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April 18 - 22, 2009

The Hilton Clearwater Beach Resort Clearwater, Florida

Syllabus

o f y dem AcA An A ric me April 18 - 22, 2009 The Hilton
o f y dem AcA An A ric me April 18 - 22, 2009 The Hilton
o f y dem AcA An A ric me April 18 - 22, 2009 The Hilton

Welcome to the 33rd Annual Meeting of the American Academy of Anesthesiologist Assistants!

Just as in years past, this week promises to be the big- gest annual meeting in our history. Interest in the AA pro- fession continues to grow more rapidly every year, and the best place to connect with AAs, whether in practice or in training, is at the biggest gathering of AAs in the nation, the AAAA Annual Meeting.

Take advantage of the following:

Informative lectures on a variety of topics to meet your CME needs.

Access to the leadership of the AAAA, the growing num- ber of your colleagues dedicated to getting AAs the rec- ognition they deserve.

Insights on the state of the specialty of anesthesia and the development of the relationship between the ASA and AAAA, from the perspective of keynote speaker Alex Hannenberg, ASA President-Elect.

Opportunities to meet with prospective employers

Information about the growing number of ways you can make a difference

about the growing number of ways you can make a difference Deborah Lawson, AA-C AAAA President

Deborah Lawson, AA-C AAAA President

– Clinical instruction enrichment

– Profession advocacy at the local, state, and federal level

– Charitable donations

– Committee involvement

Conversation with AAs from student to near retirement, from every corner of the AA map.

Reach out and thank our supporters, without whom our meetings would not be nearly as rich an event. Meet the AAAA office and management team from Ruggles. Join the effort to gain wider acceptance of your chosen profession. There’s no better place to do all of this than the AAAA Annual Meeting. Together we can accomplish great things, and this is our best opportunity to become the team that can deliver. Welcome!

Together we can accomplish great things, and this is our best opportunity to become the team

2

Table of Contents

AAAA Officers, Directors & Committees

4

Course Objectives

5

Faculty & Disclosures

6

33 rd Annual Conference Program

7

Saturday April 18, 2009

8:00 am-9:00 am

Perspectives on Clinical Education

10

9:00 am-10:00 am

Malpractice Lawsuit

13

10:30 am-11:30 am

The Critically Ill Obstetric Patient

26

11:30 am-12:30 pm

ASA Update

36

2:00 pm-3:00 pm

Risk Management/Management of Adverse Events

46

3:00 pm-4:00 pm

Perioperative Positioning Injuries and Their Prevention

56

Sunday April 19, 2009

12:00 pm-1:00 pm

Update on Pediatric Inductions

67

1:00 pm-2:00 pm

Post-Operative Nausea and Vomiting

72

2:30 pm-4:30 pm

Clinical Instructors’Educational Workshop

76

2:30 pm-3:30 pm

Pediatric PACU

83

3:30 pm-4:30 pm

Medication Safety in the Operating Room

88

Monday April 20, 2009

Monday April 20, 2009

8:00 am-9:00 am

Trauma Anesthesia

93

9:00 am-10:00 am

Can/Should Simulation Be Used for Certification Assessment of AA Students

101

10:30 am-11:30 am

Alpha-2 Agonists for Sedation and General Anesthesia

110

11:30 am-12:30 pm

Cardiac Output after the Pulmonary Artery Catheter

114

Tuesday April 21, 2009

8:00 am-9:00 am

Future Directions in Anesthetic Pharmacology

116

9:00 am-10:00 am

Intraoperative Fluid Management

139

10:30 am-11:30 am

Perioperative Temperature Management

164

11:30 am-12:30 pm

Lipid Rescue for Local Anesthetic Toxicity

180

Wednesday April 22, 2009

Wednesday April 22, 2009

8:00 am-9:00 am

Myocardial Ischemia and Postoperative Monitoring

193

9:00 am-10:00 am

CAAHEP/ARC-AA Update

200

10:30 am-11:30 am

Preoperative Cardiac Evaluation

201

Product Descriptions

248

Exhibitor Floor Plan & Hours

250

Conference Supporters & Exhibitors

251

3

Annual Conference Committee

Chris Caldwell, AA-C

Committee Chair

Carie Twichell, AA-C

CommitteeVice Chair

Committee Chair Carie Twichell, AA-C CommitteeVice Chair AAAA Officers & Directors PRESIDENT Deborah Lawson,

AAAA Officers & Directors

PRESIDENT Deborah Lawson, AA-C

IMMEDIATE PAST PRESIDENT Mike Nichols, AA-C

DIRECTOR #4 Lance Franklin, AA-C

PRESIDENT-ELECT Pete Kaluszyk, AA-C

DIRECTOR #1 Joe Rifici, AA-C

DIRECTOR #5 Len Boras, AA-C

SECRETARY Ellen Allinger, AA-C

DIRECTOR #2 Saral Patel, AA-C

DIRECTOR #6 Rob Wagner, AA-C, RRT

TREASURER Barry Hunt, AA-C

DIRECTOR #3 Bradley J. Maxwell, AA-C

DIRECTOR #7 Carie Twichell, AA-C

AAAA Committees

Executive Committee President, Chair President-Elect Treasurer Secretary Immediate Past President

By-laws and Ethics Committee Chair Vice-Chair

Communications Committee Chair Vice-Chair (External) Vice-Chair (Internal)

Deborah

Lawson

Pete Kaluszyk

Barry Hunt

Ellen Allinger

Mike Nichols

Saral Patel

Claire Chandler

Sarah Russell

Hojdila

Leslie Dean

Lauren

Newsletter

Co-Editors

Tiffany

Lewis-Roberts and Alyson Finamore

Committee on Education and Practice Chair Vice-Chair for Practical & Clinical Instruction Vice-Chair for Education

Finance Committee

Mike Nichols

Joe Mader

Joe Rifici

Chair

Barry

Hunt

Vice-Chair

Mike

Nichols

Membership Committee Chair Vice-Chair

National Affairs Committee Chair Vice-Chair

Amie Schilling

Hojdila

Lauren

Ellen

Mike

Allinger

Nichols

Nomination and Elections Committee Chair

Mike Nichols

Student Committee

Chair

Gudron Henry (South)

Website Committee

Chair

vacant

Delegate Assembly

Co-Speakers

Dave Biel and Shane Angus

Leadership Development Council Director

Claire Chandler

Committee for Community Initiatives Chair

Carie Twichell

Vice-Chair

Jen

Jackson

Data Collection Taskforce Chair

4

Megan Varellas

American Academy of Anesthesiologist Assistants

American Academy of Anesthesiologist Assistants 33rd Annual Conference Target Audience Certified anesthesiologist

33rd Annual Conference

Target Audience

Certified anesthesiologist assistants, anesthesiologist assistant educational program directors, and students in an accredited anesthesiologist assistant educational program will benefit from attending this meeting.

Overall Conference Objective

This conference is designed to update those who care for patients whose surgery or procedure requires the participation of the anesthesia care team. Based on comments from past conference participants, this year’s sessions are devoted to various aspects of anesthesia practice, including perioperative and postoperative issues, pediatrics, medication safety, risk management, and updates from ASA, CAAHEP and the ARC-AA. Upon completion of this course, the attendee will have a better understanding of the topics presented, have the most up to date information from the ASA, CAAHEP, and the ARC-AA, and have seen what the AAAA has done, and is continuing to do, to advance and improve the AA profession.

Statement of Need

The successful outcome of each surgery or procedure requiring anesthesia is dependent upon the knowl- edge and teamwork of the anesthesia care team. Ul- timately, the purpose of this course is to enhance the care of the patient that requires the services of the anesthesia care team. This program is also designed to enhance the educational and professional growth of anesthesiologist assistant students.

Accreditation by the American Academy of Physician Assistants

This program has been reviewed and is approved for a maximum of 21 hours of AAPA Category I CME credit by the Physician Assistant Review Panel. Physician assistants should claim only those hours actually spent participating in the CME activity. This program was planned in accordance with AAPA’s CME Standards for Live Programs and for Commercial Support of Live Programs.

Participants attending the Certification Review Course may claim a maximum of 3 hours of AAPA Category I CME credit by the Physician Assistant Review Panel.

maximum of 3 hours of AAPA Category I CME credit by the Physician Assistant Review Panel.

Hilton Clearwater Beach Resort

maximum of 3 hours of AAPA Category I CME credit by the Physician Assistant Review Panel.

5

AAAA 33rd Annual Conference Faculty

ellen Allinger, AA-c, MMSc Secretary, AAAA; National Affairs Committee Chair Anesthesia Associates of Rock Hill Rock Hill, NC

Shane Angus, MS, AA-c Assistant Program Director Assistant Professor Anesthesiologist Assistant Program Nova Southeastern University Fort Lauderdale, FL

Ann Bailey, Md Professor of Anesthesiology and Pediatrics University of North Carolina Chapel Hill Chapel Hill, NC

claire chandler, AA-c Faculty Physician Assistant Education Program University of Manitoba Winnipeg, MB, Canada

John e. ellis, Md Adjunct Professor, Department of Anesthesiology and Critical Care University of Pennsylvania School of Medicine Philadelphia, PA

Tong J. Gan, MB, BS, MHS, FrcA Professor and Vice Chair Duke University Medical Center Durham, NC

Alexander A. Hannenberg, Md President-Elect, ASA Newton-Wellesley Hospital Newton, MA

Gerald A. Maccioli, Md, FccM ASA Director (NC), Chair ASA Section on Education & Research Critical Health Systems of North Carolina Raleigh, NC

Joseph P. Mader, rn, AA-c Vice Chair, Education & Practice Committee Staff Anesthetist Mercy Anesthesiologists Springfield, OH

Tricia A. Meyer, Pharmd Director of Pharmacy, Assistant Professor of Anesthesiology Scott and White Healthcare System Temple, TX

robert c. Morell, Md Editor, APSF Newsletter Clinical Associate Professor of Anesthesiology Wake Forest University School of Medicine Adjunct Clinical Associate Professor of Anesthesia University of Florida College of Medicine Staff Anesthesiologist-Twin Cities Hospital Niceville, FL

Michael S. nichols, AA-c, MSA Immediate Past President; Chair, Education & Practice Committee; Vice Chair, National Affairs Committee Assistant Program Director & Assistant Professor Anesthesiologist Assistant Program Nova Southeastern University Fort Lauderdale, FL

roy G. Soto, Md Director of Anesthesiology Education Beaumont Hospitals Royal Oak, MI

Matthew W. Zeleznik, Md Anesthesiologist Physician Specialists in Anesthesia Atlanta, GA

Joel Zivot, Md Associate Professor, The University of Manitoba, Department of Anesthesiology; Director, Intensive Care Unit, Cardiac Sciences Program, Winnipeg Regional Health Authority; Medical Director, ICCS Cardiac Sciences Program St. Boniface General Hospital Winnipeg, MB, Canada

Disclosure Key

1. Honorarium

2. Consultant

3. Grants/Research Support

4. Stock Shareholder

5. Other Financial or Material Support

6. Speakers’Bureau

7. No Relationship with Commercial Supporters

8. Employee

Disclosures

Shane Angus, AA-C

7

Ann Bailey, MD

7

Chris Caldwell, AA-C

7

Claire Chandler, AA-C

No Disclosure Provided

John E. Ellis, MD Baxter, The Medicines Company

Tong J. Gan, MD Baxter Schering Plough, MGI, Baxter, Edwards Lifescience

Alexander A. Hannenberg, MD

Gerald A. Maccioli, MD, FCCM

6

1

3

7

7

Joseph P. Mader, RN, AA-C

7

Patricia Meyer, PharmD Merck

3

Abbott

6

Robert C. Morell, MD

7

Michael S. Nichols, AA-C Advance Education Solutions, LLC

8

Roy Soto, MD

7

Carie M. Twichell, AA-C

7

Matt Zeleznik, MD

7

Joel Zivot, MD

7

6

33rd Annual Conference Program

concurrent sessions

Friday April 17, 2009

3:00 pm-5:00 pm 5:00 pm-8:00 pm

Early Registration Board of Directors Meeting

Saturday April 18, 2009

7:00 am-4:30 pm 7:30 am-8:00 am 8:00 am-9:00 am

9:00 am-10:00 am

10:00 am-10:30 am 10:30 am-11:30 am

11:30 am-12:30 pm

12:30 pm-1:00 pm

1:00 pm-2:00 pm 1:00 pm-3:00 pm 2:00 pm-5:00 pm 2:00 pm-3:00 pm concurrent sessions
1:00 pm-2:00 pm
1:00 pm-3:00 pm
2:00 pm-5:00 pm
2:00 pm-3:00 pm
concurrent sessions

3:00 pm-4:00 pm

4:30 pm-5:30 pm 6:00 pm-8:00 pm

Registration Continental Breakfast with Exhibitors Perspectives on Clinical Education Shane Angus, AA-C / Joseph P. Mader, RN, AA-C Malpractice Lawsuit Gerald A. Maccioli, MD Coffee Break and Committee Meet and Greet with Exhibitors The Critically Ill Obstetric Patient Gerald A. Maccioli, MD ASA Update Alexander A. Hannenberg, MD Honor Awards Presentation

Lunch with Exhibitors Leadership Lunch Certification Review Course Carrie Twichell, AA-C / Joel Zivot, MD Risk Management/Management of Adverse Events Robert Morell, MD Perioperative Positioning Injuries and Their Prevention Robert Morell, MD President’s Reception (For distinguished guests and President’s Club members) Welcome Reception

Blood Drive Saturday, April 18 8 am – 5 pm Sunday, April 19 11 am
Blood Drive
Saturday, April 18
8 am – 5 pm
Sunday, April 19
11 am – 5 pm
Mandalay Room

Sunday April 19, 2009

7:00 am-5:00 pm 8:00 am-11:00 am 11:00 am-12:00 pm 12:00 pm-1:00 pm

1:00 pm-2:00 pm

2:00 pm-2:30 pm

 

2:30 pm-4:30 pm

2:30 pm-3:30 pm

3:30 pm-4:30 pm

Registration Breakfast, Annual Business Meeting, Delegate Assembly Break with Exhibitors Update on Pediatric Inductions Ann Bailey, MD Post-Operative Nausea and Vomiting Tricia A. Meyer, PharmD Coffee Break with Exhibitors Clinical Instructors’Educational Workshop Shane Angus, AA-C

Pediatric PACU Ann Bailey, MD Medication Safety in the Operating Room Tricia A. Meyer, PharmD

7

concurrent sessions

4:30 pm-5:00 pm 5:00 pm-6:00 pm 6:00 pm-8:00 pm

Break with Exhibitors Jeopardy—No CME credit awarded Student Social and Job Fair in Exhibit Area

Monday April 20, 2009credit awarded Student Social and Job Fair in Exhibit Area   7:00 am-5:30 pm 7:30 am-8:00

 

7:00 am-5:30 pm 7:30 am-8:00 am 8:00 am-9:00 am

Registration Continental Breakfast Trauma Anesthesia

9:00 am-10:00 am

Roy Soto, MD Can/Should Simulation Be Used for Certification Assessment of AA Students

10:00 am-10:30 am 10:30 am-11:30 am

Michael S. Nichols, AA-C Coffee Break Alpha-2 Agonists for Sedation and General Anesthesia

11:30 am-12:30 pm 11:30 am-12:30 pm

11:30 am-12:30 pm

11:30 am-12:30 pm

Roy Soto, MD Cardiac Output after the Pulmonary Artery Catheter

Joel Zivot, MD AA Spokesperson Training/Mock Legislative Committee Hearing (Leadership)—No CME credit awarded

12:30 pm-2:00 pm 2:00 pm-4:00 pm 4:00 pm-5:00 pm

Ellen Allinger, AA-C, MMSc Lunch on Own Student Forum Student Spokesperson Training Shane Angus, AA-C

Tuesday April 21, 2009

7:00 am-12:00 n 7:30 am-8:00 am 8:00 am-9:00 am

Registration Continental Breakfast Future Directions in Anesthetic Pharmacology

9:00 am-10:00 am

Tong J. Gan, MD Intraoperative Fluid Management

10:00 am-10:30 am 10:30 am-11:30 am

Tong J. Gan, MD Coffee Break and Committee Meet and Greet Perioperative Temperature Management

11:30 am-12:30 pm

Matt Zeleznik, MD Lipid Rescue for Local Anesthetic Toxicity

2:00 pm

Matt Zeleznik, MD 2nd Annual AAAA Golf Scramble

Wednesday April 22, 20092:00 pm Matt Zeleznik, MD 2nd Annual AAAA Golf Scramble 7:00 am-12:00 n 7:30 am-8:00 am

7:00 am-12:00 n 7:30 am-8:00 am 8:00 am-9:00 am

Registration Continental Breakfast Myocardial Ischemia and Postoperative Monitoring

9:00 am-10:00 am

John Ellis, MD CAAHEP/ARC-AA Update

10:00 am-10:30 am 10:30 am-11:30 am

Claire Chandler, AA-C Coffee Break Preoperative Cardiac Evaluation John Ellis, MD

8

concurrent sessions

Saturday April 18, 2009

7:00 am-4:30 pm

7:30 am-8:00 am

8:00 am-9:00 am

9:00 am-10:00 am

10:00 am-10:30 am

10:30 am-11:30 am

11:30 am-12:30 pm

12:30 pm-1:00 pm

1:00 pm-2:00 pm

1:00 pm-3:00 pm

 

2:00 pm-5:00 pm

2:00 pm-3:00 pm

3:00 pm-4:00 pm

4:30 pm-5:30 pm

6:00 pm-8:00 pm

Registration

Continental Breakfast with Exhibitors

Perspectives on Clinical Education Shane Angus, AA-C / Joseph P. Mader, RN, AA-C

Malpractice Lawsuit Gerald A. Maccioli, MD

Coffee Break and Committee Meet and Greet with Exhibitors

The Critically Ill Obstetric Patient Gerald A. Maccioli, MD

ASA Update Alexander A. Hannenberg, MD

Honor Awards Presentation

Lunch with Exhibitors

Leadership Lunch (by invitation only)

Certification Review Course Carrie Twichell, AA-C / Joel Zivot, MD

Risk Management/Management of Adverse Events Robert Morell, MD

Perioperative Positioning Injuries and Their Prevention Robert Morell, MD

President’s Reception (For distinguished guests and President’s Club members)

Welcome Reception

9

Perspectives on Clinical Education

Shane Angus, AA-C / Joseph P. Mader, RN, AA-C

Objective: At the conclusion of this course,the participant will 1) comprehend the significance of clinical education;2) recognize differing student learning approaches;3) understand the distinct clinical preceptor types;and 4) appreciate clinical feedback methods.

learning approaches;3) understand the distinct clinical preceptor types;and 4) appreciate clinical feedback methods. 10

10

1

Approaches to and Styles of Learning

2 Approach to Learning

3 Approach to Learning

Outcome Surface Superficial level of understanding May have knowledge of factual information Strategic Verbal level of understanding Depends on course requirements and methods of assessment

4 Approach to Learning

Outcome Deep Integrates principles with facts Uses evidence to develop arguments Deep level of understanding

5 What are learning styles?

6 Different Learning Styles

5 What are learning styles? 6 Different Learning Styles There are more than 50 different learning

There are more than 50 different learning styles. The following are the 4 main learning styles that have been identified by Honey & Mumford:

7 Active Learners

Activists… Are open minded and enthusiastic about new ideas Enjoy doing things Like to be involved Active learners learn more effectively when… They get involved in new experiences They work with others in groups and role play Chairing meetings and leading discussions Active learners learn less effectively when… Listening to lectures Following precise instructions They are reading, writing or thinking on their own

11

8

Reflective Learners

Reflectors…. Like to look at a situation from different perspectives Prefer to listen to the views of others before offering their own Think carefully before coming to a conclusion Reflective learners learn more effectively when… They have had chance to think about what they have learned They have the opportunity to observe individuals or groups at work They produce work without deadlines to meet Reflective learners learn less effectively when… They are performing in front of others They have no time to prepare

9 Theoretical Learners

Theorists… Are analytical rather than subjective in their thinking Like to think things through in a logical order Tend to be perfectionists Theoretical Learners learn more effectively when… They have to use their skills and know how They have a clear purpose They are given the opportunity to question what they are learning Theoretical Learners learn less effectively when… They have to express emotions and feelings (i.e. role play) Instructions are poor

10 Pragmatic Learners

Pragmatists… Like to try things out Can be impatient, practical and down to earth Pragmatic learners learn most effectively when… They can try out techniques and get feedback Advantages of differing techniques are made obvious There is a link between what they are learning and the task in hand Pragmatic learners learn less effectively when… They cannot see how they will benefit from what they are learning Learning is all ‘theory’ There are no instructions on how to do something

12

Malpractice Lawsuit

Gerald A. Maccioli, MD

Objective: At the conclusion of this course,the participant will be able to have a more complete understanding of the medical-legal interface and how to more actively participate if they are named in a lawsuit.

understanding of the medical-legal interface and how to more actively participate if they are named in

13

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14

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15

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16

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17

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18

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Judge’s Instructions
OnOn thisthis issueissue thethe burdenburden ofof proofproof isis onon thethe plaintiffplaintiff ThisThis meansmeans
OnOn thisthis issueissue thethe burdenburden ofof proofproof
isis onon thethe plaintiffplaintiff
ThisThis meansmeans
thatthat thethe plaintiffplaintiff mustmust prove,prove, byby thethe
greatergreater weightweight ofof thethe evidence,evidence,
thatthat thethe defendantsdefendants werewere negligentnegligent
andand thatthat suchsuch neneggliliggenceence waswas aa
proximateproximate causecause ofof thethe deathdeath ofof
PatriciaPatricia Scott.Scott.
NegligenceNegligence refersrefers toto aa person'sperson's
failurefailure toto followfollow aa dutyduty ofof conductconduct
imposedimposed byby law.law.
 The plaintiff not only has the burden of proving negligence, but also that such
 The plaintiff not only has the burden of
proving negligence, but also that such
negligence was a proximate cause of the
injury.
 ProximateProximate causecause isis aa causecause whichwhich inin aa naturalnatural
andand continuouscontinuous sequencesequence producesproduces aa person'sperson's
injury,injury, andand isis aa causecause whichwhich aa reasonablereasonable andand
prudentprudent healthhealth carecare providerprovider couldcould havehave
foreseenforeseen wouldwould pprobablrobablyy pproduceroduce suchsuch injurinjuryy oror
somesome similarsimilar injuriousinjurious result.result.
 ThereThere maymay bebe moremore thanthan oneone proximateproximate causecause
ofof anan injury.injury. Therefore,Therefore, thethe plaintiffplaintiff needneed notnot
proveprove thatthat thethe defendant'sdefendant's negligencenegligence waswas thethe
solesole proximateproximate causecause ofof thethe injury.injury. The plaintiff
must prove, by the greater weight of the
evidence,, onlyonly thatthat thethe defendant'sdefendant's negligencenegligence
waswas a proximate cause

24

II instructinstruct youyou thatthat negligencenegligence isis notnot toto bebe presumedpresumed fromfrom thethe meremere
II instructinstruct youyou thatthat negligencenegligence isis notnot toto
bebe presumedpresumed fromfrom thethe meremere factfact ofof
ininjjururyy
EveryEvery healthhealth carecare providerprovider isis underunder aa dutyduty  1.1. toto useuse hishis oror herher
EveryEvery healthhealth carecare providerprovider isis underunder aa dutyduty
 1.1. toto useuse hishis oror herher bestbest judgmentjudgment inin thethe
treatmenttreatment andand carecare ofof theirtheir patientpatient;;
 2.2.
toto useuse reasonablereasonable carecare andand diligencediligence inin
thethe applicationapplication ofof hishis oror herher knowledgeknowledge andand
skillskill toto theirtheir patient'spatient's care;care; and,and,
 33
toto provideprovide healthhealth carecare inin accordanceaccordance
withwith thethe standardsstandards ofof practicepractice amongamong
membersmembers ofof thethe samesame healthhealth carecare
professionprofession withwith similarsimilar trainingtraining andand
experienceexperience situatedsituated inin thethe samesame oror similarsimilar
communitiescommunities atat thethe timetime thethe healthhealth carecare isis
rendered.rendered.
Proximate Cause  There may be more than one proximate cause of [an injury] [damage].
Proximate Cause
 There may be more than one proximate cause of [an
injury] [damage]. Therefore, the plaintiff need not prove
that the defendant’s negligence was the sole proximate
cause of the [injury] [damage]. The plaintiff must
prove, by the greater weight of the evidence, only that
the defendant’s negligence was a proximate cause.
– Proximate cause is:
– a cause which in a natural and continuous
sequence produces a person’s [injury] [damage]
and is
– a cause which a reasonable and prudent health
care provider could have foreseen would probably
produce such [injury] [damage] or some similar
injurious result.

Was the death of Patricia Scott caused by negligence of Gerald Maccioli?

1.

Answer: 2. Was the death of Patricia Scott caused by negligence of Michele Weaver? Answer:
Answer:
2. Was the death of Patricia Scott caused by
negligence of Michele Weaver?
Answer:
Scott caused by negligence of Michele Weaver? Answer: 25 1. Was the death of Patricia Scott

25

1.

Was the death of Patricia Scott caused by negligence of Gerald Maccioli?

NO Answer: 2. Was the death of Patricia Scott caused by negligence of Michele Weaver?
NO
Answer:
2. Was the death of Patricia Scott caused by
negligence of Michele Weaver?
NO
Answer:

The Critically Ill Obstetric Patient

Gerald A. Maccioli, MD

Objective: At the conclusion of this course,the participant will have a more complete understanding of critical illness in the pregnant patient and the anesthetic implications.

will have a more complete understanding of critical illness in the pregnant patient and the anesthetic

26

ASA Update

Alexander A. Hannenberg, MD

Objective: At the conclusion of this course,the participant will be more informed on the recent initiatives of the American Society of Anesthesiologists in advancing the quality of anesthetic care and the education of anesthesia providers nationwide.

of Anesthesiologists in advancing the quality of anesthetic care and the education of anesthesia providers nationwide.

36

Achieving Excellence, Providing Value

Achieving Excellence, Providing Value Alexander A. Hannenberg, M.D. President Elect American Society of Anesthesiologists

Alexander A. Hannenberg, M.D.

President Elect American Society of Anesthesiologists

Tufts University School of Medicine Newton-Wellesley Hospital Newton, MA

Agenda

What’s going on at ASA?

Our education & research mission

Advocacy achievements & challenges

Organizational Improvement

Strategic Plan

Staffing needs assessment

Human Resources Director

Personnel performance assessment

Compensation/Benefits Policy

Upgraded Budget & Accounting

Information Technology Assessment

Integrate Park Ridge, Washington activities

Business Model for Subspecialty Support

37

Specialty Society Horsepower 2006
Specialty Society Horsepower
2006
John A. Thorner, J.D.

John A. Thorner, J.D.

Executive Vice President - Park Ridge

Executive Vice President - Park Ridge

J.D. (Georgia), M.A. Journalism (Columbia), B.A. (Duke)

Washington Post, Associated Press

Board of Directors, ASAE

Exec Director, Natl Recreation & Parks Assn.

Exec Director, Optical Society of America

of Directors, ASAE  Exec Director, Natl Recreation & Parks Assn.  Exec Director, Optical Society
of Directors, ASAE  Exec Director, Natl Recreation & Parks Assn.  Exec Director, Optical Society
of Directors, ASAE  Exec Director, Natl Recreation & Parks Assn.  Exec Director, Optical Society
of Directors, ASAE  Exec Director, Natl Recreation & Parks Assn.  Exec Director, Optical Society
of Directors, ASAE  Exec Director, Natl Recreation & Parks Assn.  Exec Director, Optical Society

A Varsity Team

Dawn Glossa, M.P.A. Director of Communications Robert Fine, J.D. Director of Subspecialty Societies Jason Byrd,
Dawn Glossa, M.P.A.
Director of Communications
Robert Fine, J.D.
Director of Subspecialty Societies
Jason Byrd, J.D.
Associate Director (DC)
Practice Mgmt & Quality Initiatives
Tom Conway, M.B.A., C.P.A. Chief Financial Officer Celeste Kirschner Director of Member Services Michael E.
Tom Conway, M.B.A., C.P.A.
Chief Financial Officer
Celeste Kirschner
Director of Member Services
Michael E. Parker, M.P.A.
Director of Information Services
Karen Buehring,
M.B.A.
Director of Human Resources

38

 

Non Dues Revenue

Enhanced Revenue from Existing Programs

Annual Meeting Exhibitor Contracting

Newsletter Advertising

New Programs/Services for Members

Coding Webinar

Products for Non-Anesthesiologists

Coding and Billing Instruction

Training in Moderate Sedation

Financial Downturn & ASA  2009 Operating Budget: 6.7% from Spendable Account  $2 million
Financial Downturn & ASA
 2009 Operating Budget: 6.7% from Spendable Account
$2 million
 Revenue from Industry at Risk
 Advertising
 Meeting Exhibits
 Foundation support
 Member Earnings
 Unemployment --> Uninsured
 Decline in Elective Surgical Procedures
 Hospital Closures
 Travel/Meeting Restrictions

Anesthesia Quality Institute

ASA-Related 501c3 Charitable Foundation

Owner & Operator of Anesthesiology’s National Clinical Registry

Quality Benchmarking Integration with Subspecialty and Surgical Registries

Credentialing: Hospital and Health Plan

MOCA

Public Reporting

Clinical Research

39

FAER Research Support 1995-2007
FAER Research Support
1995-2007
Safety Research Funding
Safety Research Funding
Annual Meeting Content Growing Program Growth 2002-2008
Annual Meeting Content Growing
Program Growth 2002-2008

40

Simulation Registry http://simulation. asahq.org/search/index.asp
Simulation Registry
http://simulation. asahq.org/search/index.asp

Money

Medicare Payment

Sustainable Growth Rate

Anesthesia Conversion Factor

Teaching Penalty

Annual Economic Value of Advocacy

 

Specialty

Member

Conversion Factor

$400 M

$13,000

SGR Relief

$170 M

$5,700

Teaching Rule

$50 M

$11,000*

Coding Changes

$300 M

$10,000

 

$920 M

$39,700

30,000 Active Members 4,500 Teaching Anesthesiologists

41

Medicare Physician Payments vs Inflation Impact of Sustainable Growth Rate Formula
Medicare Physician Payments vs Inflation
Impact of Sustainable Growth Rate Formula
SGR Reform Alternative Budget Options, Vol. I: Health Care. Congressional Budget Office, Dec 2008
SGR Reform Alternative
Budget Options, Vol. I: Health Care. Congressional Budget Office, Dec 2008

Payment Issues in Pain Medicine

ASA Advocacy

Five Year Review: E&M Increases

Practice Expense Methodology

Further Update Pending Survey Results

Imaging Services - Volume Payments

Work Value Reassessment (Survey Responses)

High Volume

3rd Five Year Review

OIG: Facet Coding Incorrect

Pump Refills & Compounded Drugs

42

Health Care Reform 2009 Anesthesiology Watch List  Expanded Health Insurance Coverage  Increase in
Health Care Reform 2009
Anesthesiology Watch List
 Expanded Health Insurance Coverage
 Increase in Government Based Programs
 Application of Medicare Payment Formula
 “Innovative” Payment Methodology
 Bundled Payments as alternative to Fee-for-Service
 Episode Treatment Groups
 Prometheus System
 Acute Care Episode Demonstration
Health Care Reform 2009 Anesthesiology Watch List  Newly Insured Seek Elective, Preventive Services 
Health Care Reform 2009
Anesthesiology Watch List
 Newly Insured Seek Elective, Preventive
Services
 Massachusetts Universal Coverage Mandate
 Demand for Services > Physician Capacity
 Primary Care Opportunity
 Non-Physician Opportunity
Physician Supply & Demand Primary Non-Primary Care Care Physician Supply and Demand: Projections to 2020,
Physician Supply & Demand
Primary Non-Primary Care Care
Physician Supply and Demand: Projections to 2020, U.S. Department of Health and Human
Services, Health Resources and Services Administration , Bureau of Health Professions
October 2006

43

Are Primary Care Recruitment Problems Economic in Origin?

Relationship of medical student debt to specialty choice:

Rosenblatt RA, Andrilla HCA

(n=14,240)

“the effect was modest” [OR=0.96]

Kahn MJ, Markert RJ et al

(n=2,022)

Acad Med 2005; 80:815

MedGenMed 2006:8(4)

“…total debt was not a predictor of a primary care residency…”[p=0.64]

Hauer KE, Durning SJ et al

(n=1,177)

JAMA 2008;300(10):1154

“…debt was not related to specialty choice.” [p=0.37]

Annual Graduating Class Size
Annual Graduating Class Size
Point, Click and You’re a Doctor On-Line Doctor of Nursing Practice Degree
Point, Click and You’re a Doctor
On-Line Doctor of Nursing Practice Degree

44

Who is a Licensed M.D. ? n=1001 2006
Who is a Licensed M.D. ?
n=1001
2006
Anesthesiologists: Physicians Providing the Lifeline of Modern Medicine
Anesthesiologists:
Physicians Providing the Lifeline of Modern Medicine
ahannenberg@partners.org
ahannenberg@partners.org

45

Risk Management/Management of Adverse Events

Robert Morell, MD

Objective: At the conclusion of this course,the participant will be able to 1) understand the nature of perioperative risk;2) appreciate the importance of eliminating the culture of blame and focusing on system approaches;3) appreciate the importance of audible alarms and 4) become familiar with medication errors, their causes and prevention.

appreciate the importance of audible alarms and 4) become familiar with medication errors, their causes and

46

Risk Management and Management of Adverse Events Robert C. Morell, MD Editor: APSF Newsletter Clinical
Risk Management and Management
of Adverse Events
Robert C. Morell, MD
Editor: APSF Newsletter
Clinical Associate Professor of Anesthesiology
Wake Forest University School of Medicine
Adjunct Clinical Associate Professor
University of Florida College of Medicine
Fort Walton Beach Anesthesia
Six Sigma Perspective • Would you fly on an airplane with 99% reliability? • Would
Six Sigma Perspective
• Would you fly on an airplane with 99% reliability?
• Would you fly on an airplane with 99.9% reliability?
• Would you fly on an airplane with 99.99% reliability?
99.99% reliability • 1:10,000 • Charlotte Douglas airport has over 500 arrivals and departures per
99.99% reliability
• 1:10,000
• Charlotte Douglas airport has over 500
arrivals and departures per day
• 1:10,000 means 1 crash every 20 days
UNACCEPTABLE

47

Key Concepts • Risk can never be zero • Goal is six-sigma • Eliminate culture
Key Concepts
• Risk can never be zero
• Goal is six-sigma
• Eliminate culture of blame
• Focus on system fixes
• Foster teamwork and team training
99.99% Reliability sounds pretty darn good, doesn’t it?
99.99% Reliability
sounds pretty darn
good, doesn’t it?
If 99.9% Reliability is OK We would expect: 500 incorrect surgeries each week 20,000 incorrect
If 99.9% Reliability is OK
We would expect:
500 incorrect surgeries each week
20,000 incorrect prescriptions filled annually
16,000 pieces of mail lost each hour
19,000 babies dropped at birth each year
22,000 paychecks incorrectly posted each hour
Your heart will fail to beat 32,000 times per year
HRO: High Reliability Organization • Failure free operation despite: – High tempo – Varying conditions
HRO: High Reliability Organization
• Failure free operation despite:
– High tempo
– Varying conditions
– Production pressures
– Changing personnel
Flattening the hierarchy • Anyone on the team can, and should, speak out without fear
Flattening the hierarchy
• Anyone on the team can, and should,
speak out without fear of reprisal
• Input of everyone is valuable and
important
• Numerous aviation examples
Don’t be afraid to speak up Don’t be too proud to listen • 30 seconds
Don’t be afraid to speak up
Don’t be too proud to listen
• 30 seconds later a 2 nd plane flies by 500
feet above the first plane
• Airman’s willingness to speak up saved a
lot of lives

48

Flattening the Hierarchy
Flattening the Hierarchy
Flattening the hierarchy • Military plane in flight • Pilot requests permission to climb to
Flattening the hierarchy
• Military plane in flight
• Pilot requests permission to climb to
35,000 feet
• Tower responds, transmission a bit hard to
hear
• Pilot believes he is granted permission
• Young airman interrupts and says he
heard differently
An Active Process is Needed HRO approach to safety requires a top down approach Production
An Active Process is Needed
HRO approach to safety requires a
top down approach
Production pressures cannot be
allowed to erode safety
All participants must “buy in”
Intensive Training During Routine Operations and In Simulations Train the system, not just the individual
Intensive Training During Routine Operations and In
Simulations
Train
the system,
not just the
individual
Over entire
career, not
just the
beginning
Tying this together – Strive toward 6 Sigma Reliability (HRO) – Eliminate the culture of
Tying this together
– Strive toward 6 Sigma Reliability (HRO)
– Eliminate the culture of blame
– Enhance communication
– Proactively examine processes (FMEA)
– Retroactively examine errors (RCA)
Why bother with those pesky alarms? Case #1 • 23 y.o. healthy male for laparoscopic
Why bother with those pesky alarms?
Case #1
• 23 y.o. healthy male for laparoscopic BIHR
• First such procedure in this hospital – filmed
• General anesthesia with Isoflurane & Atracurium
• Anesthesiologist left head of bed to watch film
crew and see video monitors
• Surgeon switched sides and anesthesiologist
returned to HOB

49

HRO Lessons Learned Teams & Microsystems are critical • Interchangeable parts model (any nurse, any
HRO Lessons Learned
Teams & Microsystems are critical
• Interchangeable parts model (any nurse, any MD)
will not always work
• Need to create & foster real teams
• Train intensively about and/or in teams
• Flatten the hierarchy
• Enhance Communication
Find system fixes, not individual fixes
• If one individual “screws up”, others probably will too
• System has to be resilient against individual failures
Clinical Alarms • Clinical alarms are often turned off • Do you always have your
Clinical Alarms
• Clinical alarms are often turned off
• Do you always have your audible alarms
turned on?
Why bother with those pesky alarms? Case #1 • Disconnect at the Y-piece, full arrest
Why bother with those pesky alarms?
Case #1
• Disconnect at the Y-piece, full arrest
• Visual alarms flashing but audio had been
silenced
• Severe permanent brain damage
Isolated occurrence? Case #2 • 32 y.o. female for laparoscopic chole • Plain film shot
Isolated occurrence?
Case #2
• 32 y.o. female for laparoscopic chole
• Plain film shot during cholangiogram
• Ventilator turned off during x-ray to
minimize artifact
No one can be vigilant 100% of the time Case #3 • 54 year old
No one can be vigilant 100% of the time
Case #3
• 54 year old for ORIF of ankle under SAB
• Patient sedated and snoring loudly
• Spinal wearing off, patient became
restless and agitated
• Additional fentanyl and midazolam given
• Patient moving hands and knocking pulse
oximeter off of his finger
• Alarm silenced
Can this happen to me? • All 3 of these cases are real cases •
Can this happen to me?
• All 3 of these cases are real cases
• Files of a malpractice carrier
• All would have been prevented by audible
alarms
• No one can be 100% vigilant 100% of the time
• When interviewed the anesthesiologists said
things like “I just got distracted, it seemed like
such a short time.”
You Bet it Can

50

We have all been there Case #2 • X-ray tech had trouble removing cassette from
We have all been there
Case #2
• X-ray tech had trouble removing cassette from
under table
• Anesthesiologist tried to help, but bed gears
became jammed
• X-ray finally removed…surgery resumed
• Anesthesiologists looks at monitor and sees
severe bradycardia
• Ventilator had been off for many minutes
• Patient died
Alarms protect our patient and protect us Case #3 • Anesthesiologist goes to foot of
Alarms protect our patient and protect us
Case #3
• Anesthesiologist goes to foot of table to
ask surgeon how much longer
• Engages in chit-chat while watching
closure
• Case over, drapes removed, patient
agonal and cyanotic
• Profound brain damage after resuscitation
It is Now Standard of Care ASA Standards for Basic Anesthetic Monitoring - October 2005
It is Now Standard of Care
ASA Standards for Basic Anesthetic Monitoring - October 2005
When the pulse oximeter is utilized, the variable pitch
pulse tone and the low threshold alarm shall be audible
to the anesthesiologist or the anesthesia care team
personnel.
When capnography or capnometry is utilized, the end
tidal CO2 alarm shall be audible to the anesthesiologist
or the anesthesia care team personnel.
Institute of Medicine 44,000-98,000 annual deaths due to preventable medical error 50% of adverse drug
Institute of Medicine
44,000-98,000 annual deaths due to
preventable medical error
50% of adverse drug reactions due to
error
ADR adds 4.6 extra hospital days and
costs $5,800 per event
How Errors Occur TRIGGER (wrong drug prescribed) 1 st Defense (distracted nurse) Latent failure (understaffing)
How Errors Occur
TRIGGER
(wrong drug prescribed)
1 st Defense
(distracted nurse)
Latent failure
(understaffing)
2 nd Defense
(pharmacy)
Latent failure
(no Rx tracking)
3 rd Defense
(another distracted nurse)
Latent failure
(understaffing)
EVENT
Enhanced Communication • Communication is a two way street • Clarity and accuracy are important
Enhanced Communication
• Communication is a two way street
• Clarity and accuracy are important for both
written and verbal communication
• Use repeat back!
• COE improves accuracy
• Don’t assume – catastrophe can follow

51

Magnitude of Drug Errors • 1990 Harvard study of New York hospitals – 19.4% of
Magnitude of Drug Errors
• 1990 Harvard study of New York hospitals
– 19.4% of errors were medication related
• Analysis of 289,000 medication orders
– Error rate was 3.1/1000 written orders
– Significant errors were 1.8/1000 written orders
• Pediatrics = high risk
– 4.9 errors/1000
– 27/479 errors were potentially lethal
How Errors Can Be Prevented TRIGGER (wrong drug prescribed) 1 st Defense (distracted nurse) Latent
How Errors Can Be Prevented
TRIGGER
(wrong drug prescribed)
1 st Defense
(distracted nurse)
Latent failure
(understaffing)
2 nd Defense
(pharmacy)
Latent failure
(no Rx tracking)
3 rd Defense
(vigilant nurse)
Latent failure
(understaffing)
Adverse Event Averted
Sources: Reason J Human error: Models and Management, BMJ, 18
March 2000. Cook R. University of Chicago, 1991-99.
Australian Incident Monitoring Study • 2000 incident reports • 117 events where wrong drug given
Australian Incident Monitoring Study
• 2000 incident reports
• 117 events where wrong drug given
• 27 events wrong drug nearly given
• 74% had potential for serious harm
• 93% involved syringes/50% were correctly
labeled
Common Causes of Medication Errors Miscommunication of Drug Orders • Written prescriptions - legibility •
Common Causes of Medication Errors
Miscommunication of Drug Orders
• Written prescriptions - legibility
• Look-alike names
• Sound-alike names
• Misuse of decimal points and zeroes
• Inappropriate abbreviations
• Misuse of metric and apothecary measures
• Ambiguous or incomplete orders
Type of Drug Administration Errors • Misidentification or a vial, ampoule, or prefilled syringe •
Type of Drug Administration Errors
• Misidentification or a vial, ampoule, or
prefilled syringe
• Mislabeling or a syringe
• Syringe swap
• Right drug but wrong concentration
• Right drug but wrong route of
administration
Labels Can Make or Break You
Labels Can Make or Break You

52

Goals for Drug Safety • Correct drug • Correct dose (death by decimal - 0.1
Goals for Drug Safety
• Correct drug
• Correct dose (death by decimal - 0.1 vs
1.0)
• Correct timing
• Correct route of administration
• Correct concentration
• Correct documentation
Typical Intraoperative Work Surface
Typical Intraoperative Work
Surface
route of administration • Correct concentration • Correct documentation Typical Intraoperative Work Surface
Look Alike Pitfalls
Look Alike Pitfalls
The Simple Things Can Get You
The Simple Things Can Get You
Visual Clues Can Fail
Visual Clues Can Fail

53

Visual Clues Can Fail
Visual Clues Can Fail
Read the Label 3 Times • When you draw up the drug • When you
Read the Label 3 Times
• When you draw up the drug
• When you attach the syringe
• When you administer the drug
One Must Read the Label
One Must Read the Label
More Needs to be Done
More Needs to be Done
Taking care of the patient • Incident supervisor • Immediate care/ resuscitation • Follow up
Taking care of the patient
• Incident supervisor
• Immediate care/ resuscitation
• Follow up care
• Appropriate consultation
Full disclosure after adverse events • Recent mandate • Old fears loosing credence • May
Full disclosure after adverse events
• Recent mandate
• Old fears loosing credence
• May actually decrease liability losses
• Patients and family deserve and need
disclosure
• Numerous examples support this

54

So what do we do when an error occurs? • Take care of the patient
So what do we do when an error occurs?
• Take care of the patient
• Take care of the family
• Take care of the providers
• Take care of the system
Taking care of the family • Full Disclosure • OK to say you are sorry
Taking care of the family
• Full Disclosure
• OK to say you are sorry
• Support
– Clergy
– Location
– Privacy
– Administration
Full disclosure • Beginning to be protected • OK to say you are sorry •
Full disclosure
• Beginning to be protected
• OK to say you are sorry
• Sorryworks.net
• Once again, good communication is key!
Full Disclosure • Shows respect for the patient, acknowledges the hurt • Re-establishes trust •
Full Disclosure
• Shows respect for the patient,
acknowledges the hurt
• Re-establishes trust
• Assures patient they were not at fault
• Reassures patient against further harm
• Shows provider is “suffering” too – levels
the playing field
Disclosure reduces Liability • Children's hospital of Minneapolis has seen nearly a 50% drop in
Disclosure reduces Liability
• Children's hospital of Minneapolis has
seen nearly a 50% drop in malpractice
lawsuits since it began the full disclosure
program.

55

Full Disclosure “Apologizing may be the most important thing that we do after an serious
Full Disclosure
“Apologizing may be the most important
thing that we do after an serious event,
both to help the patient begin to heal and
to heal ourselves”
Lucian Leape
Adjunct Professor of Health Policy
Harvard School of Public Health
Co-Founder of the NPSF

Perioperative Positioning Injuries and Their Prevention

Robert Morell, MD

Objective: At the conclusion of this course,the participant will be able to 1) identify the most common position related injuries;2) appreciate predisposing factors and the etiology of position related injuries and 3) become familiar with the types of perioperative visual loss and risk factors,and the diagnosis of these injuries.

3) become familiar with the types of perioperative visual loss and risk factors,and the diagnosis of

56

concurrent sessions

Sunday April 19, 2009

7:00 am-5:00 pm

8:00 am-11:00 am

11:00 am-12:00 pm

12:00 pm-1:00 pm

1:00 pm-2:00 pm

2:00 pm-2:30 pm

 

2:30 pm-4:30 pm

2:30 pm-3:30 pm

3:30 pm-4:30 pm

4:30 pm-5:00 pm

5:00 pm-6:00 pm

6:00 pm-8:00 pm

Registration

Breakfast, Annual Business Meeting, Delegate Assembly

Break with Exhibitors

Update on Pediatric Inductions Ann Bailey, MD

Post-Operative Nausea and Vomiting Tricia A. Meyer, PharmD

Coffee Break with Exhibitors

Clinical Instructors’Educational Workshop Shane Angus, AA-C

Pediatric PACU Ann Bailey, MD

Medication Safety in the Operating Room Tricia A. Meyer, PharmD

Break with Exhibitors

Jeopardy—No CME credit awarded

Student Social and Job Fair in Exhibit Area

66

Update on Pediatric Inductions

Ann Bailey, MD

Objective: At the conclusion of this course,the participant will understand the common methods of premedication and induction of anesthesia including having parents present in the operating room.

the common methods of premedication and induction of anesthesia including having parents present in the operating

67

Induction Techniques in Children: 2009 Ann Bailey M.D. FAAP

When discussing pediatric induction techniques, one must consider premedication options, whether parents will participate in the actual induction event, and which pharmacologic agents will be used for the induction. While some feel that premedication is not necessary, others have demonstrated that decreasing the anxiety of the child may improve postoperative outcomes and may increase parental satisfaction.

Premedication can involve many different drugs and routes of administration. Midazolam is the most commonly used pediatric premedication in the United States. It can be used intranasally in a dose 0.2 mg/kg with rapid bioavailability (5-10 min). A burning sensation in the nose and bitter taste on the posterior tongue make this less pleasant than oral midazolam. When using the commercial oral preparation (Roche), 0.5 mg/kg was found to be the minimally effective dose for a decrease in anxiolysis within 20 minutes. The IV preparation used orally may be better absorbed and therefore work more quickly. Most anesthesiologists use a maximum dose of 20 mg PO. Midazolam can be used rectally (0.3-1 mg/kg) or IM (0.1 mg/kg) but usually require specific indications.

Ketamine is another drug with multiple routes of administration. It can be used nasally (3-5 mg/kg), rectally (5-10 mg/kg), IM (2-5 mg/kg), or PO (3-9 mg/kg). Its advantages include less respiratory depression, immobility and analgesia. The disadvantages include hallucinations and secretions. Its most popular use is perhaps the PO or IM injection in patients who are combative. Often it is mixed with midazolam to allow lower doses and fewer side effects (e.g., 3 mg/kg K + 0.25 mg/kg M PO; 3 mg/kg K + 0.05 mg/kg M IM).

Alpha 2 agonists dexmedetomidine and clonidine have emerged as possible premedicants. Both have been used orally and nasally. They taste better than midazolam, but have a completely different effect on the child. While midazolam often produces a disinhibited child, the alpha-2 agonists render the child sleepy if no one arouses him/her. Unfortunately, onset of this type of sedation may take up to 60 minutes. Typical doses of both PO and nasal clonidine and dexmedetomidine are 1-4 mcg/kg.

Other premedicants such as oral fentanyl and rectal brevital have been used for pediatric patients, but their use is limited by issues such as respiratory depression. Very few anesthesiologists use these techniques regularly.

Parental presence at the induction of anesthesia (PPIA) has grown in popularity primarily in children’s hospitals. While parental satisfaction is improved when they are allowed to accompany their children to the OR, not all children are helped by this. Only those parents who are calm are able to help an anxious child. There is much data to support pharmacologic premedication as a superior anxiolytic. However, having a motivated and calm parent can helpful in some circumstances. Before embarking on a policy of PPIA in your hospital, write a policy to avoid the angry parents who insist on staying with their child, though it might be more detrimental than helpful. Define which children this will

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pertain to (usually greater than 9 months), how many parents may go back, situations where contraindications are present (RSI), and specify that the anesthesia provider has the final word on allowing parents. You must also engage your OR nurses in this policy, as they must accompany the parent from the OR while your induction proceeds.

The actual induction of pediatric patients can be accomplished by IM, IV or inhalational methods. IM Ketamine is often reserved for those patients with cardiovascular compromise or combative/highly uncooperative patients without IV access. The typical induction dose is 5 mg/kg IM, but a smaller ―stun doseof 2-3 mg/kg will often render

the

patient immobile and sedated in order to achieve IV access.

IV

propofol or pentothal can be used for inductions in children. Much as the inhalation

agents have age-related MAC requirements, the IV agents have age-related ED-50 dose requirements. In the first 14 days of life, 2-3.5 mg/kg of pentothal is required with an

increase of up to 6 mg/kg by 6 months of age. It declines to 4-5 mg/kg as the child gets

older. Propofol should be 1-2 mg/kg in the first few weeks of life, increasing to 3 mg/kg

by 6 months of age. Obviously the stability of the child dictates whether these doses are

appropriate in the actual OR setting. Propofol will cause pain in the extremity which is often not muted with fentanyl or lidocaine.

Inhalation inductions most often occur with sevoflurane, as halothane is rarely used anymore in this country. Desflurane and isoflurane are too pungent to allow an inhalation induction. While the classic teaching of incremental increases of sevoflurane remains popular, there is little scientific evidence to support this practice. If there is no contraindication to nitrous oxide, it should be used in a concentration of 70% with 30% oxygen prior to starting sevoflurane in a cooperative child. Once the child is sedated, sevoflurane should be added with an almost immediate jump to 8%. The child will have a quicker transition through stage 2 and less agitation. Because of the large alveolar

ventilation to FRC ratio (5:1) in infants and neonates, induction will be very fast and may

be accompanied by apnea. Bradycardia can occur, but is less common than with

halothane.

With rapid administration of 8% sevoflurane, seizure activity has been reported late in induction. The use of nitrous oxide may be protective against this activity. Hypocapnea associated with assisted ventilation, may provoke it. Should this occur, it is usually self- limiting with a reduction in sevoflurane concentration and allowing the CO 2 to rise.

REFERENCES FOR INDUCTION TECHNIQUES

1. Almenrader N, Larsson P, Passariello M, Haiberger R, Pietropaoli P, Lonnqvist P, Eksborg S. Absorption pharmacokinetics of clonidine nasal drops in children. Paediatr Anaesth 2009 (in press)

2. Almenrader N, Passariella M, Coccetti B, Haiberger R, Pietropaoli P. Steal induction after clonidine premedication: a comparison of oral and nasal route. Paediatr Anaesth 2007: 17: 977-82

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3.

Almenrader N, Passariello M, Coccetti B, Haiberger R, Pietropaoli P. Steal-induction after clonidine premedication: a comparison of the oral and nasal route Pediatric Anesthesia 17 (3), 230–234

4. Baum V, Yemen T, Baum L. Immediate 8% sevoflurane induction in children: a comparison with incremental sevoflurane and incremental halothane. Anesth Analg 85; 313-6; 1997

5. Bergendahl H, Lonnqvist P, Eksborg S et al. Clonidine vs. Midazolam as premedication in children undergoing adeno-tonsillectomy: a prospective, randomized controlled clinical trial. Acta Anaesthesiol Scand 48; 1292-1300; 2004

6. Berry F. Midazolam as premedication: is the emperor naked or just half-dressed?. Pediatric Anesthesia 2007; 17:4, 400–401

7. Brosius K, Bannister C. Oral Premedication in Preadolescents and Adolescents. Anesth Analg 94; 31-6; 2002

8. Caldwell-Andrews A, Kain Z, Mayes L, et al. Motivation and Maternal Presence during induction of anesthesia. Anesthesiology 103; 478-483; 2005

9. Christiansen E, Chambers N. Induction of anesthesia in a combative child: management and issues. Pediatric Anesthesia 15; 421-25; 2005

10. Constant I, Dubois M, Piat V et al. Changes in EEG and autonomic CV activity during induction of anesthesia with sevoflurane compared with halothane in children. Anesthesiology 91; 1604-15; 1999

11. Constant I, Seeman R, Murat I. Sevoflurane and epileptiform EEG changes. Paediatr Anaesth 15; 266-74; 2005

12. Cote’ C. Preoperative preparation and premedication. Br J Anesth 83; 16-28; 1999

13. Cote C, Cohen I, Suresh S et al. A comparison of 3 doses of commercially prepared oral midazolam syrup in children. Anesth Analg 94; 37-43; 2002

14. Dubois M, Piat V, Constant I et al. Comparison of three techniques for induction of anesthesia with sevoflurane in children. Pediatr Anaesth 9; 19-23; 1999

15. Fazi L, Jantzen E, Rose J et al. A comparison of oral clonidine and oral midazolam as preanesthetic medications in the pediatric tonsillectomy patient. Anesth Analg 92; 56-61;

2001

16. Feld L, Negus J, White P. Oral midazolam preanesthetic medication in pediatric outpatients. Anesthesiology 73; 831-4; 1990

17. Finley G, Stewart S, Buffet-Jerrott S et al. High levels of impulsivity may contraindicate midazolam premedication in children. Canadian Journal of Anesthesia 53:73-78 2006

18. Kain Z, Caldwell-Andrews A, Maranets I et al. Preoperative Anxiety and Emergence Delirium and Postoperative Maladaptive Behaviors. Anesth Analg 99; 1648-54; 2004

19. Kain Z, Caldwell-Andrews A, Maranaets I et al. Predicting which child-parent pair will benefit from PPIA: a decision-making approach. Anesth Analg 102; 81-4; 2006

20. Kain ZN, Mayes LC, Wang SM, et al.: Parental presence during induction of anesthesia versus sedative premedication: Which intervention is more effective? Anesthesiology 1998; 89:1147–56

21. Kain ZN, Maclaren J, Wienber M, Juszti H, Anderson D, Mayes L. How many parents should we let into the operating room? Pediatr Anesth 2009, in press

22. Kain Z, Mayes L, Wan S, et al. Parental Presence and sedative premedicant for children undergoing surgery: a hierarchical study. Anesthesiology 92; 939-7; 2000

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23.

Kain Z, Caldwell-Andrews A, Krivutza D et al. Trends in the Practice of PPIA and the use of preoperative sedative premdication in the US, 1995-2002: Results of a follow-up national survey. Anesth Analg 98; 1252-9; 2004

24. Karl H, Rosenberger J, Larach MG. Transmucosal administration of midazolam for pediatric patients. Comparison of the nasal and sublingual routes. Anesthesiology. 78(5):885-91 1993

25. Kogan A, Katz J, Efrat R, Eidelman L. Premedication with midazolam in young children:

a comparison of four routes of administration. Pediatric Anesth 12; 685-89; 2002

26. Lerman J. Anxiolysis—by the parent or for the parent? Anesthesiology 92; 925; 2000

27. Lonnqvist P, Habre W. Midazolam as premedication: Is the emperor naked or just half- dressed? Pediatric Anesthesia 2005; 15 (4), 263–265.

28. McCann M, Kain Z. The Management of Preoperative Anxiety in Children: an Update. Anesth Analg 93; 98-105; 2001 (great review article!)

29. Palermo T, Tripi P, Burgess E. Parental presence during anesthesia induction for outpatient surgery of the infant. Pediatric Anesthesia 10; 487-91; 2000

30. Sarner J, Levine M, Davis P et al. Clinical Characteristics of Sevoflurane in Children: A Comparison with Halothane. Anesthesiology 82; 38-46; 1995

31. Weber F, Wulf H, Gruber M, Biallas R. S-Ketamine and s-norketamine plasma concentrations after nasal and iv administration in anesthetized children. Pediatric Anesthesia 14; 983-988; 2004

32. Scheepers L, Montgomery C. Kinahan A et al. Plasma concentration of flumazenil following intranasal administration in children. Can J Anaesth 47; 120-4 2000

33. Stella M, Bailey A. Intranasal clonidine as a premedicant: three cases with unique indications. Paediatr Anaesth 2008: 18; 71-3.

34. Yuen VM, Hui TW, Irwin MG, Yeun MK. A comparison of intranasal dexmedetomidine and oral midazolam for premedication in pediatric anesthesia: a double-blinded randomized controlled trial. Anesth Analg 2008; 106; 1715-21

35. Zub D, Berkenbosch J, Tobias JD. Preliminary experience with oral dexmedetomidine for procedural and anesthetic premedication. Paediatric Anesthesia 15; 2005

71

Post-Operative Nausea and Vomiting

Tricia A. Meyer, PharmD

Objective: At the conclusion of this course,the participant will be able to discuss recently published guidelines for PONV.

At the conclusion of this course,the participant will be able to discuss recently published guidelines for

72

Medication Errors in the OR By Tricia A. Meyer PharmD, MS, FASHP

One of the most notable developments in the science of "medication errors and

safety" is the Institute for Medication Safety (IOM) reports titled "To Err is Human:

Building a Safer Health System" and “Preventing Medication Errors: Quality Chasm

Series.” The first IOM report is an in-depth review of errors in the health care setting.

The second IOM report highlighted that on average, a hospitalized patients is subject to at

least one medication error per day with at least 1.5 million preventable adverse drug

reactions resulting each year. Additionally, this report focused on medication safety

strategies, both new and established, with recommendations for actions to be

implemented now and in the future.

More specifically directed to the perioperative setting, another national

report in 2006 was published by The United States Pharmacopeia (USP) Center for the

Advancement of Patient Safety’s book titled “ MEDMARX Data Report: A Chartbook of

Medication Error Findings from the Perioperative Setting from 1998-2005”.

The

publication provides an in-depth review of errors occurring in the perioperative area. This

includes outpatient surgery, preoperative holding area, operating room and the

postanesthesia care unit. The report conducted an examination of 11,239 perioperative

errors reported voluntarily to the MEDMARX system. The analysis found that 3.3% of

errors in the outpatient surgery area resulted in harm; 2.8% of errors in the preoperative

holding area resulted in harm; 7.3% of errors in the operating room resulted in harm;

5.8% of errors in the postanesthesia area resulted in harm.

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An estimated 72 million patients underwent surgical and non surgical procedures

in 1996. The operating room is the most medication-intensive area of the hospital.

Anesthesia care providers decide what medication and dose that is needed, prepare the

medication and administer to the patient. With the large number of high risk

pharmacologic agents used in the majority of these cases and with the volume of

procedures increasing, so does the opportunity for medication errors.

Regulatory agencies and voluntary safety groups, such as the Institute for

Healthcare Improvement, Institute for Safe Medication Practices and the Joint

Commission, have focused on medication error reduction and adopted safety goals or

error reduction techniques to address this problem. The literature also contains research

studies and reviews on medication safety strategies in the O.R. These include

standardization (drug preparation procedures, layout of work space, syringe sizes, IV

drug concentrations), prefilled and labeled syringes, distinctive and colored labels,

separate storage areas for hazardous medications, bar coding etc. Other

recommendations include a perioperative multidisciplinary team to include anesthesia

care providers, representatives from nursing and pharmacy to develop processes for

improved perioperative medication safety.

1. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human-Building a safer health

system. Committee on the Quality of Healthcare in America; Institute of Medicine.

Washington DC: National Academy Press; 1999

2. Institute of Medicine. Preventing medication errors: Quality chasm series. Washington DC, National Academies Press; 2007

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3.

Hicks R.W. , Becker, S.C. and Cousins, D.D. (2006). MedMarx Data Report: A

Chartbook of Medication Error Findings from the Perioperative Settings from

1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety

4. Jensen L.S., Merry A.F., Webster, C.S., Weller, J. and Larsson, L. Evidence-

based strategies for preventing drug administration errors during anaesthesia.

Anaesthesia. 2004; 59:493-504

5. AORN Guidance Statement-Safe Medication Practices in Perioperative Practice

Settings. Association of Operating Room Nurses. AORN Journal; 2004;79: 674-

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6. Robinson,

Pursuing Safe Medication Use and the Promise of Technology.

MedSurg Nursing. 2007;16:92-99

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Clinical Instructors’ Educational Workshop

Shane Angus, AA-C

Objective: At the conclusion of this course,the participant will have 1) enhanced knowledge of learning methods;2) enhanced teaching skills for management of the learning environment in the operating room and classroom; 3) improved teaching efficiency and 4) learned to provide more constructive feedback.

the operating room and classroom; 3) improved teaching efficiency and 4) learned to provide more constructive

76

Pediatric PACU

Ann Bailey, MD

Objective: At the conclusion of this course,the participant will understand the common problems encountered by pediatric patients in the recovery room and methods to prevent and/or treat them.

the common problems encountered by pediatric patients in the recovery room and methods to prevent and/or

83

PACU Problems in Children Ann Bailey, M.D. FAAP

The pediatric patient who is emerging from an anesthetic will likely experience at least one problem in the PACU. The most frequently encountered complications are emergence delirium, pain, PONV, and airway problems. We will discuss these issues in more detail and the methods to prevent or treat them.

One of the most disturbing events for a parent to witness is emergence delirium (ED) sometimes called emergence agitation. It has been defined as “a disturbance in a child's awareness of and attention to his/her environment with disorientation and perceptual alterations including hypersensitivity to stimuli and hyperactive motor behavior in the immediate postanesthesia period.” Although originally reported in 1961, the incidence has gone up dramatically with the introduction of sevoflurane and desflurane. Both agents are associated with more ED than halothane or isoflurane. Younger age (<5 yrs), short surgery, preoperative anxiety, and an emotional temperament predispose to ED.

What can be done to prevent ED? First and foremost, insuring that the child is not awakening in pain is important. Fentanyl has been found to decrease the incidence of ED, even when used in anesthetics for radiologic procedures when no surgery was performed. Secondly, the type of anesthetic is very important. Propofol is associated with very little ED when used as a maintenance agent or given in a bolus of 1 mg/kg at the end of the anesthetic. In addition to narcotics and propofol, alpha-2 agonists have been successfully used during the course of the anesthetic to prevent ED. Clonidine 1-2 mcg/kg or dexmedetomidine (0.5-1 mcg/kg) given IV near the end of the anesthetic may prevent ED.

In spite of efforts to prevent ED, some children will still experience wild thrashing in the PACU. Narcotics can be used as a first choice to insure that pain is not the causative factor. Alternatively, clonidine or dexmedetomidine have been used to treat ED in the PACU. Additionally, boluses of propofol have proven effective in the PACU, although one must insure that the airway remains patent, as the child may return to a state of general anesthesia transiently.

As mentioned above, analgesia should be provided if the child is uncomfortable in the PACU. This should be accomplished through a multi-modal approach. Mild to moderate pain can be treated with acetaminophen. Ideally this would be administered as 10-15 mg/kg PO preoperatively or 40 mg/kg rectally intraoperatively to allow time to reach a peak effect in the PACU. In some cases of musculoskeletal pain, NSAIDs are highly effective analgesics. Ibuprofen 10 mg/kg can be given PO, and ketorolac 0.5 mg/kg (max dose 30 mg) can be given IV. While there are some contraindications (bleeding, renal failure), these types of drugs are highly effective in most children.

Narcotics can be given as both IV and PO formulations in the PACU. Most anesthesia providers feel comfortable using fentanyl in 0.5-1 mcg/kg boluses up to 2 mcg/kg in the PACU. Alternatively, if the child is being admitted to the hospital, morphine 0.05-0.1 mg/kg IV has a longer effect. If the child is going home, PO narcotics can be given to provide pain relief in the car and upon arrival to the home environment. Oxycodone elixir is very effective in a dose of 0.1 mg/kg. Many surgeons still order codeine for

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postoperative analgesia. Codeine is metabolized to morphine which is the active agent. Unfortunately, 10% of the population doesn’t have the enzyme necessary to convert it to an active form. More worrisome, some patients are ultra-rapid metabolizers and convert quickly with resultant respiratory depression; death has been reported as a result.

Regional anesthesia is another modality to provide for postoperative analgesia. Major blocks such as caudals can be performed in the OR for common procedures such as hernia or hypospadius repairs. Equally important, local anesthesia in the area of the surgery placed by surgeons can be very effective at ameliorating the pain.

PONV is another important complication in children. While thousands of studies have been reported in adults, less attention has been given to the children. In the most recent SAMBA guidelines for PONV prophylaxis, attention was directed to prophylaxis and management of the pediatric patient. Ondansetron and other 5 HT3 antagonists have clearly been demonstrated to be effective, as has dexamethasone. In combination, the effect is even greater. Other agents can be used be used, but have some issues. Promethazine (phenergan) is highly effective as a rescue drug, but is contraindicated in children less than 2 years of age. “Superhydration” with 30 ml/kg isotonic IV fluids was found to reduce the incidence of PONV in children. Conversely, forcing children to drink postoperatively before discharge may increase the incidence of vomiting.

Finally, respiratory issues may complicate the recovery period. It is beyond the scope of this discussion to elaborate on the many different types of airway problems, especially as related to the abnormal airway. Croup remains a largely avoidable cause of delays in PACU discharge in children. It is largely preventable in children by using appropriate sized endotracheal tubes. Most textbooks will recommend that age/4 + 4 is the appropriate inner diameter in mm of an uncuffed ETT for most children. Cuffed endotracheal tubes are now being used by most pediatric anesthesiologists for all ages of children. Cuffed ETT’s are particularly advantageous for children with a risk of aspiration, procedures associated with low lung compliance (thoracoscopies and laparoscopies), and in cases where precise control of CO2 is necessary (neurosurgery). Newer tubes are being manufactured with very thin cuffs that do not change the outer diameter significantly. Although original articles recommended that the equation for cuffed ETT’s is age/4 + 3 in mm, most users are moving to a half-size smaller than an uncuffed ETT. Always when using a cuffed ETT, cuff pressures should be measured and the cuff should be inflated to just seal at 20-30 cm H2O.

In summary, pediatric patients experience issues with emergence delirium, pain, PONV, and croup in the PACU. By anticipating the problems, the anesthetic can be tailored to prevent their occurrence. However, in spite of the best anesthesia, problems will still arise, and the anesthesia provider should be prepared to treat them appropriately.

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References for Pediatric PACU Problems

1. Vlajkovic GP, Sindjelic RP. Emergence Delirium in children: many questions, few answers. Anesth Analg. 2007 Jan;104(1):84-91 (great review article!)

2. Aono, J, Wasa U, Kikyo M, Takimoto E, Manabe M. Greater Incidence of Delirium during recovery from Sevoflurane Anesthesia in Preschool Boys. Anesthesiology 1997; 87; 1298-1300

3. Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology 2004;100:1138–45

4. Davis P, Cohen I, McGowan F, Latta K: Recovery Characteristics of Desflurane versus halothane for maintenance of anesthesia in pediatric ambulatory patients. Anesthesiology 1994; 80: 298-302

5. Cravero J, Surgenor S, Whalen K. Emergence agitation in pediatric patients after sevoflurane anesthesia and no surgery; a comparison with halothane. Paediatr Anaesth 2000; 10; 419-24

6. Welborn L, Hannallah R, Norden J, Ruttimann U, Callan C. Comparison of Emergence and Recovery Characteristics of Sevoflurane, Desflurane, and Halothane in Pediatric Ambulatory Patients. Anesth Analg 1996; 83; 917-20

7. Tobias, et al. Additional experience with Dexmedetomidine in Pediatric patients. South Med J. 2003 Sep;96(9):871-5

8. Ibacache et al; Single-Dose Dexmedetomidine Reduces Agitation After Sevoflurane Anesthesia in Children Anesth Analg. 2004 Jan;98(1):60-3

9. Isik et al. Dexmedetomidine decreases emergence agitation in pediatric patients after sevoflurane anesthesia without surgery. Pediatric Anesthesia 2006

10. Malviya S, et al: Clonidine for the prevention of emergence agitation in young children:

efficacy and recovery profile. Pediatric Anesthesia; 16; 554-559; 2006

11. Lankiinen U, Avela R, Tarkkila R. The prevention of emergence agitation with tropsietron or clonidine after sevoflurane anesthesia in small children undergoing adenoidectomy. Anesth Analg 102; 1383-1386; 2006

12. Aouad MT, Yazbeck-Karam VG, Nasr VG et al. A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia Anesthesiology. 2007 Nov;107(5):733-8

13. Abu-Shahwan I. Effect of propofol on emergence behavior in children after sevoflurane general anesthesia Paediatr Anaesth. 2008 Jan;18(1):55-9.

14. Galinkin J, Fazi L, Cuy R, Chiaviacci R, Kurth D, Shah U, Jacobs I, Watcha M. Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia. Anesthesiology 2000; 90; 1378

15. Birmingham P, Tobin M, Fisher D, Henthorn T, Hall S, Cote’ C. Initial and Subsequent Dosing of Rectal Acetaminophen in Children. Anesthesiology 2001; 94: 385-9

16. Birmingham P, Tobin J, Henthorn T, Fisher Dm Berelhamer M, Smith F, Fanta K, Cote’ C: 24 hour pharmacokinetics of rectal acetaminophen in children. Anesthesiology 1997: 87; 244-52

17. Houck C, Wilder RT, McDermott J, Sethna N, Berde C. Safety of intravenous ketorolac therapy in children and cost savings with a unit dosing system. J Pediatrics 1996; 129; 292-6

18. Rusy L, Houck C, Sullivan L, Ohlms L Jones D, McGill T, Berde C. A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding. Anesth Anal 1995: 80; 226-9

19. Anderson BJ, Holdord N, Woollard G, Kanagasundarum S, Mahadevan M. Perioperative pharmacodynamics of acetaminophen analgesia in children. Anesthesiology 1999; 90; 411-21

20. Tobias J. Weak Analgesics and Nonsteriodal Anti-inflammatory agents in the management of children with acute pain. Ped Clin N Amer 2000; 47; 527-43

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21.

Finkel J, Cohen, Hannallah R, Patel K, Kim M, Hummer K, Choi S, Pena M, Schreiber S, Zalzal G. The effect of intranasal fentanyl on the emergence characteristics after sevoflurane anesthesia in children undergoing surgery for BMT placement. Anesth Analg 92; 2001: 1164-8

22. Clark E, Plint A, Corrett R et al. A randomized trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics 2007; 119; 460-7

23. Hiller A, Meretoja O, Korpela R, et al. The analgesic efficacy of acetaminophen, ketoprofen, or their comgination for pediatric surgical patients having soft tissue or orthopedic surgery. Anesth Analg 102; 13651371; 2006

24. Madan R, Bhatia A, Chakithandy S, et al.Prophylactic Dexamethasone for Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Dose Ranging and Safety Evaluation Study. Anesth Analg 2005;100:1622-1626

25. Hertzka R, Gauntlett I, Fisher D, Spellman M. Fentanyl induced ventilatory depression: effects of age. Anesthesiology 70: 213-8: 1989

26. Edler A, Mariano E, Golianu B, Kuan C, Pentcheva K. An analysis of factors influencing postanesthesia recovery after pediatric ambulatory tonsillectomy and adenoidectomy; Anesth Analg 104; 784-89; 2007

27. Patel R, Davis P, Orr R, Ferrari L, Rimar S, Hannallah R, Cohen I, Colingo K, Donlon J, Haberkern C, McGowan F, Prillaman B, Parasuraman T, Creed M. Single-dose ondansetron prevents postoperative vomiting in pediatric patients. Anesth Analg 1997; 85; 538-45

28. Khalil S, et al.A Double-Blind Comparison of Intravenous Ondansetron and Placebo for Preventing Postoperative Emesis in 1- to 24-Month-Old Pediatric Patients After Surgery Under General Anesthesia. Anesth Analg; 2005;101:356-361

29. Goodarzi M, et al. A prospective randomized blinded study on the effect of intravenous fluid therapy on PONV in children undergoing strabismus surgery. Pediatric Anaesth 2006; 16; 49-53

30. Sadhasivam S, Shende D, Madan R. Prophylactic Ondansetron in prevention of postoperative nausea and vomiting following pediatric strabismus surgery. Anesthesiology 2000; 92; 1035-42

31. Schreiner M, Nicholson S, Martin T, et al: Should children drink before discharge from day surgery? Anesthesiology 1992; 76; 528-533

32. Gan TJ, Meyer TA, Apfel CC, et al.SAMBA guidelines for management of PONV. Anesth Analg 2007; 105: 1615-28

33. Eberhart LH, Geldner G, Kranke P, et al. The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Anesth Analg. 2004

Dec;99(6):1630-7

34. Schreiner M, Nicholson S. Pediatric ambulatory anesthesia: NPO before or after surgery? J Clin Anesth; 1995; 7; 589-596

35. Khine et al: Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology 1997; 86: 627-31

36. Duracher et al. Evaluation of cuffed tracheal tube size predicted using the Khine formula in children. Pediatric Anesthesia 18 (2) , 113–118; 2008

37. James I: Cuffed tubes in children. Pediatric Anaesth 2001; 3; 259

38. Fine G, Borland L. The future of the cuffed endotracheal tube. Pediatric Anesthesia 2004; 14;

38-42

39. Dullenkopf, A., Gerber, A. C. & Weiss, M. Fit and seal characteristics of a new paediatric tracheal tube with high volume–low pressure polyurethane cuff.Acta Anaesthesiologica Scandinavica 49 (2), 232-237

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Medication Safety in the Operating Room

Tricia A. Meyer, PharmD

Objective: At the conclusion of this course,the participant will be able to recommend at least two strategies for improvement of medication safety in the operating room.

will be able to recommend at least two strategies for improvement of medication safety in the

88

Medication Errors in the OR By Tricia A. Meyer PharmD, MS, FASHP

One of the most notable developments in the science of "medication errors and

safety" is the Institute for Medication Safety (IOM) reports titled "To Err is Human:

Building a Safer Health System" and “Preventing Medication Errors: Quality Chasm

Series.” The first IOM report is an in-depth review of errors in the health care setting.

The second IOM report highlighted that on average, a hospitalized patients is subject to at

least one medication error per day with at least 1.5 million preventable adverse drug

reactions resulting each year. Additionally, this report focused on medication safety

strategies, both new and established, with recommendations for actions to be

implemented now and in the future.

More specifically directed to the perioperative setting, another national

report in 2006 was published by The United States Pharmacopeia (USP) Center for the

Advancement of Patient Safety’s book titled “ MEDMARX Data Report: A Chartbook of

Medication Error Findings from the Perioperative Setting from 1998-2005”.

The

publication provides an in-depth review of errors occurring in the perioperative area. This

includes outpatient surgery, preoperative holding area, operating room and the

postanesthesia care unit. The report conducted an examination of 11,239 perioperative

errors reported voluntarily to the MEDMARX system. The analysis found that 3.3% of

errors in the outpatient surgery area resulted in harm; 2.8% of errors in the preoperative

holding area resulted in harm; 7.3% of errors in the operating room resulted in harm;

5.8% of errors in the postanesthesia area resulted in harm.

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An estimated 72 million patients underwent surgical and non surgical procedures

in 1996. The operating room is the most medication-intensive area of the hospital.

Anesthesia care providers decide what medication and dose that is needed, prepare the

medication and administer to the patient. With the large number of high risk

pharmacologic agents used in the majority of these cases and with the volume of

procedures increasing, so does the opportunity for medication errors.

Regulatory agencies and voluntary safety groups, such as the Institute for

Healthcare Improvement, Institute for Safe Medication Practices and the Joint

Commission, have focused on medication error reduction and adopted safety goals or

error reduction techniques to address this problem. The literature also contains research

studies and reviews on medication safety strategies in the O.R. These include

standardization (drug preparation procedures, layout of work space, syringe sizes, IV

drug concentrations), prefilled and labeled syringes, distinctive and colored labels,

separate storage areas for hazardous medications, bar coding etc. Other

recommendations include a perioperative multidisciplinary team to include anesthesia

care providers, representatives from nursing and pharmacy to develop processes for

improved perioperative medication safety.

1. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human-Building a safer health

system. Committee on the Quality of Healthcare in America; Institute of Medicine.

Washington DC: National Academy Press; 1999

2. Institute of Medicine. Preventing medication errors: Quality chasm series. Washington DC, National Academies Press; 2007

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3.

Hicks R.W. , Becker, S.C. and Cousins, D.D. (2006). MedMarx Data Report: A

Chartbook of Medication Error Findings from the Perioperative Settings from

1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety

4. Jensen L.S., Merry A.F., Webster, C.S., Weller, J. and Larsson, L. Evidence-

based strategies for preventing drug administration errors during anaesthesia.

Anaesthesia. 2004; 59:493-504

5. AORN Guidance Statement-Safe Medication Practices in Perioperative Practice

Settings. Association of Operating Room Nurses. AORN Journal; 2004;79: 674-

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6. Robinson,

Pursuing Safe Medication Use and the Promise of Technology.

MedSurg Nursing. 2007;16:92-99

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concurrent sessions

concurrent sessions Monday April 20, 2009   7:00 am-6:00 pm Registration 7:30 am-8:00 am Continental

Monday April 20, 2009

 

7:00 am-6:00 pm

Registration

7:30 am-8:00 am

Continental Breakfast

8:00 am-9:00 am

Trauma Anesthesia Roy Soto, MD

9:00 am-10:00 am

Can/Should Simulation Be Used for Certification Assessment of AA Students Michael S. Nichols, AA-C

10:00 am-10:30 am

Coffee Break

10:30 am-11:30 am

Alpha-2 Agonists for Sedation and General Anesthesia Roy Soto, MD

 

11:30 am-12:30 pm

Cardiac Output after the Pulmonary Artery Catheter Joel Zivot, MD

11:30 am-12:30 pm

AA Spokesperson Training/Mock Legislative Committee Hearing (Leadership) No CME credit awarded Ellen Allinger, AA-C, MMSc

 
 

12:30 pm-2:00 pm

Lunch on Own

2:00 pm-4:00 pm

Student Forum

4:00 pm-5:00 pm

Student Spokesperson Training Shane Angus, AA-C

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Trauma Anesthesia

Roy Soto, MD

Objective: At the conclusion of this course,the participant will be able to 1) discuss leading causes of injury in the United States with associated morbidity and mortality;2) understand the importance of initial evaluation and immediate resuscitation of the trauma patient;3) discuss appropriate transfusion triggers for blood and blood components in the trauma patient and 4) discuss appropriate management of the patient with the unstable cervical spine.

components in the trauma patient and 4) discuss appropriate management of the patient with the unstable

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Anesthesia for Trauma Surgery Roy G. Soto, M.D.

Introduction

Depending on the practice you ultimately choose, trauma may become a daily part of your anesthetizing life. Patients presenting with traumatic injuries can represent a significant challenge to many aspects of your practice, with airway and IV challenges being the norm, and hemodynamic stability being a constant challenge. In this discussion we will discuss the epidemiology, assessment, and specific challenges associated with traumatic injury.

Epidemiology

Injuries are the leading cause of death in America for children and young adults, with 150,000 deaths and 450,000 new patients suffering permanent disability each year. 1/3 of all hospital admissions are for injury, and the estimated annual cost of trauma care exceeds $400 billion. Contrary to common belief, trauma is not a random occurrence, and these patients have an increased likelihood of drug abuse, intoxication, and hepatitis/HIV infection.

Regional trauma care is organized on the premise that most patients die soon after injury, and care received in the “golden hour” after injury is most likely to reduce mortality. Level 1 and 2 trauma centers were developed in an attempt to get “the right patient to the right hospital at the right time.”

Mechanisms of injury

Data from the National Trauma Data Bank reveal the following trends:

1)

The majority of reported traumas occur in young males

2)

Case fatality rises with age at time of injury

3)

Motor vehicle accidents are the main cause of injury in young and middle-aged patients,

4)

with falls becoming predominant in elderly patients The vast majority of injuries are blunt

5)

Penetrating injuries have the highest associated mortality

6)

Burns result in the longest hospital stay

7)

America leads the world in firearm related deaths in both adults and children, with an

8)

incidence 4x higher than any other industrialized country Firearm deaths occur predominantly in African-American men

Patient assessment

It is very important to remember that traumatic injuries rarely occur in isolation, meaning that a dislocated shoulder following an MVA is probably not the patient’s only injury. As a result, a number of scoring systems have been developed to ensure uniformity in the approach to injury. Airway/Breathing/Circulation/Disability represent the “A, B, C, and D” approach to initial assessment, and Advanced Trauma Life Support, taught by the American College of Surgeons, is designed to assess a patient in a standardized fashion, ensuring a “tube or finger in every orifice”. The patient’s clothes are removed, IV access is obtained, and the entire body is visually examined for injury. The Injury Severity Scale correlates well with risk of coagulopathy, case fatality, and hospital stay, and takes into account severity of injury of separate body parts:

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ISS = A 2 + B 2 + C 2 A, B, C = AIS

ISS = A 2 + B 2 + C 2

A, B, C = AIS score of three most injured of:

Head Face Thorax Abdomen Extremities (incl. pelvis)

*AIS=Abbreviated Injury Scale

The Glasgow Coma Scale (GCS) was developed to assess level of neurologic injury, and includes assessments of movement, speech, and eye opening:

was developed to assess level of neurologic injury, and includes assessments of movement, speech, and eye

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Regardless of assessment method, however, it is vital to remember that these scores do not predict ease of intubation/ventilation, or reflect volume, pulmonary, or cardiac status. In other words, a patient with a high GCS and low ISS may still require urgent intubation or may be suffering myocardial ischemia due to injury-related stress.

Specific challenges

Many hospitals routinely call anesthesia personnel to the emergency department for incoming trauma patients. As a result, anesthesia providers are frequently involved in resuscitation and airway management within minutes of patient arrival. Since initial trauma care occurs on a continuum from the emergency department to operating room, many of the following discussion points are pertinent to each specialty and each locale. As a result, anesthesia providers must be prepared to “work” in a potentially unfamiliar environment with a different (not necessarily better or worse) level of help and equipment than is typically available in a well-stocked trauma operating room.

The trauma arrest

Patient’s requiring CPR following trauma have an almost universally poor prognosis, with blunt trauma + arrest mortality approaching 100%, and penetrating trauma + arrest being just as bad, with the exception of young, otherwise healthy patients receiving hospital care within 10min of their injury. For any hope of survival, early intubation with appropriate oxygenation and ventilation is required, as is aggressive fluid management.

The trauma airway

Emergent management of the trauma airway can be the single most challenging aspect of anesthesia care, and proper preparation and multiple backup plans are equally important. Airway damage, cervical spine injury, intoxication, and coexisting injury can combine to create a situation requiring experience, expertise, and luck! Fiberoptic intubation may be impossible due to airway blood or patient belligerence. Rapid sequence induction may be contraindicated due to neck or head injury. LMA placement may be complicated by a full stomach. The patient may come with a Combitube in place, but then require positive pressure ventilation for increased ICP.

My own “combative trauma airway” plan looks something like this:

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If the airway appears “easy” (and that’s certainly open to interpretation), then I proceed with

If the airway appears “easy” (and that’s certainly open to interpretation), then I proceed with an asleep intubation with inline stabilization (inline traction used to be used, but was associated with neck injury). If the airway is “difficult” (again, open to interpretation, hence the asterisk) I would proceed, again, with RSI with ENT backup (meaning that they’re standing next to me with a knife ready) or try to hedge my bets and give a dose of intravenous or intramuscular ketamine with the hopes that ventilation would be maintained, and I’d be able to proceed with awake techniques.

If at all possible, and I find myself on the red side of the flowchart, I prefer to bring the

patient to the operating room for the intubation. I can manage my equipment better there, I have help that is used to dealing with airway management, and I have a well lit, non-chaotic environment to work in. Finally, if intubating in the ER, and someone else wants to try the intubation first, the answer is always “no”! The first attempt is always the best.

One of my favorite sayings? “Good judgement comes from experience, and experience comes from bad judgement” (that would be represented by the question-mark box). Good luck!

Clearing the C-spine

Typical scenario: A patient comes to the operating room from the CT scanner for urgent splenectomy. He’s been poked, prodded and scanned prior to arrival, but is still wearing

a C-collar. Is it OK to take it off? Just how does one clear the C-spine definitively? The

short answer is that all imaging studies must be negative, and the patient must be able to clearly tell you that nothing hurts. That said, patients frequently can’t do that. So for

me to clear a C-spine, I need:

1)

Cleared films (X-ray, CT, and/or MRI). Note that following an MVA the most

2)

likely injuries are to C1 > C5 > C6 > C7, and following a fall C5 > C6 > C7 The patient has to be awake, coherent, and cooperative

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3)

The patient cannot be intoxicated (alcohol, drugs, or otherwise)

4)

The patient cannot have a distracting injury that is causing more pain than he

5)

may have in his neck The patient cannot have received a significant dose of opiates (just how much is

6)

significant is unclear, but if the patient is somnolent, I don’t trust that the opiates haven’t blunted subjective pain complaints) The patient cannot have tenderness to neck palpation or tenderness to gentle neck flexion/extension

If all of these criteria are not met (they rarely are), then I again proceed with a rapid sequence induction with inline stabilization (given a normal airway). The job of the person holding stabilization is to not only hold the head/neck in neutral position, but also to inform the intubator if the neck is moving due to vigorous laryngoscopy. Note that there will be another person holding cricoid pressure during this process, and I therefore always remove the anterior portion of the cervical collar during intubation.

Head trauma

Patients presenting with head trauma can pose a difficult challenge to anesthesia providers. Laryngoscopy, succinylcholine, and sedation/hypoventilation are associated with increases in intracranial pressure (ICP). Techniques to maintain cerebral perfusion pressure >60mmHg (MAP minus ICP) while also keeping ICP as low as possible include:

1)

Fluid restriction (difficult if coexisting injuries present)

2)

Diuresis with mannitol (0.5gm/kg)

3)

Steroids (dexamethasone 1mg/kg)

4)

Barbiturates or hypothermia in rare instances for reduction of cerebral metabolic

5)

rate Hyperventilation to a PaCO 2 of 26-30mmHg

6)

Lidocaine and/or opiates to attenuate laryngeal/tracheal response to intubation

7)

Slight head-up position

8)

Avoidance of ketamine

9)

Avoidance of hyperglycemia

10) Hypertonic saline (unproven benefit, although may be beneficial for volume resuscitation of other injuries in the brain-injured patient)

As always, communication with the surgeon is important, as is having a high index of suspicion for coexisting injuries that may complicate management. As a rule, “conscious sedation” of brain injured patients is contraindicated as it may result in hypoventilation, hypercapnea, and acidosis. Similarly, spontaneous ventilation under general anesthesia (for instance with an LMA) is also associated with predictable hypercapnea and should be avoided.

Bleeding

All bleeding stops eventually…unfortunately it’ll stop either with or without your help! Trauma patients frequently need volume resuscitation, blood, coagulation factors, and more volume resuscitation while surgeons attempt to fix whatever was broken, ruptured, or eviscerated. ATLS requires trauma patients to have large-bore IV access, ideally via central catheters. Femoral venous lines are frequently placed, but beware of vena caval

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injuries and resuscitation through a groin line. It does no good for blood to be pumped by you into the patient’s abdomen and onto the floor! Consider a line above and below the suspected area of injury.

Progressive hypothermia, coagulopathy, and hypovolemia/acidosis (the so-called “lethal triad”) result in progressive mortality. Resuscitation efforts must be geared towards avoiding all three, and aggressive volume replacement, room/fluid temperature control, and blood product/factor replacement must be addressed simultaneously.

Hypothermia: Trauma ORs should be kept warm, all fluids should be warmed (ideally starting in the ER), and irrigation should be near body temperature. Rapid fluid infusers do a good job of warming fluids quickly, and should be used whenever possible for massive tranfusion.

Hypovolemia/acidosis: Commonly administered crystalloid solutions are acidic, with 0.9% normal saline having a pH of 5.0, and lactated ringers having a pH of

6.2. Large volumes of crystalloid resuscitation can result in metabolic acidosis

from the fluids alone, let alone from the initial hypovolemia, so care in fluid choice

should be given. Colloids have not been shown consistently to be better or worse than crystalloids, and many providers will mix and match in an attempt to avoid giving too much of any one thing. In the face of uncontrolled bleeding, evidence suggests that the goal should be a BP s of ~80mmHg, although existing head trauma and CPP should be kept in mind (see below).

head trauma and CPP should be kept in mind (see below).  Coagulopathy: Crystalloid/colloid resuscitation can

Coagulopathy: Crystalloid/colloid resuscitation can result in dilutional coagulopathy, which can worsen coagulopathy from blood replacement or hypothermia. Rather than giving factors only if laboratory values are abnormal, most hospitals have adopted a massive transfusion protocol aimed at replacing factors at pre-set intervals. Recombinant Factor VIIa has been used by some in trauma resuscitation, and it appears that survival may be improved with its use. The high cost of the drug (>$5000/dose), however, limits its utility. Finally, calcium replacement must be considered during massive transfusion as calcium

is a cofactor in both the intrinsic and extrinsic clotting pathways, and citrate in

transfused blood can result in hypocalcemia. trauma blood/massive transfusion protocol)

(see below for our hospital’s

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Trauma Blood, William Beaumont Hospital

O-neg x 2 units, then

O-pos if

o

o

Male

Obviously non-child bearing age

Continue with O-neg

Massive Transfusion Protocol, William Beaumont Hospital

Thaw 4u FFP and 1u Cryo

Crossmatch 6u PRBC and 1u Plt

Deliver to OR

Cooler #1: 4u PRBC

Cooler #2: 2u PRBC + 3u FFP

Bucket: Cryo + Plt

Continue to replenish coolers/bucket until told to stop

A final word about bleeding. Surgeons are very good at packing wounds to stop them from bleeding, and at times it is important to ask the surgeons to “stop working, pack the wound, and let me get caught up on blood loss here (please)”. Similarly, there are times when an injury should be packed and the patient sent to the ICU, with a plan to bring the patient back another day for a staged repair. As eloquently stated by one author: “The key underlying principle is that the completeness of the anatomic repair is temporarily sacrificed so as to address the patient's physiologic insult before the patient's fragile physiologic envelope is shattered.” Always remember, your surgeon is your ally in this bloody battle, and you must communicate back and forth throughout the trauma case.

References:

1. Sell SL, Avila MA, Yu G, Vergara L, Prough DS, Grady JJ, DeWitt DS. Hypertonic resuscitation improves neuronal and behavioral outcomes after traumatic brain injury plus hemorrhage. Anesthesiology. 2008; 108:873-81

2. Spinella PC, Perkins JG, McLaughlin DF, Niles SE, Grathwohl KW, Beekley AC, Salinas J, Mehta S, Wade CE, Holcomb JB. The effect of recombinant activated factor VII on mortality in combat-related casualties with severe trauma and massive transfusion. J Trauma. 2008; 64:286-93

3. Hirshberg A, Stein M, Adar R. North Am. 1997; 77:897-907

Reoperation. Planned and unplanned. Surg Clin

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Can/Should Simulation Be Used for Certification Assessment of AA Students

Michael S. Nichols, AA-C

Objective: At the conclusion of this course,the participant will be able to 1) describe current AA certification testing mechanisms;2) describe elements of validity and reliability in performance testing;3) relate positive aspects and potential pitfalls of utilizing simulation-based assessment and 4) understand the theory behind potential changes in the AA certification process.

simulation-based assessment and 4) understand the theory behind potential changes in the AA certification process. 101

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Can or Should Simulation Be Used for Assessment of Anesthesiologist Assistant Competence for Clinical Practice

Michael S. Nichols, AA-C, MSA

Assistant Program Director Anesthesiologist Assistant Program Assistant Professor Nova Southeastern University College of Allied Health & Nursing

Immediate Past President American Academy of Anesthesiologist Assistants

Course Purpose: A basic explanation of the rationale behind various high-stakes testing modalities used to assess clinical competence. Additionally, the course will cover an explanation of the positive and negative aspects of utilizing simulation and/or oral board examinations as a component of the anesthesiologist assistant certification.

Learning Objectives:

(1) Define the need for assessment of clinical competence in anesthesia practice

(2) Describe current AA certification testing and evaluation mechanisms

(3) Describe elements of validity and reliability in performance testing, with a focus on simulation

(4) Relate positive aspects and potential pitfalls of utilizing simulation-based assessment in high-stakes testing

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There is only one sort of licensing test that is significant, namely a test that ascertains the practical ability of the student confronting a concrete case to collect all relevant data and to suggest the positive procedure applicable to the conditions disclosed. A written examination may have some incidental value; it does not touch the heart of the matter.

Introduction

(Flexner, 1910)

It is generally accepted that the public perceives that board certification, such as by the National Commission for the

Certification of Anesthesiologist Assistants (NCCAA) or American Board of Anesthesiology (ABA) is the “gold standard” and, if a clinician possesses this credential, he or she has the knowledge and skills required to be competent. However, evidence is mixed as to whether successfully attaining these qualifications actually results in safe and competent practice (McIntosh, 2009).

Trends in modern health care are patient-centered, incorporating as much customer service and patient safety as medical knowledge. This ‘new, old paradigm of medicine’ (Sween, 2009) includes a demand that the performance

of clinicians be assessed formally. Additionally, pressure is now coming from a variety of sources, whether external

regulation or internal quality control, to provide evidence that graduates from training programs have reached a satisfactory standard (Glavin & Gaba, 2008). However, there is little or no understanding of the difficulties involved

in the design of valid tests of performance. Of the many problems facing an investigator who is setting out to

measure performance, one of the greatest is devising a standardized procedure.

The complexity of evaluation of medical competence has been well documented in the educational literature (Morgan & Cleave-Hogg, 2000), which is compounded by the lack of reliable and valid techniques with which to teach and evaluate the clinical skills of students and seasoned clinicians, having long been recognized as a deficiency of medical education (Murray, 2002). Simulation is one method that can be used to evaluate a clinician’s ability to integrate diagnostic hypotheses and provide treatment in situations that require rapid action.

Assessment of clinical competence is moving away from testing what a clinician knows, towards assessing what a he or she does in clinical practice (Weller, 2003). Direct observation of performance in the workplace would be the

most valid method for assessing clinical performance, but has obvious limitations. Even more difficult is assessment

of performance in a crisis situation. In this presentation we will review some of these developments, discuss the

limitations and pitfalls in the assessment of clinical reasoning, and offer suggestions for future assessment practice.

The Role of Assessment in Defining Clinical Competence

A competency is the ability to handle a complex professional task by integrating the relevant cognitive, psychomotor

and affective skills. More specifically, one can define competence in medicine as “…the habitual and judicious use

communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice ”

for the benefit of the individuals and communities being served

of

(Crossley J, 2002).

Work on the assessment of competent clinical reasoning began in the 1960s and 1970s. At that time clinical reasoning was perceived as a generic quality-a personal attribute reflecting the ability to solve problems in the clinical domain. As such it was thought to be largely independent of factual knowledge and procedural skills; in other words, a good problem-solver would be effective in solving problems irrespective of the clinical circumstances. From this perspective clinical reasoning was akin to a psychological characteristic or personality trait. In that era, clinical reasoning was typically measured by asking students to respond to problems that could be presented in standardized format with objective scoring of answers.

Ideally, the assessment of competence (what the student or physician is able to do) should provide insight into actual performance (what he or she does habitually when not observed), as well as the capacity to adapt to change, find and generate new knowledge, and improve overall performance (Epstein, 2007). It is also essential to be able to assess

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these skills explicitly to provide structured feedback about performance and to allow training effectiveness to be evaluated (Fletcher, 2003). To the detriment of the students, traditional medical education tends to persist an inclination to break down the competency trying to be assessed into smaller units, which are then assessed separately in the conviction that mastery of the parts will automatically lead to competent performance of the integrated whole (Crossley J, 2002). However, a vital component of the education of competent anesthesia providers is the integration of these competencies into clinical practice.

Modern educational theory dictates that learning is facilitated when tasks are integrated. Educational programs that

are restricted to the stackingof components or sub-skills of competencies are less effective in delivering competent professionals than methods in which different task components are represented and practiced in an integrated fashion, which creates conditions that are conducive to transfer. These theories were illustrated by noted psychologist George Miller in 1990, when he proposed a framework for

assessing clinical competence.

level of the pyramid is knowledge (knows), followed by competence (knows how), performance (shows how), and action (does). In this framework, Miller distinguished between "action" and the lower levels. "Action" focuses on what occurs in practice rather than what happens in an artificial testing situation. Work based methods of assessment target this highest level of the pyramid and collect information about clinicians’ performance in their normal practice. In this pyramid, assessment moves from the knows” stage via knows how(paper and computer simulations) and shows how(performance simulations) to the final doeslevel of habitual performance in day-to-day practice.

” level of habitual performance in day-to-day practice. At the lowest The competency movement is a

At the lowest

The competency movement is a plea for an integrated approach to competence, which respects the (holistic or tacit) nature of expertise. Van der Vleuten (2005) argues that the learning and assessing of professional judgment is the essence of what medical competence is about. This means that, rather than being a quality that augments with each rising level of Miller’s pyramid, authenticity is present at all levels of the pyramid and in all good assessment methods. A good illustration of this is the way test items of certifying examinations in the United States are currently being written. Compared with a few decades ago, today’s items are contextual, vignette-based or problem- oriented and require reasoning skills rather than straightforward recall of facts.

Unique Considerations of Competence in Modern Anesthesia Practice

It can be said that there exist a common set of important personal traits that are shared amongst all aspects of medicine and patient care, but there are specific skills that can be acknowledged as specialty-based or context- specific, especially in anesthesiology. Anesthesiology has experienced dramatic technological innovations, the introduction of increasingly potent, shorter-acting drugs, increasingly complex medical patients, and advances in surgical techniques; all of this has created new educational challenges while experiencing increasing pressure to be time-and-cost effective and practice safe medicine. Although anesthesiologists historically have given safety the highest priority, forces from inside and outside the specialty are directing more resources toward reducing the already low risk of anesthesia. Studies have identified deficiencies in human performance as an important component in the causation of critical incidents in anesthesia (Holzman, 1995). The dynamic, tightly-coupled, and critical nature of anesthesia practice can be most accurately described as a complex adaptive system; that is, the successful operation involves many different elements, each of which is subject to direct or indirect influence from a variety of sources, and all of which interact in ways that are constantly subject to change. The vocabulary, theories, and techniques of human factor analysis created in the wake of nuclear power, aviation, and space flight disasters can be applied to the performance of anesthesia providers. It is incumbent upon an educational system (i.e. anesthesiologist assistant educational programs) to reorganizes, changes its focus, or adds new systems to respond to the perceived needs of students, professionals, and the culture in which they function.

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Decision making in anesthesiology, as in relatively few medical specialties, is a special subset of decision making because it is an event-driven phenomenon. The environment in which the anesthesia provider works-complex technical machines, patients with variably disordered physiologic systems, and a constantly changing surgical milieu-has many interconnected, “tightly-coupled” parts. What happens in one part of the system directly affects other portions of the system. There is usually some degree of uncertainty about the data indicating the patient’s

physiologic state; it may be ambiguous, incomplete, insensitive, or erroneous. Finally, there is the constant presence

of risk. This combination of factors is characteristic of the practice of anesthesiology and is not the typical task

environment of most medical professionals (Holzman, 1995).

While the basis of expert reasoning is intimately connected to the fund of knowledge of the practitioner, it is not simply the knowledge but the way the knowledge is stored, retrieved, and used that distinguishes the expert from the novice. The expert clinician accumulates knowledge in the context of concrete medical problems a process that enhances the chance of effective retrieval. With experience, the need for a reasoning process diminishes as the mental processes become automated into patterns or "scripts" (Klein, 2007). The process becomes highly efficient and effective. Professional expertise thus develops as a transition from a conceptually high and rational knowledge base (acquired from educational experience) to a non-analytical ability to recognize and handle familiar clinical situations (acquired from extensive clinical experience) (van der Vleuten & Newble, How can we test clinical reasoning?, 1995).

Students begin their training at a novice level, using abstract, rule-based formulas that are removed from actual practice. At higher levels, students apply these rules differentially to specific situations. During the program, trainees make judgments that reflect a holistic view of a situation and eventually take diagnostic shortcuts based on a deeper understanding of underlying principles. Experts are able to make rapid, context-based judgments in ambiguous real- life situations and have sufficient awareness of their own cognitive processes to articulate and explain how they recognize situations in which deliberation is essential. Clinical expertise implies the practical wisdom to manage ambiguous and unstructured problems, balance competing explanations, avoid premature closure, note exceptions to rules and principles, and — even when under stress — choose one of the several courses of action that are acceptable but imperfect (Klein, 2007). Testing either inductive thinking (the organization of data to generate possible interpretations) or deductive thinking (the analysis of data to discern among possibilities) in situations in which there is no consensus on a single correct answer presents formidable psychometric challenges (Epstein, 2007).

Current Assessment Techniques in Anesthesiologist Assistant Education

The assessment of clinical competence is one of the most difficult tasks facing medical education (Howley, 2004). Whether the purpose is to certify a level of achievement, provide feedback to students about their clinical skills, or provide faculty with information about curriculum effectiveness, the method of assessment has a powerful effect on how and what students learn. If the assessments are inappropriate or primarily focused on basic cognitive skills, misinformation will be given back to students, and poor decisions will be made. Ultimately, inferior assessment practices will result in dissatisfied patients and compromised health care. The field of medical education is becoming increasingly more complex. What once was considered a credible form of education and assessment now falls below our acceptable level of standards (Howley, 2004). Traditionally, clinical evaluation methods consisted primarily of faculty and/or preceptor observations, oral examinations, and multiple-choice tests; however, as evidence in assessment effectiveness and the demand for assurance of clinical competence grows, the anesthesiologist assistant community must adapt to meet the needs of the population we serve.

Important Aspects of Assessment Techniques

A sound assessment modality must include a clear statement of purpose, a detailed description of what is to be

measured, a set of instructions for feasible administration and scoring, and guidelines for data interpretation

(Howley, 2004). If intended to measure complex cognitive skills, it is reality based and taps into the high-level skills

of application, analysis, synthesis, and evaluation. Additionally, besides such classical criteria as reliability and

validity, any assessment model must include consideration of elements such as educational impact, the acceptability

of the method to the stakeholders and the investment required in terms of resources, as well as other perfunctory

components such as transparency, meaningfulness to the profession, cognitive complexity, directness and fairness.

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Finally, it must also includes sufficient evidence that the scores derived from the modality are reliable and valid indicators of students’ clinical competencies (Epstein, 2007).

In the anesthesiologist assistant educational community, the most prominent and heavily weighted assessment methods of clinical competence include (a) faculty observations of clinical performance with rating scales, and (b) multiple choice examinations of clinical competence. Faculty and clinical preceptor observation of students’ clinical performance remains the primary evaluation method in AA education.

Multiple Choice Exams

An important aspect of both the anesthesiologist assistant educational programs and the certification process’ assessment program is the measurement of knowledge, and this can be done efficiently with methods such as the multiple choice question (MCE). Multiple-choice examinations are commonly used for assessment because they can provide a large number of examination items that encompass many content areas, can be administered in a relatively short period, and can be graded by computer. These factors make the administration of the examination to large numbers of AAs and AA students straightforward and standardized. Formats that ask the examinee to choose the best answer from a list of possible answers are most commonly used (Epstein, 2007). However, newer formats may better assess processes of diagnostic reasoning.

The down-side of this strategy is that many multiple choice examinations have been shown to measure little more than the ability to reproduce isolated facts; and a growing awareness of the detrimental effect this may have on student learning, and on acquisition of clinical reasoning skills, has encouraged the development of alternative test formats (van der Vleuten & Newble, How can we test clinical reasoning?, 1995). Multiple-choice examinations may also create situations in which an examinee can answer a question by recognizing the correct option, but could not have answered it in the absence of options (Epstein, 2007). This effect, called ‘cueing’, is especially problematic when diagnostic reasoning is being assessed, because premature closure — arriving at a decision before the correct diagnosis has been considered — is a common reason for diagnostic errors in clinical practice (Epstein, 2007).

Preceptor, Faculty & Student-Self Evaluations

Though feedback, both summative and formative, from the preceptor to the AA student is critical to day-to-day correction of deficiencies or reinforcement of best practice is critical to the maturation of the student, the formalized clinical evaluation may be so subjective as not to be reliable. Although, the reliability of our clinical assessments has yet to be formally investigated, several studies have shown wide interfaculty ratings of same student performance, evident on daily clinical evaluations (Morgan & Cleave-Hogg, 2000). There is little `control' over the intra-operative teaching sessions and student feedback has indicated a wide variation in day-to-day experiences with clinical faculty in this setting.

During observations of student performance on the high-fidelity simulator, we had anticipated a higher correlation between the clinical and simulator evaluations since the simulator environment replicates the operating room. However, it is evident that most students have not experienced many of the events that occur during the simulator session, nor have they witnessed a preceptor managing similar problems. Consequently, evaluation mechanisms for clinical experience are inherently different than those in the simulated environment.

Student self-assessments are often included as a component of AA programs’ evaluation modalities, however, fundamental cognitive limitations in the ability of humans to know themselves as others see them restrict the usefulness of self-assessment (Epstein, 2007). Furthermore, rating oneself on prior clinical performance may not achieve another important goal of self-assessment: the ability to monitor oneself from moment to moment during clinical practice.

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Utility of Simulation as an Assessment Technique

There are several factors that place pressure on the health care simulation community to become involved increasingly in summative assessment. First, the development of the competency-based approach to training in the healthcare professions has moved the focus of assessment away from knowledge and simple practical skills (more suited to multiple choice examinations) to more complex clinical activities where non-technical skills such as information gathering, prioritization and effective team-working with other health care professionals are factors critical to successful management of a perioperative course (Glavin & Gaba, 2008). Second, the momentum of the patient safety movement (to which many from the health care simulation community have made significant contributions) is also focusing on the range of countermeasures to human error with expectations that clinicians may be expected to demonstrate their abilities to a recognized standard determined by the profession and the community it serves.

To effectively determine if simulation offers a viable means of assessment of clinical competency, one must evaluate the utility of this method. Van der Vleuten (1995) describes five criteria for determining the usefulness of a particular method of assessment: (1) reliability (the degree to which the measurement is accurate and reproducible); (2) validity (whether the assessment measures what it claims to measure); (3) impact on future learning and practice; (4) acceptability to learners and faculty, and (5) costs (to the individual trainee, the institution, and society at large) (Epstein, 2007).

Validity refers to whether an instrument actually does measure what it is supposed to. Newer developments concerning assessment methods in relation to validity have typically been associated with the desire to attain a more direct assessment of clinical competence by increasing the authenticity of the measurement (van der Vleuten & Schuwerth, 2005). The validity of an assessment has a number of components:

(1)

Content validity refers to how representative the test is of learning objectives or, stated another way,

2003).

(2)

whether the test measures skills important and is valuable to learning the construct. Content validity is based on judgment, and would be high with simulator assessments so long as the simulation scenarios were designed such that it could be reasonably assumed that a minimally competent AA should be able to handle the situation. Construct validity represents how well the test measures what it claims to be measuring, and can be

measured by how well the test results meet expectations of performance. Construct validity can be evaluated by comparing the performance of groups of clinicians, where substantially better performance in one group would be expected. This has been confirmed in several studies assessing simulator performance where experienced anesthetists performed better than less experienced anesthetists, supporting the proposition that simulator performance has some validity as a measure of real-life performance (Weller,

(3)

Face validity refers to whether the instrument seems as though it is measuring the appropriate construct and relies heavily on how realistic the simulator, scenario, and environment are to the participants. Face validity of the simulator is high, in that it appears to assess what it sets out to assess (Weller, 2003). It is designed to be a highly realistic representation of an anesthetic crisis in an operating theatre.

The predominant condition affecting the reliability of assessment is domain- or content-specificity, because competence is highly dependent on context or content (van der Vleuten & Schuwerth, 2005). This means that we will only be able to achieve reliable scores if we use a large sample across the content of the subject to be tested.

The complex nature of the diagnostic and management skills required to implement therapy in an acute care setting can make the evaluation of a simulated performance complex. The multitude of cognitive, psychomotor, inferential

and deductive skills required to treat the patient suggests that quantifying the results from a simulated performance via checklists (e.g. lists of appropriate medical and technical actions) or behavioral ratings of various patient management activities could be subject to several potentially confounding factors (Murray, 2002). Fortunately, initial studies have shown that anesthesiologists’ technical and behavioral performances in crisis settings can be

Nevertheless, these investigations have generally been limited to

scored reliably by faculty raters (Murray, 2002).

quantifying sources of error attributable to the rater (i.e. inter-rater reliability studies) or the particular set of checklist items (internal consistency).

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Basically, the message is that no method is inherently unreliable and any method can be sufficiently reliable, provided sampling is appropriate across conditions of measurement (Crossley J, 2002). An important consequence of this shift in the perspective on reliability is that there is no need for us to banish from our assessment toolbox instruments that are rather more subjective or not perfectly standardized, provided that we use those instruments sensibly and expertly. Conversely, we should not be deluded into thinking that as long as we see to it that our assessment toolbox exclusively contains structured and standardized instruments, the reliability of our measurements will automatically be guaranteed.

Although simulators have been judged to be highly realistic, able to improve the acquisition and retention of knowledge and produce reasonably consistent scores (Murray, 2002), additional psychometric studies are required. This reliability and validity testing is required before the patient simulator can be fully embraced as an evaluation tool. The advantage of high-fidelity simulation systems compared with the current method for testing and certification, including written and oral examinations, is that they allow the examinee to demonstrate clinical skills in a controlled clinical environment while still exhibiting cognitive and language skills (Issenberg, McGaghie, & Hart, 1999). While these simulation assessments are not perfect, they are no worse than our existing instruments and methods, and they certainly offer a unique window on performance that is not represented in our current assessment armamentarium. At present, simulation is perceived more as an educational tool than an instrument to be used for certification purposes. However, provided that barriers such as the high cost of construction and operation of a simulation center can be addressed, the ability to observe examinees demonstrating clinical skills in a controlled environment will definitely allow for a more legitimate and equitable assessment of competence, especially in high-stakes testing situations.

The key element in the successful use of simulators is that they become integrated throughout the entire continuum of our anesthesiologist assistant education curriculum so that deliberate practice to acquire expertise over time is possible. By analogy, the number of years someone plays a sport or practices a profession bears limited relation to how well they perform. What does correlate with quality of performance is the amount of ongoing deliberate practice that includes “informative feedback and opportunities for repetition and correction of errors.” (Issenberg, McGaghie, & Hart, 1999)

Conclusions

Examinations define the curriculum, often in a way that is not intended by an academic staff or profession at large. The lesson is that, if we wish students to develop effective clinical reasoning skills, we must devise examinations that reflect this intent. It is the presenter’s view that the preceding discussion constitutes a strong plea for a shift of focus regarding assessment, that is, a shift away from individual assessment methods for separate parts of competencies towards assessment as a component that is inextricably woven together with all the other aspects of a training program.

Clinical competence is an extremely complex construct and one that requires multiple, mixed, and higher order methods of assessment to support valid interpretations (Howley, 2004). Although our AA students are frequently tested, the methods of assessment are still primarily focused on low-level skills. If we expect excellence of our future AAs, we must begin to ensure competence in high-level skill areas. This begins with the use of simulation- based testing and other more authentic clinical performance assessments. The development of optimal performance assessments, at a local or national level, is complex—requiring time, commitment, resources, and substantial efforts. However, this is the price to pay if we are to ensure clinical competence, protect the quality of patient care, and subsequently “touch the heart of the matter.”

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References

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Crossley J, H. G. (2002). Assessing health professionals. Medical Education , 800-4.

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Gaba, D. (1992). Improving anesthesiologists' performance by simulating reality. Anesthesiology , 76:491-4.

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where

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Alpha-2 Agonists for Sedation and General Anesthesia

Roy Soto, MD

Objective: At the conclusion of this course,the participant will be able to 1) evaluate methods for the systematic assessment of patient sedation and analgesia in acute care settings to optimize use of appropriate sedatives and analgesics; 2) analyze current research data to reevaluate use of sedatives and analgesics in specific patient populations and 3) summarize data comparing alpha-2 agonists to other sedatives in the perioperative setting.

patient populations and 3) summarize data comparing alpha-2 agonists to other sedatives in the perioperative setting.

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Perioperative Dexmedetomidine Roy G. Soto, M.D.

Introduction

For years clonidine has been the only alpha-2 agonist used in routine anesthetic practice, finding a niche in the world of regional anesthesia and pain management. Dexmedetomidine is an alpha-2 agonist with a significantly higher alpha-2 specificity than clonidine, and its unique pharmacokinetic and dynamic properties make it an ideal anesthetic adjunct for select patients.

Sedation

Although not as effective as propofol, dexmedetomidine is a reasonable sedative and is unique in that it produces a 'sleep-like' EEG pattern. What this means clinically is that even when someone is nicely sedated with dexmedetomidine, you can arouse them easily and they will wake up completely lucid. BIS studies have shown a rapid return of level of consciousness upon patient stimulation. In contrast, if a patient becomes oversedated and uncooperative during propofol sedation, there’s frequently no recourse but to wait it out.

Analgesia

Although not as effective as fentanyl, dexmedetomidine has a measurable opiate sparing effect. If used during general anesthesia, this results in a significant decrease in narcotics needed (plus the sedative effect allows you to use ~ 30% less volatile agent). Perfect for the morbidly

obese

Less opiates and volatiles = (potentially) less postoperative confusion and emergence delay.

you

need less other "stuff", so patients wake up more quickly. Ditto for the elderly.

Sympatholysis

Although not as effective as lidocaine/esmolol/fentanyl, the sympatholytic effect of

dexmedetomidine is still good

good sympatholytic effect that lasts as long as plasma levels are therapeutic. Again, nice for vasculopaths having minimally invasive procedures such as endovascular surgery. Note that an

overaggressive loading bolus will result in vasoconstriction leading to hyper tension due to high

dose alpha-2 stimulation.

during cardiac surgery (although some authors suggest a direct cardioprotective effect of dexmedetomidine, akin to that of volatile anesthetics). Meta-analyses suggest that peri-CABG use of dexmedetomidine reduces morbidity and mortality, decreases ICU time, speeds extubation in the ICU, and reduces total hospital/ICU cost.

typically,

patients gets ~ a 15% drop in MAP and HR, with a

The sympatholytic effect also has contributed to its increased use

Respiratory Properties

No matter how much you give, you get absolutely no reduction in TV, RR, or minute ventilation. Again, beautiful choice for sedation in patients with sleep apnea, bad COPD, etc having procedural sedation.

The Negatives

Unlike propofol which yields a dramatic and immediate effect, dexmedetomidine takes a while to start working, mainly due to the requirement for a slow bolus. This makes the drug less useful

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for endoscopy and other rapid turnover procedures. I start my infusions as soon as the patient hits the room, so that plasma levels are therapeutic once the patient is prepped/draped and the surgeon is ready.

Although having an agent that potentially can quicken wake-up, reduce use of other anesthetics, and enhance patient safety sounds great, many institutions have balked at the cost: $55/bottle (which should last about 3 hours) compared to less than $5/bottle for the new generic formulations of propofol.

As mentioned previously, a unique aspect of dexmedetomidine is that patients wake up when you prod them, which can take some adjustment! This is how a typical first case goes with a new dexmedetomidine-user: your patient is perfectly sedated on the drug and they're snoring, and the surgeon asks "can I go ahead?" and you poke the patient and say "how're you doing?", the patient opens his eyes, smiles, and says "I'm fine, how're you?". Then you'll think he's not sedated enough, you'll give a bunch of fentanyl/versed/propofol and the next step involves an oral airway and jaw thrust! Leave the patient alone, make sure the surgeon uses enough local, and you'll be fine…please don’t send me hate mail until you’ve used it at least 5 times!

Dosing

1. Drug is dosed in mcg/kg/hr, NOT per minute. This is common error #1

2. The bottle has 200mcg in 2cc. It says "100mcg/cc" on the bottle, and it's a small bottle, so people assume it's only 100mcg in there. This is common error #2

3. I mix the 200mcg into 50cc of diluent in a syringe pump yielding a concentration of 4mcg/cc (or 0.004mg/cc)

4. Dosing range is 0.2-0.8mcg/kg/hr

5. Package insert says to load 1mcg/kg over 10min. This will occasionally cause hypertension or bradycardia. Most authors recommend a lower load, and I use 0.5mcg/kg over 20min.

6. Half-life is about 6-8min, so it'll go away very quickly if your syringe runs out, or you turn it off at the end of the case