning and IOP across all surgical specialties.
They concluded that the rise in IOP was time dependent
and, consequently, that patients were very likely to be
at risk of POVL events as the duration of surgery increased. Both prone and ST position cases were included.
Cases of POVL reported to the American Society of
Anesthesiologists registry occurred after a mean surgical time of 5.5 hours.1 We recommend a time-out at the
4-hour surgical time point to discuss projected surgical
completion. A supine intervention is introduced at that
time if ST or prone position is needed for an additional
hour or more.
Conclusion
Dorzolamide-timolol (Cosopt) drops significantly reduce
elevated IOP and periorbital edema of patients who
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undergo lengthy laparoscopic robotic surgery in the ST
position. Preventive and interventive treatment at any
time during the ST procedure arrested the trend in escalating IOP. Practitioners should monitor signs of periorbital edema if not IOP, and an institutional protocol may
help limit the potential for ischemic optic neuropathy
and POVL when procedures in prolonged ST or prone
position are indicated. Preventive dorzolamide-timolol
may provide practitioners with an alternative to frequent
repositioning during these prolonged surgical procedures.
REFERENCES
1. Lee LA, Roth S, Posner KL, et al. The American Society of Anesthesiologists Postoperative Visual Loss Registry: analysis of 93 spine cases
with postoperative visual loss. Anesthesiology. 2006;105(4):652-659.
2. Dunker S, Hsu HY, Sebag J, Sadun AA. Perioperative risk factors for posterior ischemic optic neuropathy. J Am Coll Surg. 2002;194(6):705-710.
3. Bui BV, Edmunds B, Cioffi GA, Fortune B. The gradient of retinal
functional changes during acute intraocular pressure elevation. Invest
Ophthalmol Vis Sci. 2005;46(1):202-213.
4. Rhee DJ, Alvarado JA, Calkins DJ, Gupta N. The brain the drain. Eye
Net. 2011 Nov/Dec;36-41.
5. Johnstone MA, Grant WG. Pressure-dependent changes in structures
of the aqueous outflow system of human and monkey eyes. Am J
Ophthalmol. 1973;75(3):365-383.
6. Yeh J, Kravitz D, Francis B. Rational use of the fixed combination of
dorzolamide-timolol in the management of raised intraocular pressure and glaucoma. Clin Ophthalmol. 2008;2(2):389-399.
7. Molloy BL, Cong X. Perioperative dorzolamide-timolol intervention
for rising intraocular pressure during steep Trendelenburg position
surgery. AANA J. 2014;82(3):203-211.
8. Riva CE, Hero M, Titze P, Petrig B. Autoregulation of human optic
nerve head blood flow in response to acute changes in ocular perfusion
pressure. Graefes Arch Clin Exp Ophthalmol. 1997;235(10):618-626.
9. Baskaran M, Raman K, Ramani KK, Roy J, Vijaya L, Badrinath SS.
Intraocular pressure changes and ocular biometry during Sirsasana (headstand posture) in yoga practitioners. Ophthalmology.
2006;113(8):1327-1332.
10. Lasseck J, Jehle T, Feltgen N, Lagrèze WA. Comparison of intraocular
tonometry using three different non-invasive tonometers in children.
Graefes Arch Clin Exp Ophthalmol. 2008;246(10):1463-1466.
11. Hayreh SS. Ischemic optic neuropathy. Prog Retin Eye Res. 2009;28(1):
34-62.
12. Trochim WMK, Donnelly JP. Nonprobability sampling. The Research
Methods Knowledge Base website. http://www.socialresearchmethods.
net/kb/sampnon.php. Updated October 20, 2006. Accessed March 26,
2014.
13. Baig MN, Lubow M, Immesoete P, Bergese SD, Hamdy EA, Mendel
E. Vision loss after spine surgery: review of the literature and recommendations. Neurosurg Focus. 2007;23(5):E15.
14. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed.
Hillsdale, NJ: Lawrence Earlbaum Associates; 1988.
15. Gilbert ME. Postoperative visual loss: a review of the current literature. Neuroophthalmology. 2008;32(4):194-199.
16.Murgatroyd H, Bembridge J. Intraocular pressure. Br J Anaesth.
2008;8(3):100-103.
17. Harris A, Ciulla TA, Chung HS, Martin B. Regulation of retinal and
optic nerve blood flow. Arch Ophthalmol. 1998;116(11):1491-1495.
18. Evans D, Harris A, Garrett M, Chung HS, Kagemann L. Glaucoma
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patients demonstrate faulty autoregulation of ocular blood flow during posture change. Br J Ophthalmol. 1999;83(7):809-813.
19.Molloy BL. Implications for postoperative visual loss: steep Trendelenburg position and effects on intraocular pressure. AANA J.
2011;79(2):115-121.
20. 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.
21. Cooper J, Caplan R, Gaba D. APSF workshop engages audience in
communication skills and drills. APSF Newslett. 2013:27(3):45-72.
22. Molloy BL. A preventive intervention for rising intraocular pressure:
the development of the Molloy/Bridgeport Anesthesia Associates
observation scale. AANA J. 2012;80(3):213-222.
23.Porciatti V, Nagaraju M. Head-up tilt lowers IOP and improves
RGC dysfunction in glaucomatous DBA/2J mice. Exp Eye Res. 2010;
90(3):452-460.
24. Linder BJ, Trick GL, Wolf ML. Altering body position affects intraocular pressure and visual function. Invest Ophthalmol Vis Sci. 1988;
29(10):1492-1497.
25. Molloy BL, Watson C. A comparative assessment of intraocular pressure in prolonged steep Trendelenburg vs. supine position intervention. J Anesth Clin Sci. 2012;1-9. http://www.hoajonline.com/journals/
jacs/content/pdf/9.pdf. Accessed March 21, 2016.
26.Shamesh G, Moisseiev E, Lazar M, Kurtz S. Intraocular pressure
reduction of fixed combination timolol maleate 0.5% and dorzolamide 2% (Cosopt) administered three times a day. Clin Ophthalmol.
2012;6:283-287.
27. Pinkney TD, King AJ, Walter C, Wilson TR, Maxwell-Armstrong C,
Acheson AG. Raised intraocular pressure (IOP) and perioperative
visual loss in laparoscopic colorectal surgery: a catastrophe waiting to
happen? A systematic review of evidence from other surgical specialities. Tech Coloproctol. 2012;16(5):331-335.
AUTHORS
Bonnie Lee Molloy, PhD, CRNA, is a Certified Registered Nurse Anesthetist employed by and affiliated with Bridgeport Anesthesia Associates,
Bridgeport Hospital/Yale New Haven Health System, Bridgeport, Connecticut. Email: [email protected].
Xiamei Cong, PhD, RN, is employed by the University of Connecticut
School of Nursing, Storrs, Connecticut. Email: [email protected] .
Charles Watson, MD, FCCM, is past chairman, Anesthesia Department,
Bridgeport Hospital, and employed by Bridgeport Anesthesia Associates,
Bridgeport, Connecticut. Email: [email protected].
DISCLOSURES
The authors have declared they have no financial relationships with any
commercial interest related to the content of this activity. The authors did
not discuss off-label use within the article.
ACKNOWLEDGMENTS
The authors thank the AANA Foundation, Park Ridge, Illinois, for
financial and collaborative support. They also thank these mentors and
advisors: Anthony Peluso, MD, Anesthesia Department, Bridgeport Anesthesia Associates, Bridgeport, Connecticut, advisor; Anthony Musto, MD,
chairman of ophthalmology, Bridgeport Hospital Bridgeport, Connecticut;
Bruce Shields, MD, past chairman, Department of Ophthalmology, Yale
New Haven Health System, New Haven, Connecticut; research assistants
Esra Anson, CRNA; Keisha Johnson, CRNA; Kathryn Sapiente, CRNA, and
Theresa Donnelly, CRNA; and surgical associates Scott Thornton, MD,
colorectal surgeon, Bridgeport Hospital, Daniel Silasi, MD, robotic gynecologic surgeon, Yale New Haven Health System; and medical illustrator
Victoria Skomal Wilchinsky.
www.aana.com/aanajournalonline
Unknown Pseudocholinesterase Deficiency in a
Patient Undergoing TIVA with Planned Motor
Evoked Potential Monitoring: A Case Report
Candace Binkley, MSN, CRNA
Pseudocholinesterase abnormalities are a genetic
cause of aberrant metabolism of the depolarizing
muscle relaxant succinylcholine. This article examines
a case where succinylcholine was chosen to facilitate intubation due to its ultra short duration and the
request of the surgeon to monitor motor evoked potentials. Following succinylcholine administration the neu-
C
holinesterase is a broad term used to describe
a family of enzymes that hydrolyze choline
esters. Two subtypes of cholinesterase exist:
acetylcholinesterase and pseudocholinesterase (PChE). Some individuals demonstrate
genetic variations in PChE that can cause prolonged
apnea and paralysis when exposed to the depolarizing
muscle relaxant succinylcholine due to aberrant metabolism of the drug. Sixty-five inherited variants have been
identified that may cause slight to marked post-succinylcholine paralysis.1 Monitoring intraoperative motor
evoked potentials requires the absence of paralysis. This
frequently leads the anesthesia provider to select succinylcholine to facilitate intubation due to its ultra short
duration. In the presence of an unknown pseudocholinesterase deficiency, the duration of paralysis after succinylcholine administration may be significantly increased,
resulting in the inability to monitor evoked potentials.
This case report is an addition to the available literature
describing the impact an unknown pseudocholinesterase
deficiency can have on the anesthetic plan.
Case Summary
An 81-year-old man (182 cm, 88 kg) presented to the
surgical suite for C3-C6 anterior discectomy and fusion.
The patient had a past medical history significant for hypertension, sleep apnea, chronic obstructive pulmonary
disorder (COPD), and lung cancer status post chemo
and radiation. Past surgical history included an appendectomy, cholecystectomy, surgically repaired abdominal
aortic aneurysm (AAA), and left upper lobectomy. The
preoperative evaluation completed by the anesthesiologist indicated that the patient complained of fear due
to the inability to move during a previous anesthetic.
During the interview with the student registered nurse
anesthetist, the patient could not recall what surgery this
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rophysiologist was unable to obtain motor evoked
potentials. This case study highlights the intraoperative
and postoperative management of an elderly patient
with an unknown pseudocholinesterase deficiency.
Keywords: Anesthesia, dibucaine number, motor
evoked potentials, pseudocholinesterase deficiency.
had occurred but stated it was not experienced during
his last procedure. The patient had no allergies and was
unaware of any surgical or anesthetic complications
among his closest blood relatives. The student registered
nurse anesthetist’s subjective preoperative airway assessment did not indicate a potential difficult airway. The
patient’s electronic record from the previous aneurysm
repair revealed an uncomplicated intubation facilitated
by succinylcholine. When reviewing the record for the
lobectomy it was noted that rocuronium had been given
to assist with intubation.
The patient was transported into the OR. Standard
anesthesia monitors were applied and preoxygenation
occurred with 10 L per minute of oxygen. General anesthesia was induced at 0754 with lidocaine, 100 mg;
propofol, 150 mg; and fentanyl, 250 µg. Intubation was
facilitated with 100 mg, succinylcholine.
In this case the surgeon requested that nervous system
function be monitored utilizing motor evoked potentials
(MEPs). When MEP monitoring is indicated, anesthesia
providers typically avoid nondepolarizing neuromuscular blockers and volatile anesthetics due to profound depression of motor evoked response amplitude.2 For this
reason succinylcholine was chosen to assist with tracheal
intubation and total intravenous anesthesia was planned.
The anesthetist intubated the patient without difficulty
and endotracheal tube placement was confirmed by the
presence of end-tidal carbon dioxide (ETCO2), chest rise,
and bilateral breath sounds. Total intravenous anesthesia
(TIVA) was initiated utilizing a propofol drip started
at100 µg/kg/min and a remifentanil drip started at 0.25
µg/kg/min. These infusions were titrated based on hemodynamic parameters and surgical stimulation to maintain
an adequate plane of anesthesia.
The patient was prepped and an arterial line was placed
for hemodynamic monitoring. Incision was made at 0856.
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The neurophysiologist attempted to establish the patient’s
baseline MEPs. At 0901 the neurophysiologist made the
surgeon, CRNA, and student registered nurse anesthetist
aware that motor evoked potentials were unable to be
elicited. After confirming with the anesthesia team that
succinylcholine had been administered the neurophysiologist began to troubleshoot the monitoring equipment.
The student registered nurse anesthetist checked a
train of four (TOF) response using the nerve stimulator
to evaluate the patient’s recovery from neuromuscular
blockade. The lack of response led to a presumptive diagnosis of pseudocholinesterase deficiency. The battery
and electrodes of the nerve stimulator were checked and
confirmed to be in working order. The surgeon and anesthesiologist were made aware of the lack of response. The
surgeon stated the case could be safely continued without
the motor evoked potentials and requested that MEPs
periodically be followed to detect the return of muscle
responsiveness.
Early in the case the patient experienced hypotension
and a phenylephrine infusion was initiated and titrated
to maintain a mean arterial pressure of 70 or greater.
Otherwise, the case remained uneventful. Approximately
3 hours into the case, at 1202, the neurophysiologist
notified the team that the MEPs had returned to the patients’ presurgery baseline. The student registered nurse
anesthetist rechecked the TOF response and noted 4
strong equal twitches. MEPs were then monitored continuously throughout the remainder of the surgery.
The case was completed at 13:04. Five hours and 10
minutes had elapsed since the succinylcholine had been
administered. After discussion among the anesthesia
team, propofol and remifentanil were discontinued in anticipation of emergence. Approximately 20 minutes later,
despite measurable MEPs and a complete return of the
TOF, the patient remained weak. The patient was able to
blink eyes in response to questions but could not lift arms,
legs, or head off the bed. When asked to take a maximal
inhalation, tidal volume was noted to be less than 100
mL. The cause of the prolonged paralysis was explained
to the patient to decrease anxiety. Fentanyl, 100 µg and
a propofol drip at 50 µg/kg/min were initiated for patient
comfort and sedation. The patient was taken to the post
anesthesia care unit (PACU) intubated. The anesthesiologist continued the care of the patient in PACU. According
to the extubation note written by the anesthesiologist, the
patient was weaned to a t-piece and the endotracheal tube
was removed at 14:46. This was approximately 7 hours
after the succinylcholine administration. The patient was
taken from the PACU to the intensive care unit for continued airway monitoring and subsequently discharged to
a rehabilitation facility 5 days later.
Discussion
Prolongation of succinylcholine can be caused by either
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a decreased quantity or quality of pseudocholinesterase.
Diminished quantities may be seen in the presence of
malignancies, pregnancy, liver disease, collagen vascular disease, malnutrition, and hypothyroidism.3 In this
case, the dibucaine inhibition test was drawn and sent
for analysis to determine if the patient had an atypical
variant of PChE. The normal result of the dibucaine
inhibition test is 80. This means that 80% of the PChE
activity was inhibited by the local anesthetic dibucaine.
These individuals are labeled homozygous normal and
would be briefly paralyzed by succinylcholine. Those
with a dibucaine number of 20 would be homozygous
atypical and can be expected to have a marked response
to succinylcholine with paralysis typically exceeding 1
hour. A dibucaine inhibition test result of 60 would be
defined as heterozygous and generally only produce a
slight prolongation of succinylcholine. Postoperatively,
it was noted that the patient’s dibucaine inhibition test
result was 27. This indicates an atypical PChE variant
with the genetic label of homozygote atypical.1,2 The incidence of a patient homozygous for pseudocholinesterase
mutations is one in 2,500 patients.4
Studies have shown that patients with pseudocholinesterase deficiency have a normal response to remifentanil, leading the author to believe it is unlikely that the
remifentanil contributed to the prolonged recovery of
the patient.5 Remifentanil is a synthetic opioid with swift
onset and short duration. It allows predictable titration
of anesthesia with rapid recovery of consciousness and
respiration independent of the duration of infusion. The
context-sensitive half-life is 3-4 minutes. Remifentanil is
metabolized by nonspecific esterases in tissues and blood
and is not mediated by pseudocholinesterase.6
An indication that this patient may have had a pseudocholinesterase deficiency came from the preoperative
interview when the patient stated that he was unable to
move during a prior anesthetic. Past surgical records for
the aortic aneurysm repair did include the administration of succinylcholine followed by rocuronium. TOF
response had not been charted between the two, however
6 hours later a four-twitch response to TOF was documented prior to reversal. The patient was taken to PACU
intubated and the reason indicated on the anesthesia discharge summary was pulmonary edema. The lobectomy
had occurred after the AAA repair and succinylcholine
had not been administered. This explains why the patient
had indicated he could not recall having an anesthetic
complication with his most recent surgery.
The author acknowledges that a baseline TOF should
have been elicited prior to the administration of succinylcholine. An early discovery could have alerted the
surgeon to the inability to elicit intraoperative MEPs
prior to skin incision. Multiple case reports describe the
importance of monitoring neuromuscular blockade when
administering succinylcholine.3,4,7,8
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When faced with a patient experiencing a prolonged
duration of paralysis, in addition to safety, a primary goal
is comfort of the patient. The patient was found to be
awake and able to blink eyes in response to questioning.
The patient was reassured, sedated, and ventilated until
it was decided by the anesthesiologist that the patient
satisfactorily met the extubation criteria. The patient was
educated regarding his atypical enzyme and given a letter
regarding his pseudocholinesterase deficiency for future
anesthesia experiences.
Conclusion
In summary, this was a unique case of unanticipated
prolonged paralysis observed in an elderly patient during
a surgery where motor evoked potentials were being
monitored. The inability to elicit a TOF response led the
student registered nurse anesthetist to an early presumptive diagnosis of pseudocholinesterase deficiency. In
this patient population education regarding the cause of
the paralysis is important to decrease anxiety and avoid
the future use of depolarizing muscle relaxants by other
healthcare providers.
REFERENCES
1. Soliday FK, Conley YP, Henker R. Pseudocholinesterase deficiency:
a comprehensive review of genetic, acquired, and drug influences.
AANA J. 2010;78(4):313-20.
2. Haghighi SS, Madsen R, Green KD, Oro JJ, Kracke GR. Suppression
of motor evoked potentials by inhalation anesthetics. J Neurosurg
Anesthesiol.1990;2(2):73-78.
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3. Maiorana A, Roach RB Jr. Heterozygous pseudocholinesterase deficiency: a case report and review of the literature. J Oral Maxillofac
Surg. 2003;61(7): 845-847.
4. Cassel J, Staehr-Rye AK, Nielsen CV, Gätke MR. Use of neuromuscular
monitoring to detect prolonged effect of succinylcholine or mivacurium: three case reports. Acta Anaesthesiol Scand. 2014;58(8):1040-043.
5.Manullang J, Egan TD. Remifentanil’s effect is not prolonged
in a patient with pseudocholinesterase deficiency. Anesth Analg.
1999;89(2): 229-230.
6. Michelsen LG, Hug CC, Jr. The pharmacokinetics of remifentanil. J
Clin Anesth. 1996;8(8):679-682.
7. Ramirez JG, Sprung J, Keegan MT, Hall BA, Bourke DL. Neostigmineinduced prolonged neuromuscular blockade in a patient with atypical
pseudocholinesterase. J Clin Anesth. 2005;17(3):221-224.
8. Branch A, Rafacz J, Boudreaux L. Prolonged neuromuscular block in
a 74-year-old patient. AANA J. 2011;79(4):317-21.
AUTHOR
Candace Binkley, MSN, CRNA, was a senior student registered nurse anesthetist at Bloomsburg University, Geisinger school of nurse anesthesia, in
Danville, Pennsylvania at the time this article was written. She currently is
practicing as a CRNA in Virginia and Pennsylvania. Email: cbinkley11@
gmail.com.
DISCLOSURES
The author has declared no financial relationships with any commercial
interest related to the content of this activity. The author did not discuss
off-label use within the article.
ACKNOWLEDGMENT
The author thanks the Geisinger Bloomsburg Nurse Anesthesia Program
Director, Brenda Wands, PhD, CRNA, for her dedication to her students
and encouragement to publish.
www.aana.com/aanajournalonline
AANA Journal Course
2
Update for Nurse Anesthetists
Tranexamic Acid in Anesthetic Management of
Surgical Procedures
Jessica Mayeux, MSN, CRNA
Kathy Alwon, MSN, CRNA
Shawn Collins, DNP, PhD, CRNA
Ian Hewer, MSN, MA, CRNA
Blood loss during surgical procedures poses a grave
risk to the patient, but transfusion is costly and associated with adverse outcomes. Antifibrinolytics, however, offer an economical and effective means of
decreasing blood loss associated with surgical procedures. Tranexamic acid (TXA) is an antifibrinolytic that
blocks lysine-binding sites of fibrinogen and fibrin, preventing the breakdown of existing clots. This journal
course reviews extensive research demonstrating that
antifibrinolytics such as TXA decrease blood loss and
in some studies reduce allogeneic transfusion requirements. In addition, this journal course addresses con-
Objectives
At the completion of this course, the reader should be
able to:
1.
Describe the physiologic process in which tranexamic acid inhibits fibrinolysis.
2.Identify contraindications to the administration of
tranexamic acid.
3.
Describe administration guidelines of tranexamic
acid.
4.Identify surgeries in which tranexamic acid could
provide benefit to the patient.
5Discuss adverse effects associated with administration of tranexamic acid.
Introduction
Higher perioperative blood loss is associated with surgical procedures such as cardiac, orthopedic, and trauma
procedures. One of the most common treatments of
massive blood loss is blood transfusion, but there
are many complications and risks associated with this
practice. With advancements in surgical techniques,
cerns that use of antifibrinolytics increases embolic
events, reviews research that demonstrates TXA does
not increase the incidence of vascular occlusive events,
and describes methods of TXA use in cardiac and
orthopedic surgical procedures, neurosurgery, and
obstetrics. The Certified Registered Nurse Anesthetist
should consider the possibility, on a case-by-case
basis, of using TXA in surgical procedures to reduce
blood loss with minimal adverse effects.
Keywords: Antifibrinolytic, coagulant, surgery, surgical blood loss, tranexamic acid.
autologous blood donations, cell scavenge, and antifibrinolytic drugs, healthcare providers have been able
to decrease the number of blood transfusions and thus
the associated complications. Decreasing perioperative
bleeding through the prophylactic use of antifibrinolytic
agents, such as aprotinin, tranexamic acid (TXA), and
ε-aminocaproic acid (EACA), has become increasingly
popular. This journal course will examine the properties
of TXA and use of this medication in the operating room.
Historical Background
Presently, the only labeled indications for TXA by the
US Food and Drug Administration (FDA) are for shortterm use in patients with hemophilia undergoing tooth
extractions and to treat menorrhagia.1 However, since
the 1960s, TXA commonly has been prescribed off-label
to minimize blood loss for various high blood loss surgeries such as cardiac and orthopedic surgical procedures.
Recently, TXA also has been used in trauma surgery to
decrease blood loss.2 Despite the success of TXA as an antifibrinolytic—and its widespread use in countries such
AANA Journal Course No. 36: AANA Journal course will consist of 6 successive articles, each with an objective for the reader and
sources for additional reading. This educational activity is being presented with the understanding that any conflict of interest on behalf
of the planners and presenters has been reported by the author(s). Also, there is no mention of off-label use for drugs or products.
Please visit AANALearn.com for the corresponding exam questions for this article.
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201
Figure 1. Coagulation Cascade and Fibrinolysis
Abbreviations: Ca++, calcium ion; tPA, tissue plasminogen activator; uPA, urokinase.
as the United Kingdom and Japan—it was not as popular
in the United States until the early 2000s, when aprotinin, an antifibrinolytic, was removed from the market.
In 2008, TXA was proposed to be included in the
World Health Organization (WHO) Model List of
Essential Medicines for reducing perioperative blood
loss in adults undergoing cardiac surgical procedures
requiring cardiopulmonary bypass (CPB); in 2011, that
proposal was approved. The Model List of Essential
Medicines helps countries plan for effective healthcare
delivery by identifying the potential impact and importance of medications. Following inclusion of TXA in the
Model List of Essential Medicines for cardiac procedures,
in 2013 it was included for use in adult trauma patients
with ongoing substantial hemorrhage, or at risk of severe
hemorrhage within 8 hours of injury.3
Use of Tranexamic Acid to Decrease Allogeneic Blood Requirements
Providing universal access to safe blood products is a
major objective of global health agencies, such as the
WHO. However, considering the limited supply and cost
of blood products and the risk of adverse outcomes associated with blood transfusion, interventions such as TXA
administration that could reduce transfusion requirements are highly desirable. A systematic literature review
suggests that administration of blood products is associ-
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ated with increased morbidity and mortality, and urges
reevaluation of transfusion practices among healthcare
providers.4
Allogeneic blood transfusion is a multibillion-dollar
industry with increasing costs and decreasing supply.5 In
2009 alone, the costs the American Red Cross incurred to
provide whole blood and its components were estimated
to be $2.217 billion.5 The most recent estimated cost of
1 U of red blood cells is $210.74, and the charge to the
patient receiving the transfusion is $343.63.6 In comparison, 1 g of TXA supplied in a 10-mL vial is estimated to
cost between $45 and $55.7 There is growing evidence to
support the use of drugs such as TXA in the reduction of
perioperative blood loss; this could reduce the frequency
of blood transfusion requirements, ultimately allowing
for improved allocation of resources and decreased costs
to patients.5
Coagulation and Fibrinolysis
Hemostasis is the complex process of maintaining vascular integrity, limiting blood loss, and keeping blood
in a fluid state. It is a delicate balance between vascular,
platelet, and plasma factors that create a fibrin clot and
the regulatory mechanisms of the fibrinolytic system that
dissolve a fibrin clot.8 Hemostasis begins with the formation of a platelet plug, followed by the creation of a fibrin
network that binds to and strengthens the platelet plug.8
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blocking the lysine-binding sites.11 Tranexamic acid acts
to prevent fibrinolysis by blocking the lysine-binding
sites in a similar mechanism to α2-antiplasmin.
Pharmacology of Tranexamic Acid
Figure 2. Schematic Diagram of Molecular Interactions
During Fibrinolysisa
aFibrinolytic system consists of plasminogen, which is converted
into plasmin by tissue plasminogen activator. Once plasmin is
activated, it binds to fibrin via the lysine-binding sites (represented
as legs of the animal). Free circulating plasmin glycoproteins
become inactivated by α2-antiplasmin.
(From Collen and Lijnen.11 Reprinted with permission from
Lippincott Williams & Wilkins.)
The coagulation cascade and fibrinolytic system are activated simultaneously in normal circumstances, which
allows repair of the vascular injury while preventing
thrombosis and ischemia.8 Figure 1 depicts the different
components of hemostasis: platelet-mediated hemostasis,
plasma-mediated hemostasis, and fibrinolysis.
Just as important as forming a blood clot through
coagulation is the process of removing the blood clot by
fibrinolysis. The coordinated events of coagulation and
fibrinolysis must occur together to allow appropriate
blood flow without blood loss.9 The fibrinolytic system
consists of plasminogen, which becomes converted into
plasmin using plasminogen activators: tissue plasminogen
activator (tPA) and urokinase.9 In the initial stages of coagulation, plasminogen becomes trapped in the clot while
waiting to be activated into plasmin.8 Plasminogen activators tPA and urokinase are released slowly by the surrounding damaged endothelial cells.9 Within a few days
of the clot being formed and the blood vessel stabilized,
tPA reaches plasminogen and converts it into plasmin.9
Once activated, lysine-binding sites on plasmin are
responsible for binding with fibrin, cell surface receptors, and other proteins that help mediate fibrinolysis,
such as α2-antiplasmin.9 One of the primary regulatory
proteins of the fibrinolytic system, α2-antiplasmin is responsible for inactivating tPA and urokinase.9 Plasmin
proteolyzes fibrin into soluble fibrin degradation products and d-dimer, which are then removed by the circulatory system.10 Figure 2 presents a schematic diagram of
fibrinolysis.
Inhibition of fibrinolysis can occur at 2 points, by
either inhibiting binding of the plasminogen activators or
preventing the binding of plasmin to the fibrin mesh by
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Tranexamic acid is a synthetic antifibrinolytic amino
acid that competitively blocks the lysine-binding sites of
both plasminogen and plasmin, therefore inhibiting each
enzyme’s action. Plasmin usually assists with dissolving
blood clots, but when TXA saturates the lysine-binding
sites of plasminogen and plasmin, plasminogen can still
be converted to plasmin, but plasmin can no longer bind
to fibrin. Without the presence of plasmin, there is no
degradation of fibrin, and thus bleeding is reduced.
Potency comparisons have varied significantly according to tests used, but TXA has approximately 8 times
the antifibrinolytic activity of EACA.2 Tranexamic acid
is minimally protein bound and cleared by the kidneys.
In patients with normal renal function, TXA’s half-life is
2 to 3 hours.12 Lower dosing strategies should be considered for patients with kidney disease because of TXA
being cleared by the kidneys. Impaired renal function
does not constitute a contraindication, but to avoid accumulation, it should be given over longer intervals and
adjusted to patient weight. The most recent suggestions
regarding renal dosing have been given by Nuttall et al
(Table 1).13
Side effects and adverse reactions of TXA are rare and
appear limited; mild side effects include nausea, vomiting, and diarrhea. Absolute contraindications include
active intravascular clotting disorders (Table 2).12 Use of
TXA in conjunction with other procoagulant drugs could
also increase the likelihood of thrombotic complications.
The most recent 2011 Cochrane Review on antifibrinolytics indicated that TXA does not increase or decrease
the risk of thrombotic events such as myocardial infarction, stroke, or renal dysfunction (Table 3).20 The low
incidence of these adverse events and lack of evidence
showing a positive correlation or association with TXA
administration compared with placebo suggest its safety
for use in the perioperative period.
In addition to undesirable procoagulant effects, a
potential adverse effect of TXA is retinal change. In an
animal model, doses approximately 7 times greater than
the maximum dose for humans were associated with
retinal changes.21 For diagnosis of TXA toxicity using an
ophthalmic examination, it would require a patient to
have functioning color vision before surgery. Therefore,
patients with acquired defective color vision (color blindness) should not receive TXA. Despite no human testing
having been done, it is still recommended to screen patients for acquired defective color vision.12
Although TXA has a low incidence of side effects, its
safety has recently been challenged. The large retrospective study of Sharma et al22 associated a cumulative high
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Procedure
(unlabeled use)
Dosing regimena
Elective cesarean delivery
Reference
Gungorduk, 201314
Vaginal delivery
10 min before incision: 1 g over 5 min
At delivery of anterior aspect of shoulder: 1g over 5 min
Hip fracture surgery
15 mg/kg; repeat dose 3 h later
Cardiac surgery
30 mg/kg over 30 min, followed by 16 mg/kg/h until sternal closure; add 2 mg/
kg to CPB circuit
Cardiac surgery
10 mg/kg over 20 min, followed by 2 mg/kg/h continued for 2 h after transfer
to ICU; add 50 mg for a 2.5-L CPB circuit
Nuttall, 200813
Spinal surgery
10 mg/kg, followed by 1 mg/kg/h until wound closure
Wong, 200817
Total hip arthroplasty
15 min before skin incision: 10-15 mg/kg (or 1 g) over 5-10 min; followed by
either of the following:
1. 10 mg/kg (or 1 g), 3 h after surgery
2. 1 mg/kg/h for 10 h
Total knee arthroplasty
First dose (10 mg/kg) immediately before tourniquet was deflated; repeat dose
3 h later
Trauma
1 g over 10 min, followed by 1g over 8 h; begin treatment within 8 h of injury
CRASH-2 Trial
Collaborators, 20102
Renal dosing, cardiac
surgery
Same loading dose. Reduce maintenance infusion based on serum creatinine
level as follows:
Nuttall, 200813
Gungorduk, 201314
Zufferey, 201015
1.6-3.3 mg/dL
1.5 mg/kg/h (25% reduction)
3.3-6.6 mg/dL
1 mg/kg/h (50% reduction)
> 6.6 mg/dL
0.5 mg/kg/h (75% reduction)
Fergusson, 200816
Oremus, 201418
Camarasa, 200619
Table 1. Recommended Dosing Strategies for Tranexamic Acid
Abbreviations: CPB, cardiopulmonary bypass; ICU, intensive care unit.
aTranexamic acid should be administered intravenously immediately before skin incision unless specified otherwise. Tranexamic acid
may be mixed with any crystalloid solution, and loading doses of varying amounts diluted in 50 to 250 mL administered over 5 to 30
minutes. With rapid administration, one may see orthostatic reaction; therefore, the recommended maximum rate of injection should be
100 mg/min.
Absolute contraindication
Relative contraindication
Acquired defective color vision
History of vascular occlusive events
Hypersensitivity to TXA
Concomitantly with another procoagulant
Active intravascular clotting
Concomitantly with hormonal contraception
Subarachnoid hemorrhage
Table 2. Contraindications to Tranexamic Acid12
Abbreviation: TXA, tranexamic acid.
(From Pharmacia and Upjohn Co. Cyklokapron—tranexamic acid injectable, solution. May 2013.)
dose of TXA (80 mg/kg) with an increased incidence
of postoperative seizures in cardiac surgical patients.
Controversy remains regarding this association because
of the selection bias that confounds retrospective studies.
Researchers theorize that seizures due to TXA may be
secondary to neuronal γ-aminobutyric acid (GABA) inhibition or the crossing of TXA into cerebrospinal fluid.23
There are only a few reported studies on the pharmacokinetics of intravenous TXA; therefore, determining
the minimum effective dose that inhibits fibrinolytic
activity has been challenging. Furthermore, those studies
have investigated TXA plasma concentrations in healthy
volunteers, and have not proven relevancy in more hemodynamically fragile older patient populations.24 Dosing
schedules thus far have been empirical and hypothesized,
and dosages cited in studies may vary over a 10-fold
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range (loading dose, 10-150 mg/kg).20 The discrepancy
of dosing and efficacy among studies has created confusion about the optimal duration of TXA treatment and
techniques to maintain therapeutic TXA concentrations.20
Comparatively, there is a higher ratio of cardiac studies
concerning the dosing of TXA vs TXA dosing in orthopedic or trauma surgeries. Without definitive guidelines,
anesthesia providers must proceed with caution when
choosing a dosing regimen for their patient. A summary
of dosing strategies for specific procedures can be seen in
Table 1.
Use in Cardiac Surgery
Close to 1.25 million adults worldwide undergo cardiac
surgery each year.25 Surgical blood loss and the need for
blood transfusions pose serious complications for many
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Effect of tranexamic acid
Adverse event
RR
95% CI
Death
0.60
0.33 to 1.10
Myocardial infarction
0.79
0.41 to 1.52
Stroke
1.23
0.49 to 3.07
Deep venous thrombosis
0.71
0.35 to 1.43
Renal failure
0.89
0.33 to 2.37
Pulmonary embolism
0.67
0.23 to 1.99
Table 3. Adverse Events Associated With Tranexamic
Acid Administrationa During the Perioperative Period20
Abbreviations: CI, confidence interval; RR, risk ratio.
aData were extrapolated from 65 trials (4,482 patients) that
compared tranexamic acid (TXA) with a control in a variety of
surgical procedures. Results showed no difference in the rate of
events between TXA and placebo.
cardiac surgical patients and have shown a strong association with in-hospital mortality.26 These risks have led
to the use of antifibrinolytics such as TXA in the cardiac
surgical patient to minimize blood loss. Although its use
in cardiac surgery remains off-label, TXA shows promise
in decreasing complications associated with blood loss.
Over the last 20 years, several meta-analyses have assessed the efficacy and safety of TXA using endpoints such
as blood loss, frequency of blood transfusions, occurrence
of adverse events, in-hospital mortality rate, and reoperation due to rebleeding. Unfortunately, the measurement of
these endpoints has differed substantially among studies,
making it difficult for researchers to decipher statistically
significant results. To make analysis even harder, some
studies have grouped the lysine analogs TXA and EACA
together when comparing them with aprotinin, instead
of assessing each independently. Overall, meta-analyses
of randomized clinical trials agree that TXA is effective at
reducing the need for blood transfusions when compared
with no antifibrinolytic treatment.27-29
Currently, there is no consensus regarding optimal
TXA dosing in cardiac surgery. In 2008, the WHO recommended a TXA dose of 10 to 30 mg/kg intravenously
followed by an infusion of 1 to 16 mg/kg/h and 1 to
2 mg/kg added to the cardiopulmonary circuit (pump
prime).25 Some researchers have implied that CPB may
influence TXA’s elimination kinetics and subsequently
blood concentrations of TXA, but no specific research
has been conducted regarding CPB kinetics of TXA.
Butterworth et al23 did find CPB-related elimination
effects with EACA, so it is common practice to supplement the circuit with additional TXA because EACA and
TXA have similar kinetic properties.
Indications for use of TXA vary among professional
guidelines. For example, in 2006 the American Society
of Anesthesiologists published guidelines concerning antifibrinolytic therapy, stating that antifibrinolytics should
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not be administered routinely and use should be determined on an individual basis.30 However, the Society
of Thoracic Surgeons and the Society of Cardiovascular
Anesthesiologists published their joint guidelines in
2007, which recommended the use of TXA for blood conservation in cardiac surgery since TXA limits total blood
loss and reduces the number of patients who require
blood transfusion after cardiac procedures.31
In a 2011 Cochrane Review, when TXA was compared
with no treatment in cardiac surgical patients, there was
no significant difference in mortality rate. The authors
also determined that there is no conclusive evidence of
increased risk of thrombosis associated with TXA. This
review looked at 34 studies published on the use of
TXA in 3,006 cardiac surgical patients. The TXA loading
or bolus dose ranged from 2.5 to 100 mg/kg, and the
maintenance dose of TXA ranged from 0.25 to 4.0 mg/
kg/h delivered over 1 to 12 hours. Comparison of the
literature was difficult because data collected vary among
studies, including the volume of blood transfused and
the amount of blood loss, whether it be intraoperative,
postoperative, or recorded as combined. Other variables
making comparison challenging are hospitals’ variation
in transfusion protocols and providers’ blood transfusion
thresholds; perioperative aspirin use, autotransfusion
procedures, and types of CPB technology and practice.
In the context of cardiac surgery, postoperative bleeding
was shown, on average, to be reduced 273 mL across 22
of the trials. Tranexamic acid did not significantly reduce
the risk of reoperation for bleeding, exposure to blood
transfusions; nor did it reduce length of hospital stay.
The authors concluded that the decrease in postoperative
bleeding and limited side effects of TXA offset possible
fear or belief that TXA may increase the risk of vascular occlusion events. The findings from the Cochrane
Review confirmed and strengthened previous research
on the use of TXA in cardiac surgery.
Use in Orthopedic Surgery
Orthopedic surgery can be associated with substantial
intraoperative and postoperative blood loss and may
require blood transfusion to replace blood loss. Although
the pneumatic tourniquet is one strategy commonly
used to address blood loss intraoperatively, recent metaanalyses have found that the use of a tourniquet does not
decrease total blood loss or the transfusion rate in the
perioperative period, and there are several adverse complications associated with its use, including increased
risk of thromboembolic events.32,33
However, TXA does effectively reduce postoperative
blood loss. A Cochrane Review20 compares TXA with
placebo in orthopedic surgery, including total knee and
total hip arthroplasties. It finds that the use of TXA in
orthopedic surgery reduced intraoperative blood loss by
116 mL per patient, and postoperative blood loss by 229
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mL per patient. Overall, the review concludes that the
use of TXA in orthopedic surgery significantly reduces
the total amount of blood lost during the perioperative
period. This conclusion is based on the results of 20 trials
that compared TXA with placebo in orthopedic surgery,
including 1,201 patients, of which 605 received TXA and
596 received a placebo.
Many meta-analyses and studies have been conducted
attempting to discern the best practice for administering TXA in orthopedic surgery; however, the best drug
dosage, dosing regimen, or method of delivery of TXA
for total knee or total hip arthroplasty has yet to be
definitively determined. Studies either choose to give an
upfront bolus of medication before inflation of tourniquet
or skin incision, with no medication to follow, another
bolus to follow, or a continuous infusion to follow. In a
subgroup analysis of the meta-analysis by Huang et al,34
it was determined that regardless of the dosing scheme or
amount delivered, there continued to be a positive effect
and reduction of blood loss from TXA administration.
A systematic review of the literature by Alshryda et al35
concluded that not only did TXA reduce blood loss, but it
also reduced blood transfusion requirements during total
knee arthroplasties. A meta-analysis evaluating the use of
TXA for total hip arthroplasty also determined that TXA
reduces intraoperative blood loss by a mean of 104 mL
and reduces allogeneic blood transfusions.36 These metaanalyses support continued investigation and improved
heterogeneity in further studies to obtain clear data on
proper TXA administration.
A major concern with the use of TXA in orthopedic
procedures is the risk of thrombosis. Administration of
TXA has been slow to become popular in orthopedic
populations because of this perceived risk. In their systematic review of the literature , Huang et al34 observed
no increase in thromboembolic events in patients who
received TXA compared with placebo. Other meta-analyses, performed by Alshryda et al35 and Sukeik et al,36
confirmed that there was no increased risk of adverse
events or complications among study groups when TXA
was used for total knee or total hip arthroplasty.
Although there remains controversy over optimal
timing, dosage and method of administration of TXA in
orthopedic surgery, there is overwhelming evidence to
suggest that providing TXA in these procedures reduces
blood loss in total knee and total hip arthroplasty. A
survey of the literature reveals that TXA does not increase likelihood of adverse effects, such as deep-vein
thrombosis or pulmonary embolism as previously believed. Continued research is necessary to fully determine best practice for TXA administration in orthopedic
procedures.
Use in Neurosurgery
In spine surgery, higher blood loss occurs because of sur-
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gical techniques using spinal instrumentation since bony
surfaces are not conducive to traditional hemostatic maneuvers used during soft-tissue surgery.17 Other potential
causes of blood loss during spinal surgery include surgery
duration and the number of vertebral levels decompressed.17 Formation of an epidural hematoma in close
proximity to the spinal canal can lead to severe neurologic
damage due to spinal cord or cauda equina compression.37
A meta-analysis38 published in 2013 suggests TXA
significantly decreases blood loss and frequency of blood
transfusion, without increasing the risk of deep-vein
thrombosis in spine surgery. However, a limitation of
the publication is the small number of studies that were
included in the meta-analysis. In 2008, Wong et al17 assessed the efficacy of TXA in adults undergoing elective
spinal reconstructive surgery and found that calculated
perioperative blood loss was significantly less in the TXA
group vs the placebo group.17 The incidence of transfusion of blood products or the hospital length of stay did
not differ significantly between the 2 groups.17
Topical use of TXA in lumbar spine fixation surgery
has the potential to reduce postoperative blood loss.
Krohn et al39 compared 30 patients who received either
TXA in irrigation solution during wound closure (n =
16) or saline irrigation solution alone (n = 14). The TXA
group had significantly reduced postoperative blood loss
compared with the placebo group.39
Substantial perioperative blood loss is associated with
surgical correction of scoliosis in the pediatric population
and often requires administration of blood products.40
Sethna et al40 studied efficacy of TXA in children and
adolescents undergoing elective spinal fusion, evaluating whether TXA administration would decrease blood
loss or transfusion requirements. The TXA group had a
statistically significant reduction in blood loss, by 41%,
compared with the placebo.40
Further research comparing dosing regimens, (eg,
single bolus vs bolus and continuous infusion) is important to determine a safe and effective treatment for
patients undergoing neurosurgery. At this time, there is
a discrepancy between study dosing strategies, as well as
insufficient numbers of studied patients to be able to determine best practice. Although current evidence strongly suggests TXA reduces blood loss in neurosurgery,
additional research is necessary to establish best practice.
Use in Trauma Surgery
Trauma is the sixth leading cause of death worldwide,
with hemorrhaging as the secondary cause.41 Trauma
patients experience many coagulopathies, including hyperfibrinolysis leading to hemorrhage, and it is believed
that trauma and surgery have similar hemostatic responses
after severe vascular injury. Tranexamic acid may oppose
hyperfibrinolysis and reduce mortality due to bleeding in
trauma patients.42 Recently, TXA has been incorporated
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into several resuscitation and massive transfusion protocols across the United States.
The Clinical Randomization of an Antifibrinolytic
in Significant Haemorrhage-2 (CRASH-2) study was
the first to assess the effects of TXA administration in
trauma patients with or at risk of major hemorrhaging.
This study specifically looked at the influence of TXA on
death rate, vascular occlusive events, and frequency of
blood transfusions in more than10,000 patients randomly assigned to receive TXA. Both all-cause mortality and
risk of death due to bleeding were significantly reduced
with TXA administration. Vascular occlusive events and
blood product administration did not vary significantly
between placebo and TXA groups. The absence of an
increased risk of thrombotic events with TXA administration reemphasizes its safety profile. The power of the
study may be reduced because diagnosis of traumatic
hemorrhage is difficult and the study included patients in
the trial who may not have been actually hemorrhaging.2
As of now, no other studies have been published comparing TXA with placebo in trauma patients.
Early administration of TXA is crucial to decrease
blood loss. Therefore, the CRASH-2 study dosed TXA as
a bolus of 1 g over 10 minutes and then an infusion of
1 g over 8 hours. The study investigators also believed
that stopping TXA administration within 8 hours would
decrease the risk of death due to thrombotic events and
coagulopathies associated with trauma in the later hours
after injury. In the event of an emergency, it may be difficult to determine a patient’s weight, so fixed dosing was
the best solution.2
Use in Obstetric and Gynecologic Procedures
The use of TXA in obstetric-gynecologic procedures is
controversial; however, multiple studies are under investigation to determine the safety and efficacy of TXA
in the obstetric population. In 2013, global accounts of
maternal mortality included 289,000 women who died
from complications during pregnancy or childbirth, 99%
of which occurred in developing countries.43 Because
severe bleeding accounts for 27% of all maternal deaths
worldwide,43 the use of TXA could prove beneficial in
reducing blood loss and saving lives.
Tranexamic acid crosses the placenta, producing
cord blood concentrations similar to maternal plasma
concentrations.44 The FDA has categorized TXA as a
Category B drug, because there have been no adequate,
well-controlled studies in pregnant women; however,
the administration of TXA in animal reproduction
studies have failed to demonstrate risk to the fetus.12
Tranexamic acid is present in mothers’ breast milk at
low concentrations, approximately 1% of the maternal
serum concentration.44
The WHO recommends the use of TXA for postpartum hemorrhage in the event that the administration
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of oxytocin and second-line treatment options are ineffective, or if the bleeding is also due to trauma.45 A
Cochrane Review published in 2010, concludes, from
the results of 2 randomized control trials, that there was
decreased postpartum blood loss after vaginal and cesarean births when TXA was used.46 However, the reviewers
recommend that further investigations are necessary to
illustrate the safety and efficacy of TXA in preventing
postpartum hemorrhage.46
The use of TXA has been studied for populations
undergoing elective cesarean delivery or vaginal delivery.14,47 Each study demonstrated decreased mean
estimated blood loss in the TXA group compared with
the placebo group. There was no significant difference
between the 2 study groups for requiring blood transfusion or hospital length of stay for those undergoing
cesarean delivery or having vaginal delivery. However,
significantly more women in the placebo group required
additional uterotonic agents and had lower hemoglobin
and hematocrit levels the day after delivery in the study
assessing use of TXA for vaginal delivery.14
A large, international, randomized, double-blind
study, World Maternal Antifibrinolytic Trial (WOMAN),
is currently under way to determine the efficacy of TXA
compared with a placebo in 15,000 women with postpartum hemorrhage.48 It aims to determine the effect of early
administration of TXA following vaginal or cesarean
delivery assessing mortality, hysterectomy, surgical intervention, and blood transfusion.48 Studies to date have not
been powered sufficiently to demonstrate risk of adverse
vascular events related to TXA administration, but the
WOMAN Trial will have sufficient power to determine
the risk of TXA.48 Recruitment is ongoing, with hospitals
from Africa, Asia, Latin America, and Europe currently
collaborating.
Conclusion
Currently, TXA is being used in a wide range of surgical
procedures without increased risk of thrombosis or other
adverse effects.20 The results of several large clinical
trials and many small trials support its use to decrease
bleeding and reduce mortality and have a proven safe
pharmaceutical profile.20 It is yet to be determined if the
increased use of antifibrinolytic agents actually reduces
the rate of blood transfusions, but TXA has been shown
to reduce the degree of blood loss perioperatively. This
inexpensive and safe drug is increasingly being used
since aprotinin went off the market and because it is
more potent than EACA. Further research is needed to
differentiate possible alternate mechanisms of action of
TXA, procedure-specific dosing regimens, and even use
of TXA in traumatic brain injuries, including hemorrhage. In addition, future research should involve larger
trials that definitively prove the effectiveness of TXA
because existing smaller trials may be biased.
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REFERENCES
1. Napolitano LM, Cohen MJ, Cotton BA, Schreiber MA, Moore EE.
Tranexamic acid in trauma: how should we use it? J Trauma Acute Care
Surg. 2013;74(6):1575-1586.
2. CRASH-2 Trial Collaborators, Shakur H, Roberts I, Bautista R, et al.
Effects of tranexamic acid on death, vascular occlusive events, and
blood transfusion in trauma patients with significant haemorrhage
(CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376
(9734):23-32.
3. Roberts I, Kawahara T, 18th Expert Committee on the Selection and
Use of Essential Medicines, World Health Organization. Proposal for
the inclusion of tranexamic acid (anti-fibrinolytic–lysine analogue) in
the WHO model list of essential medicines. http://www.who.int/selection_medicines/committees/expert/18/applications/TRANEXAMIC_
ACID_10_2.pdf?ua=1. Published June 2010. Updated link accessed
March 23, 2016.
4. Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the
critically ill: a systematic review of the literature. Crit Care Med. 2008;
36(9):2667-2674.
5. Leahy MF, Mukhtar SA. From blood transfusion to patient blood
management: a new paradigm for patient care and cost assessment of
blood transfusion practice. J Intern Med. 2012;42(3):332-338.
6. Toner RW, Pizzi L, Leas B, Ballas SK, Quigley A, Goldfarb NI. Costs
to hospitals of acquiring and processing blood in the US: a survey of
hospital-based blood banks and transfusion services. Appl Health Econ
Health Policy. 2014;9(1):29-37.
7. Reed H. The role of tranexamic acid in EMS & preoperative trauma
management. JEMS. March 27, 2013, issue 4. http://www.jems.com/
articles/print/volume-38/issue-4/patient-care/role-tranexamic-acidems-preoperative-tr.html. Accessed March 28, 2016.
8. Guyton AC, Hall JE. Hemostasis and blood coagulation. In: Textbook
of Medical Physiology. 12th ed. Philadelphia, PA: Saunders Elsevier;
2011:451-461.
9. Cesarman-Maus G, Hajjar KA. Molecular mechanisms of fibrinolysis.
Br J Haematol. 2005;129(3):307-321.
10. Moake JL. Overview of hemostasis [online]. Merck Manual Online.
http://www.merckmanuals.com/professional/hematology_and_oncology/hemostasis/overview_of_hemostasis.html. Accessed September
14, 2014.
11. Collen D, Lijnen HR. Basic and clinical aspects of fibrinolysis and
thrombolysis. Blood. 1991;78(12):3114-3124.
12. Cyklokapron-tranexamic acid injectable, solution [package insert].
Kalamazoo, MI: Pharmacia & Upjohn Co; May 2013.
13. Nuttall GA, Gutierrez MC, Dewey JD, et al. A preliminary study of a
new tranexamic acid dosing schedule for cardiac surgery. J Cardiothorac
Vasc Anesth. 2008;22(2):230-235.
14. Gungorduk K, Asicioğ lu O, Yildirim G, Ark C, Tekirdağ AI, Besimoglu B. Can intravenous injection of tranexamic acid be used in
routine practice with active management of the third stage of labor
in vaginal delivery? A randomized controlled study. Am J Perinatol.
2013;30(5):407-413.
15. Zufferey PJ, Miquet M, Quenet S, et al, for the investigators of the
tranexamic acid in hip-fracture surgery (THIF) study. Tranexamic acid
in hip fracture surgery: a randomized controlled trial. Br J Anaesth.
2010;104(1):23-30.
16. Fergusson DA, Hébert PC, Mazer CD, et al, BART Investigators. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery
[published correction appears in N Engl J Med. 2010;363(13):1290].
N Engl J Med. 2008;358(22):2319-2331.
17. Wong J, El Beheiry H, Rampersaud YR, et al. Tranexamic acid reduces
perioperative blood loss in adult patients having spinal fusion surgery.
Anesth Analg. 2008;107(5):1479-1486.
18. Oremus K, Sostaric S, Trkulja V, Haspl M. Influence of tranexamic
acid on postoperative autologous blood retransfusion in primary total
hip and knee arthroplasty: a randomized controlled trial. Transfusion.
2014;54(1):31-41.
19. Camarasa MA, Ollé G, Serra-Prat M, et al. Efficacy of aminocaproic,
208
AANA Journal

June 2016

Vol. 84, No. 3
tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial. Br J Anaesth. 2006;96(5):576-582.
20. Henry DA, Carless PA, Moxey AJ, et al. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database
Syst Rev. 2011(3): CD001886 .
21. Ekvarn S. Summary and evaluation of toxicological data. Stockholm,
Sweden: Data on file, KabiVitrum AB; 1983.
22. Sharma V, Fan J, Jerath A, et al. Pharmacokinetics of tranexamic acid
in patients undergoing cardiac surgery with use of cardiopulmonary
bypass. Anaesthesia. 2012;67(11):1242-1250.
23. Dowd NP, Karski JM, Cheng DC, et al. Pharmacokinetics of tranexamic
acid during cardiopulmonary bypass. Anesthesiology. 2002;97(2):390-399.
24. Benoni G, Bjorkman S, Fredin H. Application of pharmacokinetic
data from healthy volunteers for the predication of plasma concentrations of tranexamic acid in surgical patients. Clin Drug Invest.
1995;10(5):280-287.
25.Carless P, 17th Expert Committee on the Selection and Use of
Essential Medicines, World Health Organization. Proposal for the
inclusion of tranexamic acid (anti-fibrinolytic -lysine analogue) in the
WHO Model List of Essential Medicines [draft report]. http://www.
who.int/selection_medicines/committees/expert/17/application/
TRANEXAMIC_ACID.pdf. Published November 25, 2008. Accessed
September 12, 2014.
26.Karkouti K, Wijeysundera DN, Yau TM, et al. The independent
association of massive blood loss with mortality in cardiac surgery.
Transfusion. 2004;44(10):1453-1462.
27. Laupacis A, Fergusson D. Drugs to minimize perioperative blood loss
in cardiac surgery: meta-analyses using perioperative blood transfusion as the outcome. The International Study of Peri-operative Transfusion (ISPOT) Investigators. Anesth Analg. 1997;85(6):1258-1267.
28. Fremes SE, Wong BI, Lee E, et al. Metaanalysis of prophylactic drug
treatment in the prevention of postoperative bleeding. Ann Cardiothorac Surg. 1994;58(6):1580-1588.
29. Henry D, Carless P, Fergusson D, Laupacis A. The safety of aprotinin
and lysine-derived antifibrinolytic drugs in cardiac surgery: a metaanalysis. CMAJ. 2009;180(2):183-193.
30. American Society of Anesthesiologists Task Force on Perioperative
Blood Transfusion and Adjuvant Therapies. Practice guidelines for
perioperative blood transfusion and adjuvant therapies: an updated
report by the American Society of Anesthesiologists Task Force on
Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology. 2006;105(1):198-208.
31.Society of Thoracic Surgeons Blood Conservation Guideline Task
Force and Society of Cardiovascular Anesthesiologists Special Task
Force on Blood Transfusion. Perioperative blood transfusion and
blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical
practice guideline. Ann Thorac Surg. 2007;83(5 suppl):S27-S86.
32.Smith TO, Hing CB. Is a tourniquet beneficial in total knee
replacement surgery? A meta-analysis and systematic review. Knee.
2010;17(2):141-147.
33. Zhang W, Li N, Chen S, Tan Y, Al-Aidaros M, Chen L. The effects of
a tourniquet used in total knee arthroplasty: a meta-analysis. J Orthop
Surg Res. 2014;9(1):13.
34. Huang F, Wu D, Ma G, Yin Z, Wang Q. The use of tranexamic acid
to reduce blood loss and transfusion in major orthopedic surgery: a
meta-analysis. J Surg Res. 2014;186(1):318-327.
35. Alshryda S, Sarda P, Sukeik M, Nargol A, Blenkinsopp J, Mason JM.
Tranexamic acid in total knee replacement: a systematic review and
meta-analysis. J Bone Joint Surg Br. 2011;93(12):1577-1585.
36. Sukeik M, Alshryda S, Haddad FS, Mason JM. Systematic review and
meta-analysis of the use of tranexamic acid in total hip replacement.
J Bone Joint Surg Br. 2011;93(1):39-46.
37. Tsutsumimoto T, Shimogata M, Ohta H, Yui M, Yoda I, Misawa H.
Tranexamic acid reduces perioperative blood loss in cervical laminoplasty. Spine. 2011;36(23):1913-1918.
38. Yuan C, Zhang H, He S. Efficacy and safety of using antifibrinolytic
www.aana.com/aanajournalonline
agents in spine surgery: a meta-analysis. PLoS One. 2013;8(11): e82063.
39.Krohn CD, Sørensen R, Lange JE, Riise R, Bjørnsen S, Brosstad
F. Tranexamic acid given into the wound reduces postoperative
blood loss by half in major orthopaedic surgery. Eur J Surg Suppl.
2003;588:57-61.
47. Gungorduk K, Yildirim G, Asicioğ lu O, Gungorduk O, Sudolmus S,
Ark C. Efficacy of intravenous tranexamic acid in reducing blood loss
after elective cesarean section: a prospective, randomized, doubleblind, placebo-controlled study. Am J Perinatol. 2011;28(3):233-239.
40. Sethna NF, Zurakowski D, Brustowicz RM, Bacsik J, Sullivan LJ, Shapiro
F. Tranexamic acid reduces intraoperative blood loss in pediatric patients
undergoing scoliosis surgery. Anesthesiology. 2005;102(4):727-732.
48. Shakur H, Elbourne D, Gülmezoglu M, et al. The WOMAN Trial
(World Maternal Antifibrinolytic Trial): tranexamic acid for the
treatment of postpartum haemorrhage: an international randomized,
double blind placebo controlled trial. Trials. 2010;11:40-53.
41. Søreide K. Epidemiology of major trauma. Br J Surg. 2009;96(7):
697-698.
AUTHORS
42. Lawson JH, Murphy MP. Challenges for providing effective hemostasis in surgery and trauma. Semin Hematol. 2004;41(1 suppl 1):55-64.
43. WHO, UNICEF, UNFPA, The World Bank, United Nations Population Division. Trends in maternal mortality: 1990-2013. Estimates by
WHO, UNICEF, UNFPA, The World Bank and the United Nations
Population Division [online]. http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/. Published
May 2014. Accessed September 4, 2014.
44. McCormack PL. Tranexamic acid: a review of its use in the treatment
of hyperfibrinolysis. Drugs. 2012;72(5):585-617.
45. WHO Guidelines for the Management of Postpartum Haemorrhage and
Retained Placenta. Geneva, Switzerland: World Health Organization; 2009.
http://apps.who.int/iris/bitstream/10665/44171/1/9789241598514_
eng.pdf. Accessed March 28, 2016.
46. Novikova N, Hofmeyr GJ. Tranexamic acid for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2010;(7): CD007872.
www.aana.com/aanajournalonline
Jessica Mayeux, MSN, CRNA, is employed by Mission Health System,
Asheville, North Carolina. At the time this article was written she was a
student at Western Carolina University, Asheville, North Carolina.
Kathy Alwon, MSN, CRNA, is employed by Harborview Medical
Center, Seattle, Washington. At the time this article was written she was a
student at Western Carolina University, Asheville, North Carolina.
Shawn Collins, PhD, DNP, CRNA, is the director of the Nurse Anesthesia Program at Western Carolina University, Asheville, North Carolina.
Email: [email protected].
Ian Hewer, MSN, MA, CRNA, is the assistant director of the Nurse Anesthesia Program at Western Carolina University, Asheville, North Carolina.
DISCLOSURES
The authors have declared they have no financial relationships with any
commercial interest related to the content of this activity. The authors did
discuss off-label use within the article.
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CALENDAR OF EVENTS
Advertisers who list their prior-approved CE programs in the
Calendar of Events enjoy wider exposure for their approved programs because the $125 per listing fee includes a duplicate listing
on the AANA website as well as a link directly to the online
Calendar of Events in the bi-monthly Anesthesia E-ssential (the
AANA’s electronic newsletter). Additionally, the web address
provided in the advertisement will be hyperlinked directly to the
websites allowing viewers access to company and program information for more exposure and target-directed traffic.
Go to http://www.aana.com/cecalendarofevents for specific
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submission.
For additional information, contact Ann Carlson, Continuing
Education Department, at (847) 655-1190.
June 1, 2016-December 31, 2017, Texas; Dannemiller,
Inc. - Provider-Directed Independent Study - 36 CEC.
June 1, 2016-April 19, 2019, Illinois;
American Association of Nurse Anesthetists
- 1 CEC. “AANA Learn-Ultrasound Physics.”
“AnesthesiaFile: Notebook Vol. 33.” Barbra Thompson, 5711
Northwest Parkway, San Antonio, TX 78249; (210) 641-8311; fax (210)
641-8329; email, [email protected]; www.dannemiller.com.
June 1, 2016-December 31, 2017, Texas; Dannemiller,
Inc. - Provider-Directed Independent Study - 36 CEC.
“Anesthesiology Online Vol. 16.” Barbra Thompson, 5711 Northwest
Parkway, San Antonio, TX 78249; (210) 641-8311; fax (210) 641-8329;
email, [email protected]; www.dannemiller.com.
June 1, 2016-December 31, 2017, Texas; Dannemiller,
Inc. - Provider-Directed Independent Study - 24 CEC.
“Painstracts Volume 16.” Barbra Thompson, 5711 Northwest Parkway,
San Antonio, TX 78249; (210) 641-8311; fax (210) 641-8329; email,
[email protected]; www.dannemiller.com.
June 1, 2016-May 31, 2018, Florida; Frank Moya
Continuing Education Programs - Provider-Directed
Independent Study - 26 CEC. “Current Reviews for Nurse
Anesthetists, Volume 39.” Frank Moya, MD, 1828 SE First Avenue, Ft.
Lauderdale, FL 33316; (954) 763-8003; fax (800) 425-1995; email,
[email protected]; www.currentreviews.com.
June 1, 2016-December 31, 2018, Michigan; Institute
For Post Graduate Education - 40 CEC. “CE Anywhere
- Self Directed Independent Study.” Bernard Kuzava, CRNA, PO Box
28, Hastings, MI 49058; (877) 692-0430; fax (269) 948-2507; email,
[email protected]; www.ipge.com.
June 1, 2016-April 10, 2019, Illinois;
American Association of Nurse Anesthetists
- 1 CEC. “AANA Learn-New Technological Modalities
in Anesthesia.” American Association of Nurse
Anesthetists, Park Ridge, IL. (847) 939-3530; email,
[email protected]; www.AANALearn.com.
June 1, 2016-April 12, 2019, Illinois;
American Association of Nurse Anesthetists
- 1 CEC. “AANA Learn-Inhalational Anesthetics.”
American Association of Nurse Anesthetists, Park Ridge,
IL. (847) 939-3530; email, [email protected];
www.AANALearn.com.
June 1, 2016-April 17, 2019, Illinois;
American Association of Nurse Anesthetists
- 1 CEC. “AANA Learn-Everything You Wanted
to Know About Hormones But Were Afraid to Ask.”
American Association of Nurse Anesthetists, Park Ridge,
IL. (847) 939-3530; email, [email protected];
www.AANALearn.com.
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Vol. 84, No. 3
American Association of Nurse Anesthetists, Park Ridge,
IL. (847) 939-3530; email, [email protected];
www.AANALearn.com.
June 1, 2016-April 24, 2019, Illinois;
American Association of Nurse Anesthetists
- 1 CEC. “AANA Learn-The Wondrous Story of
Anesthesia: Where Nurses Led and Where They Followed.”
American Association of Nurse Anesthetists, Park Ridge,
IL. (847) 939-3530; email, [email protected];
www.AANALearn.com.
June 1, 2016-May 1, 2019, Illinois; American
Association of Nurse Anesthetists - 1 CEC.
“AANA Learn-Parenteral Anesthetics.” American Association
of Nurse Anesthetists, Park Ridge, IL. (847) 939-3530;
email, [email protected]; www.AANALearn.com.
June 1, 2016-May 3, 2019, Illinois; American
Association of Nurse Anesthetists - 1 CEC.
“AANA Learn-The History of Supervision.” American
Association of Nurse Anesthetists, Park Ridge, IL.
(847) 939-3530; email, [email protected];
www.AANALearn.com.
June 1, 2016-May 8, 2019, Illinois; American
Association of Nurse Anesthetists - 1 CEC.
“AANA Learn- Potential Pee: A Journey Through the
Nephron.” American Association of Nurse Anesthetists,
Park Ridge, IL. (847) 939-3530; email,
[email protected]; www.AANALearn.com.
June 1, 2016-May 10, 2019, Illinois; American
Association of Nurse Anesthetists - 1 CEC.
“AANA Learn-Neonatal Anesthesia.” American Association
of Nurse Anesthetists, Park Ridge, IL. (847) 939-3530;
email, [email protected]; www.AANALearn.com.
June 1, 2016-May 15, 2019, Illinois; American
Association of Nurse Anesthetists - 1 CEC.
“AANA Learn-Ultrasound Scanning Basics.” American
Association of Nurse Anesthetists, Park Ridge, IL.
(847) 939-3530; email, [email protected];
www.AANALearn.com.
June 1, 2016-May 15, 2019, Illinois; American
Association of Nurse Anesthetists - 2 CEC.
“CPC Module 1 - Airway Management Techniques.”
(847) 939-3530; email, [email protected];
www.AANALearn.com.
www.aana.com/aanajournalonline
June 1, 2016-May 17, 2019, Illinois; American
Association of Nurse Anesthetists 1 CEC. “AANA Learn-Jan Stewart Lecture: Empowering
Calm Through Engaged Resilience.” American Association
of Nurse Anesthetists, Park Ridge, IL. (847) 939-3530;
email, [email protected]; www.AANALearn.com.
June 13, 2016-June 12, 2018, Illinois;
American Association of Nurse
Anesthetists - 2.5 CEC. “CPC Module 2 - Applied
Clinical Pharmacology.” (847) 939-3530; email,
[email protected]; www.AANALearn.com.
June 24-25, 2016, Illinois; American
Association of Nurse Anesthetists - 15.75
CEC. “Business of Anesthesia Conference.” Sofitel
Chicago Water Tower, Chicago, IL. (847) 655-8797; email,
[email protected]; www.aana.com/meetings.
June 24-26, 2016, Alabama; Lower Alabama
Continuing Education Seminars, Inc. - 20 CEC. “2016
LACES Summer Seminar.” Perdido Beach Resort, Orange Beach, AL.
Laura Lesley, MS, 5571 Carrington Lake Pkwy, Trussville, AL 35173;
(205) 937-4139; email, [email protected]; www.Lacesinc.com.
July 11-14, 2016, Massachusetts; Northwest Seminars
- 20 CEC. “Topics in Emergency Medicine: Emphasis on
July 18-22, 2016, Oregon; Northwest Anesthesia
Seminars - 20 CEC. “Current Topics in Anesthesia.” Sunriver
Resort, Sunriver, OR. NWAS, PO Box 2797, Pasco, WA 99302;
(800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
July 25-28, 2016, Florida; Northwest Anesthesia
Seminars - 20 CEC. “Current Topics in Anesthesia.” Opal
Sands Resort, Clearwater Beach, FL. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
July 25-30, 2016, Alaska; Northwest Anesthesia
Seminars - 20 CEC. “Clinical Concerns in Anesthesia.” Celebrity
Infinity Alaska Hubbard Glacier Cruise sailing from Vancouver, BC,
Canada. NWAS, PO Box 2797, Pasco, WA 99302; (800) 222-6927;
(509) 547-7065; fax (509) 547-1265; email, [email protected];
www.nwas.com.
July 29-31, 2016, Washington DC; EverWonk, Inc.
- 20 CEC. “Topics in Anesthesia Practice.” Mayflower Hotel,
Washington, DC. Kendall Pease, 3337 Crescent Oaks Blvd., Tarpon
Springs, FL 34688; (619) 892-2467; email, [email protected];
www.everwonk.com.
August 1-4, 2016, Hawaii; Dannemiller - 24 CEC.
Pediatrics.” Sea Crest Beach Hotel, North Falmouth (Cape Cod),
MA. NWAS, PO Box 2797, Pasco, WA 99302; (800) 222-6927; email,
[email protected]; www.northwestseminars.com.
“Hawaii Anesthesiology Update 2016.” Sheraton Kaui Resort, Poipu
Beach, Koloa, HI. Barbra Thompson, 5711 Northwest Parkway, San
Antonio, TX 78249; (210) 641-8311; fax (201) 641-8329; email,
[email protected]; www.dannemiller.com.
July 11-15, 2016, Hawaii; Northwest Seminars - 20
CEC. “Current Topics in Emergency Medicine.” The Royal
August 1-5, 2016, Canada; Northwest Anesthesia
Seminars - 20 CEC. “Clinical Topics in Anesthesia.” The Rimrock
Hawaiian, Honolulu, HI. NWAS, PO Box 2797, Pasco, WA 99302;
(800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.northwestseminars.com.
Resort Hotel, Banff, Alberta, Canada. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
July 11-15, 2016, Montana; Northwest Anesthesia
Seminars - 20 CEC. “Current Anesthesia Practice.” The Lodge at
August 7-18, 2016, Amsterdam; Northwest Anesthesia
Seminars - 20 CEC. “Topics in Anesthesia.” 14 Day British Isles
Whitefish Lake, Glacier National Park, Whitefish, MT. NWAS, PO Box
2797, Pasco, WA 99302; (800) 222-6927; (509) 547-7065; fax (509)
547-1265; email, [email protected]; www.nwas.com.
July 11-16, 2016, British Columbia, Canada; Northwest
Seminars - 20 CEC. “Topics in Emergency Medicine.” Holland
America - ms Noordam, Vancouver, British Columbia, Canada.
NWAS, PO Box 2797, Pasco, WA 99302; (800) 222-6927; email,
[email protected]; www.northwestseminars.com.
July 11, 2016-July 10, 2019, Illinois; American
Association of Nurse Anesthetists - 9 CEC.
“CPC Module 3 - Human Physiology and Pathophysiology.”
(847) 939-3530; email, [email protected];
www.AANALearn.com.
July 14-17, 2016, Missouri; Northwest Anesthesia
Seminars - 20 CEC. “Current Topics in Anesthesia.” Hilton
Branson Convention Center Hotel, Branson, MO. NWAS, PO Box
2797, Pasco, WA 99302; (800) 222-6927; (509) 547-7065; fax (509)
547-1265; email, [email protected]; www.nwas.com.
July 15-17, 2016, Connecticut; Core Concepts
Anesthesia Review - 24 CEC. “Core Concepts Anesthesia
Review/Refresher Course.” The Omni Hotel at Yale, New
Haven, CT. Marianne S. Cosgrove, CRNA, DNAP, APRN, 64
Signal Hill Road, Madison, CT 06443; (203) 567-0272; email,
[email protected]; www.ccanesthesiareview.com.
July 18-21, 2016, California; Northwest Seminars - 20
CEC. “Topics in Emergency Medicine.” Disney’s Grand Californian
Hotel & Spa, Anaheim, CA. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; email, [email protected];
www.northwestseminars.com.
www.aana.com/aanajournalonline
Cruise, aboard Celebrity Silhouette, sailing from Amsterdam, The
Netherlands. NWAS, PO Box 2797, Pasco, WA 99302; (800) 222-6927;
(509) 547-7065; fax (509) 547-1265; email, [email protected];
www.nwas.com.
August 9-12, 2016, California; Northwest Anesthesia
Seminars - 24 CEC. “Relevant Topics in Anesthesia.” Hotel
Solamar, San Diego, CA. NWAS, PO Box 2797, Pasco, WA 99302;
(800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
August 15-18, 2016, North Carolina; Northwest
Anesthesia Seminars - 20 CEC. “Topics in Anesthesia.”
The Omni Grove Park Inn Resort, Asheville, NC. NWAS, PO Box
2797, Pasco, WA 99302; (800) 222-6927; (509) 547-7065; fax (509)
547-1265; email, [email protected]; www.nwas.com.
August 15, 2016-August 14, 2018, Illinois;
American Association of Nurse Anesthetists
- 3.5 CEC. “CPC Module 4 - Anesthesia Technology.”
(847) 939-3530; email, [email protected];
www.AANALearn.com.
August 16-19, 2016, Pennsylvania; Northwest
Anesthesia Seminars - 20 CEC. “Topics in Anesthesia.”
The Hershey Lodge, Hershey, PA. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
August 21-26, 2016, Washington; Northwest
Anesthesia Seminars - 20 CEC. “Clinical Concerns in
Anesthesia.” 7-Night Alaska Explorer Cruise via Glacier Bay aboard ms
Westerdam sailing from Seattle, WA. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
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August 21-27, 2016, Tennessee; Healthy Visions American School of Clinical Hypnosis, International
- 40 CEC. “Hypnosis Certification.” Healthy Visions, Clinton,
TN. Ron Eslinger, CRNA, 351 Market Street, Clinton, TN 37716;
(865) 269-4616 or toll free (866) 312-3159; email, [email protected];
www.hypnosiscertification.com.
August 22-26, 2016, Montana; Northwest Seminars
- 20 CEC. “Current Topics in Emergency Medicine.” The Lodge
at Whitefish Lake, Whitefish, MT. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.northwestseminars.com.
August 30, 2016, Florida; Gulfcoast Ultrasound
Institute - 7.25 CEC. “Ultrasound-Guided Regional Anesthesia.”
Gulfcoast Ultrasound Institute, St. Pete Beach, FL. Lori Green, 4615
Gulf Blvd Ste 205, St. Pete Beach, FL 33706; (727) 363-4500; email,
[email protected]; www.gcus.com.
September 4, 2016, Nevada; Northwest Anesthesia
Seminars - 8 CEC. “Business Concepts in Healthcare: A Practical
September 17-18, 2016, Virginia; Nurse Anesthesiology
Faculty Associates - 15 CEC. “2016 Anesthesia Crisis Resource
Management Course.” Virginia Commonwealth University, Richmond,
VA. Michael Fallacaro, PO Box 980226, Richmond, VA 23298; (804)
828-6734; email, [email protected]; http://www.nafa-va.org/.
September 17-30, 2016, Greece; Spiekermann Travel 20 CEC. “Current Issues in CRNA Practice.” Greece. Michael Rieker,
DNP, CRNA, Nurse Anesthesia Program, Medical Center Boulevard,
Winston-Salem, NC 27157; (800) 645-3233; fax (586) 775-9556;
email, [email protected]; http://www.mideasttrvl.com/.
September 19-23, 2016, Wyoming; Northwest
Anesthesia Seminars - 20 CEC. “Anesthesia Update: Emphasis
on Trauma.” Hotel Terra, Teton Village, WY. NWAS, PO Box 2797,
Pasco, WA 99302; (800) 222-6927; (509) 547-7065; fax (509)
547-1265; email, [email protected]; www.nwas.com.
September 19-29, 2016, Amersterdam; Northwest
Anesthesia Seminars - 20 CEC. “Current Topics in
Approach for Healthcare Providers.” The Cosmopolitan, Las Vegas,
NV. NWAS, PO Box 2797, Pasco, WA 99302; (800) 222-6927; (509)
547-7065; fax (509) 547-1265; email, [email protected]; www.nwas.com.
Anesthesia.” 12-Night Iberian Adventure Cruise (Holland America/
ms Koningsdam), Amsterdam, The Netherlands. NWAS, PO Box
2797, Pasco, WA 99302; (800) 222-6927; (509) 547-7065; fax (509)
547-1265; email, [email protected]; www.nwas.com.
September 5-8, 2016, Nevada; Northwest Anesthesia
Seminars - 20 CEC. “Topics in Anesthesia.” The Cosmopolitan,
September 22-25, 2016, South Carolina; Northwest
Anesthesia Seminars - 20 CEC. “Relevant Topics in
Las Vegas, NV. NWAS, PO Box 2797, Pasco, WA 99302; (800)
222-6927; (509) 547-7065; fax (509) 547-1265; email, [email protected];
www.nwas.com.
September 9, 2016, Washington, DC; American
Association of Nurse Anesthetists - 7 CEC. “Airway
on Demand Workshop.” Washington Marriott Wardman Park,
Washington, DC; (847) 655-8797; email, [email protected];
www.aana.com/meetings.
September 9, 2016, Washington, DC; American
Association of Nurse Anesthetists - 6 CEC. “Fundamentals
in Perioperative Transesophageal Echocardiogram Workshop.”
Washington Marriott Wardman Park, Washington, DC; (847)
655-8797; email, [email protected]; www.aana.com/meetings.
September 9, 2016, Washington, DC; American
Association of Nurse Anesthetists - 7 CEC. “Neuraxial
Regional Anesthesia-Epidural Workshop.” Washington Marriott
Wardman Park, Washington, DC; (847) 655-8797; email,
[email protected]; www.aana.com/meetings.
September 10, 2016, Florida; Twin Oaks Anesthesia - 8
CEC. “Twin Oaks Anesthesia 2016 Cardiac Conference.” Renaissance
Tampa International Plaza Hotel, Tampa, FL. Jonathan Kline, 26714
Winged Elm Drive, Wesley Chapel, FL 33544; (813) 857-5559; email,
[email protected]; www.twinoaksanesthesia.com.
September 10-13, 2016, Washington, DC; American
Association of Nurse Anesthetists - 25 CEC. “AANA
Nurse Anesthesia Annual Congress.” Washington Marriott Wardman
Park, Washington, DC; (847) 655-8797; email, [email protected];
www.aana.com/meetings.
September 12-16, 2016 California; Northwest
Anesthesia Seminars - 20 CEC. “Clinical Anesthesia Update.”
Tenaya Lodge, Fish Camp, CA. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
September 16-18, 2016, Alabama; Lower Alabama
Continuing Education Seminars, Inc. - 20 CEC. “2016
Anesthesia.” Westin Hilton Head Island Resort and Spa, Hilton Head
Island, SC. NWAS, PO Box 2797, Pasco, WA 99302; (800) 222-6927;
(509) 547-7065; fax (509) 547-1265; email, [email protected];
www.nwas.com.
September 24-25, 2016, Illinois; American Association
of Nurse Anesthetists - 12 CEC. “Upper and Lower Extremity
Nerve Block Workshop.” AANA Foundation Learning Center, Park
Ridge, IL. 222 S. Prospect, Park Ridge, IL 60068; (847) 655-8797;
email, [email protected]; www.aana.com/meetings.
September 26-29, 2016, Arizona; Northwest Seminars
- 20 CEC. “Topics in Emergency Medicine.” Hilton Sedona
Resort at Bell Rock, Sedona, AZ. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.northwestseminars.com.
September 26-29, 2016, California; Med City
Anesthesia Seminars - 20 CEC. “A Taste of Anesthesia in
Wine Country.” The Lodge at Sonoma Renaissance Resort & Spa,
Sonoma, CA. Karissa Goodrich, CRNA, PO Box 711, St. Charles, MN
55972; (800) 558-0217; email, [email protected];
www.medcityanesthesiaseminars.com.
September 26-29, 2016, Rhode Island; Northwest
Anesthesia Seminars - 20 CEC. “Current Topics in
Anesthesia.” Hyatt Regency Newport Hotel & Spa, Newport, RI.
NWAS, PO Box 2797, Pasco, WA 99302; (800) 222-6927; (509)
547-7065; fax (509) 547-1265; email, [email protected]; www.nwas.com.
September 30-October 2, 2016, Florida; EverWonk, Inc.
- 20 CEC. “Topic in Anesthesia Practice.” Sanibel Harbour Resort &
Spa, Fort Myers, FL. Kendall Pease, 3337 Crescent Oaks Blvd., Tarpon
Springs, FL 34688; (619) 892-2467; email, [email protected];
www.everwonk.com.
September 30-October 2, 2016, Massachusetts; Airway
Management Education Center - 18.5 CEC. “The
Difficult Airway Course: Anesthesia.” Hyatt Regency Boston, Boston,
MA. Registration Office, 333 South State Street, Suite V-324, Lake
Oswego, OR 97034; (866) 924-7929; fax (404) 795-0711; email,
[email protected]; www.theairwaysite.com.
LACES Fall Seminar.” Perdido Beach Resort, Orange Beach, AL. Laura
Lesley, MS, 5571 Carrington Lake Pkwy, Trussville, AL 35173; (205)
937-4139; email, [email protected]; www.Lacesinc.com.
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www.aana.com/aanajournalonline
October 1-15, 2016, Israel and Jordan; Spiekermann
Travel - 20 CEC. “Current Issues in CRNA Practice.” Israel
October 21-23, 2016, Kansas; Core Concepts
Anesthesia Review - 24 CEC. “Core Concepts Anesthesia
and Jordan. Michael Rieker, DNP, CRNA, Nurse Anesthesia
Program, Medical Center Boulevard, Winston-Salem, NC 27157;
(800) 645-3233; fax (586) 775-9556; email, [email protected];
http://www.mideasttrvl.com/.
Review/Refresher Course.” University of Kansas at KUMC,
Kansas City, KS. Marianne S. Cosgrove, CRNA, DNAP, APRN, 64
Signal Hill Road, Madison, CT 06443; (203) 567-0272; email,
[email protected], www.ccanesthesiareview.com.
October 3-6, 2016, Bahamas; Northwest Anesthesia
Seminars - 20 CEC. “Current Anesthesia Topics.” Atlantis
October 29-30, 2016, Illinois; American
Association of Nurse Anesthetists. “Jack Neary
October 3-6, 2016, Florida; Northwest Anesthesia
Seminars - 20 CEC. “Anesthesia Update.” Ritz Carlton Amelia
October 30-November 4, 2016, Hawaii; Northwest
Anesthesia Seminars - 20 CEC. “Anesthesia Topics.” Hyatt
Resort, Paradise Island, Bahamas. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
Advanced Pain Management Workshop Part II.” Orthopedic
Learning Center, Rosemont, IL. (847) 655-8797; email,
[email protected]; www.aana.com/meetings.
Island, Fernandina Beach, FL. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
Regency Maui, Lahaina, HI. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
October 3-6, 2016, Maine; Encore Symposiums - 21
CEC. “Autumn in Bar Harbor & Acadia National Park 2016
November 2, 2016, Illinois; American
Association of Nurse Anesthetists - 8 CEC.
October 4-12, 2016, Spain; Northwest Anesthesia
Seminars - 20 CEC. “Clinical Concerns in Anesthesia.” Celebrity
November 3-5, 2016, Illinois; American
Association of Nurse Anesthetists - 21
CEC. “Spinal and Epidural Workshop.” AANA
Anesthesia Encore Symposiums.” The Harborside Hotel, Spa & Marina
Resort, Bar Harbor, ME. Nancy LaBrie, RN, 1907 Loch Lomond Court,
Winston-Salem, NC 27106; (336) 768-9095; fax (336) 768-9055;
email, [email protected]; www.escrnas.com.
Equinox, sailing from Barcelona, Spain. NWAS, PO Box 2797, Pasco,
WA 99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265;
email, [email protected]; www.nwas.com.
October 6-9, 2016, Tennessee; Northwest Anesthesia
Seminars - 20 CEC. “Anesthesia Spectrum.” The Park Vista, a
Doubletree Hotel, Gatlinburg, TN. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
October 7-9, 2016, New Mexico; Institute For Post
Graduate Education - 15 CEC. “The Annual Balloon
Fiesta Anesthesia Meeting.” Sheraton Albuquerque Uptown
Hotel, Albuquerque, NM. Bernard Kuzava, CRNA, PO Box 28,
Hastings, MI 49058; (877) 692-0430; fax (269) 948-2507; email,
[email protected]; www.ipge.com.
October 7-9, 2016, Oregon; Oregon Association
of Nurse Anesthetists - 17 CEC. “2016 ORANA Annual
Conference.” Marriott Portland Downtown Waterfront, Portland, OR.
Evelyn Bloomhart, PO Box 4444, Salem, OR 97302; (503) 874-1105;
email, [email protected]; www.oregon-crna.org.
October 15-18, 2016, Florida; Valley Anesthesia - 20
CEC. “CE for the CRNA.” Naples Grande Beach Resort, Naples,
FL. Scott Schaus, 2583 Alpine Dr., Woodbury, MN 55125; (651)
395-0777; fax (651) 846-5034, email, [email protected];
www.valleyanesthesia.com.
October 17-20, 2016, Rhode Island; Encore
Symposiums - 21 CEC. “Newport Mansions Fall Foliage
“Essentials of Obstetric Analgesia/Anesthesia Workshop.”
AANA Foundation Learning Center, Park Ridge, IL. 222
S. Prospect, Park Ridge, IL 60068; (847) 655-8797; email,
[email protected]; www.aana.com/meetings.
Foundation Learning Center, Park Ridge, IL. 222 S.
Prospect, Park Ridge, IL 60068; (847) 655-8797; email,
[email protected]; www.aana.com/meetings.
November 3-6, 2016, Florida; Northwest Anesthesia
Seminars - 20 CEC. “Keys in Anesthesia.” Westin Resort &
Marina, Key West, FL. NWAS, PO Box 2797, Pasco, WA 99302;
(800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
November 4-6, 2016, Nevada; Airway Management
Education Center - 18.5 CEC. “The Difficult Airway
Course: Anesthesia.” Bally’s Resort Las Vegas, Las Vegas, NV.
Registration Office, 333 South State Street, Suite V-324, Lake
Oswego, OR 97034; (866) 924-7929; fax (404) 795-0711; email,
[email protected]; www.theairwaysite.com.
November 4-6, 2016, Tennessee; Focus Nurse
Anesthesia Review - 15 CEC. “The Basics and Beyond Session
1: Focus in Music City.” Sheraton Nashville Downtown Hotel,
Nashville, TN. Lindsay Studt, 5031 Timber Lake Trail, Clarkston, MI
48346; (248) 618-3481; email, [email protected]; www.focusnar.com.
November 5-6, 2016, Florida; Northwest Anesthesia
Seminars - 14 CEC. “Ophthalmic Regional Block Hands-On
Workshop.” The Hyatt Grand Cypress, Orlando, FL. NWAS, PO Box
2797, Pasco, WA 99302; (800) 222-6927; (509) 547-7065; fax (509)
547-1265; email, [email protected]; www.nwas.com.
November 5-20, 2016, India; Spiekermann Travel - 20
CEC. “Current Issues in CRNA Practice.” India. Michael Rieker,
Experience 2016 Anesthesia Encore Symposiums.” Hotel Viking,
Newport, RI. Nancy LaBrie, RN, 1907 Loch Lomond Court, WinstonSalem, NC 27106; (336) 768-9095; fax (336) 768-9055; email,
[email protected]; www.escrnas.com.
DNP, CRNA, Nurse Anesthesia Program, Medical Center Boulevard,
Winston-Salem, NC 27157; (800) 645-3233; fax (586) 775-9556;
email, [email protected]; http://www.mideasttrvl.com/.
October 17-21, 2016, Colorado; Northwest Anesthesia
Seminars - 20 CEC. “Clinical Anesthesia Update.” Gateway
November 6, 2016, Arizona; Encore Symposiums - 8
CEC. “Sedona Ultrasound Workshop 2016 by Encore Symposiums.”
Canyons Resort, Gateway, CO. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
www.aana.com/aanajournalonline
Hilton Sedona Resort at Bell Rock, Sedona, AZ. Nancy LaBrie,
RN, 1907 Loch Lomond Court, Winston-Salem, NC 27106;
(336) 768-9095; fax (336) 768-9055; email, [email protected];
www.escrnas.com.
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November 6-9, 2016, South Carolina; Wake Forest
School of Medicine - 19 CEC. “22nd Annual Advances in
November 29-December 2, 2016 Georgia; Northwest
Anesthesia Seminars - 24 CEC. “Current Topics in
Physiology & Pharmacology in Anesthesia and Critical Care.” The
Westin Hilton Head Island Resort & Spa, Hilton Head Island, SC.
Pam Martin, Medical Center Blvd., Winston-Salem, NC 27157; (336)
716-2712; Fax (336) 716-8190; email, [email protected];
www.Wakehealth.edu/anes-cme-annual-meeting.
Anesthesia.” Hyatt Regency Savannah, Savannah, GA. Anna Hilliard,
PO Box 2797, Pasco, WA 99302; (800) 222-6927; (509) 547-7065; fax
(509) 547-1265; email, [email protected]; www.nwas.com.
November 7-10, 2016, Arizona; Encore Symposiums
- 21 CEC. “Sedona Red Rock & Grand Canyon Adventure 2016
Island, Bahamas. Barbara McNulty, 1828 SE First Avenue, Ft.
Lauderdale, FL 33316; (954) 763-2233; fax (954) 762-9111; email,
[email protected]; www.nurseanesthetist.com.
Anesthesia Encore Symposiums.” Hilton Sedona Resort at Bell Rock,
Sedona, AZ. Nancy LaBrie, RN, 1907 Loch Lomond Court, WinstonSalem, NC 27106; (336) 768-9095; fax (336) 768-9055; email,
[email protected]; www.escrnas.com.
November 7-10, 2016, Florida; Institute For Post
Graduate Education - 20 CEC. “Discussions in Clinical
Anesthesia.” Westin Key West Resort & Spa, Key West, FL. Bernard
Kuzava, CRNA, PO Box 28, Hastings, MI 49058; (877) 692-0430; fax
(269) 948-2507; email, [email protected]; www.ipge.com.
November 7-10, 2016, Virginia; Nurse Anesthesiology
Faculty Associates - 22 CEC. “40th Annual Anesthesia
Conference.” Williamsburg Lodge, Williamsburg, VA. Michael
Fallacaro, PO Box 980226, Richmond, VA 23298; (804) 828-6734;
email, [email protected]; www.nafa-va.org.
November 11-13, 2016, California; University of
California, Davis Health System - 20.75 CEC. “27th
Annual UC Davis Anesthesiology Update.” Monterey Plaza Hotel,
Monterey, CA. Beng Salud, 4150 V Street, PSSB Suite 1200, Sacramento,
CA 95817; (916) 734-1574; fax (916) 734-2975; email, bsalud@
ucdavis.edu; www.ucdmc.ucdavis.edu/anesthesiology/.
November 11-13, 2016, Florida; Frank Moya
Continuing Education Programs - 20 CEC. “45th Annual
Refresher Course for Nurse Anesthetists.” Hilton Orlando Walt Disney
World Resort, Lake Buena Vista, FL. Frank Moya, MD, 1828 SE First
Ave, Ft. Lauderdale, FL 33316; (954) 763-8811; fax (954) 762-9111;
email, [email protected]; www.currentreviews.com.
November 11-13, 2016, Illinois; American
Association of Nurse Anesthetists. “2016 Fall
Leadership Academy.” Westin O’Hare Hotel, Rosemont,
IL. (847) 655-8797; email, [email protected];
www.aana.com/meetings.
November 14, 2016, Nevada; Northwest Anesthesia
Seminars - 8 CEC. “Business Concepts in Healthcare: A Practical
Approach for Healthcare Providers.” The Cosmopolitan, Las Vegas,
NV. NWAS, PO Box 2797, Pasco, WA 99302; (800) 222-6927; (509)
547-7065; fax (509) 547-1265; email, [email protected]; www.nwas.com.
November 14-18, 2016, Costa Rica; Southwest
Anesthesia and Medical Seminars - 20 CEC. “Medical
Spanish for Health Professionals.” Playa Flamingo, Guanacaste, Costa
Rica. Richard M. Saucier,CRNA, MBA, 4466 North Saddle View
Drive, Tucson, AZ 85750; (614) 582-3393; email, [email protected];
www.swamseminars.com.
November 28-December 1, 2016, Florida; Nurse
Anesthesiology Faculty Associates - 22 CEC. “35th Annual
Anesthesia Meeting.” Disney’s Yacht and Beach Club Resort, Lake
Buena Vista, FL. Michael Fallacaro, PO Box 980226, Richmond, VA
23298; (804) 828-6734; email, [email protected]; www.nafa-va.org.
November 29-December 2, 2016 California; Northwest
Anesthesia Seminars - 20 CEC. “Topics in Anesthesia.” Napa
Valley Marriott Hotel and Spa, Napa, CA. Anna Hilliard, PO Box
2797, Pasco, WA 99302; (800) 222-6927; (509) 547-7065; fax (509)
547-1265; email, [email protected]; www.nwas.com.
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December 5-8, 2016, Bahamas; International Seminars,
LLC - 20 CEC. “Nurse Anesthesia Update.” Atlantis, Paradise
December 5-9, 2016, Christiansted, St. Croix, US
Virgin Islands; Northwest Anesthesia Seminars - 20
CEC. “Applied Pharmacology Update.” The Buccaneer, Christiansted,
St. Croix, US Virgin Islands. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
December 13-16, 2016, Florida; Northwest Anesthesia
Seminars - 20 CEC. “Current Topics in Anesthesia.” Eden Roc
Miami Beach, Miami Beach, FL. NWAS, PO Box 2797, Pasco, WA
99302; (800) 222-6927; (509) 547-7065; fax (509) 547-1265; email,
[email protected]; www.nwas.com.
January 9-11, 2017, California; C & H Educational
Systems - 20 CEC. “The California Wine Country Anesthesia
Update.” The Fairmont Sonoma Mission Inn and Spa, Sonoma,
CA. Catherine Wagner, CRNA, MS, 130 Mackinaw Dr, Twin Lakes,
CO 81251; (719) 486-3558; email, [email protected];
www.homestead.com/chedusys/index.html.
January 16-20, 2017, Aruba; Frank Moya Continuing
Education Programs - 20 CEC. “Caribbean Seminar in
Anesthesiology.” Aruba Marriott Resort & Stellaris Casino, Palm Beach,
Aruba. Frank Moya, MD, 1828 SE First Ave, Ft. Lauderdale, FL 33316;
(954) 763-8811; fax (954) 762-9111; email, [email protected];
www.currentreviews.com.
February 4-10, 2017, Colorado; University of
Florida - 25 CEC. “Concepts in Anesthesiology.” Steamboat
Grand Hotel, Steamboat Springs, CO. Medical Seminars LLC, 2451
Cumberland Parkway, Suite 3366, Atlanta, GA 30339; (800) 871-0326;
fax (770) 847-8655; email, [email protected];
www.conceptsinanesthesiology.com.
February 24-26, 2017, Florida; American
Association of Nurse Anesthetists. “Assembly of
School Faculty.” Westin Beach Resort, Fort Lauderdale,
FL. (847) 655-8797; email, [email protected];
www.aana.com/meetings.
April 7-11, 2017, Washington, DC; American
Association of Nurse Anesthetists. “Mid-Year
Assembly 2017.” Renaissance Washington DC Downtown
Hotel, Washington, DC. (847) 655-8797; email,
[email protected]; www.aana.com/meetings.
September 8-12, 2017, Washington; American
Association of Nurse Anesthetists. “Nurse
Anesthesia Annual Congress.” Washington State
Convention Center, Seattle, WA. (847) 655-8797; email,
[email protected]; www.aana.com/meetings.
February 16-18, 2018, Arizona; American
Association of Nurse Anesthetists. “Assembly
of School Faculty.” The Scottsdale Resort, Scottsdale,
AZ. (847) 655-8797; email, [email protected];
www.aana.com/meetings.
www.aana.com/aanajournalonline
April 20-24, 2018, Washington, DC;
American Association of Nurse Anesthetists.
April 5-9, 2019, Washington, DC; American
Association of Nurse Anesthetists. “Mid-Year
September 21-25, 2018, Massachusetts;
American Association of Nurse Anesthetists.
“Nurse Anesthesia Annual Congress.” Hynes
August 9-13, 2019, Illinois; American
Association of Nurse Anesthetists. “Nurse
“Mid-Year Assembly 2018.” Grand Hyatt, Washington,
DC. (847) 655-8797; email, [email protected];
www.aana.com/meetings.
Convention Center, Boston, MA. (847) 655-8797; email,
[email protected]; www.aana.com/meetings.
www.aana.com/aanajournalonline
Assembly 2019.” Grand Hyatt, Washington, DC.
(847) 655-8797; email, [email protected];
www.aana.com/meetings.
Anesthesia Annual Congress.” Hyatt Regency
Chicago Hotel, Chicago, IL. (847) 655-8797; email,
[email protected]; www.aana.com/meetings.
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