CRNAs Contribute to ERAS Solutions

by

Carol Schmidt, MS, CRNA
Director, Anesthesia Services
Beaumont Hospital - Royal Oak

Presented by the Enhanced Recovery Shared Interest Group

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Enhanced recovery programs can range in complexity from highly complex to simple protocols designed to improve patient outcomes. The following is an example where Mary Beth Boeson, CRNA identified that patients age 65 years and older are at risk for postoperative delirium. After review of the literature she found that polypharmacy contributed to delirium. Working with the perioperative team she created a simple protocol for patients undergoing vitrectomy that eliminated medications that contribute to delirium and also reduced the amount of medication that was administered during the procedure. We used LMA over GET so we could avoid muscle relaxants and reversal agents. We engaged the patients and families to avoid the use of Versed.

Situation
Identified that patients age 65 or older are at risk for lengthy PACU stays and postoperative delirium. We found that this population sometimes received over 10 medications for the procedure.

Background
Evidence suggests that polypharmacy (the use of 5 or more medications) has been associated with increased risk of delirium. Additionally, the use of benzodiazepines, anticholinergics and antihistamines increase the risk.

Assessment

  • Pre intervention
    • 20 charts were audited (patients greater than 65 who underwent a vitrectomy under general anesthesia) to assess medication use and PACU length of stay
    • 85 percent of patients received 2 mg Versed
    • Average PACU length of stay was 100 minutes
  • Post intervention
    • 26 charts audited for the same population
    • 53 percent decrease in the use of Versed
    • 5 or less medications administered
    • Average PACU length of stay was 73 minutes

Protocol

  • Pre op
    • Patient Engagement - Explain to the patient that you are going to avoid using sedative drugs that may linger delaying full recovery
  • Intra op
    • LMA
      • Propofol/Etomidate
      • Lidocaine 100mg IV
      • Sevoflurane
      • Zofran, if history of PONV
      • Toradol 0.5 mg/kg IV
  • PACU
    • Avoid IV opioid

Recommendations
Following a protocol that minimizes and/or eliminates polypharmacy reduces PACU length of stay by 30 minutes. We plan to assess for post op delirium in the future.