Perioperative Vision Loss Following Prone Spine Surgery: A Case-Control Study.

PURPOSE: Perioperative vision loss (POVL) is a rare and devastating complication following prone spine surgery. Due to the rare nature of this complication, there is limited research available about patient and surgical risk factors that increase the risk of POVL. The objective of this study was to investigate associated risk factors for POVL with use of the National Surgical Quality Improvement Program (NSQIP) database. DESIGN: This study used a case-control secondary data analysis methodology that included five cases of POVL and 250 controls from the American College of Surgeons National Surgical Quality Improvement Program database who all underwent prone spine surgery between 2010 and 2020. METHODS: Each POVL case was matched to 50 randomly selected controls (n = 250) based on type and year of surgery. Demographics and variables of interest were compared among the POVL cases, among POVL cases and the aggregate control group (n = 250), and POVL cases against their matched control group. Univariate and multivariate conditional logistic regression were then used to estimate the odds of developing POVL in relation to potential patient and surgical risk factors. FINDINGS: When POVL cases were compared to the 250 control cases using univariate analysis, patients who developed POVL were more likely to have received a blood transfusion within 72 hours of surgery (P < .0001). and have longer operative times (odds ratio = 1.01, 95% CI [1.003, 1.017], P = .003). CONCLUSIONS: Two surgical risk factors were determined to be statistically significant, including the need for perioperative blood transfusion and prolonged operative time. These findings support previous research on POVL which often identified blood loss and prolonged operative times as surgical risk factors. The narrow patient population used in this project may have limited the ability to perform a more robust study on POVL. Therefore, further research on POVL using the National Surgical Quality Improvement Program database is strongly encouraged.

Patient-specific Predictors of Surgical Delay in a Large Tertiary-care Hospital Operating Room.

PURPOSE: The purpose of this study was to describe patient-specific factors predictive of surgical delay in elective surgical cases. DESIGN: Retrospective cohort study. METHODS: Data were extracted retrospectively from the electronic health record of 32,818 patients who underwent surgery at a large academic hospital in Los Angeles between May 2012 and April 2017. Following bivariate analysis of patient-specific factors and surgical delay, statistically significant predictors were entered into a logistic regression model to determine the most significant predictors of surgical delay. FINDINGS: Predictors of delay included having monitored anesthesia care (odds ratio [OR], 1.28; 95% confidence intervals [CI], 1.20-1.36), American Society of Anesthesiologist class 3 or above (OR, 1.21; 95% CI, 1.15-1.28), African American race (OR, 1.25; 95% CI, 1.12-1.39), renal failure (OR, 1.20; 95% CI, 1.09-1.32), steroid medication (OR, 1.13; 95% CI, 1.04-1.23) and Medicaid (OR,1.18; 95%CI, 1.09-1.30) or medicare insurance (OR, 1.14; 95% CI, 1.07-1.21). Six surgical specialties also increased the odds of delay. Obesity and cardiovascular anesthesia decreased the odds of delay. CONCLUSIONS: Certain patient-specific factors including type of insurance, health status, and race were associated with surgical delay. Whereas monitored anesthesia care anesthesia was predictive of a delay, cardiovascular anesthesia reduced the odds of delay. Additionally, obese patients were less likely to experience a delay. While the electronic health record provided a large amount of detailed information, barriers existed to accessing meaningful data.

California Certified Registered Nurse Anesthetist Workforce Study.

BACKGROUND: Nurse anesthesia in California has been instrumental in shaping Certified Registered Nurse Anesthetist (CRNA) practice nationally, but to date, no workforce data has been published on this group of Advanced Practice Registered Nurses. PURPOSE: The purpose of this workforce study was to explore the demographic information, education, and practice patterns of CRNAs working in California. METHODS: Survey methodology was conducted to gather workforce data from a sample of licensed CRNAs working in California. DISCUSSION: California CRNAs provide anesthesia services in very diverse settings among different anesthesia delivery models, including independent practice. CRNAs practice in a majority of California counties and are the sole anesthesia providers for four underserved counties. CONCLUSION: The CRNA workforce in California is comparatively young, highly educated, and desires more education. CRNAs improve access to care for California patients; however, more ethnically diverse CRNAs and CRNAs with Non-Surgical Pain Management Certification are needed.

Demystifying Buprenorphine with Current Evidence-Based Practice in Acute and Chronic Pain Management.

Buprenorphine has been widely used in opioid medication assisted treatment (MAT) in the past decade. However, due to misinterpretation of its intrinsic mu opioid receptor activity extrapolated from preclinical and animal data, buprenorphine's clinical application in pain management has been greatly limited. Buprenorphine acts as a full mu agonist with fewer side effects compared to traditional opioids and can be effectively used in the treatment of acute and chronic pain. A strong body of evidence demonstrates that buprenorphine is an effective analgesic agent in both adult and pediatric surgical patients. In addition, buprenorphine has been successfully used in treating chronic pain, particularly in cancer pain and neuropathic pain. In this Journal course, buprenorphine's receptor pharmacology and pharmacokinetics are reviewed. Specifically, misinterpretation of its intrinsic mu receptor activity, and both analgesic ceiling effect and efficacy are clarified. Differences between suboxone and buprenorphine, and specific applications are explained. Pain management options and guidelines for surgical patients on buprenorphine are discussed, as well.

Concept analysis of longitudinal assessment for professional continued certification.

BACKGROUND: This concept analysis presents a scholarly epistemological approach to defining the attributes, empirical referents, antecedents, and consequences of a knowledge maintenance approach-known as longitudinal assessment-to professional certification. AIM: The analysis reports on the efforts of the National Board of Certification and Recertification for Nurse Anesthetists to explore this educational method as an approach to meet requirements for continued professional certification. METHOD: Using the classical approach to concept analysis, the authors explore the structure and function of longitudinal assessment and define the characteristics of the concept in a way that is meaningful to the continued certification of nursing and medical professionals. CONCLUSION: This analysis establishes a link between the goal and outcome of the continued certification process, including continuing education in nursing and medical practice, and the desirable characteristics of longitudinal assessment, which include proven principles of educational psychology. Through exploring model and borderline cases, the authors seek to demonstrate that longitudinal assessment is the best approach to foster lifelong learning of continuously evolving scientific, theoretical, and clinical knowledge in support of safe care for patients.

Longitudinal assessment: A strategy to improve continuing professional certification.

Healthcare certification organizations carefully balance a commitment to bring value to their membership through programs that support lifelong learning and professional growth, while protecting the public by ensuring competent certified practitioners. These certifying bodies are challenged with remaining current with their maintenance of certification programs while keeping pace with the growing breadth of knowledge, industry standards and guidelines, innovative advances, and rapid technological gains in testing and assessment. Within the context of process innovation, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) evaluated the current landscape of Longitudinal Assessment (LA) as a potential strategy for the assessment of core knowledge as part of their Continued Professional Certification Program for Certified Registered Nurse Anesthetists. This manuscript details the evaluation of LA using a Logic Model as the tool to scaffold inquiry, a review of LA literature, an environmental scan of current LA programs with identification of LA program elements available, and the results of a LA feasibility study. The findings substantiate that continued professional certification which incorporates a LA strategy can augment lifelong learning, but is not an assessment strategy that can be implemented without thoughtful planning, customization and continuous maintenance.

Anesthetic Management of a Patient With Mast Cell Activation Syndrome: A Case Study.

Mast cell activation syndrome (MCAS) is a relatively new diagnosis for a constellation of symptoms with sometimes devastating results for patients. A 40-year old woman with MCAS underwent arthroscopic repair of her right shoulder, with successful anesthetic management. This case report discusses the basic immunologic physiology surrounding this syndrome, myriad medications often used by this patient population, and the anesthetic management of this patient. With additional knowledge of this disorder, exposure to its clinical presentation in the perioperative setting, and anesthetic considerations specific to MCAS, the Certified Registered Nurse Anesthetist will be better equipped to effectively manage the complex requirements of this patient population.

Preventing Surgical Delay and Cancellation with Patient-Centered Interventions.

Delay and cancellation can significantly impact cost and outcomes among surgical patients. While the causes of delay and cancellation are not fully enumerated, possible reasons include delivery-related causes such as facility, equipment, and provider availability as well as patient-related issues such as readiness and health status. Despite limited research explaining patient-related causes, there are many studies that evaluate patient-centered interventions to decrease delay and cancellation. This article highlights patient-centered interventions including preoperative clinics, preoperative screening, and focused education that have been shown to reduce delay and cancellation. This information provides perianesthesia nurses and advanced practice nurses ideas to maximize their roles in improving efficiency by prevention of delay and cancellation. This article should also stimulate additional research to help better understand the causes and the role of the nurse in the implementation of evidence-based practice projects that use patient-centered interventions.

The Opioid Crisis and the Certified Registered Nurse Anesthetist: Caring for Patients With Opioid Use Disorder in Drug-Free Recovery.

Opioid Use Disorder (OUD), the diagnostic term for opioid addiction, is estimated to affect millions of Americans and cost those who suffer it enormously. Given that opioid analgesics are a common component of anesthesia, how can we deliver safe and effective care to those who are in drug-free remission? This editorial will provide a background of this disorder, and will focus specifically on recommendations and guidelines available to the nurse anesthetist on the appropriate anesthetic care for the surgical patient population with OUD in recovery and not on maintenance therapy.

Increased Central Nervous System Interleukin-8 in a Majority Postlaminectomy Syndrome Chronic Pain Population.

Background and Objectives: Multiple processes have been identified as potential contributors to chronic pain, with increasing evidence illustrating an association with aberrant levels of neuroimmune mediators. The primary objectives of the present study were to examine central nervous system cytokines, chemokines, and growth factors present in a chronic pain population and to explore patterns of the same mediator molecules over time. Secondary objectives explored the relationship of central and peripheral neuroimmune mediators while examining the levels of anxiety, depression, sleep quality, and perception of pain associated with the chronic pain patient experience. Methods: Cerebrospinal fluid (CSF) from a population of majority postlaminectomy syndrome patients (N = 8) was compared with control CSF samples (N = 30) to assess for significant differences in 10 cytokines, chemokines, and growth factors. The patient population was then followed over time, analyzing CSF, plasma, and psychobehavioral measures. Results: The present observational study is the first to demonstrate increased mean CSF levels of interleukin-8 (IL-8; P < 0.001) in a small population of majority postlaminectomy syndrome patients, as compared with a control population. Over time in pain patients, CSF levels of IL-8 increased significantly (P < 0.001). Conclusions: These data indicate that IL-8 should be further investigated and psychobehavioral components considered in the overall chronic pain paradigm. Future studies examining the interactions between these factors and IL-8 may identify novel targets for treatment of persistent pain states.

The Opioid Crisis and the Certified Registered Nurse Anesthetist: How Can We Help?

This guest editorial reviews the facts surrounding the current opioid overdose crisis in the United States, including the history of opioid use and abuse leading up to the current crisis, and the impact of the crisis on the healthcare system. The editorial concludes with concrete recommendations and actions that Certified Registered Nurse Anesthetists (CRNAs) can take to combat this deadly and tragic epidemic. As leaders in the healthcare system and experts in opioid use and pain management, CRNAs have a moral and professional obligation to help patients and families affected by opioid misuse in any way possible.

Cerebrospinal Fluid Cytokines and Neurotrophic Factors in Human Chronic Pain Populations: A Comprehensive Review.

Chronic pain is a prevalent and debilitating condition, conveying immense human burden. Suffering is caused not only by painful symptoms, but also through psychopathological and detrimental physical consequences, generating enormous societal costs. The current treatment armamentarium often fails to achieve satisfying pain relief; thus, research directed toward elucidating the complex pathophysiological mechanisms underlying chronic pain syndromes is imperative. Central neuroimmune activation and neuroinflammation have emerged as driving forces in the transition from acute to chronic pain, leading to central sensitization and decreased opioid efficacy, through processes in which glia have been highlighted as key contributors. Under normal conditions, glia exert a protective role, but in different pathological states, a deleterious role is evident--directly and indirectly modulating and enhancing pain transmission properties of neurons, and shaping synaptic plasticity in a dysfunctional manner. Cytokines and neurotrophic factors have been identified as pivotal mediators involved in neuroimmune activation pathways and cascades in various preclinical chronic pain models. Research confirming these findings in humans has so far been scarce, but this comprehensive review provides coherent data supporting the clear association of a mechanistic role of altered central cytokines and neurotrophic factors in a number of chronic pain states despite varying etiologies. Given the importance of these factors in neuropathic and inflammatory chronic pain states, prospective therapeutic strategies, and directions for future research in this emerging field, are outlined.

Chronic Pain and Decreased Opioid Efficacy: An Inflammatory Link.

Chronic pain is a devastating amalgam of symptoms that affects millions of Americans at tremendous cost to our healthcare system and, more importantly, to patients' quality of life. Literature and research demonstrate that neuroimmune cells called glia are not only responsible for initiating and maintaining part of the chronic pain disease process, but also release inflammatory molecules responsible for decreasing the efficacy of one of the most prominent treatments for pain, opioid analgesia. This article describes chronic pain as a disease process that has ineffective treatment modalities, explores the mechanisms of glial cell activation and inflammatory responses that lead to chronic pain and decreased opioid treatment efficacy, and hypothesizes novel chronic pain treatment modalities based on the glial cell inactivation and anti-inflammatory pathways.