SOAP Newsletter Highlights

Transcription

1 SOAP Newsletter Highlights President's Message Dr. Gerry Bassell shares his vision for SOAP. A Sesquicentennial Celebration Dr. Don Caton, medical historian and SOAP member, takes a look at the early years of obstetric anesthesia. SOAP 1998 Get ready, we're going to Vancouver! SOAP Newsletter Highlights Fall 1997 A Publication of the Society for Obstetric Anesthesia & Perinatology Useful & Useless Things To Do On the InterNet Dr. Scott Segal takes a candid look at the Net! Pro-Con Forum What role should obstetrical nurses play in [ Home ] SOAP MISSION STATEMENT The Society For Obstetric Anesthesia And Perinatology was founded in 1968 to provide a forum for discussion of problems unique to the peripartum period. SOAP is comprised of anesthesiologists, obstetricians, pediatricians, and basic scientists who share an interest in the care of the pregnant patient and the newborn. The mission of the Society is to promote excellence in research and (1 of 2) [2/2/2005 4:26:01 PM]

2 SOAP Newsletter Highlights obstetric analgesia? The Research Corner Sporadic looks at your data could spoil your study! SOAP Index Exit to the SOAP HomePage. practice of obstetric anesthesiology and perinatology. Through the newsletter, Internet site, and annual meetings, this Society allows practitioners of several specialties to meet and discuss clinical practice, basic and clinical research, and practical professional concerns. A membership in SOAP is an opportunity to meet people who share your interests, and to stimulate improvements in health care for pregnant patients. Editor Gerald Burger, M.D. Edited for the Internet Gerald Burger, M.D. -- webmaster@soap.org For a complete issue of the SOAP Newsletter please contact: SOAP P.O. Box Richmond, VA (804) / FAX (804) SOAP Copyright 1997 The Society for Obstetric Anesthesia & Perinatology (2 of 2) [2/2/2005 4:26:01 PM]

3 President President's Message Three apparently unrelated occurrences during the past few months illustrate some challenges being faced by obstetric anesthesiologists. They may also provide opportunities for SOAP members to influence the future of obstetric anesthesia practice. First was an informational communication to the SOAP Board of Directors from Joy L. Hawkins, MD, Chairperson of ASA's Committee on Obstetrical Anesthesia. Dr. Hawkins acquainted the Board with an ongoing correspondence between herself and representatives of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONNpronounced A-one) concerning AWHONN's position statement on the "Role of the Registered Nurse in the Management of Analgesia by Catheter Techniques." Within that statement, under the heading "For the Pregnant Woman," was included "The insertion, initial injection, or initiation of a continuous infusion of epidural catheters for analgesia should be performed only by a qualified and credentialed, licensed anesthesia care provider as described by the American Society of Anesthesiology, [sic] Guidelines...and the American Association of Nurse Anesthetists...[r]ebolus of an epidural catheter includes injection of the catheter by syringe or increasing the rate of a continuous infusion." AWHONN had used the ASA Guidelines to preclude its members from injecting or even adjusting flow through epidural catheters when the block was inadequate or required modification. In a well-reasoned response Dr. Hawkins addressed the lack of morbidity and mortality data supporting the introduction of a national policy on the role of the obstetric nurse in this regard. She pointed out that local policies had apparently worked satisfactorily. In addition, she made the very cogent point that nurses frequently administer potent medications by other routes so why should the care of an epidural catheter be any different? In a follow-up letter from AWHONN, Judith H. Poole, RNC, MN, Chair, Committee on Practice, reported some results from a member survey on this topic. One thousand members responded, of whom 765 did not "intervene independently and manage the patient should there be a negative response to the analgesia." Of the 235 who do intervene, they do so because "anesthesia is unavailable." [Italics mine] Second was the request I received from ASA for SOAP's opinion of the questions developed by the Ad Hoc Committee on Performance Based Credentialing (PBCC). ASA did not seek answers to the questions, rather SOAP's input was sought relative to the design and appropriateness of the questions themselves. I sought input from the other members of the Board of Directors, then forwarded a response to the ASA committee. The next step in this process will be to circulate the finalized questions to the specialty societies and others and use the resultant answers to develop practice parameters. Third was the event that generated a volume of e-, voice-, and snail mail that overwhelmed me for more than a weekthe August issue of Good Housekeeping. In an article entitled "The Best Doctors for Women" the magazine engaged in an increasingly popular publishing endeavor in which it listed the 401 "best" gynecologists of all subspecialities in the U.S.A. Of course, my correspondents were not commenting on (1 of 3) [2/2/2005 4:26:02 PM]

4 President the choicesalmost all recognized people on the list possessing dubious diagnostic skill and technical abilityno, almost to a person the complaint was the non-inclusion of anesthesiologists on the list. "Don't they realize that the advances made in the care of women would have been impossible without the contributions of anesthesiologists?" was the oft-repeated theme. Why do I believe these seemingly disparate events are similar? In short, because they speak to our failure as anesthesiologists to educate those around us including patients, nurses, other physicians, health care administrators, and the general public. The AWHONN chronicle, now more than five years in duration, results from a lack of information and presence of misinformation that should have been preventable had we acquitted our educational responsibilities at the individual hospital level. Simply put, we should ensure that labor nurses understand what it is that we do and assure their level of comfort with what we ask of them. The question of what anesthesiologists should reasonably expect an obstetric nurse to know and do with regard to a woman receiving epidural analgesia during labor obviously has many answers depending on the local practice situation and the personnel involved. In many countries, nurses routinely re-inject epidural catheters and otherwise manage labor blocks. These nurses are apparently educated to recognize and initiate treatment of related problems. In the U.S.A., nurses initiate cardiac arrhythmia treatment, routinely administer potent respiratory depressant drugs, monitor fetal well being and institute appropriate treatment, function as physician extenders in a variety of roles, and have been extremely vocal in requesting recognition as "professionals." Thus, there is no question that properly trained nurses have the ability to undertake the additional monitoring requirements attendant upon epidural labor block, and may have the capacity to play an even greater role depending on their desire to be educated to that extent. The concept of practice parameters is anathema to some, suggesting as it does that the art of medicine can somehow be evaluated on the basis of a list of attributes, and that, further, decisions on physician qualifications, privileges, et cetera, should be based on those measures. The push to develop practice parameters demonstrates, in part, recognition that the current methods by which society (e.g., hospitals) evaluates physicians and their practices have shortcomings. The ASA President has charged the relevant committee with developing those parameters within a relatively brief time. SOAP will play as large a role as it can in this endeavor. The popularity of physician lists in the lay press is a response to the perceived inability of organized medicine to rank and rate physicians. Consumers are somehow reassured when they see that the car they drive has been rated highly by Consumer Reports and their nephrologist by Rolling Stone. The fact that there has not been a list of the country's (world's, universe's) best obstetric anesthesiologists simply reflects the fact that nobody has thought that there would be value in producing one. We have not yet educated our colleagues or magazine editors. Or perhaps we are only legends in our own minds! Gerard M. Bassell, M.D. President, SOAP (2 of 3) [2/2/2005 4:26:02 PM]

5 President [ Home Search Inside SOAP] (3 of 3) [2/2/2005 4:26:02 PM]

6 SOAP.org The Society for Obstetric Anesthesia And Perinatology was founded in 1968 to provide a forum for discussion of problems unique to the peripartum period. SOAP is comprised of anesthesiologists, obstetricians, pediatricians, and basic scientists who share an interest in the care of the pregnant patient and the newborn. The mission of the Society is to promote excellence in research and practice of obstetric anesthesiology and perinatology. Through the newsletter, Internet site, and annual meetings, this Society allows practitioners of several specialties to meet and discuss clinical practice, basic and clinical research, and practical professional concerns. A membership in SOAP is an opportunity to meet people who share your interests, and to stimulate improvements in health care for pregnant patients. Our Website is a Resource for Anesthesiologists, Obstetricians, Mothers of the Future and their Families... Contact SOAP Celebrating Over 150 Years of Obstetric Anesthesia Website sponsored by IMD, Inc. Copyright 2005 SOAP [All Rights Reserved] - Website sponsored by IMD, Inc. [2/2/2005 4:26:02 PM]

7 A Sesquicentennial Celebration A Sesquicentennial Celebration By Don Caton, M.D. (Dr. Caton, a member of SOAP, is vice president of the Board of Trustees of the Wood LibraryMuseum. He is author of the forth-coming book "What a Blessing She Had Chloroform: The Medical and Social Response to the Pain of Childbirth from 1800 to 1960." During this year's meeting of the ASA he delivered the Lewis H. Wright Memorial Lecture, "The Influence of the Early Feminist Movement on the Development of Obstetric Anesthesia.") This year we celebrate one hundred fifty years of obstetric anesthesia. Obstetric anesthesia began on January 17, 1847 when James Young Simpson administered diethyl ether to a woman with a deformed pelvis to facilitate delivery. Within three months he had anesthetized another five patients and published a paper, which described his accomplishment. By September of the same year he had discovered the anesthetic properties of chloroform, the anesthetic that British physicians favored for obstetrics for the next seventy five years. Simpson's most important contribution, however, may have been his outspoken support of obstetric anesthesia. Initially, virtually every other prestigious obstetrician opposed him. Simpson's technique for anesthetizing obstetric patients was simple. He merely adopted the same crude method then being used for surgery. Simpson placed a cloth over the women's face, poured chloroform onto it until she lost consciousness, and then kept her in that state until she delivered. Often he started the anesthetic early in the first stage of labor. It remained for others to refine Simpson's method and to develop new ones. Of those who refined Simpson's technique, John Snow had the most impact. Snow, a London physician and a contemporary of Simpson, was also a strong advocate of obstetric anesthesia. Slower to publish than Simpson, he made careful observations on many patients before he described his technique. Before his death in 1858, he had anesthetized more than one hundred women for childbirth. Snow recognized that obstetric and surgical patients responded differently to anesthesia and he modified his approach accordingly. He realized, for example, that laboring women required less anesthesia. Therefore, he reduced the concentrations of inhaled gas. To obtain better control over depth of anesthesia he recommended using a special inhaler, one that he had designed himself, instead of open drop chloroform. Whenever possible, Snow delayed inducing anesthesia until the second stage of labor. From clinical observation he recognized that ether and chloroform may cross the placenta and affect the child, and that anesthesia in higher concentrations may depress spontaneous contractions of the uterus. Other early advocates of obstetric anesthesia, including Simpson, denied these possibilities. It was Snow, of course, who anesthetized Queen Victoria for each of her last two deliveries. The method that Snow used for the Queen subsequently became the standard method adopted by others. Despite improvements, physicians remained dissatisfied with ether and chloroform. Apart from their fear (1 of 3) [2/2/2005 4:26:03 PM]

8 A Sesquicentennial Celebration of the effects on the child and the uterus, physicians found inhalation agents inconvenient when they were alone and responsible for both administration of the anesthetic and delivery of the child. Consequently they sought alternatives. At one time they even used oral salicylic acid and acetyl salicylic acid. Morphine was available and by 1850 they had the needles and syringes to administer it by hypodermic injection. Few physicians were comfortable using opioids for normal labor, however, for fear of its effects on the child and on uterine contractions. Fear of opioids continued among physicians, even after 1914 when C. J. Gauss, a German obstetrician, popularized "Twilight Sleep" among the general public. The discovery of local anesthesia in 1884 stimulated physicians to explore other options. During the first half of the twentieth century a spate of papers appeared that described the obstetric applications of spinal, presacral, periaortic, and paravertebral blocks. Of these many methods, the only ones to survive were spinal and epidural blocks. During the first half of the twentieth century, obstetricians used spinal blocks extensively for the second stage of labor, as part of a philosophy of practice that favored routine use of an episiotomy and forceps, even for uncomplicated deliveries. Epidural anesthesia became popular after 1940, through the clinical studies of Robert Hingson, the development of plastic catheters, and the discovery of safer, more effective local anesthetic drugs. The recent discovery of pain receptors in dorsal nerve roots sensitive to opioids has increased the usefulness of these blocks. Dramatic innovations in clinical management should not overshadow the important contributions of basic science. Many improvements in the management of the pain of childbirth were a direct outgrowth of studies of the anatomy and physiology of pain, the physiology of labor, placental transport, drug action, and of descriptions of the physical and chemical environment of the fetus. Nor should we overlook the contributions of patients. For physicians, the first century of obstetric anesthesia was an era of hesitancy. They resisted using anesthesia for normal deliveries in the belief that childbirth was a natural process and that anesthesia was an unnecessary intrusion. They resisted using any new drugs or techniques until they could prove their safety. In many respects the attitude of nineteenth century physicians resembles that of the Food and Drug Administration today. It was several decades of intense social pressure from patients, not clinical or scientific data, that finally induced physicians to forget their fears and use anesthesia regularly for normal deliveries. In every sense, the progress in obstetric anesthesia for the last century and a half represents a collaboration between physicians and patients. The exhibit of the Wood LibraryMuseum at this year's meeting of the ASA will celebrate a century and a half of progress in the medical management of the pain of childbirth. It will also honor many physicians and patients, now dead, who contributed to the development of our specialty. Donald Caton, M.D. University of Florida (2 of 3) [2/2/2005 4:26:03 PM]

9 A Sesquicentennial Celebration [ Home Search Inside SOAP] (3 of 3) [2/2/2005 4:26:03 PM]

10 Useful and Useless Things to Do on the Internet Useful and Useless Things to Do on the Internet By Scott Segal, M.D. I am an Internet fan. As a method for disseminating information, it ranks with inventions such as movable type or television and radio. But I am also an Internet critic because our ability to post and retrieve information from the `net has far outstripped our ability to find specific content of high quality and relevance. In this article, I will outline some of the strengths and limitations of the Internet (specifically the World Wide Web or WWW), with the intention of outlining some strategies for finding the useful nuggets among the mountain of useless sites. Advantage: The Internet is vast. Disadvantage: The Internet is vast. Advantages and Disadvantages of the Web It is difficult to estimate the number of discrete "pages" of information on the WWW because many are found in small, unindexed sites (host computers) with few or no links to other sites. But the number is certainly very large, at least 50,000,000, and growing at the rate of several percent per month. This enormous volume is a strength, inasmuch as it means we have access to more information than is present in most large university libraries at very low cost (one estimate claims we will be able to download a petabytea quintillion bytes, or the content of more than a million CD ROMsof information for $100 within a few years). But the vastness of cyberspace is also a problem, because there are huge amounts of duplicative information littering the landscape. Table 1 shows the number of "hits", or matches for various search terms I posed to Alta Vista, one of the largest search services. Obviously, if one is to find anything specific, much more powerful indexes and searches are needed. Table 1. Anesthesia 30,000 "Michael Jordan" 200,000 Mars 209,310 Italy 262,217 Sex 700,000 "Bill Clinton" 300,000 Advantage: The Internet is diverse. Disadvantage: The Internet is poorly indexed. The WWW has allowed unprecedented access to mass media by individuals and groups with diverse, even bizarre, interests. Never before has it been so easy to reach a worldwide audience of millions for so little money and effort and, not surprisingly, the web reflects the rich diversity of intellectual and entertainment tastes of us all. Just for fun, next time you access the WWW, call up a search service and try to "stump the Internet" by searching for something truly obscure. You will find it quite (1 of 6) [2/2/2005 4:26:03 PM]

11 Useful and Useless Things to Do on the Internet difficult. Table 2 shows the results of a few attempts of my own, with the resulting number of hits. Search services on the Web have been proliferating but a few major players dominate (see site listings, below). Most of them index sites based on words found in the beginning of the text of the web pages or, sometimes, by the frequency with which a word is used. Few use human reviewers to categorize sites (Yahoo and America Online specialize in this sort of indexing). Because of this relatively primitive way of listing web sites, a search often turns up many irrelevant hits. For example, Alta Vista returned 700 hits for "Room 222" (see Table 2) when I attempted to find information about a 1970's television show by that name. But it also returned 500 for "Room 221" and most of the hits on both lists were references to room numbers in office buildings! Table 2: You can't stump the Internet. Cilantro 10,000 Capybara 1000 "Room 222" 700 "Room 221" 500 "Torsades de Pointes" 100 "David Birnbach" 14 There are, of course, ways to search more effectively. First, select a good search service. Alta Vista has the largest database of sites but has a relatively unsophisticated search engine. Infoseek has only half as many sitesstill many times more than you could ever readbut a much more powerful search system. In particular, you can limit a search for a keyword to only search sites found in your previous query so that, by "nesting" your search requests, you can zero in on the sites you really want. So, for example, if you want information on hotels in Florence, Italy you could search sequentially under "Italy", "Florence", and "hotels". I have found this technique more reliable than trying to use syntax such as "Florence and Italy and Hotels". A second technique is to try your most specific request first, enclosing multiple words or even short phrases in quotation marks, so the words are treated as all one request rather than separate oneword requests. For example, Infoseek correctly handled my request for information about the "Miata Club of America" as a single query. Third, use predigested web indexes when appropriate. Yahoo and America Online, among others, organize high quality sites (using real human reviewers) into categories and subcategories which you can peruse without doing web-wide searches. Finally, use word-of-mouth and third party reviews to find useful sites. Often newspapers, journals, trade magazines, and other web users will have already found some of the best content available for you. Advantage: The Internet is widely accessible. Disadvantage: The Internet is not peer reviewed. Anybody can get on the web, not just as a user or viewer of material, but as a publisher of web pages for others to view. This makes the WWW the most egalitarian source of information on the planet; consider, by contrast, how difficult it is to get an article or book published in print. This is the reason why there is something on just about every topic imaginable somewhere on the Internet. But caveat surfor! No one edits the web for content, accuracy, style, or taste. I recommend extreme caution before using information published by a source you don't already know and trust. Unfortunately, many users may not (2 of 6) [2/2/2005 4:26:03 PM]

12 Useful and Useless Things to Do on the Internet exercise such skepticism and there are now famous stories of misinformation propagated by the Internet. For a frightening look at how obstetric anesthesia can be portrayed, visit some of the sites listed below under "Lay Childbirth Information." Advantage: The Internet is cool. Disadvantage: The Internet is slow. "Cool" in web parlance often refers to all the audiovisual bells and whistles incorporated into web pages. As a showcase of computer technology, the Internet has wowed users and Wall Street alike. And there is some fascinating stuff out there: sound clips, live radio broadcasts, telephone hookups and shared whiteboard conferencing, photographs, movies, even 3-D visuals. But for now, at least, most of this technology is painfully slow. Yes, you can download a street map showing the exact location of your house. But they might build a new street while you're waiting for it to appear on your screen. Much of the most advanced technology runs so slowly on average computers connected by average modems that it leads to hours of wasted time and frustration on the part of many users. It's no coincidence that the WWW has been nicknamed the World Wide Waste. Getting The Most Out Of The Internet Many view the Internet as an intellectual playground of vast proportions. A case can be made that the web is just a really diverse place to spend free time using your computer just for entertainment. But if you are seeking to use the Internet as an information resource, a goal-directed approach to web surfing, using a powerful search service and some thought in generating queries, and perhaps the advice of friends or reviews of web sites in print publications, can yield a fruitful return of useful information. Alta Vista Internet Resources for Anesthesiologists Search Engines The largest index and search service with over 30 million web pages and 500,000 sites. The basic search engine is simple and usually returns far too many hits to be practical. Some complex search requests were mishandled in my tests. Still, the largest and most comprehensive listing; probably the best place for finding really obscure stuff. Infoseek (3 of 6) [2/2/2005 4:26:03 PM]

13 Useful and Useless Things to Do on the Internet About 1/3 to 1/2 fewer pages returned on the average search vs. Alta-Vista, but features a much more powerful search engine. You can search only the hits from the previous query with your next query, to form nested requests and help you narrow your search. Also allows complete phrases to be submitted as search requests, which were handled far more accurately than with Alta-Vista. Considered by web experts to be the best for searches of a very specific nature. Yahoo The darling of Wall Street, its 30 year-old owners are hundred-millionaires. Good basic search engine and some nice advanced options such as limiting to a date a site was added, or a specific category of Yahoo sites. By far the best "predigested" content of the popular search services with hundreds of categorized and subcategorized sites directly reachable without a keyword search (like America Online). Also has direct links to stock quotes, city maps, and sports scores. For some, this is the place to start every new web surf. Lycos Similar to Yahoo in concept, but less famous. Has a map making feature available from the main page that lets you enter an address for anywhere in the U.S. and print out a street map with the location marked. Excite Magellan GASNet Medical Search and Index Pages The premier website for anesthesiologists with links to everything you can think of. Not sexy, but very topical and most useful. See the next site as well. WWW Virtual Library: Anesthesiology (4 of 6) [2/2/2005 4:26:03 PM]

14 Useful and Useless Things to Do on the Internet A listing of over 200 sites of interest to anesthesiologists with brief synopsis of the content of each. An invaluable bookmark to keep on your browser if you're using the net to find anything about anesthesiology. Comprehensive but not exhaustive, though by linking to the sites that are listed you'll find just about anything else. Medscape Lots of links to everything medical, though a bit thin on anesthesiology per se (see other sites for that anyway). Has free medline searches to those who register (also for free); several papers may be published while you wait. ASA Medical and Scientific Sites Meeting listings, membership listings and searches, abstracts of the annual meeting, links to other societies, ASA publications on-line. SOAP Meeting information, newsletter, officers, membership information. Worldwide Congress on Pain Virtual library of pain articles with available CME program, meeting and publication information, links to pain societies and associations. Anesthesia Positions Available Job listings in anesthesia. AMA NIH (5 of 6) [2/2/2005 4:26:03 PM]

15 Useful and Useless Things to Do on the Internet Grant information and applications, research news. Link to NIH's gopher site, CRISP, which allows online searching for abstracts of all current grants. Ob/Gyn Network Doulas of North America Lay Childbirth Information Official site of the doulas' main organization. Includes completely "documented" diatribe against epidural analgesia. Parents Place See "Ask the Midwife" for valuable information about epidural analgesia. Alternative Birthing Practices You have to read it for yourself. Childbirth.Org A fairly balanced selection of information and links to other resources. Scott B. Segal, M.D. Brigham & Women's Hospital Boston, MA bssegal@zeus.bwh.harvard.edu [ Home Search Inside SOAP] (6 of 6) [2/2/2005 4:26:03 PM]

16 Pro Con Forum PRO-CON Clinical Forum The Role of Obstetric Nurses in Labor Analgesia Management Recently, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) issued a policy statement recommending that rebolus of an epidural catheter be performed only by a qualified anesthesia provider. Particularly in the community setting, many anesthesia groups utilize labor and delivery nurses whom they have trained, to assist them with this task. What follows is one practitioners experience with this approach and information from AWHONN on how and why they arrived at this decision. If you have personal experience or feelings on this matter, please let other SOAP members know how you feel via the SOAP Box. Valerie Arkoosh, M.D. Chair, Education Committee Quick Links AWOHNN Position Statement ASA Committee on Obstetrics Response AWHONN Response Community Response Association of Women's Health, Obstetric and Neonatal Nurses Position Statement Approved by the AWOHNN Executive Board 1996 ISSUE: ROLE OF THE REGISTERED NURSE (RN) IN THE MANAGEMENT OF THE PATIENT RECEIVING ANALGESIA BY CATHETER TECHNIQUES (EPIDURAL, INTRATHECAL, INTRAPLEURAL, OR PERIPHERAL NERVE CATHETERS) A registered nurse (RN) manages the care of nonpregnant patients with catheters or devices for analgesia to alleviate acute postsurgical pain, pathological pain, or chronic pain. The RN may monitor the care of (1 of 10) [2/2/2005 4:26:04 PM]

17 Pro Con Forum the pregnant patient receiving epidural analgesia following stabilization of vital signs after either bolus injection or establishment of continuous pump infusion. The RN may remove the catheter from either the pregnant or nonpregnant patient when educational criteria have been met and institutional policy and state laws allow. The registered nurse may remove the catheter that has been used for analgesia upon receipt of a specific order from a qualified anesthesia or physician provider. For the Pregnant Women: The insertion, initial injection, or initiation of a continuous infusion of epidural catheters for analgesia should be performed only by a qualified and credentialed, licensed anesthesia care provider as described by the American Society of Anesthesiology, Guidelines For Practice, Oct. 1994, and the American Association of Nurse Anesthetists, Guidelines for Obstetrical Anesthesia and Conduction Analgesia, Rebolus of an epidural catheter includes injection of the catheter by syringe or increasing the rate of a continuous infusion. Rebolus should be performed only by a qualified and credentialed, licensed anesthesia care provider. A qualified and credentialed licensed anesthesia care provider must be readily available as defined by institutional policy. The RN may monitor the mother and fetus, replace empty infusion syringes or infusion bags with new pre-prepared solutions, stop the infusion, initiate emergency therapeutic measures under protocol if complications arise, and remove the catheter. For the Nonpregnant Women: It is within the scope of practice of the registered nurse to manage the care of nonpregnant patients receiving analgesia by catheter as defined above only when the following criteria are met: The registered nurse managing the care of the patient does not assume responsibility for the catheter until the provider who placed the catheter/infusion device has verified correct catheter placement and the patient's vital signs have stabilized. Management and monitoring of analgesia by catheter techniques, including reinjection and/or alteration of infusion rate by nonanesthetist RNS are allowed by state laws and institutional policy, procedure, and protocol. Consistent with the law, the attending physician or the qualified anesthesia provider placing the catheter or infusion device selects and orders the drugs, dosage, and concentrations of opioids, local anesthetics, steroids, alpha-agonists, or other documented safe medications or combinations thereof. (2 of 10) [2/2/2005 4:26:04 PM]

18 Pro Con Forum Guidelines for patient monitoring and drug administration and protocols for dealing with potential complications or emergency situations are available and have been developed in conjunction with the anesthesia or physician provider. Replaces 1991 statement of same title. ASA Committee on Obstetrics Opinion I am writing in reference to the AWHONN statement noted above. Your revised statement was sent to the American Society of Anesthesiologists' Committee on Obstetrical Anesthesia last year for possible endorsement. We chose not to endorse the statement because of the following concerns: 1) there was no morbidity or mortality data to support this change in policy, 2) there are too many practice styles around the country to mandate a single policy for every hospital on this issue, and 3) there is no basis for separating gynecology patients from obstetric patients as the complications of epidural analgesia are the same. Since your statement has been released, our committee has received numerous calls from around the country from anesthesiologists, nurses, hospital administrators, etc. who have concerns about the impact this statement is having on their labor and delivery practice. Our committee recently reviewed your document again with these practice concerns in mind, and we wish to raise the following issues against your change in policy: 1. To our knowledge, there is no morbidity or mortality data available to support or necessitate a change in policy on a national level. We endorse policies made at individual institutions depending upon nursing education and training. 2. Changes in nurse practice mandated by the AWHONN statement may impact obstetric patients' pain relief and satisfaction in some practices if this document is adopted as policy without prior arrangements for alternate personnel who can adjust infusion rates or administer additional doses. In some units epidural analgesia may be denied or delayed because of a lack of personnel. 3. The policy does not allow for variations in nursing education and training at different institutions. If the protocols, credentialling, and educational support systems are in place, there are institutions where nurses can safely manage epidural analgesia. This is supported by the fact that AWHONN allows such practices in gynecology patients. In many practices around the country, L&D nurses have been safely managing epidural infusions and bolus doses with such protocols in place. (3 of 10) [2/2/2005 4:26:04 PM]

19 Pro Con Forum 4. The guidelines should allow hospitals to develop their own nursing policies based on their nurses' education and training. Anesthesiologists value their relationships with L&D nurses and should be involved in this type of education and credentialling. 5. Nurses administer other potentially dangerous medications to obstetric patients such as magnesium and intravenous narcotics with training and credentialling. Care of epidural catheters should not be treated differently. 6. Another example of the safe practice of non-anesthesia personnel providing epidural bolusing is patient-controlled epidural analgesia (PCEA). With this technique, the patient administers a preset dose of anesthetic, a dose similar to one administered by a trained RN. Nursing protocols which allow nurses to change the rate on an infusion pump or bolus from a pump or prefilled syringe by protocol and with training is a similar practice. We hope you will respond to these concerns and consider revising your statement to reflect the need for appropriate training and credentialling of nurses rather than simply a restriction in their practice without supporting data. Sincerely, Joy L. Hawkins, M.D. Chairman, ASA Committee on Obstetrical Anesthesia AWHONN Opinion The current position statement is a revision of a document that originated from a multi-association effort in It appears that a number of state nurses associations asked the American Nurses Association (ANA) for guidance in the nurses role with epidural analgesia and conscious sedation. The National Federation of State Nursing Organizations collaborated with the ANA to address these issues. The ANA sponsored an issues-focused discussion group for interested nursing specialty organizations at the 1990 Nursing Organizations Liaison Forum. A series of meetings to develop the written document occurred over the next several months. The result was a two-part position statement signed by 22 participating nursing specialty groups, which was distributed in In 1995 concerns began to surface across our membership regarding the lack of clarity for the nurses role in supporting epidural analgesia for the pregnant woman. During the next several months the committee (4 of 10) [2/2/2005 4:26:04 PM]

20 Pro Con Forum on practice entertained discussion and review of this issue. In the summer of 1996 the Executive Board of AWHONN accepted the committee's recommendation to revise this position statement based on these factors: (1) The fetus is the second patient for whom the nurse is responsible. (2) The fetus is dependent on maternal physiology. If the mother is compromised, the fetus suffers that compromise first. (3) The pregnant woman differs physiologically from the nonpregnant woman. Her increased sensitivity to local anesthetics like the "caine" drugs,, the engorgement of the epidural vein which increases the potential for catheter migrations, and her obliterated response to supine hypotension are the basis for viewing her epidural management in a different context than the nonpregnant woman. (4) Finally, we do not believe that the staff nurse, in most hospitals, is educated or trained to intervene independently and manage the patient should there be a negative response to the analgesia. The data from our member survey highlights the latter point. Almost one third of the nurses who do provided an intervention to the epidural, through a bolus or increase in infusion rate, indicate they have received no education or training for this responsibility. Of the 1000 members who responded to the survey 76.5% do not provide the intervention. All of the 24.5% who provide this intervention indicted they do so because "anesthesia is unavailable." We do believe we should make a distinction between the pregnant woman and the nonpregnant woman in relationship to epidural analgesia. And because there are no data to support the safety of staff nurses providing a bolus of increasing an infusion, AWHONN altered its 1991 position statement. Your letter also suggests that epidural analgesia should not be viewed differently than other medications nurses administer to obstetric patients, such as magnesium sulfate and intravenous narcotics. The technical function is not in dispute, but the management of potential complications is the issue. Other interventions are considered part of core curriculum in nursing programs, and they are found in the major nursing texts as well as nursing literature. This is not the case with increasing infusion rates or providing a bolus with epidural analgesia for the pregnant woman. We agree with Terry Walman, M.D., J.D. who comments in the February 1997 OB-GYN Malpractice Prevention newsletter, "An RN who gives a bolus injection to the epidural or removes the catheter assumes the same liability as the anesthetist who inserted the catheter. Judith H. Poole, RNC, MN Chair, Committee on Practice AWHONN (5 of 10) [2/2/2005 4:26:04 PM]

21 Pro Con Forum Community Opinion The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) has been striving to have their position incorporated into the various state regulations governing the practice of the Registered Nurse (RN). If successful, this needlessly would disrupt approximately 25 percent of the current obstetrical anesthesia services. In a letter to The American Society of Anesthesiology (ASA), Gail Kincaide, Executive Director of AWHONN, asked the ASA to endorse AWHONN's Position Statement. The first paragraph reads: (in entirety) "Our Executive Board has withdrawn the position statement titled Role of the Registered Nurse in the Management of Analgesia by Catheter Techniques, reaffirmed June This decision was based on the Committee on Practice recommendation that the staff nurse providing re-injection of epidural analgesia to the pregnant woman poses a risk-management concern. If the mother has an adverse reaction to epidural medication there can be serious consequences if the reaction is not managed effectively: the fetus is the second patient dependent on maternal physiology. Anesthesia personnel are educated and trained in the management of these complications." Correctly, the ASA has declined endorsement. AWHONN has not furnished the data necessary to justify support. AWHONN must explicate the "risk-management concern" they perceive. Accurate assessment, and thorough analysis, come before policy endorsement. Prior to asking for endorsement, AWHONN must determine that the "risk-management concern" referred to, is a tenable adverse event, and not simply a "windmill". To authenticate their position, they need to present data which: 1. Establishes the existence and frequency of the identified adverse event. 2. Determines whether the event is, as they imply, confined to the pregnant patient. 3. Documents the morbidity and mortality experienced by mother and baby. 4. Elucidates the factor(s) causing the event, as opposed to those that simply might be associated with the event. 5. Demonstrates that their proposed policy mandate, if enacted, would eliminate the perceived adverse event. 6. Discusses the possible negative effects the proposed mandate would have on the availability of labor analgesia. (6 of 10) [2/2/2005 4:26:04 PM]

22 Pro Con Forum 7. Suggests viable alternatives to the current, experience proven practice. AWHONN has proposed an encompassing, restrictive policy, that markedly conflicts with current practice. For many years, anesthesiologists at my institution and others have delegated to trained RN's the adjustment of epidural infusion rates and the administration of small bolus injection, in established labor epidurals without compromising patient safety. This has been by physician order following standardized protocol with the anesthesiologist immediately available. In a communiqué from AWHONN to the ASA Judith H. Poole, RNC, MN, Chair, Committee on Practice makes reference to a survey of 1,000 AWHONN members. Ms. Poole states that 24.5 percent of the members reported that they "provide an intervention to the epidural, through a bolus or increase in infusion rate". Although she alludes to "potential complications", there is no mention of any specific adverse event(s). The SOAP membership has confirmed AWHONN's findings. At the last SOAP meeting (Bermuda, April 1997) a Workshop was devoted to discussing existing labor analgesia practices. 1 Of the 80 participants responding: 26 percent reported in their practices RNS adjust epidural infusion rates according to written instructions. In 11 percent of the practices, "top up" doses were administered by RNS. In response to the specific question: "Is anyone aware of an adverse outcome caused by a RN adjusting the epidural infusion rate of, or administering a bolus to, an established labor epidural?" no one responded in the affirmative. Although perhaps not conclusive, such data at least shows that - and agrees with AWHONN's survey that - in approximately 25 percent of existing practice settings the RN safely adjusts labor epidurals. At the same SOAP meeting Eli Alon, M.D. presented data concerning the labor analgesia practices in his native Switzerland. He reported that over 90 percent of labor epidurals, once established, are managed by non-anesthesia personnel. For the past 21 years the group with whom I am associated, (at Tucson Medical Center, Tucson, Arizona) has maintained a 24 hour obstetric anesthesia service. The anesthesiologist is in-house and has no responsibility other than labor and delivery. We have performed more than 60,000 epidurals. All epidurals were established by an anesthesiologist. For most of the years we utilized a patient-request rebolus method for continuing the epidurals. The vast majority of the repeat boluses were administered by trained RNs according to the anesthesiologist's orders per written protocol. We experienced no adverse outcomes to either mother or baby as a result of a bolus administered by a RN. In recent years, we have converted to the continuous infusion technique. After training, RNs are permitted to adjust the infusion rate and administer bolus injections within written confines. In approximately 25 percent of the epidurals the RN either adjusts the infusion rate or administers a bolus injection. Again, we have had no adverse outcomes to either the mother or the baby as a result of rate adjustment or bolus injection by the (7 of 10) [2/2/2005 4:26:04 PM]

23 Pro Con Forum RN. While we are very comfortable with our practice protocol, in no way would we suggest that our preferences be adopted as a national mandate. Our experiences at Tucson Medical Center, while extensive, is by no means unique. Others report similar experience. A SOAP colleague from Virginia Beach, Virginia reports their 30 year experience with approximately 50,000 labor epidurals. They also utilize the expertise of RNS and recount "no problems or bad results". Similar information is reported from a member in the San Francisco area. Following this Newsletter I'm sure we will hear from others with even greater experience. AWHONN's position statement is not consistent with the acknowledged responsibilities of the labor RN. Labor RNs administer many potent medications including oxytocin, magnesium sulfate, terbutaline, and narcotics; all of which have well-documented, potentially adverse effects for both mother and baby. Each medication has minor complications that easily can be detected and corrected by the RN. However, each medication has recognized but fortunately very rare complications, the management of which requires personnel whose training is beyond that of the RN. It is the protocol of administering the medication that assures safety. Properly, the details of the protocol are the prerogative of the individual institution. As an example, oxytocin is recognized as one cause of uterine rupture, the management of which requires an obstetrician. However, it would be inefficient, inappropriate, and unnecessarily disruptive to require that the obstetrician personally make all adjustments of an intravenous oxytocin infusion. The RN is able to function within individual institutional protocol guidelines to safely and efficiently manage the infusion. Changing the infusion rate of an existing epidural or bolusing an existing epidural should be considered the analogous to adjusting an infusion of oxytocin. AWHONN's position statement, if enacted, would result in less effective pain relief with no evidence of increased safety for mother or baby. Anesthesia and nursing personnel must blend their expertise and availability to maximize the safety and comfort of every mother and baby. Individual institutional prerogative is the cornerstone to this achievement. A factor, unique to the safety of medications administered by the labor room RN, is the virtually constant observation the RN can offer following administration. While we expect each surgical patient to be attended by their exclusive anesthesia and surgical personnel, no such expectations exists for the labor patient - nor can it be provided - nor is it necessary. In (8 of 10) [2/2/2005 4:26:04 PM]

24 Pro Con Forum obstetrics, it is the RN who offers the parturient constant vigilance. Both the obstetrical provider and the anesthesia provider must be able to engage the expertise of the RN to assure the safest, most efficient, and most effective patient care. There is no need to deny the adjustment of an existing labor epidural while the anesthesia provider is establishing another labor epidural. There is ample evidence that the trained RN currently assists effectively and safely. There is no evidence to the contrary. There is no morbidity data to support AWHONN's proposal for differentiating the pregnant from the non-pregnant patient. At least, I am not aware of any data; and, as AWHONN has not presented any, I assume they have none. Ms. Kincaide's statement: "If the mother has an adverse reaction to epidural medication there can be serious consequences if the reaction is not managed effectively: the fetus is the second patient dependent on maternal physiology." while a truism, in no way validates AWHONN's position of arbitrarily allowing the RN to alter the rate of infusion for non-pregnant patients while prohibiting adjustment for pregnant patients. AWHONN's position statement is in conflict with the extensive experience from patient controlled epidural analgesia (PCEA). Certainly, the trained RN is as competent to administer a bolus injection as the medically untrained parturient is to administer her own bolus injection. At the previously referenced SOAP Workshop Session, 26 percent of respondents said they use PCEA in their practices. Numerous articles confirm the safety and efficacy of PCEA. (See the excellent review article and extensive bibliography by M.J. Paech.) 2 The mechanical act of administering the bolus injection has been done by anesthesia providers, obstetrical providers, nursing personnel, and even the patient herself. No one has reported an adverse outcome attributed to who is doing the injection. The safety of PCEA is achieved by adhering to the individual institutional protocol. The safety experience with PCEA is convincing that in an established, functioning epidural, the bolus injection can be done with equal safety by the anesthesiologist, the nurse anesthetist, the RN, or the patient. Are there factors other than a "risk-management concern" that compel AWHONN to propose their policy statement? (9 of 10) [2/2/2005 4:26:04 PM]