The Development and Validation of an Objective Assessment Tool for Performing Ultrasound-Guided Transversus Abdominis Plane Blocks.

The transversus abdominis plane (TAP) block is a regional anesthesia technique used as part of a multimodal pain management plan in patients undergoing abdominal surgery. There are numerous approaches and techniques described in the literature, resulting in a lack of consistency in block performance. This potentially reduces efficacy while increasing risk to the patient. Competency assessment tools have been shown to lower patient risk and improve outcomes by improving provider skill. Checklists are used as formative and summative assessment tools throughout healthcare education, however, there is no validated tool for ultrasound-guided TAP blocks. The purpose of this evidence-based project was to develop a checklist using a modified Delphi method. The primary outcome measure was validation of the assessment tool, established by an expert panel consensus and guided by Messick's validity framework. A 43-item checklist was validated by six certified registered nurse anesthesiologists throughout the United States with expertise in regional anesthesia. Three rounds of feedback were required to exceed the threshold of consensus (0.8), establishing a method of evaluation that may allow future research in educational settings through improved skill assessment among providers performing TAP blocks.

Anesthetic Considerations for Gender-Affirming Airway and Facial Procedures.

Approximately 0.6% of the United States population identifies as transgender or gender nonbinary. The term transgender refers to a person who experiences incongruence between their sex at birth and their gender identity. The care of the transgender patient is complex, often requiring the expertise of various medical and surgical specialties. The prevalence of gender-affirming surgery is increasing as societal acceptance and cultural norms are shifting. While gender-affirming procedures include a variety of body systems, airway and facial procedures are of particular importance to anesthesia providers. Anesthetic concerns for masculinization and feminization procedures of the airway and face include bleeding, injury to the airway, and other perioperative challenges. Transgender procedures of the airway and face often require advanced airway techniques. Following airway surgery, patients are at an increased risk for tracheal stenosis or perforation, glottic stenosis, vocal cord damage or dysfunction, and/or dysphagia. Additionally, transgender patients may undergo hormone therapy to achieve their gender goals. Providers should be aware of the implications associated with administration of hormones such as thromboembolic events, cardiovascular effects, and changes in various laboratory values. A knowledge of novel surgical procedures, medical therapies, and the psychosocial implications associated with transition is essential for the safe, comprehensive, and holistic care of the transgender patient.

Imagining in Time: The Legacy of Olive Berger (1898-1981).

Olive Berger was a true nurse anesthesia pioneer for our profession. She dedicated her life to the advancement of nurse anesthesia through her leadership, advocacy, scholarly writing, clinical achievements and innovation. She blazed the trail by forming and establishing education requirements for nurse anesthesia programs, established a state nurse anesthesia organization, and led the American Association of Nurse Anesthetists as its 14th president in 1958. She was the Chief Certified Registered Nurse Anesthetist and Program Director at the Johns Hopkins Hospital and is best known for her collaboration with surgeons Dr. Alfred Blalock and Dr. Helen Taussig, providing anesthesia care during the groundbreaking repair of tetralogy of Fallot on infants.

The Application of Radiofrequency Ablation in Acute and Chronic Pain Management.

Radiofrequency ablation (RFA), also known as rhizotomy, is one of the frequently used modalities in interventional pain management. This nonsurgical procedure delivers radiofrequency waves to the targeted nerves to interrupt transmission of nociceptive signals from the peripheral tissues to the central nervous system, thereby reducing pain perception. Recent studies have demonstrated the efficacy of RFA treatment as an effective interventional pain management technique to treat a variety of acute and chronic pain conditions including facial pain, headaches, postmastectomy, musculoskeletal, and major joint pain (knee, hip, shoulder, sacroiliac), and cancer pain. As more certified registered nurse anesthetists are involved in pain management, it is important to be familiar with current nonsurgical pain interventions. This journal course describes the unique mechanism of action of radiofrequency for pain modulation and provides emerging evidence to support its applications in both acute and chronic pain management.

Airway Complications in a Patient With Ehlers-Danlos Syndrome: A Case Report.

A female patient, known to have hypermobile Ehlers-Danlos syndrome (hEDS), underwent several elective gastroscopies under sedation in different hospitals. Except for a single incident of mild laryngospasm during emergence, all procedures were uneventful. On that occasion, following the procedure in the postanesthesia care unit, the patient suffered severe airway obstruction, and standard airway rescue techniques exacerbated adequate ventilation. After the removal of all stimuli and maintaining only an indirect oxygen supply via a mask in front of her face, her airway improved, and the patient fully recovered after 17 minutes. After the gastroscopy, physical examination revealed that the patient had an extremely flexible trachea that could be completely moved outside the midline to the extreme right and left. For the subsequent procedures, an airway plan was developed in conjunction with the patient and resulted in uncomplicated perianesthetic care. This case report serves to alert readers to the risk of adverse airway events in patients with EDS and suggests an alternative approach to avoid such complications. When patients receive care in different hospitals, adequate documentation is essential and adequate preoperative assessment is crucial. This case study demonstrates the value of patient-coproduction care plans.

Effect of a non-reactive absorbent with or without environmentally oriented electronic feedback on anesthesia provider's fresh gas flow rates: A greening initiative.

STUDY OBJECTIVE: To examine the effects of a non-reactive carbon dioxide absorbent (AMSORB® Plus) versus a traditional carbon dioxide absorbent (Medisorb™) on the FGF used by anesthesia providers and an electronic educational feedback intervention using Carestation™ Insights (GE HealthCare) on provider-specific change in FGF. DESIGN: Prospective, single-center cohort study set in a greening initiative. SETTING: Operating room. PARTICIPANTS: 157 anesthesia providers (i.e., anesthesiology trainees, certified registered nurse anesthetists, and solo anesthesiologists). INTERVENTIONS: Intervention #1 was the introduction of AMSORB® Plus into 8 Aisys CS2, Carestation™ Insights-enabled anesthesia machines (GE HealthCare) at the study site. At the end of week 6, anesthesia providers were educated and given an environmentally oriented electronic feedback strategy for the next 12 weeks of the study (Intervention #2) using Carestation™ Insights data. MEASUREMENTS: The dual primary outcomes were the difference in average daily FGF during maintenance anesthesia between machines assigned to AMSORB® Plus versus Medisorb™ and the provider-specific change in average fresh gas flows after 12 weeks of feedback and education compared to the historical data. MAIN RESULTS: Over the 18-week period, there were 1577 inhaled anesthetics performed in the 8 operating rooms (528 for intervention 1, 1049 for intervention 2). There were 1001 provider days using Aisys CS2 machines and 7452 provider days of historical data from the preceding year. Overall, AMSORB® Plus was not associated with significantly less FGF (mean - 80 ml/min, 97.5% confidence interval - 206 to 46, P = .15). The environmentally oriented electronic feedback intervention was not associated with a significant decrease in provider-specific mean FGF (-112 ml/min, 97.5% confidence interval - 244 to 21, P = .059). CONCLUSIONS: This study showed that introducing a non-reactive absorbent did not significantly alter FGF. Using environmentally oriented electronic feedback relying on data analytics did not result in significantly reduced provider-specific FGF.

Predictors of Substance Use Risk in Nurse Anesthetists.

BACKGROUND: Certified registered nurse anesthetists (CRNAs) are exposed daily to highly addictive substances and stressful work environments, placing them at risk for substance use disorders (SUDs). Previous research, which is scarce, indicated that drugs of choice were opioids and propofol. Therefore, the purpose of this study was to investigate predictors of SUD risk using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test. METHOD: From June to July 2020, an online survey was sent via the American Association of Nurse Anesthesiology Research Survey Service to 3,000 CRNAs with a response of approximately 225 members. RESULTS: CRNAs were found to be at a moderate risk for SUDs in the following categories: 10.27% for tobacco, 23.56% for alcohol, and 6.28% for cannabis. Regression analysis by substance category includes robust, differing models in this homogeneous sample. Predictors for all three models include a collection of demographic variables, religiosity, anxiety, difficulties due to anxiety, depression, substance use history, contact with the American Association of Nurse Anesthesiology Peer Assistance Program, and organizational support. CONCLUSION: Over 10% of CRNAs are at risk for developing tobacco use disorder, and almost one quarter of those surveyed are at a moderate risk for developing alcohol use disorder. These data are of concern and may indicate a shift of preferred substances used by CRNAs from controlled substances to alcohol.

The impact of a medically directed student registered nurse anesthesia staffing model on Postprocedural patient outcomes.

STUDY OBJECTIVE: In 2018, the American Society of Anesthesiologists stated that student registered nurse anesthetists (SRNAs) "are not yet fully qualified anesthesia personnel." It remains unclear, however, whether postprocedural outcomes are affected by SRNAs providing anesthesia care under the medical direction of anesthesiologists, as compared with medically directed anesthesiology fellows or residents, or certified registered nurse anesthetists (CRNAs). We therefore aimed to examine whether medically directed SRNAs serving as in-room anesthesia providers impact surgical outcomes. DESIGN: Retrospective, matched-cohort analysis. SETTING: Adult patients (≥18 years old) undergoing inpatient surgery between 2000 and 2017 at a tertiary academic medical center. PATIENTS: 15,365 patients exclusively cared for by medically directed SRNAs were matched to 15,365 cared for by medically directed CRNAs, anesthesiology residents, and/or fellows. INTERVENTIONS: None. MEASUREMENTS: The primary composite outcome was postoperative occurrence of in-hospital mortality and six categories of major morbidities (infectious, bleeding, serious cardiac, gastrointestinal, respiratory, and urinary complications). In-hospital mortality was analyzed as the secondary outcome. MAIN RESULTS: In all, 30,730 cases were matched using propensity score matching to control for potential confounding. The primary outcome was identified in 2295 (7.5%) cases (7.5% with exclusive medically directed SRNAs vs 7.4% with medically directed CRNAs, residents and/or fellows; relative risk, 1.02; 95% CI, 0.94-1.11). Thus, our effort to determine noninferiority (10% difference in relative risk) with other providers was inconclusive (P = .07). However, the medically directed SRNA group (0.8% [118]) was found to be noninferior (P < .001) to the matched group (1.0% [156]) on in-hospital mortality (relative risk, 0.75; 95% CI, 0.59-0.96). CONCLUSIONS: Among 30,730 patients undergoing inpatient surgery at a single hospital, findings were inconclusive regarding whether exclusive medically directed SRNAs as in-room providers were noninferior to other providers. The use of medically directed SRNAs under this staffing model should be subject to further review. Clinical Trial and Registry URL: Not applicable.

Comparison of anaesthesia-related outcomes in patients monitored by newly recruited nurse anaesthetists and anaesthesiologists: An observational study.

AIMS: To compare anaesthesia-related outcomes between patients monitored by newly recruited nurse anaesthetists and those monitored by newly recruited anaesthesiologists. DESIGN: This was a retrospective study. METHODS: We conducted a retrospective study that collected demographic information on newly recruited nurse anaesthetists and anaesthesiologists between 2017 and 2022 and recorded information on patients within 6 months of monitoring. Postoperative pain, emergency agitation, nausea, and vomiting were designated anaesthesia-related outcomes. Propensity score matching was used to adjust for covariates. The study adhered to the STROBE guidelines. RESULTS: The study's statistical analysis included 4483 patients monitored by 22 newly recruited nurse anaesthetists and 4959 patients monitored by 23 newly recruited anaesthesiologists. Compared with patients monitored by newly trained anaesthesiologists, the patients monitored by nurse anaesthetists were younger (42.07 ± 20.00 vs. 47.39 ± 18.45 years, p < 0.001) and had a lower body mass index (23.56 ± 4.46 vs. 24.19 ± 4.25, p < 0.001). Patients monitored by anaesthesiologists had a greater proportion of women (61.62% vs. 59.25%, p < 0.001), a high proportion of ASA III and ASA IV (17.1% vs. 8.88%, p < 0.001), and a longer mean surgery duration (78.65 ± 59.01 vs. 70.70 ± 60.65 min, p < 0.001). After propensity score matching was used to adjust for covariates, no statistically significant differences were found in the prevalence of postoperative pain, emergency agitation, or postoperative nausea and vomiting between the two groups (p < 0.05). CONCLUSION: Nurse anaesthetists monitoring alone during anaesthesia maintenance is feasible and safe. The two groups had no significant differences in the incidence of postoperative pain, emergency agitation, or postoperative nausea and vomiting. RELEVANCE TO CLINICAL PRACTICE: The shortage of anaesthesiologists leads to heavy work burden and high incidence of occupational burnout among anaesthesiologists. The study found that it was safe for nurse anaesthetists to perform anaesthetic monitoring alone in the operating room under the supervision of the attending anaesthesiologist and did reduce the burden of anaesthesiologists' work. The results of the current study contribute to the expansion of occupational categories for nurse anaesthetists in countries where anaesthesiologists are in short supply. It provides new ideas for hospital administrators and policy-makers to formulate medical and nursing service policies.

Especialización de enfermería en anestesiología y reanimación como necesidad formativa en Cuba / Nursing specialization in anesthesiology and resuscitation as a training need in Cuba

Introducción: Las especialidades de posgrado constituyen la formación académica que le proporciona al profesional la actualización, profundización, perfeccionamiento o ampliación de las competencias laborales para el desempeño asistencial que requiere. Objetivo: Explorar la percepción de los enfermeros certificados para la práctica de la anestesiología sobre la necesidad de la formación de enfermeros especialistas en anestesiología y reanimación. Métodos: Se realizó un estudio cualitativo, de tipo Investigación Convergente Asistencial en el Departamento de Docencia e Investigación del Hospital Provincial Pediátrico Universitario de Villa Clara, Cuba, entre los meses de enero y marzo del año 2022. El universo estuvo compuesto por 100 profesionales de enfermería certificados en anestesiología, y la muestra seleccionada a través de un muestreo teórico quedó constituida por 80. Se realizaron entrevistas informales y ocho grupos de discusión en el proceso investigativo. Resultados: Los participantes perciben como necesaria la formación de enfermeros especialistas en anestesiología, reanimación y alivio del dolor. Las estrategias para lograr esta formación deben estar dirigidas a su aprobación por parte de las instancias de posgrado del Ministerio de Salud Pública y el Ministerio de Educación Superior. Conclusiones: Perciben como perentorio la formación de enfermeros especialistas en anestesiología y reanimación, ya que permitirá garantizar la adecuada renovación de este recurso humano, contar con enfermeras capacitadas y capaces de brindar atención anestesiológica óptima, alcanzar un nivel profesional superior que los coloque paralelos a otras áreas del cuidado y formar recursos humanos más jóvenes que tengan un nivel de preparación superior en esta especialidad.

Introduction: Postgraduate specialties constitute the academic training that provides the professional with the updating, deepening, improvement or expansion of labor competencies for the care performance that is required. Objective: to explore the perception of certified nurses for the practice of anesthesiology on the need to train specialist nurses in anesthesiology and resuscitation. Methods: A qualitative study of the Convergent Care Research type was carried out in the Teaching and Research Department of The Provincial Pediatric University Hospital of Villa Clara, Cuba between the months of January and March of the year 2022. The universe was composed of 100 nursing professionals. certificates in anesthesiology and the sample selected through a proven theory was made up of 80. Informal interviews and discussion groups were conducted as instruments in the investigative process. Results: the participants will perceive as necessary the training of specialist nurses in anesthesiology, resuscitation and pain relief. The strategies to achieve this training must be directed to its approval by the postgraduate instances of the Ministry of Public Health and the Ministry of Higher Education. Conclusions: the training of nurses specialized in anesthesiology and resuscitation is imperative, as it will guarantee the adequate renewal of this human resource, have trained nurses capable of providing optimal anesthesiological care, reach a higher professional level than place them parallel to other areas. of care and train younger human resources that have a higher level of preparation in this specialty.

Improving Certified Registered Nurse Anesthetists' Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol.

PURPOSE: The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. DESIGN: This quality improvement project was conducted using a pre- and postimplementation design. METHODS: Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). FINDINGS: Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P = .588), confidence (P = .031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. CONCLUSIONS: Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.

Preoperative Preparation and Guidelines for Cannabis-Using Patients Undergoing Elective Surgery.

PURPOSE: Appropriate preoperative screening techniques are needed to safely provide anesthesia to increasing numbers of cannabis using surgical patients. DESIGN: This was a quasi-experimental quality improvement project. METHODS: Preoperative identification of cannabis users by registered nurses (RNs) and certified registered nurse anesthetists (CRNAs) was compared to baseline identification rates. CRNAs' compliance with evidenced base guidelines was recorded. Perioperative medication requirements were recorded and compared between cannabis-users and noncannabis users. FINDINGS: Identification of cannabis users by CRNAs conducting preanesthetic assessments increased from 4.08% to 14.36% while RN identification improved from 11.22% to 13.81%. Compliance with identification guidelines was 69.2% among CRNAs. There were no differences in anesthetic requirements, complications, or postanesthesia care unit (PACU) length of stay between cannabis users and nonusers. CONCLUSIONS: Preoperative identification of cannabis users allows for safer, more effective perioperative care by CRNAs, registered nurses, and surgical staff.

Certified Registered Nurse Anesthetists' occupational exposure to inhalational anesthetic agents: a survey of anesthetic gas safety.

BACKGROUND: Anesthetic gases have been known to cause damage when inhaled over long periods of time. Modern safety measures have been put in place to reduce the risk to anesthesia providers, however there is continued lack of information on providers experiencing short term effects (lethargy, fatigue, headache, slowed cognitive ability, nausea, and mucosal irritation) thereby leading to long-term sequalae (sister chromatid exchanges, micronuclei, chromosomal aberrations, and comet assays). METHOD: A thirteen item, multiple choice survey was sent to 3,000 anesthesia providers, of which 463 completed the survey. A Chi-square test of independence was used to determine the association between gas exposure and participant self-reported symptoms. A Spearman's Correlation test was also utilized to interpret this data since both frequency of smelling gas and frequency of symptoms were ordinal variables for which Spearman's rho correlation was the appropriate measure of association. RESULTS: The major findings were that as the frequency of smelling anesthetic gas increased, so too did the frequency of self-reported headaches and fatigue. Spearman's rho = .148 and .092. P value = .002 and .049, respectively. CONCLUSION: There have been many efforts to decrease the risk of exposure of anesthesia providers to anesthetic gases. While there is a decrease in reported exposures, indications of possible long-term effects remain a concern in anesthesia providers. Potential implications of exposure could lead to chromosomal aberrations, sister chromatid exchanges, comet assays, spontaneous abortions, and genotoxic effects.

Chronic Opioid Use After Surgery: An Exploratory Study Examining Rural Certified Registered Nurse Anesthetist Strategies to Mitigate Chronic Opioid Use and Their View of Their Role in the Opioid Crisis.

Certified registered nurse anesthetists (CRNAs) provide most of the anesthesia care in the rural United States. Rural regions of the US also have the highest opioid prescribing rates and opioid-related hospital admissions and deaths. Although CRNAs are the primary anesthesia providers in these regions, little research examines the strategies CRNAs may use to mitigate the development of chronic opioid use after surgery. The purpose of this study was to assess the views of rural CRNAs regarding their role in mitigating chronic opioid use after surgery and to determine what, if any, preventative strategies they may use. A survey was developed and distributed to CRNAs practicing in rural areas of the US with the highest opioid prescribing rates. Of the 160 CRNAs who responded, 73% agreed that they could influence whether their patient developed chronic opioid use after surgery. Those who agreed were more likely to be involved in policy development to decrease opioid use. The survey also found that CRNAs with a doctoral degree, compared with those with master's level preparation, were more likely to report that they could influence whether their patient developed chronic opioid use after surgery.

Knowledge, safety, and teamwork: a qualitative study on the experiences of anaesthesiologists and nurse anaesthetists working in the preanaesthesia assessment clinic.

BACKGROUND: The preanaesthesia assessment clinic (PAC) has been shown to contribute to safe anaesthesia assessment in hospitals. In the PAC, patients are assessed with an interview and can also ask relevant questions about anaesthesia. The intention is to ensure that patients are comprehensively prepared for the surgery and hospital stay. Although earlier studies have assessed the effects of PAC, attitudes and satisfaction of the healthcare personnel working in PAC remain unknown. Thus, this study aimed to examine the experiences of anaesthesiologists and nurse anaesthetists working in PACs as well as to explore barriers and facilitators in this context. METHODS: A descriptive qualitative approach was used to explore the experiences of anaesthesiologists and nurse anaesthetists working in PACs. Thirteen semi-structured interviews were conducted using face-to-face, telephone, or digital platforms in five hospitals in west, south, and north Norway between 2020 and 2021. The interviews were transcribed and thematically analysed according to Braun and Clarke's six-steps semantic reflexive analysis. RESULTS: Four themes and nine subthemes were identified through an active analysis process, including developing competence in clinical anaesthesia practice, identifying barriers and facilitators influencing collaboration and teamwork, improving patient safety and outcomes through structured assessment, and identifying other organisational factors affecting the delivery of healthcare to surgical patients. CONCLUSIONS: Working in the PAC contributed to competence development among the personnel. Additionally, teamwork was considered important for the proper functioning of the PAC. Patient safety was perceived as improved owning to the structured assessment in PAC, with patients getting the opportunity to improve their knowledge and being more involved in the upcoming anaesthesia.

Reducing the Carbon Footprint of Anesthesia: Low-Flow Anesthesia and Other Techniques.

According to a joint statement by the US National Academy of Sciences and the UK Royal Society, it is now more certain than ever that human activity is a leading cause of rapid, accelerated climate change. Our volatile anesthetics have up to 2,000 times more greenhouse gas contributing potential than the same amount of carbon dioxide, yet no emission regulations have been imposed. The carbon footprint of volatile agents exists in all anesthesia practices, indirectly affecting all humans. It manifests daily in the clinical practice of over 30,000 certified registered nurse anesthetists in the United States, as their anesthetic choices directly impact the environment. However, education about anesthetic choice and its impact has been overlooked, making many anesthesia providers unaware of meaningful ways to reduce ecological and economic costs. Decreasing the use of volatile agents by low-flow techniques and the use of a total intravenous anesthetic could dramatically reduce carbon footprint produced by anesthesia. The authors review other advantages of limiting or avoiding volatile agents beyond green anesthesia such as decreased costs, reduced postoperative nausea and vomiting, and lowering the risk of malignant hyperthermia.