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AANA J [journal]
- The role of deep neuromuscular blockade in surgical procedures. [Journal Article]
- AANA J 2013 Dec.:4-7.
- AANA Journal Course: Update for nurse anesthetists--part-4--transcatheter aortic valve replacement. [Journal Article, Review]
- AANA J 2013 Oct; 81(5):399-408.
Aortic stenosis is the most frequently acquired heart disease, and the prevalence is rising because of the aging population. If the disease is left untreated, survival in symptomatic patients averages only 2 to 3 years. Surgical aortic valve replacement is the only definitive treatment, yet 30% of elderly patients are not considered candidates because the presence of comorbidities makes the risk of sternotomy and cardiopulmonary bypass prohibitively high. Transcatheter aortic valve replacement (TAVR) is an innovative, high-tech, less invasive alternative. The procedure is usually performed using general anesthesia and a multidisciplinary team from interventional cardiology and cardiothoracic surgery in a "hybrid" operating environment with advanced imaging capabilities. There are 2 major catheter-based approaches to the aortic valve: retrograde percutaneous through the femoral artery and aorta or direct antegrade through a thoracotomy and the left ventricular apex. Apnea and rapid ventricular pacing are used to interrupt cardiac ejection during balloon valvuloplasty and prosthesis implantation. The most significant complications include vascular damage, stroke, paravalvular aortic insufficiency, and heart block. Outcomes studies comparing TAVR with medical management demonstrate improved patient survival, functional status, and quality of life. Currently TAVR is considered the treatment of choice for patients who are not surgical candidates and is a proven alternative for high-risk surgical candidates.
- Anesthetic management of a simultaneous emergency craniotomy and cesarean delivery. [Case Reports, Journal Article]
- AANA J 2013 Oct; 81(5):394-8.
Fetal heart tone monitoring is a frequently used tool during nonobstetric maternal surgery to evaluate the immediate well-being of a fetus. We present a case of a parturient requiring an emergency craniotomy, during which fetal heart tone monitoring demonstrated fetal distress patterns. A simultaneous emergency craniotomy and emergency cesarean delivery proceeded with favorable outcomes for both mother and infant. We present several issues associated with managing an emergent and concurrent maternal-fetal procedure.
- A novel approach to improving the safety of patients undergoing lumbar laminectomy. [Journal Article]
- AANA J 2013 Oct; 81(5):389-93.
The anesthesiology field has recently embraced the use of checklists to obviate the need for long-term memory, improve safety, and achieve goals and tasks. These checklists serve to increase safety, improve consumer satisfaction, and reduce mortality and morbidity. Spinal surgery with the patient lying prone is associated with complex morbidities when there is inattention to proper positioning technique. Problems arising from malpositioning of the patient undergoing spinal surgery are attributed to body habitus and the body's contact with specialized and complex operating room table frames. Common problems associated with the prone position are brachial plexus injury, cervical spine nerve injuries, and postoperative visual loss. The purpose of this research project was to examine the use of a checklist for nurse anesthetists who provide care for patients undergoing spinal surgery. The checklist addressed specific positioning needs as a means of decreasing mortality and morbidity. It is theorized that the use of a checklist will serve as a systematic aid to memory and enable the anesthetist to adhere to proper positioning techniques in this patient population and thereby improve outcomes.
- Anesthetic implications of myasthenia gravis: a case report. [Case Reports, Journal Article]
- AANA J 2013 Oct; 81(5):386-8.
Myasthenia gravis is an autoimmune neuromuscular disorder that causes the destruction and overall decrease in functional acetylcholine receptors at the neuromuscular junction. The resultant respiratory and cardiovascular implications are a primary cause of mortality; therefore, a complete and comprehensive understanding of this disorder is vital for the anesthesia provider. The case presented demonstrates the anesthetic challenges involved, with a focus on the overall approach, pharmacologic considerations, physiological changes, and an emphasis on preoperative optimization.
- Development of an amygdalocentric neurocircuitry-reactive aggression theoretical model of emergence delirium in posttraumatic stress disorder: an integrative literature review. [Journal Article, Review]
- AANA J 2013 Oct; 81(5):379-84.
The purposes of this integrative literature review were to (1) present a synopsis of current literature describing posttraumatic stress disorder (PTSD), the amygdalocentric neurocircuitry, emergence delirium, reactive aggression, and the interaction of general anesthetics and the amygdalocentric neurocircuitry; (2) synthesize this evidence; and (3) develop a new theoretical model that can be tested in future research studies. Over the past decade, a dramatic rise in PTSD among veterans has been reported because of recent combat deployments. Modern anesthetics alter the function of the amygdalocentric neurocircuitry to produce amnesia and sedation. The etiology of emergence delirium is poorly understood, and the condition is uncommon outside the pediatric population. Emergence delirium among patients with PTSD, however, has been reported by military nurse anesthetists. To date, there have been no scientific studies conducted to identify the cause of emergence delirium in combat veterans with PTSD. This new theoretical model may explain why noxious stimuli at the time of emergence may stimulate the thalamus, leading to activation of an uninhibited amygdalocentric neurocircuitry. Because of the loss of top-down inhibition, the hyperactive amygdala then stimulates the hypothalamus, which is responsible for creating an increase in excitatory activity in the unconscious patient, resulting in emergence delirium.
- Anesthetic management of a patient with congenital insensitivity to pain: a case report. [Case Reports, Journal Article]
- AANA J 2013 Oct; 81(5):376-8.
Pain protects the body from damaging effects of harmful stimuli. Congenital insensitivity to pain is a rare inherited disorder characterized by diminished or absent sensitivity to pain, touch, and pressure that leads to frequent trauma and self-mutilation. The disorder is part of the hereditary sensory and autonomic neuropathy (HSAN) family, in which 5 types have been recognized. Research and case reports of anesthetic risks and analgesic needs of these patients is limited due to the infrequent nature of the disorder. Recommendations for anesthesia include modification of intraoperative opioid requirements, use of anesthetics to ensure cooperation and immobility, and intraoperative temperature monitoring. It is imperative for anesthesia providers to understand which type of HSAN their patient experiences and to conduct a thorough preoperative interview because a different interpretation of sensory loss may occur in each HSAN category. This article reports the case of a patient with HSAN type 2 who presented for knee arthroscopy.
- Use of a left-sided double-lumen endotracheal tube in a patient with a prior left pneumonectomy. [Case Reports, Journal Article]
- AANA J 2013 Oct; 81(5):369-75.
A 77-year-old man, 7 years after left pneumonectomy, was scheduled for a right upper pulmonary lobectomy. The early identification of a newly developing carcinoma on the right upper pulmonary lobe warranted surgical resection. Right exploratory thoracotomy, pleural lysis, partial pleurectomy, and right upper lobe wedge resection were completed, and the patient was discharged without sequelae. This case report describes the intraoperative anesthetic management of a right upper lobe wedge resection and attributes the uneventful intraoperative outcome to a strategically and skillfully placed left double-lumen endotracheal tube.
- Impact of goal-directed perioperative fluid management in high-risk surgical procedures: a literature review. [Journal Article, Review]
- AANA J 2013 Oct; 81(5):357-68.
Guidelines for the perioperative administration of fluid are often based on static hemodynamic targets such as central venous pressure, and delayed volume status indexes such as blood pressure, heart rate, capillary refill, and urine output. Traditional fluid management protocols also rely heavily on algorithmic estimates of fluid deficit, intravascular fluid volume status, fluid loss, and basal fluid requirements to guide perioperative fluid administration. Such formulaic approaches lack definitive physiologic endpoints for determining fluid optimization and fail to address the roles of tissue oxygenation and end-organ perfusion in achieving positive long-term patient outcomes. Recent advances in hemodynamic monitoring have produced sophisticated dynamic measures of volume status, such as stroke volume variation and pulse pressure variation, which may serve as functional indexes for perioperative fluid administration. This article reviews randomized controlled trials measuring the impact of perioperative goal-directed therapy on outcomes among patients undergoing high-risk surgical procedures. A broad literature search was conducted, and 12 studies met the inclusion criteria. Studies were evaluated for design, population, goal-directed therapy targets, monitoring devices used, clinical endpoints, methods, and results. Goal-directed therapy was associated with decreased hospital stay compared with the control group (in 7 studies) and reduced number of postoperative complications (7 studies).