Articles 
Anesthetic Management of Patients With Major Burn Injury
Kimy R. Harbin, CRNA, MSN
Teresa E. Norris, CRNA, EdD
Burn injury is a leading cause of life-threatening trauma worldwide, affecting more than 450,000 Americans each year and is associated with an average mortality rate of 0.8%. Patients with an increased risk of death from burn injuries include elderly patients and patients with large burns or inhalation injury. Providing optimal care for patients with major burn injuries requires the coordinated effort of multidisciplinary teams in which anesthesia providers play a critical role. Anesthetic management for burn surgery can be technically challenging because of difficult airway management and vascular access, as well as cogni­tively demanding because of dramatic pathophysiologic changes that compromise hemodynamic stability and alter patient response to many anesthetic agents. This article reviews the literature related to the pathophysiology and clinical management of major burn injuries and highlights the key concepts relevant to the delivery of safe and effica­cious anesthesia for these patients.

Keywords: Burn management, burn shock, burn surgery, inhalation injury, major burn surgery.

Print version: 2012;80(6):430-439. 

 

Rethinking the Paradigm: Evaluation of Ketamine as a Neurosurgical Anesthetic
Eric D. Bowles, CRNA, MS
Michele E. Gold, CRNA, PhD

Although anesthetists have long assumed that ketamine’s role in neuroanesthesia is limited because of its association with increased intracranial pressure, this article presents a review of recent clinical literature suggesting otherwise. When ketamine is used as an adjuvant anesthetic agent along with mechanical ventilation to maintain normocap­nia, ketamine does not have adverse cerebral hemodynamic effects. Furthermore, ketamine possesses a unique phar­macologic profile that provides analgesia, bronchodilation, and sympathetic stimulation, thereby reducing patients’ vasoactive agent requirements. Caution must be exercised because of ketamine’s action at the N-methyl-d-aspartate receptor (NMDAR), as ketamine may antagonize both neuroprotective and neurodestructive NMDAR-mediated pathways. This article examines how ketamine may prove to be a safe part of a neuroanesthetic regimen, and it should no longer be considered absolutely contraindicated as a result of its cerebral hemodynamic effects.

Keywords: Ketamine, neurodestruction, neuroprotection, NMDA, N-methyl-d-aspartate.

Print version: 2012;80(6):445-452.

 

Descriptors of Anesthesia Support Personnel From the Perspective of Practicing Certified Registered Nurse Anesthetists
Mary Bryant Ford, CRNA, PhD
Anesthesia support personnel provide direct support to anesthesia providers. They bring extra supplies or equip­ment, prepare equipment for the case, maintain and clean equipment, and generally function as directed by the anesthesia provider. Given the importance of anesthesia support personnel in maintaining equipment essential to safe anesthesia practice, it is necessary to ensure that these individuals are properly trained and capable of complying with safety standards. However, the literature describing this population is limited and shows variation in the utilization and qualifications of these personnel. A prospective, descriptive survey of Certified Registered Nurse Anesthetists was conducted to describe the educa­tion, training, job functions, and work environment of anesthesia support personnel. Results (N = 354) indicated that utilization of anesthesia support personnel varies by hospital but has a propensity for greater utilization at larger medical centers that have a level I or II trauma center. Formal supervision of these personnel is limited. Their tasks tended to be more frequently directed at equipment management, with a smaller portion of anesthesia support personnel performing tasks related to direct patient care. This article illustrates how further research is needed to adequately describe this population.

Keywords: Anesthesia equipment, anesthesia support personnel, anesthesia technicians.

Print version: 2012;80(6):453-459.

 

AANA Journal Course: Update for Nurse Anesthetists – Part 5 – The Perioperative Implications of Posttraumatic Stress Disorder
LCDR Ken Wofford, CRNA, MS, NC, USN
Michael Hertzberg, MD
Charles Vacchiano, CRNA, PhD

Posttraumatic stress disorder (PTSD) is an anxiety dis­order that develops after exposure to a traumatic event and is characterized by symptoms of reexperiencing, emotional numbing, persistent arousal, and avoidance. Approximately 6.8% of the people in the United States will be diagnosed with PTSD at some point in their lives. The presence of PTSD in a surgical patient can be important because PTSD is associated with the use of psychoactive medications, risky health behaviors, cardiovascular comor­bidities, depression, chronic pain, and cognitive dysfunc­tion, all of which may influence the risk of perioperative morbidity and mortality. In addition, patients with PTSD are anxious around unfamiliar people and in unfamiliar environments. The purposes of this Journal course are to provide anesthetists with a working knowledge of the symptoms, treatments, and comorbidities associated with PTSD and to suggest ways of interacting with patients with the disorder that increase trust and decrease the risk of evoking posttraumatic symptoms in the perioperative environment.

Keywords: Anesthesia, mental health, posttraumatic stress disorder, PTSD, surgery.