The Utility of BIS™ Monitoring in Anesthesia for Elderly Patients.

Aging leads to anatomic and physiologic changes in the brain, making it more sensitive to the depressant effects of anesthetic medications and increasing the risk of postoperative neurocognitive complications such as postoperative delirium and postoperative cognitive dysfunction. This article explores the implications of anesthesia on elderly patients' brain health, emphasizing the heightened risk of postoperative neurocognitive disorders, and describes the BIS™ Monitoring System as a neuromonitoring tool for anesthesia professionals to assess the depth of anesthesia. The integration of the BIS Monitoring System into clinical practice can contribute to a more tailored and patient-centered approach to anesthesia management, ultimately improving perioperative outcomes and safety.

Supporting CRNA Clinical Practice: A Review of New and Updated Professional Practice Documents.

The American Association of Nurse Anesthesiology (AANA) Practice Committee, in collaboration with AANA Professional Practice staff, advisory panels, and subject matter experts, annually applies a standardized evidence-based process to review, evaluate, and revise clinical resource documents found in the Professional Practice Manual for the CRNA (Certified Registered Nurse Anesthetist) and on the AANA website. This article highlights several revised and newly developed documents, which include topics such as diversity, equity, and inclusion, anesthesia and analgesia for obstetric patients, and safe injection guidelines.

The genomes of Hercules beetles reveal putative adaptive loci and distinct demographic histories in pristine North American forests.

Beetles, despite their remarkable biodiversity and a long history of research, remain lacking in reference genomes annotated with structural variations in loci of adaptive significance. We sequenced and assembled high-quality chromosome-level genomes of four Hercules beetles which exhibit divergence in male horn size and shape and body colouration. The four Hercules beetle genomes were assembled to 11 pseudo-chromosomes, where the three genomes assembled using Nanopore data (Dynastes grantii, D. hyllus and D. tityus) were mapped to the genome assembled using PacBio + Hi-C data (D. maya). We demonstrated a striking similarity in genome structure among the four species. This conservative genome structure may be attributed to our use of the D. maya assembly as the reference; however, it is worth noting that such a conservative genome structure is a recurring phenomenon among scarab beetles. We further identified homologues of nine and three candidate-gene families that may be associated with the evolution of horn structure and body colouration respectively. Structural variations in Scr and Ebony2 were detected and discussed for their putative impacts on generating morphological diversity in beetles. We also reconstructed the demographic histories of the four Hercules beetles using heterozygosity information from the diploid genomes. We found that the demographic histories of the beetles closely recapitulated historical changes in suitable forest habitats driven by climate shifts.

Analysis of a Needs Assessment Survey to Develop an Online Resource Repository Supporting Nurse Anesthesia Educators.

BACKGROUND: Without highly qualified nurse anesthesia educators and administrators, the health care system will be threatened by the inadequate supply of certified registered nurse anesthetists (CRNAs). PURPOSE: American Association of Nurse Anesthesiologists' Faculty Stabilization Task Force (FSTF) analyzed reasons for high faculty turnover and developed recommendations to support nurse anesthesia faculty and administrators. METHODS: A survey evaluated participants' current role, leadership development opportunities, mentorship experiences, and resource needs. RESULTS: Of 109 respondents, 87 (80%) were program administrators or assistant administrators with less than 5 years of experience in their role. Despite academic experience, 51% felt adequately prepared for their role. CONCLUSIONS: The FSTF provided 2 recommendations: to create a robust faculty development program for all faculty at all levels of CRNA education and a repository of information needed for program administrators and faculty to oversee and educate students in a high-quality CRNA program.

Integrating the ASRA Pain Medicine Cannabis Consensus Guidelines into Certified Registered Nurse Anesthetist Clinical Practice.

The American Association of Nurse Anesthesiology Practice Committee and subject matter experts recently evaluated newly published cannabis guidelines titled "ASRA Pain Medicine Consensus Guidelines on the Management of the Perioperative Patient on Cannabis and Cannabinoids." A summative review of the evidence-based guidelines provides essential recommendations, which are directly applicable to certified registered nurse anesthetist clinical practice.

Long-read Sequencing Data Reveals Dynamic Evolution of Mitochondrial Genome Size and the Phylogenetic Utility of Mitochondrial DNA in Hercules Beetles (Dynastes; Scarabaeidae).

The evolutionary dynamics and phylogenetic utility of mitochondrial genomes (mitogenomes) have been of particular interest to systematists and evolutionary biologists. However, certain mitochondrial features, such as the molecular evolution of the control region in insects, remain poorly explored due to technological constraints. Using a combination of long- and short-read sequencing data, we assembled ten complete mitogenomes from ten Hercules beetles. We found large-sized mitogenomes (from 24 to 28 kb), which are among the largest in insects. The variation in genome size can be attributed to copy-number evolution of tandem repeats in the control region. Furthermore, one type of tandem repeat was found flanking the conserved sequence block in the control region. Importantly, such variation, which made up around 30% of the size of the mitogenome, may only become detectable should long-read sequencing technology be applied. We also found that, although different mitochondrial loci often inferred different phylogenetic histories, none of the mitochondrial loci statistically reject a concatenated mitochondrial phylogeny, supporting the hypothesis that all mitochondrial loci share a single genealogical history. We on the other hand reported statistical support for mito-nuclear phylogenetic discordance in 50% of mitochondrial loci. We argue that long-read DNA sequencing should become a standard application in the rapidly growing field of mitogenome sequencing. Furthermore, mitochondrial gene trees may differ even though they share a common genealogical history, and ND loci could be better candidates for phylogenetics than the commonly used COX1.

Supporting the Foundation of Nurse Anesthesia Education: A Report of the Faculty Stabilization Taskforce.

Without highly qualified educators and educational program administrators, the ability to provide anesthesia and pain management services throughout the healthcare system will be threatened by the inadequate supply of Certified Registered Nurse Anesthetists (CRNAs). The average turnover rate between the years 2016-2020, for CRNA program administrators, was 15% with some programs changing leadership as often as every two to four years. In response, the American Association of Nurse Anesthesiology (AANA) and the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) created the Faculty Stabilization Taskforce (FSTF) to review reasons for the high turnover rate and to develop methods and tools to support program faculty and administrators in their role of educating the future CRNA workforce. The FSTF provided two recommendations: 1) to create a robust faculty development program for all faculty at all levels of CRNA education, and 2) to create a repository of information needed to administrate, and educate students, in a high-quality CRNA program. This article summarizes the report made to the AANA Board of Directors (BOD) which was unanimously accepted and is already being implemented by AANA and COA staff. The full text of the report can be found on the AANA's website at www.aana.com/FSTF.

A Review of New and Updated Professional Practice Documents.

The American Association of Nurse Anesthesiology (AANA) Practice Committee, in collaboration with AANA Professional Practice staff, advisory panels, and subject matter experts, applies a standardized evidence-based process to review, evaluate, and revise clinical resource documents found in the Professional Practice Manual for the CRNA (Certified Registered Nurse Anesthetist) and on the AANA website. This article highlights several revised and newly developed practice documents, which include topics such as the scope of nurse anesthesia practice, point of care ultrasound in anesthesia care, anesthesia for patients with substance use disorder, office-based dental anesthesia, workplace civility, and health disparities.

Methacholine challenges: comparison of different tidal breathing challenge methods.

Tidal-breathing methacholine challenges are now recommended by guidelines, to avoid the bronchoprotective effects of deep inhalation. This study compared different tidal breathing methacholine challenge methods; assessed the agreement between tidal dosimetric and continuous output challenges; and assessed challenge repeatability with different methods. 15 asthma patients performed dosimetric challenges and a continuous-output breath-actuated challenge, all ≥3 days apart. All subjects had a pre-bronchodilator forced expiratory volume in 1 s (FEV1) ≥65% predicted, and a cumulative dose causing a 20% reduction in FEV1 (PD20) <1.2 mg. Of the dosimetric challenges, one method increased methacholine concentration (standard dosimetric challenge), and one adjusted nebuliser output time to increase dose (adjusted dosimetric challenge). The adjusted dosimetric and continuous output challenges were performed twice on separate days to assess for repeatability. All challenges were matched for dose at each dose step. The mean PD20 ratio of the standard dosimetric challenge to the adjusted dosimetric challenge was 0.90 (95% CI 0.66-1.23, p=0.49) and intraclass correlation coefficient (ICC) was 0.82. Repeated adjusted dosimetric challenges had an ICC 0.62 for PD20. Repeated continuous output challenges had an ICC 0.74 for PD20. The adjusted dosimetric and continuous output challenges correlated (r=0.69, p=0.0043; ICC 0.65), but PD20 was higher for the adjusted dosimetric challenge (mean PD20 ratio 2.31, 95% CI 1.57-3.40; p=0.0004). Tidal dosimetric methacholine challenge using adjustment of nebuliser output produces results with good repeatability. The results of this adjusted dosimetric method differed from the continuous output method, underscoring that the results of different methacholine challenge methodologies may not be directly comparable.

Creating a Cognitive Aid for Use During Intraoperative Power Failures.

An intraoperative power failure (IOPF) is a complete or partial absence of the electrical power supply with or without the availability of a backup generator system during an operative or other invasive procedure. An IOPF can be stressful for the OR team and puts surgical patients at risk for adverse outcomes. To prepare providers for an IOPF, a CRNA piloted a project to create an evidence-based, facility-specific cognitive aid (CA) to guide decision making and enhance patient management and outcomes during an IOPF. The project team tested the battery-power capabilities of essential anesthesia equipment, including anesthesia gas machines, IV pumps, and vital sign monitors, and included the results in the CA. A needs assessment survey was sent to the anesthesia professionals at the facility to promote clinician buy-in and solicit feedback for creating the CA.

Basic Airway Management for the Professional Nurse.

The registered nurse (RN) on a medical-surgical nursing unit may be the first health care professional to encounter a patient with the signs of impending respiratory failure. Importantly, the RN must recognize the signs of respiratory compromise and possess the competence and confidence to intervene without delay. Signs of respiratory deterioration, physical assessment, and respiratory laboratory studies are reviewed. Modes of oxygen therapy, basic airway management techniques, including bag mask ventilation, and use of oropharyngeal and nasopharyngeal airways are discussed. The assembly of equipment and medications frequently used for intubation are also outlined.

Evolution of adult male horn developmental phenotypes and character displacement in Xylotrupes beetles (Scarabaeidae).

Character displacement that leads to divergent phenotypes between sympatric species has been hypothesized to facilitate coexistence and promote the accumulation of biodiversity. However, there are alternative evolutionary mechanisms that may also lead to the evolution of phenotypic divergence between sympatric species; one of the mechanisms is evolutionary contingency. We studied the evolution of the presence and absence of a major male horn phenotype, which may have ecological implications for promoting coexistence between sympatric beetles, across geographic populations from different Xylotrupes beetles. By using a previously published phylogeny with 80 Xylotrupes taxa, we estimated the transition rates between the two phenotypic states (i.e., presence vs. absence of a major male phenotype). Based on the estimated transition rates, we then simulated possible phenotypic outcomes between sympatric species. We found that sympatric species were equally likely to evolve the same versus distinct phenotypic states based on the estimated transition rates given the phylogeny. The empirically observed number of sympatric species showing different phenotypic states can be explained by evolutionary contingency alone. We discussed the importance of applying phylogenetic comparative methods when studying phenotypic evolution and more generally to investigate the effect of stochastic processes before making deterministic inferences.

Faculty development workshop on gender-associated incivility in nursing education.

BACKGROUND: Men comprise the minority of entry-level baccalaureate nursing students and are at increased risk of experiencing gender-associated incivility. PROBLEM: Uncivil peer-to-peer behavior can negatively affect students' mental and physical well-being, and learning experience. Nursing faculty must be able to identify and address gender-associated incivility among students. AIM: The purpose of this quality improvement program was to train nursing faculty to prevent, identify, and manage gender-associated incivility in the educational environment. METHODS: A day-long interactive workshop utilizing trigger films, small group discussions, and interactive theater was developed to train nursing faculty to implement proactive and reactive techniques to address uncivil behavior which will enhance the learning environment for all students. Utilizing Kirkpatrick's Model of Evaluation, participants were surveyed at the conclusion of the workshop and four months postworkshop to evaluate their learning and its implementation. RESULTS: Participants gained greater understanding of the impact of gender-associated incivility and felt both empowered and better prepared to manage gender-associated conflict. CONCLUSION: Similar approaches may be useful for schools of nursing that wish to empower their nursing faculty to support an equitable nursing education environment free of gender-associated incivility.

Using a Retrospective Secondary Data Analysis to Identify Risk Factors for Pulmonary Complications in Trauma Patients in Pietermaritzburg, South Africa.

BACKGROUND: The trauma burden in South Africa is significant. The objective of this project was to investigate the incidence of posttrauma pulmonary complications (PPCs) and to identify patient, health risks, and hospital factors, which predispose trauma patients to develop PPCs hospital in Pietermaritzburg, South Africa. METHODS: The design was a retrospective secondary data analysis of patients who presented as a trauma admission via the health systems' Hybrid Electronic Medical Registry. The final data set included 6382 trauma admissions. RESULTS: The PPC rate was 9.4% for patients with a surgical intervention versus 1.9% for those without a surgical intervention. Of the total 289 PPCs reported, the most common included pneumonia or atelectasis (46.4%) and prolonged ventilation (36.0%). The risk of developing a PPC was statistically significantly (P < 0.0001) associated with surgical intervention and the number of surgeries. CONCLUSIONS: The trauma burden in South Africa requires complex medical and surgical interventions. The incidence of PPCs is significantly associated with surgical intervention. With the increasing demand to harness data and improve patient care, the Hybrid Electronic Medical Registry proves to be a driver for quality improvement.

Point-of-Care Ultrasound in Anesthesia Care: New AANA Practice Document Adopted by AANA Board of Directors.

The American Association of Nurse Anesthetists recently released a practice considerations document titled, "Point-of-Care Ultrasound in Anesthesia Care," that clinicians, administrators, and other stakeholders are encouraged to download and read in their entirety, available at aana.com/PracticeManual.

Improving Emergency Cricothyroidotomies: Simulation-Based Training for Critical Care Providers.

This article discusses skill proficiency of providers related to emergency cricothyroidotomies. Various techniques to improve procedural skills were studied. Accurate identification of the cricothyroid membrane via palpation remained consistently inadequate. High-fidelity simulation including the use of human cadavers may be the preferred method of skill training for crisis management. The authors emphasize that additional research is needed regarding a method for rapid cricothyroid membrane identification as well as needle cricothyroidotomy versus surgical airway on cadavers. More consistent training will enable emergency care providers to perform this rare but lifesaving skill.

Increasing Medication Access by Promoting Appropriate Use of Multi-dose Vials.

Medication shortage is a problem that affects patients, providers, and institutions of all sizes and scope across the United States. The objective of this quality improvement project was to promote the appropriate use of multi-dose vials (MDVs) by anesthesia providers at an independent plastic surgery office. Multi-dose vials can be used to decrease waste and potentially cost, thus increasing access to necessary medications for the patients at this practice. A focus group was used to obtain an understanding of barriers to the use of MDVs at this practice. A focused E-learning module on safe use based on established guidelines was then created, and a simplified flow sheet was implemented and placed in medication preparation areas as a cognitive aid. The education and flow sheet focused on identification and preparation of the medication area, proper identification of MDVs versus single-use vials, hand hygiene, proper beyond-use labeling, septum cleaning, use of a new sterile syringe and needle, and administration time frames. Provider feedback included high levels of satisfaction with the E-learning module. Our comparison of the use of ketamine from MDVs during the pre- and postimplementation phases showed a 14% increase in the number of doses used per vial. This finding suggests that were similar practices implemented at a larger site with MDVs of medications other than ketamine, resources could be impacted to manage shortages and increase access to medications.

Considerations for an aging nurse anesthetists workforce.

The Certified Registered Nurse Anesthetists (CRNA) workforce is aging. It is estimated that nearly half (49.7%) of the CRNA workforce is age 50 or greater, with those practicing in management positions and as educators having the oldest mean ages. Older CRNAs face workplace challenges that can lead to decreased productivity and overall job satisfaction. Common injuries to older practitioners result from repetitive motion, slips and falls, needle sticks, fatigue, and emotional or mental health related illness. Because of the high acuity environment in which CRNAs practice they are at an elevated risk for these injuries. Creating a healthy and supportive work environment has been shown to improve the retention of aging healthcare workers, and succession planning is essential in preparing for their retirement.

Maximizing Use of Social Media to Improve Member Engagement in a Professional Organization.

The North Carolina Association of Nurse Anesthetists recognized concerns surrounding decreased member engagement and communication. Member engagement and communication is the lifeblood of an organization and is directly related to the success of an organization's outcomes and goals. Revamping of social media is a cost-effective method to help increase membership engagement and communication. The purpose of this project was to identify Certified Registered Nurse Anesthestist membership preferences for social media-based communication and engagement through the measurement of activity levels based on Facebook posting content, feature, and time. Therefore, a literature review and retrospective analysis was conducted. Results revealed that posting content of public relations/advocacy, the feature of tagging, and the time of week was influential on audience engagement on the association's Facebook account. The aims of the project were met. Social media allows organizations to employ various features and techniques to increase member engagement and communication. To successfully use social media to engage and communicate with members, organizations will need to continuously analyze and adjust their social media posts.