Implementation of a Perioperative Lung Protective Ventilation Protocol for Robotic-Assisted Surgeries.

This project sought to educate providers on the benefits of lung protective ventilation (LPV), implement a LPV protocol in robotic surgery, and evaluate adherence to the protocol in the adult (≥ 18 years) robotic-assisted surgery population. This project used a pre/post quality improvement design with a retrospective chart review and periodic knowledge, attitude, and practice surveys over the course of 6 months. This project retrospectively reviewed electronic medical records to assess adherence to the LPV protocol. The type of surgery; ventilator settings including positive end-expiratory pressure, FiO2, tidal volume, SpO2, ventilator mode, compliance, driving pressure and peak pressure; patient height and weight; patient body mass index; and American Society of Anesthesiologists physical status classification were collected. Analyzed results compared baseline preeducation data and data collected at 3- and 6-months postimplementation. Adherence to the LPV protocol parameters of tidal volume (P < .001), respiratory rate (P = .014), and driving pressure (P < .001) within LPV limits improved with statistical significance from pre- to postimplementation. Provider confidence and knowledge increased from pre- to posteducation (P = .049). Adherence to a LPV protocol improved with education and information tools.

Exploring the Experience of CRNAs Choosing to Quit Their Jobs: A Qualitative Study.

The purpose of this study was to explore the experience of certified registered nurse anesthetists (CRNAs) choosing to quit their primary place of employment. Interpretative phenomenological analysis is the qualitative framework for this study. Ten CRNAs were interviewed about their experience of quitting their job. Interview transcripts were analyzed for common themes. Common themes were the desire for better work-life fit, the impact of stressful work intensity, and exposure to poor leadership. This study suggests that a focus on ensuring job fit for personal goals outside of work may improve CRNA retention. This study also provides practice implications for hospital leadership, as well as direction for future qualitative and quantitative research.

Evaluation of the International Scope of Practice of Nonphysician Anesthesia Providers Between 2012 and 2022.

In 2012, representatives of the 44 International Federation of Nurse Anesthetists (IFNA) member countries were surveyed about their scope of practice. Ten years later, the researchers repeated the study to evaluate the professional development of nonphysician anesthesia providers. The survey was prepared by the IFNA Practice Committee and explored demographics, training, anesthesia team members, and daily activities of the nonphysician anesthesia providers (NPAPs). The online survey was sent to all IFNA Country National Representatives. In 2022, 22 out of 44 countries had more than one type of NPAP including five countries that had anesthesia technicians. NPAPs work in operating theatres (94.4%), postanesthesia care units (81.9%), intensive care units (46%), acute (51%), chronic pain (28%), air ambulance (28%), resuscitation (69%), or trauma team (42%), preoperative screening (57%). Formal recognition of the profession and the requirement of licensure to practice has increased. Education levels have increased substantially, which resulted in more indirect supervision. Direct supervision by physicians is related to education levels and limited scope of practice. The NPAP workforce is growing toward IFNA standards, but it has become a more diversely educated workforce. NPAPs who are educated at a bachelor or higher level and require officially recognized licensure to practice, have an extensive scope of practice.

Ultrasound-Guided Quadratus Lumborum Block Versus Caudal Block for Perioperative.

Quadratus lumborum block is an effective truncal block for postoperative analgesia in patients undergoing abdominal surgeries. We aimed to compare the analgesic efficacy of caudal block versus ultrasonography-guided quadratus lumborum block in pediatric patients undergoing open pyeloplasty. Fifty patients weighing ≤ 16 kg (age ≤ 4 years) with ASA physical status I-II scheduled for elective open pyeloplasty under general anesthesia were randomized into caudal block or transmuscular quadratus lumborum block groups. Fifty patients were included in the analysis. The mean duration of postoperative analgesia in the caudal group was 6.85 ± 1.99 hr, and for the quadratus lumborum block group it was 11.27 ± 3.74 hr (P < .001). There was no significant difference between the groups in terms of perioperative fentanyl requirement. However, there was a significant difference in postoperative paracetamol requirement between the groups (P = .005). There was a significant difference in postoperative pain score between the groups at 30 min, 1 hr, 1.5 hr, 2 hr, 8 hr, and 24 hr (P < .05). Mean heart rate and mean arterial pressure were comparable. No complications were recorded. Quadratus lumborum block was more effective than caudal block in terms of duration of postoperative analgesia and postoperative analgesic consumption.

Impact of a Tranexamic Acid Dosing Practice Guideline in Reducing Blood Product Administration in Pediatric Scoliosis Surgery.

Pediatric patients who undergo spinal corrective surgery often require multiple blood product transfusions. The use of antifibrinolytics, especially tranexamic acid (TXA), to mitigate intraoperative blood loss has increased in popularity. The goal of this quality improvement project was to evaluate provider compliance with a TXA dosing protocol during pediatric corrective spine procedures. A retrospective chart review was conducted to compare pre- and postimplementation data on cell saver and packed red blood cell (PRBC) administration and dose of antifibrinolytic administered. A total of 486 patients (68% idiopathic and 32% neuromuscular) were evaluated over a 9-year period. Following implementation of the protocol, patients of idiopathic origin experienced a 20% reduction in cell saver administration, a 10% reduction in PRBC administration, and a 37% increase in provider compliance with the dosing protocol. Patients of neuromuscular origin experienced a 53% increase in provider compliance with the recommended TXA dosing protocol; however, this patient population did not experience a statistically significant reduction in transfusion requirements. Implementation of an antifibrinolytic protocol can facilitate compliance with recommended TXA dosing parameters and potentially decrease intraoperative blood loss, reducing blood product transfusion requirements.

Shared Experiences of Nurse Anesthesiology Faculty During the COVID-19 Pandemic.

The COVID-19 pandemic impacted all aspects of healthcare, including the education of certified registered nurse anesthesiologists. While the literature contains reports of the impact of COVID-19 on physician anesthesiologist faculty, there was no research identified describing the impact on nurse anesthesiologist faculty. The purpose of this study was therefore to describe and explore the impact of the COVID-19 pandemic on nurse anesthesiology faculty. This qualitative ethnographic study used small focus groups and semistructured and probing questions to examine the phenomenon of interest. Through thematic analysis of the narrative, five overarching themes were identified: 1) ability to adapt to adversity, 2) disruption leads to change, 3) perceived positive outcomes, 4) previously untapped resources, and 5) curricular innovation and integrity.

Successful Treatment of Idiopathic, Intractable Hiccups With Prescriptive Positive Pressure Ventilation-A Case Report.

A 65-year-old male patient presenting with idiopathic, intractable hiccups was to undergo bilateral thoracotomies for phrenic nerve stimulator placement but initially underwent a treatment utilizing the administration of prescriptive positive pressure ventilation as a less invasive treatment option and had successful resolution of hiccups. The patient's hiccups began after a prior hiatal hernia repair and was refractory to pharmacologic treatment and phrenic nerve blocks. Utilizing neuromuscular blockade for diaphragm paralysis and administering three vital capacity breaths to peak inspiratory pressures of 25 cm H2O via endotracheal tube, the patient had successful resolution of symptoms and further surgical intervention was not warranted.

Dexmedetomidine for Postoperative Delirium Prevention in the Older Adult: An Integrative Review.

The brain and cognition are particularly vulnerable to anesthetic and surgical insults, with postoperative delirium being the most common postoperative complication in patients aged ≥ 65 years. The body releases psychoactive proinflammatory cytokines in response to surgical trauma, including interleukin-1ß, interleukin-6, and tumor necrosis factor-α. This promotes a porous blood-brain barrier, promoting postoperative cognitive dysfunction. Aging adults lose brain volume, cerebrospinal fluid, and dendritic synapses, thereby increasing neurologic stress and vulnerability to these surgical changes. Anesthetic technique influences the process, necessitating the importance of educated certified registered nurse anesthetists. Dexmedetomidine, a nonspecific α2-adrenergic receptor agonist, exhibits anti-inflammatory properties that counteract the proinflammatory mechanisms initiated by surgical insult. Additionally, dexmedetomidine mimics natural sleep pathways and reduces opioid dosing requirements, promoting cognitive preservation. While further research is required to establish an association with long-term effects, current literature indicates that dexmedetomidine may reduce postoperative delirium and cognitive dysfunction in older adults through various dosing regimens. This journal course reviews the pathophysiology of postoperative neurocognitive dysfunction and delirium, dexmedetomidine as an adjunct to mitigate these pathologic changes, and the current literature on dexmedetomidine's impact on postoperative delirium in older adults.

Barriers to effective clinical preceptorship in nurse anesthesiology.

BACKGROUND: Clinical preceptorship is an effective teaching tool for Certified Registered Nurse Anesthetists (CRNAs) and Student Registered Nurse Anesthetists (SRNAs). Strategies for success and barriers to effective clinical preceptorship have been explored across the literature to improve learning experiences for SRNAs. PURPOSE: The purpose of this literature review was to identify barriers to effective clinical preceptorship in the field of nurse anesthesiology. METHOD: A rapid review of the literature utilizing PubMed, Embase, CINAHL, Scopus, and Cochrane Library ultimately yielded 14 relevant articles. RESULTS: Clinical preceptorship in the discipline of nurse anesthesiology has a significant impact on both student experiences and preceptor satisfaction. Barriers within the clinical preceptorship model have been identified across the literature from both the preceptor and student perspectives. CONCLUSIONS: The overarching theme is that development of clinical preceptor workshops and specific guidelines would enhance the experiences of both clinical preceptors and students and allow goals and objectives to be more easily met.

Collaborative nursing education between advanced practice registered nurses.

The surge in healthcare demands due to the explosion of growth in the aging adult population demands that academic institutions address enhanced education of Advanced Practice Registered Nurses (APRNs). This is particularly challenging amidst nurse faculty shortages in specialty areas, stemming from factors such as lack of pay competitiveness with clinical positions, and doctoral-prepared nurses seeking faculty positions. Despite efforts to address the shortages, recruitment challenges persist, necessitating innovative approaches. This article explores the interprofessional collaborative teaching between Nurse Anesthesia (NA) and Adult Gerontology Nurse Practitioner (NP) programs, focusing on airway management, sedation techniques, chest X-ray interpretation, and ultrasound skills. To date, this collaboration between NA and NP faculty has proven effective. Both synchronous and online asynchronous teaching have received overwhelmingly positive student feedback. Ongoing communication and collaborations between NA and NP faculty facilitate teaching and educational strategies across programs, sharing faculty expertise, and mitigating reduced faculty numbers. This innovative model benefits faculty and students and provides a platform for firsthand interprofessional collaboration, fostering mutual respect and preparing students for effective interdisciplinary healthcare teamwork.

A new approach to peripheral nerve block education with the Anatomage Table as a learning adjunct.

Human anatomy education serves as a gateway for entering the intricacies of health science. Human cadavers have been the gold standard for learning regional and gross anatomy. However, increasing barriers in acquisition, maintenance, and longevity have pushed anatomy education toward technology-based alternatives such as the Anatomage Table (AT), an interactive, life-sized virtual dissection table with many anatomy education-centric features. The AT has found purchase in various contexts, such as clinical settings, research, outreach, and education. Studies into the efficacy of the AT in teaching settings have been generally positive but limited in its application, particularly in clinical procedure education. In this study, we conducted an informal workshop for second-year Certified Registered Nurse Anesthetist (CRNA) students to aid in being able to identify the important neuraxial landmarks for performing peripheral nerve blocks (PNBs), an anesthetic technique often used before other procedures. In our workshop, we paired the AT with identification of the same neuraxial landmarks on volunteer models with an ultrasound probe to provide students with relevant tactile experience for the procedure. From our pre-/post-surveys of the participants (n = 29), we found that our workshop significantly increased student confidence in identifying the relevant neuraxial landmarks for and in performing PNBs. Our results support the use of the AT in clinical education as a supplement, particularly where other anatomic teaching tools, such as cadaver models, may be too difficult to implement.NEW & NOTEWORTHY We implemented the Anatomage Table (AT) and portable ultrasound to teach neuraxial landmarks for performing peripheral nerve blocks (PNB), an anesthetic technique for Certified Registered Nurse Anesthetist (CRNA) students. The workshop significantly increased student confidence in identifying the relevant neuraxial landmarks for performing PNBs. Our results support the use of the AT in clinical education as a supplement.

Impact of changes in anaesthesia staff assignments on billing compliance, financial margins, and costs of anaesthesia services: development and application of a margin-cost estimation tool.

BACKGROUND: The US Centers for Medicare and Medicaid Services provide guidelines for the coverage of anaesthesia residents and certified registered nurse anaesthetists (CRNAs) by anaesthesiologists. We tested the hypothesis that changes in the anaesthesia staffing model increase billing compliance. METHODS: We analysed 13 926 anaesthesia cases performed between September 2019 and November 2019 (baseline), and between September 2020 and November 2020 (after change in staff model) at a US academic medical centre using an estimation tool. The intervention was assignment of additional 12-h weekday CRNAs plus an additional anaesthesiologist who covered weekdays after 17:00, weekends, and holidays. The proportion of cases with billing compliant coverage (covered either by solo anaesthesiologist or anaesthesiologist covering two or fewer residents or four or fewer CRNAs) was analysed using logistic and segmented regression analyses. RESULTS: The change in staff model was associated with a decrease in non-optimal anaesthesia staff assignments from 4.2% to 1.2% of anaesthesia cases (adjusted odds ratio 0.25; 95% confidence interval [CI] 0.20-0.32; P<0.001) and an increase in billable anaesthesia units of 0.6 per anaesthesia case (95% CI 0.4-0.8; P<0.001). An increased revenue margin associated with optimal staffing levels would only be achieved with salary levels at the 25th percentile of relevant benchmark compensation levels. Total staff overtime for all anaesthesia providers decreased (adjusted absolute difference -4.1 total overtime hours per day; 95% CI -7.0 to -1.3; P=0.004). CONCLUSIONS: Implementation of a change in anaesthesia staffing model was associated with improved billing compliance, higher billable anaesthesia units, and reduced overtime. The effects of the anaesthesia staff model on revenue and financial margin can be determined using our web-based margin-cost estimation tool.

Moral Distress of Anesthesia and Intensive Care Nurses in Latvia.

Moral distress is recognized as a serious problem not only among healthcare providers, but also in the healthcare system in general. It is considered that moral distress in health care is defined as a phenomenon in which nurses know how to proceed ethically in certain situations but are constrained from acting. There are currently no studies conducted on moral distress among anesthesia and intensive care nurses in Latvia, but the moral distress scale has been adapted since beginning the research. Additionally, there have been no studies conducted in Latvia to analyze the correlations between the level of moral distress and burnout syndrome. The results of the conducted research confirmed H0 (null hypothesis), which suggests that there is no association between moral distress and burnout rates in nursing practitioners in anesthesiology and intensive care. The results of the study and a review of the existing literature suggest that there is a statistically significant relationship between moral distress rates and the rates of emotional exhaustion, as well as the rates of depersonalization.

Implementation of a Power Down Initiative in 34 Operating Rooms.

Operating rooms (ORs) use energy-intensive equipment such as anesthesia gas machines, patient monitors, and lights. They are major contributors to an institution's carbon footprint; yet ORs are unoccupied 40% of the time. Implementing an initiative to power down electrical devices can reduce energy consumption, equipment failure, and financial outlay. This quality improvement project developed and implemented a power down initiative for anesthesia staff to use in ORs. The initiative included turning off anesthesia gas machines, patient monitors, auxiliary oxygen delivery, and room lights at the end of scheduled cases in ORs that were not used for emergencies. Convenience audits were conducted. Pre- and postimplementation compliance outcomes showed that there was an increase in powering down the anesthesia gas machine, patient monitor, auxiliary oxygen, and room lights. Powering down unnecessary equipment at this facility has the potential to save approximately $50,000 and prevent the emission of over 80 metric tons of CO2 per year. Other facilities can implement a similar quality improvement project aimed at fiscal and ecological conservation.

Opportunities and Obstacles: The Impact of COVID-19 on Student Registered Nurse Anesthetists.

In March of 2020, the World Health Organization declared COVID-19 a pandemic. The pandemic had unprecedented impacts on nurse anesthesia education delivery. The aim of this mixed methods study was to describe and quantify the personal and educational impacts of the COVID-19 pandemic on student registered nurse anesthetists (SRNAs). Three themes emerged from the qualitative arm of the study: 1) COVID-19 caused feelings of isolation, anxiety, and stress; 2) COVID-19 was a financial silver lining; and 3) COVID-19 changed nurse anesthesia education delivery and learning for SRNAs. The quantitative arm of the study revealed that SRNAs experienced anxiety, social isolation, and a sense of being overwhelmed. Almost half of the participants received federal stimulus money. Most participants reported an increase in distance education delivery and virtual simulation. This study summarizes the impact of the COVID-19 pandemic on SRNAs and how nurse anesthesia education was altered.

Predicting Intraoperative Hypotension: An Intraoperative Case Report.

Intraoperative hypotension (IOH) is a common issue associated with acute kidney injury, myocardial injury, stroke, and death. IOH may be avoided with the incorporation of newer advanced hemodynamic monitoring technologies. This case study examines the use of advanced hemodynamic monitoring with an early warning system for the intraoperative hemodynamic management of a patient presenting for pancreaticoduodenectomy. Incorporating the hypotension prediction index and other hemodynamic parameters to anticipate impending hypotension and treat potential causative factors is an emerging technological advancement. Understanding and embracing the potential for new advanced hemodynamic technology to reduce intraoperative hypotension's severity, duration, and occurrence is key to reducing negative patient outcomes.

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.