OR Today - December 2018 by MD Publishing

MARKET ANALYSIS STERILIZATION

CE ARTICLE POSTANESTHESIA

SPOTLIGHT ON BILL MUIR

DECEMBER 2018

Keeping Up With

TECHNOLOGY

IN THE OR

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TO FOAM OR

NOT TO FOAM

Using Prepzyme® with the PrepValet™ Foamer Easy & Efficient Way to Pretreat Your Instruments

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Using PrepzymeÂŽ Forever Wet with ForeverPrepâ&#x201E;˘ Spray System Long-Lasting & Safe Way to Pretreat Your Instruments

Multi-tiered enzymatic humectant forms a moist coating over the instruments that lasts for up to 72 hours. The Operating Room safe, nonaerosol product helps prevent bioburden from drying on the surface of soiled instruments and scopes.

PROFORMANCE™ CLEANING VERIFICATION CLEARLY VISIBLE, EASY TO INTERPRET, OBJECTIVE TESTS OF CLEANING METHODS

LUMCHECK™ The LumCheck™ is designed as an independent check on the cleaning performance of pulse-ﬂow lumen washers. Embedded on the stainless steel plate is a specially formulated blood soil which includes the toughest components of blood to clean.

FLEXICHECK™ This three part kit simulates a flexible endoscope channel and is designed to challenge the cleaning efficiency of endoscope washers with channel irriga�on apparatus. The kit includes a clear flexible tube, a�ached to a stainless steel lumen device. The test coupon is placed in the lumen and the en�re device is hooked up to the irriga�on port of the endoscope washer.

HEMOCHECK™/PROCHEK-II™ Take the guess work out of evalua�ng the cleanliness of instruments with the HemoCheck™ blood residue test kit and the Prochek-II protein swab test. HemoCheck™ is simple to interpret and indicates blood residue down to 0.1μg. The ProChek-II™ measures for residual protein on surfaces down to 0.1μg.

SONOCHECK™ When the ultrasonic cleaner is supplying suﬃcient energy and condi�ons are correct, SonoCheck™ will change color. Problems such as insuﬃcient energy, overloading, water level, improper temperature and degassing will increase the �me needed for the color change. In the case of major problems the SonoCheck™ will not change color at all.

TOSI® Reveal the hidden areas of instruments with the TOSI™ washer test, the easy to use blood soil device that directly correlates to the cleaning challenge of surgical instruments. TOSI™ is the ﬁrst device to provide a consistent, repeatable, and reliable method for evalua�ng the cleaning eﬀec�veness of the automated instrument washer.

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Designed for use in the clean core soiled utility/clean up area, the sink is designed to quickly and automatically remove gross soils and bioburden from instruments prior to being sent to the SPD

TBJ sinks are designed specifically for the pre-cleaning of surgical instruments and endoscopes. All of our sinks are custom made to order to enable you to design a system around your specific needs. A wide range of optional features and accessories enable you to tailor a design that puts the tools you for efficient, effective and ergonomic pre-cleaning right at your fingertips.

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Is your sterile field actually sterile? While hanging sheets, drapes, and plastic bags may offer a solution, there is still a risk of contamination. Ensure you are protecting patients with C-Armor®, the product specifically designed to cover the C-Arm during horizontal imaging and help keep the sterile field sterile, period. Copyright © 2017 TIDI Products, LLC. All Rights Reserved. Copyright LLC. © 2017 TIDI Products, LLC. All Rights Reserved. C-Armor registered trademark is property of TIDI Products, C-Armor registered trademark is property of TIDI Products, LLC. MKT0425 REV A 112717

OR TODAY | December 2018

contents features

KEEPING UP WITH TECHNOLOGY IN THE OR Technology changes at such a rapid pace that it can be hard to keep up with the latest developments. This is especially true when it comes to healthcare technology in general – and perioperative technology specifically. A wide range of new technologies are changing how many perioperative procedures are performed. Often, the results are improved surgical outcomes and higher levels of patient satisfaction. But these new technologies present many challenges for OR nurses and other personnel.

The ASCA Foundation has partnered with One World Surgery to support its mission. Through this partnership, the ASCA Foundation provides a scholarship program for nurses, surgical techs and scrub techs interested in One World Surgery’s one-week medical missions in Honduras.

The global sterilization equipment and disinfectants market is forecasted to reach a market value of $9.15 billion by the end of 2019. Rising geriatric population is one of the primary factors for the growth of this market.

Postanesthesia patients often need continued intensive care that requires the nurse to possess critical thinking skills and complex nursing expertise. This module will address Joint Commission standards and evidence-based standards and guidelines for perioperative care.

ASCA ARTICLE

MARKET ANALYSIS

CE ARTICLE

OR Today (Vol. 18, Issue #12) December 2018 is published monthly by MD Publishing, 18 Eastbrook Bend, Peachtree City, GA 30269-1530. 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. © 2018

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contents features

PUBLISHER John M. Krieg

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VICE PRESIDENT Kristin Leavoy

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SPOTLIGHT ON

EDITOR John Wallace

Bill Muir

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ART DEPARTMENT Jonathan Riley Karlee Gower Kathryn Keur

ACCOUNT EXECUTIVES Jayme McKelvey Megan Cabot Jeffrey Berman

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DIGITAL SERVICES

win lunch for your department!

Grits

OR TODAY CONTEST

RECIPE OF THE MONTH

Travis Saylor Cindy Galindo Kennedy Krieg

CIRCULATION Lisa Cover Melissa Brand

WEBINARS Linda Hasluem

INDUSTRY INSIGHTS 10 News & Notes 18 Webinar Recap

ACCOUNTING Diane Costea

IN THE OR

25 Market Analysis 26 Product Focus: Sterilization Equipment and Disinfectants 30 CE Article: Caring for the Postanesthesia Patient

OUT OF THE OR 46 Spotlight On 48 Fitness 50 Health 53 Nutrition 54 Recipe 56 Pinboard 58 Index

8 | OR TODAY | DECEMBER 2018

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INDUSTRY INSIGHTS

news & notes

Checklist, Little Yellow 3M Introduces Box Transform Surgeries Advanced CHG Skin Prep With the help of a little yellow box, international nonprofit Lifebox has been making surgery safer for millions of patients throughout the world. Founded in 2011 by four of the world’s leading medical organizations with surgeon and writer Atul Gawande as its chairperson, Lifebox’s sole mission is to improve surgical safety in low-resource countries by providing the tools and education needed to implement the World Health Organization’s (WHO) Surgical Safety Checklist. As it celebrates its 10-year anniversary, this simple checklist, which can be completed in under two minutes, has been shown to reduce surgical complications and deaths by one-third. For the past seven years, Lifebox’s primary goal has been to ensure that no surgery be performed without a pulse oximeter, the only instrument included on the WHO checklist and one critical for preventing anesthesia-related deaths through the monitoring of blood oxygen levels during sedation. However, the cost of the device and the difficult conditions in many of the world’s operating rooms (ORs) make traditional pulse oximeters unusable and unavailable in an estimated 77,000 ORs worldwide. To overcome this obstacle, Lifebox developed a rugged, battery-operated, low-cost pulse oximeter. With 18,000 Lifebox oximeters distributed to date, this little yellow box has made surgery safer for 10 million patients in more than 100 countries. But an instrument alone cannot save lives without clinicians properly trained to use it. The nearly 150 training sessions conducted with anesthesia clinical teams and a variety of education and communication tools created for Lifebox by health advertising agency precisioneffect have been key to the success of the pulse oximeter program. Expanding that communications effort, Lifebox launched the “Deadliest Conditions” campaign at the American College of Surgeons (ACS) 2018 Clinical Congress in Boston. This is the first initiative in the organization’s history aimed at raising awareness among American health care professionals about global efforts to improve surgical safety procedures in low-resource countries. Lifebox also held a panel discussion at the ACS Clinical Congress meeting to celebrate the 10th anniversary of the WHO surgical safety checklist. •

10 | OR TODAY | DECEMBER 2018

3M has announced the launch of 3M SoluPrep FilmForming Sterile Surgical Solution, a chlorhexidine gluconate (CHG) and isopropyl alcohol prep, and the first and only FDA-approved surgical prep with sterile solution. The new solution brings 3M’s expertise in polymer and adhesive technology to bear in the form of proprietary 3M Prep Protection Film. When this copolymer film technology dries it forms a durable coating on the skin, helping the CHG ingredients stay on the skin where it is needed. 3M Prep Protection Film has been shown to withstand the rigors of simulated surgical conditions – including repetitive wiping – to keep the CHG active ingredient on the skin for continued antimicrobial protection against a broad range of bacteria through and beyond surgery. “As a surgeon, I know there is always a risk to the patient of acquiring a surgical site infection,” said Dr. Daniel Segina, orthopedic trauma surgeon with Health First, Holmes Regional Medical Center. “New technologies are welcomed as an opportunity for us to better care for our patients and reduce potential complications associated with surgery.” 3M SoluPrep Film-Forming Sterile Surgical Solution offers broad-spectrum bacterial quick kill, 96 hours of antimicrobial persistence and the added benefits of 3M Prep Protection Film. “At 3M, we apply our science to deliver safe and effective solutions that are skin-focused and aimed at reducing healthcare-related complications to improve patient care and outcomes,” said Dr. Todd Fruchterman, vice president and general manager, 3M Medical Solutions Division. “3M SoluPrep Film-Forming Sterile Surgical Solution not only addresses challenges clinicians may face with current preps, but for patients, it also delivers a unique film-forming property that offers antimicrobial protection – in and beyond - the OR.” 3M SoluPrep Film-Forming Sterile Surgical Solution, featuring 3M Prep Protection Film, will be available in two sizes: 10.5 ml and 26 ml. • For more information, visit go.3M.com/SoluPrepFilm.

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INDUSTRY INSIGHTS

news & notes

Case Medical Exceeds Chemical Footprint Project Requirements Case Medical Inc. has met and exceeded the requirements of the Chemical Footprint Project (CFP). Case Medical is a U.S. EPA Safer Choice Partner of the Year. Case Medical was recognized by the U.S. Environmental Protection Agency for outstanding achievement in the manufacture of chemistries that are safer for patients, staff and the environment. Now, the company has received the Chemical Footprint Project’s highest rating for 2018, 91 percent, for transparency and for benchmarking its chemical footprint and selecting safer alternatives to chemicals of concern. Case Medical is honored to be included with other leading brands to demonstrate pathways

to chemical and material health and to commit to a program for continuous improvement. “The Chemical Footprint Project allows us to benchmark the reduction and elimination of hazardous chemicals and challenges us to stay innovative – providing only the safest products for patient care and the environment. We are proud to be part of this movement.” said Marcia Frieze, CEO of Case Medical. The mission of the CFP project is to transform global chemical use by measuring and disclosing data on business progress to safer chemicals. •

Introducing the Clorox Total 360 System At the Association for the Healthcare Environment (AHE) EXCHANGE 2018 annual conference, Clorox Professional Products Company announced that the award-winning Clorox Total 360 System is available to health care facilities across the spectrum of care. While experts agree that thorough cleaning and disinfection of health care surfaces and equipment is essential for reducing the risk of infections, studies suggest that only 30 to 50 percent of surfaces in patient rooms and operating rooms are effectively disinfected and nearly 85 percent of hospital wheelchairs are contaminated with Staphylococcus aureus or Methicillin Resistant Staphylococcus aureus (MRSA). Using patented electrostatic technology to optimize product delivery, the Clorox Total 360 System provides an efficient, cost-effective solution to overcome this challenge and enhance environmental hygiene in a wide range of health care settings. The Clorox Total 360 System combines electrostatic technology with U.S. Environmental Protection Agency (EPA)-registered Clorox disinfecting and sanitizing solutions to quickly and easily provide superior coverage in even the hardest-to-reach places. The innovative system covers up to 18,000 square feet per hour. “While improving efficiency, this technology also enhances thoroughness and efficacy by enabling facilities to reach surfaces outside the line of sight where conventional trigger sprays may miss, reducing the risk of human error and providing more complete, uniform surface coverage,” explains

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Katherine Velez, PhD – senior scientist, Clorox Professional Products Company. “This makes the Clorox Total 360 System an ideal solution for many large and difficult-to-clean spaces, surfaces and objects found in a variety of health care settings including acute care facilities, emergency medical services, long-term care and assisted living, outpatient settings, rehabilitation and physical therapy facilities, and more.” Designed for efficient, comprehensive surface treatment and broad surface compatibility, the Clorox Total 360 System can be used to treat surfaces in patient care areas, disinfect wheelchairs and other mobile equipment and improve environmental hygiene in large areas and high-traffic public spaces such as waiting rooms, hallways and rehab units. • For more information, visit www.CloroxProfessional.com.

DECEMBER 2018 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Provation Launches Cloud-Based Procedure Documentation Platform Provation, a provider of clinical productivity software, has launched Provation Apex, a new, cloud-based procedure documentation SaaS platform designed to improve outcomes, clinical efficiency and physician satisfaction in ambulatory surgery centers and hospitals. Accessible on any Internet-enabled device, Apex is designed to be intuitive and aligned with the physician’s workflow. It provides guided capture of relevant details for more than 3,000 procedures in multiple specialties and automatically generates coding for all reimbursable actions. “The Apex benefits – cloud-based, accessible on mobile devices and equipped with personalization features like machine-learned favorites – help drive clinical outcomes, productivity and physician satisfaction,” said David Del Toro, president and CEO of Provation. “We designed Apex

to overcome common problems that erode overall performance, like inaccurate billing, operational inefficiencies and incomplete quality reporting.” Together, these features can help reduce the amount of time physicians spend on clerical and electronic health record (EHR) tasks and increase time for providing patient care. According to a 2017 report in the Journal of the American Medical Association (JAMA), for every hour of clinical work, physicians spend two hours on clerical or EHR-related tasks. The Apex software platform supports procedures ranging from common interventions to complex surgeries in gastroenterology, pulmonology, orthopedics and pain management, with more specialties planned. • For more information, visit provationmedical.com.

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When Quality Matters

PowerMATE® Special Purpose Relocatable Power Taps

Getinge Launches Maquet PowerLED II Surgical Light Getinge has unveiled the Maquet PowerLED II Surgical Light. The Maquet PowerLED II Surgical Light brings best-in-class technology to surgical suites or hybrid OR by improving working conditions for surgeons and staff. The best-in-class Maquet PowerLED II Surgical Light brings clear, shadow-free illumination to the conventional or hybrid operating room, improving tissue visualization for better surgical outcomes. The Maquet PowerLED II Surgical Light is the evolution of the proven Maquet PowerLED technology which has been used in operating rooms for more than a decade. Important new features include laser guidance for precise positioning, and an adjustable light patch to direct light where it’s most needed. Novel technologies include fully automated controls, self-guided intensity adjustment and dynamic presence sensors for unrivalled shadow management. Multiple colors of ambient light are available to limit monitor glare, improving clarity during MIS procedures. Eye fatigue protection is a vanguard feature of the new comfort light, an innovation that supports a gentle transition from the brightly illuminated surgical field to the obscured surroundings. The light is also designed to reduce the risk of complications from nosocomial infections, with antibacterial coatings and smooth surfaces that minimize turbulent airflow. It is fully compatible with the hygienic Maquet Satelite Anchoring System. The Maquet Satelite system allows equipment to be safely positioned within reach of the surgeon, without exposed cables and wires that can present a hazard to staff. The Maquet PowerLED II Surgical Light is compatible with Getinge accessories that can be shared among multiple ORs, minimizing equipment redundancy and helping customers to reduce the total cost of ownership (TCO). Equipment can be easily added, removed and upgraded to maximize customers’ long-term lighting investment. •

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DECEMBER 2018 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Philips, Children’s Health Eye Patient Monitoring Royal Philips and Children’s Health have announced an up to 15-year, long-term, strategic agreement worth up to $75 million to innovate its patient monitoring and PACs systems for nearly one million patients in North Texas. Through this agreement, standardized patient monitoring will take place on the Philips Intellivue X3 patient monitor, which offers the ease of a smartphone-style operation, mobility and allows staff to track a patient’s vitals during transport and at the bedside. In addition to the Philips X3 patient monitor, Children’s Health will have access to other Philips patient monitoring technologies such as IntelliVue Guardian with Early Warning Scoring and Intellivue Mobile Caregiver. These technologies can further empower staff, by putting critical patient information at their fingertips in an intuitive, easy to understand format.

14 | OR TODAY | DECEMBER 2018

“We are committed to making life better for children, and providing our patients with the best care possible,” said Pamela Arora, senior vice president and chief information officer at Children’s Health. “Aligning with Philips will help us improve the experience for our patients and their families.” As hospital systems move from fee-based to value-based care, long-term, strategic arrangements are becoming the business model of choice for hospitals and health systems to better manage the cost and complexity of their technology investments, while expanding quality access to advanced medical care for their communities. Other pediatric health systems that have also adopted this model include Phoenix Children’s Hospital, Children’s Hospital and Medical Center of Omaha, and the Maria Fareri Children’s Hospital, part of Westchester Medical Center Health. •

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SurgiSLUSH

Intelligent Automation Delivers

NanoTouch Materials Opens Center for Innovation NanoTouch Materials, creators of NanoSeptic Self-Cleaning Surfaces, has finished construction of, the Center for Innovation in Smart Materials. After three years of research and development funded by a $2 million grant, NanoTouch decided to foster development of other types of smart materials that improve people’s lives and reduce environmental impact. “While NanoTouch is focused on continued development of self-cleaning surfaces for health care, education, travel and commercial cleaning, we are excited about the prospect of partnering with scientists and innovative companies to expand the role of smart materials in our society,” says co-founder Dennis Hackemeyer. NanoTouch has moved its research, product development and manufacturing operations to the new facility, located in the New London Technology Park in Forest, Virginia. And, have already come up with a new self-cleaning surface – a clear film for touchscreens. “We had already developed self-cleaning portable mats for travelers and a self-cleaning liner for TSA security bins,” says co-founder Mark Sisson. “But the latest news about airport check-in kiosk touchscreens being the dirtiest places in airports drove our team to come up with a solution. These screens, which in one study were shown to be 1,000 times dirtier than a toilet seat, can now become continuously self-cleaning with the addition of our new clear film.” Smart materials can positively disrupt various industries in terms of improving health and reducing environmental impact and energy usage. NanoSeptic self-cleaning skins for high traffic touch points, like door handles, are already disrupting the commercial cleaning and facility management industries. Not only do they create cleaner places for people to touch, but their visibility creates a “Halo” effect. People assume the rest of the facility is cleaner when they see these surfaces. Commercial cleaners even view the installation and maintenance of these surfaces as a new value-added service which brings a much-needed boost to the perceived value of their services. And industries like health care are a natural fit. Physicians and dentists benefit from these visibly cleaner surfaces through improved patient experience. “Our patients love the NanoSeptic touch points and other self-cleaning products in our facilities,” says Lauren Bennett, director of operations with Central Virginia Family Physicians. • For more information, visit www.nanoseptic.com.

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DECEMBER 2018 | OR TODAY |

INDUSTRY INSIGHTS

news & notes

Healthmark Adds Swanky Athletic Sock Line Healthmark has added Swanky Athletic Socks to its personal protection equipment accessory product line. Health care professionals can energize their tired legs with these fashionable and comfortable socks. Swanky Athletic Socks deliver controlled pressure from ankle to calf for better blood flow throughout the lower leg. Designed to enhance circulation, the Swanky Athletic Socks provide support, help relieve foot and leg fatigue, as well as reduce swelling and recovery time for active individuals. Ideal for everyday wear, the socks are made with built-in arch support, a non-restrictive top and help reduce muscle strain. The Swanky Athletic Socks have a 10-14 mmHg gradient compression and are made from 90 percent nylon, 8 percent elastic, 2 percent spandex. The socks are offered in a medium size to fit women’s shoe sizes 6-10 and men’s shoe sizes 5-9. • For more information, visit www.hmark.com.

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INDUSTRY INSIGHTS webinar

Free Presentation Addresses Active and Passive Warming Staff report he OR Today webinar “Start Warm Stay Warm: Every Minute Counts” presented by Angie O’Connor, RN, BS, director of clinical resources at the Encompass Group, reviewed the evolving outpatient surgical population, described the continuing prevalence of hypothermia and reviewed typical warming methods. She also discussed ways to combine active and passive warming to achieve optimal outcomes.

Attendees who attended the Encompass Group-sponsored webinar had the opportunity to learn how cutaneous heat loss contributes to hypothermia along with AORN and ASPAN recommendations for preoperative warming. Attendees also achieved an understanding of the role of early recovery after surgery and patient warming. An understanding of the role of the perioperative team in maintaining normothermia was also discussed. The session, which attracted over 100 attendees, received positive feedback via a post-webinar survey. “One of the best webinars I’ve attended. I work in the OR and most of what Angie went over we’re already implementing in our facility. I hate to see patients exposed when I go over to pre-op area. I usually give my patients a blanket or two and tell them that I’m pre-warming them before we head out to the OR. You did mention

18 | OR TODAY | DECEMBER 2018

that there’s a cost attached to reprocessing these blankets, but I don’t think it’s as much as when they had complications from hypothermia,” said C. Anonuevo, RN. “I love OR Today’s webinars! They are great,” shared A. Lyons, director of surgery access. “Excellent presentation of the facts! Really gave me a deeper understanding of the subject and how I can apply what I have learned. Anxious to share much of the information with my co-workers,” said C. Schrom, RN, materials manager. “As an educator for surgical services, which includes not only OR but PACU, holding, and discharge areas, it is important for me to help each of these areas in keeping our patients warm from start to finish. This webinar had some good ideas and interesting facts about how to keep patients warm, as well as evidence to back up the standards,” said D. Cleaves, surgical services education coordinator. “This was great! Up-to-date information, very relevant to my practice, and easy to follow. I will definitely be sharing this around work,” said E. Pressnalle, PACU RN. “This program was excellent! It was very well organized with data and resources to back up the recommendations. The presenter was very knowledgeable and engaging to listen to,” said S. Rickley, director of quality services. “A very informative webinar. It gave us something to think about in regards

“ Excellent presentation of the facts! Really gave me a deeper understanding of the subject and how I can apply what I have learned. Anxious to share much of the information with my co-workers.” –C. Schrom, RN, materials manager

to keeping patients warm throughout their stay at our surgery center. We will consider many of the suggestions,” said M. Gavilanez, RN. For more information, including a list of upcoming webinars, visit ORToday.com

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The sterile field should be covered if it will not be immediately used or during periods of increased activity. – AORN 2019*

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AORN Guideline for Sterile Technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 2018: electronic release.*

INDUSTRY INSIGHTS

CCI

The Times They are a Changin' with Apologies to Bob Dylan By James x. Stobinski he Competency and Credentialing Institute (CCI), the organization that administers the CNOR and CSSM credentials, is amid a strategic planning process. Part of that process is an environmental scan to determine the current place of CCI within the larger world of perioperative nursing practice. As the CEO of CCI, I have been actively engaged in that process and have gained a few insights. First, the profession of perioperative nursing and the nature of surgery within the context of American health care is in a period of disruptive and turbulent change. Even the sites where surgery is performed are changing.

The total number of surgeries continues to increase as does the amount of surgery performed in ambulatory settings but the amount of surgery requiring admission to a hospital is not rising in tandem. (Munnich & Parente, 2014). And, the number of hospitals is slowly declining (Statista, n.d.). Advances in technology and procedures underlie these changes but another causative factor is the transition to value-based care. The sum of these changes culminates in things like same day surgery for total joint procedures, a process difficult to even imagine when I entered the OR 30-plus years ago. These changes have enhanced the role of perioperative nursing and created new opportunities. However, these new opportunities bring

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heightened expectations and increasing demands for our profession. CCI has observed that continuous professional development (CPD) is now a necessity throughout a career. And â&#x20AC;Ś familiar methods long used in the profession will no longer suffice to meet the learning needs of perioperative nurses. American nurses have long used continuing education (CE) courses to remain current in their practice. At CCI, we believe the use of CE (as currently configured) will no longer suffice to maintain the clinical competency of perioperative nurses going forward. A review of the evidence regarding our current system of CE reveals that the link between the use of CE and improvements in nurse competency is at best â&#x20AC;&#x201C; weak. (IOM, 2010). The question for perioperative nurses then becomes â&#x20AC;&#x201C; if the use of evidencebased practice in our clinical work is now commonplace should we also apply that perspective to the educational and administrative segments of our practice? CCI believes that based on the evidence we need to strengthen and refine our professional development efforts to give optimal patient care. As CCI changes relative to the implementation of our strategic plan we hope to align our work with the professional development needs of our perioperative nurses to deliver the highest quality care within a rapidly evolving American health care system. CCI believes that the complexity and pace of change in modern perioperative nursing requires a robust system supporting lifelong

learning and CPD which will lessen the dependence on CE. We see the current CE-based system replaced in some measure by structured, systematic lifelong learning consistent with the recommendations from the Institute of Medicine report on the future of nursing. (2011, p. 13). CCI continues to invest in technology such as the freestone Learning Management System (LMS) to develop an optimal learning environment for certified perioperative nurses. CCI, in the very near future, will have a perioperative centric LMS with a repository of meaningful learning activities for its certificants. We hope, in working with our partners such as OR Today Live, to establish a dynamic and sustainable system that perioperative nurses can utilize throughout their career. For our current certified nurses and those who aspire to certification, stay tuned. CCI and our partners and stakeholders have some exciting changes coming. We look forward to working with you to deliver excellent perioperative nursing care in these rapidly changing times. James X. Stobinski, Ph.D., RN, CNOR, CSSM (E), is the CEO of the Competency and Credentialing Institute. He may be reached at jstobinski@cc-institiute.org.

References

1. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, D.C.: The National Academies Press. Accessed October 5, 2018 at: https://www.nap.edu/read/12956/ chapter/1#ii. 2. Institute of Medicine. (2010). Redesigning continuing education in the health professions.

DECEMBER 2018 | OR TODAY |

INDUSTRY INSIGHTS asca

ASCA/One World Surgery Partnership Supports Free Surgical Care in Honduras By William Prentice n a 2,000-acre ranch about an hour from Honduras’ capital city, Tegucigalpa, an ASC known as the Holy Family Surgery Center is providing life-changing surgical procedures for free to Hondurans who cannot afford to pay for the surgery they need. In 2017, alone, the center touched the lives of more than 7,000 people.

The Holy Family Surgery Center is owned and operated by One World Surgery, a US-based nonprofit organization committed to providing access to high-quality surgical care globally. The ranch where it is situated also serves as a children’s home known as Nuestros Pequeños Hermanos (NPH). Half of the ASC’s staff members were raised

22 | OR TODAY | DECEMBER 2018

there. An orthopedic surgeon serves as a full-time, on-site medical director for the program. The surgery is provided inside a modern medical facility with three operating rooms and seven overnight recovery bays. To help in the center and on the ranch, One World Surgery coordinates weeklong medical missions that bring physicians, other clinical staff, nonclinical participants and family members to NPH. The program hosts one or two medical mission teams each month, with up to 60 volunteers per team. Typically, about half of each team is clinical personnel with approximately seven physicians, 20 nurses and two sterile processors. Participants in the mission trips contributed more than 26,000 hours of volunteer service in 2017. Along with the surgery it provides, One World Surgery supports educa-

tion, training and capacity-building activities aimed at filling gaps in the current medical system and investing in the future of surgical care for the country. Recently, for example, a CRNA who visited the ASC for her 17th time hosted a training program for the Honduran anesthetists and provided continued training.

Scholarships for ASCA Members The ASCA Foundation has partnered with One World Surgery to support its mission. Through this partnership, the ASCA Foundation provides a scholarship program for nurses, surgical techs and scrub techs interested in One World Surgery’s one-week medical missions in Honduras. The scholarship is derived from the revenue ASCA earns from its affinity partners and can remove a WWW.ORTODAY.COM

INDUSTRY INSIGHTS

asca

“ This trip has changed my outlook on life and what is really important to me. In the end, what really matters is the lives we touch along the way and the people we help.” financial burden for eligible ASCA members, allowing them to use their clinical skills to participate in one of these life-changing medical brigades. Each scholarship covers the program fees associated with participating in the medical mission, as well as round-trip coach airfare for the participant. Program fees cover food and lodging, ground transport in Honduras, and emergency medical and evacuation insurance. For information, including eligibility requirements, visit ASCA’s Medical Mission Scholarships page.

What Is a Mission Trip Like? In March 2018, ASCA member Cindy Young, RN, CASC, administrative director of the Surgery Center of Farmington in Missouri and an ASCA Board member at the time, accepted an invitation to join One World Surgery at its ASC in Honduras to help kick off ASCA’s new scholarship program. Asked to report on her experience there, she said: “There is no greater joy for me than to go to Honduras and be a small part of giving the gift of surgery to people. These people have been to the public hospital and other places, and they come to One World with their last ounce of hope for help. After their surgery WWW.ORTODAY.COM

is finished, it is priceless to see the happiness and gratitude on their face. I’ve seen a woman, hours after total knee replacement, when she was walking for the first time, crying and singing with joy because she was so happy. Another woman, who had been through several devastating events in her life, was given the gift of sight after cataract surgery. This woman brought tears to the staff’s eyes as she explained what a blessing it was to be able to see again.” Young reported that the facility was very comparable to the ASCs you see in the U.S. and that she worked some long and busy days as the center completed a total of 17 ear, nose and throat, 30 ophthalmology and 36 orthopedic procedures in just one week. Accommodations for the volunteers, she added, were clean and comfortable and included single beds for each person, four people to a room, designated space for each person’s clothes and other personal belongings, and access to a shower, double sink and bathroom. Young also reported that she felt very safe during her entire visit. Volunteers met her at the airport and accompanied her on the bus trip to and from NPH. The ranch, itself, was protected 24/7 by armed security guards.

Get Involved One World Surgery Executive Director Claire Cunningham says that volunteer RNs and nursing circulators are always in demand at the center. For those who cannot participate in a medical mission trip, monetary support and donations of supplies and equipment are always appreciated. “Once you go to Honduras,” says Young, “you will leave a piece of your heart and a desire to return. This trip has changed my outlook on life and what is really important to me. In the end, what really matters is the lives we touch along the way and the people we help.”

Please Remember This January, ASCA is hosting its 2019 Winter Seminar, January 1719 in Austin, Texas. You can choose from tracks on infection prevention, coding and reimbursement strategies and ASC management essentials (new this year!). Between May 15-18, we will hold ASCA 2019, our annual conference and expo, in Nashville, Tennessee. If you work in or with the ASC community, we hope you will join us for one or both of these events.

DECEMBER 2018 | OR TODAY |

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IN THE OR

market analysis

Global Sterilization Equipment and Disinfectants Staff report ccording to the report “Sterilization Equipment and Disinfectants Market—Global Industry Analysis, Size, Share, Growth, Trends and Forecast, 2013-2019,” published by Transparency Market Research, the global sterilization equipment and disinfectants market is forecasted to reach a market value of $9.15 billion by the end of next year.

Rising geriatric population is one of the primary factors for the growth of this market. Additionally, increasing number of surgeries performed and per capita health care expenditure coupled with rising incidences of hospital-acquired infections will propel the demand of sterilization equipment and disinfectants market, researchers predict. The report describes the usage and types of sterilization equipment and disinfectants, amongst which sterilization equipment market accounted for the largest share (over 70 percent) of the total market in terms of revenue. Sterilization equipment market is expected to grow at a Compound Annual Growth Rate (CAGR) of 9.1 percent during the forecast period. The sterilization equipment market has been further segmented as heat sterilization equipment, low-temperature sterilization equipment, filtration sterilization, and radiation sterilization. The lowtemperature sterilization equipment market is expected to grow at a CAGR of 10.9% during the forecast period 2013 to 2019. The market for disinfectants has been segmented as low-, intermediWWW.ORTODAY.COM

ate- and high-level, and oxidizing and non-oxidizing disinfectants. The low-, intermediate- and high-level disinfectants market is expected to grow at a CAGR of 7 percent during the forecast period 2013 to 2019. The market for sterilization equipment and disinfectants in medical devices application accounted for the largest share (60.8 percent) of the total market in 2012 and is expected to grow at the highest CAGR during the forecast period. This growth is attributed due to rising incidences of hospitalacquired infections and an increase in the number of surgeries performed. A PR Newswire update also predicts continued growth of the market over the next several years that references a report added to ResearchAndMarkets.com’s offering. The global sterilization equipment market is expected to reach $11.14 billion by 2023 from $7.94 billion in 2018, at a CAGR of 7 percent, according to the PR Newswire release. The major factors driving the growth of this market are the rising incidence of hospital-acquired infections, increasing number of surgical procedures, rising focus on food sterilization and disinfection, technological advancements in sterilization equipment, and increasing number of hospitals in Asia, according to ResearchAndMarkets.com. On the basis of end user, the sterilization equipment market has been segmented into hospitals and clinics, medical device companies, food and beverage industry, pharmaceutical companies, and other end users. The

hospitals and clinics segment accounted for the largest share of the sterilization equipment market in 2017. The large share of this segment can be attributed to increasing incidence of healthcare-associated infections (HAIs), growing number of hospitals in Asian countries and increasing number of surgical procedures. In 2017, North America accounted for the largest share of the sterilization equipment market. The increasing demand for sterilization technologies from the health care industry to minimize the occurrence of HAIs and the increasing number of surgeries in this region are the major factors supporting the growth of the sterilization equipment market in North America. According to another release from PR Newswire, other markets will also be affected by sterilization trends and practices. “The global medical plastics market size is expected to value at $33.6 billion by 2025. The market is subject to witness a substantial growth due to the growing demand for sterilized plastics from the health care sector. Implementation and up gradation of infection prevention standards is one of the critical factors responsible for the growth of medical plastics industry of late,” according to the report. “The other factors such as rise in the number of surgical, hospital and outpatient procedures are expected to boost the market growth over the forecast period. Globally, the medical plastics market is predicted to grow at CAGR of 5.7 percent in forecast period, providing numerous opportunities for market players to invest in research and development in the market.” DECEMBER 2018 | OR TODAY |

IN THE OR

product focus

Attest Auto-reader 490 The 3M Attest Auto-reader 490 now has the ability to provide 24-minute Attest biological indicator (BI) readouts for both steam and vaporized hydrogen peroxide (VH2O2) in any of its incubation wells. The dual capability is also available to current 3M customers through a software upgrade to existing Attest Auto-reader models 490 and 490H at no extra charge. This innovation enables facilities to simplify, standardize and streamline their sterilization department’s workflow processes to keep OR schedules on time and provide a high standard of care. • For more information, visit go.3M.com/At-

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Halyard and Belintra

Smart-Fold Steri-System The Halyard and Belintra Smart-Fold Sterisystem is a unique sterilization packaging, transport and storage solution, designed to reduce the risk of tears, cuts and holes in wrapped instrument trays. Smart-Fold, with its proprietary manufacturing and superior bacterial filtration, along with the Sterisystem’s stainless steel instrument baskets, shelves and transport carts, safeguard the sterility of instruments with only two touchpoints during handling, transport and storage after sterilization until use in the OR. Additionally, the system enhances organization allowing for simpler, faster storage and access to the right instruments at the right time. •

26 | OR TODAY | DECEMBER 2018

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IN THE OR

product focus

Tuttnauer

Class B Pre/Post Vacuum Sterilizers The Elara11 table top autoclave is reliable, robust and great for small spaces. The closed door drying and pre-vacuum air removal system come standard with a high-volume vacuum pump that is very effective at removing moisture from instruments. This ensures sterility and efficient drying of pouches. The 5075HSG autoclave is a free-standing, cabinet enclosed unit with a built-in steam generator and wheel mounted design. The system provides a deep and powerful vacuum due to a high-volume water-ring vacuum pump for reliable and complete air removal. The 5075HSG offers all the features and reliability of a large capacity autoclave at a fraction of the size and cost. â&#x20AC;˘

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DECEMBER 2018 | OR TODAY |

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IN THE OR

continuing education

30 | OR TODAY | DECEMBER 2018

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IN THE OR

CE115-60

continuing education

Caring for the Postanesthesia Patient Lisa Hughes, MSN-Ed, RN, CCRN

urses care for postoperative patients in postanesthesia phase 1 or postanesthesia phase 2, according to designations made by the American Society of PeriAnesthesia Nurses. Nursing responsibilities during phase 1 focus on providing a transition for the patient from a totally anesthetized state to care in the inpatient setting, phase 2, or the intensive care setting for continued care.1 Assessment in the postanesthesia care unit (PACU) focuses on respiratory and cardiovascular systems, and maintenance of a patent airway or continued ventilatory support. The primary purpose of the PACU is critical assessment and stabilization of postanesthesia patients with an emphasis on prevention or treatment of complications.2 Postanesthesia patients often need continued intensive care, which requires the nurse to possess critical thinking skills and complex nursing expertise. Postanesthesia phase 2 focuses on preparing the patient and family for care in the home or extendedcare environment.1 Because of the complexity of care and increased patient responsibilities in the immediate postoperative period, it’s not surprising that The Joint Commission mandates that an RN supervise perioperative nursing care and that a sufficient number of qualified staff are available to recover patients.3 WWW.ORTODAY.COM

Assessing the Immediate Postanesthesia Patient Before patients are transferred from the OR to the PACU, receiving nurses need to know when they will arrive and what they will require, such as equipment for ventilatory support or monitoring. The Joint Commission’s standards require appropriate physiological monitoring and resuscitative equipment be available, as well as equipment to administer IV fluids, drugs, and blood or blood components as necessary.3 Upon transfer, a thorough report from the anesthesia provider supplemented by the OR nurse should include relevant preoperative information regarding patient status, including emotional status; the surgical procedure performed; types of anesthesia and the drugs used; length of anesthesia or sedation; any reversal agents; pain management interventions; intraoperative estimated blood loss, surgical drain volume and urine output; IV fluid and blood products infused; any anesthetic and surgical complications that occurred; vital signs, including pulse oximetry and temperature; and any coexisting medical disorders.1 This report from the anesthesia provider to the PACU RN is a critical patient handoff, and accurate information about the patient is essential. Standards from the American Society of Anesthesiologists and the American Association of Nurse Anesthetists require the anesthesia provider to supply a verbal patient report to the responsible PACU nurse.4,5 The Joint Commission patient care standards require that handoff communication provide for the opportunity

OnCourse Learning 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 38 to learn how to earn CE credit for this module.

Goal and objectives The goal of this continuing education program is to update nurses’ knowledge about the care of postanesthesia patients and to familiarize nurses with applicable Joint Commission standards. After studying the information presented here, you will be able to: • N ame three important areas of concentration for assessing the postanesthesia patient • Describe two complications specific to regional anesthesia • Identify the etiologies of six complications of general anesthesia and their treatments

DECEMBER 2018 | OR TODAY |

IN THE OR

continuing education for discussion between the giver and receiver of care.3 Expectations of The Joint Commission relative to monitoring of the postanesthesia patient include the following standards:3 The patient is assessed immediately after the procedure. Each patient’s physiological status, mental status, and pain level are monitored. Monitoring is at a level consistent with the potential effect of the procedure or sedation or anesthesia. The nurse accepting the patient needs to complete an initial assessment that includes the patient’s level of consciousness, vital signs, oxygen saturation, end-tidal CO2 (if applicable), heart and breath sounds, surgical site and drainage devices, and IV access site so that any changes that occurred during transport can be identified immediately. Subsequently, a complete system assessment is performed and postoperative orders initiated. The report and assessment findings should be documented according to the institution’s policies and procedures. Cardiopulmonary System: Maintenance of adequate gas exchange with adequate ventilation is vital. The patient should have unlabored, quiet respirations with adequate chest excursion; a respiratory rate of 16 to 20 breaths per minute is normal for an adult (higher in children), but may be slower, particularly in a patient who has received opioids. Patients should be encouraged to take deep breaths. The respiratory function should be monitored, including oxygen saturation, and if available and appropriate, end-tidal CO2 levels.2 Generally, an oxygen saturation level measured with a pulse oximeter should be higher than 92% to 94% or the same as preoperative status. The cardiac output and perfusion should be assessed and monitored

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by checking arterial blood pressure for evidence of hypotension or hypertension (postoperative blood pressure should be plus or minus 20% compared with the preoperative measurement6), heart rate and rhythm for signs of dysrhythmias, skin color, temperature, and peripheral pulses for peripheral perfusion status. The fluid intake and output should be reviewed for indications of possible hypovolemia or hypervolemia and for total fluids infused, including blood products compared with urinary output, estimated blood loss, and volume in surgical drains. Peripheral edema or jugular venous distention should be noted. Numerous factors can alter cardiopulmonary function, including pain and residual anesthetic affects, and the underlying causes needs to be identified to resolve problems effectively. Central Nervous System: CNS assessment includes evaluation of consciousness, orientation, and behavior. Drugs used to produce general anesthesia cause unconsciousness as well as amnesia and analgesia. The incidence of emergence delirium ranges from 3% to 53% in adults.7 Causes for emergence delirium include pre-existing cognitive impairment, medication, pain, bladder distention, or cerebral hypoxia, with the older patient at a greater risk.7,8 In a recent study, the risk factors for emergence delirium in 1,868 adult patients were premedication with benzodiazepines, induction of anesthesia with etomidate (Amidate), younger and older age (younger than 40 and older than 64), higher postoperative pain scores (6 to 10 on a 1-to-10 scale), and musculoskeletal surgery.9 Young children also often experience delirium.8,10 The patient exhibits restlessness, confusion, and disorientation, and may be combative, uncooperative, or uninhibited during this time. Although the delirium does not last long, it’s important to promote the patient’s safety as well as that of the healthcare profes-

sional by remaining calm, speaking softly, and reassuring and orienting the patient.7,8,10 Drug therapy may be necessary to resolve the agitation, such as a benzodiazepine or physostigmine, which reverses agitation caused by atropine (Atropen), an anticholinergic drug.10 However, before drug therapy is considered, other causes of delirium should be identified and corrected, such as hypoxia, hypercarbia, hypothermia, gastric dilatation, and urinary retention.8,10 Temperature: Hypothermia, a core temperature below 96.8 F (36 C), is a common, but adverse, side effect of anesthesia.11,12 Every patient should be assessed for hypothermia and warming initiated for any hypothermic patient.11 Infants and the elderly are more susceptible to hypothermia because of immaturity and diminished sensitivity of temperature-regulating mechanisms.10 The reduced metabolic rate caused by hypothermia can prolong the effects of anesthetics and delay recovery, while the associated shivering increases oxygen consumption10 four to five times, increasing the risk for angina and dysrhythmias in patients with cardiovascular disease. Postoperative shivering is controlled by using IV fluid warmers, skin-surface warming devices, such as forced warm-air devices, and drugs such as meperidine (Demerol) (25 mg IV).10-12 In the PACU, hypothermic patients should continue to have an assessment of temperature at least hourly, assessment of thermal comfort, and passive thermal-care measures, such as a warmed blanket. Hypothermic patients should have an application of forced-air warming, such as with a Bair Hugger, and consideration of additional adjuvant measures, such as warmed IV fluids and humidified warm oxygen.12, 13

Anesthetic Techniques Surgery within ORs can be performed under a variety of anesthetic techWWW.ORTODAY.COM

IN THE OR

continuing education

niques. Three concepts are integral to a comprehensive understanding of these methods and their effects on postoperative patients. Analgesia is defined as the lack of normal pain sensation.14 Amnesia, an essential element of general anesthesia and a desired element of regional and sedation techniques, is the absence of awareness of stimuli and events.15 Anesthesia, a partial or complete loss of sensation with or without loss of consciousness, can be achieved using regional or general techniques.14 Many procedures are performed with IV sedation and local anesthesia injected at the surgical site, commonly referred to as monitored anesthesia care or local standby with sedation. Opioids or benzodiazepines and IV anesthetic agents, such as propofol (Diprivan), provide an anxiolytic and analgesic state while the surgeon provides local anesthesia.

Analgesia, Amnesia, Anesthesia

Analgesia is defined as the lack of normal pain sensation. Amnesia, an essential element of general anesthesia and a desired element of regional and sedation techniques, is the absence of awareness of stimuli and events. Anesthesia, a partial or complete loss of sensation with or without loss of consciousness, can be achieved using regional or general techniques. Regional anesthesia includes spinal, epidural, and caudal anesthesia. This type of anesthesia interrupts the patient’s sensory, motor, and sympathetic nervous system impulse transmissions at the selected surgical site.16 Used in conjunction with IV sedation, regional anesthesia can provide an effective alternative to general anesthesia in certain procedures on the extremities or lower abdomen. The drug used and the site of drug installation affect the WWW.ORTODAY.COM

intensity of blockade, as well as the adverse reactions and the level and duration of anesthesia.16 Postoperative care of patients with regional anesthesia includes assessment of the sensory and motor function in the block and its surrounding area. The return of motor function should be documented based on the patient’s ability to progressively move toes, feet, legs and thighs. Return of sensory function is demonstrated by the ability to distinguish sensations of cold (alcohol swab) or touch (smallgauge needle pricks). Patients with a “high” sensory/motor block (spinal/ epidural) may complain of numbness and tingling of the hands and may exhibit signs of labored respirations. Anesthesia-induced hypotension is due to vasodilatation caused by the sympathetic blockade that leads to decreased venous return and cardiac output. These patients need continuous assessment, including oxygenation and ventilation and vascular volume status, while supplemental oxygen is provided and venous return is increased using IV fluids and positioning. Patients who have difficulty breathing or who have a reduction in oxygen saturation may require endotracheal intubation and ventilatory support, and those whose hypotension persists may need a sympathomimetic drug, such as ephedrine. Other possible causes of the hypotension, such as bleeding from the operative site, should be assessed.16 General anesthesia produces unconsciousness, amnesia, analgesia, skeletal muscle relaxation and sensory blockade.15 A combination of drugs, administered as inhalants or IV, is used to achieve adequate surgical anesthesia. Nurses can anticipate potential problems if they know which agents have been used during the surgical procedure. Opioids include morphine (AVINza, Kadian, MS Contin), the prototype to which all others are

compared; fentanyl (Sublimaze); remifentanil (Ultiva); sufentanil (Sufenta); alfentanil (Alfenta); and hydromorphone (Dilaudid). Fentanyl is 75 to 125 times more potent than morphine, remifentanil has an analgesic potency like fentanyl, and sufentanil is 5 to 10 times more potent than fentanyl.17 Alfentanil is one-fifth to one-tenth as potent as fentanyl, which makes it a popular IV adjunct in outpatient settings because of its rapid onset and short duration of action. Opioids produce analgesia, euphoria, and sedation. Morphine reduces blood pressure due to vagal-induced bradycardia and histamine release, reactions not seen with other opioids, such as fentanyl.17 Hydromorphone, like morphine, has seen a renewed popularity in the PACU. It has a rapid onset of action and virtual lack of active metabolites after breakdown in the liver.17 Due to the potential for histamine release, morphine is contraindicated for the asthmatic patient. Other adverse effects, including somnolence, urinary retention, nausea and vomiting, and respiratory depression (which may be reversed with naloxone), are common to all opioids. Meperidine is not typically used for long-term pain management due to its metabolite, normeperidine, which causes CNS excitability.17 The reversal agent for opioids is naloxone (Narcan), which can reverse adverse effects such as respiratory depression, but should be titrated and not given by rapid IV push. Benzodiazepines produce amnesia. Diazepam (Valium) use is limited since the introduction of midazolam (Versed), which is shorter acting and water soluble, causing less venous irritation. Adverse effects may include delayed awakening, somnolence, disorientation, amnesia, and postoperative respiratory depression, especially if used in conjunction with opioids. Flumazenil (Romazicon), a benzodiazepine antagonist, may be used to reverse significant adverse effects, such DECEMBER 2018 | OR TODAY |

IN THE OR

continuing education

as respiratory depression. Barbiturates, including sodium thiopental (Pentothal) and methohexital (Brevital), have been a mainstay of IV anesthetic practice for more than 50 years. These hypnotics producing drugs are used for induction or sedation and have a low incidence of postoperative nausea and vomiting. Large or repeated doses intraoperatively may prolong the drug’s effects postoperatively, causing delayed awakening, somnolence, hypotension and respiratory depression. Barbiturates do not provide adequate analgesia and must be supplemented for pain control.18 Propofol (Diprivan), a sedative hypnotic, produces dose-dependent depression of the CNS. About twice as potent as sodium thiopental, it may be used for sedation or induction and maintenance of general anesthesia. Other CNS depressants, such as opioids, increase propofol’s hypnotic effect. Adverse effects include hypotension, which is more pronounced if the patient is elderly or has poor left ventricular function. Fluid resuscitation and vasopressor therapy may be required.18 Etomidate (Amidate), another sedative hypnotic, is often used as an alternative to propofol and barbiturates for emergency surgery when volume resuscitation is ongoing and for patients with cardiac disease.18 It has less of an effect on blood pressure, heart rate, myocardial contractility, and cardiac output than the other sedative hypnotic drugs.18 Involuntary muscle contractions or tremors are adverse effects, and nausea and vomiting are more common postoperatively than with sodium thiopental or propofol. Neuromuscular blocking agents (NMBA) are used principally to relax and paralyze skeletal muscles, facilitating endotracheal intubation and muscle retraction in the surgical field.19 They do not possess analgesic, amnesic, or anesthetic properties and

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are classified according to how they act upon the neuromuscular junction: depolarizing or nondepolarizing. Succinylcholine (Anectine) is the only depolarizing NMBA currently available in the U.S., and there’s no reversal agent for this drug.20 Nondepolarizing NMBAs include intermediate-acting rocuronium (Zemuron), vecuronium (Norcuron), cisatracurium (Nimbex), and atracurium (Tracrium), and long-acting pancuronium (Pavulon). Adverse effects may include cardiac dysrhythmias, post-blockade myalgia, prolonged blockade and persistent weakness.20 There are also certain drugs, such as local anesthetics, antibiotics, antidysrhythmics, and diuretics that can potentiate the effects of NMBA, contributing to a prolonged recovery.20 The most serious postoperative complication is inadequate reversal, which may result in short jerky attempts at respiration with little or no gas exchange. Patients exhibit uncoordinated “floppy fish” gasps for air. Nurses need to assess respiratory rate, oxygen saturation level, and tidal volume, and report findings to the anesthesia provider. Reversal agents for nondepolarizing NMBA — neostigmine (Prostigmin), edrophonium (Enlon), or pyridostigmine (Regonol) — may be given if needed.19,20 It’s recommended that an anticholinergic is given with the NMBA to prevent bradycardia, bronchoconstriction, and hypotension, which are adverse effects of these reversal agents; atropine is given with edrophonium or glycopyrrolate (Robinul) with neostigmine or pyridostigmine.19,20 When the supine patient can lift his or her head off the bed and hold it for five seconds, neuromuscular blockade recovery is considered adequate. Inhalation anesthetics halothane (Fluothane), isoflurane (Forane), desflurane (Suprane), and sevoflurane (Ultane, Sojourn) are used for general anesthesia. In addition to depressing

the CNS, these drugs depress baroreceptor sensitivity and myocardial and respiratory function. Nurses need to frequently assess blood pressure; cardiac rhythm; peripheral perfusion; and respiratory rate, rhythm, and depth.15

General Anesthesia Postoperative Complications Respiratory depression (reduced tidal volume, respiratory rate, and O2 saturation) may result from residual drug effects. Inadequate reversal of muscle relaxants reduces tidal volume; if unresolved by additional reversal agents, reintubation may be necessary. Residual opioids primarily diminish respiratory rate, and patients may require naloxone titrated to reverse opioid depression. On occasion, reduced tidal volume and O2 saturation result from pain and splinting, and may improve with opioid analgesia. Because patients who have had general anesthesia have had some interference with their respiratory processes, most experts suggest these patients should receive supplemental oxygen during the recovery period.21 Upper airway obstruction can also result from relaxation of the pharyngeal musculature due to residual drug effects. The patient should be observed for signs of obstruction, such as snoring, nasal flaring, and sternal retractions.6 Raising the head of the bed, if not contraindicated, or performing a simple jaw lift or mandible thrust is often sufficient to bring the tongue forward and relieve the upper airway obstruction. If this is ineffective, a nasal airway can be inserted. If a nasal airway is contraindicated by a history of epistaxis, cranial surgery, facial fractures, or a low platelet count, an oral airway may be inserted if the patient is unconscious; 6 stimulation of the patient’s gag reflex may cause vomiting, increasing the risk for aspiration. If upper airway obstruction is not relieved immediately, the anesthesia WWW.ORTODAY.COM

IN THE OR

continuing education

provider should be notified to assess for reintubation. Obstructive sleep apnea affects 2% to 26% of the general population, with up to 62% of patients older than 60 experiencing it. Patients with OSA have an increased chance of experiencing postoperative complications.1 Patients should be screened during the preoperative period for OSA and postoperative care planned at that time. Patients with OSA can be positioned in a lateral or sitting position. Continuous positive airway pressure may also be provided early in the postoperative period. The patient may require extended monitoring in PACU, especially with the extensive use of opioids.1 Mechanical obstacles, such as teeth, vomitus, or hematomas, may also cause obstruction. Patients who have had head and neck surgery need continuous assessment for airway patency. Hemorrhage or clot formation at the surgical site may require further surgical exploration. An emergency tracheostomy setup needs to be at the bedside for these patients if signs and symptoms indicate respiratory distress.22 Laryngospasm, which may result in complete closure of the vocal cords and inability of the patient to ventilate, requires immediate assistance from anesthesia personnel. Those at risk for laryngospasm include patients with chronic pulmonary disease, those who smoke, those with a history of asthma, and those who had a difficult intubation. Patients will often display “rocking” abdominal respirations with no air exchange. Initial treatment is positive-pressure ventilation using a bag-valve mask device with 100% O2. The anesthesia provider will give a nonparalyzing dose of succinylcholine ([Anectine], about one-tenth of the full intubating dose) if this maneuver is unsuccessful. Reintubation may be a last resort.10 Hypotension is commonly caused WWW.ORTODAY.COM

by hypovolemia from hemorrhage, insensible (third-space) losses, or inadequate fluid replacement. But hypotension can also be caused by decreased systemic vascular resistance and myocardial contractility, which are residual effects of anesthetic agents.8 Arterial hypoxemia, cardiac dysrhythmias, pulmonary embolism, pneumothorax, and cardiac tamponade can also lead to hypotension.8 Treating hypotension depends upon its etiology; however, oxygen therapy is usually a standard treatment regardless of cause. Assessment starts with an evaluation of fluid status, including a thorough review of estimated intraoperative blood loss and fluid replacement, urine output, and postoperative bleeding at the wound site and from surgical drains. If blood loss is suspected, hemoglobin and hematocrit levels should be checked. Evidence of bleeding and a low hematocrit level are signs of inadequate surgical hemostasis, and the surgeon should be notified. Based on a patient’s cardiovascular status, fluid challenges of 200 cc to 500 cc may restore blood pressure to baseline values if hypovolemia is present.10 Other etiologies require further assessment and specific treatments. Hypertension in the immediate postoperative period is often due to the sensation of pain as the patient emerges from anesthesia.8 However, it may result from hypoxemia; hypercarbia; a full bladder; hypothermia with arterial and venous constriction; fluid overload; and the administration of exogenous sympathomimetic agents, such as ephedrine or phenylephrine.10 As with hypotension, the etiology of hypertension determines treatment. First, the nurse should assess such factors as airway and ventilation, unrelieved pain, or the presence of a full bladder. Correction and treatment of one or more of these factors may return the patient’s blood pressure to baseline value. Patients may need to

have their fears allayed, have analgesics administered for pain, empty their bladders, and be encouraged to deeply breathe and cough. Patients with pre-existing hypertension, who often exhibit wide ranges of blood pressure postoperatively, need to be carefully returned to baseline values with antihypertensive medications, calcium channel blockers, or vasodilators. Aspiration may occur in patients recovering from general anesthesia and IV sedation, when airway reflexes are impaired. Patients most commonly aspirate gastric contents, which can result in severe pneumonitis and bronchospasm with resultant hypoxemia. Some signs include wheezing, sustained coughing, and laryngospasm. Pulmonary infiltrates may appear on the chest X-ray immediately or within 24 hours of the event.10,23 Postoperative aspiration is life-threatening, and patients demonstrating an inability to maintain a patent airway or the absence of pharyngeal or laryngeal reflexes require immediate intervention by anesthesia personnel. Postoperative endotracheal intubation may be required to protect the airway from gastric contents or foreign materials. Skeletal muscle pain, especially in the neck, abdomen, and back, may occur from the use of the depolarizing muscle relaxant succinylcholine. The discomfort is thought to be due to muscle damage caused by unsynchronized contractions of the skeletal muscles (fasciculations) associated with generalized depolarization.19 Patients who exhibit skeletal muscle myalgia postoperatively should be reassured that the duration of this pain is generally short, dissipating within 24 to 48 hours. Treatment of myalgia includes analgesics, such as acetaminophen (Tylenol). Nausea and vomiting is one of the most common postoperative problems, affecting 20% to 30% of patients.8 Primary risk factors fall into DECEMBER 2018 | OR TODAY |

IN THE OR

continuing education

three categories — patient specific, anesthetic related, and surgery related. A patient with risk factors, including being female, nonsmoking history, use of opioids, and history of postoperative nausea and vomiting (PONV), or motion sickness, has an 80% chance of having PONV, with each risk factor increasing the risk of PONV. Measures to prevent and treat PONV include the use of pharmacological agents. Serotonin antagonists (5-HT3 receptor antagonists) prevent and relieve nausea and vomiting by blocking a chemical called serotonin, which is produced in the brain and the stomach. Dopamine receptor agents, such as prochlorperazine (Compazine) and droperidol (Inapsine), block the dopamine (D2) receptor sites. Droperidol was a common treatment until the FDA black box warning regarding possible dysrhythmias. Promethazine (Phenergan) or diphenhydramine (Benadryl) can be given to block the histamine receptor sites. Glycopyrrolate or scopolamine patches can be used for the muscarinic receptors. Dexamethasone (Decadron) has been used effectively, especially in combination with a serotonin or dopamineblocking agent. Metoclopramide blocks D2 receptor sites and enhances gastric emptying. The newest drug is aprepitant (Emend), which targets the neurokinin 1 (NK-1) receptors and is available orally for prophylaxis of PONV.24, 25 Other measures to reduce nausea and vomiting are the administration of oxygen and analgesics, decreased stimulation and movement of the patient, adequate hydration, aromatherapy, and P6 acupoint stimulation with acupuncture or acupressure techniques.8, 25, 26 Nurses should work as a team with anesthesia providers to follow multidisciplinary guidelines to guide the care of postanesthesia patients.25, 27

36 | OR TODAY | DECEMBER 2018

Discharge Criteria from the Postanesthesia Care Unit The Joint Commission’s standards require patients to be discharged from the PACU by a licensed independent practitioner or according to rigorously applied criteria approved by the medical staff.3 An example of such criteria follows: A patent airway Adequate tidal volume, respiratory rate, and oxygen saturation with or without supplemental oxygenation Stable vital signs for an established time based on the procedure and anesthesia technique Alertness when stimulated (able to be aroused and capable of summoning help from the nursing staff) A tolerable level of pain, which is variable for each patient. Patients should not be discharged immediately after an initial dose of opioid Adequate return of motor and sensory function (patients who have received regional anesthesia with supplemental sedation) A numeric scoring system approved by the department of anesthesia may also be used to determine patient readiness for discharge from the PACU.6 The most common scoring system for the Phase 1 PACU patient in use presently is the Aldrete scoring system. Activity, respiration, circulation, consciousness, and oxygen saturation level are each scored from 1 to 2, with a total score of 8 to 10 as acceptable for PACU discharge. The postanesthesia caregiver should give a full report of the intraoperative course of events and postanesthesia phase to the nurse assuming care of the patient after discharge from the postanesthesia care unit, again allowing for an opportunity to ask and respond to questions.2 Patients may receive anesthesia

through a variety of techniques in the surgical suite. Regardless of the technique, they all require careful postoperative monitoring and assessment. With the advent of new technology and pharmacological adjuncts, morbidity associated with the administration of anesthesia has dropped dramatically. Postoperative monitoring and recovery of the patient are still times for careful assessment and skilled intervention. Effective collaboration between anesthesia and nursing services promotes quality patient care and positive surgical outcomes. EDITOR’S NOTE: Michael Kost, MS, CRNA, the original author of this educational activity, has not had the opportunity to influence the content of this version. OnCourse Learning guarantees this educational activity is free from bias. Lisa Hughes, MS-Ed, RN CCRN, is an associate professor at Arizona State University, a critical care nurse, and an education consultant for a large healthcare system in Phoenix. Her many years of consultative work span nearly all adult acute care areas, including perioperative, critical care, med/surg, endoscopy, and organ procurement. REFERENCES 1. American Society of PeriAnesthesia Nurses. Perianesthesia Nursing Standards and Practice Recommendations 2012-2014. Cherry Hill, NJ: ASPAN; 2012. 2. Schick L. Assessment and monitoring of the perianesthesia patient. In: Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders Elsevier; 2013:352-380. 3. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: The Joint Commission; 2013. WWW.ORTODAY.COM

4. Camacho G, Agudana R, Han L. Improving RN satisfaction of hand-off report from anesthesia to PACU RN. J Perianesth Nurs. 2016;31(4):e4. doi: 10.1016/j.jopan.2016.04.013.

12. Giuliano K, Hendricks J. Inadvertent perioperative hypothermia: current nursing knowledge. AORN J. 2017;105(5):453-463. doi:10.1016/j. aorn.2017.03.003.

5. Standards for nurse anesthesia practice. American Association of Nurse Anesthetists Web site. http://www.aana. com/resources2/professionalpractice/ Pages/Standards-for-Nurse-AnesthesiaPractice.aspx. Updated January 2013. Accessed August 9, 2017.

13. Hooper V. Thermoregulation issues. In: Stannard D, Krenzischek DA, eds. PeriAnesthesia Nursing Care: A Bedside Guide for Safe Recovery. Sudbury, MA: Jones & Bartlett; 2012:55-60.

6. Odom-Forren J. Postoperative patient care and pain management. In: Rothrock JC. Alexander’s Care of the Patient in Surgery. 15th ed. St Louis, MO: Mosby; 2015:270-293. 7. Sanders RD, Pandharipande PP, Davidson AJ, Ma D, Maze M. Anticipating and managing postoperative delirium and cognitive decline in adults. BMJ. 2011;343:d4331. doi: 10.1136/bmj.d4331. 8. O’Brien D. Postanesthesia care complications. In: Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders Elsevier; 2013:394-414. 9. Radtke FM, Franck M, Hagemann L, Seeling M, Wernecke KD, Spies CD. Risk factors for inadequate emergence after anesthesia: emergence delirium and hypoactive emergence. Minerva Anesthesiol. 2010;76(6):394-403. 10. Schick L. Perianesthesia complications. In: Schick L Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure Phase I and Phase II PACU Nursing. 3rd ed. St. Louis, MO: Saunders Elsevier; 2016:571-596. 11. Hooper VD. Care of the patient with thermal imbalance. In: Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders Elsevier; 2013:740-750. WWW.ORTODAY.COM

14. Venes D, Taber CW, eds. Tabor’s Cyclopedic Medical Dictionary. 22nd ed. Philadelphia, PA: FA Davis; 2013. 15. Drain CB. Inhalation agents. In: Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders Elsevier; 2013:253-264. 16. Moos DD. Regional anesthesia. In: Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders Elsevier; 2013:325-341. 17. Drain CB. Opioid intravenous anesthetics. In: Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders Elsevier; 2013:278-290. 18. Nagelhout JJ. Intravenous induction agents. In: Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St Louis, MO: Saunders Elsevier; 2014:104-124. 19. Drain CB. Neuromuscular blocking agents. In: Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders Elsevier; 2013:291-310. 20. Nagelhout JJ. Neuromuscular blocking agents, reversal agents, and their monitoring. In: Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St Louis, MO: Saunders Elsevier; 2014;158-185.

21. O’Brien D. Patient education and care of the perianesthesia patient. In: Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders Elsevier; 2013:381-393. 22. McEwen D. Otorhinolaryngological care. In: Schick L, Windle PE, eds. PeriAnesthesia Nursing Core Curriculum: Preprocedure Phase I and Phase II PACU Nursing. 3rd ed. St. Louis, MO: Saunders; 2016:1155-1187. 23. Robinson M, Davidson A. Aspiration under anesthesia: risk assessment and decision-making. Contin Educ Anesth Crit Care Pain. 2014.14(4):171-175. doi: 10.1093/bjaceaccp/mkt053. 24. Golembiewski J, Tokumaru S. Pharmacological prophylaxis and management of adult postoperative/ postdischarge nausea and vomiting. J Perianesth Nurs. 2006;21(6):385-397. 25. American Society of PeriAnesthesia Nurses PONV/PDNV Strategic Work Team. ASPAN’s evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. J Perianesth Nurs. 2006;21(4):230-250. doi: 10.1016/j.jopan.2006.06.003. 26. Jokin, J, Smith A, Roewer N, Eberhert L, Kranke P. Management of postoperative nausea and vomiting: how to deal with refractory PONV. Anesthesiol Clin. 2012;30(3):481-493. doi: 10.1016/j. anclin.2012.07.003. 27. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2014;118:85-113. doi: 10.1213/ANE.0000000000000002.

DECEMBER 2018 | OR TODAY |

CE115-60

IN THE OR

continuing education

How to Earn Continuing Education Credit

Clinical VignettE For CE115-60 Susan Kendall, age 35, arrived in the PACU with her anesthesia provider and OR nurse at 10 a.m. after a laparoscopic cholecystectomy under general anesthesia. You received a report that included anesthetic agents and all other pertinent information. When you turned to ask a question about the patient, the anesthesia provider and OR nurse had already quickly returned to the OR for the next case. Susan’s vital signs were 180/90, HR 100, RR 24, and an admission temperature of 95.9 F (35.5 C). Her pain level on admission is 9/10. After giving Susan 2.5 mg of morphine IV for pain, her vitals are BP 150/78, HR 88, RR 16. However, as soon as the medication is given, she is nauseated and vomiting. n appropriate patient handoff occurred during 1 A this patient transfer from the OR to the PACU.

a. True

b. False

usan’s hypertension may be due to: 2 S a. Sleeping

c. Full bladder

b. History of hypotension

d. Bleeding

hat is the appropriate response to 3 W Susan’s admission temperature?

a. N othing. Her temperature is within normal range.

c. Give meperidine to increase her temperature

b. Apply a warm blanket

d. Apply a forced warmair device, such as a Bair Hugger

hat four risk factors would cause Susan 4 W to have an 80% chance of PONV?

a. F emale, smoker, use of opioids, and history of motion sickness b. Female, hypertension, use of opioids, and history of PONV

c. Female, nonsmoker, use of opioids, and history of motion sickness d. Patient’s age, female, history of motion sickness, and hypertension

1. Answer: B. The nurse did not have time to ask questions with a response from the anesthesia provider or OR nurse. 2. Answer: C. Urine retention due to anesthesia can lead to hypertension. 3. Answer: D. While applying a warm blanket may increase comfort, the most appropriate response for a temperature below normal is an active method of warming. Meperidine is appropriate to decrease shivering only, not to increase the patient’s temperature. 4. Answer: C. If a patient is female, is a nonsmoker, has been administered perioperative opioids, and has a history of motion sickness or previous PONV, studies indicate the patient would have an 80% chance of PONV, if not treated prophylactically.

38 | OR TODAY | DECEMBER 2018

1. Read the Continuing Education article. 2. Go online to ce.nurse.com to take the test for $12. 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 https://www.nurse.com/ sign-up for $49.95 per year.

Deadline Courses must be completed by 8/30/2019 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 evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.

Accredited In support of improving patient care, OnCourse Learning is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider #50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider #CEP16588.

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Questions

Nurse.com/CE You can take this test online or select from the list of courses available. Prices subject to change.

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

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Keeping

Up With

TECHNOLOGY

IN THE OR By Don Sadler

Technology changes at such a rapid pace that it can be hard to keep up with the latest developments. This is especially true when it comes to healthcare technology in general – and perioperative technology specifically. A wide range of new technologies are changing how many perioperative procedures are performed. Often, the results are improved surgical outcomes and higher levels of patient satisfaction. But these new technologies present many challenges for OR nurses and other personnel. “As the health care environment and the technology toolbox evolve, OR nurses will need to evolve with them and maintain both their team and patient relationships,” says J. Scot Mackeil, CBET, senior anesthesia BMET.

An Up-close View As a biomed, Mackeil has an up-close view of many cutting-edge technologies that are being implemented in ORs today. He says he’s especially excited about surgical systems and video technology used in conjunction with 3D surgical navigation systems in integrated video surgical rooms.

42 | OR TODAY | DECEMBER 2018

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“The ability to see clearly inside the body with 4K HD video surgical systems is far better than the first generation composite video systems and 480p TV monitors I was involved with during my first year of biomed practice in 1991,” Mackeil says. “When you couple the improved resolution of HD video with 3D navigation, refinements and innovations of surgical instruments, and today’s surgical techniques, the changes since 1991 are amazing,” he adds. 3D printing is another technology that Mackeil believes has tremendous potential. “3D printing has allowed my biomed department to prototype and deploy some innovative holders, brackets and positioning devices for medical equipment, as well as fabricate an occasional replacement part that was not available from conventional sources,” he says. Mackeil believes we may witness a time when 3D metal printers and scanners plan, construct and print surgical implants in real time to aid in plastic and orthopedic surgeries. “We might also see biomaterial printers producing patient-specific implantables,” he adds.

Hybrid Imaging Technology Danielle C. McGeary, MS, BME, CHTM, PMP, vice president, Healthcare Technology Management with AAMI, points to the use of hybrid imaging technology as one of the biggest technological advances currently impacting ORs. “In a hybrid OR, advanced imaging equipment is combined with cutting-edge surgery, which enables more complex surgeries to be performed,” says McGeary. “This allows perioperative teams to preform technologically advanced procedures with fewer incisions, which results in faster patient recovery times and reduced health care costs.” WWW.ORTODAY.COM

“ The current robotics extend the surgeon and his tools to places where conventional instruments and human hands just cannot go.” James Piepenbrink, BSBME, deputy executive director with the AAMI Foundation, echoes McGeary’s enthusiasm about hybrid ORs. “One example of a hybrid OR is converting a traditional cardiac catheterization system into a cardiothoracic operating system all in a single OR suite,” he says. “The benefit of this is that a single room can now meet two functions,” Piepenbrink adds. “It also eliminates the transport time from the catheterization lab to the OR and the inherent risks associated with that.” Piepenbrink also points to the use of so-called “smart ORs” by hospitals to perform minimally invasive surgeries. “Traditionally, separate devices are brought into the OR environment, such as electrosurgical units, insufflators, printers and recorders,” he says. “But this results in a very crowded space and also introduces potential safety hazards.” According to Piepenbrink, smart OR suites have booms where these disparate devices are housed and connected to a centralized control system. “Features and functions of the systems can be controlled to achieve specific requirements of the procedure,” he says.

Surgical Robotics and AI No discussion of OR technology would be complete without men-

tioning surgical robotics and artificial intelligence (AI). “Surgical robots are an evolving tool in the surgical toolbox,” says Mackeil. “The current robotics extend the surgeon and his tools to places where conventional instruments and human hands just cannot go.” According to Mackeil, the first generation of surgical robots can augment and assist perioperative personnel by holding and guiding cameras or positioning and guiding surgical tools in conjunction with surgical navigation systems. “But I hope to see the next generation of surgical robots evolve considerably beyond this in the near future,” he says. “For example, I expect to see multi-functional robotic arms mounted to the light column to position cameras and retractors, and maybe even pick up and deliver instruments and supplies from a preloaded sterile cassette with voice commands,” Mackeil adds. Meanwhile, Mackeil believes that achieving the scale of AI that will be necessary for health care applications will require tremendous computational power and the IT infrastructure necessary to support it. “The computer power needed for this is now on the horizon and the medical software engineers who can create the matrix are out there,” he says. “In the short term, I would hope that AI will be able to help DECEMBER 2018 | OR TODAY |

Keeping Up With TECHNOLOGY IN THE OR

Michael Blaivas,

MD, MBA, FACEP, FAIUM, chief medical officer for EchoNous

J. Scot Mackeil,

CBET, senior anesthesia BMET

improve scheduling and resource coordination and help make hospital HIS systems more user-friendly.” Michael Blaivas, MD, MBA, FACEP, FAIUM, chief medical officer for EchoNous, notes that AI algorithms are being used with ultrasound devices to do much of the work of calculating in the perioperative environment. “For example, AI combined with ultrasound can help nurses easily and non-invasively identify how much urine is in a bladder,” Blaivas says. Ultrasound guidance for challenging peripheral IV placement has taken what Blaivas says was once nearly a mythical artform and made it routinely easy to perform. “AI can help novice nurses identify correct structures and suggest the best approach and even catheter and needle size,” he says. According to Blaivas, acute and dramatic patient changes in perioperative settings can be difficult to assess. “AI-driven ultrasound applications can help even a near-novice OR nurse identify a pneumothorax causing hemodynamic instability or

44 | OR TODAY | DECEMBER 2018

oxygenation problems in seconds,” he says. “In the near future, automated cardiac assessment with AI-driven ultrasound tools will be able to rapidly help identify hypovolemia, depressed systolic function, pericardial effusions and other pathology which could cause rapid patient deterioration at the most critical times,” Blaivas adds.

Technology and Training McGeary points out that with new technology comes the need for training on the new equipment. “Since this is such a complex environment, it is essential that nurses, interventionalists, physicians and anesthesiologists all learn how to work seamlessly together in the perioperative environment,” she says. “OR nurses become very involved in the training and support of technology during procedures and help navigate the use of equipment so the surgical team can be efficient,” adds Piepenbrink. “This is a great example of how OR nurses are becoming more systems-focused

and have expanded their knowledge of technology.” Blaivas says that technology training associated with AI integration with ultrasound will be highly focused and limited. “Spending days at courses is simply not feasible given the pressures on staff time and resources,” says Blaivas. “Staff will be required to familiarize themselves with the product, how it works and some basics about ultrasound and anatomy.” Mackeil points out that technology itself does not improve patient outcomes. “It takes good doctors, nurses, technicians, clinicians and support staff all working together with a shared vision of using technology to support the mission of improving patient satisfaction and clinical outcomes,” he says. “It all comes down to one thing: the people who are working in the OR environment,” says Mackeil. “Technology only gives us tools we can use to enhance our efforts in support of our mission to care for patients.”

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SPOTLIGHT ON

Bill Muir BY MATT SKOUFALOS

In 2001, Bill Muir was playing in a rock band in Japan, teaching English and martial arts. He had been picked up by video game maker Square Enix to sing “Otherworld,” the opening song on the best-selling Final Fantasy X soundtrack. For a kid who started out in a Philadelphia suburb, he was about as far away from the home in which he’d grown up, doing things he’d never likely have predicted he’d be doing. And then a pair of planes flew into the World Trade Center in New York City, and everything was suddenly quite different. Muir remembers watching footage of the attack on a neighbor’s television, and deciding “right then and there that I was joining the military.” “I had been in Japan for eight years,” Muir recalled. “I was in a rock band, I was an English teacher, I was teaching martial arts; I’m not going to say my life wasn’t cool. But right after 9-11, it sounded like the apocalypse.” Muir had considered the idea of military service since college, but as a vegan, he didn’t want to enlist because soldiers are equipped with leather combat boots. After the September 11 attacks, that impulse felt “insignificant,” Muir said; plus, as a medic, he could “offset whatever karma” leather would incur, “and I would be able to help both sides.”

46 | OR TODAY | DECEMBER 2018

With aspirations of becoming an Army ranger, Muir made it into airborne infantry training before the selecting officers saw his vegan tattoo, “and lost their minds that I would be in the special forces.” (The official reason, he said, was that he was caught using his cellphone during a duty day, to let his girlfriend know he was going to jump out of a plane.) Instead, however, Muir was assigned to the 173rd Airborne, stationed in Italy, and deployed to Afghanistan. “It was what I went in to do,” he said. “I can’t say enough about how it worked out for me.” Muir was assigned as the Delta Battery First Platoon medic, and said he worked as much on Afghani locals as on U.S. soldiers, volunteering with a surgical unit at a local clinic. He recalled lots of amputation and gunshot injuries, and others from common hazards in the countryside. “We were often the only chance for them to get any medical care,” Muir said. “I don’t know how many babies I saw that fell into a cooking fire; mosquito-borne diseases. It’s a rough place to live, period, and there was so much good for people to do if they were inclined to do good.” Through it all, he kept to a vegan diet, “a weird layer to being in a warzone that most people who get deployed just don’t have,” Muir said. Through a website called Anysoldier. com, he received donations of vegan fare from supporters in America,

Canada and England. Sometimes he traded his rations with the Afghani locals for rice, beans or footbread. “A vegan in Afghanistan; that’s such a crazy concept,” Muir said. “So people helped me out. The locals, I might as well have told them that I was a Martian and I ate rainbows.” Muir has been vegan since 1992, when he gave up meat for lent, almost as an experiment. What would today be thought of as a healthy cleanse earned him remarks from friends like, “Nice knowing you.” He recalled surviving on “a lot of peanut-butter-and-jelly sandwiches and poorly made pasta,” but saw his health and mood improving, and stuck with it. “I said, ‘I’ve got to be going in the right direction if people are freaking out about it,’ ” Muir said. “The more you do it, the better it gets. I got stronger, healthier, ran some marathons, and at no point did I feel like I needed to eat animals to be strong or be healthy. It only reinforced my whole worldview that came from being straight-edge, which is to try to make the world a better place and keep my eyes open to all the other nonsense that society gives us.” “When I saw that joining the military would be a chance for me to make the world a better place, because of the climate of 9-11, I wasn’t worried about being in a position that it would compromise my ethics, because I knew were I stood, and I WWW.ORTODAY.COM

"A vegan in Afghanistan; that’s such a crazy concept. So people helped me out. The locals, I might as well have told them that I was a Martian and I ate rainbows. knew who I was,” he said. Because a meat-free lifestyle was already part of his experience, that discipline aided Muir during his discharge from service. The transition from military to civilian life can be emotionally taxing, and despite the support from his family, it was difficult for Muir, too. But he never felt the need to compromise with unhealthy behaviors. “Trying to reconcile the things you had to do, the way you acted to get through being deployed, that won’t help you back in the United States,” he said. “The same thinking that will help you identify targets and threats won’t help you build relationships.” “Luckily with my background as straight-edge, I did not get into the cycle of selfmedicating,” he said. “It wasn’t something that was even an option. I would go to the gym to work off frustration.” When his deployment ended, Muir went to culinary school, planning to open a vegan restaurant. After struggling to find the right location, he got swept up in the disaster recovery efforts around the 2010 Haitian earthquake, and joined a non-governmental organization called “For This One” as a nurse-EMT. “I bandaged a bunch of people up, handed out meds, and thought, ‘I really miss doing this,’ ” Muir said. That led to a stint in the Army reserves, a YouTube blog as “Sgt. Vegan,” and completion of his training as a registered nurse at the West Los Angeles VA Medical Center, where he works presently in the telemetry unit. “I feel like this job works primarily because as a veteran, I’m able to help other veterans,” Muir said. “I feel like I have that connection; I feel like there’s a point to me waking up and going to work.” “Being in nursing, I feel like every day, almost everything we do has meaning to it,” Muir said. “Being able to advocate for the patients when they’re having a super-rough go of it, I think it makes all the difference in the world.”

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DECEMBER 2018 | OR TODAY |

OUT OF THE OR fitness

Beginning a Workout at Any Age or Skill Level by Brandpoint ur bodies crave exercise at all ages, whether that means daily walks, fitness classes or a night of dancing. Although physical fitness may look different at age 65 than it did at 20, being active on a regular basis is still important to maintaining health and wellbeing.

Exercise helps establish better balance and flexibility and reduces falls. It improves sleep patterns and boosts mood. But it can be difficult to adapt our fitness routines or start new ones as our bodies change with age. An overview at www.cdc.gov outlines weekly goals for amount and types of exercise for people over 65. Below are five exercises that can be modified for different skill levels and range of motion and can be done almost anywhere, anytime. If you prefer working out in a gym environment, some health plans, including UnitedHealthcare, offer gym memberships at no additional cost. Talk with your doctor about healthy ways to incorporate fitness into your routine. For individuals

48 | OR TODAY | DECEMBER 2018

recovering from an injury, consider seeking advice from a physical therapist who may identify areas requiring special focus. Here are some exercises that can be helpful.

Squats: A familiar movement, bending and lifting to pick up a grandchild or a bag of groceries requires training to help avoid back injury. Fine-tune your form by trying this move that can build muscle strength in the glutes, abdomen and leg muscles. Begin by standing in front of a chair. With your weight in your heels and big toes, slightly drive your knees out, squeeze your glutes and lower yourself to the chair. To come up, lean forward slightly and push your knees out again. Repeat. If you’re able, try the move without the chair.

Push-ups: Drop and give us two, or 10 or 12. No matter how many push-ups you can muster, making time for this all-star exercise offers a high return on investment – building strength, balance and stability. For beginners, push-ups can be done against a tall counter, rather than all the way down to the floor. Stand with your palms on a counter and feet flat on the floor.

Keeping your elbows tight to your side, lower your upper body slowly until it taps the counter. Hold the position for one second, come up and repeat. As you get stronger, you can progress to lower counters or tables until you’ve made it to the floor.

Single-leg balance drill: Boost your stability and balance by including this exercise into your at-home workout rotation. It can even be done while brushing teeth or washing dishes. Start by removing your shoes so your foot muscles can feel the floor. Stand with your feet flat on the floor, then shift your weight to your left leg and slowly bend your right knee, aiming to get your thigh parallel to the floor. Hold for five to 10 seconds, depending on your strength and stability, then, return that foot to the floor. Repeat this motion 10 times on the same leg, before switching to the opposite side. To increase difficulty, add some weight to one hand and transfer it from hand to hand while balancing. And don’t worry – a little wobble means you’re making those muscles work!

Planks: Side, center, forearm or – you guessed it – all of the above! Planking is a great way to engage your abdominals while strengthening and lengthWWW.ORTODAY.COM

OUT OF THE OR fitness

ening spine, back and shoulder muscles. Begin on all fours, with your hands under or slightly behind your shoulders. Extend your legs straight behind you and come up onto your toes. Keep your eyes focused downward, pull your belly button toward your spine and lower your midsection so your body forms a straight line. Beginners can drop their knees to the floor. Engage your core and hold the pose for 10 to 15 seconds. For side planks, start lying on your side, with knees stacked one on top of the other and bent so your heels are behind you. Rise up onto one elbow, stacked under your shoulder, with your palm spread. Squeeze your glutes and lift your hip. Look forward and raise your top hand to the ceiling.

is time-tested, has few age or ability barriers and offers benefits ranging from increasing flexibility to reducing falls. Two good starting positions are downward dog and warrior one. For downward dog, start the same way you start a plank but push your backside to the ceiling rather than toward the floor, so your legs are straight and your torso is straight. Keep your heels down and head relaxed. The more flexible you are, the closer together you can keep your feet. From downward dog, raise one leg and step it forward and place it between your hands. Walk your hands back, lower your back heel and slowly rise up. Bend your front knee and raise your hands above your head. You are now in warrior one.

Yoga: If you haven’t already, it’s time to give yoga a go.

NOTE: Consult your doctor prior to beginning an exercise program or making changes to your lifestyle or health care routine.

This holistic practice blending exercise and mindfulness

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DECEMBER 2018 | OR TODAY |

OUT OF THE OR health

Yes, You Can Buy Happiness! By Marilynn Preston mericans are known around the world for eating too much, but when it comes to time, we are starving ourselves. It’s called “time famine” – an unpleasant, uncomfortable feeling that we have too much to do in too little time. Social scientists have been studying it for more than 20 years.

“I’m behind before I get up!” my mother-in-law used to say. Sound familiar? It’s that existentially endless to-do list that keeps us feeling rushed, hassled, busy-busy-busy, the opposite of all is well. Sadly, I don’t have the time necessary to explain all the reasons why “time famine” is overwhelming so many of us and why “time affluence,” the blissful sense of having plenty of time, is so elusive. But you can bet your favorite digital device that it has everything to do with the crush of modern technology and what sociologist Simon Gottschalk calls “the oppression of speed.” “Unchecked acceleration has consequences,” writes Gottschalk, a sociology professor at the University of Las Vegas. “It disturbs our leisure time, our family time – even our

50 | OR TODAY | DECEMBER 2018

consciousness.” Ashley Whillans, an assistant professor at Harvard Business School, and Elizabeth Dunn, a psychology professor at the University of British Columbia, have done some eye-opening research about how we value our time versus our money and how those attitudes affect our well-being. Whillans and Dunn divide the world into Taylors and Morgans. You’re a Taylor if you value your time over your money, and you’re a Morgan if you value your money over your time. Their research shows that people are pretty much split between the two. But here’s the takeaway: It’s the Taylors of the world, the people who consciously make time in their days to take a walk, play the guitar, call a loved one, tend their garden, volunteer or meet a friend for coffee, who report a much higher level of happiness in their lives. Hmm ... In one of Whillans and Dunn’s studies, participants were given $40 and told they had to spend it on something that would save them time. Some used the money to pay someone to clean the house, order

in food or hire a kid to mow the lawn. Later, the same participants were given another $40 but now they had to spend it on something material: a T-shirt, new shoes, whatever. Guess which experience brought them more happiness? Bingo! Now hear this, especially if time famine is eating you alive: People who prioritize their time over their money experience greater happiness and life satisfaction. And the happiness they feel is directly associated with alleviating time pressure. So what can you do to maximize your happiness and minimize your stress? I think you’re going to love this first answer ...

Chose To Do Nothing. “Doing nothing – or just being – is as important to human well-being as doing something,” says Gottschalk in a recent article called “In Praise of Doing Nothing.” The problem is that “in a hypermodern society propelled by the twin engines of acceleration and excess, doing nothing is equated with waste, laziness and lack of ambition.” Don’t fall for it. “Albert Einstein WWW.ORTODAY.COM

NO MORE

WHEEL obstructions was well-known for staring for hours into space in his office. ... spending time in simple reflection and contemplation are essential to health, sanity and personal growth.”

Buy Time. Yes, if you work fewer hours and spend more hours at play, engaged in what you love doing – riding your bike, taking your kids to a park – you may earn a little less money, but you’ll gain greater happiness. To enhance your well-being, consider paying (or bartering with) other people to do certain tasks. (In my family, we call that “closing the gap.”) The trick is to use your recaptured time to have experiences that spark joy and enhance relationships. Paying someone to clean your house while you stay inside, working at the computer, checking email, scrolling through Facebook, is not what we’re talking about, OK?

Choose To Decelerate. Our lives are too busy, and we are moving too quickly. Take your foot off the pedal, says Gottschalk, “by simply turning off all the technological devices that connect us to the Internet – at least for a while – and assess what happens when we do.” Fabulous advice ... but there’s nothing simple about it. – Marilynn Preston is the author of “Energy Express,” America’s longestrunning healthy lifestyle column. For more, visit www.MarilynnPreston.com.

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DECEMBER 2018 | OR TODAY |

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OUT OF THE OR nutrition

Compounds May Explain Whole Grain Health Benefits By University of Eastern Finland cientists have discovered new compounds that may explain whole grain health benefits, reports a new study led by the University of Eastern Finland. A high intake of whole grains increased the levels of betaine compounds in the body which, in turn, was associated with improved glucose metabolism, among other things. The findings shed new light on the cell level effects of a whole grain-rich diet, and can help in the development of increasingly healthy food products.

“Whole grains are one of the healthiest foods there is. For instance, we know that a high intake of whole grains protects against type 2 diabetes and cardiovascular diseases. Up until now, however, we haven’t understood the cellular mechanisms through which a whole grain-rich diet impacts our body,” says Dr. Kati Hanhineva, principal investigator of the study at the University of Eastern Finland. Using metabolomics analysis, Hanhineva’s research group investigated the effects of a whole grain-rich diet on the body’s metabolites. The effects were

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studied in mice fed with bran-rich fodder, and in humans following a diet rich in whole grain products over the course of 12 weeks. A whole grain-rich diet increased the levels of betaine compounds in mice and humans. “This is the first time many of these betaine compounds were observed in the human body in the first place,” Hanhineva says. At the end of the 12-week follow-up, the researchers also observed a correlation between improved glucose metabolism and increased presence of betaine compounds in the body. “Pipecolic acid betaine, for example, is particularly interesting. Increased levels of pipecolic acid betaine after the consumption of whole grains was, among other things, associated with lower post-meal glucose levels,” Hanhineva says. The new compound worked similarly to a heart drug in cell level experiments. One of the betaine compounds discovered by the researchers is 5-aminovaleric acid betaine (5-AVAB) which seems to cumulate in metabolically active tissues, such as the heart. With this observation in mind, the researchers set out to further test its effects in a cell model. “We observed that 5-AVAB reduces cardiomyocytes’ use of fatty acids as a

source of energy by inhibiting the function of a certain cell membrane protein,” Researcher Olli Kärkkäinen from the University of Eastern Finland says. “This cell level effect is similar to that of certain drugs used for cardiovascular diseases. However, it is important to keep in mind that we haven’t proceeded beyond cell level experiments yet. We need further research in animals and humans to verify that 5-AVAB really can impact the function of our body,” Hanhineva says. However, the discovery of the new compounds associated with whole grains significantly enhances our understanding of why whole grain products are good for our health. “In the future, we seek to analyze in greater detail the multitude of effects these new compounds can have on the human body, and we will also look into how intestinal microbes possibly contribute to the formation of these compounds,” Hanhineva continues. The findings were reported in Scientific Reports and The American Journal of Clinical Nutrition. The study was funded by, e.g., the Academy of Finland, Business Finland and Biocenter Finland.

DECEMBER 2018 | OR TODAY |

OUT OF THE OR recipe

Circa 1886 Grits

Recipe

INGREDIENTS: • • • • • • •

1 cup grits 1 cup heavy cream 1 cup chicken stock 1 cup water 2 teaspoons Worcestershire 1 teaspoon Tabasco 8 ounces shredded sharp white cheddar • Salt and pepper, if necessary • 4 ounces mascarpone cheese

the

54 | OR TODAY | DECEMBER 2018

Diane Rossen Worthington is an authority on new American cooking. She is the author of 18 cookbooks, including “Seriously Simple Parties,” and a James Beard Awardwinning radio show host. You can contact her at www.seriouslysimple.com.

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OUT OF THE OR recipe

What’s Cooking in Charleston? Grits! rowing up in California, I knew very little about Southern food. So when an opportunity presented itself as a birthday trip to Charleston, South Carolina, I jumped on it. On my first night, I visited Zero Restaurant + Bar located in Charleston’s historic area. Attached to a boutique hotel, it’s a culinary gem. Elegant, quaint, individual dining rooms with charming decor envelop guests in cozy comfort, but I really knew we hit a winner when our first bite was a Jerusalem artichoke, scooped out and deep-fried with a delectable lemon-yogurt filling. Diners at Zero can pick from the tasting menu or order a la carte. I recommend that you plan far ahead for any special occasion you can come up with for a truly memorable experience. You can also sign up for a cooking class. I also couldn’t wait to try Rodney Scott’s BBQ: a small, modern restaurant that even has a drive-thru if you are in a hurry. I had the opportunity to chat with Scott and was charmed by his Southern graciousness. I tried almost every single dish he had to offer and thought this must be what Southern heaven looks like! His two barbecue sauces, made with differ-

ent types of vinegar, are epic. They accompany main course dishes such as pit cook barbecued chicken, a steak sandwich and spare ribs. The sides were every bit as good as the mains and included hush puppies, potato salad and mac and cheese, to name a few. You also do not want to miss the one and only dessert: Ella’s Banana Puddin’! The last stop I’m taking you on this culinary tour is the beautifully restored Wentworth Mansion, where breakfast is included in your stay. Each morning featured an elegant selection of Southern breakfast dishes: frittatas, pancakes and grits. The server at the mansion’s Circa 1886 dining room said I had to try the grits, so I did. I always thought grits would be kind of bland and boring. Needless to say, I was very wrong. Picture a creamy, savory, warm bowl of comfort. That’s what it was. I will never think of grits any other way again. Make sure to look for fresh grits and keep them refrigerated for the best flavor. I used Anson Mills white grits for the following recipe. I have worked on the chef’s recipe, and this is perfect for the home cook. It is actually Seriously Simple.

Circa 1886 Grits Serves 4 1.

Place the cream, stock, water, Worcestershire and Tabasco in a heavy bottom pot. Bring to a boil, and add the grits. 2. Reduce heat to medium. Stir constantly for the first 3 minutes, and then reduce heat to low; continue to cook until the grits are soft, stirring every so often to keep the bottom from burning, about 45 minutes. 3. Once the grits are soft add the shredded cheddar cheese, and stir until melted. Season with salt and pepper, and fold in the mascarpone cheese last. 4. Spoon into shallow serving bowls, or serve as a side with eggs or any simple main course.

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DECEMBER 2018 | OR TODAY |

OUT OF THE OR pinboard

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Inglewood, CA Pictured from left to right are Vincent Llamzon, Technician; Karely Deal, RN, center director; Tamara Uyehar, RN; Gerry Lopez, Technician; and Teri Chavez, receptionist.

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The News and Photos

that Caught Our Eye This Month Power of Vitamin D levels linked to lower cholesterol in children

OUT OF THE OR pinboard

Endocrinology and Metabolism.

Vitamin D is known to be essential for bone metabolism, and low serum 25(OH) D levels increase the risk of rickets, osteomalacia and osteopenia. Vitamin D may also improve plasma lipid levels and have beneficial impact on other risk facThere is a link between higher serum vita- tors of cardiovascular diseases. However, min D levels and lower plasma cholesterol evidence on these other health effects of vitamin D is still scarce and partially levels in primary school children, new conflicting, and therefore not a sufficient research from the University of Eastern basis for giving recommendations. Finland shows. Children whose serum 25-hydroxyvitamin D levels exceeded Lifestyle factors, such as healthy diet, 80 nmol/l had lower plasma total and physical activity, and spending time low-density lipoprotein (LDL) cholesoutdoors leading to the production of terol levels than children whose serum vitamin D in the skin, may be linked to 25-hydroxyvitamin D levels were below both higher serum vitamin D levels and 50 nmol/l, which is often regarded as a threshold value for vitamin D sufficiency. lower plasma lipid levels. The researchers 25-hydroxyvitamin D is the major circulat- found that the link between higher serum vitamin D levels and lower plasma choing form of vitamin D. The findings were lesterol levels was independent of body reported in one of the leading journals adiposity, dietary factors, physical activity, of endocrinology, the Journal of Clinical

CONTINUE YOUR EDUCATION

parental education and day length prior to blood sampling. Moreover, hereditary factors that have previously been linked to serum vitamin D levels did not modify the observed association. More research is needed to uncover the reasons behind the inverse association of serum vitamin D with plasma lipid levels. The new findings provide support for the importance of following recommendations for vitamin D intake, which vary from country to country. The most important dietary sources of vitamin D are vitamin D fortified products such as dairy products, spreads and fish. In addition to the dietary intake, vitamin D supplement use is also recommended for the general population in several countries. For more information, visit www.panicstudy.fi. – University of Eastern Finland

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DECEMBER 2018 | OR TODAY |

INDEX

advertisers

Alphabetical 3M……………………………………………………………………… 24

Cygnus Medical…………………………………………………… 9

Pacific Medical……………………………………………………16

AIV Inc.…………………………………………………………………13

Healthmark Industries Company, Inc.…………… 4

Paragon Services……………………………………………… 29

Alco Sales Service, Co.…………………………………… 57

Innovative Medical Products………………………… 60

Parkdale Center for Professionals………………… 28

AORN………………………………………………………………… 39

Innovative Research Labs…………………………………51

Ruhof Corporation…………………………………………… 2,3

ASCA………………………………………………………………… 28

Jet Medical Electronics Inc…………………………… 52

TBJ Incorporated………………………………………………… 5

BD……………………………………………………………………… 45

MD Technologies inc.……………………………………… 49

TIDI……………………………………………………………… 6, 17, 19

C Change Surgical………………………………………………15

MedWrench……………………………………………………… 52

Case Medical, Inc.………………………………………………41

Mobile Instrument Service & Repair…………… 20

categorical ANESTHESIA

GENERAL

Jet Medical Electronics Inc…………………………… 52

Innovative Research Labs…………………………………51

AIV Inc.…………………………………………………………………13

Mobile Instrument Service & Repair…………… 20

Paragon Services……………………………………………… 29

HOSPITAL BEDS/PARTS

ASSOCIATION

Alco Sales Service, Co.…………………………………… 57

AORN………………………………………………………………… 39

INFECTION CONTROL

ASCA………………………………………………………………… 28

Pacific Medical……………………………………………………16

REPROCESSING STATIONS TBJ Incorporated………………………………………………… 5

Alco Sales Service, Co.…………………………………… 57

RESPIRATORY

CARDIAC PRODUCTS

Cygnus Medical…………………………………………………… 9

Innovative Research Labs…………………………………51

C Change Surgical………………………………………………15

Healthmark Industries Company, Inc.…………… 4

Jet Medical Electronics Inc…………………………… 52

Ruhof Corporation…………………………………………… 2,3

SAFETY

CARTS/CABINETS

TBJ Incorporated………………………………………………… 5

Alco Sales Service, Co.…………………………………… 57

TIDI……………………………………………………………… 6, 17, 19

Healthmark Industries Company, Inc.…………… 4 TIDI……………………………………………………………… 6, 17, 19

SINKS

Case Medical, Inc.………………………………………………41

INSTRUMENT STORAGE/TRANSPORT

Cygnus Medical…………………………………………………… 9

Case Medical, Inc.………………………………………………41

Healthmark Industries Company, Inc.…………… 4

Cygnus Medical…………………………………………………… 9

Innovative Research Labs…………………………………51

TIDI……………………………………………………………… 6, 17, 19

TBJ Incorporated………………………………………………… 5

INSTRUMENT TRACKING

CRITICAL CARE

Case Medical, Inc.………………………………………………41

Innovative Research Labs…………………………………51

MONITORS

CS/SPD

Pacific Medical……………………………………………………16

Case Medical, Inc.………………………………………………41

TBJ Incorporated………………………………………………… 5

ONLINE RESOURCE

SURGICAL

MD Technologies inc.……………………………………… 49

DISINFECTION

MedWrench……………………………………………………… 52

TBJ Incorporated………………………………………………… 5

SKIN PREPARATION BD……………………………………………………………………… 45

STERILIZATION 3M……………………………………………………………………… 24 Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4

MD Technologies inc.……………………………………… 49

OR TABLES/BOOMS/ACCESSORIES

TIDI……………………………………………………………… 6, 17, 19

Innovative Medical Products………………………… 60

SURGICAL INSTRUMENT/ACCESSORIES

OTHER

C Change Surgical………………………………………………15

AIV Inc.…………………………………………………………………13

Cygnus Medical…………………………………………………… 9

Parkdale Center for Professionals………………… 28

Healthmark Industries Company, Inc.…………… 4

PATIENT MONITORING

TELEMETRY

AIV Inc.…………………………………………………………………13

Jet Medical Electronics Inc…………………………… 52

Pacific Medical……………………………………………………16

TEMPERATURE MANAGEMENT

Mobile Instrument Service & Repair…………… 20

POSITIONING PRODUCTS

C Change Surgical………………………………………………15

Ruhof Corporation…………………………………………… 2,3

Cygnus Medical…………………………………………………… 9

WASTE MANAGEMENT

Case Medical, Inc.………………………………………………41 Cygnus Medical…………………………………………………… 9 Ruhof Corporation…………………………………………… 2,3

DISPOSABLES Alco Sales Service, Co.…………………………………… 57

ENDOSCOPY Cygnus Medical…………………………………………………… 9 Healthmark Industries Company, Inc.…………… 4 MD Technologies inc.……………………………………… 49

FALL PREVENTION Alco Sales Service, Co.…………………………………… 57

Innovative Medical Products………………………… 60

REPAIR SERVICES

MD Technologies inc.……………………………………… 49 TBJ Incorporated………………………………………………… 5

Cygnus Medical…………………………………………………… 9

58 | OR TODAY | DECEMBER 2018

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