Anesthesia for Vertical Expandable Prosthetic Titanium Rib surgery
in Children with Cerebral Palsy: A Case Study
Michael Storm CRNA, MNA
Missouri State University
Cerebral palsy (CP) children often present with scoliosis. When the Cobb angle becomes significant, these children may benefit from having Vertical Expandable Prosthetic Titanium Rib (VEPTR) surgery. Cerebral palsy children frequently have some degree of medical comorbidities, making the anesthesia both challenging and potentially worrisome for the certified registered nurse anesthetists (CRNAs). This case study describes some of the essentials of the cerebral palsy disease, scoliosis development in these children, the VEPTR device, and the operative anesthesia checklists. Furthermore, the study will discuss health disparities in the CP population, necessary CRNA leadership qualities as well as challenges and barriers during the dissemination of this study. Finally, the study proposes how to present this knowledge to a group of CRNAs and students nurse anesthetists at a single institution.
Keywords: Cerebral palsy; vertical expandable prosthetic titanium rib; VEPTR; CRNA; anxiety.
Providing anesthesia for a Vertical Expandable Prosthetic Titanium Rib (VEPTR) procedure in cerebral palsy children with scoliosis can be the cause of anxiety for the lesser experienced certified registered nurse anesthetists (CRNAs). Cerebral palsy children often present with multiple comorbidities and providing anesthesia for these children during the implantation of the VEPTR device can be a challenge. The patient is in the prone position for many hours, blood loss can be expected, and the CRNAs must adhere to strict neuro-monitoring guidelines. There is a need for meticulous teamwork prior to taking these children back to the operating room the day of surgery. The CRNA, together with the surgeon, is often in a central position and can be the co-driver of the team. This case study provides knowledge and insight for the lesser experienced CRNAs at my institution to assume this leadership role. Furthermore, the study outlines an operative checklist and a fluid calculation sheet that can provide the necessary insight and help to reduce the anxiety for the CRNAs with little experience in VEPTR surgery.
The theme of my case study is the provision of anesthesia for cerebral palsy children with scoliosis having Vertical Expandable Prosthetic Titanium Rib (VEPTR) surgery.
Certified Registered Nurse Anesthetists (CRNAs) administering anesthesia for cerebral palsy children with scoliosis in need of VEPTR surgery at Palmetto Health Richland Hospital, Columbia, SC.
Cerebral Palsy Background
Cerebral palsy (CP) is a term used to describe a non-progressive cerebral nervous system (CNS) disorder (Hines R. L., 2012, p. 604). An abnormality occurring in the developing brain causes this disorder. When similar or identical symptoms occur after age three it is not termed cerebral palsy (Hines R. L., 2012, p. 604). Cerebral palsy has an incidence of 1.5-4 per 1,000 live births and is the most common motor disability in childhood (“Data and Statistics | Cerebral Palsy | NCBDDD | CDC,” 2015; Davis, P. J., Cladis, F. P., Motoyama, 2011, p. 863). In other words, each year 10,000 babies will develop cerebral palsy (“Prevalence of Cerebral Palsy | Incidence | CerebralPalsy.org,” n.d.).
CP’s clinical manifestations may change over the lifetime of the child and may include poor muscle control, weakness, increased muscle tone, spasticity, dyskinesia, seizures, scoliosis, poor balance, unsteady gait, intellectual disability, vision difficulties, dental problems, hearing loss, and joint problems (“Cerebral Palsy - HealthyChildren.org,” n.d.; Davis, P. J., Cladis, F. P., Motoyama, 2011; Hines R. L., 2012). Although the exact causes of CP are unknown, problems during pregnancy, such as infection, maternal health issues, genetic disorder, low birth weight or prematurity, and, although not very common, disruption of blood supply during childbirth, all are risk factors for developing CP (“Cerebral Palsy - HealthyChildren.org,” n.d., “Data and Statistics | Cerebral Palsy | NCBDDD | CDC,” 2015; Davis, P. J., Cladis, F. P., Motoyama, 2011, p. 864; Hines R. L., 2012, p. 605). Anything that can cause a malformation of the developing brain prior to age three can be the cause of CP (Hines R. L., 2012, p. 604).
Cerebral Palsy and Anesthesia
CP children often have multiple comorbidities that can make anesthesia for these patients challenging. It becomes imperative to prepare and anticipate the problems that may arise from these comorbidities when creating the anesthetic plan.
The most common complications encountered by Wass et al. (2012) were non-lethal hypothermia (55%) and hypotension (15%). Many factors may be in play causing this drop in core temperature, but long exposure time while prepping the patient prior to the surgical start time is a major component. Wass et al. further mention the poikilothermic role in children with a damaged central nervous system (p. 863). While hypothermia is not a lethal complication Wass et al. point out that the drop in core temperature does have significant influence on many other areas, e.g. “wound infection, extended duration of hospitalization, more profound surgical blood loss and allogeneic blood transfusion, morbid cardiac events including ventricular tachycardia, prolonged neuromuscular blockade, delayed emergence, shivering, and thermal discomfort” (p. 863-864). Increasing the ambient room temperature until the patient is fully covered, and use of forced-air body warming during surgery can significantly moderate the issue with hypothermia. The second most common complication in the study by Wass et al. was hypotension. Cardiac problems are typically not a major concern for CP children and this finding by Wass et al. may be associated with increased autonomic sensitivity among CP patients to drugs used during general anesthesia (p. 863).
CP children have low pharyngeal tone, which may cause gastroesophageal reflux and potentially lead to pulmonary aspiration (Davis, P. J., Cladis, F. P., Motoyama, 2011; Hines R. L., 2012; Wass et al., 2012). The anesthesia provider should adopt a low threshold for endotracheal intubation with this patient population (Hines R. L., 2012, p. 605) and possibly include preoperative antacid medications, e.g. H2 antagonist and proton pump inhibitors (Wass et al., 2012, p. 864).
CP children typically have issues with motor dysfunction and therefore, are medicated with antispasmodic medications. These medications have the potential to cause drowsiness, sedation, ataxia, dizziness, and lethargy (Hines R. L., 2012, p. 605; Wass et al., 2012, p. 864). These side effects can result in delayed emergence from anesthesia. Use of non-depolarizing muscle relaxant during surgery may also cause delayed emergence. CP children have a prolonged recovery time from non-depolarizing muscle relaxants (Davis, P. J., Cladis, F. P., Motoyama, 2011, p. 864; Hines R. L., 2012, p. 605). Although the use of muscle relaxant is not recommended during VEPTR surgery due to neuro-monitoring, a short-acting nondepolarizing muscle relaxant is often used during the early stage while positioning the patient. There may be an increased sensitivity to non-depolarizing muscle relaxants, which could prolong recovery time (Hines R. L., 2012, p. 605) although, others mention the opposite and predict a faster recovery from muscle relaxant due to the increased amount of extrajunctional acetylcholine receptors (Davis, P. J., Cladis, F. P., Motoyama, 2011, p. 865). CP has no association with malignant hyperthermia, and, therefore, depolarizing muscle relaxant “is not contraindicated but should be used with discretion” (Hines R. L., 2012, p. 605). Positioning of the CP child with scoliosis can be challenging due to significant contractures and the required prone position. The CRNA must pay meticulous attention to bony prominences and other pressure points during positioning.
A considerable amount of CP children have epilepsy (Wass et al., 2012, p. 864), and antiepileptic medications will have an impact on the anesthetic plan. The CRNAs must pay close attention (a) to drugs that have cytochrome P-450 induction properties, e.g. phenytoin and carbamazepine; (b) epileptogenic effect of some anesthesia drugs, e.g. ketamine, sevoflurane, etomidate, and meperidine; (c) as well as increased bleeding potential from especially valproic acid (Davis, P. J., Cladis, F. P., Motoyama, 2011, p. 864; Imrie & Yaszay, 2010, p. 534; McCarthy et al., 2006, p. 371; Wass et al., 2012, p. 864).
Airway management may be difficult due to restricted range of motion or poor and malpositioned dentition (Davis, P. J., Cladis, F. P., Motoyama, 2011, p. 864). Davis, Cladis, and Motoyama further write that CP children can have significant narrowing of their palates, which may cause increased risk for airway obstruction (p. 864). Children with CP and scoliosis may have significantly impaired pulmonary function. Imrie and Yaszay (2010) mention that “impaired vital capacity and forced expiratory volume in the first second increases the risk for prolonged mechanical ventilation” (p. 534). “Children with developmental disabilities are more than three times more likely to develop sedation-related hypoxia” (Davis, P. J., Cladis, F. P., Motoyama, 2011, p. 864). The potentially impaired pulmonary function makes it vital to be cautious when extubating at the end of a long VEPTR surgery.
Although the VEPTR implantation carries a low risk of blood loss, (K. K. White, Song, Frost, & Daines, 2011, p. 1337) availability of blood should be considered and cell saver should be utilized. Use of tranexamic acid or aminocaproic acid could be a consideration to help reduce blood loss during surgery.
Postoperative pain control becomes paramount for the comfort of the patient. Good pain control for the patient translates to great comfort for the parents. The study by Comstock, Leach, and Wenger (1998) clearly showed that a major point of criticism by the parents was their child’s degree of pain (p. 1420).
Scoliosis in Cerebral Palsy Children
Scoliosis in CP children is quite common. The overall incidence is quoted as 20-25% with a range in studies from 6-100%. Children with spastic CP has the highest incidence around 70%, whereas athetoid CP (involuntary, purposeless weaving motions of the body or its extremities) has the lowest incidence of 6-50% (Imrie & Yaszay, 2010; McCarthy et al., 2006; “Mosby’s Medical Dictionary,” 2009). In children with limited mobility, the incidence of scoliosis increases and in bedridden CP children, the incidence is 75-100% (Imrie & Yaszay, 2010, p. 531; McCarthy et al., 2006, p. 367). It is not completely clear why CP children develop scoliosis, but a combination of muscle weakness, truncal imbalance, and asymmetric tone in paraspinous and intercostal muscles are thought to be contributing factors (Imrie & Yaszay, 2010, p. 531; McCarthy et al., 2006, p. 368). The definition of scoliosis is the Cobb angle (red circle in Figure 1) being greater than 10 degrees (McCarthy et al., 2006, p. 367). “The Cobb angle of a scoliotic curve is the angle formed by the intersection of two lines, one parallel to the
Figure 1 – The Cobb angle. (Copyright (c) 2005 Skoliose-Info-Forum.de, n.d.)
endplate of the superior end vertebra and the other parallel to the endplate of the inferior end vertebra” (Kim et al., 2010, p. 1826). Scoliosis among CP children tends to appear at a younger age and therefore has the propensity to develop into more significant of a problem, e.g. stiffer and more pronounced curvatures than scoliosis seen in non-CP children, also known as adolescent idiopathic scoliosis (AIS) (Imrie & Yaszay, 2010, p. 532).
The goals for non-surgical interventions for CP scoliosis focus on maintaining comfortable upright sitting position and allowing the functional use of upper extremities. Pursuing these goals will maximize a patient’s ability to interact with their environment (Imrie & Yaszay, 2010, p. 533). Braces are used in AIS to stop the progression of scoliosis, but in CP children scoliosis does not stop, so bracing is not as effective in this population. Soft braces are still an option to help maintain posture and for wheelchair bound children; molded inserts of the seating may be utilized to accomplish this goal (Imrie & Yaszay, 2010, p. 533; McCarthy et al., 2006, p. 369). Physical therapy has not shown to be effective for CP children with scoliosis (Imrie & Yaszay, 2010, p. 533; McCarthy et al., 2006, p. 369).
The goals of surgical intervention for the CP scoliosis patient are to stop the progression of scoliosis, level the pelvis, and create a corrected, well-balanced spine. These corrections will enable to child to breathe easier, limit the pulmonary complications, have a better sitting position, and overall have a better quality of life. There are no solid guidelines to determine when a child needs surgery (Imrie & Yaszay, 2010, p. 533). However, several requirements should be met, such as Cobb angle > 50° and still progressing and interference with effective sitting (Imrie & Yaszay, 2010, p. 533; McCarthy et al., 2006, p. 370). Beyond these requirements each patient’s specific needs, family goals, comorbidities, and pulmonary function must be taken into consideration.
Vertical Expandable Prosthetic Titanium Rib
The Vertical Expandable Prosthetic Titanium Rib (VEPTR) is a relative new option for these children. The original creation of the VEPTR was for children with the thoracic insufficiency syndrome, a congenital condition where severe deformities of the chest, spine, and ribs prevent normal breathing, lung growth, and lung development (“Vertical Expandable Prosthetic Titanium Rib (VEPTR) | The Children’s Hospital of Philadelphia,” n.d.). Where classic surgical options for the CP scoliosis focus on correction of the Cobb angle, the VEPTR surgery goals address many more components of thoracic deformity, e.g. the spine, the rib cage, and the diaphragm, all without compromising thoracic growth (Thompson, Lenke, Akbarnia, McCarthy, & Campbell, 2007, p. 163-164). After initial insertion of the VEPTR, the device is then lengthened every six months while the spine is growing (Thompson et al., 2007, p.164). When the spine reaches maturity, the surgeon will perform a spinal fusion making the spine and chest wall corrections permanent (“Vertical Expandable Prosthetic Titanium Rib (VEPTR) | The Children’s Hospital of Philadelphia,” n.d.).
The main benefits of VEPTR surgery include easement of breathing, less use of supplemental oxygen, a decrease of spine deformity, enhanced normal growth, and prolonged life span (“Vertical Expandable Prosthetic Titanium Rib (VEPTR) | The Children’s Hospital of Philadelphia,” n.d.).
Assess the Environment
Children with congenital spine deformities and especially CP children are prone to debilitating comorbidities from their deformities. While it is not possible to cure CP, limiting the complications of the disease become important goals. Scoliosis is almost inevitable
Figure 2 – VEPTR device. (“Vertical Expandable Prosthetic Titanium Rib,” n.d.)
for the CP child. One approach of limiting the scoliosis deformity is to use an implantable device to slow the progression of deformity and to stabilize the spine at the same time. Such a device is the Vertical Expandable Prosthetic Titanium Rib (VEPTR) (Figure 2). DePuy Synthes Spine division manufactures the VEPTR device (“Vertical Expandable Prosthetic Titanium Rib,” n.d.).
Currently, about 500,000 children under age 18 have cerebral palsy with 20-25% having scoliosis as well (“Prevalence of Cerebral Palsy | Incidence | CerebralPalsy.org,” n.d.). 20-25% translates into more than 100,000 children in potential need for surgical intervention to limit their spinal deformity. CP children often have many comorbidities apart from scoliosis and, therefore, have a high familial, economic impact on health care expenses. Limiting the progress and severity of scoliosis in these children can potentially have a significant, positive, financial influence on the family economics.
VEPTR surgery is a very specialized procedure, and there is limited access to an orthopedic surgeon capable of this level of surgery (F. Piehl, MD, personal communication, June 18, 2015). Some of the children that could benefit from a VEPTR surgical device may not have the familial support necessary for such an intervention (F. Piehl, MD, personal communication, June 18, 2015).
Anesthesia for VEPTR surgery in the CP children carry increased risks. Meticulous attention to detail, e.g. positioning, fluid management, blood loss and replacement, temperature loss, and hemodynamics are clearly important. Special training is highly advisable. Monitoring of the spinal cord by a neuro-monitoring team is done throughout the initial surgical procedure as well as during all follow-up expansion procedures.
Certified Registered Nurse Anesthetists (CRNAs) administering anesthesia for cerebral palsy children with scoliosis in need of VEPTR surgery at my institution, Palmetto Health Richland Hospital, Columbia, SC.
Provide, through this case study, a general overview of the cerebral palsy patient and VEPTR devices.
Provide standardized checklists for use when preparing and implementing the anesthetic plan:
- Operative checklist (Appendix A);
- Fluid calculation sheet (Appendix B).
These lists will be available to all CRNAs at my institution while planning for and providing anesthesia for cerebral palsy children with scoliosis having VEPTR surgery.
All CRNAs at my institution interested in providing anesthesia for VEPTR surgery will be oriented to this case study and all checklists mentioned above.
The comparison group is CRNAs at my institution that will not receive the checklist training. This group includes the CRNAs who normally do not provide anesthesia to VEPTR patients.
The expected outcome of this case study is reduced anxiety of the CRNAs while providing anesthesia for cerebral palsy children with scoliosis having surgery related to the Vertical Expandable Prosthetic Titanium Rib (VEPTR) device at my institution.
The goal of this case study is to reduce anxiety among CRNAs and student nurse anesthetists at my institution scheduled to provide anesthesia for cerebral palsy children having Vertical Expandable Prosthetic Titanium Rib (VEPTR) surgery.
Disparities in health care are a well-known consequence of the American health care system (Zaccagnini & White, 2011, p. 392). The difficulty among non-English speaking Hispanics and African-Americans to obtain quality health care is well documented (Fiscella, Franks, Doescher, & Saver, 2002, p. 52; Fiscella & Williams, 2004, p. 1140). This disparity in ability to obtain quality health care increases the likelihood that many African-Americans and non-English speaking Hispanics CP children will not enter the health care system. Entering the health care system is the first step for screening and in so doing possibly receive an offer to help with their disability. It is essential that my project does not discriminate against anybody based on gender, ethnicity, or socioeconomic status. All patients brought to my institution for VEPTR surgery will receive the same high-quality care from the anesthesia team.
The conceptual framework for this case study is inductive reasoning (Bergdahl & Berterö, 2014, p. 112; Terry, 2015, p. 37). I will use my personal experience from previous anesthetics I have provided to CP children having VEPTR surgery and apply that experience to this case study. The goal with the case study is to create a framework for the CRNAs and student nurse anesthetists at my institution to feel less anxious while planning for and providing anesthesia for VEPTR surgeries.
My primary goal with this case study is to make information available for CRNA colleagues at my institution providing anesthesia for CP children having VEPTR surgery. A secondary goal will be that CRNAs assigned to provide anesthesia for a VEPTR procedure will utilize the information available through this case study. Finally, as a tertiary goal, I will make this case study available for anesthesia students, specifically for anesthesia students from University of South Carolina/Palmetto Health Richland (USC) anesthesia program. Reaching my goals will be accomplished by:
- Providing evidence based practice information regarding
- Cerebral palsy in children;
- Scoliosis in cerebral palsy children;
- The VEPTR device;
- Anesthetic technique for VEPTR surgery in cerebral palsy children.
- Providing informal teaching sessions for interested CRNAs at my institution.
- Providing a speaking session for USC anesthesia students.
- Uploading my case study to the stormanesthesia.com website.
- Consider publication in a peer-reviewed journal.
IOM (Institute of Medicine) Goals (Harris, Roussel, Walters, & Dearman, 2011, p. 72-73; Institute for Healthcare Improvement, 2001, p. 3; Terry, 2015, p. 236)
Avoid preventable injuries to patient by applying a consistent anesthesia care formula, including CRNAs specifically trained and experienced in scoliosis surgery for CP children. The CRNAs will consistently utilize a pre-formatted paper trail during the case.
This case study will provide the basic amount of evidence based knowledge to provide the best available anesthesia at my institution. This will help reduce the anxiety among CRNAs at my institution providing anesthesia for VEPTR surgeries.
The anesthetic plan will pay close attention to both the child and the parents specific needs on the day of surgery. Initial VEPTR surgery is a very big surgical experience for both child and parents, which must be addressed prior to surgery. The child and their parents should be allowed to participate in the anesthetic planning as much as possible so they have sufficient knowledge to give informed consent for anesthesia.
The anesthetic plan will initiate when the child and the parents meet with the anesthesia team either the day of surgery, or, if possible, at a preoperative assessment meeting with a CRNA. During surgery the parents will be kept informed about surgical progress by the circulating RN. The anesthetic plan will continue till the morning after surgery, where the anesthesia team will attempt a follow up visit in the unit where the child is admitted. If the child is not admitted there will be no immediate follow up done. My institution attempts to do telephone follow up on all out-patients within the first week after discharge (personal communication with outpatient RNs at my institution, July 02, 2015).
The consistent approach to the scoliosis surgery in CP children developed in this case study will reduce waste of time and energy for the anesthesia team on the day of surgery. This reduced waste of time and energy may open up possibilities for continuous improvement of future anesthetics for this patient population. The consistent approach will alleviate much of the uncertainty among CRNAs at my institution when asked to provide anesthesia for CP children having VEPTR surgery.
Implementing this anesthetic approach will ensure that the quality of anesthesia will not vary because of personal or patient/family characteristics such as gender, ethnicity, and socioeconomic status.
SWOT Analysis (Appendix C)
I have used a SWOT analysis to identify perceived strengths and weaknesses as well as the opportunities and threats confronting this case study (Pearce, 2007; White & Dudley-Brown, 2012, p. 219).
Strengths (internal, positive factors)
Our department has a stable and engaged group of CRNAs. There are many young and energetic CRNAs willing to take on this specialized task of providing anesthesia to CP children undergoing scoliosis surgery.
Our management is supportive of initiatives that can improve patient outcomes, patient relations, surgeon relations, and anesthesiologist relations.
We currently have several CRNAs with experience in anesthesia for VEPTR surgery, who can contribute to the successful implementation of this new uniform approach.
The number of surgeons performing this procedure is limited, which makes it easier to maintain a consistent group of CRNAs administering the anesthesia for these cases.
Weaknesses (internal, negative factors)
CRNAs are a group of autonomous people, which may make it difficult to have everybody adhere to this uniform approach.
Because of a large anesthesia department, it could on occasion be impractical only to use the trained CRNAs for the VEPTR surgeries. Using non-trained CRNAs could make it difficult to maintain the same high standard of anesthesia as within the trained group of CRNAs.
Our department does not have a history of a uniform approach to the anesthetic plan, which could make it challenging to implement such a plan.
Our institution has a group of anesthesiologist with many years of experience, which may make it difficult to convince individuals within this group about the benefits of a standardized approach.
Opportunities (external, positive factors)
My personal journey towards my DNAP degree is a perfect opportunity for our department to streamline the anesthesia process and anesthetic plan for VEPTR surgeries.
Our department currently has several CRNAs pursuing their DNAP degree. Having several colleagues in pursuit of their terminal degree could make it easier to find buy-in and support among CRNAs for the implementation of this project.
Threats (external, negative factors)
My personal journey towards my DNAP degree can be very time-consuming. Time is a finite resource, and I may not have enough time available to provide consistent support during the implementation of this new approach to the VEPTR anesthesia.
Unforeseen demands on individual CRNAs committed to this process have the potential to derail the successful implementation of the project.
Individuals in the group of supervising anesthesiologists may not agree with the uniform anesthesia plan. This disagreement may make it difficult to adhere to the plan if these individuals are assigned to the particular operating room the day of surgery.
For this case study I have chosen to utilize the Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation, which is often shortened to The Ace Star model (Appendix D) (Stevens, 2012; White & Dudley-Brown, 2012, p. 17).
The five points in this model fall closely in line with the approach I believe will generate the best outcome for this case study.
- Personal experience tells me that when CRNAs, who do not provide anesthesia on a regular basis to children having VEPTR surgeries, are assigned a VEPTR case they feel increased levels of nervousness.
- The amount of literature regarding specifics of providing anesthesia to the Cerebral Palsy patient having VEPTR surgery is sparse. I will research available evidence.
- I will provide knowledge regarding CP, scoliosis, and VEPTR device and create checklists to help the CRNAs during the different phases of the anesthetic plan. I believe knowledge and these checklists can alleviate the anxiety of providing anesthesia for VEPTR surgery patients.
- I will educate the group of CRNAs at my institution about the checklists. I will seek support from management for the use of these checklists for VEPTR surgery.
- To evaluate if the new evidence based checklists for VEPTR surgery helped decrease anxiety among assigned CRNAs, I will ask the CRNAs, who have done anesthesia for VEPTR surgery, if they felt the checklists helped decrease their anxiety.
Quality Improvement and Risk Management
After development of the checklists I will solicit input from CRNAs with experience in Cerebral Palsy children undergoing VEPTR surgery to improve the quality of the checklists. I will incorporate any suggested safety concerns into the checklists before implementation at my institution. After implementation of the checklists I will solicit evaluations from CRNAs who have used these checklists and I will be examining the feedback for reduced anxiety, increased anxiety, or indifference when the CRNAs are utilizing the checklists.
I will use an outcome based logic model (Appendix E) (Foundation, 2004; Zaccagnini & White, 2011, p. 480). I think this model may work best, since I’m implementing a series of checklists. Use of a Logic Model provides a quick and easy overview of resources, activities, outputs, outcomes, and associated impacts the case study is expected to have.
VEPTR surgery is a big undertaking for everybody involved. The patient and the family must be well prepared. This preparation is not only on the physical part, e.g. fasting the day of surgery, free of acute illness, etc. but so much more in regards to the mental aspect of the journey ahead. Although the surgeon is the main driver of this preparation, this case study provides the assigned CRNAs the information and evidence they need to understand the importance of involving and informing the family judiciously prior to surgery. A major complaint from the families is a lack of preoperative information regarding the difficulties during the postoperative hospital stay. Comstock, Leach, and Wenger (1998) write:
Recurrent criticism from this group [the families] was that the acute postoperative course was more difficult than anticipated. They felt unprepared for the experience in the intensive care unit – particularly, the degree of pain experienced by and the appearance of their child (multiple intravenous catheters, monitors, tubes, urinary catheters) (p. 1420).
Much of this criticism covers areas where the CRNAs can be an excellent source of information.
The introduction of VEPTR-specific operative checklists is a form of transformational and empowerment leadership (Burke et al., 2006, p. 292; Grossman & Valiga, 2013, p. 73). Having official checklists can empower the CRNAs to embrace this added responsibility of informing the family regarding realistic expectations to the surgical journey, as well as taking part in driving the team towards successful outcomes. Knowledge is necessary for empowerment (Grossman & Valiga, 2013, p. 189) and this case study will bring knowledge and expertise to the assigned CRNAs. Use of these checklists by the CRNAs can ensure that many of the areas of criticism mentioned above will be addressed prior to surgery. Information should be provided during a preoperative visit ahead of surgery, but at a minimum the CRNAs will have the opportunity to inform the family on the day of surgery. Through this added opportunity, the CRNAs can take greater ownership in the outcomes for these patients and their families.
As mentioned earlier, VEPTR surgery is a big undertaking. Communication among the members of the surgical team, e.g. surgeon, anesthesia, RNs, and necessary technologists must be flawless for the procedure to be most successful. The CRNAs are in a unique position to assume a leadership role. The CRNAs have the expertise to make decisions when the surgeon is not available. Just like the implementation of and instruction in the use of the operative checklists take tact and civility by the author of this case study, the CRNAs assigned to the surgery must approach the leadership role in a civil and tactful manner. The availability of this case study as well as the operative checklists will give the CRNAs knowledge and, therefore, empower them to assume this leadership position. The best patient outcomes are a consequence of exceptional teamwork (Burke et al., 2006, p. 303). The CRNAs behavior should be courteous towards any member of the surgical team. Behavior becomes particularly critical when the CRNAs undertake the leadership role. As previously mentioned, the empowered CRNAs take ownership and feel increased pride in their work; a concept they should apply to the rest of the surgical team. When the CRNAs can empower other members, the whole team becomes more effective (Burke et al., 2006, p. 293).
Challenges or Barriers
Translating into new ways of doing known procedures can present challenges and barriers to acceptance and implementation from resistant practitioners even if the known way has been shown to be wrong or inefficient (Haynes & Haines, 1998, p. 273). White and Dudley-Brown (2012) mention that “only one-half of evidence reaches widespread use” (p. 191). Many of these barriers are old rationalizations and White and Dudley-Brown point out several, e.g. “insufficient time on the job” and “the nurse does not have time to read research” (p. 191). Many of these barriers are predictable and can be addressed prior to the implementation phase of the case study. Appendix F lists some of the foreseeable challenges and barriers to this case study and illustrates ways I will attempt to overcome these challenges and barriers. Unforeseeable challenges and barriers to the implementation of this case study are by nature unknown (Zaccagnini & White, 2011, p. 483). These challenges and barriers will be addressed if they arise.
Individual anesthesia practitioners concerns can be addressed using a modified Pathman’s pipeline (White & Dudley-Brown, 2012, p. 196) described by Diner et al. (2007, p. 1009). Diner et al. suggest teaching the practitioners, use tutorials to instruct the practitioners in the new processes, and potentially split the new processes up into smaller chunks (p. 1012). Appealing to the individual practitioners professional pride may entice them to embrace the new processes. Evidence-based practice is very much a buzzword in anesthesia practice today, and most CRNAs and student nurse anesthetists show interest when it comes to embracing how things are done according to evidence-based best practices.
Legal or Ethical Issues
The utilization of the operative checklists by the anesthesia providers is voluntary. The checklists proposed in this case study do not replace, nor interfere with, any standards of care, and the checklists do not rise to the level of clinical practice guidelines. For that reason, there should not be any legal implications for the anesthesia provider or the institution when utilizing these checklists (White & Dudley-Brown, 2012, p. 202). The checklists are a compilation of already accepted best practices, although, not all anesthesia providers may be aware of these best practices.
Use of evidence-based best practices should always be what drives our anesthesia practice. As ethical anesthesia providers, we have a moral obligation to provide the best service we can. As Larkin et al. (2007, p. 1046) write:
Freethinking, ethical, and educated EPs [emergency physicians] must look to their patients’ interests and their own conscience, not legal dicta or malpractice fears, as the ideal moral compass for getting the right knowledge into practice for the right patient, at the right place, in the right amount, for the right price, and at the right time.
This ethical dilemma is not present in this case study. The proposed checklists are all within usual and standard practice for CRNAs and student nurse anesthetists. The checklists are a tool providing easy access to both standard questions as well as strategies for the anesthetic plan.
As stated previously, the goal of this case study is to reduce anxiety among CRNAs and student nurse anesthetists at my institution scheduled to provide anesthesia for CP children having VEPTR surgery. The knowledge provided by this case study is meaningless without dissemination of the information to the interested CRNAs and student nurse anesthetists at my institution. A quote often attributed to Johann Wolfgang von Goethe: “Knowing is not enough; we must apply. Willing is not enough; we must do” (Harris et al., 2011, p. 179).
To promote this case study among my fellow CRNA colleagues, I plan to give an in-service at a general staff meeting in my department. I will make a short presentation highlighting the important areas of the case study. Furthermore, I will introduce the checklists (Appendixes A and B) and encourage the use of these checklists during VEPTR surgeries. There may be challenges and barriers to the adoption of the idea of a standardized approach to the VEPTR procedure. The foreseeable obstacles are mentioned and countered in Appendix F. Unforeseeable challenges and barriers are by nature unforeseeable and must be handled as they arise; besides, I do not expect every CRNA to embrace this change in practice. I will also make the checklists readily available in the preoperative area and in the operating rooms where the VEPTR surgeries take place. The significance of this case study is to reduce anxiety among the nurse anesthesia providers for these surgeries. Therefore, it becomes imperative to make the information readily available. After the introduction of the case study as well as the checklists to the CRNAs, the student nurse anesthetists will be given the same presentation at one of their weekly seminars.
But like Goethe wrote, knowledge and willingness are not enough, the anesthesia providers must also implement this standardized approach for optimal outcomes. Although, the goal for this case study is to reduce anxiety among lesser experienced VEPTR anesthesia providers, I do believe, a standardized approach may potentially improve the outcomes for the patients. To entice my more skeptical colleagues to embrace this standardized approach, I will recruit a few CRNAs, who are already involved with these surgeries, and use them as champions for usage of the checklists.
After initial implementation, it is imperative to follow-up with the CRNAs assigned to provide anesthesia for VEPTR surgeries to ensure they are comfortable with the checklists. Furthermore, it is vital to solicit feedback from the CRNAs using the checklists to make sure they remain relevant and accurate. Underutilization of the checklists is a foreseeable challenge. Inquiry among the CRNAs not utilizing the checklists as to reasons why, as well as involving them in any future improvements of the checklists, may convince them about the feasibility of these lists.
The final step in my dissemination plan will be pursuing publication in a peer reviewed journal. The AANA Journal would be an obvious choice for a CRNA to approach for publication. Other more general nursing journals may be options as well.
The potential usefulness of simple procedure-specific checklists should not be overlooked by the anesthesia provider. Anxiety of providing anesthesia to big cases can be mitigated with knowledge, preparation, and utilization of procedure-specific checklists. This case study have provided knowledge regarding (a) children with cerebral palsy (CP), (b) scoliosis in the CP children population, (c) the Vertical Expandable Prosthetic Titanium Rib (VEPTR) device, and created procedure-specific checklists for use when providing anesthesia for CP children having VEPTR surgery.
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Fluid Balance Sheet
The Academic Center for Evidence-Based Practice Star Model (ACE Model)
Challenges and Barriers
|Implementation challenges and barriers|
|Challenges and barriers||How to address the issue|
|CRNAs not interested in changing what already works well||
|CRNAs feel the standardized approach with a checklist will infringe on their autonomy to practice||
|CRNAs are nervous about trying new approach to the procedure||
|CRNAs express they do not understand research language||
|CRNAs feel they do not have enough time to read the case study prior to surgery||
|CRNAs may underutilize the checklists, even if they think the lists are helpful. Underutilization of the checklists, e.g. forgot to have the checklist available, forgot to start the list and therefore never bothered, was too busy early on in the case and then forgot, etc.||
|There is no support from department management to print checklists||
|Department management does not support this new process||