Health Informatics Within the Anesthesia Department

Introduction

Incorporating health informatics in anesthesiology is beneficial due to better patient data collection, storage, and circulation, which results in timely decision-making. Computer technologies embedded into anesthesia information management systems (AIMS) help Certified Registered Nurse Anesthetists (CRNA) interpret patients’ physiological data and deliver appropriate care using the anesthesia workstation. Informatics applications collect data directly from the latter and transfer it to databases and documentation systems, improving other clinical functions and facilitating patient safety.

Main body

To incorporate the concept of patient health informatics, the Anesthesia Department should consider AIMS and its embedded tools. This system improves anesthesia displays due to better records, timely bedside documentation, and frequent bedside scanning and monitoring. As a result, health care professionals turn to less biased and erroneous intraoperative data during their work since the recorded data is more robust than the handwritten one. It also supplements the knowledge of anesthesiologists by enabling the “synthesis of large amounts of patient data, current literature, and clinical guidelines.” Clinical decision support (CDS) assists anesthetists in avoiding care omission by accurately displaying patient data. In addition, it provides prompts and reminders to them for timely intraoperative interventions. For instance, AIMS sends real-time visual reminders to health care professionals to remind them to administer antibiotics during surgeries. The system is also able to compare the performance of a particular provider to the facility’s standards. CDS was found to improve antibiotic administration and facilitate anesthesia billing. Implementation of CDS within AIMS addresses documentation and clinical weaknesses of anesthesia departments by enhancing practice changes that improve financial sustainability and quality of patient care.

Furthermore, computerized physician order entry (CPOE), a part of CDS, assists clinicians in writing proper care and medication orders for their patients. Mastrian and McGonigle argue that “CPOE solves the safety issues associated with poor handwriting and unclear or incomplete medication orders.” It avoids typical mistakes associated with verbal orders and paper-based systems. RFID technology often accompanies CPOE to monitor medication circulation within medical facilities setting a system of checks and balances. The system warns about possible drug allergies, interactions, or overdoses and enhances collaboration between physicians, CRNAs, and pharmacists. It is very challenging for practitioners to remember how to adjust all drugs in the case of a specific disease; thus, CPOE contributes massively to patient safety by providing dosing parameters.

Qualified Clinical Data Registry (QCDR) is a reporting mechanism that collects data regarding different aspects of anesthesia care. The Center for Medicare and Medicaid Services (CMS) aims to analyze this medical and clinical data in order to improve the quality of health care. The PQRS was not suitable for specialists such as anesthesiologists; however, QCDR enables providers to set their own list of measures. This reporting is of high importance for the further improvement of patient care and safety.

Conclusion

To conclude, computer technologies continue to improve and expand their potential in helping specialists with their daily tasks. The Anesthesia Department should consider deploying AIMS that supports such tools as CPOE, CDS, and QCDR. All of them enhance monitoring of patient’s health, medication circulation, and timely drug administration. Consumer health informatics have a positive influence on intermediary health outcomes contributing to higher patient safety. Handwritten systems find facility and CRNAs at risk of making other data misinterpretations that lead to mistakes. Therefore, despite some disadvantages, presented technologies should be implemented within the department.

References

Peterson JJ, White KW, Westra BL, Monsen KA. Anesthesia information management systems: imperatives for nurse anesthetists. AANA Journal. 2014;82(5):346-351.

Mastrian, K, McGonigle D. Informatics for health professionals. Burlington, MA: Jones & Bartlett Learning. c2017:254-266.

“Postoperative Recovery Advantages in Patients Undergoing Thyroid and Parathyroid Surgery Under Regional Anesthesia.” by Suri

This review seeks to examine the article by Suri et al. (2010) titled “Postoperative Recovery Advantages in Patients Undergoing Thyroid and Parathyroid Surgery under Regional Anesthesia.” The purpose of this review is to investigate some of new insights that the article brings into the field of medical surgery.

Additionally, the review examines the findings of the study and how it can help to improve or change the practice in health institutions, especially among medical professionals dealing with surgery. There are intriguing debated about the advantages of using regional anesthesia during minimally invasive parathyroidectomy. In evaluating the extent to which general and regional anesthesia succeed as a method of conducting surgery, Suri et al. (2010) assessed the postoperative recovery advantages in these two techniques.

Previous studies have established that carrying out parathyroidectomy under local or regional anesthesia using sedation has significant advantages, including less postoperative nausea, pain, vomiting, and opioid analgesic requirements. Although these studies have found inextricable evidence suggesting the benefits of general anesthesia, recent studies indicate that it is possible to undergo these surgeries without inducement of general anesthesia.

Suri et al. (2010) purposed to discover some of advantages of regional versus general anesthesia. From the research article, the researchers found that patients undergoing parathyroid surgery under superficial cervical plexus block are more advantageous compared to when undergoing general anesthetic procedures.

The study brings on board new insights to the theory and practice of medical surgery. The study suggests that patients undergoing regional anesthetic procedures usually experience a fast rate of recovery after parathyroid surgery. The study’s findings confirm the results of prior researches, which have found that patients are undergoing the general anesthesia experience quick recovery and get back to healthy life faster compared to the ones undergoing general anesthesia.

While some studies have suggested that patients were satisfied with both general and regional anesthesia with sedation, Suri et al. (2010) found that the pain reduction was eminent in procedures where patients are undergoing parathyroid surgery under regional anesthesia.

The article shows that they consulted other existing literature, which has investigated the advantages of applying general and regional anesthesia procedures. This is seen from a number of referral studies, which undertook to examine various anesthetic procedures during surgery. The sound and precise background developed by the researches gives a formidable platform to understand the subject under review.

Although it is arguable that the article used previous studies to ground its theory, a review of the article shows that the researchers did not give the study a full scope of coverage. It is critical for a researcher to set off a study from an extensive an extensive background, which forms the momentum for the study.

According to the study, Suri et al. (2010) found no significant difference between the general and the regional anesthesia procedures in terms of some of postoperative advantages, including the timing of pain, narcotic pain medication, and incidence of nausea, voice hoarseness, vomiting, or swallowing problems.

The study reveals that although both anesthesia procedures involved in general and regional techniques had far-reaching postoperative advantages, the Suri et al. (2010) found that patients undergoing bilateral superficial cervical plexus block recorded incidents of sharp pains.

In conclusion, the research article by Suri et al. (2010) utilized a relatively large sample that allows for generalization of the results. The confirmation of previous studies’ findings serves to show that the study remains in conformity with the research standards.

Reference

Suri, K. B., Hunter, C. W., Davidov, T., Anderson, M. B., Dombrovskiy, V., & Trooskin, S. Z. (2010). Postoperative Recovery Advantages in Patients Undergoing Thyroid and Parathyroid Surgery under Regional Anesthesia. Seminars in Cardiothoracic and Vascular Anesthesia, 14(1).

General Anesthesia in Dentistry

In the field of dentistry, the uses of methods involving sedation, for the treatment of patients are often used. It is however crucial that these methods and techniques are safe and help in making the procedure more effective while reducing the pain of patients undergoing dental procedures. A commonly used technique for dentistry procedures is General Anaesthesia. The safety of the technique of general anesthesia has been of constant concern to the anesthesia regulatory bodies and there are several guidelines and standards for its use in the medical field. The Royal College of Anaesthetists (RCA), has concerns regarding the increasing number of general anesthetics being used for dentistry (1,2) and that these anesthetics may not always be necessary, as such patients face the unnecessary risk, sometimes even resulting in the death of healthy patients, due to the use of these anesthetics (3).

The use of general anesthesia has been associated with certain levels of risks and it has been widely accepted that dentistry procedures must be performed by using local anesthetic measures where ever [possible. In cases of patients with elevated levels of anxiety, it has been proposed that the technique of conscious sedation be used (4). The Royal College of Anaesthetists strictly states that the use of general anesthesia must be limited only to the patients and clinical situations where local anesthesia is not possible. The college maintains that there should be persistent pressure regarding the use of the general anesthesia technique.

The College recommends dentists ensure that very young children must be administered anesthesia only at the hands of pediatric anesthetists who are specialized in the field.

Standards and Guidelines for use of General Anaesthesia Guidelines and training (10, 11)

In most circumstances, sedation is conducted by non-anesthesiologists. To prevent or manage complications during sedation, the practitioner has to follow certain safe practice guidelines. Various professional bodies and organizations, such as the Royal College of Anesthetists, have promulgated guidelines to assist the practitioner in performing sedation safely. These guidelines outline the general principles of safe practice without providing specific details. Individual departments need to build their own practice guidelines based on these principles to cater for variations in patients, procedures, practitioner skills, and physical setting (10, 11).

Doctors and nurses involved with sedation should undergo regular recertification of cardiopulmonary resuscitation skills. Protocols for resuscitation such as the Advanced Cardiac Life Support protocol, and for managing complications such as desaturation, should be adopted in areas where sedation is conducted. The staff involved should also receive training in the use of sedative drugs and in appropriate monitoring of patients (10, 11).

Assessment of patient and discussion

In administering general anesthesia to patients there are a number of standards and guidelines which are necessary to be followed in the practice of dentistry.

It is necessary to perform a screening of the patient by the referring dentist to take into account the full history and inform the patient about the risks involved in the use of general anesthesia, also informing him about the alternative techniques present (4).

Consent form & Medico-legal aspects

General anesthesia is a technique that carries significant risks to the patient. It is necessary to explain all significant risks to the patient and to obtain consent for sedation. It is also important to have another person present during the sedation process to circumvent any potential claims with legal ramifications made by the patient (5).

The consent of the patient is crucial before the use of general anesthesia, the best method of doing so is by signing a consent form. This is important as the patient will be unconscious while the dental procedures are being performed (4, 5).

Staffing

Medical practitioners involved with sedation should have a good knowledge of the physiology/pharmacology of sedation, and be competent in patient monitoring and resuscitation. The anesthesiologist is the ideal person to sedate and monitor the patient.

The RCA recommends the categories of staff for administering dental anesthesia to dental patients. These include trainees working in programs affiliated to the RCA under proper guidance (6) and non-consultant career grade doctors who work under the supervision of named consultant doctors with a membership of a reputable hospital or community trust (7,8).

Monitoring

The performing anesthetists are required to have sincere assistants who have received prior training for the job function. Till the time the unconscious person regains consciousness, careful and accurate monitoring of the patient needs to be done in a setting equipped with adequate recovery facilities (9). The guidelines state that one nurse per patient must be present for monitoring and after-care of unconscious patients.

The Clinical Setting

The clinical setting for the practice of administering general anesthesia to patients must take the ‘worst-case scenario’ into account. Although modern practices of anesthesia do not offer risks and complications, the team performing the procedure must be skilled and efficient, so that the patient is not at any kind or risk of permanent harm to the patient (10). The risk to the life of a patient is greater if the administration of general anesthesia takes place far away from the aid of essential clinical services, thus the administration setting must be close to clinical services which may ensure access to emergency services (10).

Equipment and drugs

The equipment used by the dentist and the anesthetist must be specially designed for use in dental settings and procedures. Besides the equipment and the anesthetic drugs, adequate equipment for monitoring the patient must also be available which also includes the necessary drugs crucial for resuscitation of the patient (10, 12, & 13).

All the equipment and drugs available must be checked by the anesthetist (14) before the conduction of the procedure and special care must be taken to ensure that in case there is the failure of one or more equipment, there is/are substitute equipment and facilities available for immediate use and access. It is also the duty of the anesthetist to ensure that the medical gases which have been supplied and stored are in accordance with the necessary rules and regulations of the medical regulations (15).

The area where sedation is conducted should be supplied with appropriate equipment and drugs required for cardiopulmonary resuscitation, and airway, ventilatory, and circulatory support (13).

Aftercare

The modern dental procedures used for sedation do necessitate prolonged hours of unconsciousness and the patients recover quickly. It is necessary that patients are evaluated, to check their fitness levels before being discharged. Especially in the case of administration of general anesthesia, the patients are required to stay for at least a day, before the effects and hang-over effects of the drug are eliminated (16).

Management of anxious patients using general anesthesia

General anesthesia is not very commonly used for dental procedures, with several modern and effective techniques available to dentists today. However, in the case of extremely phobic patients, general anesthesia may be administered to patients. Since the technique of general anesthesia involves the complete sedation of the patient, all the senses of the patient are de-activated, causing the patient to go into a deep sleep (4).

It is therefore crucial for the anesthetist, to carefully monitor all the physical vital functions of the patient including the heart and pulse rate, blood pressure, and breathing. It is the duty of the functioning anesthetist to carefully monitor and control the amount of anesthesia to the patient to avoid any complications and risks (4).

Effects of General anesthesia

General anesthesia may be used for extremely phobic patients, but the technique is not without any substantial risks. The most immediate effects of general anesthesia are nausea and dizziness. The procedure is more expensive than the other sedation techniques used. According to several researches conducted, anxious children who had been administered general anesthesia for dental procedures, displayed several symptoms of nausea, vomiting, sickness, and prolonged bleeding, following the procedure (17, 18). Some children were even reported having psychological trauma, one month after the procedure had been conducted (17). A few children were reported having nightmares and bad memories while one child experienced depression for several days after being administered general anesthesia for the dental procedure (17). Thus, researchers have concluded that dental procedures and extractions which are conducted using the administration of general anesthesia among young children have several ill effects including morbidity and distress (17).

Researchers have substantially proved that the practice of general anesthesia for extractions and dental procedures in anxious young children does not in any way help to curtail or manage the phobia among children (18). The after-effects are several and commonly include morbidity (19) and distress among anxious patients, with substantial side-effects stretching from a day to several weeks and sometimes even a month after the dental procedure has taken place (17, 18).

It is therefore the duty of the dentist and the anesthetist to inform the parents of the child regarding the side-effects of the administration of general anesthesia for dental procedures (18).

References

Whittle JG, Jones CM, Hannon CP. Trends in the provision of primary care dental general anaesthesia in the North of England, 1991/92-1994/95. British Dental Journal 1998; 184: 230-234. See also: Whittle JG, Hannon CP, Jones CP. Dental general anaesthesia in the North of England 1991/92 to 1996/97. The Dental Public Health Northern Quality Improvement Group. 1998.

Dental Practice Board for England and Wales. Digest of Statistics.

General Dental Council. Maintaining Standards: Guidance to Dentists on Professional and Personal Conduct. 1998.

Association of Anaesthetists of Great Britain and Ireland. Consent for Anaesthesia. (In Press.).

Bachelor P, Sheiham A, Albert D, Cowell C. Department of Dental Public Health, The London Hospital Medical College; January 1994.

The Association of Anaesthetists of Great Britain and Ireland. Non-Consultant Career Grade Anaesthetists. 1998.

Royal College of Anaesthetists. Guidance for the Appointment of the Staff Grade, Associate Specialist and Hospital Practitioner Grade Anaesthetist. 1998.

The Association of Anaesthetists of Great Britain and Ireland. Recommendations for Standards of Monitoring during Anaesthesia and Recovery; Revised. 1994.

Standing Dental Advisory Committee. Report of an expert Working Party (Chairman: Professor D Poswillo). General Anaesthesia, Sedation and Resuscitation in Dentistry. 1990.

Clinical Standards Advisory Group. Dental General Anaesthesia. 1995.

The Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland. Good Practice: A Guide for Departments of Anaesthesia. 1998.

Colquhoun MC, Handley AJ, Evans TR (Eds). ABC of Resuscitation, 3rd Edn. London: BMJ Publishing Group; 1995.

The Association of Anaesthetists of Great Britain and Ireland. Checklist for Anaesthetic Apparatus 2. 1997.

European Committee for Standardisation. The European Standard EN 737-4: 1998. Medical Gas Pipeline Systems. 1998.

The Royal College of Surgeons of England Commission on the Provision of Surgical Services. Guidelines for Day Case Surgery. Revised 1992.

Bridgman CM, Ashby D, Holloway PJ. An investigation of the effects on children of tooth extraction under general anaesthesia in general dental practice. Br Dent J 1999; 186: 245–247.

M. T. Hosey, L. M. D. Macpherson, P. Adair, C. Tochel, G. Burnside & C. Pine. Dental anxiety, distress at induction and postoperative morbidity in children undergoing tooth extraction using general anaesthesia. Br Dent J 2006; 200: 39-43.

Arch LM, Humphris GM, Lee GTR. Children choosing between general anaesthesia or inhalation sedation for dental extractions: the effect on dental anxiety. Int J Paed Dent 2000; 11: 41–48.

History of Early Anesthesia: From the Early 1840s to Nowadays

Introduction

Administration of anesthesia on patients undergoing surgery started in the early 1840s and gained a lot of impact in 1946 when William Morton used ether on gilbert as anesthesia at Massachusetts hospital in Boston. Before its discovery, surgery was very agonizing and was only done as a last resort to save a life. The efficiency of a surgeon then was determined by his or her speed as many patients did not survive the agony experienced because they used alcohol and morphine to reduce the pain. Latter, chloroform was used but caused liver damage in spite of its good work and popularity. Today anesthesia has achieved objectives like causing patients to get asleep faster and in a pleasant process, as well as the development of local anesthesia. Nowadays, surgeons have enough time to be more accurate, especially on complex procedures. They are also well trained, and anesthesia is very safe, with an estimated number of 1 death in 250,000. (Bankert, 2005 pp 23-35).

Role of early anesthetists

Catherine S. Lawrence became the first nurse to provide anesthesia with the assistance of other nurses during the civil war between 1861 to 1865, but just a little of the medicine was administered as it was considered too unsafe. However, Sister Mary Bernard was the first nurse to be officially recognized in1878 when she was practicing as a nun at St. Vincent’s Hospital. The roles of the early anesthetists were to find out if the patient was fit for the process and gave the framework for a professional assessment. They did all the tests required ahead of the surgery and checked the outcomes of the screening. They also explained the effects of anesthesia to the patients for them to make the final decision. (Thatcher, 2004 pp 4550).

Anesthesia leaders Alicia Magaw and Sister Mary Bernard

Alicia Magaw became the most popular anesthetist and was recognized as the mother of anesthesia of the 19th century because of her effectiveness in her work, especially in the use of open-drop inhalation using ether and also because of the publishing of her research. However, the earliest records regarding the care of anesthesia patients showed the works of Sister Mary Bernard, who was also a Catholic nun at St. Vincent hospital.

History of nurse anesthetist’s education up to the present

In America, the education of anesthetists is monitored by the American association of nurse anesthetist’s council through the established programs. The education and titles awarded vary depending on the state of the trainee where he receives a degree or a certificate after meeting all the requirements for the program. By 1982, registered nurses were required by AANA to be baccalaureate and have a master’s in anesthesia program. After the study, anesthetists practice in countries that are developed as the undeveloped ones do not have adequate knowledge, although this is to the disadvantage of the developing countries. (Ganado, 2005 pp 25-36).

Present job roles of the nurse anesthetists

The anesthetist cares for the patient throughout the process and even after by carrying out the assessments and offers preoperative teachings to the patient as well as making preparations for the process management. They also administer the medicine to free the patient from pain and oversee his or her recovery through the postoperative process in the care unit.

Grounds for disciplinary proceedings

Health is the most important aspect of human life. With poor or unstable health, one becomes weak and unable to perform most of the basic activities. That is why the health personnel is required to master their work so well to avoid occurrences that may lead to loss of life. To ensure that nurses are well conversant with their jobs, the syllabuses that they are to handle tend to cover all relevant areas that they expect to meet in the field through class presentations, lab demonstrations, and numerous exercises. To conduct a program or a curriculum of nursing and prepare students to register as nurse anesthetists without any accreditation of that particular syllabus by the board is considered a legal offense.

Legislation, therefore, has been put in place to ensure the protection, safety, and welfare of the public, with its primary purpose to promote, preserve and protect the public. No person is allowed to practice or perform any duty of a registered nurse anesthetist without a legible license that is approved by the board. The licenses are valid for only a specified period, after which they need to be renewed; failure to do so after an expiry period has lapsed calls for stern action from the board. The penalties of such an offense, as well as other instances of any breach of the law, are varied. In a case of a violated rule by a practicing nurse, the board may decide to revoke, suspend, probate, or limit the nurse’s license. They may also impose fines, and those who are still in the process of their studies may be barred from entering or advancing to the next clinical phase of their education. Such penalties can also be imposed in a case of detected negligence, inability to practice because of lack of skills, or when rendered so by drug abuse, for instance, alcohol-that leads to mental incompetence. Other actions that are considered an offense against a nurse’s ethics include any licensee found selling a license or falsely obtaining the same. Only the board has the authority to approve, revoke or renew a license or revise rules, and all appointments by the administrators to govern a department are subject to confirmation or approval by the senate.

For anyone who is not satisfied by the decision by the board to revoke his/her license, they are free to challenge that decision by appealing in court, but such appeals have to be done within thirty days after the mailing of the notice of the decision by certified. On the other hand, the board can obtain a restraining order which is not subject to release upon the bond; this order can then be converted into a permanent injunction.

Conclusion

The impact of nurse anesthetist’s today is that they are the only providers in more than 67% of all hospitals in the U.S serving more than 70 million patients. They are allowed by the law to practice anywhere in the states as long as they are registered. An average certified nurse in America earns about $ 140, 000 which is a registered scale arrived after a survey in several human resource departments in almost all types of employers. Current issues in the field of nurse anesthesia include serving the community with competent service and extend their participation to the leadership that supports their profession. Anesthetists have made a major breakthrough in healthcare trends by finding solutions to major challenges and offering safe care to patients. The life of a patient under surgery largely depends on the anesthetist, and therefore they need the application of every bit of knowledge and skills learned in college.

References

Bankert M. (2005): A history of American nurse anesthetists: continuum New York Pg. 23-35.

Ganado T. (2005): History of anesthesia: Churchill Livingstone Pg. 25-36.

John J. Nagelhout & Karen L. Zaglaniczny: “Nurse Anesthesia”: 3rd Edition.

Thatcher V. (2004): History of anesthesia with emphasis on nurse specialists: JB Lippincott. Pg. 4550.

Nurse Anaesthetist’s History and Role: Local Anesthesia and Complex Procedures

History of early anesthesia

Administration of anesthesia on patients undergoing surgery started in the early 1840s and gained a lot of impact in 1946 when William Morton used ether on gilbert as anesthesia at Massachusetts hospital in Boston. Before its discovery, surgery was very agonizing and was only done as a last resort to save a life. The efficiency of a surgeon then was determined by his or her speed as many patients did not survive the agony experienced because they used alcohol and morphine to reduce the pain.

Latter chloroform was used but caused liver damage in spite of its good work and popularity. Today anesthesia has achieved objectives like causing patients to get asleep faster and in a pleasant process as well as the development of local anesthesia. Nowadays surgeons have enough time to be more accurate especially on complex procedures. They are also well trained and anesthesia is very safe with an estimated number of 1 death in 250,000. (Bankert, 2005 pp23-35)

Role of early anesthetists

Catherine S. Lawrence became the first nurse to provide anesthesia with the assistance of other nurses during the civil war between 1861 to 1865 but just a little of the medicine was administered as it was considered too unsafe. However, Sister Mary Bernard was the first nurse to be officially recognized in1878 when she was practicing as a nun at St. Vincent’s Hospital. The roles of the early anesthetists were to find out if the patient was fit for the process and gave the framework for a professional assessment. They did all the tests required ahead of the surgery and checked the outcomes of the screening. They also explained the effects of anesthesia to the patients for them to make the final decision. (Thatcher, 2004 pp4550)

Anesthesia leaders, Alicia Magaw and Sister Mary Bernard

Alicia Magaw became the most popular anesthetist and was recognized as the mother of anesthesia of the 19th century because of her effectiveness in her work especially in the use of open-drop inhalation using ether and also because of her publishing of her research. However, the earliest records regarding the care of anesthesia patients showed the works of Sister Mary Bernard who was also a Catholic nun at St. Vincent hospital.

History of nurse anesthetist’s education up to the present

In America, the education of anesthetists is monitored by the American association of nurse anesthetist’s council through the established programs. The education and titles awarded vary depending on the state of the trainee where he receives a degree or a certificate after meeting all the requirements for the program. By 1982, registered nurses were required by AANA to be baccalaureate and have a master’s in anesthesia program. After the study, anesthetists practice in countries that are developed as the undeveloped ones do not have adequate knowledge although this is to the disadvantage of the developing countries. (Ganado, 2005 pp25-36)

Present job roles of the nurse anesthetists

The anesthetist cares for the patient throughout the process and even after by carrying out the assessments and offers preoperative teachings to the patient as well as making preparations for the process management. They also administer the medicine to free the patient from pain and oversee his or her recovery through the postoperative process in the care unit.

Conclusion

The impact of nurse anesthetist’s today is that they are the only providers in more than 67% of all hospitals in the U.S serving more than 70 million patients. They are allowed by the law to practice anywhere in the states as long as they are registered. An average certified nurse in America earns about $ 140, 000 which is a registered scale arrived after a survey in several human resource departments in almost all types of employers.

Current issues in the field of nurse anesthesia include serving the community with competent service and extend their participation to the leadership that supports their profession. Anesthetists have made a major breakthrough in healthcare trends by finding solutions to major challenges and offering safe care to patients. The life of a patient under surgery largely depends on the anesthetist and therefore they need the application of every bit of knowledge and skills learned in college.

Annotated Bibliography

Bankert M. (2005): A history of American nurse anesthetists: continuum New York pp. 23-35.

The research question was finding the effectiveness of alcohol in minimizing pain during a minor surgical operation involving rats. The method used a sample of 10 rats aged 1-2 months administered on alcohol and a control group that received no administration on alcohol. The significance of the findings was much reduction in pain when alcohol was administered shortly before surgery although the little pain felt also caused some agony. The implication for practice was that alcohol intervention as anesthesia can reduce pain during surgery inhuman beings and it requires minimal training and is not expensive.

Thatcher V. (2004): History of anesthesia with emphasis on nurse specialists: JB Lippincott. pp. 45-50.

The research question was whether chloroform reduced pain during painful operations on rats and whether the effects persist for a long period of time. How does the practice of chloroform in surgery perceived by another scientist as an intervention towards relieving pain during surgery in human beings? Methods used involved 5 rats aged 3 weeks being administered on chloroform and a control set of the same number that did not receive chloroform. There was a reduction in pain on the rats administered with chloroform and the effectiveness of this practice was proved because of an even greater reduction of pain applicable even in human beings compared with alcohol.

Ganado T. (2005): History of anesthesia: Churchill Livingstone pp. 25-36.

The research question investigated the effect of morphine as a sedative during major surgical operations where the first experiments were done on rabbits. The research method involved 10 rabbits administered on morphine and 10 rabbits not administered on morphine for comparison. Rabbits on morphine copped well with the surgery while those on the control experiment suffered distress. The implication was the same medicine on controlled dosage was applied equally on human beings. However, there was still some agony caused by the little pain as the medicine was not 100% effective. It is not there commended anesthesia for human beings.

Anesthesiology: Pain Management

Introduction

Many people in the world suffer from different forms of pain. Almost everyone has experienced pain at one time in their life. An example is like when one’s finger is burnt or one’s toe is stepped on. However, many people suffer from chronic pain where they endure great magnitude of pain for many days or even years. This is common especially for the elderly and people in their late adult ages. Doctors have therefore come up with pain management techniques that include administration of narcotics to the suffering. Though narcotics are suitable for relieving pain, their prolonged use is discouraged due to their addiction potential. Some good examples of narcotics are heroin, morphine, codeine among others. (Covington 86)

Main Discussion

When administered to the suffering, narcotics may significantly reduce pain. It is known that chronic pain may negatively affect someone psychologically, professionally, and even lower their self esteem. Pain has also been known to destroy peoples resolve for living. Research has shown that people with intractable pain do not respond to narcotics in the same way as street addicts. This is due to tolerance toward the drugs and the motivating factors for taking them. The pain patient can be treated with narcotics with little risk of developing the self-destructive behavior characteristic of addiction. Even though dosages may sometimes exceed those that are considered normal, this has not been found to be a basis for addiction. (Covington 87)

Since the effectiveness of pain medication varies greatly from one person to another, the fact that some people may require higher dosage is not necessarily a sign that one is addicted. Medication on different people varies depending on metabolism and tolerance among other factors. Narcotics have enabled patients to get on with their lives and to interact with family and friends. They have also enabled them to be involved in productive activities in the society. (Covington 90)

One common belief is that long term narcotics use for anyone inevitably leads into addiction. This is not really the case considering a study case of cancer patients. A study performed on a group of cancer patients in 1990 showed that they only depended on the drug physically but not psychologically. In all the cases analyzed, dependence on the drug was found to be non existent in almost all the cases. (Foley 2258)

One of the setbacks of using narcotics in pain medication is the fact that they can easily lead to addiction. Studies have shown that opiates can cause drowsiness, nausea and constipation among other side effects. In addition, extended use of opiates can lead to a case where the body becomes accustomed to certain amounts of the drug and stops reacting to it. (Foley 2259) For this reason therefore, the extended use of these opiates should be discouraged due to their addiction.

The last major reason why it is discouraged is because it places medical care at the mercy of euthanasia. Doctors have been charged of murder for wrongfully administering narcotics to patients who have died from an overdose or other complications. It can also be argued that the use of narcotics has prevented many patients from getting medication. This is because many doctors tend to turn them away due to legal ramifications that may arise from the treatment. Others simply limit the amount of narcotics that they will prescribe for any one patient. (Foley 2262)

Conclusion

My opinion is that narcotics should be used for the treatment of chronic pain syndromes. When properly administered, narcotics can tame pain, a master that is worse than death. Although they may have some shortcomings, most or all of these can be avoided by strict observance of proper medical practices. After all, responsibility is something that has to be applied when doing any other thing apart from pain management techniques.

Works Cited

Covington, Edward C. “Management of the patient with chronic benign pain, Modern Medicine.’’ 57.1, (1989): 75-100. Print.

Foley, Kathleen M. “Controversies in cancer pain, Cancer’’, 2257-2264. June 1 Supplement 1989. Print.

Description of Topical Anesthesia

Uses

Topical anesthesia is a local anesthesia that is mainly used to numb an external area of our skin. Its use helps in controlling the pain, which is associated with certain procedures, which require laceration repair. It is used to avoid using local anesthesia injections, which cause a lot of pain. It can be used for relieving itching and pain caused by small cuts, poisonous plants, insect stings and bites, minor burns and sunburns, skin eruptions, like in chickenpox, and scratches.

It can also be used in optometry and ophthalmology for numbing the surface around the eye. Certain topical anesthetics, like oxybuprocaine, can also be used in otolaryngology. Manual Small Incision Cataract Surgery or MSICS also uses topical anesthesia. It is used in various mucous membrane and skin conditions. It is sometimes also used as a local analgesia on undamaged skin. It is also used for numbing the inner side of our nose, throat, ear, genital area and anus. (Mace, 2005)

Topical anesthesia is also used for minimizing the discomfort and pain experienced during a routine hysteroscopy by endometrial biopsy, which diagnoses infertility and in endometrial pathology. It is sometimes also used to determine whether the pain felt by the patient is coming from the surface of his body or from inside of his body which the tropical anesthesia is not able to touch. Topical anesthesia is available as jellies, lotions, ointments, aerosols, patches, sprays and creams. Some topical anesthetics are – tetracaine, proparacaine, oxybuprocaine, benzocaine, proxymetacaine, pramoxine, lidocaine, dibucaine and butamben.

Depth of penetration

The depth of penetration for the topical anesthetics typically ranges from 2 to 4 mm, plus or minus 1 mm. (Mace, 2005)

Oraqix and Dentipatch

Oraqix is a non-injectable local anesthetic gel, which has been specifically designed and used for Scaling / Root Planning (SRP) procedures in dentistry. It looks like a liquid and comes in 1.7 gm dental carpules. It has been marked as a periodontal gel and its each carpule contains 2.5 % of prilocaine and 2.5 % of lidocaine, i.e. they are in a 1:1 weight ratio, and thermosetting agents. Unlike other local anesthetics that have to be injected, Oraqix has to be applied around the periodontal pocket by a particular blunt tip applier. (Kumar, 2002)

On the other hand, Dentipatch is an oral transmucosal release system, which comes as an anesthetic dental patch. It is a very small adhesive band containing lidocaine, which is frequently used in dentistry. It prevents pain caused during soft tissue dental operations and by oral injections. Thus, instead of injecting us with local anesthesia our dentists can simply place the adhesive strip on our gum numbing the area within minutes before giving an injection. (Kumar, 2002)

The main difference between Oraqix and Dentipatch is that the first comes as a gel while the latter comes as an adhesive strip. Oraqix contains prilocaine along with lidocaine while Dentipatch only contains lidocaine. The duration of Oraqix is around 20 minutes but Dentipatch remains effective even up to 45 minutes. Oraqix works by becoming gel when we expose it to body temperature. Only the tissues around the periodontal pocket get affected. Dentipatch sticks to our dry gingival tissues and releases the anesthetic through our mucous membranes present inside the mouth. However, while Oraqix can be applied anywhere inside the mouth, Dentipatch can only be placed in dry areas. (Mace, 2005)

References

Kumar, Chandra M. Chris Dodds, Gary L. Fanning; 2002; Ophthalmic Anaesthesia; Taylor & Francis.

Mace, Sharon E. & James Ducharme, Michael F. Murphy; 2005; Pain Management and Sedation: Emergency Department Management; McGraw-Hill, Medical Pub. Division.

Analgesia and Anesthesia for the Breastfeeding Mother

Introduction

The recommendations provided in this guideline focus on analgesia and anesthesia during labor, anesthesia for cesarean section, analgesia after birth, and anesthesia during surgery for breastfeeding women. In addition, the guideline provides vital information regarding the agents that are used for pain management. This article focuses on the guidelines on anesthesia for cesarean section concept.

A Brief Overview of the Guideline

The guideline was revised in 2012 with the aim of suggesting recommendations that would guarantee safe, as well as the proper application of pharmacological agents, anesthesia, and pain relief, particularly in females who are breastfeeding during labor. It also includes postpartum mothers and those who are lactating during a surgical operation. The guideline targets women in labor pain, painful postpartum period, as well as breastfeeding mothers who have already been subjected to a surgical procedure. Among the outcomes that are considered in this guideline include pain management, events in the breastfed newborn that could pose adverse effects as a result of treatment, milk drug levels, and the safe initiation and continuation of breastfeeding.

Anesthesia for C-Section

Summary

The guideline hereby recommends that regional anesthesia; that is, epidural or intrathecal, should be preferred for general anesthesia. Further, the mother and the infant ought not to be separated longer than is inevitable. Instead, the newborn can begin breastfeeding even in the operation room. It is advisable to commence breastfeeding while the mother is in the recovery room because the surgical wound is still under anesthesia. Finally, the guideline recommends that mothers who have undergone general anesthesia are ready for postoperative breastfeeding immediately they get alert enough to hold the newborn (Montgomery, Hale, & Academy of Breastfeeding Medicine, 2012).

How Anesthesia for C-Section Could Improve the Working Environment

Improved Pain Management

These guidelines are definitely indispensable. The rate of cesarean births is on a steady increase. This is accompanied by painful experiences; therefore, guidelines on pain management are very vital because mothers are expected to breastfeed immediately they have delivered. According to the CDC report of 2005, 30.2% of women undergo a cesarean section. This is a 46% increase from the 1996 statistics (Hamiliton, Martin & Ventura, 2006). This high rate is worrying owing to the fact that cesarean section has been associated with maternal and newborn morbidity, mortality, depression, and low maternal satisfaction, among other experiences (Nolan & Lawrence, 2009).

The bonding between the mother and the newborn is very crucial; thus, the longer the postoperative pain, the longer the separation between the mother and the infant. This results in poor bonding that apparently affects the connection between the two even in later years because the foundation for bonding spans from pregnancy through the post-delivery period (Young, 2013). Ross (2012) argues that the level of the bonding between the mother and the fetus is manifest in the mother’s self-sacrificing acts to ensure safe delivery, as well as the health of the child. This further cements the importance of having safer and better delivery methods.

Mothers who go through a C-section during delivery have a lot of pain in the initial days after the operation (Karlstrom et al., 2009). This is very detrimental because it directly affects the post-delivery events. Breastfeeding and caring for the newborn during the recovery phase of a C-section is important. However, this is adversely affected by the post-operative pain that the mothers may be subjected to. Karlstrom et al. (2009) report that when women are subjected to high levels of pain, regardless of the mode of cesarean section employed, it substantially affects breastfeeding and newborn care negatively. In this study, women who had experienced high levels of pain post-surgery exhibited poor breastfeeding and childcare significantly.

Safety

The safety of patients is of great concern for those who provide prenatal health care for women during labor, pregnancy, and childbirth. It is more complex to deal with pregnant mothers because one deals with two parties. If the mother’s wellbeing is compromised, then the infant’s health is bound to be affected too (Gaiser, 2009). A study conducted by Karlstrom et al. (2009) found that a substantial number of women have difficulties in breastfeeding and child care due to post-operative pain. On the other hand, low levels of pain after a cesarean section facilitated better breastfeeding, as well as the care for the infant. Pregnant women differ significantly from non-pregnant ones, both physiologically, as well as anatomically; therefore, they are bound to experience more complications.

It should be noted that women who have undergone a cesarean section are expected to adopt motherhood immediately after recovery from the surgery. However, as noted, this is not possible if they are subjected to high levels of pain. Therefore, it is very important for the post-operative pain relief to be properly applied to ensure optimal pain relief. Chung and Lus (2003) found out that post-operative pain slows recovery and it can result in complications like impaired respiration, venous thrombosis, and immobility, among others. Postoperative pain is accompanied by physical limitations that affect the early days of a mother who is breastfeeding.

Cost

It is advantageous to have an improved post-operative pain management approach in as far as finances are concerned. In Sweden, for instance, Källén, Rydström, and Otterblad-Olausson (2005) found out that cesarean section birth lengthened the period of hospital stay by two days in comparison to vaginal birth. This had financial implications because the longer the stay in the hospital, the more the financial expenses incurred. However, the study by Karlstrom et al. (2009) discovered that optimal pain relief reduced the period of hospital stay by one day. This is beneficial to both the woman and her family and the hospital, as well.

Applying Anesthesia for C-section

Local anesthesia is better than general anesthesia. Gaiser (2009) argues that regional application of epidural anesthesia promotes a pharmacological sympathectomy that could lower blood pressure, as well as delay a compensatory reaction to supine and hypotension syndrome. It is, thus, important to ensure safe regional anesthesia. This calls for specialized education and competence. Karlstrom et al. (2009) report that the pre-operative, as well as the post-operative pain experience is greatly improved for the women who are undergoing a cesarean section when opioids are added to spinal anesthesia. The same study found out that the change in the anesthetic routine yielded significantly better results with regard to pain relief for the women subjected to cesarean section. This provided for easier transition to motherhood even a day after the surgery.

Conclusion

The guidelines for anesthesia for the mothers undergoing cesarean birth are very important as demonstrated in the discussion above. It is notable that post-operative pain has serious consequences on the infant care after birth and possible complications for the mother. Furthermore, financial expenses are incurred, whereby the longer the period of pain, the more expensive the procedure turns out to be. It is, therefore, crucial for anesthesia to be improved in cesarean births. Specialized, as well as competent care should also be considered to ensure safe and better management of post-operative pain.

References

Chung, J., & Lui, J. (2003). Postoperative pain management: Study of patients’ level of pain and satisfaction with health care providers’ responsiveness to their reports of pain. Nursing & Health Sciences, 5(1), 13–21.

Gaiser, R. (2009). “Physiologic changes of pregnancy.” In D. H. Chestnut, L. S. Polley, L. C. Tsen, & C. A. Wong (Eds.), Chestnut’s obstetric anesthesia: Principles and practice (4th ed., pp. 15–36). Philadelphia, PA: Mosby Elsevier.

Hamilton, B. E., Martin, J. A., & Ventura, S. J. (2006). Births: Preliminary data for 2005. National Vital Statistics Report, 55(11), 1-20.

Källén, K., Rydström, H., & Otterblad-Olausson, P., (Eds.). (2005). Kejsarsnitt i Sverige 1990–2001 (Caesarean Sections in Sweden 1990–2001). Epidemiological Center, Swedish National Board of Health and Welfare, Stockholm.

Karlstrom, A., Engstrom-Olofsson, R., Nystedt, A., Sjoling, M., & Hildingsson, I. (2009). Women’s postoperative experiences before and after the introduction of spinal opioids in anaesthesia for caesarean section. Journal of Clinical Nursing, 19(9-10), 1326-1334. Web.

Montgomery, A., Hale, T. W., & Academy of Breastfeeding Medicine. (2012). ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother, revised 2012. Breastfeeding Medicine, 7(6), 547-553. Web.

Nolan, A., & Lawrence, C. (2009). A pilot study of a nursing intervention protocol to minimize maternal-infant separation after cesarean birth. J Obstet Gynecol Neonatal Nursing, 38(4), 430-42. Web.

Ross, E. (2012). Maternal-fetal attachment and engagement with antenatal advice. British Journal f Midwifery, 20(8), 566-575.

Young R. (2013). The importance of bonding. International Journal of Childbirth Education, 28(3), 11-16

6 Local Anesthetics in Buccal Infiltration Anesthesia

Introduction

The paper under consideration is titled “The efficacy of 6 local anesthetic formulations used for posterior mandibular buccal infiltration anesthesia” (Abdulwahab et al 2009). It is published in the Journal of the American Dental Association (JADA) in 2009. The main purpose of this paper is to assess the efficacy of the five commonly marketed dental anesthetic formulations in achieving pulpal anesthesia after mandibular buccal infiltration and compare them with a control formulation of lidocaine with epinephrine (L100) (Abdulwahab et al 2009). Additionally, it aims to evaluate the adverse drug reactions and side effects in the participants.

Evaluation of the Paper

This paper uses the Randomized Controlled Trial (RCT) method which is commonly applied to clinical examinations. Proper randomization is effective in this case as it leaves little scope for any kind of business in the assignment of treatments to patients. Moreover, as the RCT is double-blind, the research is expected to yield objective results.

The trial is conducted on a group of 18 healthy participants between 18-65 years of age who have met certain specific criteria. Thus, a larger cross-section of the society in terms of age is taken into consideration. The local dental anesthetic formulations used in this study are the popular amide-based anesthetics commonly available in the US namely, A200, A100, P200, Mw/o, and B200 (Abdulwahab et al 2009). The participants are administered a very small amount of anesthetic (0.9ml) in the form of buccal infiltration injections of anesthetic solutions adjacent to the molar and this procedure is repeated throughout six sessions. The degree of pulpal anesthesia is then determined by analyzing the scores against the Electronic Pulp Test (EPT) criteria. The entire method is, thus, carried out on the lines of a scientific experiment.

The EPT scores for the six anesthetic formulations are 43.5% for L100, 44.8% for B200, 51.2% for P200, 66.9% for A200, 68.3% for Mw/o and 77.3% for A100 (Abdulwahab et al 2009). Minor critical reactions to the mandibular molar infiltration test are reported but these are independent of the local anesthetic formulations. The authors concluded that “mandibular infiltration with 0.9mL of the tested dental anesthetics could induce only partial pulpal anesthesia, a level … inadequate for most dental procedures” ( Abdulwahab et al 2009). As per the data available, the pulpal anesthesia achieved with A100 is found to be statistically greater than the others.

I fully agree with the conclusions of the study that the degree of pulpal anesthesia achieved after mandibular buccal infiltration of all the local anesthetic formulations is inadequate for most dental operations. Furthermore, based on the results obtained, it may be inferred that the degree of pulpal anesthesia achieved via mandibular buccal infiltration depends, to a large extent, on the type of local anesthetic formulation used. However, a larger sample would have given a more concise idea.

Criticism

Fundamentally, the study seems to overlook the fact that the efficacy of mandibular infiltration anesthesia depends, to a large extent, on the site of injection, the anesthetic formulation used as well as the technique involved. Secondly, it should be noted that anesthetic efficacy has been determined across a time frame of 20 minutes which is not sufficient for yielding effective results. Proper assessment of the technique should be done for a minimum of one hour.

Reference

Abdulwahab, M., Boynes, S., Moore, P., Seifekar, S., Al-Jazzaf, A., Alshuraldh, A., Zovko, J. & Close, J. (2009). The efficacy of 6 local anesthetic formulations used for posterior mandibular buccal infiltration anesthesia. Journal of the American Dental Association, 140, 1018-1024.

Awareness During Anesthesia and Its Prevention

Awareness During Anesthesia and The Need to Address It

The unexpected and explicit recollection of sensory perception when under general anesthesia is known as intraoperative consciousness. According to Cardinale et al. (2019), one of the unexpected complications while performing surgical procedures is unintentional awareness during general anesthesia (UAGA), which occurs when patients maintain consciousness and explicit remembrance while undergoing treatment. The use of “neuromuscular blocking agents (NMBs),” emergency operations, obstetric and cardiothoracic surgery, obesity, age, and prolonged operating time are all risk factors for intraoperative awareness (Cardinale et al., 2019, p. 98). According to Huh et al. (2020), awareness during anesthesia happens in 1 in 1000 to 2000 patients each year, with individuals regaining consciousness intermittently or remaining cognizant throughout the surgery. While this complication is infrequent, the clinical signs and potential serious psychological implications necessitate a thorough knowledge of the occurrence. The unexpected and explicit recollection of sensory perception when under general anesthesia is known as intraoperative consciousness. Patients who are going to undergo anesthesia frequently worry that they will recall what happened during the procedure.

It is critical to do research on workable solutions to reduce the likelihood that the patient would wake up while under anesthesia. Pre-operative control and intra-operative management are two categories of preventive strategies for avoiding awareness, according to (Cascella & De Blasio, 2022). To give a critical field of examination that overlaps study topics in general anesthetic research and neurology, research synthesis is required (Cascella & De Blasio, 2022). It is necessary not only to raise awareness about the problem, but also to investigate ways that can help anesthetists prevent consciousness during anesthesia. Anesthesia mechanisms, anesthetic effects on awareness/memory, and the usage of equipment such as bispectral index (BIS) monitors may be synthesized to explore strategies to better avoid consciousness during anesthesia.

Methods of Investigation

The investigation was based on whether the use of BIS monitoring on adult patients undergoing surgical procedures reduces the chances of unintended awareness as compared to the standard monitoring procedures. CINAHL Plus and PubMed were the resources used to look for existing information on BIS monitoring and anesthetic consciousness. Phrases like “BIS Monitoring,” “Anesthesia Awareness,” “Preventing Anesthesia Awareness,” and “BIS Monitoring and Anesthesia Awareness” were searched for in both databases. The search keywords produced few results in the CINAHL Plus database. The advanced search function was utilized to separate terms in a way that resulted in more articles.

The important terms were divided into three search bars. The search was confined to peer-reviewed publications, the Journal Subset set to the USA, and the year of publication range set from 2012 to 2022 using the advanced search function. The main search term was “BIS Monitoring and Anesthesia Awareness.” This term generated the most articles that were related to the use of BIS monitoring and its usage in lowering anesthetic consciousness in the OR. The search was also focused on clinical trials, meta-analyses, randomized controlled trials, reviews, and systematic reviews. The inclusion criteria restricted the publications to patients undergoing surgical operations under anesthesia, patients in the OR, and patients whose depth of anesthesia was monitored via BIS monitoring. The papers omitted BIS monitoring that was not employed in an operating room context, such as in intensive care units. A total of ten papers addressed the PICOT topic. Statistical analysis, meta-analysis, randomized controlled trials, randomized comparative efficacy trials, systematic reviews, and observational studies were among the article categories.

Findings

Authors and Year Major Findings
Gao et al., 2018 The prevalence of intraoperative consciousness and BIS monitoring were not substantially correlated.
There is no discernible difference in the frequency of anesthetic awareness between BIS monitoring and non-BIS monitoring.
Gelfand et al., 2016 Increased age, higher ASA physical status, and excesses of BMI were patient-specific variables linked with BIS usage.
Lewis et al., 2019 Even though there were several studies that were found to be eligible, there is insufficient data to support the use of BIS to determine the level of anesthesia since intraoperative consciousness is uncommon.
Despite the fact that some studies were deemed to be eligible, there is insufficient evidence to support the use of BIS to evaluate anesthetic degree since intraoperative awareness is infrequent.

Major Strengths and Weaknesses

The main outcome of the study was that BIS-guided anesthesia when compared to clinical indicators, may lower the chance of intraoperative consciousness and speed up early recovery in patients having general anesthetic surgery. Additionally, there was no appreciable difference between BIS monitoring and non-BIS monitoring in the frequency of anesthetic consciousness, nor was there a correlating relationship between BIS monitoring and the frequency of intraoperative awareness (Gao et al., 2018). The key flaw was that, while identifying a significant number of studies that were suitable, there was no evidence of the usefulness of utilizing BIS to determine the level of anesthesia.

Proposed Solution

Awareness during anesthesia is for sure a problem without a solution. However, little, if not much can be done to minimize or reduce the chances of waking up during general anesthesia or rather alerting the practitioners. The possible solution is for patients to advise the hospital to come up with monitoring technology that can alert the anesthesiologists if the patient is on the verge of waking up. Although the technology is already in existence, previous studies have highlighted its ineffectiveness of the technology. In the study, Cascella et al., (2020) note that researchers assigned approximately half of 2,463 patients to a monitored group; the others received standard care. Only two reports of anesthesia awareness occurred in the monitored group, compared with 11 in the standard care group ((Gelfand et al., 2016).). Therefore, efforts and resources have to be pulled together to facilitate the effectiveness of the technology.

References

Cardinale, J. P., Gillespie, N., & Germond, L. (2019). In Catastrophic Perioperative Complications and Management (pp. 95-103). Springer, Cham. Web.

Cascella, M., & De Blasio, E. (2022). (pp. 137-158). Springer. Web.

Cascella, M., Bimonte, S., & Amruthraj, N. J. (2020). World Journal of Clinical Cases, 8(2), 245. Web.

Gao, W.-wei, He, Y.-hong, Liu, L., Yuan, Q., Wang, Y.-feng, & Zhao, B. (2018). Current Medical Science, 38(2), 349–353. Web.

Gelfand, M. E., Gabriel, R. A., Gimlich, R., Beutler, S. S., & Urman, R. D. (2016). Journal of Clinical Monitoring and Computing, 31(2), 281–289. Web.

Huh, H., Park, S.-H., Yu, J. H., Hong, J., Lee, M. J., Cho, J. E., Lim, C. H., Lee, H. W., Kim, J. B., Yang, K.-S., & Yoon, S. Z. (2020). Medicine, 99(5). Web.