Synchronous Online Research Presentations 9:00 am – noon
Zoom Meeting: https://fsu.zoom.us/j/97634519832
TIME: ~ 9:00AM
Title of presentation: The Effect of Intravenous Magnesium Sulfate on Reducing Tourniquet Pain
Presenter: Naomi Balingcongan and Dex Esmeralda
Advisor: Dr. Lonnie Hodges
Abstract
In the United States, 95% of surgeons in the American Association of Hip and Knee, use tourniquets during orthopedic knee surgeries (Zhang, 2014). Use of a tourniquet limits intraoperative blood loss and improves the surgical view for the surgeon. Although tourniquet pain is a common side effect from tourniquet use, successful treatment options remain limited in the clinical setting (Kumar, 2016). The purpose of this paper is to describe the effect of intravenous magnesium sulfate to attenuate tourniquet pain. The following PICO question was used to search three literature databases: Do adult surgical patients undergoing orthopedic extremity procedures involving tourniquet use (P) who receive 1 gram of magnesium sulfate IV intraoperatively (I) compared to those who do not receive magnesium sulfate intraoperatively (C) exhibit reduced tourniquet pain (O)? A critical appraisal of four randomized controlled trials yielded strong evidence to support the use of intravenous magnesium sulfate intraoperatively to treat tourniquet pain. The purpose of this project is to implement a change in clinical practice and improve quality of care to patients undergoing extremity surgeries involving the use of a tourniquet at a medium-sized community hospital in South Florida. An educational intervention was conducted and both pre- and post-intervention surveys were collected to monitor compliance. Post-intervention survey showed an 84% usage rate with a 56% increase in magnesium sulfate usage rate from the pre-intervention survey. There was consistency of evidence across all relevant literature. However, the articles used to synthesize the evidence may be perceived as outdated. Anesthesia provider turnover rate at the facility also presents itself as a challenge.
TIME: ~ 9:10AM
Title of presentation: Measuring Provider Participation in a Student-led Practice Change: Ondansetron for Treatment of Pain on Propofol Injection
Presenter: Dewey Brazelton and Kenyatta L. Taylor
Advisor: Dr. Gerard Hogan
Abstract:
Patients experiencing pain during the administration of propofol is a well-recognized phenomenon that often creates an unpleasant encounter during the induction of anesthesia. Lidocaine is commonly injected before propofol to blunt the potential burning sensation, but manufacturing delays created a shortage of 2% intravenous lidocaine at our clinical institution. Ondansetron, a 5 HT3 antagonist, has been recognized as a possible alternative, thus raising the question: do patients receiving ondansetron before propofol have a lower incidence of pain on injection? Upon a literature review, ondansetron has comparable efficacy to lidocaine, thus encouraging a quality improvement project at our hospital in lieu of a shortage. An educational intervention was performed to present the current evidence to the hospital’s Certified Registered Nurse Anesthetists (CRNAs). Provider participation was measured to determine if student-led education would lead to a clinical practice change. Our results showed the administration of ondansetron before propofol increased from 4.3% (pre-intervention) to 5.5% (post-intervention), which indicated a positive percentage change in provider participation of 27.9% after student-led education.
TIME: ~ 9:20AM
Title of presentation: Improved Out of Operating Room Times with Routine Sugammadex Administration for Neuromuscular Reversal in Patients Undergoing General Anesthesia with an Endotracheal Tube for Orthopedic Procedures
Presenter: Hannah Cooke and Trenton Suffridge
Advisor: Dr. Gerard Hogan
Abstract:
Neuromuscular blockade is a key component of anesthetic care to facilitate endotracheal intubation and ventilation and to provide musculoskeletal relaxation for optimal surgical conditions. Consequently, thorough neuromuscular blockade reversal is essential to ensure patient safety and decrease turnover times in the operating room. This paper aims to illustrate sugammadex's superiority as a reversal agent for aminosteroid neuromuscular blockers (i.e., rocuronium and vecuronium) compared to neostigmine. The PICO question utilized to ascertain evidence in the literature search is as follows: Do surgical patients undergoing orthopedic procedures (P) who receive sugammadex for neuromuscular blockade reversal (I) when compared to neostigmine (C) have faster out of operating room (OR) times (O)? This demonstration was made to show the strengths of sugammadex with evidence from a meta-analysis, a randomized control trial, a retrospective analysis, and detailed practice guidelines published by the American Association of Anesthesiology to influence practice change at a facility in Fort Lauderdale, Florida. There has been apprehension about employing sugammadex as the primary method of neuromuscular blockade reversal due to financial concerns. Therefore, the literature search and printed educational posters fixated on this topic. A discussion was made regarding overall operating room cost-effectiveness and how it should be considered outside of external factors such as individual drug cost, extubation times, operating room turnover times, postoperative complications, and patient mortality. The goal was to influence practice change at the facility with the intention to increase patient safety and overall OR efficiency. Although resistance to practice change was encountered during the efforts, pre and post-intervention data showed a 233.33% increase in sugammadex utilization for neuromuscular reversal.
TIME: ~ 9:30AM
Title of presentation: Examining Intraoperative Dexamethasone Usage: Effects of Evidence-Based Postoperative Nausea and Vomiting Prophylaxis in Adult Surgical Patients
Presenter: Ndeye Dieng and Blake Myers
Advisor: Dr. Gerard Hogan
Abstract:
Post-operative nausea and vomiting (PONV) continues to account for one of the most common complications associated with general anesthesia. Despite multiple interventions and prophylaxis strategies, PONV occurs in over 30% of patients after general anesthesia (Butterworth IV & al., 2018). This project examined the relationship between PONV guidelines and the use of dexamethasone, an antiemetic agent. The following PICO question was used to guide this project and improve patient care: In adult surgical patients, do those who receive Post-Operative Nausea and Vomiting prophylaxis using an evidence-based Clinical Practice Guideline (CPG), compared to those who are not treated using the CPG, receive dexamethasone more often intraoperatively? The goal was to increase adherence to the PONV guidelines, resulting in increased use of dexamethasone and less incidence of PONV. Posters outlining the PONV guidelines were hung in each operating room included in this study. We compared the total number of dexamethasone vials (4mg IV) dispensed in the included operating rooms- one month before and one month after the posters were put in place. According to the data, 806 vials of 4mg dexamethasone were used in the 30 days prior to our intervention. In the 30 days following our intervention, 886 vials of 4mg dexamethasone were used. The overall use of dexamethasone increased by 10% in the month after the PONV guidelines were displayed in the operating rooms. With the increased use of dexamethasone, we hypothesize that the total incidence of PONV decreased during that period. Considering the data collected in this project, a 10% increase in dexamethasone administration represents a significant change that occurred as a result of our intervention.
TIME: ~ 9:40AM
Title of presentation: Process Improvement Project: Education to Improve Anesthesia Providers’ Knowledge and Confidence When Caring for Patients That Use Cannabis Products.
Presenter: Brittany Gill and Brittany Roughsedge
Advisor: Dr. Gerard Hogan
Abstract:
Purpose: Do anesthesia providers (P) who receive education(I), as opposed to those who do not (C), have increased knowledge and confidence in caring for patients who use cannabis and cannabis-related products undergoing anesthesia (O)?
Background: Cannabis is the most commonly used federally illegal drug in the United States (US) (Substance Abuse and Mental Health Services Administration, 2020). These numbers do not reflect the recreational use of cannabis, or describe the population of Floridians. Failing to acknowledge knowledge deficits in anesthesia providers can increase the risk for short- and long-term health consequences for cannabis users undergoing elective surgeries.
Methods: The design of this project utilized a pre-survey to assess the anesthesia provider’s initial knowledge and confidence; an educational brochure was distributed; and a post-survey to assess and evaluate if any new knowledge and confidence were gained following the implementation of the educational brochure.
Results: Statistically, there were increased mean values compared to each respected post-to-pre-survey question. The mean total of the post-survey compared to the mean total of the pre-survey showed an increase in mean total value. Additionally, anesthesia providers reported having improved knowledge and confidence following the implementation of the educational brochure.
Discussion: The process improvement project demonstrated how the educational brochure led to an improved knowledge and confidence base amongst anesthesia providers and how this project could increase awareness, knowledge, and confidence. With increased knowledge and confidence obtained by the anesthesia providers, this embodies the overarching goal of better patient outcomes for patients who use cannabis and are undergoing anesthesia.
TIME: ~ 9:50AM
Title of presentation: Reducing Spinal-induced Hypotension in Cesarean Sections with Ondansetron
Presenter: Sydney Reeder and Donia Richmond
Advisor: Dr. Gerard Hogan, Dr. Lonnie Hodges
Abstract:
Evidence shows that administering ondansetron prior to spinal anesthesia may decrease hemodynamic instability by acting as a 5-hydroxytryptamine-3 receptor (5HT3) antagonist blunting the Bezhold-Jerish reflex. This evidence-based practice project aims to educate Certified Registered Nurse Anesthetists (CRNAs) on the use of ondansetron prior to spinal anesthesia, and to change the current practice for the timing of ondansetron administration. Project members monitored the use of ondansetron prior to spinal anesthesia and shared findings with the anesthesia department. The following PICO question was used to search literature databases to find studies that support this claim: Do parturients receiving a spinal for cesarean delivery (P) that receive ondansetron before block onset (I) compared to after block onset (C) have reduced incidence of hypotension (O)? Pre-intervention surveys indicated that approximately 46% of CRNAs reported administering ondansetron prior to spinal anesthesia. Post-intervention data indicated 91% of CRNAs administered ondansetron prior to spinal anesthesia. The project resulted in a change in clinical practice after education on the mechanism of action of ondansetron prior to spinal anesthesia and demonstrates the increased likelihood of clinicians to comply with process change when improved outcomes are correlated through research and education.
Keywords: spinal anesthesia, cesarean sections, hypotension, bradycardia, Bezhold-Jerish, ondansetron.
TIME: ~ 10:00AM
Title of presentation: Sugammadex and Nonoperative Time
Presenter: Hunter Avera and Toren Guthrie
Advisor: Dr. Scott Stewart
Abstract:
Neuromuscular blockade is frequently utilized in many anesthetics. At the conclusion of surgery, neuromuscular blockade often necessitates reversal. When steroidal-based neuromuscular blockers are used, reversal of the blockade can be accomplished with the selective relaxant binding agent sugammadex (Bridion), or its counterpart, glycopyrrolate co-administered with neostigmine. Though sugammadex is recommended for reversal of neuromuscular blockade, especially when residual neuromuscular blockade is suspected, its access has been limited due to the expense of the drug. Although, sugammadex currently remains an expensive drug at certain facilities, its use has the potential to decrease turnover time without compromising safety. The purpose of this project is to provide quality improvement through educating anesthesia staff at a level III trauma center and acute-care hospital in Northern Florida on the reduction of nonoperative time through the use of sugammadex over glycopyrrolate co-administered with neostigmine. The following PICO question was used to search two databases: Do adult patients undergoing laparoscopic surgery under general endotracheal anesthesia (P) who receive a steroid-based neuromuscular blocking agent reversal with sugammadex (I) compared to those reversed with glycopyrrolate co-administered with neostigmine (C) have a shorter end of procedure to out of room time (O)? The results of this search were presented to anesthesia staff as a poster. Sugammadex usage was measured two weeks before the educational intervention and two weeks after the educational intervention. The results of this quality improvement study found no significant difference in sugammadex usage after educational intervention.
Keywords: anesthesia, sugammadex, nonoperative time
TIME: ~ 10:10AM
Title of presentation: Endotracheal Tube Cuff Pressure Assessment: A Quality Improvement Project
Presenter: Rebecca Couturier, Nicole Holcombe, and Sarah Siacunco
Advisor: Dr. Scott Stewart
Abstract:
This quality improvement project aimed to evaluate the incidence of inadequate endotracheal tube cuff (ETTc) inflation pressures in a surgical department at a regional acute-care facility in Northwest Florida. The goal was to determine if subjective ETTc inflation techniques resulted in adequate ETTc pressures within an ideal range. Additionally, it aimed to utilize objective inflation techniques, such as a cuff manometer, to obtain ETTc pressures within the ideal range of inflation. Appropriate and accurate ETTc pressures are beneficial in optimizing patient safety due to the risks associated with cuff pressures outside of an ideal range. Over- and under-inflated cuffs place the patient at an increased risk for injury. The following PICO question facilitated this research: Do adult surgical patients undergoing general anesthesia with cuffed endotracheal tubes (P), where a cuff manometer is used to measure cuff pressures (I) compared to subjective techniques(C), have more ETT cuff pressures within the recommended range of 20-30cmH2O (O)? After Institutional Review Board (IRB) exemption, 29 ETTc pressures were objectively assessed via an AG CUFFILL manometer. After induction and intubation, anesthesia providers inflated the ETTc and assessed cuff pressure using their usual and customary inflation technique and assessment method. The authors recorded an objective measurement to provide qualitative data findings. Subjective inflation techniques resulted in inappropriate cuff pressures in 89.7% (n=29) of patients. Objective inflation techniques with an ETTc manometer have been supported in the literature to ensure ETTc pressures are within the recommended range and to avoid adverse effects of cuff over- or under-inflation.
Keywords: Tracheal ischemia, Manometer, Endotracheal tube Cuff Pressure, Endotracheal tube Cuff Risks, Endotracheal tube Cuff Management
TIME: ~ 10:20AM
Title of presentation: Dexmedetomidine for intraoperative analgesia during neuroskeletal surgery
Presenter: Garrett Case and Ethan Belnap
Advisor: Dr. Gerard Hogan
Abstract:
In the United States alone there are roughly 900,000 spine surgeries annually 1. Intraoperative pain control plays a big role in the patient’s recovery. The development of intraoperative pain is inevitable but can be managed, mitigated, or even eliminated with a multimodal approach. The purpose of this paper is to demonstrate the efficacy of a multimodal approach with the use of Dexmedetomidine as an analgesic adjunct during neuroskeletal surgery. The following PICO question was used to search literature databases and guide the improvement project: Do adult neuroskeletal surgical patients (P) who receive perioperative dexmedetomidine (I) compared to patients who do not receive dexmedetomidine (C) experience less perioperative pain (O)? A critical appraisal of four meta-analyses showed that using a multimodal approach with Dexmedetomidine reduced perioperative pain. reduced perioperative opioid consumption, and reduced opioid related complications. This paper explains the benefits and methods that can be used to incorporate dexmedetomidine into a multimodal approach for intraoperative pain management. It also includes a clinical practice improvement project where anesthesia provider are encouraged to use dexmedetomidine in neuroskeletal cases. Data was collected on the incidence of pre and post intervention dexmedetomidine administration frequency. Project personnel found a 100% increase in the frequency of dexmedetomidine administration after provider education and assisting pharmacy to make dexmedetomidine push syringes more available.
Keywords: Analgesia, Dexmedetomidine, Opioid
TIME: ~ 10:30AM
Title of presentation: Do adult patients undergoing surgery that receive a prophylactic eye lubricant, compared to those who do not, experience less corneal abrasions?
Presenter: Jennifer Laufman and Autum Shaw
Advisor: Dr. Stacey VanDyke
Abstract:
Corneal abrasions are a known complication of non-ophthalmic surgical procedures, occurring in up to 0.17% of cases (Lichter et al., 2015). General anesthesia disrupts normal tear production and protective reflexes, increasing the risk of corneal injury due to reduced lubrication and incomplete eyelid closure (Malafa et al., 2016). Prophylactic measures such as artificial eye lubrication and manual eyelid closure with adhesive dressings have been recommended to mitigate this risk. This project aimed to promote the use of prophylactic eye lubrication during the induction of general anesthesia to reduce corneal abrasions.
Using a PICO question framework, this project investigated whether adult patients undergoing surgery who receive prophylactic eye lubricant experience fewer corneal abrasions compared to those who do not. A literature review was conducted, encompassing a case-control study, two systematic reviews, and one randomized, double-blind study. The evidence from these studies consistently supported the effectiveness of prophylactic eye lubrication in reducing corneal abrasions during general anesthesia.
Despite the evidence, the project did not observe an increase in compliance with prophylactic eye lubrication among anesthesia providers. The overall utilization rate of prophylactic eye ointment before, during, and after the project remained low at 9%. These findings underscore the challenges in implementing evidence-based practices in clinical settings. Further efforts are needed to address barriers to compliance and promote the adoption of prophylactic eye lubrication to mitigate the risk of corneal abrasions during general anesthesia.
Keywords: corneal abrasion, eye lubrication, artificial, prophylactic, prevention
TIME: ~ 10:40AM
Title of presentation: Cost Analysis of Prefilled Syringes of Phenylephrine and Ephedrine Compared to Multi Dose Vials of Phenylephrine and Ephedrine
Presenter: Benjamin Otiwu, Parker Allen, and Aristotle Boslet
Advisor: Dr. Jason Smith
Abstract:
Our project is aimed towards collaborating with pharmacy services to determine if medical organizations' utilization of pre-mixed syringes of phenylephrine and ephedrine have a decreased overall cost when compared to the use of multi-dose vials of these medications. Changing from multi-dose vials of phenylephrine and ephedrine to prefilled syringes stems from pharmacy guidelines, theoretical safety improvement, and suggested cost-savings. Twenty-six articles were selected from library databases and thirteen articles (among other resources) were utilized for our literature review. Our results concluded a cost decrease when switching to prefilled syringes of phenylephrine between $4,890 and $11,410 per year. Conversely, a cost increase was shown when switching to prefilled syringes of ephedrine between $7,290 and $24,300 per year. Limitations included large variations in medication supplier prices, protected access to hospital revenue records, and an unwillingness of hospital staff to implement this change into practice.
TIME: ~ 10:50AM
Title of presentation: Preoperative Peripheral Nerve Block Implementation Tool
Presenter: Sallyanne Braxton, Kyle Hudson, Lori Parker
Advisor: Dr. Jason Smith
Abstract:
The use of preoperative regional nerve blocks in surgical patients has improved patient outcomes and decreased the length of stay in the postoperative care unit. The purpose of this paper is to show the importance of relevant surgical patients receiving preoperative regional nerve blocks. For this reason, the following question was asked: In patients undergoing extremity surgery (P), do peripheral regional anesthesia blocks placed before surgery when (I) compared with peripheral regional anesthesia blocks placed postoperatively (C) result in less time in the postoperative care unit(O)? A critical appraisal of three controlled cohort studies and three randomized controlled trials supports the idea that preoperative peripheral nerve blocks provide better patient outcomes and decrease postoperative care unit length of stay. Results collected in the quality improvement project showed that before a teaching intervention, the anesthesia team lacked an emphasis on preoperative blocks. In the 30 cases examined before intervention, patients received a block for elective extremity surgery in the preoperative setting 60% of the time. After the research flyer was presented to the anesthesia staff, the next 30 cases of peripheral extremity procedures revealed that 76.7% were completed in the preoperative setting. Overall, preoperative blocks are best for patients when undergoing extremity surgeries because of the resulting decreased cytokine levels, time until ambulation, narcotic requirements for pain, and postoperative care unit times.
Keywords: regional nerve block, preoperative, postoperative, pain, postoperative care unit, length of stay, ambulatory time
TIME: ~ 11:00AM
Title of presentation: Ketamine as a multi-modal adjunct in general anesthesia
Presenter: Nick Ciccarelli and Kelly Murphy
Advisor: Dr. Stacey Vandyke
Abstract:
Ketamine, an N-methyl-d-aspartate antagonist, has been on the market since the 1970s as an anesthetic with promising results as a pain adjunct in sub-anesthetic doses (Drug Enforcement Agency [DEA], 2019). Illicit use of ketamine over the decades has given it a stigma as a "dirty drug" as it works as both an analgesic and a hallucinogen. It has been observed that locally in Orlando, the stigma of ketamine among anesthesia providers discourages the use of this anesthetic. Our PICO question to drive our literature search is: Do anesthesia providers (P) who receive education on the appropriate usage of ketamine as an anesthetic adjunct during general anesthesia (I) compared to their usage before education (C) have changed their perception of ketamine as a multimodal adjunct (O)? Ketamine is backed by research as an effective multi-modal adjunct in perioperative patients with the benefit of decreasing pain scores and lowering postoperative narcotic usage when used in subanesthetic doses of less than 0.3 mg/kg. Anesthesia is an art in addition to science, leading to various ways to practice that consider the provider’s anesthesia training, location, and years of practice. A survey was administered to the anesthesia group in Orlando, and insight was gained into the perceptions of ketamine among the responding anesthesia providers. Current literature on ketamine was provided to educate on using ketamine as an adjunct in anesthesia. It was followed by a second survey to reestablish the current perception of ketamine post-intervention. Statistics of the surveys revealed ketamine is not the first go-to agent of many anesthesia providers and only a 30% change of willingness to incorporate sub-anesthetic ketamine dosing as multi-modal anesthesia in general surgical patients based on our intervention of providing current literature.