Evidenced-Based Practice Guideline Development: Selection of Local Anesthetics and the Additive Dexamethasone in Brachial Plexus Blocks

Brachial plexus blocks (BPB) are a type of regional anesthesia that inhibits the sensory and motor function of the upper extremity. The efficacy of a BPB depends on the type and dose of local anesthetics (LA), as well as the use of any additive agent. The selection of LA depends on the type, concentration, and volume of LA. Certain additives, such as dexamethasone, when added to BPB, were shown to increase motor and sensory block duration. A chart audit conducted by the pharmacy and anesthesia departments revealed a significant variability of clinical practice in the use of LA and additives in BPB at a large Level 1 trauma center. The audit also revealed that only 46.4% of anesthesia providers used the additive dexamethasone. Further complicating the issue, key stakeholders also reported a lack of standardized evidence-based practice (EBP) guidelines for the choice of LA and additives utilized in BPB, which may have also contributed to the inconsistent practice among providers. The following objectives and methods were framed using the Johns Hopkins Model for EBP and were established to achieve the project’s goals: 1) synthesize the evidence around the choice of LA and the additive dexamethasone with BPB, 2) develop a guideline based on the evidence, and 3) present the guideline to the Clinical Process Improvement Team (CPIT). To enhance EBP guideline development, data was compiled through a systematic review and local/national/standard clinical practice guidelines, using the Johns Hopkins Nursing Evidence-Based Practice Synthesis and Recommendations Tool. The project was significant because the incorporation of newly developed EBP guideline into clinical practice may improve patient outcomes. The findings of the scholarly project served as a beginning point for a greater understanding of the importance of EBP, clinical knowledge, and policy. The guideline was communicated to the anesthesia and pharmacy departments for potential implementation

Cirrhosis of the Liver

Liver cirrhosis is a chronic, end-stage liver disease. It is a term given to a condition where normal liver parenchyma is replaced by fibrotic tissues. This condition arises once hepatocytes become unable to overcome the hepatic insults via undergoing the process of mitosis. Alcohol, hepatitis B, hepatitis C, Wilson disease, hemochromatosis, aldolase B deficiency, alpha 1 antitrypsin deficiency, and autosomal recessive polycystic kidney diseases are few risk factors for liver cirrhosis. Ascites, asterixis, hepatic encephalopathy, scleral icterus, portal hypertension, and gynecomastia are a few symptoms of this condition. Liver transplant is the only definitive treatment for this condition, so symptoms management become the main means of addressing the need of the majority of patients