Tag: pharmacology

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

Podcast: Play in new window | Download

Categories
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

Podcast: Play in new window | Download

Categories
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.

Podcast: Play in new window | Download

Categories
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.

Podcast: Play in new window | Download

Categories
Clinical Tips Pharmacology Preparing for Grad School/Residency

#48 – IV Induction Agents with Ashley Scheil, 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, Ashley walks us through an overview of the most common IV anesthesia induction agents. We cover propofol, ketamine, etomidate, barbiturates (e.g. methohexital), dexmedetomidine and benzodiazepines (e.g. midazolam). A run down of the mechanism of action, dosing, onset, metabolism and physiologic effects are provided. This is an excellent introduction to these common medications and how to utilize them as part of a routine IV induction of anesthesia.

Ashley Scheil earned her BSN from Purdue University in 2012. She worked as a critical care Registered Nurse in the surgical ICU at the Roudebush VA Medical Center in Indianapolis for 6 years before going back to anesthesia school to earn her DNP at Marian University in May of 2020. Dr Scheil, DNP, CRNA practices anesthesia at IU Health Arnett Hospital as of September 2021.

Resources

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

Cohen, L., Athaide, V., Wickham, M. E., Doyle-Waters, M. M., Rose, N. G., & Hohl, C. M. (2015). The effect of ketamine on intracranial and cerebral perfusion pressure and health outcomes: a systematic review. Annals of emergency medicine, 65(1), 43-51.

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

Morris, C., Perris, A., Klein, J., & Mahoney, P. (2009). Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?. Anaesthesia, 64(5), 532-539.

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

Podcast: Play in new window | Download

Categories
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.

Podcast: Play in new window | Download

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

Podcast: Play in new window | Download

Categories
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.

Podcast: Play in new window | Download

Categories
Clinical Tips Leadership in Emergencies Pharmacology

#23 – Serotonin Syndrome with Trent & Katie Bishop, CRNAs

Today my guests are Trent and Katie Bishop, a CRNA couple who practice independently and live in Durango, Colorado.  We’re going to talk about serotonin syndrome and cases that both Trent and Katie have recently experienced as providers in their practice.

Trent & Katie Bishop are CRNAs practicing independently in Durango, Colorado.

Trent has a background in biology and EMS prior to pursuing a career as a critical care Registered Nurse and now as a CRNA.  He has prior work experience at level 1 & level 2 trauma centers working in open heart and vascular surgery.  He currently enjoys working as a independent CRNA in a small surgical hospital in Durango, Colorado.  One of the things he has truly come to love about anesthesia in a rural environment is seeing his patients out in the community and knowing he did a small thing to make their lives better.

Katie has been a Registered Nurse since 2004 when she started out working on a high acuity inpatient floor before transitioning to the medical ICU in 2006.  She considers it the best experience anyone could have asked for prior to anesthesia as she ran the code team for meany years and floated & worked in other ICUs, as well.  She has worked as a CRNA at level 1 & 2 trauma centers for several years.  She absolutely loves independent  practice and regional anesthesia and is actively engaged in expanding her regional anesthesia practice.  She writes, “Aside from loving medicine and anesthesia, I absolutely adore my family and my time with our toddler, Jackson, Trent, and our furbabies (2 dogs and 1 cat).  Durango is the best place for us to be with all of the snowboarding, camping, hiking, rafting, and travel. It’s even better when friends and family come to visit.”

References

Altman, C. S., & Jahangiri, M. F. (2010). Serotonin syndrome in the perioperative period. Anesthesia & Analgesia, 110(2), 526-528.  doi: 10.1213/ANE.0b013e3181c76be9

Berger, M., Gray, J. A., & Roth, B. L. (2009). The expanded biology of serotonin. Annual review of medicine, 60, 355-366. https://doi.org/10.1146/annurev.med.60.042307.110802

Frazer A, Hensler JG. Serotonin Involvement in Physiological Function and Behavior. In: Siegel GJ, Agranoff BW, Albers RW, et al., editors. Basic Neurochemistry: Molecular, Cellular and Medical Aspects. 6th edition. Philadelphia: Lippincott-Raven; 1999. Available from: https://www.ncbi.nlm.nih.gov/books/NBK27940/

Harper Juanillo, E., Chambliss, LR. (2018). Amniotic Fluid Embolism: Clinical Challenges and Diagnostic Dilemmas. J Pediatric Women’s Healthcare. 1(2): 1012.

Wang, R. Z., Vashistha, V., Kaur, S., & Houchens, N. W. (2016). Serotonin syndrome: preventing, recognizing, and treating it. Cleve Clin J Med, 83(11), 810-7. doi:10.3949/ccjm.83a.15129

Podcast: Play in new window | Download

Categories
Anesthesia Education Clinical Tips Pharmacology Preparing for Grad School/Residency

#19 – Anesthesia Top Drawer Run Down – Part 3

The Top Drawer Run Down is a 3-part series covering the 39 most commonly administered intravenous medications in anesthesia. These medications are often found in the top drawer of anesthesia carts in the United States. The Top Drawer Run Down was originally posted on From the Head of the Bed… a podcast for the anesthesia community in September of 2019.

Michael Mielniczek, MSN, CRNA joins me to deliver the run down on these medications. Michael has a deep interest in pharmacology and completed his anesthesia training with a Master’s in Nursing from the University of Scranton in 2018. He joined me on Episode 3 of Anesthesia Guidebook for a deep dive into succinylcholine, a medication that was the focus of his graduate degree research. He has spoken at state CRNA conferences on succinylcholine, as well as at the national AANA Annual Congress.

We cover the following medications in this series:

Part 1:

  • Propofol
  • Etomidate
  • Ketamine
  • Lidocaine
  • Fentanyl
  • Morphine
  • Hydromorphone
  • Remifentanil
  • Sufentanil
  • Alfentanil
  • Succinylcholine
  • Rocuronium
  • Vecuronium
  • Cisatracurium

Part 2:

  • Atropine
  • Glycopyrrolate
  • Neostigmine
  • Sugammadex
  • Metoprolol
  • Labetalol
  • Esmolol
  • Hydralazine
  • Phenylephrine
  • Ephedrine
  • Epinephrine
  • Calcium Chloride

Part 3:

  • Heparin
  • Naloxone
  • Albuterol
  • Dexamethasone
  • Famotidine
  • Ondansetron
  • Haloperidol
  • Furosemide
  • Metoclopramide
  • Ketorolac
  • Oxytocin
  • Methylergonovine
  • Carboprost

Here is the Anesthesia Guidebook Top Drawer Run Down Study Guide:

Anesthesia-Guidebooks-Top-Drawer-Run-Down-Study-GuideDownload

The information provided in this series is as accurate as possible but mistakes can happen. It is your responsibility to consult experienced healthcare providers, up-to-date published text books and peer reviewed literature before making decisions to implement information you hear in podcasts, blogs and social media posts, including Anesthesia Guidebook. Dig deep, do your homework and own your practice. Your practice is your responsibility.

Resources:

Assante, J., Collins, S., & Hewer, I. (2015). Infection Associated With Single-Dose Dexamethasone for Prevention of Postoperative Nausea and Vomiting: A Literature Review. AANA journal, 83(4).

Katzung, B. G. (2017). Basic and clinical pharmacology. McGraw-Hill Education.

Miller, R. D., et. al. (2014). Miller’s Anesthesia. Elsevier Health Sciences.

Nagelhout, J. J., Elisha, S., & Plaus, K. (2013). Nurse anesthesia. Elsevier Health Sciences.

Ouellette, R., & Joyce, J. (Eds.). (2010). Pharmacology for nurse anesthesiology. Jones & Bartlett Publishers.

Rezai, S., Hughes, A. C., Larsen, T. B., Fuller, P. N., & Henderson, C. E. (2017). Atypical amniotic fluid embolism managed with a novel therapeutic regimen. Case reports in obstetrics and gynecology, 2017.

Tubog, T. D., Kane, T. D., & Pugh, M. A. (2017). Effects of ondansetron on attenuating spinal anesthesia-induced hypotension and bradycardia in obstetric and nonobstetric subjects: a systematic review and meta-analysis. AANA Journal, 85(2), 113-122.

Podcast: Play in new window | Download

Categories
Anesthesia Education Clinical Tips Pharmacology Preparing for Grad School/Residency

#18 – Anesthesia Top Drawer Run Down – Part 2

The Top Drawer Run Down is a 3-part series covering the 39 most commonly administered intravenous medications in anesthesia. These medications are often found in the top drawer of anesthesia carts in the United States. The Top Drawer Run Down was originally posted on From the Head of the Bed… a podcast for the anesthesia community in September of 2019.

Michael Mielniczek, MSN, CRNA joins me to deliver the run down on these medications. Michael has a deep interest in pharmacology and completed his anesthesia training with a Master’s in Nursing from the University of Scranton in 2018. He joined me on Episode 3 of Anesthesia Guidebook for a deep dive into succinylcholine, a medication that was the focus of his graduate degree research. He has spoken at state CRNA conferences on succinylcholine, as well as at the national AANA Annual Congress.

We cover the following medications in this series:

Part 1:

  • Propofol
  • Etomidate
  • Ketamine
  • Lidocaine
  • Fentanyl
  • Morphine
  • Hydromorphone
  • Remifentanil
  • Sufentanil
  • Alfentanil
  • Succinylcholine
  • Rocuronium
  • Vecuronium
  • Cisatracurium

Part 2:

  • Atropine
  • Glycopyrrolate
  • Neostigmine
  • Sugammadex
  • Metoprolol
  • Labetalol
  • Esmolol
  • Hydralazine
  • Phenylephrine
  • Ephedrine
  • Epinephrine
  • Calcium Chloride

Part 3:

  • Heparin
  • Naloxone
  • Albuterol
  • Dexamethasone
  • Famotidine
  • Ondansetron
  • Haloperidol
  • Furosemide
  • Metoclopramide
  • Ketorolac
  • Oxytocin
  • Methylergonovine
  • Carboprost

Here is the Anesthesia Guidebook Top Drawer Run Down Study Guide:

Anesthesia-Guidebook’s-Top-Drawer-Run-Down-Study-GuideDownload

The information provided in this series is as accurate as possible but mistakes can happen. It is your responsibility to consult experienced healthcare providers, up-to-date published text books and peer reviewed literature before making decisions to implement information you hear in podcasts, blogs and social media posts, including Anesthesia Guidebook. Dig deep, do your homework and own your practice. Your practice is your responsibility.

Resources:

Brull, S. J., & Kopman, A. F. (2017). Current Status of Neuromuscular Reversal and Monitoring Challenges and Opportunities. Anesthesiology: The Journal of the American Society of Anesthesiologists, 126(1), 173-190.

Katzung, B. G. (2017). Basic and clinical pharmacology. McGraw-Hill Education.

Lauria, M.  (2018)  Emergency reflex action drills.  EmCrit RACC. Retrieved from https://emcrit.org/emcrit/emergency-reflex-action-drills/

Miller, R. D., et. al. (2014). Miller’s Anesthesia. Elsevier Health Sciences.

Nagelhout, J. J., Elisha, S., & Plaus, K. (2013). Nurse anesthesia. Elsevier Health Sciences.

Ouellette, R., & Joyce, J. (Eds.). (2010). Pharmacology for nurse anesthesiology. Jones & Bartlett Publishers.

Podcast: Play in new window | Download

Categories
Anesthesia Education Clinical Tips Pharmacology Preparing for Grad School/Residency

#17 – Anesthesia Top Drawer Run Down – Part 1

The Top Drawer Run Down is a 3-part series covering the 39 most commonly administered intravenous medications in anesthesia. These medications are often found in the top drawer of anesthesia carts in the United States. The Top Drawer Run Down was originally posted on From the Head of the Bed… a podcast for the anesthesia community in September of 2019.

Michael Mielniczek, MSN, CRNA joins me to deliver the run down on these medications. Michael has a deep interest in pharmacology and completed his anesthesia training with a Master’s in Nursing from the University of Scranton in 2018. He joined me on Episode 3 of Anesthesia Guidebook for a deep dive into succinylcholine, a medication that was the focus of his graduate degree research. He has spoken at state CRNA conferences on succinylcholine, as well as at the national AANA Annual Congress.

We cover the following medications in this series:

Part 1:

  • Propofol
  • Etomidate
  • Ketamine
  • Lidocaine
  • Fentanyl
  • Morphine
  • Hydromorphone
  • Remifentanil
  • Sufentanil
  • Alfentanil
  • Succinylcholine
  • Rocuronium
  • Vecuronium
  • Cisatracurium

Part 2

  • Atropine
  • Glycopyrrolate
  • Neostigmine
  • Sugammadex
  • Metoprolol
  • Labetalol
  • Esmolol
  • Hydralazine
  • Phenylephrine
  • Ephedrine
  • Epinephrine
  • Calcium Chloride

Part 3

  • Heparin
  • Naloxone
  • Albuterol
  • Dexamethasone
  • Famotidine
  • Ondansetron
  • Haloperidol
  • Furosemide
  • Metoclopramide
  • Ketorolac
  • Oxytocin
  • Methylergonovine
  • Carboprost

Here is the Anesthesia Guidebook Top Drawer Run Down Study Guide:

Anesthesia-Guidebook’s-Top-Drawer-Run-Down-Study-GuideDownload

The information provided in this series is as accurate as possible but mistakes can happen. It is your responsibility to consult experienced healthcare providers, up-to-date published text books and peer reviewed literature before making decisions to implement information you hear in podcasts, blogs and social media posts, including Anesthesia Guidebook. Dig deep, do your homework and own your practice. Your practice is your responsibility.

Resources:

Çoruh, B., Tonelli, M. R., & Park, D. R. (2013). Fentanyl-induced chest wall rigidity. Chest, 143(4), 1145-1146.

Katzung, B. G. (2017). Basic and clinical pharmacology. McGraw-Hill Education.

Miller, R. D., et. al. (2014). Miller’s Anesthesia. Elsevier Health Sciences.

Nagelhout, J. J., Elisha, S., & Plaus, K. (2013). Nurse anesthesia. Elsevier Health Sciences.

Ouellette, R., & Joyce, J. (Eds.). (2010). Pharmacology for nurse anesthesiology. Jones & Bartlett Publishers.

Panchal, A. R., et. al. (2018).  2018 American Heart Association focused update on advanced cardiovascular life support use of antiarrhythmic drugs during and immediately after cardiac arrest.  Circulation, 138(23), e740-e749.    Retrieved from https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000613. 

Podcast: Play in new window | Download

Categories
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.

Podcast: Play in new window | Download

Categories
Pharmacology

#3 – Succinylcholine – Michael Mielniczek, BSN, SRNA

This episode on succinylcholine will unravel the mysteries and controversies around the medication – from it’s molecular shape and how that influences which receptors subtypes and locations it exerts its effects on to practical information on dosing and how to optimize airway management while mitigating the side effects of succinylcholine. 

At the time of this recording in March of 2018, Michael was a second-year Student Registered Nurse Anesthetist at the University of Scranton and a student representative for the AANA Foundation.  He has since passed his boards as a CRNA and began his anesthesia practice in the greater Boston area. His background includes experience as a cardiac critical care Registered Nurse in Austin, Texas.   As part of his graduate studies, Michael completed an in-depth project regarding the history, latest research and controversies surrounding succinylcholine. Michael has presented on succinylcholine at state association conferences and went on to give a podium presentation at the 2018 AANA Annual Congress in Boston titled “Succinylcholine:  From Discovery to Current Evidence for Everyday Practice.” 

Resources:

Alvarellos, M. L., McDonagh, E. M., Patel, S., McLeod, H. L., Altman, R. B., & Klein, T. E. (2015). PharmGKB summary: succinylcholine pathway, pharmacokinetics/pharmacodynamics. Pharmacogenetics and genomics, 25(12), 622.

Barash, P. G. (Ed.). (2009). Clinical anesthesia. Lippincott Williams & Wilkins.

Fukano, N., Suzuki, T., Ishikawa, K., Mizutani, H., Saeki, S., & Ogawa, S. (2011). A randomized trial to identify optimal precurarizing dose of rocuronium to avoid precurarization-induced neuromuscular block. Journal of anesthesia, 25(2), 200-204.

Lee, C. (2003). Conformation, action, and mechanism of action of neuromuscular blocking muscle relaxants. Pharmacology & therapeutics, 98(2), 143-169.

Nagelhout, J. J., & Plaus, K. L. (2014). Nurse anesthesia. Elsevier Health Sciences.

Miller, R. D. (2015). Miller’s anesthesia (8th ed.). Philadelphia, PA: Churchill Livingstone/Elsevier.

Schreiber, J. U., Lysakowski, C., Fuchs-Buder, T., & Tramer, M. R. (2005). Prevention of Succinylcholine-induced Fasciculation and MyalgiaA Meta-analysis of Randomized Trials. Anesthesiology: The Journal of the American Society of Anesthesiologists, 103(4), 877-884.

Tran, D. T., Newton, E. K., Mount, V. A., Lee, J. S., Wells, G. A., & Perry, J. J. (2015). Rocuronium versus succinylcholine for rapid sequence induction intubation. The Cochrane Library.

Podcast: Play in new window | Download

Categories
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

Podcast: Play in new window | Download