Category: Human Physiology and Pathophysiology

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Airway Anesthesia Education Anesthesia Equipment and Technology Cardiac Case Studies Clinical Tips Enhanced Recovery After Surgery Human Physiology and Pathophysiology Leadership in Emergencies Outpatient Anesthesia Pharmacology Preparing for Grad School/Residency

#104 – At-home cardiorespiratory events following ambulatory surgery – Chuck Biddle, PhD, CRNA

Chuck Biddle PhD, CRNA is a Professor Emeritus of anesthesiology at Virginia Commonwealth University and served as the editor in chief of the AANA Journal for 35 years.  His anesthesia education & master’s degree are from Old Dominion University and he completed his PhD in Epidemiology at the University of Missouri.  

Chuck is one of my favorite people in the world of anesthesiology.  He’s one of those folks who have put the time in over decades to develop a true, deep mastery of their profession while at the same time bringing with them a level of authenticity, integrity and humility that garners true respect.  He’s a guide.  He’s helped countless physician & nurse anesthesiology trainees develop and gain a love of the work we do.  And one of the central focuses of his career has been fervently working to understand the things that put our patients at risk and develop research and insights for practice to advance patient safety.

Which brings us to this show.  

In this episode, Dr Biddle turns our attention to what happens to patients after they go home from day surgery.  We talk about a study his team did at VCU where they sent patients home with pulse oximeter monitors and tracked their course for 48 hours following day surgery. 

We talk how novel this idea is in that very few studies have actually looked at what happens to patients following ambulatory surgery and that a certain segment of these patients – those who have obstructive sleep apnea are at particular risk for devastating postoperative complications.  Chuck points to Jonathan Benumof’s, MD 2016 article in the Canadian Journal of Anesthesia titled Mismanagement of patients with obstructive sleep apnea may result in finding these patients dead in bed (full article below).  Dr Benumof is a world-renowned physician anesthesiology and expert in airway management and pulmonary physiology. He is a professor of anesthesiology at the University of California – San Diego’s School of Medicine. Over the 15 years prior to the publication of Dr Benumof’s article in which he served as an expert witness in litigation cases, he testified on 12 cases where OSA patients died within 48 hours of surgery.  In  the article, he unpacks each of those cases and provides the following prototypical dead in bed OSA patient:

“A 58-yr-old continuous positive airway pressure (CPAP)-compliant male (170 cm, 120 kg, body mass index 40 kgm-2) with polysomnography (PSG)-proven severe OSA undergoes orthopedic, upper airway, or abdominal surgery under general anesthesia. The patient has an uncomplicated stay in the postanesthesia care unit until discharged to an unmonitored bed without CPAP or oxygen. After receiving small (and within standard of care) doses of narcotics for pain for 11 hr, the patient is found DIB [dead in bed]. Advanced cardiac life support is either not attempted or fails to return the patient to their baseline state of life (Benumof, 2016).”

This episode is one of those discussions that makes you see the work you do in a whole new light and gives you a renewed sense of ownership over making sure you and your colleagues are doing the right thing for your patients.  This show is coming out on 28 January 2024 and was originally recorded at VCU’s studio with a table top microphone back in the summer of 2017.  I apologize that the audio is a little hazy but the power of Dr Biddle’s research and passion for this topic are still very much relevant to providers today.  So with that, let’s get to the show!

Benumof, J. L. (2016). Mismanagement of obstructive sleep apnea may result in finding these patients dead in bed. Canadian Journal of Anesthesia, 63(1), 3.Download

Benumof, J. L. (2015). The elephant in the room is bigger than you think: finding obstructive sleep apnea patients dead in bed postoperatively. Anesthesia & Analgesia, 120(2), 491.

Hill, M. V., Stucke, R. S., McMahon, M. L., Beeman, J. L., & Barth Jr, R. J. (2018). An educational intervention decreases opioid prescribing after general surgical operations. Annals of surgery, 267(3), 468-472.

Biddle, C., Elam, C., Lahaye, L., Kerr, G., Chubb, L., & Verhulst, B. (2021). Predictors of at-home arterial oxygen desaturation events in ambulatory surgical patients. Journal of Patient Safety, 17(3), e186-e191. 

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Anesthesia Education Clinical Tips Enhanced Recovery After Surgery Human Physiology and Pathophysiology Opioid Free Anesthesia Pharmacology

#103 – Dexmedetomidine Deep Dive with Eliana Zimmerman

What’s up folks! This is Jon Lowrance with Anesthesia Guidebook and this is episode 103… a deep dive on dexmedetomidine with Eliana Zimmerman. This episode is coming out on January 21, 2024.

Before we get to the show I want to remind folks that I’ll be speaking in person at the Encore Symposiums’ Autumn in Bar Harbor & Acadia National Park conference running October 14-17 of this year. If you have never been to Maine, this is a great excuse to make it up here. And even if you have been or if you live here in vacationland… there’s scarcely a better place to be than Bar Harbor in October. It’s absolutely stunning. Peak leaf season usually hits in October for Bar Harbor, which is a coastal village just outside the entrance to Acadia National Park. Just google those key words… Acadia National Park – October. Or peak leaf season Bar Harbor. Then sign up for the conference ASAP because this one usually sells out quick. It’s Encore Symposiums’ Autumn in Bar Harbor & Acadia National Park conference, running October 14-17. I’m looking forward to bringing fresh perspectives on what’s new in anesthesia, pharmacology, ERAS, airway management & more for this conference. You’ll also get to meet a bunch of my friends & crew from Maine Medical Center, as this is one our team’s favorite conferences to attend… it’s close to home and has absolutely breath-taking scenery. I hope to see you there!

This is the second show I’ve done specific to dexmedetomidine… you’d have to go back a full 100 episodes… way back to episode #2 for the other show, which I did with Matt Poirier who I continue to work alongside at Maine Medical Center.

In this show, Eliana Zimmerman joins me to unpack the literature on perioperative use of dexmedetomidine, specifically focusing on the clinical impacts of dexmedetomidine in colorectal surgery.

As part of her doctorate research at Northeastern University, Eliana completed a series of expert panel inquires, synthesized with current literature, to arrive at recommendations for best practice concerning the use of dexmedetomidine in colorectal surgery. Her infographic and resources are provided in the show notes.

Eliana Zimmerman graduated Wesleyan University with a degree in Neuroscience in 2017, and University of Pennsylvania with a degree in Nursing in 2018. She worked as an ICU nurse at Jefferson Methodist Hospital from 2019 – 2022. She is currently a nurse anesthesia doctoral student at Northeastern University with an anticipated graduation of May 2025. In her limited free time she likes to backpack, run, and spend time outdoors. Her fiancé, two cats, and dog have kept her sane during the long days of anesthesia training.  

References

Chen, C., Huang, P., Lai, L., Luo, C., Ge, M., Hei, Z., Zhu, Q., & Zhou, S. (2016). Dexmedetomidine improves gastrointestinal motility after laparoscopic resection of colorectal cancer: A randomized clinical trial. Medicine (Baltimore), 95(29), e4295–e4295. https://doi.org/10.1097/MD.0000000000004295

Chen, H., & Li, F. (2020). Effect of Dexmedetomidine with Different Anesthetic Dosage on Neurocognitive Function in Elderly Patients After Operation Based on Neural Network Model. World Neurosurgery, 138, 688–695. https://doi.org/10.1016/j.wneu.2020.01.012

Cheung, C. W., Qiu, Q., Ying, A. C. L., Choi, S. W., Law, W. L., & Irwin, M. G. (2014). The effects of intra‐operative dexmedetomidine on postoperative pain, side‐effects and recovery in colorectal surgery. Anaesthesia, 69(11), 1214–1221. https://doi.org/10.1111/anae.12759

Ge, D.-J., Qi, B., Tang, G., & Li, J.-Y. (2015). Intraoperative Dexmedetomidine Promotes Postoperative Analgesia in Patients After Abdominal Colectomy: A Consort-Prospective, Randomized, Controlled Clinical Trial. Medicine (Baltimore), 94(37), e1514–e1514. https://doi.org/10.1097/MD.0000000000001514  

He, G.-Z., Bu, N., Li, Y.-J., Gao, Y., Wang, G., Kong, Z.-D., Zhao, M., Zhang, S.-S., & Gao, W. (2022). Extra Loading Dose of Dexmedetomidine Enhances Intestinal Function Recovery After Colorectal Resection: A Retrospective Cohort Study. Frontiers in Pharmacology, 13, 806950–806950. https://doi.org/10.3389/fphar.2022.806950

Lu, Y., Fang, P.-P., Yu, Y.-Q., Cheng, X.-Q., Feng, X.-M., Wong, G. T. C., Maze, M., & Liu, X.-S. (2021). Effect of Intraoperative Dexmedetomidine on Recovery of Gastrointestinal Function After Abdominal Surgery in Older Adults A Randomized Clinical Trial. JAMA Network Open, 4(10), e2128886–e2128886. https://doi.org/10.1001/jamanetworkopen.2021.28886

Qi, Y.-P., Ma, W.-J., Cao, Y.-Y., Chen, Q., Xu, Q.-C., Xiao, S., Lu, W.-H., & Wang, Z. (2022). Effect of Dexmedetomidine on Intestinal Barrier in Patients Undergoing Gastrointestinal Surgery–A Single-Center Randomized Clinical Trial. The Journal of Surgical Research, 

Sun, W., Li, F., Wang, X., Liu, H., Mo, H., Pan, D., Wen, S., & Zhou, A. (2021). Effects of Dexmedetomidine on Patients Undergoing Laparoscopic Surgery for Colorectal Cancer. The Journal of Surgical Research, 267, 687–694. https://doi.org/10.1016/j.jss.2021.06.043

Tang, Y., Liu, J., Huang, X., Ding, H., Tan, S., & Zhu, Y. (2021). Effect of Dexmedetomidine-Assisted Intravenous Inhalation Combined Anesthesia on Cerebral Oxygen Metabolism and Serum Th1/Th2 Level in Elderly Colorectal Cancer Patients. Frontiers in Surgery, 8, 832646–832646. https://doi.org/10.3389/fsurg.2021.832646

Xu, B., Li, Z., Zhou, D., Li, L., Li, P., & Huang, H. (2017). The influence of age on sensitivity to dexmedetomidine sedation during spinal anesthesia in lower limb orthopedic surgery. Anesthesia & Analgesia, 125(6), 1907-1910. https://doi.org/10.1213/ANE.0000000000002531

Zhang, J., Liu, G., Zhang, F., Fang, H., Zhang, D., Liu, S., Chen, B., & Xiao, H. (2019). Analysis of postoperative cognitive dysfunction and influencing factors of dexmedetomidine anesthesia in elderly patients with colorectal cancer. Experimental and Therapeutic Medicine, 18(3), 3058–3064. https://doi.org/10.3892/ol.2019.10611


If you want to dive deeper, recommended reading:

  1. Ischemia Reperfusion Injury:
    1. “Pathophysiology of Reperfusion Injury”  https://www.ncbi.nlm.nih.gov/books/NBK534267/#:~:text=Ischaemia%2DReperfusion%20injury%20(IRI),essential%20to%20salvage%20ischaemic%20tissues
  2. Postoperative pain and the Gut Microbiome
    1. Brenner, Shorten, & Mahony 2021

DNP Reference Tools

  1. AGREE II 
    1. Overview
      1. https://www.ncbi.nlm.nih.gov/books/NBK525667/
    1. Manual
      1. https://www.agreetrust.org/resource-centre/agree-ii/
  2. United States Preventive Service Task Force Grading
    1. Methods:
      1. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes
    1. Grading System
      1. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/grade-definitions
  3. Modified Delphi Technique Assessment of Appropriateness
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299905/
Dexmedetomidine-InfographicDownload
Zimmerman-E-Narrative-1Download

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Anesthesia Education Anesthesia Equipment and Technology Cardiac Clinical Tips Human Physiology and Pathophysiology

#101 – EKG Lead Selection for Perioperative Monitoring – Mark Kossick, DNSc, CRNA

This is an incredibly special podcast that I’m thrilled to pull forward from our old show, From the Head of the Bed, to Anesthesia Guidebook.

I love that this episode is number 101 because EKG lead selection should be 101-level knowledge for anesthesia providers, yet so many folks have not mastered this fundamental knowledge as part of their practice. I hope you get as much from this as I have over the years.

Dr Mark Kossick was a full professor of anesthesia at Western Carolina University when my wife, Kristin, and I attended the program and he actually just retired in late 2023 from that university. Kristin arranged for Dr Kossick to contribute his expertise to this podcast while we were still in the program back in early 2015 and this episode was released as one of the original group of podcasts that launched From the Head of the Bed that year.

Dr Kossick will give a more detailed introduction of his professional background at the start of this show – and, I’m thrilled to have Kristin’s voice on the podcast with all her pre-Mainer southern drawl – as she introduces him. Dr Kossick was known as an incredibly challenging yet supportive professor. His area of expertise was intra-operative monitoring and the uptake and distribution of volatile anesthetics. He had a passion for the many beautiful curves of the science of anesthesia, whether it was the oxyhemoglobin dissociation curve, the Fa/Fi curve or one of the many other curves that define the science behind what we do every day. Kristin and I and so many other CRNAs from WCU, the University of Alabama at Birmingham and others have learned so much from Dr Kossick and consider ourselves fortunate to have sat in and survived his classes.

This is an incredibly thorough review of the very basics of EKG lead placement, selection and monitoring for anesthesia care. This is a skill and knowledge set that, unfortunately, many anesthesia providers and perioperative nursing staff overlook and blaze past. As Dr Kossick says in the show, simply having a EKG pattern on the screen from careless placement of EKG leads is not enough for safe monitoring. Dr Kossick walks us through the core data on EKG monitoring, including some modified leads, so this show is excellent for both trainees and experienced providers alike.

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Human Physiology and Pathophysiology Pharmacology Preparing for Grad School/Residency

#98 – A Deep Dive on Ketorolac with Elisabeth Stewart, MSN, MSNA, CRNA

Elisabeth Stewart, MSN, MSNA, CRNA focused her Master of Science in Nurse Anesthesia project on the pharmacology of Toradol (ketorolac) and she’s here today to tell us all about it.

Elisabeth hails from Wisconsin, holds a BS in Mathematics with a pre-med concentration and engaged in HeLa cell cancer research prior to going to nursing school.  She received a Master of Science in Nursing degree at the University of Wisconsin – Milwaukee, where she worked in a transplant ICU while completing her Clinical Nurse Leader degree and certification.  Elisabeth followed that with her Master of Nurse Anesthesia degree at the University of New England and received the UNE Outstanding Student Award for her class. Her primary clinical site in training was Maine Medical Center in Portland, Maine. When Elisabeth showed up for day one of clinical, I was serving as the SRNA Clinical Coordinator and by the time she was completing her training, I was a year into my new role as Chief CRNA at Maine Medical Center. Elisabeth was one of the best SRNAs we’ve had roll through Maine Med in years and brought a degree of professionalism, conscientiousness and excellence in clinical care that inspired confidence in her practice and reallllly made me try to recruit her as a clinical staff. As it is, she’s chosen to start her career closer to family in Massachusetts and I wish her the absolute best moving forward.

I think you’re really going to enjoy hearing Elisabeth walk through the pharmacokinetics and pharmacodynamics of ketorolac with specific focus on the risk (or lack thereof) of bleeding with the use of ketorolac. Elisabeth focused primarily on the risk of bleeding in adult breast surgery patients. She reviewed 27 research articles to boil down what the literature says about the role of ketorolac in perioperative bleeding risk in breast surgery patients. Her full write up is attached in the show notes to this episode. And with that, let’s get to the show!

Careers at Maine Medical Center:

If you’re interested in joining our team at Maine Medical Center, reach out to me at Jon.Lowrance@mainehealth.org or apply for one of our CRNA positions in Portland, Maine at https://www.mainehealth.org/careers-job-opportunities

References

•Afonso, A., Oskar, S., Tan, K.S., Disa, J. J., Mehrara, B. J., Ceyhan, J., & Dayan, J. H. (2017). Is enhanced recovery the new standard of care in microsurgical breast reconstruction? Plastic and Reconstructive Surgery,139(5), 1053-61. https://doi.org/10.1097/PRS.0000000000003235.

•Barkho, J. O., Li, Y. K., Duku, E., & Thoma, A. (2018). Ketorolac may increase hematoma risk in reduction mammaplasty: A case-control study. PRS Global Open, 6, 1-5. https://doi.org/10.1097/GOX.0000000000001699

•Blomqvist, L, Sellman, G., & Strömbeck, J. O. (1996). NSAID as pre- and postoperative medication —a potential risk for bleeding complications in reduction mammaplasty. European Journal of Plastic Surgery 19, 26–8. 

•Bongiovanni, T., Lancaster, E., Ledesma, Y., Whitaker, E., Steinman, M. A., Allen, I. E., Auerbach, A., & Wick, L. (2021). A systematic review and meta-analysis of the association between non-steroidal anti-inflammatory drugs and surgical bleeding in the perioperative period. Journal of the American College of Surgeons, 232(5), 765-90. https://doi.org/10.1016/j.jamcollsurg.2021.01.005.

•Cawthorn, T. R., Phelan, R., Davidson, J. S., & Turner, K. E. (2012). Retrospective analysis of perioperative ketorolac and postoperative bleeding in reduction mammoplasty. Canadian Journal of Anaesthesia, 59(5), 466-72. https://doi.org/10.1007/s12630-012-9682-z.

•Conrad, K. A., Fagan, T. C., Mackie, M. J., & Mayshar, P. V. (1988). Effects of ketorolac tromethamine on hemostasis in volunteers. Clinical Pharmacology & Therapeutics, 43(5), 542-546.

•Corsini, E. M., Zhou, N., Antonoff, M. B., Mehran, R. J., Rice, D. C., Roth, J. A., Sepesi, B., Swisher, S. G., Vaporciyan, A. A., Walsh, G. L., & Hofstetter, W. L. (2021). Postoperative bleeding and acute kidney injury in esophageal cancer patients receiving ketorolac. Annals of Thoracic Surgery, 111, 1111-7. https://doi.org/10.1016/j.athoracsur.2020.07.028.

•Dowbak G. (1992). Personal experiences with Toradol. Plastic and Reconstructive Surgery, 89(6), 1183. https://doi.org/10.1097/00006534-199206000-00051.

•Firriolo, J. M., Nuzzi, L. C., Schmidtberg, L. C., & Labow, B. I. (2018). Perioperative ketorolac use and postoperative hematoma formation in reduction mammoplasty: A single-surgeon experience of 500 consecutive cases. Breast, 142(5), 632e-8e. https://doi.org/10.1097/PRS.0000000000004828.

•Garcha, I. S., & Bostwick, J. (1991). Postoperative hematomas associated with Toradol. Plastic and Reconstructive Surgery, 88(5), 919-20. https://doi.org/10.1097/00006534-199111000-00050.

•Gobble, R. M., Hoang, H. L., Kachniarz, B., & Orgill, D. P. (2014). Ketorolac does not increase perioperative bleeding: A meta-analysis of randomized controlled trials. Plastic and Reconstructive Surgery, 133(3), 741-55. https://doi.org/10.1097/01.prs.0000438459.60474.b5

•Gupta, A. K., & Parker, B. M. (2020). Bleeding after a single dose of ketorolac in a postoperative patient. Cureus, 12(6), 1-6. https://doi.org/10.7759/cureus.8919

•Klifto, K. M., Elhelali, A., Payne, R. M., Cooney, C. M., Manahan, M. A., & Rosson, G. D. (2021). Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery. Cochrane Database of Systematic Reviews 2021(11), 1-3. https://doi.org/10.1002/14651858.CD013290.pub2.

•Lexicomp. (n.d.). Ketorolac: Drug information. UpToDate. Retrieved September 14, 2022, from https://online-lexi-com.une.idm.oclc.org/lco/action/doc/retrieve/docid/patch_f/1797828?cesid=6fX6XGxK6EG&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dketorolac%26t%3Dname%26acs%3Dtrue%26acq%3Dketorolac#fbnlist

•Macario, A., & Lipman, A. G. (2001). Ketorolac in the era of cyclo-oxygenase-2 selective nonsteroidal anti-inflammatory drugs: A systematic review of efficacy, side effects, and regulatory issues. Pain Medicine, 2(4), 336-51. https://doi.org/10.1046/j.1526-4637.2001.01043.x.

•Majumdar, J. R., Assel, M. J., Lang, S. A., Vickers, A. J., & Afonso, A. M. (2022) Implementation of an enhanced recovery protocol in patients undergoing mastectomies for breast cancer: an interrupted time-series design. Asia-Pacific Journal of Oncology Nursing, 9, 1-5. https://doi.org/10.1016/j.apjon.2022.02.009

•Martinez, L., Ekman, E., & Nakhla, N. (2019). Perioperative opioid-sparing strategies: Utility of conventional NSAIDs in adults. Clinical Therapeutics, 14(12), 2612-28. https://doi.org/10.1016/j.clinthera.2019.10.002

•Maslin, B., Lipana, L., Roth, B., Kodumudi, G., & Vadivelu, N. (2017). Safety considerations in the use of ketorolac for postoperative pain. Current Drug Safety, 12, 67-73. https://doi.org/10.2174/1574886311666160719154420

•McCormick, P. J., Assel, M., Van Zee, K. J., Vickers, A. J., Nelson, J. A., Morrow, M., Tokita, H. K., Simon, B. A., & Twersky, R. S. (2021). Intraoperative ketorolac is associated with risk of reoperation after mastectomy: A single-center examination. Annals of Surgical Oncology, 28(9), 5134-40. https://doi.org/10.1245/s10434-021-09722-4.

•McNicol, E. D., Ferguson, M. C, & Schumann, R. (2021). Single-dose intravenous ketorolac for acute postoperative pain in adults. Cochrane Database of Systematic Reviews, 5, 1-91. https://doi.org/10.1002/14651858.CD013263.pub2

•Mikhaylov, Y., Weinstein, B., Schrank, T. P., Swartz, J. D., Ulm, J. P., Armstrong, M. B., & Delaney, K. O. (2018). Ketorolac and hematoma incidence in postmastectomy implant-based breast reduction. Annals of Plastic Surgery, 80(5), 472-474. https://doi.org/10.1097/SAP.0000000000001409

•Motov, S., Yasavolian, M., Likourezos, A., Pushkar, I., Hossain, R., Drapkin, J., … & Fromm, C. (2017). Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Annals of emergency medicine, 70(2), 177-184.

•Nguyen, B. N., Barta, R. J., Stewart, C. E., & Heinrich, C. A. (2018). Toradol following breast surgery: Is there an increased risk of hematoma? Plastic and Reconstructive Surgery Journal, 141(6), 814e-7e. https://doi.org/10.1097/PRS.0000000000004361

•O’Neill, R. C., Hayes, K. D., & Davidson, S. P. (2019). Safety of postoperative opioid alternatives in plastic surgery: A systematic review. Plastic and Reconstructive Surgery Journal, 144(4). 991-9. https://doi.org/10.1097/PRS.0000000000006074

•Rojas, K. E., Fortes, T. A., Flom, P., Manasseh, D. M., Andaz, C., & Borgen, P. (2019). Intraoperative ketorolac use does not increase the risk of bleeding in breast surgery. Annals of Surgical Oncology, 26, 3368-73. https://doi.org/10.1245/s10434-019-07557-8

•Sharma, S., Chang, D.W., Koutz, C., Evans, G. R., Robb, G. L., Langstein, H. N., & Kroll, S. S. (2001). Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction. Plastic and Reconstructive Surgery, 107(2), 352-5. https://doi.org/ 10.1097/00006534-200102000-00009.

•Singer, A. J., Mynster, C. J., & McMahon, B. J. (2003). The effect of IM ketorolac tromethamine on bleeding time: A prospective, interventional, controlled study. American Journal of Emergency Medicine, 21(5), 441-3. https://doi.org/10.1016/S0735-6757(03)00100-1

•Stephens, D. M., Richards, B. G., Schleicher, W. F., Zins, J. E., Langstein, H. N. (2015). Is ketorolac safe to use in plastic surgery? A critical review. Aesthetic Surgery Journal, 35(4), 462-6. https://doi.org/10.1093/asj/sjv005

•Strom, B. L., Berlin, J. A., Kinman, J. L., Spitz, P. W., Hennessy, S., Feldman, H., Kimmel, S., & Carson, J. L. (1996). Parenteral ketorolac and risk of gastrointestinal and operative site bleeding: A postmarketing surveillance study. JAMA, 275(5), 376–82.

•Tan, P., Martin, M., Shank, N., Myers, L., Wolfe, E., Lindsey, J., & Metzinger, S. (2017). A comparison of four analgesic regimens for acute postoperative pain control in breast augmentation patients. Annals of Plastic Surgery, 78(6), S299-304. https://doi.org/10.1097/SAP.0000000000001132.

•Walker, N. J., Jones, V. M., Kratky, L., Chen, H., & Runyan, C. M. (2019). Hematoma risks of nonsteroidal anti-inflammatory drugs used in plastic surgery procedures: A systematic review and meta-analysis. Annals of Plastic Surgery, 82(5), S437-45. https://doi.org/10.1097/SAP.0000000000001898

•Wick, E., Grant, M. C., Wu, C. L. (2017). Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: A review. Journal of the American Medical Association Surgery, 152(7), 691-7. https://doi.org/10.1001/jamasurg.2017.0898

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Airway Anesthesia Equipment and Technology Clinical Tips Human Physiology and Pathophysiology Leadership in Emergencies Pharmacology Trauma

#87 – Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA – Part 2

What’s up yall this is Jon Lowrance with Anesthesia Guidebook.  I am so pumped to bring you this series of 3 episodes on Combat Trauma Anesthesia!  

This is episode 87 and it’s part 2 off a three-part series with Dustin Degman, a CRNA formerly with the United States Army.

In the first episode, we discussed Dustin’s experience in Afghanistan serving at a forward operating base in Paktika Province in 2012 to 2013.  We talk about what makes up forward surgical teams and the role of CRNAs as the sole anesthesia provider on these teams.

In this part – part two, we discuss the principles of damage control resuscitation in the context of forward surgical bases and combat zones. While this discussion is focused on combat trauma anesthesia, the core underlying principles of damage control resuscitation hold true for civilian trauma centers.

And then in part three, we’re gonna come back and talk about the path to becoming a military CRNA and the importance of supporting our troops.  

This series was originally recorded in early 2015, just a year or so after Dustin had returned from Afghanistan and while the war there was still raging.  At the time, I was completing my anesthesia training at Western Carolina University and working on launching From the Head of the Bed… the podcast the preceded Anesthesia Guidebook.  Dustin was one of my professors and clinical faculty at WCU and was kind enough to volunteer his time for these interviews back then.  The reason I’m bringing them forward here is that they’re chock full of wildly fantastic details on the experience of a forward-deployed military anesthesia provider and the principles of trauma anesthesia, which are absolutely relevant today.

Dustin served with the Unites States Air Force from 1998 – 2002 as a critical care Registered Nurse.  He was honorably discharged and went on to complete his anesthesia training outside of the military.  In 2010, he re-enlisted with the Army Reserves as a CRNA and was deployed in November 2012 to Forward Operating Base Orgun-E in Paktika Province, Afghanistan where he was the sole anesthesia provider on a forward surgical team providing damage control resuscitation to injured soldiers.  Most recently, Dustin serves as the chief CRNA at PeaceHealth’s Peace Harbor Medical Center in Florence, Oregon.  In 2021, Dustin was awarded the PeaceHealth Mission & Values award and the organization put together an incredible video tribute to Dustin.  Degman is the real deal… he was the real deal a decade ago when he was serving in Paktika Province, Afghanistan, which he talks about in these next 3 episodes and he’s still the real deal as he serves as a CRNA with Peace Harbor Medical Center out on the coast of Oregon.

I think you’re going to really enjoy hearing from Dustin on combat trauma anesthesia and with that, let’s get to the show!

To close each of these 3 episodes out, I’d like to encourage you to make a donation to the Pat Tillman Foundation in honor of Army Ranger Pat Tillman who was killed in Afghanistan in 2004.  The Pat Tillman Foundation awards academic scholarships to military service members, veterans and their spouses.  Dustin Degman identified this as one of the several service organizations that he believes in and encourages you to give to either the Pat Tillman Foundation or an organization you connect with.  If we each give $10-20, our collective impacts will make a huge difference.

Resources:

#83 – Positive Deviance as a Catalyst for Change with Cherie Burke, DNP, CRNA

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Anesthesia Education Clinical Tips Human Physiology and Pathophysiology Opioid Free Anesthesia Pharmacology Regional Anesthesia

#85 – The McLott Mix – Part 2 with Jason McLott, MSN, CRNA

Jason McLott, MSN, CRNA developed a mix of medications for doing opioid-free anesthesia that came to be know as the McLott Mix. It’s a combination of dexmedetomidine, lidocaine, ketamine and magnesium.

Jason is clear that the McLott Mix helps achieve opioid-free anesthesia, not opioid-free analgesia, recognizing the role of opiates, if needed, in post-operative analgesia plans.

Jason completed his anesthesia training at Oakland University’s Beaumont Nurse Anesthesia program and works in a CRNA-only practice at Blue Ridge Hospital in rural North Carolina. He regularly mentors SRNAs from Western Carolina University, giving them exposure to a CRNA-only practice, extensive regional anesthesia experience and opioid-free anesthesia techniques. Jason also instructs regional anesthesia courses with Twin Oaks Anesthesia.

If you’ve followed Anesthesia Guidebook for any amount of time, you’ll probably remember that Western Carolina University is my alma mater. I would highly recommend WCU as a premier school for becoming a CRNA. The faculty & clinical sites are top notch and you can’t beat the location down in Asheville, North Carolina.

In Part 1 of this conversation, we talked about Jason’s background, what led him to get into opioid-free anesthesia and the details of the McLott Mix and how he suggests it be used. In Part 2 of our conversation, we come back to talk in more detail on the nuances of how Jason uses the McLott Mix in his practice and how providers can instigate change in moving their practices and groups towards opioid-free anesthesia. Part 2 is a prime example of what Randy Moore & Desirée Chappell & I talked about in episode 82 on change management in healthcare. Hopefully these 2 shows with Jason McLott get you thinking about real ways that you can build opioid-free techniques into your anesthesia practice.

Schenkel, L., Vogel Kahmann, I., & Steuer, C. (2022). Opioid-Free Anesthesia: Physico Chemical Stability Studies on Multi-Analyte Mixtures Intended for Use in Clinical Anesthesiology. Hospital pharmacy, 57(2), 246-252.

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Anesthesia Education Clinical Tips Enhanced Recovery After Surgery Human Physiology and Pathophysiology Opioid Free Anesthesia Outpatient Anesthesia Pharmacology Preparing for Grad School/Residency Regional Anesthesia

#84 – The McLott Mix – Part 1 with Jason McLott, MSN, CRNA

Jason McLott, MSN, CRNA developed a mix of medications for doing opioid-free anesthesia that came to be know as the McLott Mix. It’s a combination of dexmedetomidine, lidocaine, ketamine and magnesium. In this episode, Mr McLott himself unpacks the story of the mix’s development, efficacy and principles for opioid-free anesthesia. He’s clear that this mix helps achieve opioid-free anesthesia, not opioid-free analgesia, recognizing the role of opiates, if needed, in post-operative analgesia plans.

Jason completed his anesthesia training at Oakland University’s Beaumont Nurse Anesthesia program and works in a CRNA-only practice at Blue Ridge Hospital in rural North Carolina. He regularly mentors SRNAs from Western Carolina University, giving them exposure to a CRNA-only practice, extensive regional anesthesia experience and opioid-free anesthesia techniques. Jason also instructs regional anesthesia courses with Twin Oaks Anesthesia.

If you’ve followed Anesthesia Guidebook for any amount of time, you’ll probably remember that Western Carolina University is my alma mater. I would highly recommend WCU as a premier school for becoming a CRNA. The faculty & clinical sites are top notch and you can’t beat the location down in Asheville, North Carolina.

In Part 1 of this conversation, we talk about Jason’s background, what led him to get into opioid-free anesthesia and the details of the McLott Mix and how he suggests it be used. In Part 2 of our conversation, we come back to talk in more detail on the nuances of how Jason uses the McLott Mix in his practice and how providers can instigate change in moving their practices and groups towards opioid-free anesthesia. Part 2 is a prime example of what Randy Moore & Desirée Chappell & I talked about in episode 82 on change management in healthcare. Hopefully these 2 shows with Jason McLott get you thinking about real ways that you can build opioid-free techniques into your anesthesia practice.

Schenkel, L., Vogel Kahmann, I., & Steuer, C. (2022). Opioid-Free Anesthesia: Physico Chemical Stability Studies on Multi-Analyte Mixtures Intended for Use in Clinical Anesthesiology. Hospital pharmacy, 57(2), 246-252.

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Anesthesia Education Anesthesia Equipment and Technology Human Physiology and Pathophysiology Preparing for Grad School/Residency Wellness

#71 – Thrive in Training: destroying didactics with Jenny Finnell, MSN, CRNA

Jenny Finnell, MSN, CRNA joins me to talk about how anesthesia trainees can master the didactic phase of their training. We cover lots of tips in this show: everything from how to make challenging content stick to how to get organized, which apps & resources are helpful and how to maintain mental wellbeing during anesthesia training.

This episode will help you dial in your plan for success in didactics. Our goal is for you to thrive and not just survive in school. The volume of information you have to master is immense and the learning curve is incredibly steep, especially when you begin to integrate clinical training into your journey. Creating early success in didactics is key to progressing in anesthesia school.

There’s 3 domains of knowledge in any kind of training:

  • the know-what
  • the know-why and 
  • the know-how.

The know-what is the core information, principles & facts.  

The know-why is understanding the situationally-specific rationales for actions & processes.

And the know-how is where we learn to put the know-what & the know-why into practice: it’s the experiential, practical application of knowledge. 

The didactic portion of training is where we pick up most of the know-what.  What you need to know is learned by studying, being taught, reading, watching video & listening to lectures & podcasts.  It’s here where we also learn a lot of the know-why: the rationales behind why we do things the way we do them in anesthesia.  You’re only able to develop the art of anesthesia if you have a solid foundation in the science of anesthesia.  Learning the know-how: the actual mechanics and flow of putting everything together, the timing & art of anesthesia is learned best by doing… especially when that experiential education is under the guidance of a skilled preceptor, clinical coach or mentor.  

Jenny Finnell, MSN, CRNA runs the CRNA School Prep Academy, which is a mentoring and professional coaching community designed for those who want to pursue a career as a CRNA.  Her team offers a blog, podcast and public & private forums as well as individualized coaching for every phase of preparing for anesthesia training.  She’s active on Facebook & Instagram if you want to see what the CRNA School Prep Academy is all about or you can certainly cruise over to her website at CRNAschoolprepacademy.com. 

Resources:

The CRNA School Prep Academy Ultimate Resource Guide:

…this is Jenny Finnell’s Six-Page Free Resource Guide. In it, she lists the best podcasts, YouTube channels, apps, websites, books related to anesthesia, studying/learning, grad school interviews and professional resources.

Chipas, A., & McKenna, D. (2011). Stress and burnout in nurse anesthesia. AANA journal, 79(2).

Vargo Anesthesia Mega App. This is an incredibly thorough app covering run downs on surgeries, pathological conditions, pharmacology and detailed weight-based guides to pediatric anesthesia. While you have to pay for this app, the cost is definitely worth what you get.

Master Anesthesia app in App Store: check out the story from app creator Matthew Willis in Episode 38 of Anesthesia Guidebook. This app is FREE and growing in its scope of surgeries & medications but rolled out with a phenomenal calculator for quickly seeing max doses of multiple local anesthetics.

Writing in the Sciences: FREE course on professional/scientific writing from Stanford University. Take this course to improve your professional writing.

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Clinical Tips Human Physiology and Pathophysiology Opioid Free Anesthesia Pharmacology Preparing for Grad School/Residency Regional Anesthesia

#49 – Local Anesthetics with Skyler Rouhselang, BSN, SRNA

This episode was originally published in April 2019 on From the Head of the Bed… a podcast for the anesthesia community. In this podcast, Skyler provides a thorough overview of local anesthetics including relevant anatomy and physiology (i.e. nerve fibers, sodium channels, pKa, etc), types of local anesthetics and factors that effect onset, potency, duration of action and absorption. We touch on methemoglobinemia, Local Anesthetic Systemic Toxicity (LAST) and common dosing and max dosing for local anesthetics. This is a great run down for anyone wanting to brush up on local anesthetics!

At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a level 1 trauma center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. Skyler has married and changed her name to Skyler Williams, DNP, CRNA. As of September 2021, Dr Williams practices anesthesia as a CRNA at IU Health Arnett Hospital in Lafayette, IN.

Resources

Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. 

Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.

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Clinical Tips Human Physiology and Pathophysiology Pharmacology Preparing for Grad School/Residency

#47 – Pharmacodynamics of Volatile Anesthetics with Skyler Rouhselang, BSN, SRNA

This episode was originally released in April 2019 on From the Head of the Bed… a podcast for the anesthesia community.  In this podcast, Skyler walks us through the pharmacodynamics of volatile anesthetics. We talk extensively about the concepts related to minimum alveolar concentration (MAC), the mechanism of action of volatile anesthetics and the physiologic response to volatiles. You don’t want to miss this excellent overview of core anesthesia concepts!

At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a level 1 trauma center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. Skyler has married and changed her name to Skyler Williams, DNP, CRNA. As of September 2021, Dr Williams practices anesthesia as a CRNA at IU Health Arnett Hospital in Lafayette, IN.

References

Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. 

Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.

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Categories
Clinical Tips Human Physiology and Pathophysiology Pharmacology Preparing for Grad School/Residency

#46 – Pharmacokinetics of Volatile Anesthetics with Skyler Rouhselang, BSN, SRNA

This episode was originally released in April 2019 on From the Head of the Bed… a podcast for the anesthesia community. In this podcast, Skyler gives a succinct run down on the pharmacokinetics of volatile anesthetics. We talk about uptake, distribution, elimination and metabolism and unpack concepts such as blood gas solubility, oil gas solubility, Fa/Fi curves and more. You don’t want to miss this excellent overview of core anesthesia concepts!

At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a level 1 trauma center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. Skyler has married and changed her name to Skyler Williams, DNP, CRNA. As of September 2021, Dr Williams practices anesthesia as a CRNA at IU Health Arnett Hospital in Lafayette, IN.

References

Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.

Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier. 

Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences

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