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UND Nurse Anesthesia Anesthe c Management & Student Presenta ons Considera ons of the Pediatric 2015 Fall Educa onal Mee ng Pa ent with an Atrial Septal Defect North Dakota Associa on of Nurse Anesthe sts Bismarck, ND Luke Schumacher, SRNA
Introduc on
• Congenital Heart Disease – 40,000 children diagnosed with CHD yearly, 10% of that number have an Atrial Septal Defect (ASD) McEwan, 2013 – Most common ASD is known as a Secundum ASD • Pathophysiology of ASD DiNardo et al., 2011 – Le -to-right shunt is most common – Symptoms vary due to size, site and direc on of the shunt flow – Symptoms can be undetected due to acyano c characteris cs Geva et al., 2014
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Case Informa on Case Informa on
• Surgical Procedure: Nasal adenoidectomy and bilateral ear • PSH: None exam • Male, 17 months • Medica ons: Tylenol PRN • 11.5kg • Pre-op labs: none • NKDA • ASA 1 • Pre-op vital signs: • PMH: ASD (diagnosed 2 days a er birth), resolved – BP: 88/42 pneumonia, pulmonary hemorrhage, persistent pulmonary – hypertension of the newborn (PPHN), respiratory distress, HR: 110 sepsis, feeding difficul es – RR: 26 • Imagining: Day 2 Echo showing moderate secundum ASD, – T: 36.7 Day 6 Echo showing a small-moderate secundum ASD (~3mm) – SaO2: 100
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Case Informa on Anesthe c Course
• Airway evalua on: • Technique: GETA – Mallampa I – Mask Induc on: Sevoflurane 8% and Oxygen 8L/ min – Neck: Full ROM • IV start- 24 ga. – Den on: intact, none missing or loose – LR at 42ml/hr (case total: 100ml) – Fentanyl 15 mcg IV • Per nent review of systems: – Ondansetron 1mg IV – No report of SOB, orthopnea, or “blue spells” at – Dexamethasone 2 mg IV the me of surgery • 4.5 cuffed ETT inserted with Mac 2 x 1 a empt – S1S2, RRR, absent for murmurs – Maintenance: • Sevoflurane 2.4%, oxygen 1.5 L/min, and air 1.5 L/min
Anesthe c Course Discussion
• Emergence • Determinates of flow direc on between atrium: – Deep extuba on with sevoflurane 2.4% and – Size of the ASD oxygen 8L/min – SVR – Transferred to PACU with blow by oxygen 6L/min – PVR – PACU: uneven ul x 1 hour then discharged home – Ventricular Compliance – Flow ul mately determined by the right and le atrial pressure gradient – Anesthesia can have a great effect on SVR and PVR
Discussion Discussion
• Recommend IV induc on for a symptoma c • Induc on agents: ASD – Goal: to maintain hemodynamic stability – Propofol and Thiopental: May cause myocardial • Mask induc on may lead to: depression and vasodila on McEwan, 2013 – hypoven la on → hypoxemia → increased – Opioids in conjunc on with pancuronium DiNardo et al., 2011 pulmonary pressure → increased shunt – Ketamine (1mg/kg – 2 mg/kg): Minimal change in PVR DiNardo et al., 2011 – Etomidate: Short-ac ng, minimal effect on BP, HR, and CO DiNardo et al., 2011 – Key Point: Decreased SVR and/or an increased PVR will lead to increased right-to-le shunt flow DiNardo et al., 2011
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Discussion Discussion
• Maintenance: Avoidance of Nitrous Oxide – Fentanyl or sufentanil, sevoflurane or • Nitrous oxide is 34 mes more soluble than benzodiazepine • Cau on: synergis c effects may reduce SVR nitrogen • Expansion of nitrogen increases size of air emboli • Inhaled anesthe cs: DiNardo et al., 2011 – Sevoflurane: ideal agent: minimal myocardial • Avoidance of air entry through IV effect, minimal hypotension and minimal – Me culous set up of IV tubing, syringes, and the bradycardia DiNardo et al., 2011 use of an air trapping filter – Nitrous oxide: Avoid, due to expansion of air emboli McEwan, 2013
Discussion Discussion
Air Embolism Air Embolism Cont’d • Loca on and size of air bubble determine signs and symptoms • ASDs allow for a direct communica on from – Coronary arteries: venous circula on to systemic circula on • Chest pain, hypotension, dysrhythmias, myocardial depression, ventricular failure, cardiac arrest, AV block, ST eleva on, mill wheel murmur – Cerebral arteries: • Vapor lock created by air embolism • Abrupt headache, confusion, motor weakness, disorienta on, hemiparesis, convulsions, LOC, coma, abnormal RR, asymmetrical – Restricts blood flow past the emboli pupil response • Leading to mul ple outcomes – Pulmonary arteries: – Dependent on specific loca on • apnea, hypoxia, SOB, tachypnea, decreased ETCO2, decreased O2 satura on, hypercarbia, acidosis Webber et al., 2012
Discussion Discussion
Air Embolism Cont’d Air Embolism Cont’d • Treatments: Dependent on loca on and degree of • symptoms Kumar et al., 2014 Preven on of air embolism is the best – Hemodynamic support: inotropes, coronary vasodilators, balloon prac ce! pump, CPR – Direct aspira on (right side up, head down) through central catheter (mul -orifice) under fluoroscopy LeDez & Zbitnew, 2005 – Hyperbaric oxygen treatment for cerebral embolism
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Discussion Discussion
Acyano c Shunt Acyano c Shunt Management • Le -to-Right Flow • Overall: minimize shunt flow and maintain adequate oxygena on Kaye et al., 2012 – Typically resembles conges ve heart failure, tachypnea and dyspnea, jugular vein disten on, • Avoid condi ons that increase L-R shunt: – Low hematocrit, increased SVR, decreased PVR, hyperven la on, pulmonary conges on, hepatomegaly, poor hypothermia, and inhaled isoflurane Macksey, 2009 exercise intolerance – Signs/Symptoms: usually absent unless a shunt flow is significant Stayer, 2010 Kaye et al., 2012
Discussion Discussion
Cyano c Shunt Management What about An bio cs?? • Right-to-Le • DiNardo et al. (2011), “prophylaxis against – Blood bypasses lungs and unoxygenated blood is infec ve endocardi s is not recommended for delivered to systemic circula on pa ents with an ASD unless a concomitant – Cyano c presenta on and a lack of CHF symptoms valvular abnormality (mitral valve prolapse or – Avoid condi ons that increase shunt: mitral valve cle ) is present” (p. 612). • decreased SVR, increased PVR, hypoxia, hypercarbia, acidosis, possible NO and ketamine – Avoid air entrance at all costs! Macksey, 2009
Recommenda ons Conclusion
• Aim for anesthesia: Anesthesia providers must have a – Develop a plan that is personalized to the child’s comprehensive understanding of ASD current ASD and hemodynamics pathophysiology and anesthesia considera ons – Limit changes in exis ng shunt flow and provide to ensure safe and effec ve care of the pa ent hemodynamic stability with an ASD.
– Prevent any entrance of air into IV lines
– Avoid Nitrous oxide
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References References
• Barash, P.G., Cullen, B.F., Stoel ng, R.K., Cahalan, M.K., Chris ne Stock, M. Clinical Anesthesia. 6th • Kumar, D., Gadhinglajkar, S.V., Moorthy, K., Bhandari, D. (2014). Paradoxical air embolism to le anterior ed. Philadelphia, PA: Lippinco Williams & Wilkins; 2009. descending artery during induc on of anesthesia in a pa ent with an atrial septal defect. Interna onal Anesthesia Research Society, 2(6), 66-69. • th Cladis, F.P., Davis, P.J., Motoyama, E.K. Smith’s Anesthesia for Infants and Children. 8 ed. In J. • LeDez, K.M., Zbitnew, G. (2005). Hyperbaric treatment of cerebral air embolism in an infant with cyano c DiNardo, A. Shukla & F. McGowen Jr (Eds.), Anesthesia for Congenital Heart Surgery (pp. 605-673). congenital heart disease. Canadian Journal of Anesthesia, 52(4), 403-408 Philadelphia, PA: Mosby, Inc.; 2011. • Macksey, L.F. (2009). Pediatric Anesthe c and Emergency Drug Guide. Sudbury, MA: Jones and Bartle Publishers. • Cohen, G.A., Karamlou, T. (2015) Atrial Septal Defects. UCSF Department of Surgery. Retrieved from • McEwan, A. (2013). A Prac ce of Anesthesia for Infants and Children. Anesthesia for Children Undergoing Heart h p://www.surgery.ucsf.edu/condi ons--procedures/atrial-septal-defect.aspx Surgery, 5, 327-353.e6. • Djer, M.M., Ramadhina, N.N., Idris, N.S., Wilson, D., Alwi, I., Yamin, M., Wijaya, I.P. (2013). • Nagelhout, J.J., Plaus, K.L. (2014). Nurse Anesthesia (5th ed.) St. Louis, MO: Saunders Elsevier. Transcatheter closure of atrial septal defects in adolescents and adults: technique and difficul es. • Porta, N.F., Steinhorn, R.H. (2012). Pulmonary vasodilator therapy in the NICU: inhaled nitric oxide, sildenafil, and The Indonesian Journal of Internal Medicine, 45(3), 180-186. other pulmonary vasodila ng agents. Clin Perinatol, 39, 149-164. • Farquhar, M., Fitzgerald, D.A. (2010). Pulmonary hypertension in chronic neonatal lung disease. • Somura, J., Nakagawa, M., Ukiami, M., Sagawa, H., Furukawa, O., Hoshino, S., Fujino, H., Takeuchi, Y. (2015). Rela onship between electrocardiographic signs and shunt volume in atrial septal defect. Pediatrics Interna onal. Paediatric Respiratory Reviews, 11, 149-153. doi: 10.1111/ped.12569. • Ferri, F.F. (2015). Ferri’s Clinical Advisor. Atrial Septal Defect. Retrieved from h p:// • Stayer, S. (2010). Anesthesia for the Pa ent with Congenital Heart Disease Undergoing Non-cardiac Surgery. SPA www.clinicalkey.com Refresher Course; April, 2010. • Geva, T., Mar ns, J.D., Wald, R.M. (2014) Atrial Septal Defects. Lancet, 383, 1921-1932. • Tobis, J., Shenoda, M. (2012). Percutaneous Treatment of Patent Foramen Ovale and Atrial Septal Defects. Journal • Gri a, G.G. (1999). Cyano c congenital heart disease with increased pulmonary blood flow. of the American College of Cardiology, 60 (18), 1722-1732. Pediatric Cardiology, 46(2), 405-425. • Vasquez, A.F., Lasala, J.M. (2013). Atrial septal defect closure. Cardiol Clin, 31, 385-400. • Webber, S., Andrzejowski, J., Fancis, G. (2002). Gas embolism in anaesthesia. Bri sh Journal of Anaesthesia, 2(2), • Kaye, A.D., Stout, T.B., Pandos, I.W., Schwartz, B.G., Baluch, A.R., Fox, C.J., Liu, H. (2012). Le -to- 53-57. right cardiac shunt: periopera ve anesthe c considera ons. M.E.J Anesthesia, 21(6), 793-806.
Vasopressin to Treat Refractory Hypotension for Pa ents taking RAAS Thank You Antagonists Are There Any Ques ons?
Robert Walz, SRNA
Introduc on Introduc on
• Vasopressin • The pathophysiologic cardiovascular condi on – Vasopressin is an endogenous stress hormone also known as arginine that is most commonly encountered in vasopressin or ADH – It is secreted from the posterior pituitary gland in response to pa ents who require surgery is hypertension decreased MAP, decreased plasma volume, and increased plasma (Nagelhout & Plaus, 2014) osmolality. (Thoma, 2013) – Elimina on half-life of 6 minutes – 60 million Americans have a diagnosis of – Potent vasoconstrictor that work on the V1 receptor (Thoma, 2013) – In circumstances when hypotension does not respond appropriately to hypertension. common vasopressor and fluid administra on, vasopressin or – The risk for developing severe hypotension terlipressin becomes an effec ve alterna ve. (Tro er, 2012) – The use of low dose vasopressin can be used to restore vasomotor following the induc on of anesthesia increases in tone in pa ents that are resistant to catecholamines, preserving renal pa ents that are taking RAAS antagonists. blood flow and urine output. (Mitra, Roy, Sengupta, 2011) (Nabbi, Woehlck & Riess, 2013)
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Case Informa on Pre-opera ve Evalua on
• Past Medical Hx: Stage 3 CKD, orthosta c hypotension, • Procedure: Tympanomastoidectomy with migraines, Vit B12 anemia, pep c ulcer disease, mastoid oblitera on, canalplasty, and osteoporosis, HTN, abdominal aor c aneurysm, renal cell CA, hyperlipidemia car lage gra placement • Surgical Hx: lap chole, laparotomy, appendectomy, • Age: 72 year old extrac on of teeth, hernia repair, ureteral stent, abdominal hysterectomy, triple A repair • Weight: 57 kg • Meds: Imitrex, Elavil, Vit B12, Prolia, Penarin, Losartan- hydrochlorothiazide, Aspirin, Mul -vitamin, Fish oil • Gender: Female • Pre-op VS: HR 98, BP 142/93, Resp 16, SpO2 95%, Temp • ASA: 3 97.5 degrees F • Labs: Hgb 11.7, Hct 36.7, Plt 212, Glucose 93, Na 143, K 4.1, BUN 25, Creat 1.6
Anesthe c Course Intraopera ve Issues
• Technique: GETA, 7.0 cm ETT, Mac 3 blade • Hypotension – A er induc on the blood pressure • Drugs: dropped into the 50’s/30’s with a heart rate at 78 – Versed 1 mg bpm. – Fentanyl 100 mcg – A 500 ml fluid bolus was started – Propofol 150 mg – Neosynephrine boluses of 100 mcg was given. – Rocuronium 30 mg – Ephedrine 10 mg boluses were also given with the – Sevoflurane 1.4% pressure remaining in the 70’s/40’s. – Neo 800 mcg – A total of 800 mcg of Neo and 40 mg of Ephedrine – Ephedrine 40 mg were given. – Vasopressin 3 units – Vasopressin 1 unit boluses were given for a total of 3 – Zofran 4 mg units. – Decadron 5 mg
PACU Discussion
• Pt extubated at end of case once all criteria • Three ways to maintain blood pressure for extuba on was met – Sympathe c nervous system • Pt transferred to PACU on simple mask with – RASS system 02 at 6 Lpm – Vasopressenergic system • VSS in PACU • Pa ents taking RAAS inhibitors, who undergo • Pt discharged home later that evening anesthesia, are blocking two of the main ways to control blood pressure, leaving only vasopressin to maintain blood pressure. (Nagelhout & Plaus, 2014)
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Discussion Discussion
• Medica ons that can lead to hypotension • Ace Inhibitors – Histamine Release (e.g. morphine, atracurium) – Ace inhibitors can be dis nguished by a medica on name ending with “pril”. – Vasodila on by relaxing of arterial smooth muscle – ACEIs work by preven ng the conversion of angiotensin I to (e.g. vola le inhala onal agents, spinal anesthe cs, angiotensin II, which results in a reduc on of arterial resistance, induc on agents, narco cs) increased vascular capacitance, increased cardiac output, and • Consequences of not trea ng Hypotension stroke work. (Shear & Greenberg, 2012) • ARBs – Cerebral ischemia/stroke – ARBs are similar to ace inhibitors but the mechanism of ac on is – Myocardial ischemia or infarc on slightly different as they are a compe ve blocker of type I – Renal ischemia angiotensin II (AT1) receptors. (Nagelhout & Plaus, 2014) – ARBs can o en be dis nguished as medica ons that end with – Bowel ischemia “sartan”. – Spinal cord damage
Discussion Discussion
• Common ACEI’s • Common ARBs • Vasodilatory shock – Results from excessive vasodila on and the relaxa on of – Lisinopril – Losartan blood vessels – Enalapril – Valsartan – Results in hypotension – Captopril – Azilsartan • Vasopressin to treat vasodilatory shock – Fosinopril – Eprosartan – Exogenously administered vasopressin restores vascular tone, increases responsiveness to infused catecholamines – Quinapril and raises blood pressure. (Neto et al., 2012) – The successful treatment of intraopera ve hypotension in the se ng of RAAS blockade includes adequate intravascular volume reple on, as well as the use of AVP agonists (terlipressin, vasopressin) and adrenergic agonists. (Auron et al., 2011)
Discussion Discussion
• Vasopressin Treatment • Vasopressin Treatment – A systema c review and meta-analysis of nine randomized – A 0.5-1.0 unit bolus of vasopressin may be given controlled trials done by Neto et al., showed that the followed by an infusion dose of 0.03 units/min for combina on of vasopressin with norepinephrine in vasodilatory shock was safe, is associated with a reduc on vasopressin or 1-2 mcg/kg/hr for terlipressin as in pa ent mortality, and facilitates weaning of needed. (Nagelhout & Plaus, 2014) catecholamines. (Neto et al., 2012) – According to Shear and Greenberg (2012): At least 5 – Correc ng severe hypotension can generally be clinical trials have demonstrated that pa ents on chronic achieved using low dose (1-3 U/h) vasopressin ACEI/ARB undergoing general anesthesia respond to exogenous vasopressin deriva ves with an increase in while also avoiding excessive splanchnic and blood pressure and fewer hypotensive episodes. Typically, hepa c vasoconstric on. (John, Yeh, Boyd & Greilich, 2010) a 0.5-1 unit bolus of AVP is administered to achieve a rise in mean arterial pressure (p. 2).
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Discussion Discussion
• Vasoplegic syndrome during heart surgery – Severe hypotension refractory to catecholamine therapy most • Complica ons of Vasopressin commonly seen during cardiac surgery, although it can occur during – any anesthe c. (Shear & Greenberg, 2012) Gastrointes nal ischemia – A er coming off pump, these pa ents o en become resistant to phenylephrine and respond much be er to norepinephrine (16-32 – Decreased cardiac output mcg) or vasopressin (1-2 units). (Nagelhout & Plaus, 2014) – – Omar, Zedan & Nugent (2015) found that the use of low dose Myocardial ischemia or infarc on (cardiac arrest) vasopressin (<0.04 U/min) can be beneficial in these pa ents because • Decreased myocardial oxygen they have low circula ng levels of endogenous vasopressin (p. 84). – A study conducted by Morales found that the prophylac c use of a • Increased oxgen demand vasopressin infusion (0.03 U/min) ini ated before CPB in pa ents receiving ACE inhibitors for >2 weeks required lower peak – Skin or digit necrosis norepinephrine doses, a shorter me on catecholamines, had fewer hypotensive episodes, a shorter intuba on me, and a shorter ICU – Decreased organ perfusion stay. (Hasija et al., 2010)
Recommenda ons Conclusion
• Start with IV fluid boluses • The risk for anesthesia induced arterial hypotension is increased in pa ents chronically • Give Ephedrine and Neosynephrine first treated with angiotensin conver ng enzyme inhibitors and angiotensin II receptor blockers. • If BP unresponsive to standard treatments (Lange, Van Aken, Westphal & Morelli, 2008) give Vasopressin 0.5-1 Unit IV bolus – Trea ng hypotension a er the induc on of general anesthesia in pa ents taking RAAS antagonists can be – Mix 20 units (1ml) in 19 ml NS difficult. – Studies have shown that the administra on of vasopressin may be effec ve in reversing periopera ve refractory hypotension in pa ents whose sympathe c system and RAS is blunted by general anesthesia. (Lange, Van Aken, Westphal & Morelli, 2008)
References References
• Auron, M., Harte, B., Kumar, A., & Michota, F. (2011). Renin-angiotensin system antagonists in the • Hasija, S., Makhija, N., Choudhury, M., Hote, M., Chauhan, S., & Kiran, U. (2010). Prophylac c vasopressin in periopera ve se ng: Clinical consequences and recommenda ons for prac ce. Postgraduate pa ents receiving the angiotensin-conver ng enzyme inhibitor ramipril undergoing coronary artery bypass gra Medical Journal, 87(1029), 472-481. doi:10.1136/pgmj.2010.112987 [doi] surgery. Journal of Cardiothoracic and Vascular Anesthesia, 24(2), 230-238. doi:10.1053/j.jvca.2009.08.001 [doi] • John, A., Yeh, C., Boyd, J., & Greilich, P. E. (2010). Treatment of refractory hypotension with low-dose vasopressin • Barak, M. A., Yoav, L., & Abu el-Naaj, I. (0326). Hypotensive anesthesia versus normotensive in a pa ent receiving clozapine. Journal of Cardiothoracic and Vascular Anesthesia, 24(3), 467-468. doi:10.1053/ anesthesia during major maxillofacial surgery: A review of the literature Retrieved from 2015 j.jvca.2009.09.005 [doi] database. • Lange, M., Van Aken, H., Westphal, M., & Morelli, A. (2008). Role of vasopressinergic V1 receptor agonists in the • Bijker, J. B., van Klei, W., Kappen, T. H., van Wolfswinkel, L., Moons, K., & Kalkman, C. J. (2007). treatment of periopera ve catecholamine-refractory arterial hypotension. Best Prac ce & Research.Clinical Incidence of intraopera ve hypotension as a func on of the chosen defini on: Literature Anaesthesiology, 22(2), 369-381. defini ons applied to a retrospec ve cohort using automated data collec on. Anesthesiology, • Lonjaret, L., Lairez, O., Minville, V., & Geeraerts, T. (2014). Op mal periopera ve management of arterial blood 107(2), 213-220. Retrieved from pressure. Integrated Blood Pressure Control, 7, 49–59. doi:10.2147/IBPC.S45292 h p://ezproxy.undmedlibrary.org/login?url=h p:// • Mase , P., Murphy, S. F., & Kouchoukos, N. T. (2002). Vasopressin therapy for vasoplegic syndrome following search.ebscohost.com.ezproxy.undmedlibrary.org/login.aspx? cardiopulmonary bypass. Journal of Cardiac Surgery, 17(6), 485-489. Retrieved from h p://ezproxy.undmedlibrary.org/login?url=h p://search.ebscohost.com.ezproxy.undmedlibrary.org/login.aspx? direct=true&AuthType=ip,url,uid,cookie&db=c8h&AN=2009640492&site=ehost-live direct=true&AuthType=ip,url,uid,cookie&db=c8h&AN=2004038132&site=ehost-live • Bijker, J. B., van Klei, W., Vergouwe, Y., Eleveld, D. J., van Wolfswinkel, L., Moons, K. G., et al. • Mitra, J. K., Roy, J. F., & Sengupta, S. (1110). Vasopressin: Its current role in anesthe c prac ce [Cardiopulmonary (2009). Intraopera ve hypotension and 1-year mortality a er noncardiac surgery. Anesthesiology, resuscita on; hemorrhagic shock; opera ng room; sep c shock; vasopressin EDAT- 2011/08/05 06:00 MHDA- 111(6), 1217-1226. doi:10.1097/ALN.0b013e3181c14930 2011/08/05 06:01 CRDT- 2011/08/05 06:00 AID - 10.4103/0972-5229.83006 [doi] AID - IJCCM-15-71 [pii] PST - • Guidelines 2000 for cardiopulmonary resuscita on and emergency cardiovascular care. part 6: ppublish] Retrieved from 2011 Apr database. Advanced cardiovascular life support: Sec on 6: Pharmacology II: Agents to op mize cardiac • Nabbi, R., Woehlck, H. J., & Riess, M. L. (2013). Refractory hypotension during general anesthesia despite preopera ve discon nua on of an angiotensin receptor blocker. F1000research, 2, 12-12.v1. eCollec on 2013. output and blood pressure. the american heart associa on in collabora on with the interna onal doi:10.12688/f1000research.2-12.v1 [doi] liaison commi ee on resuscita on(0919). Retrieved from 2000 Aug 22 database. • Nagelhout, JJ, & Plaus, KL. Nurse Anesthesia. 5th ed. St. Louis, Missouri: Saunders Elsevier; 2014. • Hall, JE. Nervous regula on of circula on, and rapid control of arterial pressure. In: Hall JE, ed. • Omar, S., Zedan, A. F., & Nugent, K. (0227). Cardiac vasoplegia syndrome: Pathophysiology, risk factors and Guyton and Hall Textbook of Medical Physiology. Philadelphia: Saunders; 2011: 204 treatment Retrieved from 2015 Jan database.
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References
• Papadopoulos, G., Sintou, E., Siminelakis, S., Koletsis, E., Baikoussis, N. G., & Apostolakis, E. (2010). Periopera ve infusion of low- dose of vasopressin for preven on and management of vasodilatory vasoplegic syndrome in pa ents undergoing coronary artery bypass gra ing-A double-blind randomized study. Journal of Cardiothoracic Surgery, 5, 17-8090-5-17. doi:10.1186/1749-8090-5-17 [doi] • Serpa Neto, A., Nassar, A. P., Cardoso, S. O., Mane a, J. A., Pereira, V. G., Esposito, D. C., et al. (2012). Vasopressin and terlipressin in adult vasodilatory shock: A systema c review and meta-analysis of nine randomized controlled trials. Cri cal Care (London, England), 16(4), R154. doi:10.1186/cc11469 [doi] • Shear, T., Greenberg, S. (2012). Vasoplegic syndrome and renin-angiotensin system antagonists. APSF Newsle er; 27. Retrieved from h p://www.apsf.org/newsle ers/html/2012/spring/12vasoplegic.htm • Thoma, A. (2013). Pathophysiology and management of angiotensin- conver ng enzyme inhibitor-associated refractory hypotension during the periopera ve period. AANA Journal, 81(2), 133-140. Retrieved from Thank You h p://ezproxy.undmedlibrary.org/login?url=h p://search.ebscohost.com.ezproxy.undmedlibrary.org/login.aspx? direct=true&AuthType=ip,url,uid,cookie&db=c8h&AN=2012070334&site=ehost-live • Tro er, J. (2012). Catecholamine-resistant hypotension following induc on for spinal explora on. AANA Journal, Are There Any Ques ons? 80(1), 55-60. Retrieved from h p://ezproxy.undmedlibrary.org/login?url=h p://search.ebscohost.com.ezproxy.undmedlibrary.org/login.aspx? direct=true&AuthType=ip,url,uid,cookie&db=c8h&AN=2011485358&site=ehost-live • Turner, D. W., A ridge, R. L., & Hughes, D. W. (0719). Vasopressin associated with an increase in return of spontaneous circula on in acido c cardiopulmonary arrest pa ents [acidosis; cardiac arrest; epinephrine; return of spontaneous circula on; vasopressin EDAT- 2014/05/30 06:00 MHDA- 2014/05/30 06:00 CRDT- 2014/05/30 06:00 PHST- 2014/05/28 [aheadofprint] AID - 1060028014537037 [pii] AID - 10.1177/1060028014537037 [doi] PST - aheadofprint] Retrieved from 2014 May 28 database. • Yavuz, S. F., Toktas, F. F., Surer, S. F., & Eris, C. (0314). eComment. poten al therapeu c agents in vasoplegic syndrome a er cardiac surgery Retrieved from 2013 Sep database.
Introduc on
• Oxytocin is used in the majority of hospital deliveries in the United States Oxytocin Administra on following – Rou nely the first-line agent for preven on of PPH a er Cesarean Delivery cesarean delivery – Uterotonic agents have been shown to decrease the incidence of PPH by up to 40% (Munn et al., 2001) Amanda Lundgren, SRNA • Dosing and method of administra on varies greatly among anesthesia and obstetric providers.
Introduc on Cont’d Introduc on Cont’d
• In 2007, oxytocin was added to the Ins tute of Safe • No evidence-based guidelines on the Medica on Prac ce’s list of “High Alert Medica ons” administra on of oxytocin following cesarean delivery have been established. – Medica ons that “bear a heightened risk of causing significant pa ent harm when they are used in error” (ISMP, 2009) – Most texts suggest ‘20-40 units IV, trate to uterine tone’ – “the inability of technological safeguards, […] to consistently prevent pa ent harm” (Clark, Simpson, Knox, & Garite, 2009) What does the current evidence suggest is the – “remains the drug most commonly associated with preventable appropriate dose and method of administra on of adverse events during childbirth” (Clark et al., 2009) oxytocin following cesarean delivery? – “the drug implicated in nearly half of all paid obstetric li ga on claims” (Tsen & Balki, 2010)
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Case Informa on Anesthe c Course
• 26 year old, G2P1 • Medical Hx: unremarkable • 500mL LR infused prior to OR • Elec ve cesarean d/t • Surgical Hx: previous • SAB w/ 1.4 mL 0.75% bupivacaine and 20 mcg previous cesarean cesarean Fentanyl delivery 2° failure to • NKA progress. • Pre-op VS: WNL: • Addi onal 500 mL LR infused throughout SAB • 79 kg, 157 cm • Labs: WNL procedure • 39 week gesta on • Airway: mallampa I, • T4 level of anesthesia iden fied à LUD adequate TM & HM • ASA II • VSS remained stable on 2L O2 per NC
Anesthe c Course Intraopera ve Issues
• Within 6 min of incision, 2.9 kg male delivered • Within 1-2 min of oxytocin 10 IU bolus, pt w/o complica on, APGAR 8, 9 reported nausea and was anxious • Following delivery of placenta, 10 IU oxytocin – BP 82/46, HR 110 IV push administered, followed by 20 IU in • Phenylephrine 100 mcg and ondansetron 4 remaining 600 mL LR. mg given IV • Oxytocin infusion slowed • Symptoms and VS improved within several minutes
Recovery Post Partum Hemorrhage
• Surgeon reported sa sfactory uterine tone • Leading cause of maternal mortality
• EBL ~ 800 mL – Accounts for 30% of maternal deaths (Weeks, 2014) • Uncomplicated closure • PPH increased by over 26% between • Mild nausea 1994-2006 (Callaghan, Kuklina, & Berg, 2010) • VSS on RA • Cesarean deliveries have increased drama cally over last several decades: • Total 1400 mL LR and 200 mL LR w/ oxytocin significant risk factor for PPH (Murphy, MacGregor, Munishankar, & MacLeod, 2009)
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Discussion: Oxytocin Discussion Cont’d
• Mechanism of ac on: • Hemodynamic effects of oxytocin: – Dose & pa ent dependent – Binds to G-protein on uterine myocyte surface à – Range from transient to fatal increases release of calcium from the SR – Include: – Leads to ac va on of myosin light chain kinase to • Hypotension (↓ SVR) increase uterine contrac on • Compensatory tachycardia • Increased CO (↑ HR & SV) – ALSO, systemically, oxytocin ini ates release of nitric • Coronary vasoconstric on à ST segment changes oxide from endothelium of vascular smooth muscle
• Vasodila on, ↓ SVR, ↑ venous capacitance • Excerpt from Why Mothers Die 1997-1999: two case • Vasoconstric on of splanchnic and coronary arteries, release studies describe maternal cardiac arrest immediately of atrial & brain natriure c pep de a er oxytocin 10 unit bolus dose (Thomas & Cooper, 2002)
(Dryer, Butwick, & Carvalho, 2011)
Discussion Cont’d Discussion: Bolus
• Hemodynamic studies: Carvalho et al. (2004) Kiran et al. (2013) – 10 IU bolus in non-pregnant, non-anesthe zed • Found ED90 to be 0.35 IU • 90 primip, healthy, elec ve women found tachycardia, ↓ MAP, ST changes (Svanstrom et al. 2008) – 40 healthy, term, elec ve/ cesarean deliveries non-laboring – Concluded 0.5-2 units bolus – Hemodynamics may be similar in trend, but oxytocin – Concluded no more than 1 IU doses result in adequate uterine tone induced changes are significantly greater than bolus needed
delivery alone (CO, SVR, HR, SV) (Archer et al., 2008) Butwick et al. (2010) Balki et al. (2006) – Comparing 5 or 10 IU bolus doses – 10 IU doses were • Aimed to find ED90 * sta s cally significantly more likely to cause ST • Aim to find ED 90 in labor • 0, 0.5, 1, 2, or 5 unit bolus depression (Johsson et al., 2009) arrest cesarean • Prevent hypotension à likely prevent ST changes • Concluded 0.5-3 unit bolus • Found ED90 to be 2.99 u results in adequate UT
Discussion: Bolus Discussion: Bolus vs. Infusion
• Sartain et al. (2008) Langesaeter et al. (2009) Mechanism of bolus and infusion are thought to differ: “A bolus causes constric on of the venous sinuses, • 2 unit vs 5 unit followed by • Parturients w/ cardiac disease leading to placental separa on and placental bed dilute infusion 10 u/hr • Study began with 5 unit bolus haemostasis, whereas an infusion maintains doses • Phenylephrine infusion to uterine contrac lity” (Sheehan et al., 2011) • adjusted dose throughout study maintain BP from 5 IU bolus to 0.5 IU (as low • However, Kovacheva, Soens, & Tsen (2015) concluded • No difference b/w groups as 0.1u) re: EBL, uterine tone, that low dose bolus (3 unit with placebo infusion) • Concluded ultra low doses, required less total oxytocin than infusion group addi onal uterotonics repeated frequently resulted in (placebo bolus with 30 IU infusion), – 5 IU group ↑ hypotension less hemodynamic changes, yet – Similar hemodyamic effects achieved adequate UT – Infusion group received double the rescue bolus amount to achieve same UT
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Discussion: Infusion Discussion: Infusion
George et al. (2010) Murphy et al. (2009) Sheehan et al. (2011) King et al. (2010) • 40 healthy, non-laboring • Compared 5 IU bolus and • Compared 5 unit bolus and 40 IU • 143 with at least 1 risk factor cesarean deliveries placebo infusion vs 5 u infusion vs 5 unit bolus and for PPH. • Diluted in 500mL NS infused bolus and 30 IU dilute placebo infusion • Compared 5 IU bolus and 40 over 1 hr infusion IU in 500mL NS vs placebo bolus and 40 IU in 500mL NS • Concluded ↓ incidence of • Concluded bolus + infusion • Found ED90: 0.29 IU/min reduced need for addi onal • Concluded 5 IU bolus dose (approx. 17 IU/hr) PPH and ↓ prolonged uterotonic agents – did not may not be necessary: admission rates in group decrease incidence of PPH. – provided immediate UT, but with infusion – Also noted adverse effects did dissipated a er 5 min – did not not increase with infusion significantly affect end results of EBL or addi onal uterotonic – *infusion rate less than ED90 agents found by George et al. (2010)
Recommenda ons Recommenda ons Cont’d
• 10 IU bolus doses of oxytocin are not • Rule of 3’s: (Tsen & Balki, 2010) appropriate, regardless of PPH risk factors – 3 IU bolus over 15-30 seconds – Even 5 IU bolus becoming less acceptable • Assess uterine tone a er 3 minutes • Ini al bolus dose considera ons: – 3 IU bolus rescue dose #1 if needed (over 15-30 – Healthy (low/no risk for PPH), non-laboring, elec ve seconds) CD: 0.5-3 IU over 15-30 seconds • Assess uterine tone a er 3 minutes – Health, non-laboring, primpara, elec ve CD: – 3 IU bolus rescue dose #2 if needed (over 15-30 0.5-2 IU over 15-30 seconds seconds) – Laboring/failure to progress CD: 3 IU over 15-30 • Asses uterine tone a er 3 minutes seconds – Consider another uterotonic agent if uterine tone not sa sfactory/concern for PPH
Recommenda ons Cont’d Conclusion
• High risk for PPH: • Oxytocin dose-dependent side effects may be transient – Rule of 3’s plus dilute infusion to fatal, important to consider especially in cardiac – If higher doses requested, consider vasopressor complicated and hypovolemic parturients. preemp vely • Anesthesia prac oners must consider appropriate • High cardiovascular risk: dosing of oxytocin according to pa ent history and – Ultra-low dose: 0.5 IU slow bolus, repeat as presenta on and understand preven on/treatment of adverse effects. necessary – Consider vasopressor preemp vely • Need for addi onal research and evidence supported recommenda ons
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References References
• Jonsson, M., Hanson, U., Liedell, C., & Norden-Lindeberg, S. (2009). ST depression at caesarean sec on and • Murphy, D., MacGregor, H., Munishankar, B., McLeod, G. (2009). A randomized controlled trial of oxytocin 5IU and placebo the rela on to oxytocin dose. A randomized controlled trial. Bri sh Journal of Gynecology, 117(1). doi: infusion versus oxytocin 5 IU and 30 IU infusion for the control of blood loss at elec ve caesarean sec on – Pilot study. 10.1111/j.1471-0528.2009.02356.x European Journal of Obstetrics & Gynecology and Reproduc ve Biology, 142(1). doi: 10.1016/j.ejogrb.2008.09.004 • NOVARTIS Pharmaceu cals. (2009). Syntocinon. [online pamphlet]. Approved by Therapeu c Goods Administra on. • King, K., Douglas, Unger, Wong, King (2010). Five unit bolus oxytocin at cesarean delivery in woman at risk Retrieved from h p://www.novar s.com.au/pi_pdf/syt.pdf of atony: A randomized, double blind, controlled trial. Interna onal Anesthesia Research Society, 111(6). • Phaneuf, S., Rodriguez Linares, B., TambyRaja, R., MacKenzie, I., & Bernal, A. (2000). Loss of myometrial oxytocin receptors doi: 10.1213/ANE.0b013e3181f8930a during oxytocin-induced and oxytocin-augmented labour. Journal of Reproduc on and Fer lity, 120(1). doi: 10.1530/jrf. • Kiran, S., Anand, A., Singh, T., and Gupta, N. (2013). To es mate the minimum effec ve dose of oxytocin 0.1200091 required to produce adequate uterine tone in women undergoing elec ve caesarean delivery. Egyp an • Sartain, J., Barry, J., Howat, P., McCormack, D., Bryant, M. (2008). Intravenous oxytocin bolus of 2 units is superior to 5 units Journal of Anaesthesia, 29(2). doi: 10.1016/j.egja.2012.10.001 during elec ve caesarean sec on. Bri sh Journal of Anaesthesia. 101(6). doi: 10.1093/bja/aen273 • • Sheehan, S., Montgomery, A., Carey, M., McAuliffe, F., Eogan, M., Gleeson, R.,… Murphy, D. (2011). Oxytocin bolus versus Kovacheva, V., Soens, M., and Tsen, L. (2015). A randomized, double-blinded trial of a “Rule of Threes” oxytocin bolus and infusion for control of blood loss at elec ve caesarean sec on: double blind, placebo controlled, algorithm versus con nuous infusion of oxytocin during elec ve cesarean delivery. Anesthesiology, 123. randomised trial. Bri sh Medical Journal, 343(1). doi: 10.1136/bmj.d4661 Advance online publica on. doi: 10.1097/ALN.0000000000000682 • Stephens, L., & Bruessel, T. (2012). Systema c review of oxytocin dosing at caesarean sec on. Anesthesia and Intensive • Langesaeter, E., Rosseland, L. A., and Stubhaug, A. (2009). Haemodynamic effects of repeated doses of Care, 40(2). 247-252. oxytocin during caesarean delivery in healthy parturients. Bri sh Journal of Anaesthesia, 103(2). doi: • Svanstrom, M., Biber, B., Hanes, M., Johansson, G., Naslund, U., & Balfors, E. (2008). Signs of myocardial ischaemia a er 10.1093/bja/aep137 injec on of oxytocin: A randomized double-blind comparison of oxytocin and methylergometrine during caesarean sec on. • Mockler, J., Murphy, D., & Wallace, E. (2010). An Australian and New Zealand survey of prac ce of the use Bri sh Journal of Anaesthesia, 100(5). doi: 10.1093/bja/aen071 • Thomas, T. A. and Cooper, G. M. (2002). Maternal deaths from anaesthesia. An extract from Why Mothers Die 1997-1999, of oxytocin at elec ve caesarean sec on. Australian and New Zealand Journal of Obstetrics and the confiden al enquiries into maternal deaths in the United Kingdom. Bri sh Journal of Anaesthesia, 89(3). 499-508. Gynaecology, 50(1). doi: 10.1111/j.1479-828X.2009.01108.x • Thomas, J., Koh, S., Cooper, G. (2007) Haemodynamic effects of oxytocin given as i.v. bolus or infusion on women • Munn, M., Own, J., Vincent, R., Wakefield, M., Chestnut, D., & Hauth, J. (2001). Comparison of two undergoing caesarean sec on. Bri sh Journal of Anesthesia, 98(1). doi:10.1093/bja/ael302 oxytocin regimens to prevent uterine atony at cesarean delivery: A randomized controlled trial. Obstetrics • Tsen, L., & Balki, M. (2010). Oxytocin protocols during cesarean delivery: Time to acknowledge the risk/benefit ra o? and Gynecology, 98(3). 386-390. Interna onal Journal of Obstetric Anesthesia, 19(3). doi: 10.1016/j.ijoa.2010.05.001 • Wedisinghe, L., Macleod, M., & Murphy, D. (2007). Use of oxytocin to prevent haemorrhage at caesarean sec on – a survey of prac ce in the United Kingdom. European Journal of Obstetrics and Gynecology and Reproduc ve Biology, 128(1). doi: 10.1016/j.ejogrb.2007.04.007 • Weeks, A. (2015). The preven on and treatment of postpartum haemorrhage: what do we know, and where do we go to next? Bri sh Journal of Gynecology, 122(2). doi:10.1111/1471-0528.13098
Postopera ve Nausea and Vomi ng Preven on For a Pa ent Undergoing Thank You Thyroidectomy Are There Any Ques ons? David Ames, SRNA
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Introduc on Pathophysiology
• Prevalence of Postopera ve Nausea and • Located in medulla oblongata and brainstem Vomi ng (Apfel et al. 1999): region (Pierre and Whelan, 2013): – General Anesthesia PONV development – Chemoreceptor Trigger Zone (CRTZ) • Caudal end 4th Ventricle • 20-30% of all pa ents – • 50-80% with previous history of PONV Nucleus Tractus Solitaries • Lower pons area in the area postrema • Blood Brain Barrier not as developed in this region (Pierre and Whelan, 2013) – Direct s mula on
Pathophysiology Case Informa on
Nausea and Vomi ng is s mulated through receptors (Pierre and Whelan, 2013): • Surgical Procedure: Comple on of • Gastrointes nal tract • Cerebral Cortex Thyroidectomy – Enterochromaffin cells – Communicates with NTS • – Direct Vagus nerve s mula on via mul ple complex Age: 22 years old – Serotonin (5HT3) Receptors pathways • Weight: 63 kg • CRTZ communicates with • Vagal tract NTS via – Neurokinin 1 (NK1) • Gender: Female – Dopamine 2 (D2) Receptors Receptor • • ASA: 1 • Ves bular System Located within NTS • Substance P can also bind – Histamine 1 (H1) Receptors to NK1 Receptor – And acetylcholine (Ach) Receptors
Preopera ve Evalua on Preopera ve Evalua on
• Past Medical Hx • Pre-op VS • – Anxiety – HR: 65 Preopera ve – Depression – BP: 125/63 – Transdermal Scopolamine Patch 1.5 mg – Thyroid Cancer – RR: 16 – PONV – Temp: 98.2 • Applied upon arrival to Pre-op holding room • Previous hemithyroidectomy – SaO2: 98% – LR IVF • Surgical Hx • Labs – Hemithyroidectomy – Hbg: 12.6 – Midazolam 2mg IV • Medica ons – Hct: 37.3 • anxioly c – Docusate Sodium – Plt: 201 – Oxycodone/acetaminophen • Airway Evalua on – Excedrin – Mallampa : 2 – Levonorqestrel – Neck: Full ROM – Ondansetron – Den on: Intact
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Anesthe c Course Intraopera ve Issues
• Induc on • A er Induc on • No issues intraopera vely – Fentanyl 100 mcg IV – TIVA to maintain general – Pre-oxygenated anesthesia – Hemodynamically stable through out case – Propofol 150 mg • Propofol g – Titrated to keep BIS – Surgical case lasted approx. 60 min – Rocuronium 5 mg between 40-60 – • Priming dose – Acetaminophen IV 1000 Neuromuscular blockade reversed with – Rocuronium 35 mg mg • Glycopyorrlate 0.4 mg IV • A er successful ven la on – Dexamethasone 10 mg IV • Neos gmine 3 mg – Intubated with 7.0 ETT – Cefazolin 2 g IV without issues • Ondansetron 4 mg IV – Given towards end of • No issues with emergence surgical procedure
PACU/Postopera ve Discussion
• No issues in PACU • Predica ve Scoring System – Study done by Apfel, Koivuranta, Greim, and Roewer – Only received Fentanyl IV twice for post op pain (1999) • Large two center study evaluated risk factors for PONV • Included 2722 pa ents • Pa ent discharged later during the day • Risk factors were plo ed on receiver opera ng chart curve and area under the curve (AUC-ROC) – No signs or symptoms of PONV – Done to help eliminate bias – Created a probability chart • Results Found Strongest Predictors – Female gender – History of PONV or Mo on Sickness – Smoking Status – Postopera ve Opioid Usage
Discussion Discussion
• Serotonin Antagonist • Serotonin Antagonist Cont’d – Moon, Joo, Kim, and Lee (2012) – Ondansetron at the beginning vs. end of case – • Female pa ents undergoing thyroidectomy Cruz, Por lla, and Vela (2008) • Evaluated efficacy of ondansetron for PONV preven on • Evaluated efficacy of ondansetron vs. palonosetron postopera vely at – Double Blind Randomized Clinical Control Trial – 0-2 hours – Metaxari et al. (2011) Double-Blind RCT Evalua on – 2-24 hours • Double-Blind RCT of Three Serotonin Antagonists – Ondansetron given at beginning of case • Pa ents undergoing thyroidectomy – Ondansetron given within 30 min of end of the case • Evaluated at one hour, 6-12 hours, 18 hours, and 24 • All pa ents received dexamethasone 4 mg IV at start of the hours postopera vely case
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Discussion Discussion
• Dexamethasone • Dexamethasone Cont’d – Feroci et al. (2011) RCT Double-blind study – Doksrod et al., (2012) Prospec ve randomized thyroidectomy pa ents evaluated effects of double blind clinical trial hemithyroidectomy dexamethasone for PONV, Pain, Vocal Cord Func on pa ents
• Dexamethasone for PONV reduc on and postopera ve – Noted blood sugar increase 8 hours postopera vely pain relief • Nazar, Lacassie, Lopez, and Munoz, (2009) RCT evaluated BS – Found reduc on in PONV eleva on with dexamethasone administra on – Found no benefit for pain relief – Found BS eleva on peak at 8-10 hours post administra on
Discussion Discussion
• An cholinergic and Neurokinin 1 Antagonist • An histamines – Gan et al., 2009 evaluated efficacy of TDS – Forrester, Benfield, Matern, Kelly, and Pellegrini • RCT for high risk PONV development (2007) performed a double-blind, randomized control • Found TDS most effec ve when applied at least 2 hours study that involved 77 pa ents that evaluated the before induc on • TDS combined in mul modal treatment highly effec ve at effec veness of meclizine combined with PONV preven on ondansetron with pa ents that had four to five risk factors for PONV. – Green et al. (2012) evaluated aprepitant alone vs – Gan et al. (2014) aprepitant with transdermal scopolamine patch (TDS) • Diphenhydramine it is a safe and effec ve medica on when in RCT-double blind trial combined in a mul modal approach, for high-risk pa ents, • No difference with TDS when combined with aprepitant for PONV preven on. – Aprepitant is Neurokinin 1 antagonist
Discussion Discussion
• Dopamine 2 antagonists • Modifying risk factors – Apfel et al. (2009), evaluated droperidol’s – Park and Cho (2011) performed a randomized clinical control trial that evaluated TIVA versus an inhala on an eme c effect in a double-blind, randomized agent in the preven on of PONV. clinical trial done via mul center study. • PONV was significantly reduced in the TIVA group more than – Ebneshahidi, Akbari, and Mohseni (2013) found the sevoflurane group that haloperidol helped to reduce the incidence of delayed PONV from a double-blind, randomized • IV Fluid Rehydra on clinical trial with 98 pa ents. – Yavuz et al. (2014), evaluated the effects PONV reduc on of IVF hydra on in a randomized clinical • Improved efficacy when combined with trial for pa ents undergoing laparoscopic dexamethasone cholecystectomies.
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Discussion Discussion Cont’d
• Limi ng Opioids • Post Discharge Nausea and Vomi ng – Singla et al. (2015) performed a randomized clinical double-blind trial on total hip arthroplasty pa ents – Apfel et al. (2012) conducted a study, with 12 that supports the use of IV acetaminophen can different centers, to evaluate poten al risk factors decrease the amount of opioids needed for for PDNV postopera ve pa ents – Cai, Lin, Yu, and Lin (2012) evaluated the efficacy of – Risk factors found were female gender, age less performing a bilateral cervical plexus block in pa ents than 50 years old, history of PONV, opioid use in undergoing a thyroidectomy. the PACU, and nausea and vomi ng in the PACU. – Tufanogullari et al. (2008) performed randomized clinical control trial that assessed the efficacy of – Dexamethasone had a significant reduc on in different dexmedetomidine dosages versus a placebo. PDNV when u lized with a mul modal approach • Evaluated amount of opioids used
Recommenda ons Conclusion
• Mul modal approach works best • Reduc on of risk factors and mul modal – Nausea and Vomi ng is mul factorial treatment plan does work at mes • Tailor preven on to pa ent specific situa ons • At least one-third of all general anesthesia • Limit risk factors as able pa ents will develop PONV • Use longer ac ng an eme cs for those with • Mul modal treatment recommended for limited access to healthcare moderate to high risk pa ents • Beneficial for future research to focus on: – Adjust plan to pa ent wish or situa on – Most Efficacious Dosages – Adjunc ve Medica on and Treatments
References References
• Apfel, C. C., Koivuranta, M., Greim, C., & Roewer, N. (1999). A Simplified Risk Score for Predic ng Postopera ve Nausea and • Gan, T. J., Sinha, A. C., Kovac, A. L., Jones, R. K., Cohen, S. A., Ba kha, J. P., . . . Glass, P. S. (2009). A randomized, double-blind, mul center Vomi ng: Conclusions from Cross-valida ons between Two Centers. Anesthesiology. doi: trial comparing transdermal scopolamine plus ondansetron to ondansetron alone for the preven on of postopera ve nausea and vomi ng in 10.1097/00000542-199909000-00022 the outpa ent se ng. Anesthesia and Analgesia, 108(5), 1498-1504. doi:10.1213/ane.0b013e31819e431f [doi] • Gan, T. J., Diemunsch, P., Habib, A. S., Kovac, A., Kranke, P., Meyer, T. A., … Tramer, M. R. Society for Ambulatory Anesthesia. (2014). • Apfel, C. C., Cakmakkaya, O. S., Frings, G., Kranke, P., Malhotra, A., Stader, A., . . . Kolodzie, K. (2009). Droperidol has Consensus guidelines for the management of postopera ve nausea and vomi ng. Anesthesia and Analgesia, 118(1), 85-113. doi:10.1213/ comparable clinical efficacy against both nausea and vomi ng. Bri sh Journal of Anaesthesia, 103(3), 359-363. doi:10.1093/ ANE.0000000000000002 bja/aep177 [doi] • Green, M. S., Green, P., Malayaman, S. N., Hepler, M., Neubert, L. J., & Horrow, J. C. (2012). Randomized, double-blind comparison of oral • Apfel, C. C., Philip, B. K., Cakmakkaya, O. S., Shilling, A., Shi, Y. Y., Leslie, J. B., . . . Kovac, A. (2012). Who is at risk for aprepitant alone compared with aprepitant and transdermal scopolamine for preven on of postopera ve nausea and vomi ng. Bri sh postdischarge nausea and vomi ng a er ambulatory surgery? Anesthesiology, 117(3), 475-486. doi:10.1097/ALN. Journal of Anaesthesia, 109(5), 716-722. doi:10.1093/bja/aes233 [doi] 0b013e318267ef31 [doi] • Moon, Y. E., Joo, J., Kim, J. E., & Lee, Y. (2012). An -eme c effect of ondansetron and palonosetron in thyroidectomy: A prospec ve, randomized, double-blind study. Bri sh Journal of Anaesthesia, 108(3), 417-422. doi:10.1093/bja/aer423 [doi] • Cai, H. D., Lin, C. Z., Yu, C. X., & Lin, X. Z. (2012). Bilateral superficial cervical plexus block reduces postopera ve nausea and vomi ng and early postopera ve pain a er thyroidectomy. The Journal of Interna onal Medical Research, 40(4), 1390-1398. • Metaxari, M., Papaioannou, A., Petrou, A., Chatzimichali, A., Pharmakalidou, E., & Askitopoulou, H. (2011). An eme c prophylaxis in thyroid surgery: A randomized, double-blind comparison of three 5-HT3 agents. Journal of Anesthesia, 25(3), 356-362. doi:10.1007/ • Cruz, N. I., Por lla, P., & Vela, R. E. (2008). Timing of ondansetron administra on to prevent postopera ve nausea and s00540-011-1119-2 [doi] vomi ng. Puerto Rico Health Sciences Journal, 27(1), 43-47. • Nazar, C. E., Lacassie, H. J., Lopez, R. A., & Munoz, H. R. (2009). Dexamethasone for postopera ve nausea and vomi ng prophylaxis: Effect on • Doksrod, S., Sagen, O., Nostdahl, T., & Raeder, J. (2012). Dexamethasone does not reduce pain or analgesic consump on glycaemia in obese pa ents with impaired glucose tolerance. European Journal of Anaesthesiology, 26(4), 318-321. doi:10.1097/EJA. a er thyroid surgery; a prospec ve, randomized trial. Acta Anaesthesiologica Scandinavica, 56(4), 513-519. 0b013e328319c09b [doi] • • Ebneshahidi, A., Akbari, M., & Mohseni, M. (2013). Intraopera ve haloperidol does not improve quality of recovery and Tufanogullari, B., White, P. F., Peixoto, M. P., Kianpour, D., Lacour, T., Griffin, J., . . . Provost, D. A. (2008). Dexmedetomidine infusion during laparoscopic bariatric surgery: The effect on recovery outcome variables. Anesthesia and Analgesia, 106(6), 1741-1748. doi:10.1213/ane. postopera ve analgesia. Advanced Biomedical Research, 2, 85-9175.122501. eCollec on 2013. doi: 0b013e318172c47c [doi] 10.4103/2277-9175.122501 [doi] • Pierre, S., & Whelan, R. (2013). Nausea and vomi ng a er surgery. Coun ng Educa on Anesthesia Cri cal Care and Pain. 13(1): 28-32. • Feroci, F., Re ori, M., Borrelli, A., Lenzi, E., O aviano, A., & Sca zzi, M. (2011). Dexamethasone prophylaxis before • Park, S. K., & Cho, E. J. (2011). A randomized controlled trial of two different interven ons for the preven on of postopera ve nausea and thyroidectomy to reduce postopera ve nausea, pain, and vocal dysfunc on: A randomized clinical controlled trial. Head & vomi ng: Total intravenous anaesthesia using propofol and remifentanil versus prophylac c palonosetron with inhala onal anaesthesia using Neck, 33(6), 840-846. doi:10.1002/hed.21543 [doi] sevoflurane-nitrous oxide. The Journal of Interna onal Medical Research, 39(5), 1808-1815. • Forrester, C. M., Benfield, D. A.,Jr, Matern, C. E., Kelly, J. A., & Pellegrini, J. E. (2007). Meclizine in combina on with • Yavuz, M. S., Kazanci, D., Turan, S., Aydinli, B., Selcuk, G., Ozgok, A., & Cosar, A. (2014). Inves ga on of the effects of preopera ve hydra on ondansetron for preven on of postopera ve nausea and vomi ng in a high-risk popula on. AANA Journal, 75(1), 27-33. on the postopera ve nausea and vomi ng. BioMed Research Interna onal, 2014, 302747. doi:10.1155/2014/302747 [doi]
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Pre-oxygena on and Posi oning of Thank You Obese Pa ents Are There Any Ques ons? Brandon Vesel, SRNA
Introduc on Introduc on Cont’d
• Obesity is an epidemic that con nues to rise around the Obesity and Risk Factors in Anesthesia world. • Pa ents with a body mass index (BMI) of 30 or more are considered obese. • 300 million people worldwide are considered obese. The World Health Organiza on (WHO) predicts by the year • Risk Factors during Intuba on 2025 the number of severely overweight people to – Thicker neck double. – Diminished Func onal Reserve Capacity – Sleep Apnea – Airway obstruc on – Limited mouth opening • Pa ent safety can be enhanced when anesthesia – Diminished range of neck mo on providers develop anesthesia care plans that take into – Increased metabolic rate account the specific needs of pa ents with obesity. – Lower alveolar concentra on of oxygen
Introduc on Cont’d Case Informa on
Pre-oxygena on and Posi oning of Obese Pa ents • Emergent Laparoscopic • Past Medical history Cholecystectomy – GERD • An obese pa ent being pre-oxygenated for three – Asthma • minutes in the 25 degree head up positon will give the 34 year old – HTN anesthesia professional more me to intubate before the • 125 kg – Obstruc ve Sleep Apnea onset of cri cal hypoxia, providing a safer anesthe c to • BMI 38 – Current smoker – Obesity • the obese pa ent. Female • Surgical history • Mallampa III airway – Appendectomy • ASA 2 – Right Knee Replacement (Pa ent reported severe • Pre-op VS: nausea and vomi ng post- – HR 96, BP 154/66, op) Oxygen satura on 97%
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Anesthe c Management Anesthe c Management
• Preopera ve: • Intraopera ve Cont’d: – Midazolam not administered, due to severe obstruc ve – Ven lator - volume mode sleep apnea • TV 600, rate 14, 50% FiO2 • Intraopera ve: – End dal Sevoflurane maintained at 1.6% - 2.2% – Standard monitors applied – End dal CO2, 30-35 during maintenance phase – Vital signs obtained: BP 150/62, HR 92, 96% – BIS 39-43 – Induc on: Propofol 200 mg, Succinylcholine 200 mg – An eme c's given – RSI, due to NPO status uncertain, obese and history of GERD • Zofran 4 mg IV – Intubated with 7.0 ETT a er 3 a empts • Decadron 10 mg IV • Placement confirmed with bilateral breath sounds and posi ve – MAP kept above 65mmHg throughout case ETCO2
Anesthe c Management Anesthe c Management
Intraopera ve Issues: • Emergence: • During direct laryngoscopy with a MAC 3 blade, oxygen – Glycopyrrolate 1 mg IV and Neos gmine 5 mg IV satura on rapidly dropped from 97% to 86% within the first 5 seconds. given for paraly c reversal – Ven lator SIMV mode when RR dropped • The second DL a empt with a Miller 2 blade did not – Throat suc oned provide a view of the cords, with oxygen satura on dropping to 66%. – Sevoflurane discon nued – Pa ent breathing on her own and following • The third DL a empt with Glidescope provided successful intuba on, with pa ent manually ven lated to commands 100%. – Pa ent extubated without incident
PACU Discussion
• Postopera ve: • The review of literature looked at answering – Pa ent was transported to PACU on 2L nasal this ques on: cannula – Does pre-oxygena ng a pa ent, for three minutes in a 25 degree head up posi on extend the amount of me for the anesthesia prac oner to safely secure the airway, before hypoxia occurs.
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Discussion Discussion
Pre-oxygena on Pre-oxygena on Cont’d • Delivering 100% oxygen through a ghtly sealed mask, • Indicator of the completeness of pre-oxygena on replaces nitrogen in the lungs with oxygen. This is called – End dal oxygen frac on (FEO2) de-nitrogena on. • Having an FEO2 greater than 90% is the most accurate end point of preoxygena on (Tanoubi et al., 2009)
• This build up of oxygen in the lungs provides an increased • The research showed that by applying 100% oxygen amount of me to intubate before the pa ent becomes over an open airway and allowing it to passively flow hypoxic. into the lungs built up FRC (Sirian and Wills, 2009).
– Important for obese pa ents with GERD who need an RSI. • Recommended Techniques for Pre-oxygena on: – Decreased build up of air in the stomach – Three minute Tidal volume Breathing (TVB) – Eight deep breaths in 60 seconds
Discussion Discussion
Pre-oxygena on Cont’d Posi oning • Pre-oxygena on becomes more important if • Plays a key role in prolonging me to safely manage pa ent exhibits traits that could lead to a difficult the airway before desatura on occurs. mask ven la on – BMI greater than 35 • The studies show that an obese pa ent in a head up – Age greater than 55 years posi on has less weight compressing their lungs, – Limited jaw protrusion improving Func onal Residual Capacity (FRC) (Dixon – Lack of teeth et al., 2005) – Beard – Mallampa class 3 or 4
Discussion Discussion
Posi oning Cont’d Posi oning Cont’d • Types of Posi ons • Posi oning the pa ent allowing downward – Ramped displacement of the adipose ssue will • Placing blankets under the upper body – Reduced intra-abdominal pressure – 25 degree reverse Trendelenburg – Reduced risk of reflux • Adjus ng the en re bed where the upper body is higher then the lower body – Reduced risk of aspira on – Increase FRC build up – Near-si ng • Moving the bed to a beach chair posi on
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Discussion Discussion
Pre-oxygena on and Posi oning Pre-oxygena on and Posi oning Cont’d • Pre-oxygena on and posi oning used together on an • Dixon et al. (2005) determined that pa ents with obese pa ent, have the greatest impact on BMI’s >40 who were pre-oxygenated in the 25 extending the amount of me for an anesthesia degree head up posi on for three minutes had: provider to safely secure the airway before hypoxia – Pre-induc on oxygen tension of 442 compared to 360 in occurs. the supine posi on. – Time to desatura on of 92% • Head up posi on 201 seconds • Supine posi on 86 seconds
Discussion Conclusion
Pre-oxygena on and Posi oning Cont’d • Analyzing this case, the pa ent exhibited difficult • Alterma (2005) looked at the correla on of pre-oxygena on airway traits: and body posi oning in the si ng vs supine posi on of 40 – Limited jaw protrusion pa ents with BMI’s > 35. – Mallampa class 3 – Divided into two groups of 20 – Short neck • Pre-oxygenated with 8 deep breaths in one minute • Oxygen flow rate 10 liters • RSI performed • Pre-oxygena ng at a 25 degree head-up posi on • Breathing circuit disconnected would have maximized this pa ent’s oxygen – Time measured for oxygen satura on allowed to drop to 90% – Si ng group stores providing the anesthesia team more me • Time to desatura on of 90% was 214 seconds to safely intubate, without a decrease in oxygen – Supine group satura on. • Time to desatura on of 90% 162 seconds
Conclusion Cont’d References
• Alterma , F., Munoz, H., Delfino, A., Cor nez, L. (2005). Pre-oxygena on in the obese pa ent: Effects of posi on on tolerance to apnea. Bri sh Journal of Anesthesia, 95(5), 706-709. • It is recommended that anesthesia care
providers pre-oxygenate pa ents, with a BMI • Dixon, B., Dixon, J., Carden, J., Burn, A., Schachter, L.,Playfair, J., Laurie, C., O’Brien, (2005). Pre-oxygena on is more effec ve in the 25 degree head-up posi on than in the supine over 30, for three minutes in a 25 degree head posi on in severely obese pa ents: A randomized control study. Anesthesiology, 102(6), 1110-1115.
raised posi on. • Gaszynski, T. (2010). Pre-oxygena on in morbidly obese pa ents. Anestezjol IntensTer, 42(3), 133-136.
• Nagelhout, J.J. & Plaus, K.L. (2013). Nurse Anesthesia (5th ed.). St. Louis, • This will allow more me to intubate before MO: Elsevier Sanders.
the onset of cri cal hypoxia, greatly enhancing • Sirian, R., Wills, J. (2009). Physiology of apnea and the benefits of preoxygena on. Con nuing the safety of the anesthe c for the obese educa on in anaesthesia. Cri cal Care & Pain, 9(4), 105-108.
pa ent. • Tanoubi, I., Pierre, D., Francois D. (2009). Op mizing preoxygena on in adults. Can J Anesth, 56, 449-466.
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Intravenous Acetaminophen to Thank You Decrease Narco c Usage Are There Any Ques ons? Nathan Palm, SRNA
Introduc on Significance
• General anesthesia can produce undesirable • Increased use of narco cs may cause adverse effects such as: – Respiratory distress condi ons that may lead to adverse outcomes. – Airway obstruc on – Hypoxia – Confusion • Narco cs are o en used to blunt the sympathe c – Postopera ve nausea and vomi ng response for intuba on and are frequently re-dosed – Decreased pa ent sa sfac on
throughout the case in response to increased heart • Under the Affordable Care Act, pa ent sa sfac on will become rate and blood pressure. increasingly important for reimbursement rates.
• U liza on of mul modal pain management by administra on of non- • Intravenous (IV) acetaminophen has shown promising narco c analgesics may decrease overall narco c use and their results in providing non-narco c adjunc ve analgesia undesirable effects.
in the periopera ve and postopera ve pa ent. • Decreased narco c usage may provide cost savings along with improved pa ent outcomes.
Case Informa on Anesthe c Course
• 32 year-old female • RSI due to GERD – Lidocaine 50 mg IV • 98 kg – Fentanyl 50 mcg IV
– Propofol 180 mg IV • Diagnosis: cholelithiasis – Succinylcholine 200 mg IV • Surgery: laparoscopic cholecystectomy under general anesthesia • Anesthesia maintained with Desflurane – Addi onal 50 mcg fentanyl IV throughout case • PMH: – Acetaminophen 1000 mg IV – Obesity – Type II DM • Extubated awake – Asthma – Hypertension • A postopera ve visit was done in same day surgery unit – Depression approximately 1.5 hours later. – Anxiety – No recall, PONV, or pain – GERD (well controlled)
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Discussion Discussion
• Many research studies have shown that the use • Overzealous use of narco cs can cause of acetaminophen IV has been shown to adverse effects that may increase length of significantly decrease the use of narco cs and stay, cost, and morbidity and mortality which their nega ve side effects in the postopera ve decrease pa ent sa sfac on. period. – Conversely, poorly controlled pain also decreases pa ent sa sfac on. • Tradi onal algorithms of pain management – Joint Commission on Accredita on of Health Care involve use of opioids, such as fentanyl, as first Organiza ons have suggested that decreased line therapy for pain control in the periopera ve pa ent sa sfac on can be correlated with higher and immediate postopera ve period. opioid usage.
Discussion Discussion
• It is thought that the analgesic and an pyre c Oral Acetaminophen ac vity of acetaminophen act in a dose • Oral acetaminophen cannot be absorbed in the dependent manner with acetaminophen IV, stomach leading to challenges in reliable dosing in the leading to greater central penetra on and higher surgical pa ent. levels in the cerebrospinal fluid. • Delayed gastric emptying may lead to unreliable absorp on of oral acetaminophen in pa ents whose • The exact mechanism of ac on is not completely condi on predisposes delayed gastric emptying, such understood. as: – It is thought to act centrally by inhibi ng • Diabetes Mellitus cyclooxygenases, effec ng serotonin and decreasing • Cardiac surgery prostaglandin levels. • Laparoscopic cholecystectomies • Gynecological surgeries
Discussion Discussion
IV vs. PO Acetaminophen IV vs. PO Acetaminophen Cont’d • Acetaminophen is known to express its effects centrally. • Addi onally, opioids, o en given during and a er – It must cross the blood brain barrier to achieve the desired results. surgery, are known to slow gastric emptying leading to • In an IRB-approved, inves gator-ini ated single site, open-label study by Singla et poten ally unreliable dosing and pain control of oral al. (2012), the concentra on of acetaminophen was measured in the plasma and cerebrospinal fluid (CSF) to compare the pharmacokine cs of oral, rectal, and IV analgesic medica ons in the intraopera ve and acetaminophen. immediate postopera ve periods. – The doses of acetaminophen for this study were 1000 mg IV over 15 minutes, 1000 mg PO, or 1300 mg rectally.
• A study by Schuitmaker et al. (1999) observed that a • The IV plasma levels had a 76% higher C-max than oral dosing and 256% higher C- max than rectal dosing. 2000 mg dose of PO acetaminophen did not achieve a plasma level that would produce adequate pain relief • The plasma half-life was slightly longer with IV administra on but was not sta s cally significant. in the postopera ve period. • CSF levels were also higher with the IV route than the other routes.
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Discussion Discussion
IV vs. PO Acetaminophen Cont’d IV vs. PO Acetaminophen Cont’d • A study by Bannwarth, et al. (1992) indicated that the • Singla et al. (2012) cited that higher plasma levels of effect of acetaminophen is correlated to the CSF level. acetaminophen are correlated to be er analgesia in the postopera ve period as acetaminophen crosses the blood brain barrier through passive diffusion rather than an ac ve • Singla et al. also found a correla on between transport mechanism. acetaminophen’s effec veness on pain and it’s concentra on in the CSF (2012). • Apfel et al. (2013) concluded that the main advantage of IV administra on over oral administra on of acetaminophen is • “Passive diffusion of acetaminophen into the CNS is that: highly dependent on a concentra on gradient with the – “One g of IV acetaminophen is associated with about twice the plasma C-max being of primary importance” (Singla et al., and effect site concentra ons as 1 g of its oral or rectal applica ons, resul ng in greater central nervous system penetra on which 2012, p. 524). corroborates the superior analgesic efficacy seen with IV compared to oral acetaminophen in the surgical se ng” (p. 677).
Discussion Discussion
Pediatrics Pediatrics Cont’d • Children are at increased risk for adverse respiratory events from opioids. • Mul modal analgesia is recommended as evidenced based prac ce for treatment of postopera ve pain in the pediatric pa ent • One of the most common surgeries in children is a tonsillectomy, o en popula on (Lonnqvist & Morton, 2005). due to either tonsilli s or obstruc ve sleep apnea. • Including acetaminophen IV in the intraopera ve and postopera ve • “The high prevalence of sleep-disordered breathing (80%) in children analgesic plan may decrease opioid requirements in the pediatric undergoing tonsillectomy is a major concern limi ng the safe upper dose pa ent (Wong, 2013). range of intraopera ve opioids” (Subramanyam et al., 2014, p. 471). • • Pa ents with OSA, who most likely have desatura on with the apneic Pediatric pa ents have varying sensi vity to opioids which may episodes, are more sensi ve to opioids than those who have not been result in unexpected apnea in the postopera ve period. exposed to repeated desatura on. – This is most likely due to an altera on in mu receptors and leads to analgesia • Decreased opioid consump on may reduce the risk of adverse and anesthesia that occurs at lower blood levels (Cote, 2015). respiratory events, increase pa ent sa sfac on and early mobility, and decrease the length of hospital stay.
Discussion Discussion
Reduc on of PONV Reduc on of PONV Cont’d • Opioids and inhaled anesthe cs are known triggers for • A meta-analysis by Apfel et al. (2013) examined 30 research ar cles with 2364 pa ents and found that giving acetaminophen IV PONV which affects about 30% of pa ents who receive prophylac cally, before the onset of pain, had the greatest reduc on general anesthesia (Norred, 2003). of PONV.
• Gan et al. (2013) found that preven on of PONV is • The results were further analyzed by sources of funding for the study. In the inves gator-ini ated trials there was decreased PONV versus in more important to pa ents than postopera ve pain the industry sponsored trial there was no reduc on in PONV. control. – It was discovered upon further review that in the industry sponsored trials acetaminophen IV was only used as a rescue analgesic, a er the onset of pain, and not given prophylac cally whereas in the inves gator-ini ated trials it • It is difficult to completely eliminate opioids from an was given prophylac cally, before the onset of pain. anesthe c plan. – However, a reduc on of opioid use has been shown to • The data Apfel et al. (2013) collected “suggest that IV acetaminophen decrease the incidence of PONV by approximately 30% reduces PONV at least as well as established an eme cs” (p. 684). (Marret, et al., 2005).
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Discussion Discussion
Reduc on of PONV Cont’d Reduc on of PONV Cont’d • Acetaminophen may have a direct ac ng • Whether the reason for decreased PONV is due to an eme c effect. Apfel et al. (2013) found the decreased opioid usage or a direct ac ng effect of acetaminophen, there is consistent evidence to support following: that the incidence of PONV is decreased when Acetaminophen is metabolized in the brain into A acetaminophen IV is used prophylac cally M404, a metabolite that is able to inhibit the reuptake of anandamide, a known cannabinoid CB1 and CB2 • Preven on of PONV is very important to pa ents and receptor agonist. It has been shown that decreased subsequently pa ent sa sfac on may be lower in anandamide levels are associated with an increased incidences where PONV occurs. rate of nausea and vomi ng in humans. Therefore, it is possible that acetaminophen simply has a direct effect • Use of prophylac c acetaminophen IV may increase pa ent on PONV by increasing anandamide levels. (p. 685) sa sfac on by decreasing the incidence of PONV.
Discussion Discussion
IV Acetaminophen in the Bariatric Popula on IV Acetaminophen in the Bariatric Popula on Cont’d • Gonzalez et al. (2014) performed a retrospec ve study of 92 pa ents • Adverse outcomes due to respiratory complica ons, in 2014 to determine if acetaminophen IV decreased opioid PONV, and increased PACU me occur more frequently requirements in the obese pa ent undergoing bariatric surgery.
in the obese popula on. • 38 pa ents in the study received acetaminophen IV and 50 pa ents did not. • Due to increased adipose ssue the airway is narrower • No sta s cally significant differences were noted in age, BMI, gender, and obstruc ve sleep apnea may be present. ASA score, periopera ve complica ons, surgical me, or number or procedures per surgeon. • Addi onally, obese pa ents may have a higher sensi vity • Pa ents in the acetaminophen IV group received an average of 99.5 to opioids and hypercapnia. This may put this pa ent mg of opioid and the pa ents who did not receive acetaminophen IV popula on at an increased risk for adverse outcomes received an average of 164.6 mg of opioids, a difference of 39.5% less with increased opioid use. opioids.
Discussion Discussion
Cost Effec veness Cost Effec veness Cont’d • A review by Subramanyam et al. (2014) of the cost-effec veness of • Acetaminophen IV, while more expensive than acetaminophen IV for pediatric tonsillectomy found that administra on of oral acetaminophen, has been shown to be an acetaminophen IV was associated with a decrease in overall cost. appropriate choice in many pa ents that may • The decreased cost was a ributed to decreased incidence of adverse lead to overall cost savings due to decreased outcomes such as respiratory depression and PONV leading to decreased opioid consump on and shorter PACU me PACU me. (Subramanyam et al., 2014). • Subramanyam et al. (2014) determined that a combina on of acetaminophen IV and opioids decreased costs and was more effec ve than opioids alone. • Use of oral medica ons in the immediate – “Although the medica on cost of the combina on strategy were higher, the preopera ve, periopera ve, and postopera ve overall costs were less than the compe ng strategy due to reduced adverse se ngs has shown to have unreliable rates of effects and reduced me spent in PACU” (Subramanyam et al., 2014, p. 467). absorp on.
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Recommenda ons Conclusion
• Due to the high cost per dose, some organiza ons and providers • Acetaminophen IV has been shown to be a safe, may be reluctant to use acetaminophen IV instead applying opioid effec ve analgesic which provides excellent pain relief only analgesia. in combina on with opioids.
• However, a reduc on in PACU me and adverse events, including • Mul ple studies have demonstrated that decreased incidence of PONV and respiratory depression from acetaminophen IV decreases opioid consump on in overuse of opioids, may provide more cost-effec ve care and mul ple types of surgical pa ent popula ons. be er overall outcomes.
• • Opioids have many undesirable side effects which may More studies should be done examining the effec veness and lead to adverse outcomes and increased costs; reliability of cost-reduc on with this route versus oral decreasing the overall use of opioids may reduce the acetaminophen to determine if the increased cost for this route is incidence of these adverse effects. actually more effec ve than oral or rectal administra on.
Conclusion References
• Apfel, C. C., Turan, A., Souza, K., Pergolizzi, J., & Hornuss, C. (2013). Intravenous • While oral acetaminophen remains an op on for acetaminophen reduces postopera ve nausea and vomi ng: A systema c review and meta-analysis. Pain, 154, 677-689. administra on, delayed gastric emptying from • Bannwarth B., Ne er P., Lapicque F., et. al (1992). Plasma and cerebrospinal fluid fas ng or opioid induced ileus may decrease the concentra ons of Paracetamol a er a single dose of Propacetamol. Br J Clin Pharmacol, 34,79-81. reliability and effec veness of this route. • Cote, C. J. (2015). Anesthesiological considera ons for children with obstruc ve sleep apnea. Pediatric Anesthesia, 28(3). 327-332. • Gan, T. J., Meyer, T., Apfel, C. C. Chung, F., Davis, P. J., Eubanks, S., Kovac, A., Philip, B. K., Sessler, D. I., Temo, J., Tramer, M. R., Watcha. M. (2003). Consensus • Evidenced-based prac ce algorithms, such as guidelines for managing postopera ve nausea and vomi ng. Anesth Analg, 97(1), including mul -modal analgesia, will become 62-71. • Gandhi, K., Bara a, J. L., Heitz, J. W., Schwenk, E. S., Vaghari, B., Viscusi, E. R. increasingly important as healthcare (2012). Acute Pain Management in the Postanesthesia Care Unit. Anesthesiology Clinics, 30(3), 1-15. reimbursement is further driven by outcomes • Gonzalez, A. M., Romero, R. J., Ojeda-Vaz, M. M., & Rabaza J. R. (2015). Intravenous acetaminophen in bariatric surgery: effects on opioid requirements. and pa ent sa sfac on. Journal of Surgical Research, 195(1), 99-104.
References References
• Gupta, A., Daigle, S., Mojica, J., Hurley, R. (2009). Pa ent percep on of • Memis, D., Inal, M. T. Kavalci, G., Sezer, A, Sut, N. (2010). Intravenous paracetamol pain care in hospitals in the United States. Journal of Pain Research, 2, reduced the use of opioids, extuba on me, and opioid-related adverse effects 157-164. a er major surgery in intensive care unit. Journal of Cri cal Care, 25, 458-462. • Miller, R. D., Eriksson, L. I., Fleisher, L., Wiener-Kronish J. P., & Young, W. L. (2009). • Herring, B. O., Ader, S., Maldonado, A., Hawkins, C., Kearson, M., & th Camejo. (2014). Impact of Intravenous Acetaminophen on Reducing Miller’s Anesthesia (7 ed.). Philadelphia, PA: Churchill Livingstone Elsevier. Opioid Use A er Hysterectomy. Pharmacotherapy, 34(12), 27-33. • Needleman, S. (2013). Safety of rapid intravenous infusion of acetaminophen. Baylor University Medical Center Proceedings, 26(3), 235-238. • Lonnqvist P. A. & Morton N. S. (2005). Postopera ve analgesia in infants • Norred, C. (2003). An eme c prophylaxis: Pharmacology and therapeu cs. and children. Br J Anaesth, 95, 59-68. American Associa on of Nurse Anesthe sts, 71(2), 133-140. • Macario, A. & Royal, M. A. (2011). A Literature Review of Randomized • Paul W. F. (2005). The changing role of non-opioid analgesic techniques in the Clinical Trials of Intravenous Acetaminophen (Paracetamol) for Acute management of postopera ve pain. Anesth Analg, 101, S5-S22. Postopera ve Pain. Pain Prac ce, 11(3), 290-296. • Remerand, F., Le Tendre, C., Baud, A., Couvret, C., Pourrat, X, Favard, L., Laffon, • Marret E., Kurdi O., Zufferey P., Bonnet F. (2005). Effects of nonsteroidal M., Fusciardi, J. (2009). The Early and Delayed Analgesic Effects of Ketamine A er an -inflammatory drugs on pa ent-controlled analgesia morphine side Total Hip Arthroplasty: A Prospec ve, Randomized, Controlled, Double-Blind effects: meta-analysis of randomized controlled trials. Anesthesiology, Study. Anesthesia & Analgesia, 109(6), 1963-1971. doi: 10.1213/ANE. 102, 1249-60. 0b013e3181bdc8a0
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