OR Today - June 2014

PRODUCT FOCUS

UPDATE ON AHRQ’S SAFETY PROGRAM

CONTINUING EDUCATION

VASOACTIVE DRUGS IN THE OR: ENSURING PATIENTS’ SAFETY

TAKE GOOD CARE: NURSES • SURGICAL TECHS • NURSE MANAGERS

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T N E I T A P ETY SAFD THE AN GERY SURECKLIST CH

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SPOTLIGHT ON Veronica Lestagez: Charge Nurse delivers In Crisis Situations

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CONTENTS

features

42

PATIENT SAFETY AND THE SURGERY CHECKLIST

Wrong site, wrong procedure and wrong person surgery continue to be some of the most frequently reported sentinel events. OR Today looks at how following a checklist and providing proper training can reduce the frequency of these errors.

OR TODAY | June 2014

48

SPOTLIGHT ON

Veronica Lestagez did not enjoy her first six months in the OR, but she looks back and is pleased that she has been able to serve so many patients during crisis situations. It can be a hectic and stressful career, but the rewards make it all worth it.

OR Today (Vol. 14, Issue #6) June 2014 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 302691530. POSTMASTER: Send address changes to OR Today at 18 Eastbrook Bend, Peachtree City, GA 30269-1530.

For subscription information visit www.ortoday.com. The information and opinions expressed in the articles and advertisements herein are those of the writer and/or advertiser, and not necessarily those of the publisher. Reproduction in whole or in part without written permission is prohibited. Š 2014

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June 2014 | OR TODAY

7

CONTENTS

departments

PUBLISHER

John M. Krieg | john@mdpublishing.com

28

VICE PRESIDENT

Kristin Leavoy | kristin@mdpublishing.com

EDITOR

11

John Wallace | jwallace@mdpublishing.com

ART DEPARTMENT Jonathan Riley Yareia Frazier Jessica Laurain

ACCOUNT EXECUTIVES

Sharon Farley | sharon@mdpublishing.com Warren Kaufman | warren@mdpublishing.com

60 INDUSTRY INSIGHTS 11 News & Notes 14 AAAHC Update 17 ASC Update

IN THE OR 18 21 22 28

CIRCULATION Bethany Williams

ACCOUNTING Sue Cinq-Mars

WEB SERVICES Nam Bui Taylor Martin Michelle McMonigle

Suite Talk Market Analysis Product Showroom CE Article

OUT OF THE OR

54 Health 56 Fitness 60 Nutrition 62 Recipe 67 Pinboard 76 Index

8

68

Jayme McKelvey | jayme@mdpublishing.com

OR TODAY | June 2014

MD PUBLISHING | OR TODAY MAGAZINE 18 Eastbrook Bend, Peachtree City, GA 30269 800.906.3373 | Fax: 770.632.9090 Email: info@mdpublishing.com www.mdpublishing.com

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“This is a very well designed device, and it is very easy to use. We have had some very petite patients and patients in the 300+ lb range and there has been no sliding. We have been very impressed with the device.

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INDUSTRY INSIGHTS NEWS & NOTES

STAFF REPORTS

EPA CONFIRMS PRODUCTS AS EFFICACIOUS HOSPITAL DISINFECTANTS

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ype-Wipe Bleach towelettes and Bleach-Rite Disinfecting Spray have received the “Agency Approved Efficacy” designation from the U.S. EPA. The EPA’s Antimicrobial Testing Program (ATP) has completed testing the majority of hospital disinfectants and tuberculocide products at its laboratories. In its March 11, 2014 ATP report, the EPA placed registered disinfectants into three categories: • “Agency Confirmed Efficacy” which includes products that passed testing by the Agency’s lab and are confirmed as efficacious hospital disinfectants.

• “Agency Taking Action” which includes products under EPA deliberation, including undergoing testing or review, or taking regulatory or enforcement action.

• “No Post Market Testing by EPA” which includes products labeled for use in dialysis facilities, newly registered products that have not yet undergone postmarket testing and registered products that were not in production at time of collection.

The link to the results of the EPA’s Antimicrobial Testing Program is: http://www.epa.gov/oppad001/ atp-product-list.pdf.

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Hype-Wipe Bleach towelettes and Bleach-Rite Spray are ready-to-use, EPA registered hospital-grade disinfectants containing a 1:10 dilution of bleach and are stabilized for an extended shelf life. The products are approved for claims against C. Difficile Spores, tuberculosis (TB), acinetobacter baumannii, E-coli ESBL, Carbapenem-resistant Klebsiella pneumoniae (CRKP), Hepatitis A+B+C, Norovirus, Methicillin Resistant Staphylococcus aureus (MRSA), Vancomycin-resistant

enterococcus faecium (VRE), Influenza A (H1N1), and numerous additional organisms.

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June 2014 | OR TODAY

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INDUSTRY INSIGHTS NEWS & NOTES

MEDLINE PURCHASES KEY MEDTROL ASSETS In a move to help meet the healthcare industry’s growing need for effective infection prevention solutions, Medline Industries Inc. has announced a new agreement to purchase multiple cleaning and disinfectant technologies and manufacturing capabilities from Medtrol Inc. Medtrol is a leading manufacturer of disinfectants, sanitizers and cleaners designed for use in various healthcare settings. This acquisition allows Medline to develop effective cleaning and disinfectant products to help prevent patient exposure to harmful pathogens, including Clostridium difficile.

Data from the Centers for Disease Control and Prevention (CDC) shows that every day, about one in every 20 hospitalized patients has an infection caused by medical care they received, including Influenza A, SARS, MRSA, VRE, HIV, Hepatitis A, B and C, Listeria monocytogenes, E. coli, Salmonella and Clostridium difficile spores. While most types of hospital-acquired

infections (HAIs) are declining, Clostridium difficile remains at historically high levels. The CDC recommends that staff use an EPA-registered disinfectant with a Clostridium difficile spore claim in patient rooms to disinfect this harmful pathogen.

“Infection prevention is the top priority for our healthcare customers and this move will enable us to develop new and effective ways for healthcare workers to provide the best and safest care,” said Tim Abate, president of Medline’s Textiles and Environmental Services Divisions.

“We now have the technology, manufacturing capabilities and expertise to create a robust and meaningful portfolio.”

The new cleaning and disinfection products will be available this summer. Applications of these solutions will be offered in the form of liquids and pre-saturated wipes.

FOR MORE INFORMATION, visit www.medline.com.

ACCESSCLOSURE LAUNCHES THE NEXT-GENERATION MYNX ACE VASCULAR CLOSURE DEVICE AccessClosure Inc. has commercially launched its Mynx Ace Vascular Closure Device, a safe and secure vascular closure product that provides consistent results with a new, easy-to-use deployment system to seal femoral artery access sites. The device joins the pioneering line of Mynx extravascular products that help care teams reduce time to hemostasis and ambulation in patients who have undergone diagnostic or interventional endovascular procedures. The commercial launch was announced as part of the 12

OR TODAY | June 2014

annual meeting of the American College of Cardiology.

“We are proud of the advantages Mynx Ace offers to femoral closure,” said Gregory D. Casciaro, president and CEO of AccessClosure Inc. “Our continual drive toward innovations that provide physicians with outstanding products to improve patient care has allowed

us to develop a closure device that provides consistent results, while continuing to offer the safety and security that has become synonymous with the Mynx name.”

Mynx closure devices are designed for patient comfort by providing gentle vascular closure without the use of cinching, sutures, or metal implants to enhance

patient satisfaction and keep physicians on the leading edge of patient care. With Mynx Ace, physicians can consistently close femoral artery access sites through a simple, three-step deployment system. The Mynx Ace system uses AccessClosure’s proprietary Grip Technology.

Grip Technology employs an extravascular sealant that actively adheres to the artery for safe and secure mechanical closure and dissolves within 30 days, leaving nothing behind in the healed vessel.

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TRANSENTERIX ANNOUNCES FIRST HUMAN CASES USING ADVANCED ENERGY DEVICE TransEnterix Inc. has announced the first human cases performed using its recently launched fully flexible advanced energy device.

The Flex Ligating Shears, which has received 510(k) clearance from the U.S. Food and Drug Administration, is designed to deliver full flexibility to the surgeon while offering ligation and division with direct thermal energy in various laparoscopic surgical procedures.

“TransEnterix now offers the only advanced energy device that completely articulates 360 degrees to provide optimal access to surgeons within the operating field, while competing technologies offer limited or no articulation,” said Todd M. Pope, President and CEO of TransEnterix.

“With the SPIDER Flex Ligating Shears, we can offer surgeons the ability to attain precise angles when cutting and dividing tissue in a laparoscopic procedure.”

Advanced energy devices represent one of the most versatile and critical tools for surgeons in minimally invasive surgery. These devices deliver controlled energy to effectively ligate and divide tissue while greatly limiting bleeding in the operative field and minimizing thermal injury to surrounding structures.

Dr. Andrew Hargroder, a general and bariatric surgeon in Baton Rouge, La., was the first surgeon to utilize the new device for sleeve gastrectomy procedures.

“The SPIDER Flex Ligating Shears offered me a fast and simple way to cut and seal tissue,” Dr. Hargroder. “The device created no plume to impair visualization, sealed tissue extremely well, and appeared to minimize thermal spread. With 360 degrees of angulation, this device reaches areas where rigid instruments may have difficulty.”

TransEnterix’s advanced energy device has been created for surgeons to use with the company’s existing SPIDER Surgical System. The company intends to offer a similar device in the future for its SurgiBot system, a new patientside robotic surgery system currently under development.

GE HEALTHCARE COMPLETES NEWS & NOTES ACQUISITION OF ANALYTICS SOLUTIONS PROVIDER CHCA GE Healthcare has announced that it has completed the acquisition of CHCA Computer Systems Inc., an operating room management and analytics solutions provider, headquartered in Montreal, Canada. CHCA develops the leading Opera software application, which has helped increase productivity and patient satisfaction in the OR by providing real-time data to support the decision-making and management of surgical procedures.

This acquisition aligns with GE’s Industrial Internet strategy and recent commitment to invest in strong, innovative businesses that enhance GE’s software footprint. It marks GE’s second healthcare acquisition in software this year, following the acquisition of API Healthcare.

Commenting on the close, Jan De Witte, President and CEO of GE Healthcare IT’s business said: “A key tenet of our Industrial Internet investment is addressing new and pressing operational and productivity challenges facing healthcare. In the operating room – the epicenter of today’s hospital – better efficiency in turn benefits patients by reducing waiting times, preventing cancellations, and increasing patient throughput. CHCA’s Opera solution complements our current OR and Perioperative software portfolio and will allow us to deliver a more integrated offering that better connects the workflow throughout the OR, using a mix of software, real-time data and powerful analytics to help drive better outcomes for patients.”

NOVIA STRATEGIES INC. ANNOUNCES EMPLOYEE OF THE YEAR Novia Strategies Inc. employee Derek Mudd, lead Perioperative Consultant specializing in Central Sterile Processing Optimization, is being recognized for his exceptional work with Novia Strategies’ clients. Through his adept guidance and dedicated commitment, Mudd has delivered tangible results to his clients. He has been recognized for his ability to address workflow and regulatory issues; to assess and revise departmental policies, procedures, and work practices; and to ensure compliance with governing agencies.

“We are delighted to recognize Derek for his stellar accomplishments. Novia’s clients appreciate the measurable results he has achieved, improving their Perioperative and Central Sterile Processing operations with a net benefit to their bottom line. Derek is an exemplary employee who meets our clients’ needs in balancing cost and quality,” says Nancy Lakier, Managing Partner and CEO. WWW.ORTODAY.COM

June 2014 | OR TODAY

13

INDUSTRY INSIGHTS AAAHC UPDATE

BY MARCIA PATRICK, MSN, RN, CIC

CLINICAL RECORDS MANAGEMENT:

Questions that might keep you up at night

H

ave you designated an individual to be in charge of medical records at your facility? Besides making sure that the charts get filed, does that person know the true extent of his or her responsibilities?

If a paper record is used, for example, is it completed and filed in a uniform format? Are the records secure? That means controlled and limited access for all records. For your paper records, it also means no loose charts or “post-its” that can fall out or get misplaced. Does each page of the record have patient identifiers? Are your records legible?

Electronic Medical Records may take care of many of these problems, but on occasions can give rise to others. If records are scanned into digital format, they raise all of the pitfalls of paper records except that accessing them may be different.

Even with EMRs, you must have control over test results that come in from outside entities and ensure that the results are assigned to the correct patient - especially if different identifiers are used.

For paper records and EMRs alike, it’s essential that you control access to them. In the case of paper records, you need to document when a paper record is accessed or removed from 14

OR TODAY | June 2014

the record room as well as noting – in writing – the person who accessed or removed them; at what time; and when they were returned to the files in the record room.

For EMRs, the same information is needed, but since records can be accessed from many computer terminals, you must be sure that your EMR registers who accesses the record and that the entry is dated and timed – even changes to previously entered information. You should also have specific policies for delayed entry notes and notes written after the time of the clinical encounter.

If any medical record information is copied and sent out of the facility, this must be documented with details of what has been sent, to whom, and who authorized it. Is patient consent to sending records to other parties duly listed in the record? If your records are stored offsite, what are your policies for retrieval of records? Do you store them in a fireproof warehouse designed appropriately for records storage? If you use EMRs, where are

your servers located? Where are the primary servers backed up?

Once a record has been initiated, what do you do when the admission or the surgery is cancelled or postponed? Your policies should be clear about this and documentation in the record must follow your policy.

Additionally, what are your policies for including pictures from “scope” procedures or C-arm images in your records? If you still use traditional X-ray, what are your policies for storing these images? Are they consistent with your policies for retention and retirement of other medical records?

Going further, what is your policy for retirement of records? Do you follow state guidelines? Do you separate out or specifically identify pediatric and adult records, which generally have different guidelines for retention and retirement? And when you retire records, do you destroy them? If so, do you still maintain business records denoting all of their admissions with dates?

This article is not intended to be a complete primer on clinical records management. But it’s a starting point.

Nor is this fusillade of questions designed to keep you up at night. But with the transition from paper records to hybrid and true electronic WWW.ORTODAY.COM

AAAHC UPDATE

NO MORE

Wheel obstructions medical records, your policies must be up to date and take into consideration myriad factors that you might not yet have thought of.

Make sure your staff knows all about the privacy and security measures of your EMR, even if they are totally familiar with your existing privacy and security measures.

Well-documented and complete medical records can be your best allies in cases of medical malpractice.

They can also assure appropriate, continued care if information does get transferred to other providers.

Clinical records management is most assuredly not an easy task. And not to be treated lightly or taken for granted. Your staff must understand this, and the person in charge of your records must be aware that comprehensive records management is much more than just completing charts and storing them in a uniform format.

ABOUT THE AUTHOR Dr. Jack Egnatinsky is an anesthesiologist with extensive experience in the ambulatory surgery arena, both HOPD and ASC. Since starting medical school in 1961, he has been involved with many local and national professional societies and organizations and is a Past President of the Board of FASA, a predecessor to the ASC Association, and Past President of AAAHC. He remains extremely active as a Medical Director for AAAHC, in addition to being a well-travelled AAAHC accreditation surveyor, both in the USA and internationally.

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June 2014 | OR TODAY

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In 1979 the Steelers won the Super Bowl.

Saturday Night Fever was the album of the year. And AAAHC began accrediting ambulatory health care organizations.

YEARS STRONG

We’ve been raising the bar on ambulatory care through accreditation for 35 years. The secret of our success? Our peer review. AAAHC surveyors are physicians, nurses, anesthesiologists, medical directors and administrators. Which is why organizations routinely heap praise on us for our consultative and educational survey process.

And why we are the leader in ambulatory accreditation.

If you would like to know more about AAAHC accreditation, call us at 847-853-6060. Or email us at info@aaahc.org.

Or you can visit our web site at www.aaahc.org.

Improving Health Care Quality through Accreditation

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OR TODAY | June 2014

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INDUSTRY INSIGHTS ASC UPDATE

A

BY WILLIAM PRENTICE

UPDATE ON AHRQ’S SAFETY PROGRAM FOR AMBULATORY SURGERY

s mentioned in this column previously, as a part of the U.S. Department of Health and Human Services (HHS) National Action Plan to Prevent Healthcare-Associated Infections, the Agency for Healthcare Research and Quality (AHRQ) is funding a series of 12-month patient safety improvement programs for ambulatory surgery centers. To date, three cohorts of ambulatory surgery centers and hospital outpatient departments have signed up to participate.

The Safety Program for Ambulatory Surgery (SPAS) aspires to improve communication and teamwork in order to strengthen the culture of safety at ASCs. If your ASC has not participated in one of the first three cohorts, I strongly encourage you to consider participating in the upcoming fall program.

Details on participating will be posted on the ASCA website and at ascsafetyprogram.org when available.

AHRQ also has developed an ASC-specific toolkit that will help ASCs with coaching, mentoring, implementation of the surgical safety checklist, teamwork, communication and reduction in surgical site infections. It is available as a free download on the AHRQ website.

The current 12-month patient safety improvement collaborative is being conducted online and via conference calls. It is led by the Health Research and Educational Trust (HRET), an affiliate of the

WWW.ORTODAY.COM

American Hospital Association, together with ASCA, the ASC Quality Collaboration and the Harvard School of Public Health, among others.

The program focuses on effectively implementing a surgical safety checklist as a means of strengthening the culture of safety and improving communication among the surgical team. It also provides guidance for establishing facility-based monitoring and reporting systems, educational webinars and learning groups, as well as peer-to-peer learning and networking opportunities.

Participation in the SPAS program has the added benefit of demonstrating to HHS and the patients ASCs serve that ASCs are committed to improving safety and compliance in our daily practices.

As you may know, the advent of a Centers for Medicare and Medicaid Services patient experience of care survey (akin to the Hospital Consumer Assessment of Healthcare

Providers and Systems survey required of hospitals) is also drawing near. ASCs’ ability to demonstrate to their patients that they maintain an uncompromising commitment to quality and safety will be an essential element of guaranteeing exceptional survey results. I believe that participation in the SPAS program is exactly the kind of educational effort that would add real value to the relationship that surgical centers have with their patients.

What’s more, ASCs — as the low-cost provider of ambulatory surgery — are essential to slowing the growth of health care expenses that today strain the budgets of our nation and families alike. The more compellingly we can demonstrate that ASCs provide high-quality care, the stronger our argument with policymakers and insurers. The SPAS program, therefore, is an important step in ensuring quality outcomes for patients and strengthening ASCs’ position within the U.S. healthcare system.

TO LEARN MORE OR ENROLL, please contact Kelly Vrablic at kvrablic@aha.org or visit www.ascsafetyprogram.org.

WILLIAM PRENTICE is the chief executive officer of the Ambulatory Surgery Center Association.

June 2014 | OR TODAY

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IN THE OR SUITE TALK

SUITE TALK

Conversations from the OR Nation’s Listserv

Q

MONITORING TEMPERATURE AND HUMIDITY It is required that temperature and humidity levels be documented daily for each OR suite. Some facilities monitor this by using a clipboard in each room, while others have maintenance or plant operations monitor it. If maintenance or plant operations documents that they monitor temperature and humidity, is the surgery department still required to document it as well? Double documentation can potentially result in errors. If a facility policy states that maintenance/plant ops does daily monitoring with documentation, and what steps are to be done if there is a concern, is this sufficient for inspectors?

A: In our facility, we monitor each room as well as the warmers on a daily basis. The charge person assigned to the back hall takes care of recording everything prior to the day starting. On the weekends, our SPD personnel document the OR temps and humidity.

A: I have it different at all four of my facilities. We keep the book in the OR departments so we can review for issues. Is anyone documenting this on each surgery case? And if so where are you documenting it?

A: If plant operations is documenting temp and humidity it is not necessary to have a second documentation by OR staff.

A: Plant operations monitors our humidity and temperature.

A: We monitor temp and humidity for OR rooms and Sterile Processing daily. Currently, we use a clipboard log and this must be maintained even for times when the OR is closed on weekends and holidays. We do this by recording then temp/humidity ranges – highest for Saturday reading and lowest for Sunday reading and the clear the high/low memory. Be sure that you take action and document that on your log for readings that are outside the recommended ranges and be prepared to show follow up for how correction was made to a surveyor for those instances.

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OR TODAY | June 2014

WWW.ORTODAY.COM

SUITE TALK

Q

WHICH WAY FIRST When doing colonoscopies and EGDs, should the EGD always go first? It seems like a no brainier, but some physicians have their reasons. When would it be reasonable to do a colonoscopy first?

A: Our EU clinical coordinator replied as follows: Usually we do EGDs first. EU doc used to always do her colons first. That was her preference.

Now we will occasionally do the colon first if the EGD is possible. For instance, they only want to do an EGD if they don’t find anything on the colon (i.e. bleeding source).

A: It would be reasonable to do the colon first if you are concerned about a heavily sedated patient turning from lateral to supine with a diminished gag reflex from the topical anesthetic used for the EGD.

Q

COUNT PRACTICES I was looking for some feedback on counting practices in your intuitions. Is anyone currently counting implants sets? Screws, plates, etc.? I would appreciate the feedback!

A: We definitely count implant sets, not only from a patient safety perspective but also a cost perspective!

A: Do you track the lot number of plates that are implanted? I think so because it will be in for longer than six months, but want to be sure. I have a surgeon questioning this documentation.

A: Yes, we do track the lot numbers.

A: We do document the lot number of implants that are packaged by the company. Implants that come from our in-house trauma sets however don’t have lot numbers so we do not document anything but the serial number, size, manufacture, etc.

A: It does seem like a double standard, but because the lot numbers are so small and faint on many of these small plates it is impractical to read them at the time of implanting.

A: We track all implants by lot numbers and expiration dates.

THESE POSTS ARE FROM OR NATION’S LISTSERV FOR MORE INFORMATION OR TO JOIN THE CONVERSATION, VISIT WWW.THEORNATION.COM.

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June 2014 | OR TODAY

19

IN THE OR MARKET ANALYSIS

BY JOHN WALLACE

MARKET ANALYSIS T

he anesthesia and respiratory markets are closely linked in the global economy. It makes sense that the two markets would be viewed together. In fact, many manufacturers of anesthesia devices also produce respiratory devices. The opposite is also true.

A 2012 report on the global anesthesia and respiratory markets by ASDReports.com highlights reasons for growth and forecast a market worth $14 billion by 2017.

“The global anesthesia and respiratory devices market is forecast to exceed $14 billion by 2017 with a Compound Annual Growth Rate (CAGR) of 4.7 percent during the period 2010-2017,” the ASDReports document reads. “The market is expected to be primarily driven by the huge patient population suffering from respiratory diseases such as Chronic Obstructive Pulmonary Disease (COPD) and the availability of medical devices to treat Obstructive Sleep Apnea (OSA) and COPD.” “Other factors to drive the growth of the anesthesia and respiratory devices market include an increase in disposable income in emerging countries, an increase in the number WWW.ORTODAY.COM

Anesthesia of hospitals, growing demand for home healthcare devices and an expansion in reimbursement for (a) wide range of anesthesia and respiratory devices,” according to the ASDReports website.

Another beacon for growth within these markets is integration with hospital information systems that should equate to better connectivity and productivity.

“The integration of anesthesia and respiratory devices with hospital information systems solved the problem of connectivity for data management and has resulted in an increase in the usage of these devices, thereby driving growth of the overall market,” according to ASDReports.com. “In the case of anesthesia care, the identification of key information quickly and easily is critical to anesthesia practice, and this has increased the importance of information systems which can quickly record and retrieve this data.”

Technological advancements in regards to anesthesia and respiratory devices have impacted the market.

“The growing need for fast data flow in hospitals for information recording, clinical data analysis and timely delivery of results has led to the application of information technology, which has enabled the connectivity of most of the anesthesia

and respiratory devices, such as anesthesia machines, pulse oximeter systems and respiratory devices with the hospital information system. For example, Siemens Healthcare introduced Centricity Anesthesia, which is an advanced clinical information management system designed for anesthesia. Such devices enable real time data transfer to the physicians facilitating timely and better treatment,” according to ASDReports.com.

“This results in improved satisfaction for both physicians and patients, thereby driving the overall growth of the anesthesia and respiratory devices market,” the website continues. “Centralized anesthesia and respiratory care data management is a very efficient and cost-effective way to monitor patients and manage the hospital-wide allocation of anesthesia and respiratory care services. This will result in an increase in the adoption rate of anesthesia and respiratory care devices, leading to a growth of the market.”

Companies included in the ASDReports information are Covidien, Philips Respironics, ResMed, Draegerwerk AG & Co. KGaA, GE Healthcare, CareFusion Corp., Smiths Medical, Teleflex Inc. and B. Braun Medical Inc.

June 2014 | OR TODAY

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IN THE OR PRODUCT SHOWROOM

DRÄGER’S APOLLO® For more than a century, clinicians have trusted Dräger’s innovative anesthesia solutions to improve clinical and financial efficiency. Proven to reduce volatile agent costs, the Apollo’s Low Flow Wizard helps clinicians deliver low flow anesthesia with confidence and ease. Combined with its heated breathing system and precision E-vent®plus piston ventilator, the Apollo offers exceptional opportunity for uniform delivery of low flow anesthesia in your healthcare facility.

For more information, please visit www.draeger.com 22

OR TODAY | June 2014

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PRODUCT SHOWROOM

DATEX-OHMEDA’S AISYS CS² Modular and upgradeable, with Aisys CS² you’re planning for the future while protecting your investment. Electronic agent control allows you to capture set agent concentrations and precisely measures agent usage. The 15-inch touchscreen ventilator display and ecoFLOW option displays oxygen flow alongside pre-set targets while calculating anesthetic agent cost and usage in real-time. Clinicians can use this to adjust oxygen flow to help avoid unnecessarily high fresh gas flow rates.

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June 2014 | OR TODAY

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IN THE OR PRODUCT FOCUS

MINDRAY’S A-SERIES The A-Series Anesthesia System combines traditional anesthesia delivery concepts with advanced technology and an intuitive user interface. The A5’s advanced ventilation modes enable effective care across a wide range of patients with optional integrated gas analysis, dual agent auto ID, aged-based MAC values and capnography. The 15-inch color touchscreen allows clinicians to easily select ventilation settings. The A5 comes standard with VCV, PCV, PCV-w/Volume Guarantee, PS, SIMV-VC, SIMV-PC, spirometry, temp controlled breathing system, high pressure O2 port, central brake, mounting rails and adjustable workspace lighting. HL7 connectivity provides the industry standard interface for AIMS and EMR systems.

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OR TODAY | June 2014

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IN THE OR CONTINUING EDUCATION 586B

BY HOLLY FRANSON, RN, SRNA

VASOACTIVE DRUGS IN THE OR Ensuring Patients’ Safety

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CONTINUING EDUCATION 586B

H

opeless, alone and scared — this is how your patient feels as you enter the room to perform the preoperative assessment. All sense of security and independence leaches from your patient before a surgical procedure. The patient lies in bed, gazing up at you with trusting eyes. Family members surround the bed anxiously, looking to you for assurance that you will take excellent care of their loved one. OR healthcare professionalsmust realize the magnitude of your responsibility. You have only a few minutes to gain your patients’ trust before they place their lives in your hands. You are responsible for providing the highest quality of nursing, pharmacy and medical care through the entire operative period.

ContinuingEducation.com guarantees this educational activity is free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See page 39 to learn how to earn CE credit for this module.

The goal of this program is to enhance perioperative nurses’, pharmacists’ and physicians’ knowledge of the use of vasoactive drugs in the clinical setting.

After studying the information presented here, you will be able to: • Discuss the mechanism of action for common vasoactive drugs and indications for their use in the OR • Describe the physiologic effects of vasoactive drug therapy in order to anticipate and react appropriately to positive and negative outcomes • Provide standard dosages for the safe administration and titration of vasoactive drugs

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Unfortunately, not every case goes according to plan. Unexpected turns and emergencies occur. Do you have adequate knowledge about drug therapy used in the OR to manage decompensating patients? Could you react appropriately to intended or unintended hemodynamic effects of life-saving vasoactive drugs? You must familiarize yourself with these drugs to ensure patient safety and reduce the risk of patient morbidity and mortality. This module provides the information necessary to maintain safety while caring for a patient who receives vasoactive drugs during a surgical procedure.

PHARMACOLOGY Pharmacology is a fundamental part of nursing, pharmacy and medical practice, and all of these healthcare professionals must have an understanding of the drugs that patients receive.

Pharmacologic agents — such as vasopressors, vasodilators and inotropes (collectively referred to as vasoactive drugs) along with beta-blockers and calcium channel blockers — have profound effects on heart rate, blood pressure and cardiac output. A thorough understanding of the mechanism of action, clinical indications, anticipated

hemodynamic effects, potential harmful effects and appropriate doses of vasoactive drugs is essential to the safe management of unstable patients.

Vasoactive drugs alter preload, afterload, heart rate and myocardial contractility.

Preload is the volume of blood in the ventricles before contraction or at the end of diastole.

This end-diastolic volume stretches the myocardial muscle fibers and develops the force of contraction.1 The FrankStarling law explains this relationship. It states that an increase in the amount of blood entering the heart during diastole (end-diastolic volume) will result in a greater amount of blood ejected from the heart during systole (stroke volume).2,3 A greater end-diastolic volume leads to an increased myocardial wall tension, which produces greater contractility until overdistension of the heart muscles occurs.2 Preload, which is essentially venous return to the heart, is influenced by blood volume and venous compliance.

Vasopressors — such as phenylephrine (Neo-Synephrine) and vasopressin (Pitressin) — increase preload. Vasodilators — such as nitroglycerin (Minitran) and nitroprusside — reduce preload. 1 June 2014 | OR TODAY

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IN THE OR CONTINUING EDUCATION 586B

Afterload is the pressure the ventricles pump against during systolic ejection in order to eject blood. Essentially, it is arterial blood pressure, as the primary determinates are arterial tone and compliance.1 An inverse relationship exists between afterload and cardiac output: As afterload increases, cardiac output decreases.3 Heart rate is described as the chronotropic state of the heart.

Under normal circumstances, it’s under the control of the sinoatrial node. The sinoatrial node is a small group of specialized cells in the right atria. Upon spontaneous activation, the sinoatrial node generates an electrical impulse that spreads through the atria. At the base of the right atrium, the impulse reaches the atrioventricular node. There is a slight delay at the atrioventricular node, allowing for complete atrial contraction. As the impulse continues past the atrioventricular node, it reaches the bundle of His, which is located between the two ventricles.

The bundle of His divides into the right and left bundle branches between the ventricles. After passing through the right and left bundle branches, the electrical impulse reaches the Purkinje fibers. These are large cells that allow for rapid contraction of the ventricles.3 Contractility is the inotropic state of the heart. It is the ability of the heart muscles to contract independent of preload and afterload.3 The primary influence on contractility is the sympathetic nervous system. The sympathetic nervous system is a division of the autonomic nervous system and is responsible for the “fight or flight” response.3 Some sympathetic responses include increased heart rate and contractility, bronchial dilation, pupil dilation, decreased intestinal motility and 30

OR TODAY | June 2014

reduced urine output. These responses are produced by the action of sympathetic neurotransmitters (norepinephrine and epinephrine) on adrenergic receptors. Adrenergic receptors are located on multiple organs and produce sympathetic responses when activated by norepinephrine or epinephrine. A sympathetic response is caused by the activation of adrenergic receptors by neurotransmitters, and the response is individualized based on the organ and type of receptor being activated.

Adrenergic receptors are located primarily on the myocardium and coronary vessels. A detailed understanding of adrenergic receptors and the physiologic response to their stimulation is necessary to understand the mechanism of action of vasoactive drugs. The response to adrenergic stimulation depends on the location of the receptor and the most abundant type of receptor.

Adrenergic receptors are classified as α (alpha) or ß (beta) and subdivided into α1, α2, ß1, ß2.4 ß1-adrenergic receptors are found mainly in the heart. Activation produces an increase in cardiac rate of impulse generation and conduction (chronotropic effects), a greater force of contraction (inotropic effects) and an increase in conduction impulse (dromotropic effects).1,4 ß2-adrenergic receptors are located on bronchial and vascular smooth muscle, and activation results in vasodilation of smooth muscle and a decrease in systemic vascular resistance, or SVR.1,4 ß1 receptors are located in vascular smooth muscle, and stimulation results in coronary vasoconstriction, or an increase in systemic vascular resistance.1,4 ß2-receptors are found on presynaptic nerve terminals, and activation decreases the release of norepinephrine through a negative feedback mecha-

nism that produces vasodilation.1,2 Sympathomimetic drugs are vasoactive drugs that mimic the effects of the sympathetic nervous system on the heart and vasculature.5 These agents may be natural catecholamines, synthetic catecholamines or synthetic noncatecholamines.5 The mechanism by which these drugs produce their pharmacologic effects depends on the type of receptor activated. Sympathomimetic drugs may be direct acting, indirect acting or mixed, meaning they directly activate the adrenergic receptor or stimulate the release of epinephrine or norepinephrine, which then actives the receptor.6 Sympathomimetic drugs are used clinically as positive inotropes and vasopressors.5 The universal hemodynamic effect of vasopressors is to constrict the vasculature and raise systemic blood pressure.5 Commonly used vasopressors in the OR include epinephrine (Adrenalin), norepinephrine (Levophed), phenylephrine (Neo-Synephrine), dopamine (Intropin) and vasopressin (Pitressin). This classification must be taken generally, as multiple agents also have inotropic and chronotropic properties.

EPINEPHRINE Epinephrine is a direct acting, natural catecholamine that stimulates both ß- and ß-adrenergic receptors.6 At low doses, the activation of ß1-adrenergic receptors creates a positive inotropic, chronotropic and dromotropic effect, which clinically is observed as an increase in heart rate, systolic blood pressure and cardiac output.7 ß2-activation promotes vasodilation of vascular and bronchial smooth muscle, leading to decreased systemic vascular resistance, increased blood flow to skeletal muscles and bronchodilation.5 The concurrent ß-adWWW.ORTODAY.COM

CONTINUING EDUCATION 586B

renergic stimulation decreases bronchial secretions, so there is an improvement in oxygenation and decreased airway resistance, justifying its use in the treatment of bronchospasm.6 ß2-adrenergic stimulation also stabilizes mast cells located in the lower airways and decreases histamine release, which serves as the mechanism of treatment for anaphylactic reactions.6 At high doses, the ß- properties dominate the ß2, resulting in vasoconstriction.7 This leads to an increase in preload (from peripheral vasoconstriction), afterload (from increased systemic vascular resistance) and cardiac output (from the ß1 chronotropic and inotropic effects).6 Epinephrine is indicated for clinical use because of its dramatic influence on the heart, blood vessels and bronchial smooth muscle. In CPR, it’s used to re-establish a rhythm.6 One study addresses the concern of increased myocardial oxygen consumption, ventricular arrhythmias, post-resuscitation myocardial dysfunction and impaired ventilation-perfusion associated with epinephrine use.8 It’s also indicated in the treatment of shock, profound bradycardia and hypotension, bronchospasm and anaphylaxis.6 Epinephrine is not indicated as the initial treatment for septic shock because of its significant negative effect on gastric blood flow and an increase in lactate.7,9 Along with the potential benefits of epinephrine comes the risk that the inotropic and chronotropic effects may increase myocardial oxygen demand and decrease supply.5 Vigilance is necessary to ensure there is not an imbalance, leading to myocardial ischemia or infarction.10 The forceful dromotropic effects may lead to cardiac dysrhythmias due to the increased WWW.ORTODAY.COM

automaticity of the heart.6 Patients with diabetes must be monitored for hyperglycemia due to ß2 activation decreasing insulin release and increasing glycogenolysis and gluconeogenesis.5 The ß-adrenergicinduced vasoconstriction may lead to organ ischemia, especially in the kidneys. Clinicians must monitor for reduced renal blood flow.5,10 DOPAMINE Dopamine is a direct and indirect acting endogenous catecholamine that is the precursor for norepinephrine and epinephrine.9 It stimulates dopaminergic (D1 and D2) and adrenergic receptors.5 The primary effects of dopamine1 receptor stimulation are to produce renal, coronary, gastric and cerebral vasodilation.6 Dopamine2 receptor stimulation causes a release of norepinephrine, which accounts for the indirect effect of the drug.5 The hemodynamic effects of dopamine are dose related. At low doses (0.5 to 3 mcg/kg/min), dopaminergic receptors are primarily stimulated.

The main effect of this dose is increased renal and mesenteric perfusion, creating an increased urine output.7 With increased doses (3 to 10 mcg/kg/min) ß-adrenergic receptors are activated, which increases heart rate and contractility and cardiac output along with peripheral vasodilation that causes decreased systemic vascular resistance. At high doses (greater than 10 mcg/kg/min), ß-adrenergic effects dominate, causing a peripheral vasoconstriction, increased systemic vascular resistance and a decrease in urine output.7 Dopamine increases renal perfusion, glomerular filtration rate, sodium excretion and urine output, which rationalizes its use in acute renal failure.5 It improves myocardial

contractility, cardiac output and blood pressure, so clinically it is used to treat acute cardiac failure, shock and profound bradycardia.5 The American College of Cardiology and the American Heart Association suggest dopamine as a first-line drug to treat hypotension following an acute MI in patients with symptoms of shock.7 The Surviving Sepsis Campaign Guidelines support the use of dopamine (and norepinephrine) as the first-choice vasopressor to correct hypotension.9 For patient safety, urine output must be monitored during infusion due to the ß-adrenergic mediated vasoconstriction at high doses.10 Careful attention must be paid to the presence of dysrhythmias and tachycardia that may indicate an increased myocardial workload and risk of ischemia.5 Blood glucose should be monitored with prolonged use due to the inhibition of insulin secretion.5 NOREPINEPHRINE Norepinephrine is a direct-acting natural catecholamine with potent ß-adrenergic stimulation and a very small effect on ß1 receptors.7 The potent ß-adrenergic properties associated with norepinephrine produce vasoconstriction in the arterial and venous vasculature. This leads to an increased venous return to the heart, resulting in an increased preload. Afterload is also dramatically increased.10 Hemodynamically, there is an increase in systolic, diastolic and mean arterial pressure.7 The intense ß-adrenergic properties of this drug may virtually wipe out the ß1 effect due to a reflex vagal response.

Thus, there is no significant ß1 effect on heart rate and cardiac output.7 Norepinephrine is used to treat refractory hypotension due to profound vasodilation, such as shock states. It’s often used in patients with June 2014 | OR TODAY

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IN THE OR CONTINUING EDUCATION 586B

low systemic vascular resistance and adequate cardiac output.10 The intense vasoconstriction increases the myocardial workload of the heart and may significantly decrease cardiac output.10 Multiple studies suggest norepinephrine is the treatment of choice for sepsis; however, due to the risk of decreased cardiac output, it may be combined with dobutamine (Dobutrex) for the positive inotropic and chronotropic effects.9,11 It may actually be more desirable than dopamine, as it may be considered more potent, and dopamine actually requires the body to release norepinephrine stores for its effects.9 Clinicians must monitor for dysrhythmias and changes in electrocardiogram indicating myocardial stress. Peripheral vasoconstriction also leads to decreased blood flow to skin, skeletal muscle, liver and kidneys. This makes it prudent to monitor for a reduction in urine output and signs of inadequate peripheral perfusion.10 PHENYLEPHRINE Phenylephrine is a synthetic noncatecholamine that has direct effects on ß1-adrenergic receptors. It rapidly produces arterial constriction to a greater extent than venous constriction. The main effect of phenylephrine is increased systemic vascular resistance, venous return and arterial blood pressure. A reflex vagal response may lead to bradycardia, which may also decrease cardiac output.10 This drug treats hypotension without raising heart rate. It’s used to treat excessive peripheral vasodilation in states such as shock or vasodilator overdose.8 It’s a desirable choice when ß-adrenergic effects would be undesirable for the patient, such as one with coronary artery disease, aortic stenosis or supraventricular tachycardia.7 These patients 32

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would otherwise not be able to tolerate a high heart rate secondary to their disease, but need the added systemic vascular resistance support.

One of the clinically significant adverse effects of phenylephrine is related to vagally mediated bradycardia leading to a decreased cardiac output. The increased systemic vascular resistance also contributes to greater myocardial oxygen requirements from an increase in afterload and a decrease in renal, gastric and peripheral perfusion. It is important to monitor for extreme hypertension, arrhythmias and anaphylaxis.

It is preferable to administer dopamine, dobutamine, norepinephrine and phenylephrine via a central line. Peripheral infusions are extremely irritating to the vasculature; extravasation and skin necrosis may occur.1,10

High-dose vasopressin is indicated to treat severe hypotension (unresponsive to other medications), hypovolemia and shock.7 One study shows vasopressin to be a potent vasopressor used to stabilize hemodynamic status during catecholamine resistant shock.12 It’s also a part of the new advanced cardiac life support protocol for the treatment of ventricular fibrillation and pulseless ventricular tachycardia when given as a one-time dose of 40 units IV.8 Clinicians should monitor electrocardiography for signs of myocardial ischemia, infarction and dysrhythmias due to vasoconstriction of coronary arteries.6 Larger doses may precipitate gastric peristalsis, leading to severe abdominal pain, nausea and vomiting.6 Allergic reactions may occur due to antibody formation from prolonged use.5

VASOPRESSIN Vasopressin is an exogenous preparation of antidiuretic hormone.6 At high doses, it binds to vasopressin receptors and causes potent vasoconstriction.10 There are two types of vasopressin receptors, classified as V1 (located on arterial smooth muscle) and V2 (on renal vasculature).7 It is the activation of the V1 receptors that leads to the clinically significant peripheral vasoconstriction.6 The anticipated hemodynamic effect of high-dose vasopressin therapy is vasoconstriction leading to increased blood pressure without the associated tachycardia and arrhythmias presented by ß-adrenergic stimulation.

Essentially, it has a synergistic effect with other vasopressors, as it acts independently of the adrenergic receptors.10 The hemodynamic effect of vasopressin on the heart is a decrease in cardiac output and heart rate, likely caused by a reflex response from vasoconstriction and a decreased coronary blood flow.7

DOBUTAMINE Positive inotropic agents are types of sympathomimetic drugs used to increase the stretch and force of myocardial contraction, leading to an increased cardiac output. Common positive inotropes in the OR include dobutamine and milrinone.

Dobutamine is a synthetic catecholamine that has direct ß1-adrenergic effects with limited ß2 and nearly no ß effects.10 It produces a positive inotropic and chronotropic effect on the heart. The primary effect on the vasculature is vasodilation from ß2 stimulation, which decreases afterload and further improves myocardial contraction.10 Compared with other inotropic agents, it improves cardiac output without massive increases in heart rate and blood pressure. This effect is good for treatment of patients with congestive heart failure, acute MI and low cardiac output states.5 The American College of Cardiology and American Heart Association suggest WWW.ORTODAY.COM

CONTINUING EDUCATION 586B

dobutamine as a first-line agent to treat hypotension from an acute MI without symptoms of shock.7 They also suggest dobutamine as the optimal therapy for low-output states accompanied by elevated filling pressures, such as cardiogenic shock and heart failure.9 Dobutamine has proven to be an acceptable first-line drug for patients needing positive inotropic support.

High doses of dobutamine (greater than 10 mcg/kg/min) may lead to tachycardia, increasing the risk of dysrhythmias.10 Clinicians should use caution when administering dobutamine to patients with atrial fibrillation because of increases in automaticity, increasing the risk of tachydysrhythmias.5 An important point about dobutamine administration: Hypotension may occur if vasodilation is not offset by an increase in cardiac output because it is a positive inotrope, not a vasopressor.10 MILRINONE Milrinone is a noncatecholamine phosphodiesterase (PDE) III inhibitor that has both positive inotropic and vasodilating effects.5 The PDE III inhibition leads to increased intracellular levels of cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP), both of which are second messengers important in the regulation of intracellular calcium and smooth muscle relaxation, respectively.5 Second messengers are intracellular substrates responsible for carrying an extracellular hormone’s (or first messenger’s) message through the intracellular space.3 One study shows milrinone is a powerful cardiac inotrope and vasodilator.13 Its effects are completely independent of ß-adrenergic stimulation.6 The inotropic effect is WWW.ORTODAY.COM

related to the inhibition of PDE III, causing an increase in cAMP in the myocardial cells. This leads to an increase in calcium ions and positive inotropic, chronotropic and dromotropic effects.8 It’s appropriate for patients who take beta-blocking agents or who have become refractory to catecholamine therapy.7 Patients with acute cardiac failure or congestive heart failure benefit from the combined inotropic and vasodilating effects because there is a balance in myocardial oxygen supply and demand.8 Use for more than 48 hours is associated with increased mortality.6 A study of the use of milrinone in hospitalized patients showed an increased rate of sustained hypotension requiring intervention and new-onset dysrhythmias.14 Therefore, it is essential to monitor for vasodilation and hypotension with intravascular bolus, along with dysrhythmias, hyperthermia and thrombocytopenia.5,10 Vasodilators are a type of vasoactive drug used clinically to treat hypertension, produce controlled hypotension and decrease left ventricular myocardial workload.

Vasodilators decrease systemic blood pressure by decreasing systemic vascular resistance, venous return and cardiac output. Common vasodilators in the perioperative period include nitroglycerin and nitroprusside. The Heart Failure Society of America recommends nitroglycerin and nitroprusside in combination with a diuretic to treat congestive heart failure symptoms, assuming no symptomatic hypotension is present.9 NITROGLYCERIN Nitroglycerin is classified as an organic nitrate, which acts through nitric oxide-mediated smooth muscle vasodilation.5 Nitroglycerin

generates nitric oxide that through a series of enzyme reactions inhibits calcium from entering the vascular smooth muscle, resulting in vasodilation.5 Its primary effect is venous vasodilation, and as the dose increases, arterial vasodilation occurs.9 The hemodynamic effects of nitroglycerin are strongly attributed to the reduction of myocardial oxygen demand and the increase in supply via a reduction in preload, afterload and redistribution of coronary blood flow.9 There is often a reflexive increase in heart rate and a reduction in blood pressure. Nitroglycerin also relaxes respiratory smooth muscle, causing bronchodilation.5 Nitroglycerin is used to treat myocardial ischemia, hypertension and ventricular failure and to decrease myocardial infarct size.5,10 Its indication for heart failure specifically is related to its ability to decrease cardiac filling pressure and increase cardiac output. Nitroglycerin is an appropriate antianginal agent because it is a coronary vasodilator.9 The most common adverse effect of nitroglycerin is headache, likely due to the dilation of cerebral blood vessels. Monitor for reflex tachycardia, paradoxical bradycardia, hypoxia and orthostatic hypotension due to a decreased systemic vascular resistance, tolerance and nausea and vomiting.9 Avoid the use of nitroglycerin in hypovolemic patients and those who recently took phosphodiesterase inhibitors; e.g., sildenafil citrate (Viagra), to treat erectile dysfunction.9 This combination places patients at a risk for severe hypotension.9 If the anticipated length of infusion is more than 30 to 60 minutes, nitroglycerin should be administered with nonpolyvinyl chloride tubing to reduce the amount of drug absorbed into the tubing.10 June 2014 | OR TODAY

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IN THE OR OVERVIEW OF VASOACTIVE DRUGS10,15,16,20 DRUG

STANDARD DOSAGE*

PRIMARY RECEPTOR

*Doses approximate/adult

ACTIVATED OR

GENERAL HEMODYNAMIC RESPONSE

MECHANISM OF ACTION HR: increases

Epinephrine

For bronchospasm: 0.1 to 0.5 mg SC/IM q 0.5 to 4

Low doses: β and to a lesser

(Adrenalin)

hr, followed by 0.1 to 1 mcg/kg/min (inotropic support)

extent α

Contractility: increases

For anaphylaxis: 0.5 to 1 mg IV q 3 to 5 minutes

extent β

Afterload: decreases (at low doses) increases (at high doses)

High dose: α and to a lesser

CO: increases (may decrease at high doses due to vasoconstriction) Preload: increases BP: increases

For CPR: 1 mg (1:10,000) IV q 3-5 minutes 2-2.5x IV dose if given by ETT with no IV access.

Norepinephrine

For hypotension: 8 to 12 mcg/min IV initially;

(Levophed)

followed by 2 to 4 mcg/min

Contractility: increases

For CPR: 0.1 mcg/kg/min (max 2 mcg/kg/min)

Afterload: increases

α, to a lesser extent β

HR: reflex decreases

CO: increases or decreases (due to intense vasoconstriction) Preload: increases BP: increases

Phenylephrine (Neo-Synephrine)

Bolus: 1 to 10 mcg/kg IV; increase as needed Infusion: 0.5 to 10 mcg/kg/min IV

α

HR: reflex decreases

Contractility: no direct effect

CO: decreases (due to reflex decreases HR) Afterload: increases

Preload: increases (minimal) BP: increases

Dopamine

Typical adult dosage: 2-20 mcg/Kg/minute

(Intropin)

continuous IV infusion

Low dose (renal): 0.5 to 3 mcg/kg/min IV

Moderate dose (cardiac): 3 to 10 mcg/kg/min IV

High dose (vascular): greater than 10 mcg/kg/min

Low dose: D1 and D2

HR: slight increases

(plus D1 and D2)

CO: increases (at high dose may decrease)

and D2)

(at high dose)

Intermediate dose: β High dose: α (plus β and D1

Contractility: increases

Afterload: decreases (at low dose) and increases Preload: increases (at high dose) BP: increases

Dobutamine

Infusion: 5-10 mcg/kg/min IV continuous infusion.

(Dobutrex)

Titrate PRN

β1, to a lesser extent β2

HR: increases

Contractility: increases CO: increases

Afterload: decreases Preload: decreases BP: increases

Milrinone (Primacor)

Bolus: 50 mcg/kg IV (slowly over 10 minutes)

Infusion: 0.4 to 0.75 mcg/kg/min IV (max 1.13 mcg/ kg/min) Usual 0.5 mcg/kg/min

PDE III (inhibition)

HR: slight increases

Contractility: increases CO: increases

Afterload: decreases Preload: decreases BP: variable

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DRUG

STANDARD DOSAGE*

PRIMARY RECEPTOR

GENERAL HEMODYNAMIC RESPONSE

ACTIVATED OR MECHANISM OF

Nitroglycerin (Minitran)

*Doses approximate/adult

ACTION

For acute ischemia: bolus: 50-100 mcg

Direct venous vasodilator

Infusion: 0.1 to 7 mcg/kg/min

HR: reflex increases

Contractility: reflex increases

CO: variable (may decreases due to decreased preload)

Afterload: decreases Preload: decreases BP: decreases

Nitroprusside

0.5 to 10 mcg/kg/min IV (max 10 mcg/kg/min) Usual dose

Direct arterial and venous

3 mcg/kg/min

vasodilator

HR: reflex increases

Contractility: reflex increases CO: variable

Afterload: decreases Preload: decreases BP: decreases

Beta-adrenergic

IV bolus: 5 to20 mg IV; followed by 20-40 mg q 10-15

blocking agents:

minutes

Labetalol (Trandate)

IV infusion: 2 mg/min

PO: 100 mg BID; followed by

Nonselective β1, β2, and

HR: decreases

(alpha to beta ratio 1:7)

CO: decreases

α-adrenergic antagonist

Max dose: 300 mg

(Brevibloc)

IV bolus: 0.5 to 1 mg/kg IV

IV infusion: 50 to 150 mcg/kg/min IV

Afterload: decreases BP: decreases

200 to 400 mg PO BID

Esmolol

Contractility: decreases

Selective β1, antagonist (ultra-short acting)

HR: decreases

Contractility: decreases CO: decreases

Afterload: minimal effect BP: decreases

Metoprolol

IV bolus: 2.5 to 5 mg IV q 5 min (up to 15 mg); followed

(Lopressor)

by 100 mg BID

Selective β1, antagonist

HR: decreases

Contractility: decreases CO: decreases

PO: 50 to 100 mg/day; followed by 100 to 450 mg/day

Afterload: minimal effect BP: decreases

Calcium channel

IV bolus: 0.25 mg/kg IV over 2 min. Can increase to 0.35

Calcium ion channel

blockers

mg/kg over 2 min

inhibitor; vasodilator

Diltazem (Cardizem)

IV infusion: 10-15 mg/hr IV

HR: slight decreases

Contractility: no change or minimal decreases

Afterload: decreases

PO: 30 mg PO qid or 60 to 240 mg bid (max 360 mg/day)

Preload: no change BP: decreases

Atrioventricular conduction: decreases

Nicardipine (Cardene)

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IV bolus: 0.625 to 2.5 mg IV

IV infusion: 0.5 to 5 mg/hr IV PO: 20 to 60 mg PO

Calcium ion channel inhibitor; vasodilator, and antiarrhythmic.

HR: increases (minimal) Afterload: decreases BP: decreases

QT interval: increases

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CLINICAL VIGNETTE Jack, age 55, has a history of coronary artery disease and hypertension. He was admitted to the hospital for pain in the right subcostal area, nausea, vomiting and loss of appetite. His medical workup revealed severe gallstones and inflammation of the gallbladder. A cholecystectomy is scheduled for 8:30 a.m. today.

Preoperative assessment revealed a current medication of labetalol (Trandate) 300 mg and atorvastatin calcium (Lipitor) 20 mg. The patient states he did not take his medications the morning of surgery.

Physical examination reveals a blood pressure of 162/95 mmHg, heart rate 62 beats per minute, respiratory rate 12 breaths per minute and oxygen saturation of 99% on room air. NPO status is verified, and the patient states he has no known drug allergies.

The patient is moved to the operating table; surgical consent is verified; anesthesia is induced, and the procedure is started at 8:45 a.m. During the procedure, the patient exhibits periods of profound hypotension, followed by rapid increases in blood pressure. Treatment is administered appropriately, attempting to maintain the blood pressure within 20% of the patient’s baseline. The procedure finishes safely, and the patient is taken to the PACU. Upon admission to the PACU, the patient’s vital signs are blood pressure 178/95 mmHg, heart rate 96 beats per minute, respiratory rate 22 breaths per minute and oxygen saturation 98% on 3 liters via nasal cannula. The patient describes his pain as 1 out of 10 and appears to be resting comfortably.

Based on the clinical situation, what preoperative intervention may have reduced Jack’s labile blood pressure intraoperatively?

A. Administering a fluid bolus B. Administering the patient’s atorvastatin

calcium (Lipitor) C. Administering the patient’s labetalol (Trandate) D. Ensuring the patient was cold prior to

entering the OR

1

2

3

Based on the postoperative assessment of Jack, what is an appropriate intervention at this time?

A. Phenylephrine (Neo-Synephrine) 40 mcg IV B. 500 ml fluid bolus C. Labetalol (Trandate) 10 mg IV D. Epinephrine (Adrenalin) 0.5 mg IV

4

After reassessment in 15 minutes, Jack’s vital signs are as follows: blood pressure 230/110 mmHg, heart rate 98 beats per minute, respiratory rate 16 breaths per minute, oxygen saturation 99%. The nurse administers another dose of labetalol (Trandate) 10 mg IV with no response. What is an appropriate drug to administer at this time?

A. Dopamine (Intropin) 0.5 mcg/kg/min IV B. Nitroprusside (Nipride) 0.5 mcg/kg/min IV C. Milrinone (Primacor) 0.4 mcg/kg/min IV D. Norepinephrine (Levophed) 8 mcg/min IV

What aspect of Jack’s postoperative status is concerning?

A. Blood pressure 178/95 mmHg B. Pain rating of 1 out of 10 C. Oxygen saturation 98% D. Respiratory rate 22 breaths per minute

4. Correct Answer: B – When severe hypertension is difficult to manage postoperatively, the initiation of nitroprusside (Nipride) may be considered.

3. Correct Answer: C — Because Jack appears comfortable and pain is not an issue, the administration of a beta-blocker is appropriate to lower the blood pressure 2. Correct Answer: A — Common causes of high blood pressure in the postoperative period include pain, hypervolemia and an amplified sympathetic response. This is concerning because postoperative hypertension increases the risk of myocardial ischemia, myocardial infarction, dysrhythmias and bleeding.

1. Correct Answer: C— Ideally, patients should be normotensive before surgery, and it is recommended that medication therapy to control blood pressure be administered preoperatively. To optimize the patient’s cardiovascular status, the labetalol (Trandate) may have been given.

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CONTINUING EDUCATION 586B

NITROPRUSSIDE Nitroprusside is a direct-acting, nonselective arterial and venous peripheral vasodilator.10 Its mechanism of action is similar to nitroglycerin in that the release of nitric oxide causes an increase in intracellular cGMP levels. This inhibits the movement of calcium into the smooth muscle, which produces vasodilation.5,10 The anticipated hemodynamic effect of nitroprusside is a rapid reduction in blood pressure, preload and afterload.9 Due to the short duration of this drug, it is important to continuously monitor and maintain careful titration via an infusion pump. The effects are due to a reduction in preload and afterload from arterial and venous dilation, respectively.9 There is a reflex tachycardia and increased myocardial contractility from the decreased systemic blood pressure.

Nitroprusside is indicated to manage a hypertensive crisis or controlled hypotension. It plays a significant role in increasing cardiac index and decreasing mean arterial pressure and systemic vascular resistance in patients with heart failure.9 The administration of nitroprusside leads to a risk of cyanide toxicity.5 Cyanide is a toxic chemical compound produced during the metabolism of nitroprusside. Normally, a healthy patient can excrete cyanide so there is no accumulation in the body. However, at high rates or with long-term administration, cyanide may build up. Signs of cyanide toxicity include resistant hypertension despite high doses of nitroprusside; central nervous system dysfunction (change in mental status, seizure and coma); unexplained metabolic acidosis; and increased venous oxygen tension, which is used to assess the adequacy of tissue oxygenation.9 A definitive diagnosis is obtained by blood WWW.ORTODAY.COM

cyanide levels. Treatment includes thiosulfate 150 mg/kg in 50 mL of water given IV over 15 minutes. This drug aids in the conversion of cyanide to thiocyanate, which is eliminated by the kidneys.5 Note that since nitroprusside is subject to photodecomposition, the bag and tubing should be wrapped in metal foil during IV administration.10 BETA-BLOCKERS In addition to the vasoactive drugs, beta-blockers and calcium channel blockers have significant importance during the perioperative period. ß-adrenergic receptor blocking drugs directly inhibit the ß-adrenergic receptors, producing a decreased heart rate, blood pressure and contractility along with an increased systemic vascular resistance and antiarrhythmic effect.10 Common beta-blockers in the perioperative setting include labetalol (Trandate), esmolol (Brevibloc) and metoprolol (Lopressor). Beta-blocking agents vary in their selectivity to ß1-adrenergic receptors, ß2-adrenergic receptors or both. ß1-adrenergic receptor specificity results in a decreased chronotropic, inotropic and dromotropic effect. Furthermore, there is a reduced risk of bronchospasm and increased systemic vascular resistance produced by ß2-adrenergic receptor blockade. Nonspecific beta-blockers have antagonistic effects on both ß1- and ß2-adrenergic receptors, resulting in vasoconstriction in the bronchial and vascular smooth muscle. Clinicians should use caution when administering these drugs to patients with asthma or reactive airways.10 These drugs provide cardiovascular protection by decreasing myocardial oxygen demand and increasing supply.16,17 This desirable balance in myocardial oxygen supply and

demand may be explained by a reduction in heart rate, which increases the time allotted for diastolic perfusion along with decreased contractility that further reduces oxygen demand.17 Possible adverse outcomes of beta-blocking drugs include heart block, bradycardia, bronchospasm and congestive heart failure.10 A review of studies on beta blockade in the perioperative setting found a reduction of myocardial ischemia, MI and mortality due to cardiac events when beta-blocking therapy was initiated before surgery.17 Recommendations from the studies included achieving an average heart rate of 60 to 70 beats per minute a few weeks before surgery.17 Another study evaluated the effectiveness of perioperative beta-blocking agents on positive patient outcomes after surgery.18 Similar to the above results, this study revealed a decreased incidence of myocardial ischemia and perioperative dysrhythmias with the preoperative use of beta-blocking drugs.18 The American College of Cardiology/American Heart Association Task Force on Practice Guidelines published recommendations for perioperative beta-blocker therapy based on scientific evidence and published clinical trails.19 Recommendations include continuing beta-blocker therapy in patients being treated for hypertension, angina and arrhythmias; administering beta-blockers to patients who are undergoing a high-risk cardiac surgery or vascular surgery; and administering betablockers to patients who are undergoing vascular surgery and whose preoperative assessment reveals coronary artery disease or high cardiac risk.20 In addition, betablockers are often used in the perioperative setting to treat acute hypertension and tachycardia to ensure June 2014 | OR TODAY

37

IN THE OR CONTINUING EDUCATION 586B

adequate myocardial oxygen supply and demand and improve patient outcomes.

Patients must receive education about beta-blockers and the importance of adhering to their medication regimens. One study that assessed patients’ knowledge about the benefits of beta-blocking drugs found that patients have an inadequate understanding of the drugs’ importance.21 Nurses, pharmacists and physicians must be knowledgeable about the physiologic effects and benefits of preoperative beta blockade so they can educate their patients.

CALCIUM CHANNEL BLOCKERS Calcium channel blockers are a classification of drugs that selectively block the influx of calcium ions through calcium channels.22 Nicardipine (Cardene) and diltiazem (Cardizem) are two calcium channel blockers used in the perioperative setting. Calcium is used by many tissues in the body and affects cardiac contraction, smooth muscle contraction, hormone secretion and neuronal synapses.10 The presence of calcium in the myocardium results in an increased contraction; therefore, blockade of calcium channels results in a slowing of the heart by decreasing the depolarization of the sinoatrial node and slowing conduction through the atrioventricular node.

This process also reduces myocardial oxygen demand.21 Calcium present in the vasculature results in vasoconstriction, so calcium channel blockers cause vasodilation.21 Clinically, these drugs are used to treat hypertension, myocardial ischemia and cardiomyopathy and as prophylaxis for migraines.10 Adverse effects associated with calcium channel blockers include heart block and bradycardia, even leading to asystole.21 Patients should 38

OR TODAY | June 2014

be assessed for syncope, hypotension and bradyarrhythmias.

This review of vasoactive drug pharmacology is intended to increase perioperative nurses’, pharmacists’ and physicians’ knowledge of the mechanism of action, clinical indications, anticipated hemodynamic effects, potential harmful effects and appropriate doses of vasoactive drugs.

Nurses, pharmacists and physicians can use this information in the clinical setting and guide colleagues in the safe use of these life-saving drugs. After all, you are the patient’s last line of defense in critical lifethreatening moments.

HOLLY FRANSON, RN, is a graduate student in the nurse anesthesia program at Oakland University-Beaumont in Michigan. Before graduate school, she worked at the University of Chicago Hospitals pediatric ICU and University of Illinois Medical Center neurosurgical ICU. REFERENCES 1. Morril, P. Pharmacotherapeutics of positive inotropes. AORN J. 2000;71(1):173178,181-185.

2. McCance KL. Structure and function of the cardiovascular and lymphatic systems.

In: McCance KL, Huether SE. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 5th ed. Philadelphia, PA: Elsevier Mosby: 2006:1029-1080.

3. Widmaier EP, Raff H, Strang KT. Cardiovascular physiology. In: Widmaier EP, Raff H, Strang KT, eds. Vander’s Human Physiology: The Mechanisms of Body Function.

12th ed. New York, NY: McGraw-Hill Science/Engineering/Math; 2010.

4. Kee VR. Hemodynamic pharmacology of intravenous vasopressors. Crit Care Nurse.

2003;23(4):79-82.

5. Stoelting RK, Hillier SC, eds. Pharmacology & Physiology in Anesthetic Practice.

4th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2006.

6. Brunton L, Parker K, Blumenthal D, Buxton I, eds. Goodman & Gilman’s Manual of Pharmacology and Therapeutics. New York, NY: McGraw-Hill Professional; 2007.

7. Overgaard CB, Dzavik V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease.

Circulation. 2008;118(10):1047-1056. http:// circ.ahajournals.org/content/118/10/1047. full. Accessed December 5, 2012.

8. Wenzel, V, Kinder KH. Employing vasopressin during cardiopulmonary resuscitation and vasodilatory shock as a lifesaving vasopressor. Cardiovasc Res. 2001;51(3):529-541.

9. Coons JC, Seidl E. Cardiovascular pharmacotherapy update for the intensive care unit. Crit Care Nurs Q. 2007;30(1):44-57.

10. Hensley FA, Martin DE, Gravlee GP, eds.

A Practical Approach to Cardiac Anesthesia. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.

11. Beale RJ, Hollenburg SM, Vincent JL, Parrillo JE. Vasopressor and inotropic support in septic shock: an evidencebased review. Crit Care Med. 2004;32(11 Suppl):S455-465.

12. Dunser MW, Mayr AJ, Ulmer H, et al. Arginine vasopressin in advanced vasodilatory shock: a prospective, randomized, controlled study. Circulation.

2003;107(18):2313-2319.

13. Ludmer PL, Wright RF, Arnold JM, Ganz P, Braunwald E, Colucci WS. Separation of the direct myocardial and vasodilator actions of milrinone administered by an intracoronary infusion technique. Circulation. 1986;73(1):130-137.

14. Cuffe MS, Califf RM, Adams KF, et al.

Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA. 2002;287(12):1541-1547.

15. Deglin JH, Vallerand AH, Davis’s Drug Guide for Nurses. 4th ed. Philadelphia, PA: F.A. Davis Co.; 2012.

16. Mason KE, Davis LL, Perioperative beta blockade in the noncardiac surgery: a review of the literature. AANA J. 2006;74(2):113-117.

WWW.ORTODAY.COM

CONTINUING EDUCATION 586B

HOW TO EARN CONTINUING EDUCATION CREDIT 17. Wiesbauer F, Schlager O, Domanovits H, et al. Perioperative beta-blockers for preventing surgery-related mortality and morbidity: a systematic review and meta-analysis. Anesth

1.

2.

Read the Continuing Education article.

Go online to ce.nurse.com to take the test for $10. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at www.nurse.com/unlimitedCE for $44.95 per year.

Analg. 2007;104(1):27-41.

18. Fleisher L, Beckman JA, Brown KA, et al. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy — a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg.

2007;104(1):15-26. http://www.anesthesia-analgesia.org/content/104/1/15. full. Published January 2007. Accessed December 5, 2011.

DEADLINE Courses must be completed by January 31, 2015.

3. If the course you have chosen to take includes a clinical vignette,

you will be asked to review the vignette and answer 3 or 4 questions.

You must answer all questions correctly to proceed. If you answer a

question incorrectly, we will provide a clue to the correct answer.

4.

Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest.

To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.

5.

All users must complete the check out process to complete the process. You will be able to view a certificate on screen and print or save it for your records.

19. Fleischmann KE, Beckman JA, Buller CE, et al. 2009 ACCF/AHA focused update on perioperative beta blockade: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on practice guidelines. Circulation. 2009;120(21):2123-51. http://circ. ahajournals.org/content/120/21/2123.

Published November 2009. Accessed December 5, 2012.

20. Rosenfeld DM, Trentman TL, Hentz JG, Hagstrom SG, Demenkoff JH. Patient understanding of the importance

ACCREDITED ContinuingEducation.com is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with this activity.

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of beta-blocker use in the perioperative period. J Cardiothorac Vasc Anesth. 2007;21(3):325-329.

21. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart

ONLINE Nurse.com/CE You can take this test online or select from the list of courses available.

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Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.

2010;122(18 Suppl 3):S729-S767. http:// circ.ahajournals.org/content/122/18_ suppl_3/S729.full. Published 2010.

QUESTIONS Questions or for a complete listing of our courses Phone: 800-866-0919 Email: ce@nurse.com

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June 2014 | OR TODAY

39

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Story is provided solely for illustrative purposes and does not describe any actual surgeon, procedure or patient.

BY DON SADLER

PATIENT

SAFETY

PATIENT SAFETY

SURGERY CHECKLIST AND THE

“N

obody’s perfect.”

We’ve all heard this before, and most of us have used it at one time or another as an excuse for a mistake. But mistakes in the OR can be especially devastating — not only for patients, but also for the hospital and OR staff.

And there are few OR mistakes as potentially devastating as wrong site surgeries. “For patients and their loved ones, a wrong site or wrong side surgery or a wrong surgical procedure is life-changing,” says Linda Groah, MSN RN CNOR NEA-BC FAAN, the executive director and CEO of the Association of periOperative Registered Nurses (AORN).

“And for surgical teams and healthcare administrators, a sentinel event of any kind is profoundly demoralizing to the spirit, as well as damaging to their reputation,” Groah adds.

When the designated team member — usually the circulating nurse or surgeon — calls for time out, the surgical team members must cease all their activities and give their full attention to the review of the surgery checklist.

This process not only covers the items on the checklist, but also includes all members of the team introducing themselves and the surgeon giving a brief description of the procedure.

— LINDA GROAH

44 OR TODAY | June 2014

RARE BUT PREVENTABLE Although wrong site surgery is a rare event, it remains a serious and preventable threat to patients in the OR that should never happen. The Joint Commission Center for Transforming Healthcare reports that “wrong patient, wrong site and wrong procedures” is the second most frequently reported sentinel event, with 109 such procedures reported in 2012.

However, many experts believe the actual numbers are much higher than this, since reporting is not mandatory in most states. Even more disturbing is the fact that these 109 reported cases are more than double the 49 cases that were reported in 2004, according to Groah. This is the year when the Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery was first implemented.

The Universal Protocol is a standardized approach to eliminating wrong patient, wrong site and wrong procedures that includes pre-procedure verification, site marking and a surgery “time out” to confirm the surgical site, patient and procedure. At this time, the entire surgical team pauses to confirm and agree that the appropriate surgery is about to be performed.

According to Groah, the surgery time out is conducted immediately before starting the invasive procedure or making the incision. It involves the immediate members of the procedure team, which typically includes the individual performing the procedure, anesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning.

“When the designated team member — usually the circulating nurse or surgeon — calls for time out,

the surgical team members must cease all their activities and give their full attention to the review of the surgery checklist,” says Groah.

“This process not only covers the items on the checklist, but also includes all members of the team introducing themselves and the surgeon giving a brief description of the procedure. The surgeon should also address any questions or concerns members of the team may have at this time.”

The surgery time out is similar to the prescribed checklist that pilots and co-pilots are required to complete without interruption before a commercial airliner can take off. But unlike in the aviation industry, surgeons and OR staff are not legally required to perform the surgery time out.

MORE OR SAFETY CHECKLISTS In addition to the Joint Commission’s Universal Protocol, the World Health Organization (WHO) has created a 19-point Surgical Safety Checklist that also includes a surgery time out. And AORN has created a Comprehensive Surgical Checklist that includes the safety checks outlined in the WHO Surgical Safety Checklist, while also meeting the safety checks within The Joint Commission’s Universal Protocol in order to meet accreditation requirements.

The AORN Comprehensive Surgical Checklist uses color codes to signify WHO and Joint Commission guidelines as well as areas where the two overlap.

“It offers guidance for pre-procedure check-in, sign-in, time out and sign out,” says Groah. “Open-ended questions are also included under the time out portion to encourage active participation from all members of the surgery team.”

The AORN checklist is useful in all types of facilities, including hospital WWW.ORTODAY.COM

LINDA GROAH, MSN RN CNOR NEA-BC FAAN, the executive director and CEO of the Association of periOperative Registered Nurses (AORN).

ORs, ambulatory surgery centers and physicians’ offices. You can download it for free as a Word document or PDF at www.aorn.org/Clinical_Practice/ ToolKits/Correct_Site_Surgery_Tool_ Kit/Comprehensive_checklist.aspx.

A well-publicized study that was conducted in 2009 determined that the WHO’s Surgical Safety Checklist cut mortality rates by up to 50 percent in eight hospitals located in eight different cities. More recently, two German studies conducted in 2012 reported decreases in perioperative mortality rates of 47 percent and 62 percent. In addition, one of the German studies determined that using the WHO checklist could have prevented more than 85 percent of wrong side surgical errors.

“There is probably a lot of value in checklists, even if it can’t be measured in terms of reducing the risk of bad outcomes,” Urbach says.

“The standard practice across the country has just been, you work from memory and reason your way through a crisis,” says Atul Gawande, one of the authors of the 2009 WHO study who spearheaded the recent Boston study. “But when things hit the fan, it’s total chaos.”

The surgery checklist serves as a reminder of all the processes that are important for every patient, during every procedure, every time.

— LINDA GROAH And in a study conducted last year to determine the value of checklists during a surgical crisis like a cardiac arrest or unstable pulse or blood pressure, researchers in Boston found that surgical teams that used a checklist were 74 percent less likely to skip a potentially life-saving step during the intraoperative crisis. The study simulated more than 100 OR emergencies using a robotic patient.

Surgical teams in the study that used checklists missed six percent of life-saving processes, while teams without checklists missed 23 percent of life-saving processes. Upon completion of the simulation, almost all of the participants (97 percent) said they would prefer to have a checklist in the event of an OR crisis.

WWW.ORTODAY.COM

It’s worth noting that a more recent study conducted in Canada questions whether or not surgical checklists and the surgery time out are as effective in reducing surgery mortality and complication rates as the 2009 WHO study seems to indicate. In this study, the reductions achieved in surgery mortality and complication rates were statistically insignificant.

However, even the authors of this study acknowledge the value of checklists. According to the lead author, David Urbach, the study was not conducted to advocate the elimination of surgery checklists and the surgery time out, but rather to provide a realistic picture of how difficult it is to improve patient safety.

STRUCTURED TRAINING REQUIRED Gawande stresses that surgery checklists must be supplemented with specialized training that can take months to complete. And the researchers who conducted the German studies noted that implementing the WHO checklist was most effective when it included exemplary implementation by team leaders and structured training.

“Typical errors in implementation are lack of completeness and processing in the absence of team members,” stated the authors of one of the German studies. “It is also wrong for a single person to go through all of the items on the list without communicating his or her content to others or providing any opportunity for an exchange of information.”

Groah notes that June 11 will mark the 10th anniversary of National Time Out Day, an awareness campaign that AORN initiated in collaboration with The Joint Commission, WHO and the Council on Surgical and Perioperative Safety (CSPS).

“The surgery checklist serves as a reminder of all the processes that are important for every patient, during every procedure, every time,” Groah says. “In particular, the time out procedure is a critically important communication interaction for the preservation of patient safety in the surgical setting.”

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SPOTLIGHT ON: Veronica Lestagez

By Matt Skoufalos

“

“The OR functions on crisis management…anything that comes through the door, we’ve got to be prepared. It’s constant decision-making. You have to be able to make very quick decisions and turn around and have to do something else.”

— Veronica Lestagez

CHARGE

NURSE DELIVERS

IN CRISIS

SITUATIONS

T

he first six months to a year in the operating room were brutal, said Veronica Lestagez, Charge Nurse at Atlanta Medical Center.

The mother of four, grandmother to eight, and foster mother to many others began her nursing career with a focus on being a professional caregiver, but found it most informed by her commitment to helping people in crisis.

It was a career choice that ascended along a steep learning curve.

Lestagez had just come to the unit after an assignment as the head nurse of oncology at the same health system.

There was no formal training program for the position, she said, and Lestagez said she “hated it” at first.

“I felt woefully inadequate because the OR has a skill set that you don’t acquire on the floor,” she said. “It’s a totally different beast. I remember thinking I had made a huge mistake, but I stuck it out.”

The OR functions on crisis management, Lestagez said; surgeons “want everything yesterday, the staff feeds into that, and we’re not very kind with people who are a little bit slower, trying to learn.”

That singular experience is “totally different” from working in the intensive care unit, working a floor in the hospital, or any other nursing experience, Lestagez said, especially at a level one trauma center.

“Anything that comes through the door, we’ve got to be prepared,” 50

OR TODAY | June 2014

“ There is a satisfaction in taking something and putting it all together. It’s a joint effort, a bunch of people working together for the good of the patient. At the end of the day, you feel burnt out, but darn it, you made a difference.”

— Veronica Lestagez

she said. “It’s constant decisionmaking. You have to be able to make very quick decisions and turn around and have to do something else. You’ve got to somehow find the staffing if you don’t. It can be extremely stressful.”

When Lestagez wasn’t managing patients, she was walking a high wire among the surgical team by catering to the preferences of each, working to match the right patient to the right team of doctors at the right time. But after 33 years at the facility, she said she’s learned a great deal about how to get along in such a fast-paced environment.

“I think we all tend to be crisisoriented,” Lestagez said. “We have some quiet moments, some quiet cases, but I enjoy working in a level one trauma center because anything can come through the door. There is a satisfaction in taking something and putting it all together. It’s a joint

effort, a bunch of people working together for the good of the patient.

At the end of the day, you feel burnt out, but darn it, you made a difference.”

For professionals who work exclusively in the OR, there is an emotional disconnection that surfaces, Lestagez said. After receiving a patient in immediate, life-threatening danger, they work to mend the trauma, but seldom know what happens to them after that job is done. There’s no interaction with families or patients after the repairs are made; no understanding of the next chapter of their stories, and sometimes, that’s difficult to bear.

“That is the missing piece in the OR,” Lestagez said. “I think it makes it easier because you can focus directly on patient care; a patient is usually asleep.”

“There is no closure, and like everything else in life, it fades into a memory,” she said.

WWW.ORTODAY.COM

Veronica with Dr. Philip Ramsay,

Veronica goes over a patient’s chart

Veronica with Tina Menghe,

surgeon at Atlanta Medical Center.

with Dr. Philip Ramsay.

nurse manager of the OR.

Some of those memories linger longer than others. Lestagez recalls how, a few years ago, a 16-year-old patient was brought into her surgical suite, the victim of a tragic car accident on her birthday.

“She was in a car with a few of her friends,” Lestagez said. “They were drinking. Her three friends died, and she came up to the OR with everything broken, both arms, both legs.”

“I often think about her, about a bad decision made in innocence that really affected her life,” she said. “As a mother, as a nurse, as an aunt, as a grandmother, I think.

I hold them in memory, I say a prayer, I know their journey is going to be affected so much by the trauma they’ve been involved in.”

The job inflicts a great deal of emotional strain on those who work it, and for Lestagez, who describes herself not as religious, but very spiritual, she is calmed by family, friends, and a near-daily hike up Stone Mountain in Atlanta.

She also travels for variety, and has from a young age. Lestagez WWW.ORTODAY.COM

grew up on an 800-acre farm in the Jamaican countryside, and attended school in a private convent. But when she was 12, she left the island for northern Ontario; other relatives are now similarly scattered throughout North America and the United Kingdom, she said.

After high school, Lestagez said, she got into nursing because she “didn’t really know what she wanted to do” with her life. Her French-Canadian father wanted his daughter to become a physician, but she wasn’t interested in taking that track.

“I met an industrial nurse who encouraged me to go into nurs nursing; I had a sister who was doing nursing in England,” Lestagez said. “Nursing was the only thing I could think of that really spoke to my soul.”

So Lestagez earned her nursing certificate in Canada, and, in 1979, accepted a contract to go to work at Southern Baptist Hospital in New Orleans. Two years later, she arrived at Atlanta Medical Center, where she’s worked for the last 33 years.

“I have learned to be a better person in the OR,” Lestagez said.

“I’ve been in the OR so long now that things that I used to really stress over, I can take in stride. I know that in the end, things will work out, doors will open, the job will get done as long as you’re behind it heart and soul.”

“You generally will go home feeling good about yourself,” she said. “It’s people, relationships, being in a place where you want to be, remembering your humanity.”

June 2014 | OR TODAY

51

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OUT OF THE OR HEALTH

BY MARILYNN PRESTON

JUST SAY ‘NO’ TO YEARLY CARDIOGRAMS? ANNUAL CHECKUPS? SAY WHAT? If you want to live a longer, healthier life, be aware of this: According to top doctors, most of the medical tests you think you need to diagnose and prevent disease – yearly cardiograms, exercise stress tests, routine EKGs, annual Pap tests, MRIs for lower-back pain – don’t prevent anything and aren’t necessary.

Surprised? It gets better. Not only are many of these popular tests unnecessary; they should actually be avoided. The frequent false positives do more harm than good, many doctors have concluded, and often lead to a downward spiral of invasive follow-up procedures, drugs and surgeries.

And still, medical overtesting continues to be a competitive sport in this country. Rosemary Gibson, co-author of an eye-opening book called “The Treatment Trap,” estimates that $225 billion a year is wasted on tests, scans and other procedures that are good for the annual incomes of doctors and hospitals, but confusing and harmful for patients, who are at their mercy.

It’s time to wake up and just say “no” the next time your doctor schedules you for a bone-density 54

OR TODAY | June 2014

scan, and you’re a woman younger than 65.

That’s just one of the “10 Tests to Avoid,” as reported by Elizabeth Agnvall in a recent AARP Bulletin, not exactly a hotbed of radical thinking. Agnvall’s list is based on research conducted recently by the American Board of Internal Medicine Foundation, which asked more than 50 medical societies – including oncologists, cardiologists, family doctors – to name the tests and treatments that were often performed but rarely helpful.

Here’s an abbreviated version of her much more detailed list. These aren’t commands, but I suggest you use them for your own research, based on your risk factors and your current health. Let your home schooling inspire a heart-to-heart with your medical team:

1

Avoid nuclear stress tests and other imaging tests after heart procedures. “More testing is not

necessarily better,” says Dr. William Zoghbi, immediate past president of the American College of Cardiology Foundation. He doesn’t like the excess of radiation exposure either.

It’s more productive for the patient and doctor to focus on what we know helps when it comes to nurturing a healthy heart: manag-

ing weight, increasing exercise, controlling blood pressure.

2

Avoid yearly electrocardiograms and exercise stress tests. Too

many people with no symptoms and low risk of heart disease wind up having tests that produce false positives, leading to unnecessary heart catheterization and stents.

3

Avoid blood tests to measure PSA to screen for prostrate cancer. There’s “extremely

convincing evidence” that in men with no symptoms and usual risk, the PSA test causes more harm than benefit, says Dr. Reid Blackwelder, president of the American Academy of Family Physicians.

4

Avoid PET scans to diagnose Alzheimer’s disease. The PET

scan can pick up the presence of beta-amyloid protein found in brains of people with Alzheimer’s.

The problem is: PET scans in older people consistently find the protein in those whose memories are just fine.

5

Avoid X-rays, CT scans and MRIs for lower-back pain.

Most back pain goes away in a month, and imaging tests lead to expensive procedures that don’t help with recovery. Older people WWW.ORTODAY.COM

HEALTH

with no back pain can have terrible-looking scans.

Warning: If you do have back pain, and your legs feel weak or numb, you have a history of cancer, or you’ve had a recent infection, see your doctor.

6

Avoid a yearly Pap test. A yearly visit to

an OB-GYN is still commonly recommended, but women at average risk only need a Pap smear every three years.

7

Avoid a bone-density scan for women before age 65 and men before age 70.

Many experts argue that for women ages 50 to 65 with osteopenia – mild bone loss – testing and drugs may be a waste.

And many popular bone-strengthening medications can have awful side effects.

8

Avoid follow-up ultrasounds for small ovarian cysts. “The

likelihood of these small simple cysts ever becom-

WWW.ORTODAY.COM

ing cancer is exceedingly low,” says Dr. Deborah Levine, Harvard professor of radiology and expert on ultrasounds.

9

Avoid colonoscopies after age 75, if your

previous colonoscopies have always been normal.

10

Avoid a yearly physical.

Annual checkups don’t keep you healthy (unless your doctor doubles as your yoga teacher).

“If you have symptoms or certain risk factors, these tests can be valuable — even life-saving — but they’re performed on far too many people,” according to Elizabeth Agnvall.

MARILYNN PRESTON is the creator of Energy Express, the longest-running syndicated fitness column in the country. She has a website, marilynnpreston.com, and welcomes reader questions, which can be sent to MyEnergyExpress@aol.com.

June 2014 | OR TODAY

55

OUT OF THE OR FITNESS

BY LINDSAY WESTLEY, EATINGWELL.COM

MAKE WALKING PART OF YOUR DAILY ROUTINE

T

here are days when just the thought of leaving the house seems like a huge effort. Days when you don’t feel like getting off the couch, never mind going to the gym. But guess what – if you got out of bed this morning, you jump-started your fitness routine just by walking down the hall to the bathroom.

Add a little pep to your stride for an activity that feels less like exercise and more like living a normal life – but with the added benefits that exercise provides.

MAKE WALKING PART OF YOUR EVERYDAY ROUTINE Mark Fenton, a health and fitness consultant and author who’s written extensively about the benefits of walking, was a member of the U.S. national race walking team from 1986 to 1991. Now he works as a consultant to help communities implement safe routes for walking and bicycling.

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OR TODAY | June 2014

“Make walking a part of your normal routine and you’ll have a much easier time keeping it up,” Fenton says. “Set aside time at a specific time of day to walk, or go about your daily tasks on foot. Walk your dog; pick up your mail on foot.

If you can routinize it, you’re more likely to keep doing it.”

Find a walking buddy, or better yet, someone who’s depending on you.

Find a friend who’s willing to go walking in your neighborhood, or suggest a walking lunch break at work. If there are two of you walking, collectively you’ll benefit from having double the resolve to get out there. A little friendly competition never hurt, either. Pedometers offer an inexpensive way to challenge a colleague or friend to a walk-off, with each of you tallying steps walked and comparing totals at the end of the week.

Creating accountability is another great way to inspire you to head out the door. Fenton is an advocate for Safe Routes to School (www.saferoutesinfo.org), a program that helps kids and their parents find safe walking and bicycling routes to and from schools.

Parents take turns accompanying kids to school on designated days, so if you’ve committed to leading the pack two days a week, chances are you’ll feel motivated to get out there and walk to school.

JUST 10 MINUTES. Even walking experts sometimes need a little push to lace up their shoes. When Fenton’s motivation is flagging, he gets out the door by telling himself he’ll walk for “just 10 minutes.”

“It sounds silly, since it’s such a short amount of time, but once you get out there you start feeling the physiological effects of walking,” he says. “Your blood pressure goes down and you feel a flood of positive endorphins, so you might feel motivated to go even longer than 10 minutes. Or maybe you won’t. Either way, even exercise in modest doses is better than being sedentary.”

Still can’t convince yourself? Get up and move during commercial breaks; most 30-minute TV programs include about 8 minutes of commercials, so you’ll be 80 percent closer to reaching your minimum by the time the credits are rolling.

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59

OUT OF THE OR NUTRITION

BY SHARON PALMER, R.D.

BETTER FOOD CHOICES CAN CONTROL YOUR HUNGER PANGS

W

hether you’re trying to lose weight or simply focus on a heart-healthy eating regimen, a growling stomach can interfere with your eating goals.

Hunger is a normal body reaction and survival mechanism. But in today’s environment of ample food availability, hunger can lead us to over-consume foods, especially those that aren’t so healthful.

Appetite control is a very complex issue; your body’s over-arching goal is to maintain a balance of energy in versus energy out, and will send you a powerful hunger signal when it needs energy.

Other issues also come into play, which may encourage you to eat even when you’re not hungry – triggers that tempt you to eat, emotions, easy access to food, and large portion sizes.

Research is starting to shine the light on how daily food choices can help people feel more satisfied. Here are some of the most promising diet strategies: 60

OR TODAY | June 2014

1

SOLIDS OVER LIQUIDS Several studies have shown that when you consume calories in the form of beverages, they don’t provide the same sense of satiety (fullness). A whole apple, for example, increases satiety more than applesauce or apple juice, according to a study published in Appetite.

Research also suggests that when you consume high-calorie sweetened beverages, like soda, you don’t feel full or cut back on calories at the meal.

“Food form is an important determinant of satiety value. Beverages are really not effective, they don’t have strong satiety value,” says Richard Mattes, M.P.H., Ph.D., R.D., a satiety expert and professor at Purdue University, West Lafayette, Ind.

2

PUSH LOW-ENERGY, HIGH-VOLUME FOODS Starting your meal with a low-energy (or low-calorie) soup or salad may be effective at helping you feel more full and reducing calorie intake during the meal, according to some studies. It makes sense that if you eat more low-energy, high-volume foods, such as fruits and vegetables, you’ll feel more satisfied with a fewer number of calories.

However, Mattes cautions that this all boils down to energy balance.

“If you displace high-energy-dense foods with fruits and vegetables, then it can lead to negative energy balance, but if you simply add these foods to your diet, you’ll gain weight,” he notes.

WWW.ORTODAY.COM

3

FILL UP ON FIBER Growing data suggests that increasing your fiber intake – through whole grains, legumes, fruits, vegetables, nuts and seeds – can help you feel more satisfied, by increasing the amount of chewing time, promoting the secretion of saliva and gastric juices that lead to stomach expansion, and reducing the absorption time in the gut.

A 2013 review in the Journal of the American College of Nutrition found that 39 percent of studies using fiber treatments significantly reduced appetite, and 22 percent reduced food or energy intake.

4

POWER UP ON PROTEIN Mattes reports that protein is probably the most promising nutrient for satiety. A scientific review published in The American Journal of Clinical Nutrition reported that protein generally increases satiety to a greater extent than carbohydrates and fat, and that a moderate increase in protein intake, along with physical activity and an energy-controlled diet, can help in weight loss. Including lean meats, poultry, fish, low-fat dairy, eggs, legumes, nuts, or seeds in each meal may be a good strategy to control appetite.

5

FILLING FOOD CHOICES It may be helpful to fuel your day with particular foods – rich in protein and fiber – to reduce hunger.

“Nuts have been demonstrated to have a strong satiety value. They have fat, fiber and protein and they are crunchy,” says Mattes. Studies also have found that low-fat dairy foods – rich in protein and moderate in calories – may increase satiety. And whole grains, such as cereals, breads, and legumes, including beans, lentils and soy – naturally high in fiber, as well as protein – have been linked to appetite control.

6

TIME YOUR MEALS Skipping meals, especially breakfast, can lead to hunger and higher energy intake over the day. Small frequent meals may work for some people, but it’s not a guarantee, according to Mattes.

“It’s important to get a good handle on the amount of energy one consumes; see which times in the day are problematic, and structure the eating pattern to address that. It will differ from person to person, depending on your busy times and triggers.”

If you find that you’re especially vulnerable to hunger during specific times of the day, such as mid-morning or mid-afternoon, that’s when you should plan a high-fiber, high-protein snack.

Reprinted with permission from Environmental Nutrition, a monthly publication of Belvoir Media Group, LLC. 800-829-5384. www.EnvironmentalNutrition.com.

WWW.ORTODAY.COM

June 2014 | OR TODAY

61

OUT OF THE OR RECIPE

BY DIANE ROSSEN WORTHINGTON

A FRENCH TAKE ON GEFILTE FISH

62

OR TODAY | June 2014

WWW.ORTODAY.COM

RECIPE

I

grew up with the classic gefilte fish served as a starter to the long Passover meal.

However, this is a tasty dish that can be served anytime.

Gefilte fish is basically a fish puree, poached and served chilled. Among my friends and family, people either love it or don’t even want to see it on their plate. I came up with this terrine (a fancy French term for a rectangular loaf pan) as a response to the gefilte fish naysayers. I am happy to report that many of them come back for seconds once they tuck into this tasty reinterpretation.

Ground whitefish is blended with sauteed sweet caramelized onions and carrots and then baked in a loaf

WHITEFISH TERRINE WITH BEET-HORSERADISH RELISH

Serves 10 to 12.

2 tablespoons olive oil 3 carrots, peeled and finely chopped 1 large onion, finely chopped 3 large eggs 3 1/2 tablespoons matzo meal 3/4 cup chicken stock, fish stock, or water 1 1/2 pounds ground whitefish or a mixture of whitefish, pike and buffalo fish 2 teaspoons salt 3/4 teaspoon white pepper 1/2 teaspoon sugar 1 tablespoon fresh lime juice 1/4 teaspoon paprika

SAUCE: 1 jar (5 ounces) prepared 2

horseradish cream medium beets, cooked

WWW.ORTODAY.COM

pan rather than poached in liquid.

The ground whitefish used here is the same fish used for the popular Jewish dish gefilte fish, and is regularly available in many supermarkets and fish markets during Jewish holidays. If you can’t find the fish ground, process the fillets in the food processor, making sure first to remove the skin and all the bones.

(You’ll need about 2 pounds of whitefish fillets with the skin on if you are going to grind it yourself.)

This terrine is pretty served in overlapping slices on a large rectangular platter with matzo crackers.

The accompanying bright red beet-horseradish relish adds a burst of color and flavor to the chilled terrine. You can also serve it as the first course on individual plates with

mixed greens lightly dressed with a simple vinaigrette and a dollop of the beet-horseradish sauce on the side.

Sometimes I serve it with simple horseradish cream if I am in a hurry.

Remember, this needs to be made a day ahead of serving because it must be chilled. This is so delicious as a first course or a light main course for any time of the year. If you have any left over, it’s great for lunch.

GARNISH: • Lemon slices • Parsley sprigs

paprika. Bake for 50 to 60 minutes, or until a long wooden skewer inserted into the center comes out clean.

5. Meanwhile, prepare the sauce: Place the horseradish cream and cooked beets in a food processor and process until pureed. Transfer to a small container, cover and refrigerate.

6. Remove the terrine from oven and let cool for 15 minutes. Wrap in aluminum foil and chill overnight.

7. Loosen the sides of the terrine from the pan by running a knife blade along the edges. Invert the terrine onto a plate, and then turn upright on a platter. Slice the terrine into 3/4-inch slices. Garnish with lemon slices and parsley and serve. Pass the beet-horseradish sauce separately.

DIRECTIONS:

1. In a skillet, heat the oil over medium heat. Add the carrots and onion, and sauté for 5 to 7 minutes, or until softened. Remove from the heat and let cool for 10 minutes.

2. Preheat the oven to 350 F. Lightly coat a 9- by 5- by 2 1/2-inch loaf pan with nonstick cooking spray.

3. In a large bowl, with an electric mixer set on medium speed, beat the eggs with the matzo meal.

When well combined, add the stock, fish, cooled carrots and onion, salt, pepper and sugar, and continue to beat until well blended.

4. Pour the mixture into the prepared pan. Pick up the pan with both hands and slam it down on the counter to settle any air bubbles. Drizzle the lime juice over the top and sprinkle with the

DIANE ROSSEN WORTHINGTON is an authority on new American cooking. She is the author of 18 cookbooks, including “Seriously Simple Holidays,” and also a James Beard award-winning radio show host. You can contact her at www. seriouslysimple.com.

ADVANCE PREPARATION:

Can be prepared up to 2 days ahead, covered, and refrigerated.

June 2014 | OR TODAY

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New Technique for Femoral Distraction

Introducing the De Mayo Universal Distractor 速 Improved placement, access and an unobstructed view of the operative site.

Finally an external distractor outside the surgical site. The new, patented De Mayo Universal Distractor速 delivers finite joint distraction without obstructing your field of vision, tying up a pair of hands or placing lamina spreaders. You get finite distraction and reduced procedure time for Unicompartmental, MIS Techniques, Arthroscopies, ACL and TKA surgeries. To see all the advantages, visit www.impmedical.com or call 800-467-4944 today. And get positioned for success.

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OR TODAY | June 2014

息 2013 IMP

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OUT OF THE OR PINBOARD

PINBOARD

HEALTH

The News and Photos That Caught Our Eye This Month

OR TODAY

CONTEST • JUNE •

ALWAYS JUNE 7TH

JUNE 7 IS NATIONAL CHOCOLATE ICE CREAM DAY.

WHAT WOULD NURSE PILL SAY?

OR Today wants to know what you think Nurse Pill would say in the OR! Give us your best or funniest scenario.

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It is a great day to eat America’s favorite flavor of ice cream. We at OR Today encourage you to take a moment to enjoy some chocolate ice cream today. After all, some studies indicate that chocolate and ice cream have health benefits.

Nutrients in ice cream include minerals such as calcium, phosphorus, magnesium, zinc, iron and potassium, protein, vitamins A and B complex, folate, fat and carbohydrates. Depending on the type of flavor the ice cream is it will also have antioxidants and fiber.

On a stressful day, consider eating some ice cream because the B complex vitamins in it will help you feel happy and stress free.

February 2013 | OR TODAY

67

OUT OF THE OR PINBOARD HEALTH

CONTEST WINNER

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We had some great entries for our April “Where in the world” contest!

Here are some submissions:

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We loved the unique idea for this “group” selfie. Way to go!

Tammy Roberson

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Thank you to all who submitted!

Look for your chance to win in our OR Today Magazine monthly contests!

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OR TODAY | February 2013

Michelle Nolastnameyet WWW.ORTODAY.COM

HEALTH

OR TODAY IS NOW ON LINKEDIN Join our group!

HAPPY SUMMER

Is there a better way to enjoy the warm summer days than at a music festival. Here are some of the popular music festivals happening in June 2014:

PIN OF THE MONTH TWO-WEEK TUMMY TONER From our “Fitness” Board

Watch your tummy & thighs shrink Follow us on Pinterest: www.pinterest.com/ortoday

• Bonnaroo is an annual music festival held in Tennessee.

This music festival is usually attended by more than 80,000 people on 700 acres in Manchester. This year the festival will run June 12-15.

• The Chicago Blues Fest is the largest blues festival in the world. Music lovers can check it out June 13-15.

• What The Festival (June 19-22) is a progressive, immersive rave, complete with electronic music, a splash pool and camping, near Mt. Hood National Forest.

• On June 19-22, the Firefly Music Festival will be held in Dover, Del. This is the East Coast’s answer to Coachella.

• Break out the glowsticks for the Electric Daisy Carnival, the ultimate electronic music festival, on June 20-22.

The carnival happens in cities around the world, but the best party happens in Vegas. The fun goes down at Las Vegas Motor Speedway.

“Nursing is not for everyone. It takes a very strong, intelligent and compassionate person to take on all the ills of the world with passion and purpose and work to maintain the health and well-being of the planet. No wonder we’re exhausted at the end of the day.”

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Join the community!

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February 2013 | OR TODAY

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IMPORTANT SAFETY INFORMATION FOR THE VERION™ REFERENCE UNIT AND VERION™ DIGITAL MARKER CAUTION: Federal (USA) law restricts this device to sale by, or on the order of, a physician.

INTENDED USES: The VERION™ Reference Unit is a preoperative measurement device that captures and utilizes a high-resolution reference image of a patient’s eye in order to determine the radii and corneal curvature of steep and flat axes, limbal position and diameter, pupil position and diameter, and corneal reflex position. In addition, the VERION™ Reference Unit provides preoperative surgical planning functions that utilize the reference image and preoperative measurements to assist with planning cataract surgical procedures, including the number and location of incisions and the appropriate intraocular lens using existing formulas. The VERION™ Reference Unit also supports the export of the high-resolution reference image, preoperative measurement data, and surgical plans for use with the VERION™ Digital Marker and other compatible devices through the use of a USB memory stick.

The VERION™ Digital Marker links to compatible surgical microscopes to display concurrently the reference and microscope images, allowing the surgeon to account for lateral and rotational eye movements. In addition, the planned capsulorhexis position and radius, IOL positioning, and implantation axis from the VERION™ Reference Unit surgical plan can be overlaid on a computer screen or the physician’s microscope view.

CONTRAINDICATIONS: The following conditions may affect the accuracy of surgical plans prepared with the VERION™ Reference Unit: a pseudophakic eye, eye fixation problems, a non-intact cornea, or an irregular cornea. In addition, patients should refrain from wearing contact lenses during the reference measurement as this may interfere with the accuracy of the measurements.

Only trained personnel familiar with the process of IOL power calculation and astigmatism correction planning should use the VERION™ Reference Unit. Poor quality or inadequate biometer measurements will affect the accuracy of surgical plans prepared with the VERION™ Reference Unit.

The Aquavac® reusable suction mat is made in the USA from a special compound of high grade rubber precisionmolded to ensure full contact water seal on the Operating Room floor. The mat is an effective and economical solution for fluid control and prompt turn-over time for reuse of the Operating Room. The mats suction 1 gallon of fluid every 70 seconds, connect to any standard operating room suction equipment, decrease slips, falls, and personal injury, as well as increasing the rapid removal of contaminated body fluids.

The following contraindications may affect the proper functioning of the VERION™ Digital Marker: changes in a patient’s eye between preoperative measurement and surgery, an irregular elliptic limbus (e.g., due to eye fixation during surgery, and bleeding or bloated conjunctiva due to anesthesia). In addition, the use of eye drops that constrict sclera vessels before or during surgery should be avoided.

WARNINGS: Only properly trained personnel should operate the VERION™ Reference Unit and VERION™ Digital Marker.

Only use the provided medical power supplies and data communication cable. The power supplies for the VERION™ Reference Unit and the VERION™ Digital Marker must be uninterruptible. Do not use these devices in combination with an extension cord. Do not cover any of the component devices while turned on.

Only use a VERION™ USB stick to transfer data. The VERION™ USB stick should only be connected to the VERION™ Reference Unit, the VERION™ Digital Marker, and other compatible devices. Do not disconnect the VERION™ USB stick from the VERION™ Reference Unit during shutdown of the system.

The VERION™ Reference Unit uses infrared light. Unless necessary, medical personnel and patients should avoid direct eye exposure to the emitted or reflected beam.

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INDEX ALPHABETICAL Mobile Instrument Service & Repair……………… 4

3M Healthcare…………………………………………………… 27

EIZO Nanao Technologies……………………………… 59

AAAHC…………………………………………………………………16

Encompass Group, LLC…………………………………… 25

Palmero Health Care……………………………………… 72

AIV Inc.……………………………………………………………… 65

Enthermics Medical Systems………………………… 40

Piedmont Medical…………………………………………… 55 Polar Products………………………………………………… 58

Alcon Laboratories, Inc.…………………………… 71, BC

GelPro………………………………………………………………… 64

Ansell Healthcare Inc.…………………………………………41

Government Liquidation…………………………………IBC

Ruhof Corporation…………………………………………… 2-3

Arthro Plastics Inc.………………………………………………71

Healthmark Industries………………………………46, 58

Sage Services…………………………………………………… 64

ASC Association…………………………………………………16

Innovative Medical Products, Inc………………… 66

Select Surgical Technologies………………………… 47

BEMIS Health Care……………………………………………… 9

Innovative Research Labs, Inc.…………………………15

Serim Research Corporation………………………… 70

Bryton Corporation………………………………………… 53

International Medical Equipment.………………… 74

SIPS Consults, Corp.………………………………………… 25

C Change Surgical…………………………………………… 65

Jet Medical Electronics…………………………………… 65

SMD Wynne Corp.…………………………………………… 58

Cables and Sensors………………………………………… 57

Kapp Surgical Instrument…………………………………71

Soma Technology, Inc.…………………………………… 57

Cincinnati Sub-Zero…………………………………………… 6

KTW Group……………………………………………………… 73

Surgical Power………………………………………………… 73

Cygnus Medical………………………………………………… 53

Lumalier Corporation………………………………………… 5

TBJ, Inc.……………………………………………………………… 26

Dan Allen Surgical…………………………………………… 10

MD Technologies……………………………………………… 70

Tenacore Holdings, Inc.…………………………………… 52

David Scott Company.…………………………………… 59

MedWrench……………………………………………………… 78

Didage Sales Company, Inc.…………………………… 53

Mercury Medical……………………………………………… 78

INDEX CATEGORICAL ACCREDITATION

CARDIAC SURGERY

Kapp Surgical Instrument…………………………………14

AAAHC…………………………………………………………………16

C Change Surgical…………………………………………… 65

MD Technologies……………………………………………… 70

ANESTHESIA

CABLES/LEADS

Ruhof Corporation…………………………………………… 2-3

David Scott Company.…………………………………… 59

Sage Services…………………………………………………… 64

SIPS Consults, Corp.………………………………………… 25

Mobile Instrument Service & Repair……………… 4

TBJ, Inc.……………………………………………………………… 26

Innovative Research Labs, Inc.…………………………15 SMD Wynne Corp.…………………………………………… 58

CLEANING SUPPLIES

Tenacore Holdings, Inc.…………………………………… 52

Encompass Group, LLC…………………………………… 25 APPAREL

Ruhof Corporation…………………………………………… 2-3

FALL PREVENTIOM Encompass Group, LLC…………………………………… 25

Healthmark Industries………………………………46, 58 CLAMPS ARTHROSCOPIC SURGERY

Innovative Medical Products, Inc………………… 66

FLUID CONTROL Arthro Plastics Inc.………………………………………………71

Arthro Plastics Inc.………………………………………………71 CARTS ASSOCIATIONS

David Scott Company.…………………………………… 59

GEL PADS Innovative Medical Products, Inc………………… 66

AAAHC…………………………………………………………………14 ASC Association…………………………………………………16

DISPOSABLES Government Liquidation…………………………………IBC

GENERAL

AUCTIONS

Kapp Surgical Instrument…………………………………14

David Scott Company.…………………………………… 59

Government Liquidation…………………………………IBC

Sage Services…………………………………………………… 64

Didage Sales Company, Inc.…………………………… 53

BEDS

EMPLOYMENT

Innovative Medical Products, Inc………………… 66

SIPS Consults, Corp.………………………………………… 25

GelPro………………………………………………………………… 64 Government Liquidation…………………………………IBC Innovative Research Labs, Inc.…………………………15 International Medical Equipment.……………………61

Piedmont Medical…………………………………………… 55 ENDOSCOPY

KTW Group……………………………………………………… 73

BIOMEDICAL

Government Liquidation…………………………………IBC

Lumalier Corporation………………………………………… 5

Innovative Research Labs, Inc.…………………………15

Innovative Research Labs, Inc.…………………………15

Select Surgical Technologies………………………… 47

Mercury Medical……………………………………………… 78

International Medical Equipment.……………………61

SIPS Consults, Corp.………………………………………… 25

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INDEX CATEGORICAL PATIENT MONITORS

Arthro Plastics Inc.………………………………………………71

Cables and Sensors………………………………………… 57

Dan Allen Surgical…………………………………………… 10

HAND/ARM POSITIONERS

EIZO Nanao Technologies……………………………… 59

David Scott Company.…………………………………… 59

Innovative Medical Products, Inc………………… 66

Jet Medical Electronics…………………………………… 65

EIZO Nanao Technologies……………………………… 59

HIP SYSTEMS

PATIENT WARMING

KTW Group……………………………………………………… 73

Innovative Medical Products, Inc………………… 66

Encompass Group, LLC…………………………………… 25

Surgical Power………………………………………………… 73

Kapp Surgical Instrument…………………………………14 Lumalier Corporation………………………………………… 5 MD Technologies……………………………………………… 70 INFECTION CONTROL/PREVENTION

PATIENT POSITIONING

SMD Wynne Corp.…………………………………………… 58

3M Healthcare…………………………………………………… 27

David Scott Company.…………………………………… 59

Select Surgical Technologies………………………… 47 Surgical Power………………………………………………… 73

BEMIS Health Care……………………………………………… 9 Encompass Group, LLC…………………………………… 25

POSITIONING AIDS

Government Liquidation…………………………………IBC

Innovative Medical Products, Inc………………… 66

SURGICAL EQUIPMENT Arthro Plastics Inc.………………………………………………71

Palmero Health Care……………………………………… 72 Ruhof Corporation…………………………………………… 2-3

POSITIONERS/IMMOBILIZERS

SMD Wynne Corp.…………………………………………… 58

Innovative Medical Products, Inc………………… 66

INFUSION PUMPS

RADIOLOGY

AIV Inc.……………………………………………………………… 65

EIZO Nanao Technologies……………………………… 59

INSTRUMENTS

REFURBISHED EQUIPMENT

Government Liquidation…………………………………IBC

Piedmont Medical…………………………………………… 55

SURGICAL GLOVES Ansell Healthcare Inc.…………………………………………41 SURGICAL GRAFTS Select Surgical Technologies………………………… 47

Soma Technology, Inc.…………………………………… 57 INTERNET RESOURCES

SURGICAL SUPPLIES Cincinnati Sub-Zero…………………………………………… 6 Cygnus Medical………………………………………………… 53

REPAIR/SERVICE

David Scott Company.…………………………………… 59

AIV Inc.……………………………………………………………… 65

Government Liquidation…………………………………IBC

KNEE SYSTEMS

International Medical Equipment.……………………61

Ruhof Corporation…………………………………………… 2-3

Innovative Medical Products, Inc………………… 66

Piedmont Medical…………………………………………… 55

LAB

SHOULDER RECONSTRUCTION

KTW Group……………………………………………………… 73

Innovative Medical Products, Inc………………… 66

LATEX FREE

SIDE RAIL SOCKETS

Ansell Healthcare Inc.…………………………………………41

Innovative Medical Products, Inc………………… 66

LEG POSITIONERS

STERILE PROCESSING

Innovative Medical Products, Inc………………… 66

TBJ, Inc.……………………………………………………………… 26

OPHTHALMICS

STERILIZATION

Alcon Laboratories, Inc.…………………………… 71, BC

Lumalier Corporation………………………………………… 5

MedWrench……………………………………………………… 78

SURPLUS MEDICAL Government Liquidation…………………………………IBC SUPPORTS Innovative Medical Products, Inc………………… 66 TEMPERATURE MANAGEMENT C Change Surgical…………………………………………… 65 TEST STRIPS

SIPS Consults, Corp.………………………………………… 25 OR TABLE ACCESSORIES

Serim Research Corporation………………………… 70 ULTRASOUND AIV Inc.…………………………………………………………………81

Bryton Corporation………………………………………… 53

STRETCHERS

Innovative Medical Products, Inc………………… 66

Piedmont Medical…………………………………………… 55

ORTHOPEDIC

SUCTION MATS

Surgical Power………………………………………………… 73

Arthro Plastics Inc.………………………………………………71

OTHER

SURGEON COOLING

Select Surgical Technologies………………………… 47

Polar Products………………………………………………… 58

PATIENT AIDS

SURGICAL

Innovative Medical Products, Inc………………… 66

AAAHC…………………………………………………………………16

Tenacore Holdings, Inc.…………………………………… 52 VIDEO EIZO Nanao Technologies……………………………… 59 WASTE MANAGEMENT BEMIS Health Care……………………………………………… 9 WARMERS

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Enthermics Medical Systems………………………… 40

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Pre-op

Plan.

Conveniently and confidently determine a surgical plan targeting your desired outcome • Multiple advanced IOL formulas • Plan all incisions, rhexis, and IOL alignment with precision based on the reference image • Comprehensive astigmatism planner

Pre-op

Guide.

Brings your customized plan to your fingertips, at each stage in the surgical process • Recognizes the patient, plan, and location for all key steps during surgical execution • Communicates your pre op plan with key pieces of Cataract Refractive Surgical equipment.

• Eliminates the need for manual eye markings • Accounts for all cyclorotation • Documents all case metrics and data to help you analyze and optimize your procedures over time Intra-op

*The VERION™ Image Guided System is composed of the VERION™ Reference Unit and the VERION™ Digital Marker.

Introducing the new VERION™ Image Guided System*: Designed to help you consistently hit your refractive target.

THE CATARACT REFRACTIVE SUITE BY ALCON

CONTACT YOUR ALCON REPRESENTATIVE FOR MORE INFORMATION. © 2013 Novartis 10/13 VRN13015JAD-B

For important safety information, please see adjacent page.

6/14

Capture key diagnostic measurements, including: • Dynamic keratometry • Pupillometry, W2W, limbus • Eccentricity of the visual axis Simultaneously register the unique “fingerprint” of your patient’s eye: • Iris • Limbus • Scleral vessels

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Image.