Category: Opioid Free Anesthesia

Categories
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 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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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 Enhanced Recovery After Surgery Opioid Free Anesthesia Pharmacology Regional Anesthesia

#42 – Opioid Free Anesthesia with Tom Baribeault, DNP, CRNA & Jayme Reuter, MS, CRNA

This episode was originally released on From the Head of the Bed on March 3, 2019 and recorded in Scottsdale, Arizona. Tom Baribeault, DNP, CRNA and Jayme Reuter, MS, CRNA talk with me about opioid free anesthesia.

We discuss the progression to opioid free anesthesia (OFA), where OFA fits into enhanced recovery programs and the specific techniques of how to provide a comfortable, opioid-free perioperative experience for our patients.

Find out more about the Society for Opioid Free Anesthesia, including a resource-filled members-only section of their website which includes overviews of pharmacological alternatives to opioids and specific opioid-free anesthetic plans.

At the time of this recording, Tom Baribeault was the Chief CRNA at Lexington Surgery Center in Lexington, Kentucky. He completed his anesthesia training at Case Western Reserve University. Tom has a passion for teaching anesthesia providers and others on opioid-free anesthesia, enhanced recovery after surgery, ultrasound guided regional anesthesia and point of care ultrasound. He is the president and founder of the Society for Opioid Free Anesthesia and is a member of the American Association of Nurse Anesthetists and the Kentucky Association of Nurse Anesthetists. Since this recording, Tom completed his Doctor of Nursing Practice

Jayme Reuter, MS, CRNA is the Program Director and founder of Cornerstone Anesthesia Conferences. She completed her anesthesia training at Baylor College of Medicine and practices at Houston Methodist Hospital, which is part of Texas Medical Center. She created Cornerstone Anesthesia Conferences in 2017 with a mission to be the foundation for excellence in continuing anesthesia education.

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Clinical Tips Opioid Free Anesthesia Outpatient Anesthesia Pharmacology Preparing for Grad School/Residency Regional Anesthesia

#41 – Regional Anesthesia with Shane Garner, MS, CRNA, NSPM-C

This episode was originally released in April of 2020 on From the Head of the Bed… a podcast for the anesthesia community and is being re-released on 5 September 2021 on Anesthesia Guidebook.

In this episode, I speak with Shane Garner, MS, CRNA, NSPM-C about an introduction & overview of regional anesthesia. We discuss:

  • opioid-free anesthesia
  • how to gain experience in regional anesthesia as a SRNA or CRNA
  • fellowships in pain management available to CRNAs
  • the Non-Surgical Pain Management (NSPM) board examination
  • how to start a block program and gain surgeon buy-in
  • Exparel (bupivacaine liposome injectable suspension)
  • when to use regional anesthesia catheters and more!
Shane Garner, MS, CRNA, NSPM-C

Shane Garner is a CRNA who works in Ripon, Wisconsin and is passionate about teaching anesthesia providers on personal finance as well as regional anesthesia.  He has a Bachelor of Science in Nursing from the University of Minnesota and graduated from Rosalind Franklin University with his Master of Science in Nurse Anesthesia in 2012.  He went on to complete a fellowship in Advanced Pain Management at the University of South Florida before becoming board certified in Nonsurgical Pain Management through the NBCRNA. Shane is an adjunct faculty member at the University of Alabama at Birmingham’s nurse anesthesia program and regularly instructs with Twin Oaks Anesthesia & Cornerstone Anesthesia Conferences.

Resources:

University of South Florida Advanced Pain Management Fellowship

NBCRNA Non-Surgical Pain Management Board Exam

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Clinical Tips Enhanced Recovery After Surgery Opioid Free Anesthesia Pharmacology Regional Anesthesia

#13 – Perioperative Buprenorphine Management with Aurora Quaye, MD

Aurora Quaye, MD is an anesthesiologist who specializes in regional anesthesia and pain medicine at Maine Medical Center in Portland, Maine. She completed her residency at Massachusetts General Hospital and a fellowship in Regional Anesthesia at Brigham and Women’s Hospital.  Dr. Quaye’s clinical interests include decreasing the use of opioids for pain management, in improving provider education on non-opioid analgesic strategies, and in identifying analgesic techniques that decrease the potential for opioid misuse, dependence and addiction.  Dr Quaye has led committees to establish institutional guidelines for perioperative continuation of buprenorphine at analgesic dosing for patients with history of Opioid Use Disorder. These guidelines have been incorporated in acute pain management protocols at Massachusetts General Hospital and Maine Medical Center.  This change from the prior practice of discontinuing buprenorphine has shown early promise in facilitating postoperative pain relief while limiting opioid prescribing. 

Resources:

Quaye, A. N. A., et. al. (2020) Perioperative Continuation of Buprenorphine at Low–Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation, Pain Medicine, Volume 21, Issue 9, Pages 1955–1960, https://doi.org/10.1093/pm/pnaa020

Quaye, A. N. A., & Zhang, Y. (2019). Perioperative management of buprenorphine: solving the conundrum. Pain Medicine, 20(7), 1395-1408.

Ward, E. N., Quaye, A. N. A., & Wilens, T. E. (2018). Opioid use disorders: perioperative management of a special population. Anesthesia and analgesia, 127(2), 539.

Anderson, T. A., Quaye, A. N., Ward, E. N., Wilens, T. E., Hilliard, P. E., & Brummett, C. M. (2017). To Stop or Not, That Is the QuestionAcute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology: The Journal of the American Society of Anesthesiologists, 126(6), 1180-1186.

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Opioid Free Anesthesia Pharmacology

#2 – Dexmedetomidine – Matt Poirier, MSNA, CRNA

Matt Poirier, MSNA, CRNA joins Anesthesia Guidebook to give a run down on dexmedetomidine. We cover the pharmacology & dosing right off the bat in this episode and then we take some time to discuss the art of using dexmedetomidine peri-operatively.

Matt Poirier is a Certified Registered Nurse Anesthetist at Maine Medical Center, a level 1 trauma center in Portland, Maine.  He obtained his Bachelor of Science in nursing from the University of Southern Maine and his Master of Science in nurse anesthesia from the University of New England.  Prior to Matt’s nursing career, he attended Assumption College in Worcester Massachusetts and obtained a Bachelor of Arts in biology and chemistry and subsequently worked as both an analytic and synthetic chemist.

References

Kaur, M., & Singh, P. M. (2011). Current role of dexmedetomidine in clinical anesthesia and intensive care. Anesthesia, essays and researches, 5(2), 128. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173414/.

Liu, Y., Liang, F., Liu, X., Shao, X., Jiang, N., & Gan, X. (2018). Dexmedetomidine reduces perioperative opioid consumption and postoperative pain intensity in neurosurgery: a meta-analysis. Journal of neurosurgical anesthesiology, 30(2), 146-155.

McEvoy, M. D., Scott, M. J., Gordon, D. B., Grant, S. A., Thacker, J. M., Wu, C. L., & … Miller, T. E. (2017). American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1–from the preoperative period to PACU. Perioperative Medicine, 61. doi:10.1186/s13741-017-0064-5

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