From the Head of the Bed

Part 2: Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA.  Dustin discusses the specifics of Damage Control Resuscitation that he utilized as the sole anesthesia provider at Forward Operating Base (FOB) Orgun-E in Afghanistan. Dustin Degman, MSN, CRNA is an Associate Professor of Anesthesia at Western Carolina University works with AllCare Clinical Associates in Asheville, North Carolina as a CRNA.  He served Active Duty with the United States Air Force from 1998-2002 as a critical care nurse.  In 2010, he joined the Army Reserves as a CRNA.  Dustin was deployed in November 2012 to Forward Operating Base (FOB) Orgun-E in Paktika Province, Afghanistan where he was the sole anesthesia provider on a forward surgical team which provided damage control resuscitation to injured soldiers.  He has a special interest in trauma anesthesia and has served on trauma call teams in civilian centers as well as in his military service.  Many thanks to Dustin and the brave men and women who have served and serve in and with the United States Armed Services! Combat Trauma Anesthesia Part 1:  Key differences and challenges facing CRNAs serving in Forward Surgical Teams (FSTs) and managing combat trauma patients Part 2:  Damage Control Resuscitation principles and particulars Part 3:  Getting involved as a military CRNA and support our troops   Topics Discussed: * What constitutes the “front lines.”  You’ve got to hear Degman humbly give credit to those who, in his opinion, really served on the front lines (first two minutes of the show…). * Assessment priorities for CRNAs including physical exams “from the neck up” (i.e. ruptured tympanic membranes may indicate proximity to explosions) * Induction sequence & airway management * Use of tourniquets * Techniques to support clot formation * fluid, blood product, pharmacological and hemodynamic management * Surgical goals of damage control resuscitation   Highlights: * Blood product management * 1:1 transfusion protocol was frequently used for hemorrhagic shock patients.  Dustin did not have platelets available so one fresh frozen plasma (FFP) unit was given with every packed red blood cell (PRBC) unit. * Very limited crystalloid replacement * Walking Donor Protocol – use of direct, typed whole blood administration from uninjured soldiers to hemorrhagic shock patients.  Benefits:  the blood’s got all the products (red cells, plasma, platelets, cry0, factor 7) and it’s warm. * Colloid resuscitation end points: * 80-90 systolic blood pressure * goal for INR less than 1.5 * base excess greater that -4 * hemoglobin & pH monitoring * surgical hemostasis * Pharmacological management * Induction drugs * Overview of antibiotics * Use of ketamine with head trauma patients* * transexamic acid (TXA) and Factor 7 commonly administered * Vascular access * Goal was bilateral 16g peripheral IVs * Central lines uncommon but were typically used with 3% sodium chloride, especially once the patient was bundled or “burrito wrapped” for the flights out of the FOB to more definitive care. * Arterial lines were commonly placed * Tourniquet use * very common * hemostatic agents/products (e.g. chitosan) were not commonly used * Resuscitation end points * Dustin discusses a case from his civilian trauma experience that was similar to one he experienced in Afghanistan in which ultrasound was used to evaluate cardiac wall motion (specifically, the lack there of) in a hemorrhagic shock patient in order to make the decision to not attempt surgical resus...

Part 1: Combat Trauma Anesthesia with Dustin Degman, MSN, CRNA. In this interview, Jon sits down with Dustin Degman to discuss his role as a CRNA working at Forward Operating Base (FOB) Orgun-E in Afghanistan. Dustin Degman, MSN, CRNA is an Associate Professor of Anesthesia at Western Carolina University works with AllCare Clinical Associates in Asheville, North Carolina as a CRNA.  He served Active Duty with the United States Air Force from 1998-2002 as a critical care nurse.  In 2010, he joined the Army Reserves as a CRNA.  Dustin was deployed in November 2012 to Forward Operating Base (FOB) Orgun-E in Paktika Province, Afghanistan where he was the sole anesthesia provider on a forward surgical team which provided damage control resuscitation to injured soldiers.  He has a special interest in trauma anesthesia and has served on trauma call teams in civilian centers as well as in his military service.  Many thanks to Dustin and the brave men and women who have served and serve in and with the United States Armed Services! Combat Trauma Anesthesia Part 1:  Key differences and challenges facing CRNAs serving in Forward Surgical Teams (FSTs) and managing combat trauma patients Part 2:  Damage Control Resuscitation principles and particulars Part 3:  Getting involved as a military CRNA and support our troops   Points discussed: * Basic overview of where Dustin was & his Forward Surgical Team (FST) set up * Overview of the types of patients and types of cases Dustin saw * Differences in patient care priorities and perioperative flow in a FST from civilian trauma centers:  triage, assessment, surgical & anesthesia goals and more. * FST team members and dynamics

In this episode, Kristin and Sandry Gaillard, a CRNA who works independently at a critical access hospital in rural western North Carolina, sit down to discuss the business of anesthesia in terms of working as a 1099 employee verses a W2 employee. Topics Discussed Include: * Differences between 1099 and W2 work arrangments * Advantages/Disadvantages of 1099/W2 * Responsbilities of 1099 employment * Tips for starting 1099 employment * Types of coorporations * CRNA-only practice Shownotes: Difference between 1099 and W2 employee: – Based on 3 sets of criteria – whether there is behavior control, financial control and what the      relationship is between the parties involved – W2- specific requirements by the employer – job is directed to what, how, when, where you are going to do your job – Independent contractor – no requirements by employer – 1099 – you can have a 1099 as an independent contractor or work in a care team Advantages to W2 – Don’t have to worry about business side of things (taxes) Independent Contractor Advantages: – more control, flexibility, more money potentially, autonomy Disadvantages of 1099: – stressful, deal with all business aspects Responsibilities for 1099: – Liability insurance and health insurance – Responsible for employee portion of Social Security and Medicare – Disability insurance, Unemployment insurance – Money to plan for sick days – Determine money to put away for taxes/business/personal (**Good rule: at least 30% of what you bring home for taxes – don’t know what tax bracket you are going to be put into at the end of the year) Tips for 1099: – Get a business attorney – someone who does small business – Do your research! – Do you plan to incorporate? Keep your business and personal separate so both are protected – Find an accountant for help managing taxes (who also does small business) Types of Corporations: PC – Professional Corporation (available only to certain professions – you apply for this through the state that licenses you) S – Corp – Requires annual board meeting, documentation of minutes LLC – Limited Liability Corporation – similar to PC, less complex, less paperwork (combines the best features of your PC and S-corp) **Business attorney can help you make a good choice for you – You can do this yourself if you are business savvy! – Lots of info online CRNA only practice: – Depending on size of practice could cover call, weekends, holidays – Responsible for pre-op medical reviews, review anesthetic plan, see if they need to be cleared for surgery by other health care provides – Post-op: follow ups, if they are going home – make sure they have appropriate instructions to go home; post-operative teaching, managing post-op phones, in house post-op visits, make sure patients are pleased with anesthetics – Critical access hospitals are able to reimbursed for medicare part A – CRNAs providing anesthesia services in a rural critical access hospital – A signature by a physician is required by federal government for reimbursement;  this signature does not mean that physicians are legally liable for anything that the anesthetists does – Independent practitioners are liable for whatever they do.  If a surgeon dictates how he/she wishes you to administer the anesthesia, he/she may be liable for those decisions.

In this interview, David Andrews, MHS, CRNA, sits down with Jon Lowrance to discuss the importance of CRNAs and SRNAs advocating for their profession through state and national associations. David is the current President of the Oregon Association of Nurse Anesthetists and Clinical Director for Outpatient Anesthesia Services and has been actively involved in leadership positions in state associations as well as the American Association of Nurse Anesthetists (AANA).  This interview was conducted during the Fall of 2014 in Tualatin, OR. Topics Discussed Include: * Rationales for participating in state and national associations. * The role state and national associations have had in protecting and advancing the field of nurse anesthesia. * Importance of contributions to political action committees (PACs) whether through time or financial commitments. * The role anesthesia program directors can have in helping SRNAs get involved in advocating for their profession. * Tips for talking with legislators. * Principles of leadership and volunteerism. Resources and links: Oregon Association for Nurse Anesthetists (OANA) https://www.oregon-crna.org American Association for Nurse Anesthetists (AANA) http://www.aana.com Outpatient Anesthesia Services (OASOR) http://www.oasor.com The Future of Anesthesia Care Today http://www.future-of-anesthesia-care-today.com   Highlights: “…and the message we have [as CRNAs] is good – it’s quality of care, access to care and cost savings – that’s the side of the argument you want to be on.” David Andrews “Because of this challenge we face, we get this great opportunity to learn how to legislate and… how to lead. Our state organization and the national organization teach effective leadership… and that’s a great life lesson – that’s just a side benefit of becoming a CRNA.” David Andrews

In this episode Kristin and David Andrews, MHS, CRNA, President of the Oregon Association of Nurse Anesthetists and Clinical Director of Outpatient Anesthesia Services, sit down to discuss the challenges facing outpatient anesthesia providers. Information about Outpatient Anesthesia Services can be found at their website www.oasor.com. Shownotes: –  Challenges faced in operating outpatient surgical facilities include scheduling and flexibility in order to be a profitable company. –  Patient selection is a challenge.  The last thing you want to do is cancel a procedure on the day of surgery.  Make sure that a solid pre-anesthesia assessment is taken care of ahead of time. –  How do you assess risk?  There is a push to limit pre-operative testing because it does not necessaritly result in better outcomes.  Also, it costs more and can be a hassle for patients. –  There is financial pressure not to cancel cases.  How do we attenuate this – by trying to get as much patient information as possible before the actual surgery.  Train your office to get particular information depending on how patients present. –  Ultimately it boils down to the provider on that day to make the decision whether or not to proceed. –  There is a constant balance between rapid turnover and patient safetly.  Develop a quick, systematic efficient method of putting people to sleep and waking them up.  If you feel rushed, take a deep breath and slow down.  Every patient deserves the best care.  Ultimatley you are accountable for the care you give. –  Critical incidents are rare in the outpatient setting but the most common are airway related.  In order to deal with this properly you need preparation. –  Goals for the outpatient setting: Nausea free, quick wake up, prompt discharge within an hour, pain free and comfortable.  Regional anesthesia works great for this setting. –  Outpatient is a service industry.  CRNAs should be able to be flexible to accommadate surgeon preferences and needs within safe boundries. –  Anesthesia is the same regardless who is providing it; the way that CRNAs can really excell is by providing excellent service.

Sickle Cell Disease - Dr. Kuestner Sickle Cell Disease affects kids as well as adults. Problems related to sickle cell is seen more as people age. Scenario: A 7yr old boy presenting for a tonsil and adenoidectomy, for Obstructive Sleep Apnea. They have a history of sickle cell disease and a few crises’ but none in the past few months. Hemoglobin while taking hydroxyurea is 10. Question: Prior to receiving surgery all of the following are true except? A: He should have hematology consult preoperatively. B: He does not require a transfusion since his hemoglobin is 10. C: A hemoglobin electrophoresis should be obtained. D: Surgery should not be done in an ambulatory center. Answer: B Sickle Cell Disease is not just a simple erythrocyte deformation that makes cells that look like sickles. It involves hemolysis, anemia, microvascular occlusion and recurrent ischemic injury in all organ systems. If you think of it as just a blood problem you are missing what is really happening. It is the leading cause of morbidity and mortality among African-Americans. Acute complications of sickle cell disease that are relevant to pediatric anesthesia. Acute Splenic Sequestration this usually occurs in children age 5 months to 2 years. But may occur as late as the teenage years in children with sickle thalassemia. This results from the pooling of large quantities of blood in the spleen and leads to shock with profound anemia. Aplastic Crisis – Results with the normal brisk reticulocytosis that is associated with sickle cell disease is suppressed. So they are not forming red blood cells quickly enough. This happens when the have a viral infect with parvovirus b19. Hemolytic Crisis – Occurs in patients that have an abrupt increase in hemolytic stress, such as infection or medication induced. Many of the patients are also deficient in the enzyme glucose 6 phosphate dehydrogenase. Sepsis / Septic Shock are serious acute complications. They generally experience autoinfarction of the spleen in early childhood and they are rendered susceptible to encapsulated organism infections. Aseptic techniques and wound infection prophylaxis is critical. Vaso-Occlusive Crisis – Are episodes of painful ischemia, and tissue infarction that result from small vessel occlusion by sickle cells. Most types of the occlusive crises include: dactylitis, priapism in males, stroke, and acute chest syndrome. Chronic complications relevant to pediatric anesthesia. Can apply to pretty much all organ systems, decrease growth and maturation, increased nutritional requirements, retinopathy, stroke, cognitive dysfunction, cardiac dysfunction, elevated pulmonary vascular resistance, chronic lung injury, diminished renal tubular dysfunction, bone and joint destruction, leg ulcerations, splenic infarction. Mostly importantly to the perioperative management is the chronic changes to the cardiovascular, respiratory, and renal systems. The elevated pulmonary vascular resistance in childhood is a predictor of premature death. Treatment of the Crises include: Intravascular volume expansion. Transfusion of red blood cells. Treatment of the infection. Stopping the offending medications. Preop on children with Sickle cell. Most patients are now identified with newborn electrophoresis if they have sickle cell or not. Dehydration may predispose you to a vaso-occlusive crisis and acute chest syndromes. The most debated topic over the perioperative management of sickle cell patients is the prophylactic preoperative blood transfusion.

Matthew Kuestner, M.D., attending anesthesiologist at Kosair Children’s Hopsital, overviews hematopoiesis, fetal hemoglobin and physiologic anemia in pediatrics.  Dr Kuestner is a board certified pediatric anesthesiologist and a Diplomate of the American Board of Anesthesiology. Hematopoiesis, Fetal Hemoglobin & Physiologic Anemia in Pediatrics by Dr. Kuestner Hematopoiesis * Liver will produce fetal erythropoietin in the first 24 weeks of life. * In the last trimester of pregnancy the erythropenia will be coming from the kidney. * At 10-12 weeks 80% of hemoglobin is fetal hemoglobin or hemoglobin-F which decline to 0% by six months of age. * So a term baby has 20% of Adult or hemoglobin-A. * Hemoglobin-A is made up of 2 Alpha and 2 beta polypeptide chains. * Fetal hemoglobin behaves differently than adult hemoglobin. Fetal hemoglobin shifts from a P-50 of 19.4 on the first day of life to 30.3 at eleven months of age. * Normal adult P-50 is 27. * P-50 is the conventional measure of Hemoglobin’s affinity for oxygen. * Fetal oxygen hemoglobin dissociation curve will shifted to the Left of moms curve. * Fetal hemoglobin must have a greater affinity for oxygen than maternal hemoglobin to be accepted in the uterine villi and supply oxygen to the fetus. * Fetal hemoglobin’s greater affinity for oxygen is due to its low capacity to interact with (2,3 DPG). * The binding site for (2,3 DPG) is on the Beta chain. Which is absent in fetal hemoglobin. * Oxygen will still transfer from mother to fetus when hemoglobin-A is transfused in utero. So if you have to give a fetus a transfusion with adult hemoglobin the fetus will still get the oxygen they need.   Normal Physiologic Shift in Hemoglobin Values * Normal Neonate hemoglobin is 17, mostly hemoglobin-F. * At 3-4months of age, in a full term newborn hemoglobin will drop to 10-11. Termed the normal physiologic anemia of infancy. * At age 2 hemoglobin should be around 12. * Slow increases to 13-14 by the age of 10. The normal physiologic anemia occurs because hemoglobin-F is transitioning to hemoglobin-A.  The drop in hemoglobin stimulates the erythropoietin to be produced by the kidney.   Premature babies do things differently.  They drop further and faster and the take longer to transition to adult hemoglobin. Difference in premature and healthy full term babies. * The anemia in healthy full term babies are symptomatic. * In premature babies it occurs earlier, persist longer and it causes them to be symptomatic. * In premature babies hemoglobin may drop to as low as 8 by the 4th week of age. * The anemic infant could have bradycardia, apnea, delayed growth, and poor weight gain. * The bradycardia, apnea, and hemodynamic changes are big concerns in anesthesia. In infants weighing less than 1kg often blood sampling and lab work exceeds or equals half of their blood volume.  So then they get transfused with adult hemoglobin-A.  Therefore, there is no stimulation of for the kidneys to  produce erythropoietin.  So the red cells don’t last very long and they become anemic again. For a NICU baby make sure blood is available for these kids before going back for surgery. New information says it’s better to start transfusing on the earlier side of things, so you don’t have to give the blood so quickly and at the same time you’re decreasing their risk of hyperkalemia. You do not want to wait until the baby has become tachycardia or bradycardia to start your intervention.

Adrea Kristofy, M.D., attending anesthesiologist at Kosair Children’s Hospital, discusses single lung ventilation in pediatrics.  Dr Kristofy is an Assistant Professor of Anesthesiology at the University of Louisville School of Medicine.  She is also a Diplomate of the American Board of Anesthesiology. Single Lung Ventilation In Pediatrics The goal is to answer 2 questions: * How do we determine the need for single lung ventilation? * How do we proceed once we have made that decision? Indications for Single Lung Ventilation. * Absolute Indications – Isolate on lungs because of Contamination, Infection, Bleeding, control of ventilation for bronchopleural fistula, large cyst, ect.. * Relative Indications – Surgical Exposure, thoracic aortic aneurysm, pneumonectomy, ect… Three Different techniques used to achieve single lung ventilation. * Simplest – Single tube right or left mainstem, right easier than left. * Balloon tip bronchial blocker such as uninvent tube. * Double lumen tubes. Downside with single lumen tube only. Inadequate seal, failure of lung to collapse, easier to get contamination from one side to the other. Balloon tip bronchial blockers. Can be placed on either side. Can be dislodged somewhat easily. Balloon low volume and high pressure. Can Not suction threw the bronchial blocker. Discrepancy between outer and inner lining of the tube and be problematic in small children Double Lumen Endotracheal Tubes Most common is the Carlens tube, carinal hook endotracheal tubes used in the past. Two tubes equal length, with two cuffs one tracheal cuff and one bronchial cuff. The size is measured in French not in millimeters. So a 26fr double lumen endotracheal tube has an outer diameter of 9.3mm. Advantages of Double lumen tubes You can provide positive pressure ventilation You can suction either the operative or the non-operative lung as needed The cuffs are high volume and low pressure One thing to remember with pediatrics and double lumen tubes is that a size 26fr corresponds with approximately at 5.5-6mm cuffed singled lumen endotracheal tube. So if your patient can tolerated that size single lumen tube then they can tolerate a double lumen tube. Physiologic concerns with single lung ventilation. If decrease in saturation occurs check: Is the tube dislodged, secretions. Most of the time desaturation occurs because of mismatch of ventilation and perfusion.  To help fix this add CPAP to non-dependent, non-ventilated lung or add PEEP to ventilated lung.  May have decrease TV and increase frequency to keep ventilation pressures the same. If desaturation continues talk with your surgeon to see if you can intermittently re-expand the operative lung. If still no increase in saturation then the surgeon may be able to put a temporary or possibly a permanent ligature on the pulmonary artery. If all else fails talk with the surgeon and go directly to re-expansion of both lungs then continue trouble shooting. Charts from Hammer et al. (Anesth Analg 1999)                                   Reference Hammer, G. B., Fitzmaurice, B. G., & Brodsky, J. B. (1999). Methods for Single-Lung Ventilation in Pediatric Patients. Anesthesia & Analgesia, 89(6), 1426 1410.1213/00000539-199912000-199900019.

Steven Auden, M.D., attending anesthesiologist at Kosair Children’s Hospital, discusses myths, mistakes and misconceptions in pediatric anesthesia.  Dr Auden is the Medical Director of Kosair Children’s Hospital Department of Anesthesiology and a Clinical Professor of Anesthesiology for the University of Louisville School of Medicine.  He is a board certified pediatric anesthesiologist and a Diplomate of the American Board of Anesthesiology and the American Board of Pediatrics. Myths, Mistakes & Misconceptions In Pediatric Anesthesia by Dr. Steve Auden Two Topics of Discussion: 1.  The Cricoid Ring. 2.  Cricoid Puncture. Questions. What is the narrowest point of the pediatric airway? Is Cricoid Pressure (Sellick Maneuver) needed in pediatrics? Should Atropine be given as a premedication in the pediatric population? What is the minimal dose of Atropine? Which is more potent Atropine or Glycopyrrolate? So To Recap: What’s the narrowest point in the pediatric airway? * The glottic opening just as in adults * Proven by Dalal PG, Murray D, Messner AH, Feng A, McAllister J, Molter D. Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg, 2009;108:1475-9 * Supported again in the May 2009 issue of Anesthesia and Analgesia by Motoyama – The Shape of the Pediatric Larynx: Cylindrical or funnel shaped. What’s to remember about Cricoid Pressure? * It is very difficult to do properly. * More Importantly. DO NOT inflate the stomach. * Pre-oxygenate very well * Do NOT attempt intubation until the pt is very deep. * Use a serial twitch monitor * It is NOT effective against forceful vomiting Should Atropine be used routinely as a premedication? * No! * Unless there is a known history of bradycardia or disease process that is prone to bradycardia. * Supported by Johr in the 1999 issue of Pediatric Anaesthesia – Is it time to question the routine use of anticholinergic agents in pediatric Glycopyrrolate versus Atropine which is more potent? * Given IV there is basically No Difference in Potency. * IM there is a difference. Why? * Glycopyrrolate is a quaternary ammonium – Big and does NOT cross the BBB. So no CNS Symptoms. (Lethargy, somnolence, Seizures) * Atropine is a Tertiary Amine – Smaller – DOES cross BBB. * In a Code situation maybe give 1 dose to follow protocol otherwise just go straight to Epi. Cricoid puncture can be done in pediatrics, but it should be done by trained and qualified personnel.   Disclaimer The information provided can NOT necessarily be applied to CRNA board questions as the content of boards may have not been updated to reflect the results of the studies and information discussed.  However, hopefully this will help to improve your knowledge base and personal practice.   References: Cricoid Ring Dalal, P. G., Murray, D., Messner, A. H., Feng, A., McAllister, J., & Molter, D. (2009). Pediatric laryngeal dimensions: an age-based analysis. Anesth Analg, 108(5), 1475-1479. doi: 10.1213/ane.0b013e31819d1d99 Lerman, J. (2009). On cricoid pressure: “may the force be with you”. Anesth Analg, 109(5), 1363-1366. doi: 10.1213/ANE.0b013e3181bbc6cf Motoyama, E. K. (2009). The shape of the pediatric larynx: cylindrical or funnel shaped? Anesth Analg, 108(5), 1379-1381. doi: 10.1213/ane.0b013e31819ed494 Ovassapian, A., & Salem, M. R. (2009). Sellick’s maneuver: to do or not do. Anesth Analg, 109(5), 1360-1362. doi: 10.1213/ANE.0b013e3181b763c0 Rice, M. J., Mancuso, A. A., Gibbs, C., Morey, T. E., Gravenstein, N., & Deitte, L. A. (2009). Cricoid pressure results in compression of the postcri...

Dr Walter Rose, D.O., attending anesthesiologist at Kosair Children’s Hospital, discusses the specific attributes that make caring for pediatric patients unique as anesthesia providers.  Dr Rose is the Director of Pediatric Cardiac Anesthesia at Kosair Children’s Hospital and also serves as an Assistant Professor of Anesthesiology with the University of Louisville School of Medicine.  He is a Diplomate of the American Board of Anesthesiology. A quick overview of how pediatrics differ from adults. •Hypothetical Patient HR 190, BP 60/30, RR 60, HGB 19, WBC 30,000, K 7.5, NA 160.  Is you patient in trouble? •It depends because these are all normal values from a New Born. •Commonalities between adults and kids. •Same Species •Same Basic Anatomy •Generally use the same Anesthetic techniques •Generally use the same Pharmacological agents •Anesthesia Goal are the same •Sometimes the case is done the exact same as an Adult •Differences between Pediatrics and Adults. •Things tend to happen quicker in pediatrics •Kids desaturate more quickly and they will resaturate more quickly •Pediatric baseline heart rate is usually faster •Takes more finesse to work with pediatrics •Pediatrics have smaller airways, smaller veins, ect… •Physiology is different especially in newborns •More unique surgical procedures, such as a congenital diaphragmatic hernia repair •Pediatric Anatomy is slightly different from adults, therefore miller blade used more •Psychological concerns are different at different ages •Also must deal with the parents psychological concerns •NPO guidelines are shorter in pediatrics