AANA journal
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The challenging Florida anesthesia workforce has 3 different types of anesthesia providers competing in the same market and a growing population ranked number 2 in the United States. This study attempted to forecast changes in supply and demand of nurse anesthetists in Florida between 2014 and 2018 by surveying hospitals and ambulatory surgical centers; 17% (87/511) responded. Current anesthesia workforce and projected needs in 1, 2, and 5 years were included in the survey. ⋯ A projected surplus of 15% (114 positions) is in line with recent projected simulated models. The predicted CRNA surplus depends on current staffing models. Nonetheless, 633 new full-time positions would represent an increase in the proportion of fulltime CRNAs in the Florida workforce.
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Hypotension and bradycardia are common adverse effects following spinal anesthesia. Ondansetron has been studied in the attenuation of spinal anesthesia– induced hypotension (SIH) and bradycardia because of its antagonistic effect on the Bezold-Jarisch reflex. The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to determine the efficacy of intravenous (IV) ondansetron in reducing the incidence of SIH and bradycardia. ⋯ Heterogeneity was summarized using randomeffects model for I(2) greater than 50%; otherwise, a fixed-effects model was performed. Intravenous ondansetron reduced the incidence of hypotension in both the all-procedure analysis group (RR, 0.64; CI, 0.45-0.90) and cesarean delivery group (RR, 0.63; CI, 0.45-0.88). For bradycardia, IV ondansetron resulted in reduced risk (RR, 0.31; CI, 0.19-0.50). Findings of our meta-analysis suggest that IV ondansetron may mitigate the risks of SIH and bradycardia following spinal anesthesia.
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The use of laryngeal mask airways with morbidly obese patients remains controversial. A recent legal case involving the use of a laryngeal mask airway with a morbidly obese patient who aspirated during the anesthetic found the anesthesia providers negligent. We sought evidence examining the use of laryngeal mask airways with obese patients undergoing surgery. ⋯ Subjects received general anesthesia with a laryngeal mask airway. Outcomes included the ability to successfully place a laryngeal mask airway, ease and time of insertion, ability to ventilate, hypoxemia, presence of laryngospasm/ bronchospasm, and/or evidence of aspiration. The trials had some methodologic concerns including the inability to blind anesthesia providers, not including exclusively morbidly obese subjects, not powered to detect all complications such as aspiration, and overall small sample sizes. The investigators reported few problems when using these devices with obese subjects. However, because of the limited amount and quality of the evidence and the catastrophic nature of potential complications, future research must be done before a recommendation can be made regarding the use of these devices with morbidly obese patients.
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The use of a supraglottic airway, also called laryngeal mask airway (LMA), is gaining in popularity for delivery of general anesthesia in certain situations and is shown to be safe. Use of infraglottic airways (tracheal tubes) allows for positive pressure ventilation and maneuvers, such as holding continuous positive pressure in the airway to check for pleural and dural leaks. We describe the successful use of the LMA (Teleflex Inc) for general anesthesia, in which continuous positive airway pressure of 15 cm H2O held for 20 seconds allowed the neurosurgeon to identify the site of a cerebrospinal fluid (CSF) leak and successfully repair the leak. A well-seated LMA can be successfully used to produce continuous positive pressure in the airway not exceeding 20 cm H2O for 20 seconds to facilitate surgical identification of CSF leaks.
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This review assessed the utility of vasopressin and vasopressin analogues for the treatment of refractory hypotension associated with angiotensin-converting enzyme (ACE) inhibitors in the perioperative setting. A systematic review of the literature was conducted using MEDLINE, Embase, and ProQuest. Six randomized controlled trials met eligibility criteria. ⋯ All of the patients receiving vasopressin demonstrated improved hemodynamic stability with small, intermittent doses, without profound ischemic changes. For management (prevention and treatment) of ACE inhibitor-associated hypotension in the perioperative setting, all studies showed statistically significant success with vasopressin or vasopressin analogues for improvement of systemic blood pressures. Before vasopressin is widely accepted as a standard of care, further studies are needed to confirm these findings and assess the general utility of vasopressin in surgical populations for management of ACE inhibitor-associated refractory hypotension.