Volume 13 Number 3 Fall 2014

The International

Student Journal of Nurse Anesthesia

TOPICS IN THIS ISSUE Etomidate and Adrenal Suppression Pseudocholinesterase Deficiency Coronary Stent Occlusion Hypoglossal Nerve Palsy Visual Evoked Potentials Kartagener’s Syndrome Postoperative Delirium Massive Transfusion Total Thyroidectomy One-lung Ventilation T-wave Inversion Down Syndrome Trisomy 13

INTERNATIONAL STUDENT JOURNAL OF NURSE ANESTHESIA Vol. 13 No. 3 Fall 2014 Editor Vicki C. Coopmans, CRNA, PhD Associate Editor Julie A. Pearson, CRNA, PhD Editorial Board Laura Ardizzone, CRNA, DNP Laura S. Bonanno, CRNA, DNP Carrie C. Bowman Dalley, CRNA, MS Janet A. Dewan, CRNA, PhD Kären K. Embrey CRNA, EdD Rhonda Gee, CRNA, DNSc

Marjorie A. Geisz-Everson CRNA, PhD CDR Robert Hawkins, CRNA, MBA, DNP, NC, USN CDR Johnnie Holmes, CRNA, PhD, NC, USN Donna Jasinski, CRNA, DNSc Russell Lynn, CRNA, MSN MAJ Denise McFarland, CRNA, DNP, AN CDR Greg Nezat, CRNA, PhD, NC, USN Teresa Norris, CRNA, EdD Ilene Ottmer, CRNA, MSN CDR Justice Parrott, CRNA, DNAP, NC, USN Sarah Perez, CRNA, MS, MSN Jo Ann Platko, CRNA, BC, PhD

Michael Rieker, CRNA, DNP, FAAN CDR Dennis Spence, CRNA, PhD, NC, USN Maria Van Pelt, CRNA, MS, MSN Kelly Wiltse Nicely, CRNA, PhD Lori Ann Winner, CRNA, MSN Kathleen R. Wren, CRNA, PhD

Memorial Sloan Kettering Cancer Center; NY, NY Louisiana State University Health Sciences Center Georgetown University Northeastern University University of Southern California Millikin University and Decatur Memorial Hospital University of Southern Mississippi Naval Medical Center; Portsmouth, VA Uniformed Services University Georgetown University University of Pennsylvania 2nd FST, Gelan DSP, Afghanistan Naval Hospital; Camp Lejeune, NC University of Southern California University of Wisconsin Medical School & Medical Foundation Uniformed Services University Washington University School of Medicine/, Barnes-Jewish College; St. Louis, MO Somnia Anesthesia, Inc. Wake Forest Baptist Health Uniformed Services University Massachusetts General Hospital University of Pennsylvania University of Pennsylvania Arkansas State University

 

Contributing Editors For This Issue Jennifer E. Badeaux, CRNA, DNP Courtney Brown, CRNA, PhD Terri Cahoon, CRNA, DNP Ross Castille, CRNA, DNP Michele Gold, CRNA, PhD Bernadette Henrichs, CRNA, PhD LTC Paul M. Johnson, CRNA, DNP David M. Kalil, CRNA, DNAP Martina Steed, CRNA, BSN, MS

Louisiana State University Health Sciences Center Wake Forest Baptist Health Samford University Texas Christian University University of Southern California Barnes-Jewish College Uniformed Services University Louisiana State University Health Sciences Center Webster University

Reviewers For This Issue David Ayala CRNA, DNP Catrina Beard, CRNA, MSN Shelli Collins, CRNA, MSN Marianne S. Cosgrove, CRNA, DNAP, APRN Claire Farren, CRNA, MS Sharon Hadenfeldt, CRNA, PhD Johanna Newman, CRNA, DNAP Keri Ortega, CRNA, DNAP Kandace O’Toole, CRNA, DNP M. Leona Sayson, CRNA, MS Maria D. Motovidlak Thomas, CRNA, BA, BS, MSN Denise Tola, CRNA, MSN Crystal Trinooson, CRNA, MS LCDR Riley Williams, NC, USN, CRNA, DNP Molly Wright, CRNA, DNP

President & CEO of Ayala Anesthesia Associates Inc.

Longview Regional Medical Center; Longview, TX Excel Anesthesia, PA; Dallas, TX Yale-New Haven Hospital School of Nurse Anesthesia; Yale Medical Group, Yale University School of Medicine Northshore University Health System Bryan College of Health Sciences Florida International University Wolford College Pinnacle Partners in Medicine, Sherman Division Texas Health Presbyterian Hospital-WNJ Children's Hospital Boston Lehigh Valley Anesthesia Services; Allentown, PA Georgetown University Keck Hospital, University of Southern California Naval Hospital; Jacksonville, FL Union University

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  The opinions contained in this journal are those of the authors and do not necessarily represent the opinions of the program or the University. Disclaimer for all articles authored by military personnel: The views expressed in this journal are those of the authors and do not necessarily reflect the official policy or position of their respective Military Department, Department of Defense, nor the U.S. Government. The work was prepared as part of the official duties of the military service member. Title 17 U.S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Government’. Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.

Front Cover: Hailey Mullinax BSN and Lindsay Pate BSN, graduate students enrolled in the Lincoln Memorial University Nurse Anesthesia Program prepare to practice cricothryotomy skills on pig tracheas during an emergency airway laboratory session. The second image shows successful cricothyrotomy and lung ventilation by fellow students Scott Cantrell, BSN and Nicholas Quinton, BSN. The Guide for Authors: can be found at www.aana.com by following this path: CE & Education  Students  Scroll down to lower right, click on Student Journal Or, use this direct link: http://www.aana.com/studentjournal

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Table of Contents Case Reports Acute Adrenal Insufficiency after an Induction Dose of Etomidate .........................................6 Kathleen Black, Webster University One-Lung Ventilation for Total Pneumonectomy ......................................................................9 Elizabeth M. Broome, Samford University Anesthesia and Postoperative Delirium in the Elderly.............................................................12 Jon F. Faigle, Wake Forest Baptist Health Hepatic Trauma and Massive Transfusion ...............................................................................16 Jennifer Hults, Goldfarb School of Nursing Anesthetic Implications of Kartagener’s Syndrome.................................................................19 Amy Elizabeth O’Donnell, University of Pennsylvania Anesthetic considerations a for patient with Down syndrome ................................................22 Michael Huynh, University of Southern California T-wave Inversion after Posterior Spine Surgery ......................................................................26 Chris K. Beck, Wake Forest Baptist Health Anesthetic Management of Total Thyroidectomy with Sternotomy .......................................29 Kelsey M. Merrick, Texas Christian University The Challenges of Anesthesia and Trisomy 13..........................................................................33 Edwin George, Louisiana State University Health Sciences Center Suspected Pseudocholinesterase Deficiency ..............................................................................36 Jenna Kelly, Louisiana State University Health Sciences Center Cardiac Stent Occlusion following Discontinuation of Pradaxa .............................................38 Tamara Edie, Louisiana State University Health Sciences Center Unilateral Hypoglossal Nerve Palsy Following a Lightwand Intubation ...............................42 LT Cody R. Gremore, Uniformed Services University of the Health Sciences Evidence-based Practice Analysis Reports Visual Evoked Potentials and Anesthesia ..................................................................................45 Aaron Champagne, Louisiana State University Health Sciences Center

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Editorial ........................................................................................................................................49 Vicki C. Coopmans, CRNA, PhD Guide for Authors ........................................................................................................................50

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Acute Adrenal Insufficiency after an Induction Dose of Etomidate Kathleen Black, MS Webster University Keywords: etomidate, adrenal suppression, refractory hypotension

of midazolam 5 mg and alfentanil 1000mcg were given IV during the fiberoptic intubation in divided doses. Placement of ETT was confirmed. Ventilation mode was spontaneous intermittent mandatory ventilation. General anesthesia was induced with etomidate 20 mg and maintained with sevoflurane 1% with a mixture of 1 L/min of oxygen and 1 L/min of nitrous oxide. Dexamethasone 8mg was administered to decrease airway edema from the fiberoptic intubation and for post-operative nausea prophylaxis.

Etomidate is an induction agent often used for its hemodynamic stability. However, the administration of an induction dose of etomidate can result in acute adrenal insufficiency: a medical emergency. Etomidate has a known history of inhibiting 11-beta-hydroxylase, preventing the cortisol synthesis. The inhibition of this enzyme prevents cortisol from responding to surgical stress and triggers a state of adrenal insufficiency with refractory hypotension leading to hemodynamic instability and eventual cardiovascular collapse.1,2

The patient was placed in the beach chair position and the procedure initiated. Ten minutes into the procedure, the patient’s blood pressure began to fluctuate. Hypotension and bradycardia ensued with systolic blood pressure (SBP) falling to 70 mm Hg and heart rate (HR) in the 50s. Ephedrine 20 mg was administered and an IV fluid bolus was initiated. The blood pressure was unresponsive and additional doses of ephedrine were administered. Due to the lack of response from the ephedrine, vasopressin 1unit IV boluses were administered every 3 min. With SBP in the 80s and HR in the 60s, a vasopressin drip was initiated 0.05 units/min and titrated to effect. A second intravenous catheter was placed and colloid 250 mL was administered.

Case Report A 71-year-old, 93 kg, female patient presented for a closed reduction of the left shoulder. Significant medical history included hypertension, chronic obstructive pulmonary disease and hypothyroidism. Pertinent surgical history included a mandibular surgery from the 1980s. The patient had no known drug allergies and denied complications from previous anesthesia. The plan was to perform general anesthesia with an awake fiberoptic placement of an endotracheal tube (ETT) due to previous mandibular surgery. In the pre-operative area, glycopyrrolate 0.2 mg was administered intravenously (IV) and a dexmedetomidine bolus was initiated at 1mcg/kg and infused over 10 min. In addition, a 4% lidocaine nebulizer was administered for topical anesthesia.

The case continued and control of the blood pressure was maintained with the vasopressin drip. At the conclusion of the procedure, the patient was spontaneously breathing with tidal volumes >5 ml/kg, minute ventilation