CRNA : the clinical forum for nurse anesthetists
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Review Comparative Study
Setting the record straight on nurse anesthesia and medical anesthesiology education.
The history, qualifications, capabilities, and legal status of nurse anesthetists in the United States have been perceived by organized anesthesiology as both a professional and economic threat to the medical specialty. Such threats often lead to turf battles in which groups try to seek public affirmation of their point of view through ongoing public and/or government relation debate and activism. Medicine, including anesthesiology, has used educational preparation of physician and nurse specialists as a favorite topic for such activism. ⋯ This article is aimed at setting right the facts in the current debate used by the American Society of Anesthesiologists in regards to the comparative analysis of CRNA and anesthesiologist education. Because medicine most often uses length of education as a quality measure of that education, regardless of the validity of such arguments, this comparison is set within that framework. Unfortunately, it will not be the last work on this subject.
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The National Practitioner Data Bank (NPDB), created by the 1986 Health Care Quality Improvement Act, has been in operation since 1990. Hospitals and other credentialing bodies must query the NPDB when granting and renewing privileges. The NPDB receives about 25,000 reports of adverse actions against health practitioners each year. ⋯ Only 2% of matched reports to the NPDB made a difference in hospital privileging decisions. A limitation of NPDB information is that malpractice payments recorded in the NPDB do not necessarily constitute a comprehensive and definitive reflection of actual health care incompetence. All health care providers need to be aware of the NPDB, its mission, potential impact on their ability to be credentialed, and proposed additional uses of its information.
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Since the discovery of opiate receptors in the brain and spinal cord, considerable research has been performed to include intrathecal opioids for the control of pain. No area has used this knowledge more than the practice of obstetrical anesthesia. Intrathecal opioids have been shown to be very effective in controlling the pain experienced in the first stage of labor but have been ineffective in controlling second-stage labor pain. ⋯ Research studies have attempted to determine the optimal dose of intrathecal opioids to provide the greatest amount of analgesia with the lowest incidence of side effects. Intrathecal morphine sulfate has been shown to be effective in controlling first-stage labor pain but has been shown to be the most efficacious in controlling the pain experienced in the post-cesarean section period. This article reviews the current literature and provides background of information to understand these developments.
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A number of studies have shown conflicting results on the effect of epidural (EPI) analgesia on the length of labor. Combined spinal-epidural (CSE) and intrathecal analgesia (ITA) techniques have been used to provide pain relief for parturients, but currently there are few studies comparing EPI, CSE, and ITA techniques and their effect on the length of labor. Intrathecal opioids provide immediate pain relief for the parturient without autonomic, sensory, or motor blockade. ⋯ No statistically significant difference was found between the length of second stage for ITA and NR groups. ITA analgesia shortened the first stage significantly in both primipara and multipara patients (P < .01). These results imply that the use of intrathecal opioids in the obstetrical patient does not prolong labor and seems to shorten the first stage of labor in both the primipara and multipara patients.
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The inability to objectively evaluate the amnesic status of an anesthetized patient has been a perplexing problem for the anesthesia provider. One approach thought to be effective in evaluating the amnesic status of the anesthetized patient is the auditory midlatency response (AMLR). The AMLR is an electrophysiological response that is recorded from scalp electrodes 10 to 80 ms after the auditory pathways begin to process acoustic stimuli. ⋯ Recent results have noted that the Pa waveform, the first positive deflection of the AMLR, may be the component that may serve as an intraoperative indicator of the anesthetized patient's ability to potentially consolidate an intraoperative acoustic stimuli into a memory. With the establishment of the Pa waveform of the AMLR as a reliable indicator of intraoperative memory formation, the AMLR can then be used to significantly decrease the occurrences of traumatic neurosis in the surgical patient and subsequent medicolegal consequences for the health care team. Thus, the use of the AMLR strives to promote a safer intraoperative environment for both the patient and the anesthesia provider.