PACU

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Perioperative Pain Management: At first I was really interested in this article because we get patients with drug abuse history frequently. However as I read the article it more about CRNAs than PACU nurses. It wanted to see if using a simulation would help the CRNAs use more non-opioid analgesia. We unfortunately don't have too much of a choice of non-opioid medication to give other than toradol or tylenol. Overall it's an interesting article but it is more for patient in the OR vesus in the PACU. Kristen Warness

Malignant Hyperthermia Preparedness Training (Apr/May): This is an interesting article. I think using a cognitive aid tool would be useful for a MH situation. It would help us react faster and know what to do. I didn't fully understand why the researchers tested this by interviewing people before and after a simulation. I think it would have made more sense to have one group using the cognitive tool and the other just going off the old way of education and see how well each group did. I think it would be beneficial for us to use this cognitive tool for MH situations.

Purpose of Study: To address a gap in the perioperative delivery of pain management strategies for pts with opioid use disorder (OUD). The evaluations from this study will be used to develop perioperative competencies for training at hospitals Design of Study: The project consisted of 2 phases, The first phase was a 12 item questionnaire asking a group of CRNAs from Florida about their knowledge of OUD. The second phase was a piolot didactic and simulation based training program to improve knowledge, skill, and confidence in delivering OFA. Conclusion: There is a lack of knowledge and training of anesthesia providers on how to manage the growing population of pts with OUD. This program increased perceived ability to provide OFA care to pts with OUD presenting for surgery. Significance: In our PACU setting, pts with history of OUD are often viewed as drug seeking and this negative bias leads to decreased pain managment, decreased pt satisfaction and more complications.

"Care of Critically Ill Patients with Epidural Pain Management", JOPAN 36 (2021) 428-430 Purpose of Study: The authors in this study demonstrate that epidural pain management is highly effective in managing post operative pain relieft in pts undergoing abdominal surgeries. However, complications can arise in critically ill pts who are at risk for cardiac and pulmonary complications. It is up to the perianesthesia nurse to be able to recognize these symptoms through ongoing reassessments and knowledge of sensor and motor blockades along the dermatome pathway. Respiratory function is monitored closely for signs of depression which can lead to atelectasis and pneumonia. An in depth assessment includes LOC, sedation, SPO2, ETCO2, resp rate and depth. One of the toxic effects that can happen with epidurals is with local anesthetic via epidural can cause toxicity where the pt can have perioral numbness, seizures, agitation, drowsiness, slurred speech, confusion. Immediate intervention by the PACU nurse requires stopping the epidural and starting a lipid emulsion gtt. However, epidural management remains one of the most effective ways in managing pain relief in post surgical abdominal surgeries.

May 14, 2014 "Handover Patterns in the PACU: A Review of the Literature" JOPAN 36 (2021) 136-141 Purpose of the Study: There is no standardized handover report to convey critical health information to the PACU. This study was designed to identify the risk factors for poor pt handover report from OR to PACU as there is often missed important information not communicated effectively. Results of the Study: Eight studies were selected as relevant, ICUs was excluded from the study. Implications of the Study: The SBAR tool is an effective tool used to convey vital information in high risk/complex situations that was adopted by the US Navy and recommended by the WHO organization to be used in nursing. There were many handover tools identified in the study that have been developed for effective handover report. However, because PACU has a rapid turnover rate, the handoff should be simple and easy to remember without omitting pertinent pt information.

Intrathecal Morphine v ketamine - The purpose of this study was to examine any significant differences in postoperative pain in patients post hysterectomy after recieving either intrathecal morphine or ketamine intraop. Obviously, they did not only receive one of these medications; in addition each had sufentanil and bupivicaine. The only significant finding was 12 hours postop, the patients who received Ketamine reported their pain an average of 6/10 compared to the morphine group who rated an average of 4/10. The ketamine group recieved IV Tramadol in higher amounts for their breakthrough pain. Personally, I would rather have the Ketamine and receive IV Tramadol later because the morphine group reported higher incidents of pruritis. No, thank you to itching. / Darcie D.

The article regarding noninvasive Hgb monitoring discusses the usefulness of a pulse oximetry-type device in patients who are at risk for bleeding. The patients receiving noninvasive monitoring or point of care testing (such as iSTAT) were compared to those receiving invasive monitoring. The sample size was relatively small at only 88 patients over an 11-month period. The authors discuss the disadvantages of drawing blood to obtain a Hgb value such as contributing to anemia and delays in care unless using an iSTAT. It is suggested that noninvasive monitoring can provide early detection of hemorrhage in critically ill patients. A change in the standard of care is recommended by the researchers. In my practice, physicians called to the bedside to assess a critically ill patient suspected of hemorrhage or anemia have used the pulse oximeter to estimate Hgb. I would be interested to see the accuracy of this method as there are many urgent tasks that need to take place when a patient is thought or known to be bleeding. Early detection would be beneficial and allow nurses to intervene earlier.

Aroke et al. discuss the implications for patients on antidepressant medications recovering from anesthesia. The authors assert that the patient should not discontinue these medications abruptly and should be monitored for bleeding as the risk increases with chronic SSRI use. Additionally, there is a risk for development of Serotonin Syndrome with administration of fentanyl, tramadol, Demerol, and Zofran. TCAs may pose a risk to patients undergoing anesthesia in that they are more easily stimulated and need careful dosing of narcotics and anesthetic agents. MAOIs should never be administered with Ketamine or ephedrine because of the risk for hypertensive crisis. Lithium should be discontinued 3 days prior to surgery. As a PACU nurse, this information is important to know to act as a safety net for the patient in the event the physician orders a drug that may interfere with a patient's antidepressant medication.

The article regarding burnout and resiliency in perianesthesia nurses discussed some alarming findings. For example, more medical errors are made by nurses who are experiencing burnout and financial losses from "job stress" totalled in the hundreds of thousands per provider. Unfortunately, valuable experienced nurses are most likely to experience this issue (however, older individuals were suggested to have the ability to set boundaries thus lowering their burnout scores). The study results showed those rating high burnout felt "stuck" and dissatisfied in their role with poor social support. An important point made by the researchers was that "the focus perhaps should be on how much work can be done well and safely rather than on how much work can be done." Suggestions include a greater showing of appreciation and support of shared decision-making. For our PACU, this article sheds light on the possible reasons behind our problem with absenteeism. Working under heavier than normal conditions during a pandemic has proven taxing for our staff.

In the article " Pooled Dosing and Efficacy Analysis of the Sufentanil SL Tablet 30mcg Across Demographic Subgroups for the Management of Moderate-to-severe Acute Pain," the researchers suggest sublingual fentanyl as an alternative method of pain relief for patients in the perioperative and PACU setting. Benefits include quick onset, fewer side effects than IV medication, ability to administer independent of IV access, and longer duration. Cons include approval only for cancer breakthrough pain The researchers aim to instruct nurses and providers on the appropriate dosing of the medication in the perioperative setting across a variety of demographics subgroups. In the end, researchers found that heavier patients needed higher or more frequent doses but most patients indicated adequate pain relief from Sufentanil administration. Data regarding safety was positive. The researchers suggest use as an alternative to IV pain medication or as a bridge while access is initiated. Limitations of the study include lack of placebo control and inconsistency among type of surgery (some surgeries result in greater post op pain than more minor procedures and therefore should not be compared). As far as use in our PACU, Sufentanil would need to be approved for use in postoperative patients. Furthermore, most of our patients have adequate IV access due to medications given intra-op and the need for access in the event of an emergency. We would likely still need to gain new IV access if a patient lost their IV, but this method might provide the aforementioned "bridge" while a new IV is placed.

the Nov/Dec journal article discussed the subject of "postoperative delirium" the article emphasized the importance of identifying patients that were at greater risk of manifesting postoperative delirium. "Nearly 40% of PD can be prevented by adequately assessing older adults before surgery" the article concluded that "preoperative cognitive assessment can identify high-risk patients, stratify care, medically optimize the older adult before surgery, and improve perioperative outcomes."

sept/oct article posted November 3rd - 6:15 PM - Darcie Duer

sept/oct article The article Perioperative Pain Management Strategies in the Age of an Opioid Epidemic was a concise review of alternatives to opioids in the postoperative setting. Firstly, ERAS was discussed. This uses a multimodal pain medication approach with medications such as ketorolac, gabapentin, celecoxib, acetaminophen and small-dose ketamine to reduce opioid use, and to promote early oral nutrition and mobility. Secondly, the writers reviewed regional analgesia. Table 3 outlined the blocks and their indications. Thirdly, the writers reminded the readers nonpharmacologic approaches exist such as heat and cold, acupressure, music therapy and transcutaneous electrical nerve stimulation. There was very little new information provided for our unit since we do many of these alternative therapies to opioids presently. This article did validate that our policies and procedures are following the guidelines to reduce opioid use.

Carla Manning March/April 2020 "Pooled Dosing and Efficacy Analysis of the Sufentanil Sublingual TAblet 30 mcg Across Demographic Subgroups for the management of Moderate-to-Severe Acute Pain" Purpose : To help nurses in dosing sufentanil sublingual tablet 30 mcg administered for moderate to severe post operative pain relief vs IV opoids. Sufentanil has no active metabolites and a high therapeutic index. Study Design: One phase II study and three phase III studies. All studies were conducted on patients who had never received opioids. A randomized, double-blind, placebo-controlled. Methods: Efficacy was assessed through pain intensity to baseline over 12 hours. Limitations: Twho of the studies were not placebo controlled. Due to difficulty recruiting ASA class III patients, only 7.8% were classified as ASA III. Conclusion: Sufentanil Sublingual Tablet 30 mcg was found to be superior to placebo in managing post operative pain. Significance: SST 30 mcg would be a great althernative to IV opioid in the PACU as there are less adverse side effects with respiratory depression. I am not sure as to why this drug has never been utilized in the PACU; possibly due to cost as well as the old adage "why change something that isn't' broken". There are often obstacles to implementing new changes in an area that doesn't necessarily need to see new changes when it comes to pain relief. Management doesn't necessarily look to what is best for the patient. It is what's best for the

Testing, testing, Carla Manning

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