OBJECTS OF DESIRE Are you supplying your anesthesia providers with all they want to do their jobs?

A surgical facility doesn't run well unless the anesthesia providers are happy and content. How do you keep a smile on their faces? By stocking everything they need and want to deliver safe patient care efficiently and economically. This is true regardless of whether you have a different anesthetist every day, as is the case for 43.7% of the 135 OR managers we polled at last month's OR Excellence conference in Las Vegas, Nev., or the same anesthetist every day, as is the staffing model for 37.8% of respondents at ORX. To help you hold up your end of the bargain, we sent an online survey to a select panel of anesthetists that asked them to rank 15 drugs and devices on a 1-to-5 scale, ranging from extremely important to unimportant. Here are the 6 products that scored highest, the 6 no OR should be without, based on 72 responses.

1. Antiemetics
"Most patients would prefer to be in pain than nauseous after surgery," says Mike Donovan, CRNA, reflecting the panel consensus that antiemetics are the most highly valued tool in the anesthesiology armamentarium. "And it's always better to prevent PONV than to treat it."

Of course those spinning heads and inside-out stomachs aren't just miserable for patients, they're expensively inconvenient for facilities, too. And providers say they're employing a variety of weapons and recipes designed to make anesthesia easier to stomach.

Mr. Donovan minimizes PONV by "almost always" administering total intravenous anesthesia and blocking nausea receptors early with 4 mg of ondansetron — often considered the "gold standard" of antiemetics. He typically adds 10 mg of dexamethasone at the end of the case, both for its antiemetic properties and to help with post-op pain control.

The 5 surgeons at the (Savannah) Georgia Institute for Plastic Surgery have "zero tolerance for post-operative nausea and vomiting," says Janice Izlar, CRNA. To prevent it, she pulls out all the stops, starting with 8 mg of ondansetron as soon as patients arrive. All patients having facial procedures also get 8 mg of dexamethasone, unless contraindicated, and those with a history of PONV or motion sickness get 10 mg IV of diphenhydramine during the case. Metoclopramide (5 mg) may also be part of the recipe if patients have a history of GERD or heartburn issues.

TOP PRIORITY Nothing is more important than preventing PONV, our online panelists say.

Andrew Schulman, a CRNA at Morpheus Anesthesia Services in Cape Girardeau, Mo., starts with ondansetron for almost every patient, but in the presence of certain risk factors, augments with dexamethasone and scopolamine — completing the so-called triple therapy that's been shown effective in a wide variety of patients.

The third leg of the tripod for CRNA Robert Shearer of UltraCare Anesthesia Partners in Vineland, N.J. — along with ondansetron and dexamethasone — is Quease Ease, an aromatic inhaler that relieves nausea, but it's not always easy to come by, he says: "I'd use it more if my centers supplied it. I keep asking for them to."

And never lose sight of the basics, says Mr. Donovan: "The absolute best antiemetic drug of choice is IV fluids," he says. "Proper rehydration after being NPO may be the single most important intervention we can do as anesthesia providers."

2. Video laryngoscopes
The once lonely voices who viewed video laryngoscopes as must-haves have been joined by a chorus of supporters.

"Studies have shown that video laryngoscopy improves endotracheal intubation success rates, intubation times and first-attempt success rates," says Robert Bland, CRNA, MSN, of the Peace Harbor Medical Center in Florence, Ore.

Not only can a video laryngoscope save a life in the event of an airway emergency, but also it "can make the difference between a resolved difficult airway and a cancelled case after anesthesia induction," says anesthesiologist Michael Bart, MD, from the Gateway Surgery Center, in Everett, Wash.

ASCs may have fewer resources and thinner margins than hospitals, which can make it tougher to shell out for cutting-edge technology, but with fewer hands on deck, their importance becomes magnified, says Dr. Bart. "In an ASC setting, there aren't extra anesthesia personnel hanging around the break room or in-between cases to answer a call for help," he says. "Video laryngoscopes are essential and will, in my opinion, become the standard of care to have available."

3. Regional anesthesia
Regional anesthesia is "a total game changer for peripheral ambulatory surgery," says one anesthesiologist. It's also one of the best weapons in the intensifying battle against opioid overuse, say several panelists.

"Anesthesia providers are being tasked with utilizing all techniques that will lessen the use of opioids, both in the delivery of anesthesia and for post-op care," says Garalynn Tomas, DNAP(c), MEd, CRNA, from North Ridgeville, Ohio. "Regional blocks serve that purpose."

"It's the foundation of any multimodal anesthesia program," adds Miami CRNA Ricardo deSouza. "Above all, the incidence of chronic pain, which we're just beginning to understand and which can develop even with simple surgical procedures, is drastically reduced with peripheral nerve blocks."

Granted, a consistent, efficient regional block program takes education and effort to set up, but it's "imperative that facilities work with their anesthesia providers to provide nursing staff necessary equipment like ultrasound and flexible scheduling of cases to facilitate a successful program," says Dr. Tomas.

MUST-HAVE Ultrasound-guided blocks are increasingly popular for most providers.

4. Supraglottic airway devices
As another tool that can help both patients and providers breathe easier when unanticipated difficult airways rear their ugly heads, "supraglottic devices can often convert a patient from a can't-intubate, can't-ventilate crisis to a can't-intubate, but can ventilate scenario that's less life threatening," says Brent Dunworth, DNP, MBA, CRNA, director of advanced practice at Vanderbilt University Medical Center in Nashville, Tenn. "Their availability is critical to any anesthesia practice."

"They're an extremely important part of the (American Society of Anesesthesia's) Difficult Airway Algorithm," adds Anthony L. Kovac, MD, of the University of Kansas Medical Center in Kansas City. "They're also relatively easy to use and have a high success rate."

5. Multimodal pain protocols
The ingredients and doses vary from provider to provider and from procedure to procedure, but the goal is the same: Attack the various ways pain is perceived in the spinal cord, the peripheral nerves, the central nervous system and the brain, and do so with an eye toward minimizing opioids and the issues that surround them.

Regional anesthesia is a good starting point, and the long list of potential ingredients may include IV acetaminophen, bupivacaine, IV ibuprofen, IV diclofenac, epinephrine, clonidine, saline, steroids, NSAIDs, ketorolac, ketamine, celecoxib and gabapentinoids, among others.

Anesthesia providers have become skilled mixologists, with many actively seeking feedback and data that can help them standardize their approaches. Avoiding the knee-jerk tendency to lean too heavily on opioids is the key. "All of these multimodal pain protocols can really work," says Mr. deSouza. "But only if the support staff has the time to honestly implement them."

6. Ultrasound guidance
"It's always amazing to me why people don't use ultrasound more," says Merlin Wehling, MD, director of anesthesia at the Kearney (Neb.) Regional Medical Center. "I've never seen a downside." He and others say it's indispensable once you get the hang of it. "You can use it anywhere on anything in the body — not just for nerve blocks and pain injections. The only reason we don't use it more is the lack of machines available, but they're not terribly expensive."

A little education goes a long way, says Dr. Wehling: "We recently instructed nurses to use ultrasound with peripheral IV starts. Their reaction was, Are we allowed to? Is that within the scope of practice? People are nervous, because they've never done it. They're afraid they're going to hurt the patients or hinder the speed. But there are no side effects. It's absolutely benign. All it can do is help you." And the nurses, he says, are now well-trained and doing well on their own, "instead of calling me to put in lines."

Nice to have
Also highly desirable, according to our panelists, is sugammadex, a neuromuscular blockade reversal agent, pre-filled syringes, the "No. 1 need for safety to reduce medication errors, reduce infection and promote efficiency" and custom kits for specific procedures.

"All this equipment is important and should be required at every facility, regardless of the cost," says Susan Kollmar, CRNA, PA, who practices at various Florida facilities. OSM