Nurse anesthesia
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Case Reports Comparative Study
Isoflurane and mivacurium chloride neuromuscular blockade in patients with myasthenia gravis.
The relaxograph findings are presented in two patients. In the first, isoflurane alone is administered, and mivacurium with isoflurane is administered to the second patient with myasthenia gravis. A significantly lower dose of mivacurium is required. ⋯ In the patient that only received isoflurane, T1 was 60% to 70% of the baseline, indicating the neuromuscular blocking effects of isoflurane. These cases illustrate that inhalation anesthetics are adequate for muscle relaxant effects, and if neuromuscular blockers are necessary, then a lower dose of nondepolarizer should be administered, and the patient carefully monitored. Mivacurium appears to be an ideal agent for neuromuscular blockade in myasthenia gravis as long as careful neuromuscular blockade is performed.
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Echocardiography is recognized as a excellent diagnostic tool for non-invasive cardiac assessment. Recently, transesophageal echocardiography has been utilized as an "on line, real time" intraoperative monitoring device in cases where patients are at significant risk for intraoperative cardiac ischemia, large shifts in hemodynamic parameters, and/or air embolism. This advancement in cardiac and hemodynamic intraoperative monitoring is significant as it enables early recognition of cardiac ischemia through assessment of cardiac contractility and regional wall motion abnormalities; accurate volume status assessment with direct monitoring of cardiac chamber volumes, valvular function, and intracardiac shunting; and real time assessment of the presence, size, and location of intracardiac air. Transesophageal echocardiography is a safe and accurate tool enabling early recognition of those physiological intraoperative changes where early intervention is critical for improved patient outcome.
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This preliminary study determined certified registered nurse anesthetist (CRNA) practice experience and educational needs in the preoperative evaluation of patients using patient-controlled analgesia (PCA) for chronic and cancer pain management. A convenience sample (N = 29) of CRNAs practicing in a university teaching hospital completed the surveys developed by the investigator. Survey items related to CRNA experience with management of patients using PCA preoperatively, PCA modes of opioid delivery, and use of adjuvant medication for chronic and cancer pain patients. ⋯ Fifty-two percent of CRNAs disconnected the infusion and discarded the opioid preoperatively. Fourteen percent reported leaving the PCA device connected to the patient for use perioperatively or for continued pain management postoperatively. Based upon the findings of this preliminary study, CRNA education in management techniques for the use of PCA infusions in chronic and cancer pain is recommended.
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This article describes an airway management system designed to reduce the incidence of maternal and neonatal mortality and morbidity during cesarean section. This system was developed from a comprehensive topical review of the literature and implemented in a midwestern community hospital. The key features of the system include a strategy of early assessment and recognition of patients at risk for difficult intubation, and the establishment of management protocols designed to reduce the maternal risk associated with failed intubation.
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This clinical review explores the efficacy of the nonsteroidal antiinflammatory agent, ketorolac tromethamine, added to an anesthetic regimen utilizing intravenous propofol. Both agents have been shown to reduce the incidence of nausea and vomiting postoperatively when administered to patients undergoing minor gynecologic surgery. Because the incidence of nausea and vomiting is significantly reduced when ketorolac is used in place of opioids to attenuate postoperative pain, it would appear to be an appropriate choice of agent to use following propofol anesthesia. The use of this combination of drugs may not only reduce the incidence of postoperative nausea and vomiting in patients undergoing minor gynecologic surgery, but could reduce the duration of hospitalization and enhance recovery from anesthesia.