Abstracts for the papers scheduled to be presented at the 2015 Student Seminar

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1 Abstracts for the papers scheduled to be presented at the 2015 Student Seminar Does Levosimendan Reduce Morbidity and Mortality for Patients With Low Ejection Fraction Undergoing Cardiac Surgery? Michael D. Neumann, RN, BSN and Jeremy J. Brookins, RN, BSN Background: Levosimendan is an inodilator with three mechanisms of action: inotropy through calcium sensitization, vasodilation through opening ATP-gated potassium channels in vascular smooth muscle, and cardioprotection perhaps through ATP-gated potassium channels in mitochondria. Purpose: To test the hypothesis that levosimendan reduces morbidity and mortality for patients with low ejection fraction undergoing cardiac surgery. Methods: Meta-analysis querying Supersearch using the key terms levosimendan and cardiac surgery, for articles after Included studies were of adult human patients undergoing nonemergent open intrathoracic cardiac surgery with low EF (EF<50%). Results: Mortality was reduced among low EF patients who received levosimendan (21/455 [4.6%] in the levosimendan group vs 53/453 [11.7%] in the control group, odds ratio = 0.39 [ ], P < , with 908 patient included). Levosimendan administration decreased the incidence of renal failure, time on mechanical ventilation, serum lactate, and systemic vascular resistance index, while improving cardiac index. Conclusion: Levosimendan administration was associated with a significant reduction in mortality and morbidity in low EF patients undergoing cardiac surgery. There is a continued need for randomized controlled studies with large sample sizes that examine the effects of this medication on this population. Intravenous Local Anesthetic Administration for Treatment Following Lung Aspiration Jillian Pechacek RN, BSN and Jessica Wittenberg RN, BS Purpose: Aspiration events complicate the management of patients undergoing anesthesia. Clinical interventions, such as following NPO standards and performing rapid sequence induction, are utilized by anesthesia providers to limit the potential for aspiration. There are no immediate pharmacological interventions to treat aspiration when it does occur. This paper aims to determine if local anesthetics should be incorporated into treatment for aspiration to attenuate aspiration pneumonitis. Methods: A literature search was conducted using Google Scholar and SuperSearch databases. Nine experimental animal studies were selected from this search. Results: The components evaluated in the studies were edema, hemodynamics, lung function, inflammatory markers, and bronchial alveolar lavage analysis. Based on the animal studies, local anesthetics reduced edema, improved lung mechanics, and decreased leukocytes and albumin in bronchial alveolar lavage fluid. Conclusion: Local anesthetics have the potential to attenuate the immune response to lung injury when given before or after aspiration. However, there are too few current studies to draw reliable conclusions. Further studies should incorporate more comprehensive time intervals during testing and standardize the immune components measured.

2 Is Hydroxyethyl Starch Safe for Fluid Resuscitation in Trauma Patients? Boe T. Brink, RN, BSN and Tyson L. Flohr, RN, BS Background: Fluid resuscitation is a major factor in the treatment of trauma patients. This can be accomplished with fluids including isotonic crystalloids and colloidal solutions such as hetastarch (HES). HES solutions offer advantages over crystalloids but their safety in trauma patients has yet to be decided. Methods: We conducted a search using the Saint Mary s University Supersearch for studies which included adult trauma patients that used HES for resuscitation. Results were refined to include studies that measured mortality, coagulopathies, and the presence of renal injuries. Animal studies were excluded. Overall, 8 studies met the inclusion criteria. Results: In seven studies, mortality was reduced or unchanged with the use of HES. These results were statistically significant. Coagulopathies were present in patients that received HES, but there was no direct evidence that these changes caused increased bleeding. A conclusion of HES induced renal injuries could not be determined from the results. Conclusion: Although study results were inconsistent and had limitations, trends indicated that the use of HES solutions is safe in fluid resuscitation of trauma patients. Further research needs to be conducted on the safety of HES and should include a comparison of the various HES solutions to themselves and isotonic crystalloids. Can the Intraoperative Use of Regional Oximetry With Near-Infrared Spectroscopy Help Guide Initiation of Blood Transfusions? Erin Suntken, RN, BSN and Amy Tin, RN, BSN Cerebral oximetry with near-infrared spectroscopy (NIRS) is a noninvasive device used for the evaluation of cerebral blood flow and oxygenation. This systematic review was completed to determine if NIRS monitoring would be a useful adjunct to anesthesia monitoring, particularly in determining when to administer blood transfusions to maintain adequate tissue oxygenation and perfusion. This review of literature was conducted utilizing Google Scholar, PubMed, and SuperSearch evaluating articles published since 2002 in which NIRS was used to monitor surgical patients, critically ill patients, and patients participating in blood donation. Subjects included preterm infants to the elderly population. Data from these studies were analyzed, comparing cerebral oximetry values with traditional monitoring techniques to evaluate blood loss and tissue oxygenation. Of 13 studies reviewed, 12 supported NIRS as a useful monitor to detect blood loss by demonstrating a decrease in cerebral saturation with blood loss; one study showed no difference in cerebral oximetry values during blood loss or blood transfusion. The utilization of NIRS may allow for early recognition of cerebral oxygen desaturation with surgical blood loss. Additional studies with more participants are needed to further determine whether or not NIRS can be used as a transfusion trigger intraoperatively.

3 Is Surgical Infiltration of DepoFoam Bupivacaine More Effective Than Bupivacaine Hydrochloride in Decreasing Pain and Opioid Consumption During the Postoperative Period? Kemo Marong, RN, MAN and Robert L. Gonzalez, RN, BSN, CCRN The purpose of this literature review was to determine if a surgical injection of DepoFoam bupivacaine was more effective than bupivacaine hydrochloride in decreasing pain and opioid consumption during the postoperative period. Patient satisfaction with postsurgical pain management has been a clinical challenge for practitioners; up to 82% of patients continue to report postsurgical pain that is not acceptable. Bupivacaine is a commonly used local anesthetic for postoperative analgesia but it is limited by its short duration of action of up to 12 hours. DepoFoam bupivacaine is a new formulation with the potential to provide analgesia up to 96 hours. A literature search was performed using Saint Mary s Supersearch database, PubMed, and Google Scholar. The 6 studies reviewed found that patients who received DepoFoam bupivacaine had lower pain scores with activity and decreased opioid consumption when compared to bupivacaine. Data from the studies reviewed demonstrated that DepoFoam bupivacaine use was associated with less opioid-related adverse events when compared to bupivacaine, and is an effective adjunct to postoperative pain control at maximum dosage (266 mg). Effectiveness of Adductor Canal Blocks versus Femoral Nerve Blocks on Mobility and Pain Control For Total Knee Arthroplasty Robert Arno, RN, BSN, CCRN and Brent Chiapusio, RN, BSN, CCRN The femoral nerve block has long been used as an adjuvant treatment for postoperative pain control in patients undergoing total knee arthroplasty (TKA). The adductor canal block (ACB) is a newer approach that is currently being utilized as an alternative method of postoperative pain control. In order to determine the effectiveness of the ACB versus the FNB, a formal literature review was conducted utilizing Saint Mary s University of Minnesota s SuperSearch, OVID, MEDLINE, and ScienceDirect databases. A total of 8 peer-reviewed research studies were analyzed using postoperative pain scores, opioid consumption, ambulation, and muscle strength as primary outcomes. We found that the use of an ACB resulted in improved ambulation and preserved muscle strength. However, there were no statistically significant differences in opioid consumption and pain scores between the ACB and FNB. Research suggests that the ACB is an efficacious alternative to the FNB for pain management after TKA. In order to further compare the FNB and ACB, further research should be done using larger populations, multiple centers, and a standard anesthetic and surgical protocol. Evaluation of Pulse Pressure Variation and Stroke Volume Variation to Optimize Fluid Administration in Patients Undergoing Major Abdominal Surgery Jeremy L. Wilson, RN, BSN, CCRN and Fred Nyabicha, RN, BSN, CCRN Purpose: Stroke volume variation (SVV) and pulse pressure variation (PPV) are reliable predictors of fluid responsiveness, which can be used to guide fluid therapy in mechanically ventilated patients undergoing major abdominal surgeries. Excessive fluid administration may result in occult organ hypoperfusion or fluid overload in

4 compromised patients, thus increasing postoperative morbidity. The purpose of this literature review was to define and evaluate the efficacy of PPV and SVV in guiding fluid management. Outcomes evaluated were length of hospital stay, postoperative nausea and vomiting, return of gut function, fluid responsiveness, and overall morbidity. Method: Literature search using ScienceDirect and Google Scholar databases. Research from 2005 present was selected. Results: A SVV and PPV between 10%-13% intraoperatively was considered a reliable indicator of fluid responsiveness (P= ). The length of hospital stay for the intervention group was reduced by 3-5 days (P = ). Return of gut function was 1.66 days faster in the intervention group (P= ). Postoperative nausea and vomiting was reduced in the intervention group (P<0.05). Morbidity was also significantly reduced. Conclusions: Fluid optimization guided by dynamic indices during major abdominal surgery is associated with better intraoperative hemodynamic stability and lower incidence of postoperative organ complications. Localized Elastomeric Pain Pumps as Part of a Postoperative Management Strategy for Cardiothoracic Surgical Patients Rebekah Gramenz, RN, BSN, and Alexa Honstad, RN, BSN Adequate pain management is essential to the postoperative success of cardiothoracic surgery patients. Traditional pharmacological pain management methods for this patient population include systemic and neuraxial administration of analgesics. The purpose of this literature review was to determine if pain management improves with the utilization of a local anesthetic infused via an elastomeric pain pump in adjunct with intravenous narcotic administration when compared to traditional pain treatment protocols. Research was conducted by doing a literature review of current studies as well as an assessment of historical and background studies. Of the four studies reviewed, all found that the addition of a local anesthetic infusion via an elastomeric pump was helpful in reducing pain scores and decreasing narcotic administration in comparison with traditional practice. The effectiveness of elastomeric pumps has already been demonstrated in other surgical populations. Additional randomized control trials with large sample sizes are needed to help support the limited research applicable to cardiothoracic surgery. Recommended future research should focus on determining which local anesthetic concentration would be most effective for infusion via the elastomeric pump, as well as the influence of this pain management regimen on long-term pain. Does Perioperative Treatment With Dexamethasone Decrease Postoperative Pain in Pediatric Patients Undergoing Tonsillectomy? Michael P. Erickson, RN, BSN and Talon Johnson, RN, BSN The purpose of this synthesis paper was to assess the efficacy of dexamethasone on postoperative pain in pediatric patients who have undergone tonsillectomy, with or without, adenoidectomy. Postoperative pain after tonsillectomy in the pediatric population increases morbidity and mortality. Dexamethasone has properties that can decrease inflammation and pain post surgically by inhibiting 3 major inflammatory pathways including bradykinin, leukotrienes, and prostaglandins. A formal literature

5 review of Supersearch, Google Scholar, PubMed, and Medline databases yielded 11 articles meeting the inclusion/exclusion criteria. In particular, this review of literature points in favor for the efficacy of preoperative dexamethasone s role in decreasing time to discharge, time to oral intake, and total cumulative dose of analgesics. The most significant correlation to decreased postoperative pain in pediatric patients receiving a single preoperative dose of dexamethasone compared to placebo is time to oral intake. This finding was statistically significant (P<0.05) in six of the ten studies reviewed. This literature review also favors a single dose of preoperative dexamethasone between mg/kg to 1 mg/kg as a beneficial adjunct to help reduce postoperative pain in pediatric patients. Do Transversus Abdominis Plane Blocks Provide Adequate Postoperative Analgesia After Laparoscopic and Open Abdominal Surgical Procedures? Liliana Rascon, RN, BSN and Jennifer Malmberg, RN, BSN Purpose: Inadequate pain control can result in postoperative complications and prolonged hospital length of stay. New regional techniques are being used as an adjunct to opioids for postoperative pain control. The purpose of this literature review was to evaluate the effectiveness of transversus abdominis plane blocks (TAP) in providing adequate postoperative analgesia for patients undergoing abdominal surgery. Methods: A systematic review of the literature was conducted using the electronic databases Google Scholar and Saint Mary s University of Minnesota SuperSearch. Eleven studies were included in this literature review. Results: Seven studies found a decrease in total opioid consumption in patients receiving a TAP block. Seven of the eight studies found a decrease in postoperative pain scores. Only six studies evaluated postoperative nausea, vomiting, and sedation. Of these six studies, three studies found a decrease in the incidence of nausea and vomiting, and in the sedation level in patients receiving TAP blocks. Conclusion: TAP blocks were found to decrease postoperative opioid consumption by providing adequate pain control for patients undergoing open and laparoscopic abdominal procedures. There was no significant decrease in the incidence of opioid adverse effects such as nausea, vomiting, and sedation. Cancer Metastasis and Anesthetic Technique Daniel E. Fuller, RN, BSN and Justin Bartos, RN, BSN Background: Anesthetic techniques utilized during cancer cytoreductive surgical procedures may influence the development and progression of metastatic disease postoperatively. This review seeks to determine if nonvolatile techniques provide an advantage over general anesthesia on cancer recurrence and overall survival. Methods: Eight current research studies were reviewed to evaluate the influence of neuraxial anesthesia on cancer progression postoperatively. Four additional studies were evaluated to determine the effect of different anesthetic medications on immune function. Results: Three studies found an increase in postoperative survival time with the use of neuraxial anesthesia. However, two studies found no increase. Time to recurrence of cancer also varied. Two studies found an increase in time to recurrence; three studies found no increase. Three studies found that propofol suppressed the effect of

6 metalloproteinases on tumor spread. One study showed that thiopental, ketamine, and halothane suppressed natural killer cell activity but propofol did not. However, propofol caused a decrease in the number of natural killer cells. Conclusions: The methods and results of these studies were so varied that no definite conclusions can be drawn. Multicenter, randomized controlled trials with large sample sizes should focus on comparing general volatile anesthesia/opioid analgesia to neuraxial anesthesia with a propofol infusion. Dexamethasone as an Adjunct to Local Anesthetics for Brachial Plexus Block Danhua Liu, RN, BA and JoAnn Tran, RN, BSN, CCRN Single-injection brachial plexus nerve blocks (BPBs) are limited by the local anesthetic s (LA) pharmacological duration for a comfortable transition to oral analgesics after upper extremity surgery. The purpose of this literature review was to evaluate the effects of dexamethasone as an adjunct to LA for BPBs. Thirteen randomized controlled trials were selected after searching Saint Mary s University SuperSearch, PubMed, and Google Scholar databases. These trials were published within the last 12 years. The studies compared BPBs performed with LA alone to those performed with LA plus perineural dexamethasone. Twelve studies demonstrated a statistically significant prolonged duration of analgesia with perineural dexamethasone. Five studies found significantly prolonged duration of motor block. Four studies found faster onset of motor/sensory blockade. Seven studies found there was less postoperative pain at 3 hours, postoperative day 1, and postoperative day 2. Five studies found less postoperative analgesic consumption. Three studies found that patients were generally satisfied with the BPB, but they did not specify if they were with or without perineural dexamethasone. In conclusion, adding dexamethasone as an adjunct to LA for BPBs can help prolong duration of analgesia, duration of motor block, increase onset of motor and sensory block, and reduce postoperative pain. Do Single-Use Laryngoscope Blades Provide the Same Clinical Performance as Reusable Laryngoscope Blades During Patient Intubation? Keith M. Bull, RN, BSN and Gretchen Drangeid, RN, BSN Purpose: Several studies published show that modern sterilization techniques, including enzymatic washing and autoclave, are not effective at removing proteins from reusable laryngoscope blades, creating a vector for cross-contamination with prion-based infections. The objective of this literature review was to compare the clinical performance of reusable laryngoscope blades, metal disposable laryngoscope blades, and plastic laryngoscope blades. The blades were evaluated using outcomes including successful first-attempt intubations, incidence of difficult intubations, laryngeal view, ease of blade attachment to the handle, forces generated during laryngoscopy, time required for intubation, illumination, and clinical acceptability. Methods: Searches were performed using SuperSearch at Saint Mary s University of Minnesota Twin Cities library. Results: No significant difference was found between metal disposable and reusable blades in 4 studies. Metal disposable blades performed significantly better (P<.001) than

7 plastic blades in 3 studies. Plastic blades were inferior (P<.001) to metal reusable blades in 3 studies. Conclusion: Metal disposable laryngoscope blades eliminate the possibility of patient cross-contamination with prion-based infection and have been proven safe and effective when compared to reusable laryngoscope blades. Based on poor clinical performance, safety concerns, and product variability, the use of plastic laryngoscope blades cannot be recommended without further research. Is Sugammadex More Effective Than Neostigmine for Reversing Muscle Relaxation? Kyle Heffner, RN, BSN, and Adam Rogers, RN,BSN Purpose: A new class of neuromuscular blocking reversal agents, known as selective neuromuscular blocking binding agents, has been discovered and the first medication in this class is sugammadex. Initial findings have found sugammadex to have fewer adverse effects when compared to neostigmine administration for reversal of muscle relaxation. The purpose of this systematic literature review was to analyze available studies and present research-based conclusions. Methods: Eleven peer-reviewed articles were selected which compared time to extubation, return of spontaneous breathing, adverse effects, and overall outcomes related to reversal of neuromuscular blockade with sugammadex versus neostigmine. Results: Sugammadex was shown to have fewer adverse reactions than neostigmine. It was also demonstrated to be safer and more effective in reversing deep neuromuscular blockade than neostigmine. Sugammadex was also found to be effective in reversing residual neuromuscular blockade in an emergent recurarization scenario. Conclusion: Sugammadex was more effective at reversing muscle relaxation defined as less than four-of-four twitches on a train-of-four monitor induced by aminosteroid-based muscle relaxants. Future research must be conducted to determine the cost effectiveness of sugammadex.

8 Saint Mary s University of Minnesota Student Seminar The annual presentation of our student s thesis work. Is Surgical Infiltration of Depofoam Bupivacaine More Effective Than Bupivacaine Hydrochloride in Decreasing Pain and Opioid Consumption During the Postoperative Period? Robert Gonzalez Jr. RN, BSN, CCRN and Kemo Marong RN, MAN Do Single-Use Laryngoscope Blades Provide the Same Clinical Performance as Reusable Laryngoscope Blades for Patient Intubation? Gretchen Drangeid RN, BSN and Keith Maxwell Bull RN, BSN Do Transversus Abdominis Plane Blocks Provide Adequate Postoperative Analgesia After Laparoscopic and Open Abominal Surgery? Jennifer Malmberg RN, BSN, CCRN and Liliana Rascon, RN, BSN, CCRN Can the Intraoperative Use of Regional Oximetry With Near-Infrared Spectroscopy Help Guide Initiation of Blood Transfusions? Erin Suntken RN, BSN and Amy Tin, RN, BSN Evaluation of Pulse Pressure Variation and Stroke Volume Variation to Optimize Fluid Administration in Patients Undergoing Major Abdominal Surgery Jeremy L. Wilson RN, BSN, CCRN and Fred Nyabicha RN, BSN, CCRN Is Sugammadex More Effective Than Neostigmine/Glycopyrrolate for Reversing Muscle Relaxation? Kyle Heffner RN, BSN and Adam Rogers RN, BSN Does Levosimendan Reduce Morbidity and Mortality for Patients With Low Ejection Fraction Undergoing Cardiac Surgery? Michael D. Neumann, RN, BSN and Jeremy J. Brookins, RN, BSN Cancer Metastasis and Anesthetic Technique Justin Bartos, RN, BSN and Daniel Fuller RN, BSN Intravenous Local Anesthetic Administration for Treatment Following Lung Aspiration Jillian Pechacek RN, BSN and Jessica Wittenberg RN, BS Is Hydroxyethyl Starch Safe for Fluid Resuscitation in Trauma Patients? Boe T. Brink, RN, BSN and Tyson L. Flohr, BS Localized Elastomeric Pain Pumps as Part of a Postoperative Pain Management Strategy for Cardiothoracic Surgical Patients Alexa Honstad RN, BSN, CCRN and Rebekah Gramenz RN, BSN, CCRN Dexamethasone as an Adjunct to Local Anesthetics for Brachial Plexus Block JoAnn Tran, RN, BSN, CCRN and Danhua Liu, RN, BA Effectiveness of Adductor Canal Blocks versus Femoral Nerve Blocks on Mobility and Pain Control For Total Knee Arthroplasty Robert Arno, RN, BSN, CCRN and Brent Chiapusio, RN, BSN, CCRN Does Perioperative Treatment with Dexamethasone Decrease Postoperative Pain in Pediatric Patients Undergoing Tonsillectomy? Michael P. Erickson, RN, BSN and Talon Johnson, RN, BSN Saturday, May 16, Twin Cities Campus Saint Mary s University Center 2540 Park Avenue South Minneapolis, MN Cost $65.00 CRNA s $35.00 Students Application for 5 CEU credits is in process Continental Breakfast, Coffee, Tea, Soft Drinks and Lunch provided GRADUATE SCHOOL OF HEALTH AND HUMAN SERVICES [email protected] smumn.edu Volume 10, Number 3

9 STUDENT SEMINAR RESERVATION FORM NAME: ADDRESS: CITY / STATE / ZIP: AANA NUMBER: PLEASE MAKE CHECK OUT TO: GNA GRANT ACCOUNT 5309 Cost $65.00 CRNA s $35.00 Students Application for 5 CE credits is in process Please send application and registration fee to: Saint Mary s University of Minnesota Nurse Anesthesia Program 2500 Park Avenue Minneapolis, MN ATTN: Elise Riveness NEW LOCATION Twin Cities Campus *University Center 2540 Park Avenue Minneapolis, MN 55404