American Association of Nurse Anesthetists Board of Directors

Editorial Staff

President-PatrickM. Downey, CRNA Holy Family Hospital, Manitowoc, WI

Managing Editor, Betty Prochaska Colitti; CRNA Editorial Consultant, Josephine H. Heimler, CRNA; Assistant Editor, Denise M. Dungey; Administrative Assistant, Laura Crumback.

President-Elect- Barbara V. Adams, CRNA Baptist Hospital of Miami, Miami, FL Vice President-RichardG. Ouellette, CRNA, MEd Addison Gilbert Hospital, Gloucester, MA Treasurer-GeraldMessbarger, CRNA, BS Good Samaritan Hospital, Kearney, NE Director, Region - Bruce O'Donnell, CRNA Marshall, Tibbetts, and Horie, PA, Lewiston, ME Director,Region 2-Peggy L. McFadden, CRNA, BS Veterans Administration Medical Center, Lexington, KY Director,Region 3-James J. Claffey, CRNA, BS Wayne State University School of Nurse Anesthetists, Detroit, MI Director,Region 4-Clyde Tempel, CRNA, BSN Professional Anesthesia Associates, Inc., Rogers, AR Director,Region 5-Mary Jeanette Mannino, CRNA, JD University of California, Irvine Medical Center, Orange, CA Director,Region 6-Joseph C. Kovalich, CRNA, MEd Sacred Heart Hospital Center, Allentown, PA Director, Region 7-Elaine M. Klein, CRNA, MA The Children's Hospital, Birmingham, AL

Executive Office Staff Park Ridge, IL Executive Director John F. Garde, CRNA, MS Continuing EducationDirector Susan Smith Caulk, CRNA, MA Executive Secretary to Councils on Accreditation and Certification Doris A. Stoll, CRNA, MSEd

Editorial Advisory Board Margot Barrett, CRNA, Chicago, IL; Kathleen M. Dole, CRNA, BS, Birmingham, AL; Vera D. Griner, CRNA, BS, Cincinnati, OH; COL Sarah A. Halliburton, CRNA, PhD, ANC, New Braunfels, TX; Celestine M. Harrigan, CRNA, MS, Detroit, MI; Betty L. Johnson, CRNA, MSN, Col.-ret., San Antonio, TX; Linda C. Larson, CRNA, MS, Los Angeles, CA; Lola O'Daniel, CRNA, Corrales, NM; Barbara Reep, CRNA, BA, Decatur, GA; LCR Charles A. Reese, CRNA, PhD, USN, Portsmouth, VA; Sandra S. Shreve, CRNA, Erie, PA; Suzanne F. Stoltzner, CRNA, BSN, Rock Springs, WY; Sandra D. Tunajek, CRNA, Louisville, KY; LTC Robert J. Wehner, CRNA, MSN, Silver Spring, MD.

Journal Faculty Nancy J. Wittstock, CRNA, MS, Detroit, MI; Kathleen M. Dole, CRNA, BS, Birmingham, AL; Sandra M. Maree, CRNA, BS, Winston-Salem, NC; Esther L. Reece, CRNA, MS, Villa Hills, KY; Barry Powell, CRNA, MN, Whitmore Lake, MI; Helen P. Vos, BSN, CRNAret., Winston-Salem, NC; Linda C. Larson, CRNA, MS, Los Angeles, CA; MAJ Cecil B. Drain, CRNA, MS, ANC, Fort Sam Houston, TX; Sandy Frye-Kryder, CRNA, MS, Los Angeles, CA; Leah E. Katz, CRNA, EdD, Los Angeles, CA; Joe R. Williams, CRNA, MS, Dothan, AL; Nancy H. Bruton, CRNA, BS, Winston-Salem, NC; Christine S. Zambricki, CRNA, MS, Detroit, MI; James G. Courtad, CRNA, BS, Groten, CT; LCR Charles A. Reese, CRNA, PhD, USN, Portsmouth, VA; Paula E. Deschler, CRNA, MEd, Cincinnati, OH.

Contributions Contributions are invited. Letters from readers will be accepted for publication if they relate to specific articles appearing in the Journal and are signed. The editor reserves the right to edit letters to suit legal and space requirements. For manuscript information, see index.

Business address

Membership Director Josephine H. Heimler, CRNA

Send all editorial copy and classified advertising correspondence to the AANA Journal, 216 Higgins Road, Park Ridge, IL 60068. Send subscriptions in care of subscription department.

Public Relations Director/Editor Betty Prochaska Colitti, BS

Change of address

Controller Dennis C. Kane, CPA, MBA Legislative/Employment PracticesCoordinator John E. Kasper, BBA, APS

Please allow six weeks notice of change of address by sending old address clipped from AANA Journal envelope along with new address and zip code to Subscription Department, AANA Journal, 216 Higgins Road, Park Ridge, IL 60068.

Subscription rates The rate to nonmembers is $24.00 for the 1983 calendar year or $5.00 per issue. Subscriptions are sold only for the calendar year.

The AANA Journal, an official publication of the American Association of Nurse Anesthetists, is published bimonthly as a source of original information for persons interested in the art and science of anesthesia and the role and functions of the nurse anesthetist. Second-class postage paid in Park Ridge, Illinois; additional mailing office. Reproduction up to 250 words is allowed if the Journal is credited but longer quotation requires written approval from the author and publisher. Copyright 1983© American Association of Nurse Anesthetists, 216 Higgins Road, Park Ridge, Illinois 60068. (312) 692-7050. Material subject to this copyright appearing in the Journal may be photocopied for the noncommercial purpose of scientific or educational advancement.

442

Advertising Send display advertising, correspondence, insertion orders, printing materials to Thomas A. Kenney, Sales Manager, AANA Journal, No. Woodbury Road/Box 56, Pitman, New Jersey 08071. Questions or general information may be directed to Sales Representatives-Anthony J. Jannetti, Inc.-(609) 589-2319; Midwest Office (312) 644-0834. The opinions expressed in the Journal are those of the contributors and do not necessarily reflect the views of the American Association of Nurse Anesthetists, the AANA Journalor the editorialstaff.

Journal of the American Association of Nurse Anesthetists

TRACRIUM

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INHALATION ANESTHESIA

EDITOR

* Six home study units on clinicaily important subjects to be distributed during 198384.

CELESTINE HARRIGAN, CRNA, PhD Wayne State University EDITORIAL BOARD GOLDIE BRANGMAN,

" Each unit approved by AANA for three (3) continuing education credits.

CRNA, MA

Director, School of Anesthesia for Nurses, Harlem Hospital Center BURNELL BROWN, MD Professor and Chairman

" Content prepared under expert editorial

Department of Anesthesiology University of Arizona

direction.

BARBARA DALE, CRNA Assistant Chief Anesthetist Virginia Commonwealth University

" Published by Appleton-Century-Crofts, a

MARY KAY DAVIS, CRNA, BS

Clinincal Instructor in Anesthesia

leading medical publisher.

University of Pittsburgh BERNARD C. DeLEO, MD Professor and Chairman Department of Anesthesiology Albany Medical College

" Distributed as an educational service of Ohio Medical Anesthetics.

BARBARA DEARTH, CRNA

Northwestern Memorial Hospital Chicago. Illinois RONALD W. DUNBAR, MD

Chief of Anesthesia Doctors Memorial Hospital Atlanta. Georgia IHOMAS H. JOYCE 11. MD Professor of Anesthesia and OBIGYN Baylor College of Medicine JOYCE KELLY, CRNA, MA Director. Kaiser/Permanente School of Anesthesia for Nurses Los Angeles. California

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RICHARD OUELLETTE, CRNA, MEd

Addison Gilbert Hospital Gloucester, Massachusetts Maiden Hospital Maiden, Massachusetts M. ARTHUR SCHRAMM, CRNA, PhD Associate Professor

YES, I wish to receive CURRENT CONCEPTS IN INHALATION ANESTHESIA. 5 4 3 2 1 (Please circleunits, if any, you have alreadyreceived

Name:

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Mount Marty College Yankton, South Dakota LAWRENCE R. STUMP, CRNA, MS Assistant in Anesthesiology Duke Medical Center, Duke University

Hospital:

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Holothone U.S.P. Time Proven

HALOTHANE -THE WORLD'S STANDARD "Experience: thousands of publications, millions of administrations. " Consistency: no surprises inthe OR or recovery room. HALOCARDON-AN INDUSTRY LEADER *Experience: first manufacturer of fluorinated anesthetics in the U.S. *Consistency: pioneered inthe manufacture of the consistently purest anesthetic in the world.

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Shiley offers excellent oral/nasal endotracheal tubes in adult and pediatric sizes, which provide excellent performance and reliability for general anesthesia or long-term intubation. The adult tubes feature a high-volume, low-pressure cuff, which occludes at intra-cuff pressures of approximately 25mmHg or less. The cuff adheres to the tube when deflated to minimize trauma and aid in visualization. Available in either clear or radiopaque, the pediatric tubes incorporate a series of three reference marks spaced 1 cm apart to facilitate proper depth of intubation when placed at the vocal cords. A radiopaque marker in the tip of the tube allows confirmation of correct tube placement by X-ray. "For detailed information describing intended use, warnings, precautions, and contraindications, refer to the instructions provided with each device, or contact your local sales representative:"

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CERTIFIED REGISTERED NURSE ANESTHETISTS The University of South Alabama, Department

of Anesthesiology, is seeking qualified CRNA's to provide anesthesia for all types of surgical cases. Call is on a rotational basis with the following day off. Elaborate benefits package included. (And Mobile is only half an hour's drive from the

Gulf of Mexico.) If you would like to become a member of this growing team, please apply to the University

of South Alabama, AD 180, Mobile, AL 36688. All Inquiries Confidential. An Equal Opportunity Employer M/F/H

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CRNAs At Botsford, There Is Room for the Person as well as the Professional. Our 310-bed suburban acute care hospital is a place for progressive practice and personal satisfaction. We are located in a pleasant suburb with the cultural and educational resources of Detroit and Ann Arbor a short drive away. You'll also have a variety of recreational and housing options from which to choose with plenty of time to enjoy the many parks, lakes and activities of the area. Our CRNAs enjoy 4 weeks of vacation time, do not work weekends and are not on call. We now have full-time positions for CRNAs or eligible graduates with certification from an approved program of nurse anesthesia. We provide competitive salaries and excellent benefits and an enjoyable working environment. To find out more about an excellent opportunity to combine the best in career and lifestyle, send your resume or write to: Anne Hane, Human Resources Dept.

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AS A PATIENT, WOULD YOU WANT 02 MONITORED?

INTRODUCING THE IL408"0, MONITOR: IT PROTECTS BOTH PATIENT AND ANESTHETIST BY CONFIRMING OXYGEN DELIVERY AND CONCENTRATION. Anesthesiologists, respiratory therapists, and other OR and critical care personnel can now watch over their patients with the most accurate, reliable O2 monitor IL has ever produced. The only commercially available unit to meet ANSI, ISO and CSA standards, this instrument measures 0-100% 02 using either the IL Po, sensor with a refillable membrane, or a new disposable cartridge. The digital display and audible alarm warn of a change in oxy-

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Make these three handbooks part

of your standard equipment... Handbook of Neuroanesthesia: Clinical and Physiologic Essentials Edited by Philippa Newfield, M.D., Universityof California, San Francisco, School of Medicine; Children's Hospital of San Francisco;and James E. Cottrell, M.D., State University of New York, Downstate Medical Center College of Medicine; Kings County HospitalCenter, Brooklyn

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As a nurse anesthetist, you have to keep pace with the constant changes that occur in a highly sophisticated, dynamic field. Surgical procedures - particularly in the area of neurosurgery - are meeting with greater success, largely because of recent advances in neuroanesthesiology practice. Make sure you're using the most current, effective neuroanesthetic techniques available. Consult Handbook of Neuroanesthesia: Clinicaland PhysiologicEssentials.

The HANDBOOK's first section addresses general considerations - issues that are basic to the practice of neuroanesthesiology, such as cerebral physiology and the effect of anesthetics on cerebral blood flow and metabolism. Respiratory and cardiovascular problems and the management of fluid and electrolyte balance are considered in the second section, while the third section presents guidelines for the management of anesthesia in particularneurosurgical problems, such as intracranial aneurysms, ischemic cerebrovascular disease, cerebrovascular lesions in the pregnant patient, and trauma to the head and spinal cord. Reflecting the way neuroanesthesiology is practiced today, Handbook of Neuroanesthesia will bring you and your skills absolutely up to date. Be sure to have a copy on hand. 437 pages. # 604704, $18.95

Manual of Anesthesia, Second Edition By John C. Snow, M.D.

;,..

SFast, . .

reliable answers to fundamental questions in anesthesiology are at your fingertips in Manual of Anesthesia, Second Edition. Part 1,"General Considerations," introduces the anesthetic agents in current use in terms of their function, administration, dosage, and possible complications. Part II examines specific aspects of anesthesia administration in the major types of surgery, including thoracic, cardiac, endocrine, and pediatric surgery. Organized and indexed for instant reference in any clinical situation, the MANUAL contains all the answers when you need them fast. 434 pages, illustrated. Spiralbound, #802220, $15.95

Clinical Anesthesia Procedures of the Massachusetts General Hospital, Second Edition Edited by Philip W. Lebowitz, M.D., Leslie A. Newberg, M.D., and Michael T. Gillette, M.D. Based on the most advanced, current clinical practice, Clinical Anesthesia Procedures of the Massachusetts General Hospital, Second Edition, is a definitive procedures manual for the practice of anesthesiology. Completely revised to reflect recent developments in anesthesiology, the second edition of this pocket-sized compendium clearly explains routine as well as uncommon anesthetic procedures - from preoperative patient evaluation to respiratory intensive care. New sections have been added on regional anesthesia and closed circuit anesthesia. 597 pages, illustrated. Paperback, #518670, $14.95 -

----------------------------------------------------------Please send me the book(s) listed below on 30-day approval: O Newfield & Cottrell: HANDBOOK OF NEUROANESTHESIA, #604704, $18.95 O Snow: MANUAL OF ANESTHESIA, 2nd Ed., #802220-92AC1, $15.95 O Lebowitz, Newberg, & Gillette, CLINICAL ANESTHESIA PROCEDURES OF THE MGH, 2nd Ed., #518670-A6W1, $14.95

Clip and mail to:

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is enclosed.

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Little, Brown

and Company Distribution Center

CA, NY residents please add state sales tax.)

O Please bill me for book(s) plus postage and handling. Outsi e continental U.S.A., payment must accompany order.)

HANDLING CHARGE: 50e per book, not to exceed $2.50 per total order.

Name

Address

200 West Street

Waltham, Massachusetts 02154 City - --------------------------

(P.O. Box Numbers must be accompanied by a street address.)

-

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State -------

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and the tradition continues... . Introducing

NARKOMED 2A ANESTHESIA SYSTEM BY NORTH AMERICAN DRAGER Since the introduction of the first North American Drager products for anesthesia fifteen years ago, North American Drager has built its reputation on quality products, innovative design, dependable equipment and conscientious service. North American Drager is the recognized leader in anesthesia system technology in the United States today and we are firmly committed to the design of innovative anesthesia systems with patient safety being our prime design criterion. Management has from the beginning recognized that the design of anesthesia machines lagged behind technology in other areas by more than a decade. The challenge to close this gap was accepted and North American Drager has lead the industry in anesthesia system development. North American Drager's tradition of quality, innovation, and service continues with the introduction of the Narkomed 2A Anesthesia System.

Narkomed 2A Features * * * * * * * * * * * * * * * *

*

*

Dual Etched Flowmeter Tubes Triple Vaporizer Exclusion System Drager Pressure Monitor Drager Oxygen Ratio Monitor Oxygen Supply Pressure Sensor Oxygen Supply Pressure Failure Protection Device A.C. Line Powered Battery Back-up System Electrical Outlet Box Main Switch Minimum Oxygen Flow Yokes for Oxygen & Nitrous Oxide D.I.S.S. Pipeline Inlets Safety-Locking Fresh Gas Outlet Flowmeter Protection Device Choice of Drager AV-E Electronic Ventilator with Ascending or Descending Bellows Choice of Chrome Plated Brass Absorber or Nylon Autoclavable Absorber Wide Variety of Drawer and Shelf Options

DRAGER ... the standard by which other anesthesia systems are measured.

NORTH

AMERICAN DRAGER 148 B QUARRY ROAD TELFORD, PENNSYLVANIA 18969 (215) 723-9824 & CH8-0834

A step forward inreversal exclusively from Organon

romide inection) Now formulated without parabens, Regonol isa fast-acting reversal agent with documented advantages over neostigmine. It maintains greater cardiovascular stability,1 causes fewer muscarinic side effects, 2 and has up to 33% longer action. 2 A wider margin between the anticurare dose and the neuromuscular blocking dose2 assures better control of the patient.

25 m

in

a 5 m(5mg/ml) vial

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References: 1. Gyermek L Curr Ther Res 18:377-386, 1975 2. Katz RL Anesthesiology 28:528-534, 1967

BRIEF SUMMARY-(Please consult full package insert, enclosed in every package, before using Regonol) INDICATIONS-Pyridostigmine bromide is useful as a reversal agent or antagonist to nondepolarizing muscle relaxants. CONTRAINDICATIONS-Known hypersensitivity to anticholinesterase agents intestinal and urinary obstructions of mechanical type WARNINGS-Pyndostigmine bromide should be used with particular caution in patients with bronchial asthma or cardiac dysrhythmias Transient bradycardia may occur and be relieved by atropine sulfate Atropine should also be used with caution in patients with cardiac dysrhythmias. When large doses of pyridostigmine bromide are administered, as during reversal of muscle relaxants, prior or simultaneous injection of atropine sulfate is advisable Because of the possibility of hypersensitivity in an occasional patient, atropine and antishock medication should always be readily available When used as an antagonist to nondepolarizing muscle relaxants, adequate recovery of voluntary respiration and neuromuscular transmission must be obtained prior to discontinuation of respiratory assistance and there should be continuous patient observation Satisfactory recovery may be defined by a combination of clinical judgement, respiratory measurements and observation of the effects of peripheral nerve stimulation It there is any doubt concerning the adequacy of recovery from the effects of the nondepolarizing muscle relaxant, artificial ventilation should be continued until all doubt has been removed. Use In Pregnancy-The safety of pyridostigmine bromide during pregnancy or lactation in humans has not been established Therefore its use in women who are pregnant requires weighing the drug's potential benefits against its possible hazards to mother and child. ADVERSE REACTIONS-The side effects of pyridostigmine bromide are most commonly related to overdosage and generally are of two varieties, muscarinic and nicotinic. Among those in the former group are nausea, vomiting, diarrhea, abdominal cramps, increased peristalsis, increased salivation, increased bronchial secretions, miosis and diaphoresis. Nicotinic side effects are comprised chiefly of muscle cramps, fasciculation and weakness. Muscarinic side

effects can usually be counteracted by atropine As with any compound containing the bromide radical, a skin rash may be seen in an occasional patient. Such reactions usually subside promptly upon discontinuance of the medication Thrombophlebitis has been reported subsequent to intravenous administration DOSAGE AND ADMINISTRATION-When pyridostigmine bromide is given intravenously to reverse the action of muscle relaxant drugs, it is recommended that atropine sulfate (06 to 1.2 mg) or glycopyrrolate in equipotent doses be given intravenously immediately prior to or simultaneous with its administration Side effects, notably excessive secretions and bradycardia are thereby minimized Reversal dosages range from 0 1-025 mg /kg Usually 10 or 20 mg. of pyridostigmine bromide will be sufficient for antagonism of the effects of the nondepolarizing muscle relaxants. Although full recovery may occur within 15 minutes in most patients, others may require a half hour or more. Satisfactory reversal can be evident by adequate voluntary respiration, respiratory measurements and use of a peripheral nerve stimulator device It is recommended that the patient be well ventilated and a patent airway maintained until complete recovery of normal respiration is assured. Once satisfactory reversal has been attained, recurarization has not been reported Failure of pyridostigmine bromide to provide prompt (within 30 minutes) reversal may occur, eg in the presence of extreme debilitation, carcinomatosis, or with concomitant use of certain broad spectrum antibiotics or anesthetic agents, notably ether Under these circumstances ventilation must be supported by artificial means until the patient has resumed control of his respiration HOW SUPPLIED-Regonol is available in: 5 mg /ml. 2 ml ampuls-boxes of 25-NDC-0052-0460-02 5 ml vials-boxes of 25-NDC-0052-0460-05

Organon

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