The Use of Intraoperative Dexmedetomidine to Treat and Prevent Emergence Delirium in the Pediatric Population: A Systematic Review of Literature and Survey of Current Practice
Kari Kreger and Heidi Piszczek
Emergence delirium continues to be a ubiquitous complication experienced by up to 80% of pediatric patients receiving a general anesthetic. Although this phenomenon is self-limiting, it can negatively affect outcomes and challenges quality patient care. Traditional pharmacological adjuncts utilized to attenuate the effects of emergence delirium included midazolam, propofol, opioids such as fentanyl, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, ketamine, and clonidine. Many of these medications have fallen short of expectations, or the risks have outweighed the benefits with use. Dexmedetomidine (DEX), has challenged the conventional use of these agents by introducing a potentially safe and efficacious solution to emergence delirium by possessing sedative, anxiolytic, and opioid-sparing analgesic effects while preserving respiratory function and relative hemodynamic stability.
A systematic review of the literature was performed to determine if DEX could prevent and treat emergence delirium experienced in pediatrics following general anesthesia. All the studies observed in this project uniformly suggested that the use of intraoperative DEX can successfully attenuate and mitigate the occurrence of ED experienced after a general anesthetic in pediatric patients. Although not currently approved by the FDA for pediatric use, the literature indicates off-label doses of 0.3-0.5 mcg/kg IV administered before then cessation of surgery is effective at decreasing the incidence and severity of ED in pediatric patients.
Jacob Palmer and Matthew Merrill
Airway-related problems are common in the intraoperative period for the pediatric patient. The pediatric population is a unique group because of anatomical and physiological differences, equipment preparation, pre-operative assessment considerations, and positioning in comparison to the adult population. Other considerations for pediatric patients include: increased risk of laryngospasm and bronchospasm and a wide range of age differences within the pediatric population.
Neuromuscular Montoring & Reversal Agents: A Review of Literature & Survey for Evidence-Based Practice
Neuromuscular blocking (NMB) agents provide paralysis and play an important role in the management of surgical patients. When using a non-depolarizing NMB and paralysis is no longer required, the blockade must be reversed with a NMB reversal agent. The pharmacology of NMB agents and their reversals are well understood, however an alarming rate, upwards of 40-60% of residual paralysis remain after a reversal dose is given. Recurarization, or residual paralysis, can have lingering effects in the postoperative period and can be associated with postoperative adverse events increasing anesthesia morbidity and mortality. NMB reversal agents, along with neuromuscular monitoring, can be tools providers use to reduce the rate of postoperative recurarization.
Sugammadex, a new NMB reversal agent recently approved for use in the United States, has changed the landscape of NMB reversal. Traditional agents, such as neostigmine, have been the tried and true method of reversal prior to sugammadex, but have many side effects. This project analyzed the 2 methods of NMB reversal agents, comparing efficacy, safety, and current recommendations for their use. Sugammadex was found to be significantly faster in reversal times with fewer side effects than traditional agents. Sugammadex was also found to have less occurrences of recurarization than traditional agents.
This review also analyzed neuromuscular monitoring methods currently available to providers, and found recommendations for quantitative monitoring over qualitative monitoring. Greater accuracy with quantitative monitoring was noted when a train of four ratio of 0.9 or greater was achieved prior to reversal administration as compared to subjective assessments with qualitative monitoring having lesser accuracy, such as with a peripheral nerve stimulator.
The Administration of Balanced Crystalloid Infusion Solutions Versus 0.9% Sodium Chloride Crystalloid Infusion Solution for the Prevention of Acute Kidney Injury in Patients with Chronic Renal Disease
In every industry, and especially in health care, people need excellent systems to protect them from human imperfection. If health systems want safer care, they need better systemic processes for delivering care. Quality improvement projects are a method for changing the system in order to improve patient outcomes. (IHI) Traditionally, 0.9% sodium chloride infusion solution has been administered during the perioperative period to patients with chronic renal disease in order to avoid the complications associated with hyperkalemia. Recent research has suggested that, rather than avoiding complications, the administration of 0.9% sodium chloride to patients with chronic renal disease may lead to increased incidence of metabolic acidosis and acute kidney injury.
A systematic review was completed in order to determine whether the data support the use of balanced crystalloid infusion solutions, such as lactated Ringer’s, for perioperative fluid resuscitation and maintenance of euvolemia resulting in decreased incidence of acute kidney injury for patients with chronic renal disease. A search as conducted utilizing two databases, EBSCO Host, which is comprised of four separate databases, including Academic Search Premier, CINAHL Complete, MEDLINE, and Healthsource: Nursing Academic Edition, and the Cochrane Database of Systematic Reviews for reviews of literature, systematic reviews, meta-analysis, and review articles using relevant search criteria. Additionally, the bibliographies of relevant articles were searched. The search was limited to the previous 10 years.
Opioid Free Anesthesia Clinical Guide
Caleb Miller, David Hoang, and Eric Wright
Problem: The opioid epidemic is a serious national problem, causing the average deaths of 115 people every day.5 Reaching a solution must involve a coordinated effort from all fields in the medicine. Anesthesia can reduce or eliminate the use of opioids with well-established techniques, technologies and medications.
Purpose: The purpose of this Project was to identify ways that anesthesia can mitigate problems associated with the opioid epidemic by making opioid free anesthesia more commonly practiced. This was accomplished by the creation of a simplified, single-page clinical guide of opioid free anesthesia protocols in use. The guide included protocols in use, relevant physiology of pain, and populations who are at the greatest advantage for OFA.
Methods: Best practice guidelines and studies comparing OFA protocols with each other and contrasted with traditional anesthesia have not yet been completed. But those that are in practice have been included in the clinical guide.
Results: The laminated single page Clinical Guide to Opioid Free Education, included in chapter 5, was developed. The guide reviews the relevant physiology of OFA and populations best suited for maximal benefit of avoiding opioids. Included in the guide are six OFA protocols in use today, including recommended dosing and timing of anesthetic treatments. This guide will increase accessibility of OFA to a broader anesthesia community and potentially propel further studies into best OFA practice forward.
The Efficacy of Pectoral Nerve Blocks for Postoperative Pain Management Following Breast Surgery: A Systematic Review
Kayla Krueger, Hannah Riley, Samantha Train
Breast cancer rates in the United States continue to rise as it is currently the most common cancer among women affecting one in eight during their lifetime.1 A high majority of these patients will require surgery and up to 40 percent of them will experience severe postoperative pain.1 This is not only an acute challenge that patients and anesthesia providers face, but it can significantly impact the overall recovery and prognosis of the disease. Traditional methods of pain management may not adequately relieve severe pain following surgery and literature suggests opioids can influence tumor recurrence and metastasis. Regional anesthesia is consequently becoming an important factor in helping breast cancer surgery patients through the intraoperative, postoperative, and recovery stages. A new regional technique specific for these types of surgeries was introduced in 2011 and is called the pectoral nerve block. After eight years, this method is still not being implemented as a common modality for these patients. The following systematic review of the literature focused on nine articles that discussed definition of a pectoral nerve block, advantages and disadvantages of using it, results from completed studies, and reasons for lack of implementation. Current literature supports the usage of pectoral nerve blocks to decrease postoperative pain and opioid consumption, but it continues to need additional conclusive evidence before becoming a key treatment method for breast cancer surgery patients.
Comparing Perioperative Pain Control Efficacy of Single Shot and Continuous Adductor Canal Block
Total knee arthroplasty (TKA) is a profoundly painful procedure. Anesthesia professionals often help control pain for these patients by administering a peripheral nerve block. The femoral nerve block (FNB) had been the technique of choice; however, it was found to cause quadricep muscle weakness that delayed rehabilitation, recovery and increased the risk of falls. The adductor canal block (ACB) emerged as a peripheral nerve block treatment option that conferred pain relief without causing quadricep weakness. The femoral nerve block was found to deliver even better analgesia when given as a continuous infusion through a catheter. It was reasonable to postulate that an ACB would also give superior pain relief if it were administered as a continuous infusion instead of a one-time injection. Though both single ACB (SS-ACB) and continuous ACB (cACB) have been shown to reduce pain in patients receiving unilateral total knee arthroplasty, few studies have compared the techniques head to head. The purpose of this project was to conduct a rapid review of studies comparing the two techniques directly. Four databases were queried with specific search terms. Four randomized controlled trials directly comparing the two techniques were found. The four studies were appraised using a non-inferiority trial therapy worksheet. The findings indicate that the two techniques are equal in patient reported pain scores. Patients receiving the SS-ACB used the same or less analgesic equivalents of morphine during their hospital stay. The findings of this study indicate that the SS-ACB is non-inferior.