ISSN NUMBER: 1938-7172
Issue 3.7 VOLUME 3 | NUMBER 7

Editor:
Michael A. Fiedler, PhD, CRNA

Contributing Editors:
Mary A. Golinski, PhD, CRNA
Gerard T. Hogan, Jr., DNSc., CRNA
Alfred E. Lupien, PhD, CRNA
Dennis Spence, PhD, CRNA
Steven R. Wooden, MS, CRNA

Guest Editor:
Penelope S. Benedik PhD, CRNA, RRT

Assistant Editor
Jessica Floyd, BS

A Publication of Lifelong Learning, LLC © Copyright 2009

New health information becomes available constantly. While we strive to provide accurate information, factual and typographical errors may occur. The authors, editors, publisher, and Lifelong Learning, LLC is/are not responsible for any errors or omissions in the information presented. We endeavor to provide accurate information helpful in your clinical practice. Remember, though, that there is a lot of information out there and we are only presenting some of it here. Also, the comments of contributors represent their personal views, colored by their knowledge, understanding, experience, and judgment which may differ from yours. Their comments are written without knowing details of the clinical situation in which you may apply the information. In the end, your clinical decisions should be based upon your best judgment for each specific patient situation. We do not accept responsibility for clinical decisions or outcomes.

Table of Contents

CARDIOVASCULAR
ULTRASOUND EVIDENCE OF THE OPTIMAL WRIST POSITION FOR RADIAL ARTERY CANNULATION
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GENERAL
  LIABILITY RELATED TO PERIPHERAL VENOUS AND ARTERIAL CATHETERIZATION: A CLOSED CLAIMS ANALYSIS
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ADDICTION AND SUBSTANCE ABUSE IN ANESTHESIOLOGY
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OBSTETRIC ANESTHESIA
  ULTRASOUND IMAGING OF THE LUMBAR SPINE IN THE TRANSVERSE PLANE: THE CORRELATION BETWEEN ESTIMATED AND ACTUAL DEPTH TO THE EPIDURAL SPACE IN OBESE PARTURIENTS
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AN OPEN NON-RANDOMIZED STUDY OF RECOMBINANT ACTIVATED FACTOR VII IN MAJOR POSTPARTUM HAEMORRHAGE
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PAIN
EFFECTIVENESS OF OPIOIDS IN THE TREATMENT OF CHRONIC NON-CANCER PAIN
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PATIENT SAFETY
THE EFFECTS OF STEEP TRENDELENBURG POSITIONING ON INTRAOCULAR PRESSURE DURING ROBOTIC RADICAL PROSTATECTOMY
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TRAUMA
IMPROVEMENTS IN EARLY MORTALITY AND COAGULOPATHY ARE SUSTAINED BETTER IN PATIENTS WITH BLUNT TRAUMA AFTER INSTITUTION OF A MASSIVE TRANSFUSION PROTOCOL IN A CIVILIAN LEVEL 1 TRAUMA CENTER
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Cardiovascular

Mizukoshi K, Shibasaki M, Amaya F, Hirayama T, Shimizu F, Hosokawa K, Hashimoto S, Tanaka Y


 

 

Ultrasound evidence of the optimal wrist position for radial artery cannulation

Can J Anesth 2009;56:427-431

Mizukoshi K, Shibasaki M, Amaya F, Hirayama T, Shimizu F, Hosokawa K, Hashimoto S, Tanaka Y

 

 

Abstract

Purpose            The purpose of this study was to determine the optimal position for the angle of the wrist when performing radial artery cannulation. This was accomplished both with healthy volunteers and surgical patients scheduled for coronary artery bypass graft surgery.

Background            Radial arterial cannulation is a relatively common procedure, especially for those who work in cardiovascular or thoracic anesthesia. The radial artery is often the site of choice for continuous arterial blood pressure monitoring because it is easily accessible and has a relatively low incidence of complications. While multiple commercial devices are available to extend the wrist, there have not been any studies that looked at the optimal wrist angle for success in cannulation. Many medical textbooks describe positioning the wrist anywhere from 45 to 70 degrees. The investigators were interested in establishing the appropriate wrist joint position that would optimize success in first time radial artery cannula insertion. As many as 27% of first radial artery cannulation attempts fail.

Methodology            There were 34 participants in this study. Seventeen were healthy volunteers (nine men and eight women, 22 to 38 years of age with a mean age of 28.6 years) and 17 surgical patients scheduled for coronary artery bypass graft surgery (12 men and five women, 50 to 80 years of age with a mean age of 68.6 years). Patients with a history of peripheral vascular disease were excluded. A total of six wrist boards were developed to produce wrist angulation of between 0 degrees and 75 degrees in 15 degree increments. Once the wrist was placed on the board, the angle was checked with an arthrometer to ensure it was appropriate. The radial artery was visualized using a high resolution SonoSite ® ultrasonograph. Manual palpation of the most prominent arterial pulsations were marked and the probe was placed in that location. The investigators were careful not to cause flow disruption by pressure from the ultrasonic probe. A person not involved in the research measured radial artery lumen height and width at the systolic phase of the cardiac cycle. Vessel lumen height and width were recorded.

This was a convenience, non randomized sample. Repeated measures analysis of variance (ANOVA) was performed on the data. A one-sample t test was performed to verify whether the data was statistically significant, with significance assumed at a P <0.05.

Result            Complete measurements were obtained at all angles for every participant. There were no statistically significant differences in vessel size from right to left arm. Vessel diameter was significantly larger in male vs. female subjects. No gender difference was found relative to the change of vessel dimension during manipulation of the wrists from 0 to 75 degrees. An interesting finding was that there was no significant change in vessel width regardless of the angle (0 to 75 degrees). There were, however, differences noted in vessel height based on angle of the wrist. Vessel height decreased once the wrist was angled greater than 60 degrees. The dimension of the artery affected cannulation success – the larger the dimension, the greater the “first stick” success rate.

Conclusion            The current recommended procedure for radial arterial cannulation suggests that the wrist be “mildly angulated.” Optimal wrist joint angle for cannulation has not been established. The authors found that at angles of up to 45 degrees, there was no significant change in vessel height. Once angles of 60 and 75 degrees were established, flow was adversely affected. Though overextending the wrist may help to reduce mobility of the radial artery, it can also have deleterious effects on flow. Success rates were higher in male patients than in female patients. The authors attributed this to average vessel size being greater in males than females.

 

Comment

I was excited to find this article, but then somewhat disappointed because it really did not offer any innovative or new information. It stands to reason that the greater the angle of the wrist, the greater the likelihood of compression and flow disturbance in the radial artery. The authors did note some limitations, which included questionable resolution sensitivity of the ultrasound probe and the possibility of probe induced compression. Limitations that I noted include: no correlation between cannulation success and wrist angle (which was in essence their research question), a lack of correlation between test groups, and a correlation between radial artery dimensions and success in cannulation. An interesting statement in the article was that “Patients with a history of peripheral vascular disease were excluded.” I am not sure how those subjects who were candidates for CABG surgery were deemed not to have peripheral vascular disease. While this was an interesting study, it was not particularly informative. I believe it would be better accomplished at a large cardiothoracic surgery center on a significantly larger sample of patients. The information gleaned in that setting would be useful.

 

Gerard T. Hogan, Jr., DNSc., CRNA

 

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 7, July 31, 2009




General

Bhananker SM, Liau DW, Kooner PK, Posner KL, Caplan RA, Domino KB


Liability related to peripheral venous and arterial catheterization: a closed claims analysis

Anesth Analg 2009;109:124-128

Bhananker SM, Liau DW, Kooner PK, Posner KL, Caplan RA, Domino KB

Abstract

Purpose            The purpose of this study was to review claims made regarding peripheral arterial and peripheral venous cannulation related to provision of anesthesia services between 1975 and 2000. The study did not address claims made regarding central venous catheters.

Background            Placing either a peripheral intravenous catheter and/or a radial arterial catheter are commonplace in anesthesia. Though we take these tasks for granted at times, serious complications can occur. Claims have been filed for a variety of injuries. These include extravasation, infection, thrombophlebitis, air embolism, and vascular insufficiency. The extent of injury has ranged from pain and/or suffering to loss of limb. The authors reviewed claims data from 35 different anesthesia insurance carriers as reported to the American Society of Anesthesiologists Closed Claims database. Each claim was reviewed by an anesthesiologist and scored on a ten point scale, with zero (0) being no injury and nine (9) being death as a result of an injury.

Methodology            This was a retrospective analysis of records provided by the ASA Closed Claims database. The authors addressed multiple factors in their analysis, to include whether or not the care met the current standard of care, the severity of the injury, and the claim payment adjusted to 2007 dollars using the consumer price index. Differences between the proportions were analyzed using chi-square analysis, Fisher’s exact test, and the z test. A P <0.001 was required for statistical significance.

Result            A total of 140 claims between 1975 and 2000 were reviewed. Of the 6,894 claims made during that period, 2.1% (140 claims) involved peripheral venous or arterial cannulation. The most common adverse outcome was skin sloughing or necrosis (n=35), swelling/inflammation/infection (n=22), damage to nerves (n=22), compartment syndrome (n=20), and air embolism (n=10). Other claims included catheter shear, rashes from dressings, ecchymosis, and vasculitis. Claims determined to be “frivolous” constituted 2% of the claims reviewed. Skin slough occurred most often with pentothal, followed by vasoactive or inotropic agents (dopamine, dobutamine, norepinephrine) and calcium chloride. As expected, claims were greater for larger bore catheters. Open heart surgery claims constituted 25% of all claims. There were no statistically significant differences based on ASA status, age, sex, body habitus, or gender. There were only 13 arterial claims, seven of which were radial artery cannulation. Most were in relation to vascular compromise after placement. One case resulted in loss of several digits and subsequent settlement for over 11 million dollars.

Conclusion            Venous and arterial catheterization continue to result in injuries and financial liability for anesthesia providers. Over half of the claims made resulted in payment, with seven claims resulting in judgments over $1,000,000 (adjusted to 2007 dollar amounts). Claims related to air embolism had the most damaging outcomes and resulted in larger settlements. The authors suggested that if vasoactive medications are to be administered, they should always be given with a pump that can detect flow obstruction and extravasation. The authors cautioned against microwaving IV bags, or using non approved fluid warming techniques. Close monitoring of intravenous and arterial cannulation sites is the best way to prevent these injuries.

 

Comment

I found it interesting that most of the air embolism claims occurred as a result of air in blood infusion bags associated with red cell scavenging techniques, such as Cell Saver ®. Burns as a result of warm compresses placed to hasten the absorption of the infiltrated fluids occurred in three percent of the claims. Limitations of the study included an inability to provide a numerical estimate of risk and reliance on accuracy in the reported data. Retrospective techniques are dependent on the provided information. If the information is lacking, the statistics could potentially be flawed. This was an interesting article that brings a new respect for IV placement to my clinical practice.

 

Gerard T. Hogan, Jr., DNSc., CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 7, July 31, 2009





Bryson E, Silverstein J


 

Addiction and substance abuse in anesthesiology

 

Anesthesiology 2008;109:905-17

Bryson E, Silverstein J

 

Abstract

Purpose            The purpose of this article was to explain the theory behind addiction and addiction treatment, and present information that might help identify health care providers with a substance abuse problem.

Background            Between 1991 and 2001 approximately 8 of 10 anesthesia residency programs reported substance abuse problems among their residents and 19% of those programs indicated they had experienced at least one death because of substance abuse. The most abused substances were fentanyl and sufentanil. Other abused substances included propofol, ketamine, thiopental, lidocaine, nitrous oxide, and volatile agents. Factors thought to contribute to substance abuse were proximity to addictive drugs, ease of diversion, high stress work environment, and exposure to sensitizing agents that stimulated reward pathways.

Result            Prevalence: It is difficult to quantify the number of addicted anesthesia providers. In a review of 1,000 physicians in treatment for addiction, anesthesia residents made up 33.7% of the study population but represented only 4.6% of the physician residency population as a whole. The rate of death because of substance abuse was high. The risk of drug related death in anesthesia was highest in the first 5 years after medical school.

Etiology: Theories of drug addiction include biochemical, genetic, psychiatric, and exposure. It is thought that a genetic predisposition plays a role in the transition from substance use to addiction. Studies have shown that cholinergic muscarinic 2 receptors play a role in alcohol dependence and depression. There is also an association between chemical dependency and other psychological disorders. Individuals who had similar personality traits tended to abuse the same types of substances. A new theory of exposure suggests that low levels of opiates are exhaled by patients in the operating room leading to increased levels of neurotransmitters in the brains of susceptible health care providers. It is not clear how this exposure transitions to substance abuse.

Clinical Manifestations: Health care providers are highly educated individuals with well developed denial mechanisms who often make highly functional addicts. Health care providers rarely recognize they are addicted while coworkers, friends, and relatives make excuses for their behavior. Because the individual rarely seeks treatment on their own, it is important that others recognize addictive behavior in order to identify the problem and help facilitate treatment. Behavioral changes include:

Withdrawal from interaction with others
Mood swings
Anger, irritability, and hostility
Spending excessive and inappropriate time at the hospital
Volunteering for additional call
Refusing relief during a case
Frequent trips to the bathroom
Signing out large amounts of narcotics for typically low use cases, particularly on Friday
Weight loss and paleness

Unlike alcohol addiction, opioid addiction behavioral changes often become apparent over just a few months. Anesthesia providers who are substance abusers often put patients at risk. Entire cases may be done with inhalation agents and beta blockers to mask increased catecholamine levels while documenting opioid use and diverting them for personal use. Addicts may even rummage though a sharps container to acquire opioids.

Legal issues: Most states now require that health care providers report colleagues they suspect of substance abuse. If they do not, their own licenses are in jeopardy. Many states have alternatives to suspension or revocation of licenses. These “diversion” programs are designed to rehabilitate rather than punish an addicted provider. Voluntary entry into a substance abuse program does not require a report to the National Practitioner Data Bank. The Americans with Disability Act offers some protection to addicted providers.

Treatment: There are facilities throughout the country that specialize in treatment of health care providers. The most successful treatments include detoxification, monitored abstinence, intensive education, self help groups, and psychotherapy. Most residential treatment plans run from two months to a year or more. The focus of long term treatment is complete abstinence from all mood altering substances. Mandatory random urine tests are often used to monitor compliance with substance avoidance. Naltrexone is often used to antagonize mu receptors and reduce the craving for narcotics and alcohol in the recovering addict. The addict’s involvement in a self help group is considered imperative. International Doctors in AA and Anesthetists in Recovery are two groups that deal with addicted anesthesiologists and nurse anesthetists respectively. Involving the family in treatment has been shown to improve outcome.

Prognosis: Controversy surrounds the return of treated addicts to the same environment they left. Most believe that addicted health care providers in a training program should be encouraged to find another specialty. Limited options are available for those who are already in practice and a quick return often leads to treatment failure. One study suggested that prolonged abstinence was unusual for health care providers who abused opioids. The study indicated only a 34% treatment success rate, while 25% of the unsuccessfully treated providers died during a relapse. It is suggested that automatic re-entry into the specialty not be routine, but be considered on a case by case basis. High risk of relapse should be considered for those with a family history of substance abuse, those abusing opioids, and those with co-existing psychiatric disorders. Work re-entry contacts and compliance monitoring is critical to a positive prognosis. The first three months of re-entry to the operating room should exclude nights and weekend call as well as the handling of opioids. Some programs suggest a one year absence from the practice of anesthesia before re-entry.

Prevention: A survey of health education programs revealed that the incidence of substance abuse among students may be as high as 39%. Because of this, it is suggested that anesthesia training programs use random drug testing to identify problem providers before they start practicing on their own. Another suggested prevention and detection method is an information management system in the pharmacy that identifies substance abuse patterns among providers.

Conclusion            Addiction may very well be an occupational hazard in anesthesia. It is important that we learn to recognize those who might be addicted to mind altering substances in order to protect the health of our colleagues and also the patients we take care of. We also must keep in mind that successful treatment does not guarantee there will not be a relapse.

 

Comment

I serve on the Advanced Practice Registered Nurses licensing board in Nebraska. I am disturbed by the frequency of substance abuse cases that come to our attention. They are always difficult cases because the providers have an excuse as to why they became addicted as well as a promise that they have dealt with the problem themselves. Denial is always present, and resistance to treatment is expected. The most tragic cases we review are those of well respected anesthesia providers who are found dead because of overdose. We find that fentanyl abuse is the primary substance of choice, but perhaps not surprisingly, propofol is becoming a more frequent problem. I suspect propofol is abused because the drug is more readily available without the same restrictions as opioids.

Almost all of these addicted providers when interviewed appear quite normal and willing to do anything to keep their licenses as well as continue their practice. This article points out that anesthesia providers with an opioid abuse problem are at great risk for relapse and death if their situation is not handled appropriately. I think that this article was a good educational piece concerning anesthesia providers with substance abuse. Even though this particular article was directed mostly toward physicians, I can assure you that other providers in the operating room are just as much at risk for substance abuse, and we all must be vigilant in order to protect our colleagues as well as the patients. Those of us who are responsible for licenses and credentialing should review studies about treatment in order to tailor a plan for each situation. We need to maximize the potential for successful re-entry as well as protect the patient population.

This article explains theory behind addiction, but I am not convinced that this theory can adequately help us to identify those among us who are likely to become substance abusers. We may not like the idea of routine drug screening, but because patients are at risk when we allow addicted providers to enter the workforce, it makes sense to me that educational programs should consider using such a tool. The article also suggest that re-entry to anesthesia practice often leads to relapse because of the accessibility our profession has to opioids. I have found this to be true in our state, but I also want to help any provider willing to seek appropriate treatment. We just need to consider re-entry very carefully and on a case by case basis.

 

Steven R Wooden, MS CRNA

 

Position Statement 1.7 Substance misuse and Chemical Dependency: http://www.aana.com/WorkArea/showcontent.aspx?id=21910

Peer Assistance Hotline: 800-654-5167

Anesthetists in Recovery: 215-635-0183

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 7, July 31, 2009




Obstetric Anesthesia

Balki M, Halpern S, Carvalho JCA


Ultrasound imaging of the lumbar spine in the transverse plane: the correlation between estimated and actual depth to the epidural space in obese parturients

Anesth Analg 2009;108:1876-1881

Balki M, Halpern S, Carvalho JCA

Abstract

Purpose            The purpose of this study was to evaluate the accuracy of prepuncture lumbar ultrasound scanning in the transverse plane to estimate the depth to the epidural space, and the optimal epidural needle insertion site, in obese parturients.

Background            When performing epidural anesthesia, clinicians rely on palpation to determine the ideal epidural puncture site. However in obese parturients this can be difficult. This can lead to increased procedure times and may be associated with higher failure rates and complications.

Preprocedural ultrasonography of the epidural space can facilitate neuraxial block placement in nonobese parturients by providing an estimate of depth to the epidural space and optimal insertion point. Previous research suggests that the transverse imaging plane accurately estimates the depth to the epidural space and provides information for the ideal midline insertion point. It is unknown if the transverse imaging plane has the same accuracy in obese parturients.

Methodology            This prospective cohort study included laboring parturients with full-term singleton pregnancies requesting epidural analgesia with a prepregnancy body mass index (BMI) ≥30 kg/m2. Ultrasound scanning before epidural needle insertion was performed using a 2-5 MHz curved array probe with the patient in the sitting position. Initially the longitudinal paramedian scanning plane was used to identify the L-3 spinous process, then the transverse scanning plane to identify the midline of the L 3-4 interspace. The ideal insertion point was marked and the angle providing the best image noted. The built-in calipers were used to measure the depth from skin to the L-3 spinous process and the ultrasound depth (UD) to the epidural space or the distance from the skin to the ventral border of the ligament flavum-dura unit.

The senior resident or a fellow performing the epidural needle placement was blinded to the UD; however, the insertion point (visible markings) and the needle angle were provided verbally. The needle depth (ND) to loss of resistance was recorded. After a negative test dose, a loading dose of 0.125% bupivacaine 10 mL with fentanyl 50 µg was administered.

The primary outcomes were the precision and accuracy of the depth to the epidural space as measured by the correlation between the UD and ND. The secondary outcome was the accuracy of the insertion point, defined as the absolute difference between the UD and ND. Accuracy was evaluated using the concordance correlation coefficient, and a Bland-Altman analysis was used to present the difference between ND and UD. The numbers of redirections (different angle) or reinsertions (different skin puncture site) were recorded. Correlation coefficients were used to evaluate the association between BMI and distance from skin to spinous process, and ND, respectively. Ultrasound scanning time and epidural procedure times were recorded.

Result            Of the 54 parturients enrolled, 46 subjects were considered for analysis. The prepregnancy median BMI was 36 kg/m2, with a range of 30-79 kg/m2. The mean UD was 6.3 ± 0.8 cm, whereas the ND was 6.6 ± 1.0 cm (mean difference: 0.3 cm ± 0.5 cm, P = 0.002). There was a positive correlation between the UD and ND (r = 0.85; P < 0.001), and the concordance correlation was r = 0.79 (P < 0.001). The Bland-Altman analysis 95% CI upper limit was 1.3 cm, and lower limit was -0.7 cm. Body mass index was correlated with ND (r = 0.58, P = 0.0001) and UD (r = 0.44, P = 0.003). Mean skin-spinous process distance was 2.7 ± 0.9 cm (range 1.3-5.1 cm), and this distance correlated with BMI (r = 0.48, P = 0.001), UD (r = 0.8, P < 0.001) and ND (r = 0.76, P = 0.004).

On physical examination prior to epidural needle insertion, the spinous process could not be visualized or easily palpated on any of the patients; however, they could be palpated upon deep palpation in 63% of patients. Epidural needle placement using the predetermined ultrasound point was completed without reinsertion in 76.1% of parturients and without redirection in 67.4%. There were no complications, and there were no failed or unilateral blocks. Mean duration for ultrasound exam was 4.5 ± 2.9 min, epidural procedure time 8.3 ± 7.3 min, and time to effective pain relief was 10.3 ± 7.5 min.

Conclusion            There was a strong positive correlation between the ultrasound-estimated depth and actual measured depth in obese parturients. The use of transverse ultrasound imaging of the lumbar interspace to estimate the depth to the epidural space may optimize epidural catheter placement in obese parturients. Previous studies have found the mean depth from the skin to the epidural space to be 4.6 – 5.3 cm. This study found the epidural space to be deeper in the obese population, a mean of 6.6 cm (range 4.5 – 8.5 cm). In a majority of obese parturients a standard 10 cm needle can be used to achieve LOR.

 

Comment

The use of ultrasound in anesthesia is becoming more and more prevalent, especially in regional anesthesia. This study contributes to the growing body of research regarding use of preprocedural ultrasonography for placement of labor epidurals.1-5 I first heard about the use of preprocedural ultrasonography for lumbar epidurals from one of my students, who had written a case report on his use of the technique to facilitate epidural placement in several laboring parturients. In reviewing the literature I have found a majority of the research to be published by two groups.1,2 Carvalho et al 5 has recently provided an excellent review on the topic, and after reading the article I began using preprocedural ultrasonography for obese parturients or “difficult backs,” as well as started teaching my Nurse Anesthesia students how to perform the scanning. In one instance I used preprocedural ultrsonography to successfully place a CLE on the first attempt in an obese parturient with twins presenting for an elective repeat cesarean section. In this patient no landmarks could be palpated, and there were three unsuccessful attempts made prior to identifying the ideal insertion point and depth with preprocedural ultrasonography in the transverse plane. I think these experiences demonstrate the importance of “evidence based practice,” and highlight how clinicians can directly apply research findings, such as those in this abstract, to clinical practice. Nonetheless, further research (i.e, randomized controlled trials) is needed to determine if preprocedural ultrasonography improves outcomes, and to help “sell” it to experienced clinicians.

Finally, I want to highlight a few findings from the study. The investigators found positive correlations between BMI, ND, and UD, and with the mean distance from skin-spinous process and ND and UD, respectively. What this tells us is that many, but not all, patients with increasing BMI and in whom it is difficult to palpate spinous processes, may require a greater depth to achieve LOR. If this was a perfect positive correlation, then every time you had an obese patient (greater BMI) then your ND to LOR would be greater. However, not all patients who are obese will be difficult or require greater depth to achieve LOR because of where the body fat is distributed. Clinically I think this is what many of us that do obstetrical anesthesia experience. On a busy labor deck I believe preprocedural ultrasonography might help improve our efficiency by decreasing the number of attempts (redirections and reinsertions), improve our success rate and patient satisfaction, in obese parturients in whom it is difficult or impossible to palpate spinous processes by providing us with information on the ideal insertion point and estimated depth to the epidural space. It may also help providers decide if a longer Touhy needle is required.

 

Dennis Spence, PhD, CRNA

 

1. Grau T, Leipold RW, Horter J, Conradi R, Martin E, Motsch J. The lumbar epidural space in pregnancy-visualization by ultrasonography. Br J Anaesth 2001;86:798-804.

2. Arzola C, Davies S, Rofaeel A, Carvalho JCA. Ultrasound using the transverse approach to the lumbar spine provides reliable landmarks for labor epidurals. Anesth Analg 2007;104:1188-92.

3. Grau T, Leipold RW, Conradi R, Martin E. Ultrasound control for presumed difficult epidural puncture. Acta Anaesthsiol Scand 2001;45:766-71.

4. Grau T, Bartusseck E, Conradi R, Martin R, Motsch J. Ultrasound imaging improves learning curves in obstetric epidural anesthesia: a preliminary study. Can J Anaesth 2003;50:1047-50.

5. Carvalho JCA. Ultrasound-Facilitated epidurals and spinals in obstetrics. Anesthesiology Clin 2008;26:145-58.

 

This article, as well as a recent review article by Carvalho 5 provides a thorough description of how to perform preprocedural ultrasonography scanning for a lumbar epidural. I would encourage those readers interested in learning this technique to review these articles.

In this article the researchers presented the correlation coefficients as r2, or amount of variance explained. The r2 is calculated be squaring the r value (correlation coefficient). For example, the correlation between mean skin-spinous process distance and ND was r2 = 0.58, which indicates that 58% of the variance in ND can be explained by the variance in mean skin-spinous process distance. In this abstract, the correlation coefficient, r, was presented because this is what many readers are familiar with.

The views expressed in this article are those of the author and do not reflect official policy or position of the Department of the Navy, Department of Defense or the United States Government.

 

I would like to thank Eric Bopp MS, CRNA for his assistance with this abstract.

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 7, July 31, 2009





Ahonen J, Jokela R, Jorttila K


 

An open non-randomized study of recombinant activated factor VII in major postpartum haemorrhage

Acta Anaesthesiol Scand 2007;51:929-936

Ahonen J, Jokela R, Jorttila K

Abstract

Purpose            The purpose of this study was to evaluate institutional guidelines for recombinant factor VIIa use at a major tertiary referral hospital. The guidelines were for the use of recombinant factor VIIa in high-risk women suffering from post partum hemorrhage (PPH). Evaluating the guidelines in women who were, or were not treated with recombinant factor VIIa would allow the researchers to decide if improvements and/or modifications to the guidelines were needed.

Background            Treatment of post partum hemorrhage caused by uterine atony traditionally consists of manual massage and medication administration (uterotonics), both known to increase uterine muscle tone and halt bleeding. When additional maneuvers are necessary, the bleeding is usually the result of retained placental fragments or trauma to the uterus or birth canal. The obstetrician will often remove the retained fragments and repair the trauma surgically while volume and blood replacement is simultaneously occurring. If bleeding persists, arterial embolization may be necessary. Case reports of off-label use of recombinant factor VIIa have reported it to be effective in some situations of severe post partum hemorrhage. There are varying opinions in the obstetric community regarding recombinant factor VIIa use; the evidence remains inconclusive. It is unlikely that randomized controlled trials can be conducted utilizing recombinant factor VIIa.

Methodology            The guidelines stated that recombinant factor VIIa (rFVIIa) should be considered for use when the post partum patient had lost ~1.5X her blood volume. The ultimate decision to use rFVIIa was a collaborative effort between the anesthetist and the obstetrician. After IRB approval, a retrospective analysis was conducted to compare the outcomes of women with PPH who did or did not receive rFVIIa. While the guidelines were in place, 26 women received rFVIIa and 22 women did not. Patient demographic and surgical data was ascertained. Included also were data regarding laboratory values for Hgb, plt count, and coagulation profiles. If the full coagulation profile was not obtained, a thrombin time, activated partial thromboplastin time and plasma fibrinogen values were obtained. Ionized calcium was assessed just prior to factor VIIa administration. The outcomes of the patient who received factor VIIa were graded as:

  • Good – when bleeding was less than 1,000 mL after administration and no further interventions were needed
  • Moderate – when bleeding was more than 1,000 mL after administration but no additional surgical or other interventions were needed
  • Poor – when bleeding persisted and required arterial embolization or surgical interventions

Comparisons between those who received rFVIIa and those who did not were expressed as means + standard deviation. Both non-parametric and parametric tests were used (depending on the level of the data) and a P < 0.05 was considered statistically significant.

Result            Analysis showed no difference in the demographic data between the two groups which included: age, height, weight, gestational age, mode of delivery, parity, multiple fetuses, in-vitro pregnancy, preeclampsia or HELLP syndrome, and main cause of bleeding. The group that received rFVIIa (n = 26) included 8 patients that underwent a hysterectomy; however they had their uterus removed before the factor was administered. Three of the 8 hysterectomies were performed due to placental abnormalities; two other patients had their hysterectomy performed before transfer to the hospital where the study was conducted. Of the women who did not receive the rFVIIa (n = 22), six underwent hysterectomy. One had been performed before transfer to the study hospital. One hysterectomy was performed for placental abnormalities and in two patients the hysterectomy was considered unavoidable.

Coagulation screens were available for 25 of 26 patients who received rFVIIa and 18 of 22 women who were not given rFVIIa. In the remaining 5 women, one or more thrombin time values, APTT, or fibrinogen values were available. Of significance, a higher PTT and PT as well as lower thrombin times and fibrinogen values, were noted in women who ultimately received rFVIIa than in those who did not (p<0.05). Blood loss and need for red cell transfusion, platelets, and fibrinogen concentrate were significantly higher in the rFVIIa group (P<0.05). The ratio of units of FFP to units of RBC was not significantly different between groups. Blood gas analysis did not show severe acidosis or low ionized calcium levels when before rFVIIa was administered. The response to rFVIIa was as follows:

·      Considered GOOD in 17/26 patients

·      Considered MODERATE in 3/26 patients

·      Considered POOR in 6/26 patients

All patients who received rFVIIa were discharged home within 3-18 days compared with those who did not receive rFVIIa who were discharged within 4-16 days.

Conclusion            This retrospective analysis demonstrated that women with PPH who received rFVIIa had abnormal laboratory values and a greater total blood loss prior to rFVIIa administration. The response to the rFVIIa was considered “GOOD” in 2/3 of those who received it and “MODERATE OR POOR” in the remaining 1/3. According to the institutional guidelines, rFVIIa should only be considered when the patient had lost ~ 1.5 of their total blood volume. The assumption that these guidelines would decrease the total number of patients with PPH was not supported. The cost of the drug (the most expensive in the hospital) limited its use for treating all with PPH. For some, the hemorrhage would have ceased irrespective of rFVIIa use. It is emphasized that rFVIIa should not be used to compensate for blood and fluid replacement; it is unlikely to work effectively if there is a lack of the necessary coagulation pathway components. In the case of ongoing bleeding, efforts must be made to reveal the location of the bleeding and manage it surgically. Due to the lack of evidence, the guidelines were not extended to include the use of rFVIIa in less severe cases of PPH or as a preventative measure.

 

Comment

While the evidence remains inconclusive for the off label use of rFVIIa for the treatment of post partum hemorrhage, the authors are to be commended for using an evidence-based approach for evaluation of their guidelines. As previously mentioned, due to the complexities of post-partum hemorrhage, the gold standard of evidence such as the randomized controlled double-blinded study and meta-analysis, is not feasible. While case control studies are several ‘grades’ below the top of the evidence-based ranking pyramid, they may have to suffice. With retrospective analysis such as the one conducted here, we can continue to seek and identify new or additional or previously unidentified factors that contribute to postpartum hemorrhage. We may also seek to discover, based on these factors, what the outcomes are when different treatments are offered. With postpartum hemorrhage remaining the number one cause of maternal mortality, we simply cannot afford to stop searching for the most efficacious treatment.

 

Mary A. Golinski PhD, CRNA

 

Post partum hemorrhage- While there are varying definitions, the majority of the scientific literature describes post-partum hemorrhage as:  Hemorrhage after delivery of greater than 500 mL of blood following vaginal delivery, or 1,000 mL of blood following cesarean section. Post partum hemorrhage leads to significant dehydration which causes hemodynamic instability and a dysfunction in the coagulation pathways. It is the most common cause of perinatal maternal death in the developed world and is a major cause of maternal morbidity worldwide.

Off-label use of a drug: A medication will be approved for use by the Food and Drug Administration (FDA) for a particular condition or patient group, but the drug may also show success in treating another condition or group of individuals. Until the medication is approved by the FDA for treatment of this other condition or group of individuals, its additional use is called off–label. Therefore an off-label use of the medication is any use that is not specifically mentioned in the FDA approval labeling.

 

Guidelines for the use of rFVIIa in major PPH at the department of Obstetrics and Gynecology, Helsinki University Hospital, Finland, (condensed) –

  • Consider rFVIIa when the patient has lost 1.5X their total blood volume
  • Surgery and arterial ligation is preferable in cases of local profuse bleeding
  • If hysterectomy is being considered, administer rFVIIa first
  • If selective arterial embolization is proposed as a result of local uncontrolled bleeding, do not give rFVIIa as a general rule
  • If selective arterial embolization is proposed as a result of poorly defined or diffuse uncontrolled bleeding, administer rFVIIa and consider a second dose in 30 minutes
  • If uncontrolled bleeding continues and the embolization is delayed, administer rFVIIa
  •  Before rFVIIa is given, aim to establish:
    • Hgb >7.0 mg/dl
    • INR < 1.5
    • APTT < 1.5 x super normal range
    • PLTS > 50,000
    • Fibrinogen 1.0g/l
  • Prior to rFVIIa, determine all lab values to assess efficacy
  • After rFVIIa, infuse FXIII 1250 IU
  • In severe prolonged bleeding, give a 2nd/3rd dose in ~2 hrs; always administer 8/12 units of platelets before the 3rd dose irrespective of the platelet count
  • Within 24 h after cessation of bleeding always consider low molecular weight heparin

 

Recombinant Factor VIIa –Is recombinant human coagulation factor VIIA, intended for promoting hemostasis by activating the extrinsic pathway of the coagulation cascade. It is a vitamin K-dependent glycoprotein consisting of 406 amino acid residues. It is structurally similar to human plasma derived Factor VIIa.

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 7, July 31, 2009




Pain

Trescot A, Glaser S, Hansen H, Benyamin R, Patel S, Manchikanti L


Effectiveness of opioids in the treatment of chronic non-cancer pain

Pain Physician 2008;11:S181-S200

Trescot A, Glaser S, Hansen H, Benyamin R, Patel S, Manchikanti L

Abstract

Purpose            This article reviewed literature concerning the treatment of non-cancer pain with opioids. It evaluated the results of studies in the literature in terms of study quality, impact on quality of life, short and long term effectiveness, and the value of specific medications.

Background            Opioids were used in the United States without restrictions until regulations restricted their use in the beginning of the 20th century. One of the unintended consequences of drug regulation was that treatment of pain declined. Even today, some would rather be in pain than be considered an “addict.” Uncontrolled pain has serious consequences, but health care providers have to consider if the liberal use of opioids has greater risk than benefit. Long term opioid usage has an adverse impact on the immune system, disrupts hormones, and often leads to abuse and dependency as well as hyperalgesia. Studies have indicated that the incidence of drug abuse among those taking opioids for chronic pain is between 18% and 41%. It does not appear that evidence has established the safety and effectiveness of opioid therapy for chronic non-cancer pain.

Methodology            The authors reviewed English literature for studies that used pain relief as the primary outcome measure for long term opioid use treating non-cancer pain. Long term opioid use was defined as 6 months or more. Secondary evidence included functional improvement, psychological impact, affect on work capability, and addiction.

Result            Three systematic reviews that looked at opioid use for 16 weeks or longer found that few patients continued the use of opioids for long term pain relief. The high withdrawl rate was attributed to side effects and insufficient pain relief. Many of the other studies left patients out of the final analysis when they did not respond well to initial treatment with opioids. In addition, patients who remained in the studies required escalating doses to counter drug tolerance, but the premise that tolerance can be overcome by dose escalation is unreliable.

Morphine: Several studies have indicated that morphine may be indicated for low back pain not relieved by other methods. Studies have shown that patients on morphine exhibit lower pain intensity while improving physical status and quality of life with long term therapy. Almost 80% of the patients in one study reported constipation and nausea.

Transdermal Fentanyl: The studies evaluated found transdermal fentanyl to be an excellent rescue medication for patients already on strong opioids but developing resistance. Over a period of one year, most patients required a doubling of the dose of transdermal fentanyl in order to continue having therapeutic benefit. Those using transdermal fentanyl for long term pain relief reported significant improvement in pain scores using standard pain review forms.

Methadone: One method used to address tolerance to long term morphine was to switch the patients to oral methadone. Study results should be viewed cautiously because most of the studies found on methadone were done without control groups and were only observational studies. In addition to limited study results, methadone was found to impact cardiac electrical patterns, and to have significant nausea, vomiting, sedation, and itching related to its use.

Tramadol: Although tramadol is a serotonin and norepinephrine reuptake inhibitor, it was evaluated because it was found to be useful for long term pain relief in moderate osteoarthritis. In one study concerning abuse, tramadol was found to have half the abuse potential of hydrocodone.

Oxymorphone: One study reported that 75% of patients evaluated were on stabilized doses of oxymorphone for effective long term pain relief with tolerable side effects. Long term treatment of moderate and severe osteoarthritis pain was found to be effective with oxymorphone.

Oxycodone: Oxycodone was found to be less effective for relief of chronic pain than sustained release morphine. In a three year study of the use of oxycodone for chronic non-cancer pain, half the patients withdrew because of unacceptable side effects but the remaining patients reported sustained analgesia.

Hydrocodone: Although hydrocodone is one of the most widely used medications for chronic pain, the authors could not find any studies evaluating its long term use.

Quality of life improvement: Once a stabilized dose of opioid was reached for a chronic pain patient, studies have shown that manual dexterity, cognitive function and reaction times were relatively normal. In addition, quality of life and mood can be expected to improve in non-depressed patients. Of interest however was a study which revealed that patients on long term opioid therapy did not have a better quality of life than those not treated with opioids. One study from Denmark, where opioids were prescribed liberally for chronic pain, found that patients generally had worse pain, higher healthcare utilization and lower activity levels than chronic pain patients that did not use opioids. This suggested that the overall population of chronic pain patients do not benefit even though some do.

Conclusion            Most health care experts agree that chronic pain patients should not be denied opioids because chronic pain destroys peoples’ autonomy, dignity, and decision making capability. Generally the literature did not provide enough evidence that the overall benefit of opioid therapy was greater than the risks. There was weak evidence that morphine and transdermal fentanyl were effective in certain situations, but there was not enough strong evidence to guide prescription practices.

Comment

As with most large literature reviews, this article provided a broad range of outcomes. I thought that opioids had been studied extensively, but apparently, when it comes to chronic opioid use, the literature is limited in most areas. To me it is somewhat disturbing that when we look at a country like Denmark, which has a very liberal policy concerning opioid use for chronic pain patients, there does not appear to be glowing evidence of benefit. Instead, their patients have greater pain, less activity, and greater health care utilization than those not using opioids. There is not enough information in this article to determine if the difference in these two groups was due exclusively to opioid therapy or if there were other variables that might better explain the differences. No doubt, there are patients who need chronic opioid therapy, but I personally think that we don’t do enough in this country to tailor the treatment of pain therapy to the specific patient. Too often patients are given a prescription for an opioid without planning for the future and looking for non-opioid treatments that could provide long term pain relief without the opioid risks. In my practice, as I am sure it is with other CRNAs who have pain management practices, I find many patients who have been sent to me as a “last resort” because opioids have not successfully treated their back pain. I personally feel that opioids should either be for short term treatment or as a last resort - instead of the treatment of choice for chronic pain. I think this article supports that opinion. I am making a great deal of effort to introduce the concept of multi-modal and multi-disciplinary approaches to pain management and I hope others are doing the same.

 

Steven R Wooden, MS CRNA

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 7, July 31, 2009




Patient Safety

Awad H, Santilli S, Ohr M, Roth A, Yan W, Fernandez S, Roth S & Patel V


 

The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy

Anesth Analg 2009;109:473-478.

Awad H, Santilli S, Ohr M, Roth A, Yan W, Fernandez S, Roth S & Patel V

Abstract

Purpose            The aim of this research was to quantify the extent and duration of increased intraocular pressure (IOP) during robotic-assisted radical prostatectomy using the steep Trendelenburg (sT) position.

Background            As robotic-assisted prostatectomy becomes common, more patients are exposed to the extremes of positioning that it requires. Trendelenburg positioning has significant and well-known cardiovascular, pulmonary and endocrine effects; it is also known that sT functionally increases IOP but to what extent and the IOP profile over the time course of an anesthetic are undescribed. At least two cases of ischemic optic neuropathy have been reported after robotic prostatectomy. While the causes of ischemic optic neuropathy are multifactorial, conditions that may occur during robotic-assisted surgery have been implicated. These include long duration of anesthesia, excessive blood loss, hypotension, anemia, hypoxia, excessive fluid replacement, use of vasoconstricting agents, elevated venous pressure, and sT positioning. Due to the potential for devastating outcomes, and because providers are using robotics for a variety of genitourinary and gynecologic cases, investigation into one aspect of sT physiology—IOP—seems warranted.

Methodology            Thirty-three ASA I and II patients who were scheduled for robotic-assisted prostatectomy were recruited over a 1-month period. Median patient age was 62 years (range 37 to 74), median BMI 28 (range 20-43 kg/m2), median estimated blood loss 80 mL (range 45 to 155) and median IV fluid infused 2.0L (range 1.6 to 3.1L). The median duration of time in sT was 68 minutes (range 31 to 115 min). Patients with pre-existing eye disease (glaucoma, retinopathy, retinal detachment, cataracts), IOP > 30 mmHg, age > 80 years, or BMI > 40 were excluded from the study group. Steep Trendelenburg (sT) was defined 25° from horizontal. Intraperitoneal pressure was maintained at 15 mmHg.

A calibrated Tono-pen was used after tetracaine eye drops to measure IOP; this instrument makes 4 measurements and displays the mean and standard deviation. A single researcher performed all of the IOP measurements. Two sets of IOP measurements were made at each time increment. In this repeated-measures design, IOP and other variables were measured at 7 time points in each subject:

            1st             Awake, supine, before induction
            2nd            10 minutes after induction
            3rd            After CO2 insufflation of abdomen while supine
            4th             In sT with abdomen insufflated
            5th             In sT with abdomen insufflated at end of procedure
            6th            Supine, abdomen deflated, still anesthetized
            7th            45 to 60 minutes after awake in PACU supine

Other measured variables included vital signs, IV fluid intake, estimated blood loss, mean arterial pressure, peak and plateau ventilation pressures, end-tidal CO2, and duration of procedure. The anesthesia drug protocol was standardized for induction (propofol, fentanyl, cisatracurium) and maintenance (“desflurane in 50%/50% oxygen/air”  at 1 to 1.5 MAC with cisatracurium infusion to maintain 1 of 4 twitches).

Result            IOP was 13.3 ± 0.58 mmHg higher at the end of the sT period compared with the awake supine IOP (P < 0.0001). The post-induction IOP was significantly lower than awake (P < 0.0001). IOP at the 4th, 5th, and 6th interval were significantly higher than awake (P < 0.0001). Variables that predicted significant IOP change included ETCO2, peak airway pressure, plateau airway pressure, mean arterial blood pressure, and duration of surgery. However ETCO2 and duration of surgery were the most highly correlated variables with IOP.

Two patients had high IOP at baseline and were referred to ophthalmology for consult. No patients complained of eye complications although 7 patients had significant conjunctival edema that resolved by post-op day 1.

Conclusion            IOP increases by an average of 13 mmHg at the end of procedures done in steep Trendelenburg position.

Comment

It was gratifying to see that researchers have studied and described a phenomenon that is potentially a serious patient safety issue in all hospitals, from small community to large academic centers. It is important to be able to quantify the increase in IOP that occurs during robotic-assisted surgery. The study used the healthiest (ASA I and II), non-obese (median BMI 28) subjects and provided them with a surgeon who performed their surgery quickly (median time in sT 68 minutes) and with minimal blood loss (median 80 mL). Unfortunately, in some community centers, these surgeries can take as long as 4 to 6 hours and are associated with much more blood loss and hypotension putting patients at higher risk for ischemic optic injury.

The study excluded high-risk patients (glaucoma, other eye disease, BMI > 40) and still discovered that 6% had pre-existing increased IOP. We can only surmise the prevalence of increased IOP in the typical patient population (obese and morbidly obese) when placed in sT. These patients generally require higher peak/plateau pressures and are more difficult to keep normocapneic during CO2 insufflation. Excess carbon dioxide vasodilates the choroid plexus in the eye leading to increased IOP. In addition, increased peak airway pressures increase CVP which may reduce aqueous humor outflow, potentially increasing IOP.

It was interesting to note that IOP remained elevated at the 6th measurement (supine, abdomen deflated, still anesthetized) compared to baseline. The elevated IOP cannot be solely attributed to gravitational effects if the simple return to baseline conditions does not resolve the increase. Increases in IOP over time in other work have demonstrated a link to increased production of aqueous fluid. Would a dose of acetazolamide (Diamox) in these patients be protective?

This study suggests many further projects, including a more liberal sample population (inclusive of the more prevalent obese/morbidly obese patient), preoperative and postoperative visual acuity exams (versus patient report of “eye problems”), and potentially pharmacologic intervention (acetazolamide pre- or intra-operatively).

Armed with this preliminary data, should IOP measurement become a standard of care in cases requiring steep Trendelenburg?

 

Penelope S. Benedik, PhD, CRNA, RRT

Normal Intraocular Pressure is 10-21 mm Hg, with a mean pressure throughout the day of 15.5 mm Hg.

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 7, July 31, 2009




Trauma

Dente CJ, Shaz BH, Nicholas JM, Harris RS, Wyrzykowski AD, Patel S, Shah A, Vercruysse GA, Feliciano DV, Rozycki GS, Salomone JP, Ingram WL


 

 

Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level 1 trauma center

J Trauma 2009;66:1616-1624

Dente CJ, Shaz BH, Nicholas JM, Harris RS, Wyrzykowski AD, Patel S, Shah A, Vercruysse GA, Feliciano DV, Rozycki GS, Salomone JP, Ingram WL

 

 

Abstract

Purpose            The purpose of this study was to compare massive transfusion and patient outcome data during the first year of a massive transfusion protocol (MTP) implementation with a similar cohort of trauma patients (pre-MTP).

Background            The leading cause of death after severe trauma is exsanguination. Despite the use of damage control surgery principles, trauma-induced coagulopathy is still a significant contributing cause of morbidity and mortality. Recent research suggests that a significant minority of trauma patients are coagulopathic before therapy is started. Military researchers have found use of MTPs have helped reduce morbidity and mortality in personnel injured in recent conflicts. Currently, the U.S. Military recommends a transfusion ratio of packed red blood cells (PRBCs), units of fresh frozen plazma (FFP), and platelets of 1:1:1 in patients requiring massive transfusion. Unfortunately, there are only a limited number of trauma centers around the world with an MTP in place.

Methodology            An MTP was developed by a multidisciplinary team and implemented at Grady Memorial Hospital with the goal being to achieve a PRBC:FFP:platelet ratio of 1:1:1 in patients requiring massive transfusion (> 10 units of PRBCs in 24 hours). Prospective data was collected on patient demographics, transfusion, and patient outcomes during the first year of an MTP implementation and the results were compared with a similar cohort requiring massive transfusion in the first 24 hours of hospitalization before institution of the MTP.

Result            A total of 73 subjects were in the MTP group and 84 in the historic control group (pre-MTP). Demographics and injury severity scores were similar between the groups. Patients in the MTP group received a similar number of PRBC units (23.7 units vs. 22.8 units, P =0.67) but significantly more FFP (15.6 units vs. 7.6 units, P < 0.001). Crystalloid infusion was significantly less in the MTP group (6.9 L vs. 9.4 L, P = 0.006).

Mortality rates at 24 hours and 30 days were significantly higher in the pre-MTP group compared to the MTP group (24 hour mortality rate: 36% vs. 17%, P = 0.008; 30 day mortality rate: 55% vs. 34%, P = 0.04). Patients with blunt trauma had the most significant improvement in outcomes. Early deaths from coagulopathic bleeding were significantly less frequent in the MTP group (4/13 deaths) compared to the pre-MTP group (21/31 deaths) (P = 0.023). Exploratory analysis of the MTP group found that patients who received a PRBC:FFP ratio of < 3:1 had significantly lower 24 hour mortality rates. Patients who suffered early mortality had significantly higher PT and international normalized ratios, higher PTT, and a trend toward lower fibrinogen levels.

Conclusion            Despite early difficulties in implementing the MTP, this study found that aggressive use of FFP and platelets dramatically reduced 24 hour mortality and early coagulopathy in trauma patients. In those with blunt trauma, 30 day mortality was significantly reduced. While a MTP may not be suitable for all hospitals, individualized MTP should be implemented in an effort to improve resuscitation of trauma patients.

 

Comment

Survival from traumatic injuries by our military personnel is at an all time high in large part because we have brought operating rooms closer to the site of injury (far forward surgery), used damage control surgical principles, and implemented MTP in a 1:1:1 ratio for PRBCs, FFP and platelets.  I believe this is an important study because it demonstrates how successes with MTP by our military anesthesia providers and surgeons can be applied to improve outcomes in a civilian Level 1 trauma center. At my facility, when faced with massive blood loss our goal now is to achieve a 1:1:1 ratio for blood products. We have found this has helped reduce coagulopathy and may have contributed to improved outcomes in several cases of massive blood loss.

What I liked most about this study was that the investigators used a multidisciplinary team approach to change the way they managed massive blood loss.  I believe a multidisciplinary approach is essential to any successful system wide change, especially when it comes to implementation of an MTP. Implementation of an MTP uses a lot of resources and personnel, but I do believe it is an important protocol institutions should consider adopting.

This study also brought up additional important questions I think anesthesia providers should think about, especially those who work at smaller facilities. First, what are my facilities blood bank capabilities (number of units of PRBCs, FFP, platelets, etc.)? Do I have the capability of achieving a transfusion ratio of 1:1:1 for PRBCS:FFP:platelets? How fast can I get blood products? What is the process for releasing blood? Can I store blood products in a cooler in the operating room? Will I have a designated runner whose job it is to obtain blood products and run blood samples to the laboratory? Do I have the capability of doing point of care testing (i.e, ABG, hemoglobin and hematocrit)? What equipment do I have to rapidly administer blood products (i.e., Level I transfuser, pressure bags, fluid warmer, etc.)? Who will help during a massive transfusion when there are no other anesthesia providers around (i.e., a technician or nurse)? Asking these questions ahead of time, having protocols in place, and attempting to achieve a 1:1:1 ratio of PRBCS:FFP:platelets I believe will help improve patient outcomes secondary to trauma or in cases of massive blood loss (e.g., uterine rupture or placenta accreta).

 

Dennis Spence PhD, CRNA

The views expressed in this article are those of the author and do not reflect official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

 

© Copyright 2009 Anesthesia Abstracts · Volume 3 Number 7, July 31, 2009