Assessing CRNA Knowledge of Local Anesthetic Systemic Toxicity Treatment.

Local anesthetic systemic toxicity (LAST) is a rare life-threatening adverse event. Due to the potential for devastating patient outcomes, it is crucial for anesthesia providers to understand appropriate LAST management. The primary aim of this study was to assess certified registered nurse anesthetist (CRNA) knowledge of the 2020 American Society of Regional Anesthesia and Pain Medicine (ASRA) LAST treatment guidelines. The secondary aim was to determine whether there was a relationship between the frequency of CRNAs' exposure to perioperative local anesthetic use and their knowledge level. A quantitative descriptive study and national American Association of Nurse Anesthetists electronic survey solicited practicing CRNAs. Survey findings revealed knowledge scores averaging 47.3% among 184 respondents. Almost all (97.8%) recognized the importance of early lipid emulsion administration. Over half (54.3%) were unaware of the recommended epinephrine dosing during LAST. No relationship was found between knowledge level and CRNAs' exposure to local anesthetics. Those who reported having immediate access to written or electronic guidelines in the event of LAST had significantly higher knowledge scores than those without access (P = .049). Implementing cognitive aids may help bridge knowledge gaps identified in this study and ensure critical steps are not missed. Further studies examining the use of cognitive aids to improve CRNA knowledge of LAST management may be beneficial in the future.

How nursing care is expressed among nurse anaesthetists in the perioperative context: A meta-ethnographic synthesis.

AIM: To develop a conceptual framework describing nursing care from the anaesthesia nurse's perspective in the perioperative context. BACKGROUND: Surgical patients find themselves in a vulnerable situation in need of advanced treatment and care. Nurse anaesthetists have a central role in reducing harm and enhance patient safety, in which person-centred care has been identified as a key component. However, they are challenged by productivity and efficiency demands leading to a potential risk to patient safety. DESIGN: Noblit and Hare's interpretative meta-ethnography, directed by the eMERGe reporting guidance. METHODS: A comprehensive systematic search of nine databases without year limitation. Fifteen studies published between 2002 and 2021 were found eligible for inclusion. Quality appraisal was performed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. RESULTS: Four themes were identified: being vigilant to keep safe from harm, strengthening patients' confidence, expressing courage to act and speak up, and endorsing team collaboration to achieve best practice. The themes were synthesised into the metaphor, 'Continuously assessing and acting according to the patients' needs in a holistic perspective'. A conceptual framework was developed, illustrating the interconnection between the different nursing expressions, as the nurse anaesthetists seek to care for the patient as a whole person. CONCLUSIONS: Nurse anaesthetists aim to deliver holistic nursing care. Nursing care is expressed at two levels, foregrounding and backgrounding anaesthetic nursing, in line with the philosophy of person-centred care. Nursing care in anaesthesia is a matter of how and why it is performed, expressed in attitudes toward the recipients of care. RELEVANCE TO CLINICAL PRACTICE: The framework may be used to inform educational programs and clinical practice in nurse anaesthesia and to promote person-centred care as a shared value across all levels involved in perioperative patient care. NO PATIENT OR PUBLIC CONTRIBUTION: Data were retrieved from already published literature.

Nurse anesthetist students' experiences of peer learning in clinical education - A qualitative study.

BACKGROUND: As part of an interprofessional operating team, nurse anesthetists need to be skilled in collaboration, problem solving, attentiveness, independent decision-making and knowledge of anesthesiology nursing. Factors that are vital for nurse anesthetist students' future profession. The educational model peer learning, characterized by collaboration and learning through social interaction between individuals, may support nurse anesthetist students' development in such skills. AIM: The aim of the study was to explore nurse anesthetist students' perceptions of their experiences of peer learning as an educational model during their clinical education in a Swedish context. METHODS: The approach was a qualitative descriptive design. Seven nurse anesthetist students from four different universities were interviewed individually using a semi-structured interview guide. The data were analyzed with content analysis. RESULTS: Three generic categories revealed a description of the phenomenon: Increased independence, Holistic view and Expansive learning process. A main category brought together the content of the generic categories and shows the overall finding of the study: Peer learning promotes nurse anesthetist students' personal and professional development. CONCLUSION: Peer learning as an educational model during nurse anesthetist students' clinical education might facilitate preparation for their coming profession.

Stress Reduction Through Mindfulness Meditation in Student Registered Nurse Anesthetists.

Student registered nurse anesthetists (SRNAs) experience high levels of stress related to the level of difficulty and time commitment associated with an integrated Doctor of Nursing Practice anesthesia program. Although some degree of stress is necessary for motivation, unmanaged stress can contribute to illness, dissatisfaction, and substance use. A search of the literature showed that mindfulness meditation training reduces stress and improves academic performance in graduate student populations. An evidence-based practice project was developed and implemented to provide SRNAs with a novel stress management mechanism. A guided mindfulness meditation application for smart phones (Headspace, Headspace) was chosen as the intervention modality. Research shows that this application is an effective and convenient delivery system for mindfulness meditation training, decreasing stress during a 10-day trial. SRNAs attended a mindfulness presentation and completed an introductory guided mindfulness meditation module using the Headspace application on their personal smart phone. Preintervention and postintervention surveys (N=33) using the Depression Anxiety Stress Scales 21-item questionnaire were analyzed using the Wilcoxon signed rank test. Results showed significant reductions (P<.01) in depression (Z=-3.36), anxiety (Z=-3.07), and stress (Z=-3.46) scores, representing reductions of 32%, 32%, and 47%.

Incidence of Hypocalcemia and Role of Calcium Replacement in Major Trauma Patients Requiring Operative Intervention.

Traumatic injury is a major cause of morbidity and mortality, and hemorrhage is a primary factor. Evidence exists that major trauma patients are at high risk of hypocalcemia. The purpose of this study was to determine the incidence and rate of calcium replacement in major trauma patients requiring operative intervention, and to investigate the impact of hypocalcemia on rate of transfusion and mortality. A retrospective analysis was conducted of all top-tier trauma activations presenting to our institution during a 12-month period. A total of 638 activations were identified; 441 were excluded, primarily because of lack of operative intervention. Patients were predominantly male following blunt trauma. The mean initial calcium level was 8.11 mg/dL and 8.64 mg/dL, correcting for albumin levels. An acute decline was noted when initial serum calcium levels and intraoperative calcium levels were compared (7.51 mg/dL). Intraoperative ionized calcium levels were on the low end of the normal range, and 28.42% received supplemental calcium. Patients in our cohort arrived hypocalcemic, which has been previously associated with increased mortality. Patients requiring operative intervention are at increased risk of hypocalcemia. Recognition of this potential is key for improved outcomes.

Knowledge Assessment of Military Personnel, Veterans, and Family Taking Dietary Supplements.

Dietary supplements (DS) pose many side effects and multiple interactions with perioperative medications, which may increase surgical morbidity and mortality. Descriptive empirical data are essentially nonexistent related to DS consumption and patient knowledge of DS. The aims of this study were to investigate the prevalence of use, type of supplements used, and the knowledge base among military beneficiaries and veterans consuming DS during the preoperative period. This descriptive cross-sectional study solicited data from 2,623 volunteer, preoperative patients at 6 different military medical centers throughout the United States. Of the 2,623 participants, 847 (32.3%) reported taking at least 1 DS. Relevant to the surgical population, 154 (18.1%) of participants reported consuming DS that are associated with an increased risk of bleeding. Importantly, we found that 89.7% of patients taking DS were not aware of any potential side effects, and 97.1% lacked knowledge regarding any potential medication interactions between the supplement consumed and their prescribed medications. This vast knowledge gap could have deleterious effects on surgical outcomes. An increase in DS research is needed, and patient education should be incorporated routinely during preoperative assessments provided by military and Veterans Affairs healthcare facilities.

It's Never Just a Block: An Analysis of Regional Anesthesia Closed Claims.

Anesthesia care increasingly includes use of regional anesthesia techniques, either as a primary anesthetic or to reduce the patient's postoperative pain. Both neuraxial anesthesia and peripheral nerve blockade have several noteworthy functions. These functions include diminishing sensory sensation to pain and potentially producing a motor blockade, both of which may facilitate the surgical procedure. The desire to reduce reliance on opioid medications, protocols to enhance and accelerate patient recovery from surgery, and patient expectations all contribute to the likelihood that use of regional anesthesia will continue to gain popularity. As such, it is essential to understand whether an association exists between regional anesthesia and adverse outcomes of care. The American Association of Nurse Anesthetists Foundation Closed Claim Research Team searched the most current database of closed claims that involved adverse outcomes when either a peripheral nerve block or a neuraxial block was a component of care in the claims. Although there were only 32 claims in the dataset, a thematic analysis resulted in the identification of 3 themes: errors in cognitive decision making, ineffective communication patterns, and production pressure.

Conceptual issues in dermatology and medicine: Where do nonphysician practitioners rightfully belong-a dermatologist's perspective.

The invasion of the turf of medicine by nonphysician practitioners has not spared dermatology. The reasons behind this phenomenon are complex, as so many political issues are; some may be reasonable, others concerning. An undeniable consequence is that patients are being cared for by providers with significantly lower levels of medical education than that of medical doctors. The proper practice of dermatology, a visual specialty, is unquestionably dependent on experience complemented by scientific information; for this, years of postgraduate education are required. In this article, I expose, as I was invited to do with limitations, my opinions about the concept of having "midlevels," providing medical care to patients afflicted by skin disease.

Patients' Experiences During Carotid Endarterectomy Performed Under Local Anesthesia.

PURPOSE: To describe patients' experiences undergoing a carotid endarterectomy (CEA) under local anesthesia. DESIGN: Explorative qualitative design. METHODS: Semistructured interviews with 15 participants who had undergone CEA under local anesthesia, analyzed by content analysis. FINDINGS: Undergoing CEA under local anesthesia entails enduring stress with no possibility of withdrawal. Patients' lack of understanding of local anesthesia and experiencing pain and discomfort caused feelings of stress. The surgery resulted in a loss of control; patients had to surrender their autonomy to someone else. The nurse anesthetist was the link to the world outside the operating room (OR), and that nurse conveyed feelings of safety and security during the surgery. CONCLUSIONS: Patients' experiences ranged from being pleased with the surgical procedure and local anesthesia to vowing never to undergo such a procedure again. It is important to focus on the patients' experiences and feelings when choosing a method of anesthesia.

Occupational exposure to platinum drugs during intraperitoneal chemotherapy. Biomonitoring and surface contamination.

BACKGROUND: Hyperthermic intraperitoneal chemotherapy (HIPEC) has been introduced over the last decade for the treatment of peritoneal carcinomatosis. In this procedure, heated cytotoxic drugs are administered directly into the abdominal cavity, ensuring cancer cells to be exposed while reducing systemic toxicity. More recently, pressurized intraperitoneal aerosol chemotherapy (PIPAC), where the chemotherapeutic drug is injected into the peritoneal cavity as an aerosol under pressure, has been proposed to patients in palliative situation, as a new approach. The amount of drug used is up to 10 fold lower than in HIPEC. The use of cytotoxic drugs poses an occupational risk for the operating room personnel. This study investigated the potential exposure of the medical staff by biomonitoring and surface contamination measurements, during a HIPEC procedure and a PIPAC procedure. METHOD: Wipe samples were collected from various locations in operating rooms including gloves, hands, devices and floor. Urines samples were collected from 10 volunteers of the medical staff and from a control group. The platinum analysis was performed by inductively coupled plasma mass spectrometry. RESULTS: Significant contaminations were observed on the floor, gloves, shoes and devices. However, urinary platinum was below the limit of quantification (<10 ng/L) for more than 50% of samples from the healthcare workers performing HIPEC and PIPAC. Concentrations did not differ significantly from those reported for the control group. CONCLUSION: There appears to be little risk of exposure to platinum drugs during HIPEC and PIPAC providing the adequate safety measures are implemented.

Herbal Medications and Anesthesia Case Management.

Herbal medicine use in the United States has increased substantially. Despite this upward trend, patients often fail to disclose use of these medicines to their healthcare provider. Currently, the US Food and Drug Administration (FDA) does not require preclinical animal studies, controlled clinical trials, or postmarket surveillance of herbal supplements. Lack of FDA oversight leads to product variation in quality, purity, efficacy, harvesting, and storage. Intentional or unintentional addition of contaminants to these products remains substantial. Because herbal medicines have the potential to adversely react with medications used in the perioperative period, anesthesia providers should be aware of the purported uses of common herbal supplements, potential drug interactions with these medicines or possible contaminants, and the anesthetic implications for patients who use these medicines.

Trainers' perception of the learning environment and student competency: A qualitative investigation of midwifery and anesthesia training programs in Ethiopia.

BACKGROUND: Ethiopia has successfully expanded training for midwives and anesthetists in public institutions. This study explored the perceptions of trainers (instructors, clinical lab assistants and preceptors) towards the adequacy of students' learning experience and implications for achieving mastery of core competencies. METHODS: In-depth interviews with 96 trainers at 9 public universities and 17 regional health science colleges across Ethiopia were conducted to elicit their opinions about available resources, program curriculum suitability, and competence of graduating students. Using Dedoose, data were thematically analyzed using grounded theory. RESULTS: Perceptions of anesthesia and midwifery programs were similar. Common challenges included unpreparedness and poor motivation of students, shortages of skills lab space and equipment, difficulties ensuring students' exposure to sufficient and varied enough cases to develop competence, and lack of coordination between academic training institutions and clinical attachment sites. Additional logistical barriers included lack of student transport to clinical sites. Informants recommended improved recruitment strategies, curriculum adjustments, increased time in skills labs, and better communication across academic and clinical sites. CONCLUSIONS: An adequate learning environment ensures that graduating midwives and anesthetists are competent to provide quality services. Minimizing the human resource, infrastructural and logistical gaps identified in this study requires continued, targeted investment in health systems strengthening.

Anesthesia Practice and Perioperative Outcomes at Two Tertiary Care Hospitals in Freetown, Sierra Leone.

BACKGROUND: Anesthesia in West Africa is associated with high mortality rates. Critical shortages of adequately trained personnel, unreliable electrical supply, and lack of basic monitoring equipment are a few of the unique challenges to surgical care in this region. This study aims to describe the anesthesia practice at 2 tertiary care hospitals in Sierra Leone. METHODS: We conducted an observational study of anesthesia care at Connaught Hospital and Princess Christian Maternity Hospital in Freetown, Sierra Leone. Twenty-five percent of the anesthesia workforce in Sierra Leone, resident at both hospitals, was observed from June 2012 to February 2013. Perioperative assessments, anesthetic techniques, and intraoperative clinical and environmental irregularities were noted and analyzed. The postoperative status of observed cases was ascertained for morbidity and mortality. RESULTS: Between the 2 hospitals, 754 anesthesia cases and 373 general anesthetics were observed. Ketamine was the predominant IV anesthetic used. Both hospitals experienced infrastructural and environmental constraints to the delivery of anesthesia care during the observation period. Vital sign monitoring was irregular and dependent on age and availability of monitors. Perioperative mortality during the course of the study was 11.9 deaths/1000 anesthetics. CONCLUSIONS: We identified gaps in the application of internationally recommended anesthesia practices at both hospitals, likely caused by lack of available resources. Mortality rates were similar to those in other resource-limited countries.

Experience of anaesthesia nurses of perioperative communication in hip fracture patients with dementia.

BACKGROUND: Perioperative care in hip fracture patients with dementia can be complex. There is currently little scientific evidence on how care should be undertaken. AIMS: The aim of the study was to describe the experience of anaesthesia nurses of the difficulties that emerge in care situations and how communication with patients can be maintained in the perioperative setting of hip fracture surgery. METHODS: Individual interviews were conducted with ten anaesthesia nurses (5 men and 5 women). The interviews were carried out at a university hospital in Gothenburg (Sweden), and the data were analysed using qualitative content analysis. FINDINGS: Three main response categories were discerned: 'Communication', 'Dementia as a special issue' and 'Practical issues'. Dementia was viewed as one of the most difficult and shifting diseases an individual may suffer from. Time must be allocated to communicate clearly and patiently, to meticulously plan and carry out care while providing distinct information to enable patient participation. Establishing a mental bridgehead by confirming the patients' perceptions/feelings significantly reduced distress in a majority of the patients. A holistic and respectful approach was deemed mandatory at all times. Patients are sometimes dependent on recognition, so that small personal items brought close to the patient during surgery can calm the patient. State-of-the-art analgesia and anxiolytic medications are mandatory. CONCLUSIONS: Perioperative problems can be overcome with patience, empathy and profound knowledge of how patients with dementia respond prior to surgery. Our results may serve as a source for future care and provide information about hospital settings for better perioperative care in patients with dementia.

Ultrasound-Guided Ankle Blocks: A Review of Current Practices.

Ankle blocks are routinely indicated for surgical anesthesia and postoperative analgesia of procedures involving the foot. Traditionally, ankle blocks have been performed by relying on landmark identification of nerves. The literature regarding the performance and efficacy of ankle blocks is inconsistent. This can be attributed to several variables, such as provider technique, differences in patient populations, and the type and volume of local anesthetics administered. As with other peripheral nerve blocks originally performed using landmark technique, ultrasound imaging is now being incorporated into these procedures. Ultrasound guidance provides the anesthetist with several advantages over landmark techniques. The ability to identify peripheral nerves, view needle movements in real-time, and observe the spread of local anesthetic has been shown to result in greater block efficacy, even with reduced volumes of local anesthetic. Additionally, ultrasound imaging gives the provider the option to perform regional anesthesia in specific patient populations not considered possible when using landmark technique. Despite the limited literature on ultrasound-guided ankle blocks, outcome metrics seem to be consistent with those of other peripheral nerve blocks performed using this technology.

Reexamining traditional intraoperative fluid administration: evolving views in the age of goal-directed therapy.

Intraoperative volume administration has long been a topic of debate in the field of anesthesia. Only recently, however, has the conversation shifted to a discussion of appropriate intraoperative volume. A thorough review of the literature explores the history of today's widely accepted fluid administration equation and discusses possible explanations and consequences of iatrogenically induced hypervolemia. Current studies exploring various volume administration techniques are reviewed, as are emerging technologies available to help guide anesthesia providers with intraoperative fluid management.