Simulation in Nurse Anesthesia Educational Programs: A Report by the AANA Simulation Subcommittee.

Simulation is an integral part of the healthcare educational landscape and a key element in the future of graduate professional education. For the past three decades, simulation-based educational methodology has been gaining popularity in nurse anesthesia educational programs (NAEP). There is currently limited objective evidence documenting modalities used or educational outcomes addressed through simulation in NAEPs. In 2018, the American Association of Nurse Anesthesiology (AANA) established a Simulation Subcommittee of the AANA Education Committee and tasked the group with two primary goals: 1) to gain a better understanding of the current state of simulation education and 2) to review responses with regard to how NAEPs could best incorporate simulation elements within their curriculum to meet requirements while adhering to the guidelines of the Council on Accreditation of Nurse Anesthesia Educational Programs. A survey tool was developed and distributed to all programs to assess the utilization of simulation, available simulation resources, ongoing faculty development efforts, and barriers to use of this educational approach. Survey results indicated that simulation is valued as an effective method within NAEPs for a variety of teaching and learning activities and is utilized to support achievement of both technical and nontechnical learning outcomes for student registered nurse anesthetists.

Battle of the Crystalloids in the Operating Room: A Literature Review.

PURPOSE: The purpose of this article is to synthesize the evidence regarding the commonalities and differences between the three most common crystalloid solutions used in the operating room (normal saline [NS], lactated Ringer's [LR], and Plasmalyte [PL]) in order to determine best practice. DESIGN: This study is an integrative review of literature. METHODS: A review of the literature was conducted using the PubMed, CINAHL Plus, and Cochrane Library databases. The inclusion criteria included adult patients undergoing surgery who received either NS, LR, and/or PL (or similar solutions) for fluid maintenance therapy. FINDINGS: A total of 15 articles from 2008 to 2020 conducted in a surgical setting were selected for the review; eleven randomized controlled studies, three observational studies, and one cohort-controlled trial. CONCLUSIONS: The findings suggest balanced crystalloid solutions are superior to NS in the operating room in terms of maintaining a stable acid-base balance. PL is preferable to LR because it most closely resembles plasma concentration. Future research is needed to determine the cost-effectiveness of the solutions.

Lower Extremity Injury While Undergoing Urology Procedures in the Trendelenburg with Lithotomy Position: Three Case Reports.

PURPOSE: To report and discuss the incidence of severe lower extremity injuries associated with robotic procedures in Trendelenburg with lithotomy position. DESIGN AND METHODS: A case study method was used to describe three cases of patients who underwent robotically assisted urological procedures in Trendelenburg with lithotomy position and developed serious lower extremities injuries resulting in fasciotomies. Furthermore, a literature review was conducted to evaluate risk factors and possible interventions for the prevention of similar injuries. FINDINGS: Case analysis revealed multifactorial causes, including patient comorbidities, long surgical procedures, and blood pressure decreases below the baseline for more than 30 minutes. The severity of lower extremity injury associated with lithotomy position may be underestimated. The etiology of peripheral nerve injury can be attributed to patient comorbidities, positioning, and surgical conditions. Injury prevention should include careful patient and procedural risk assessment, staff education, and communication strategies. CONCLUSIONS: Extreme Trendelenburg with lithotomy position for longer periods can lead to serious lower extremities injuries. Preanesthetic screening and multidisciplinary team discussions for additional precautions for high-risk patients are crucial interventions to decrease incidence and severity of lower extremities injuries.

The Fine Art of Health Care: Visual Thinking Strategies for Interprofessional Skills Development in Graduate Nurse Anesthesia Education.

Visual Thinking Strategies (VTS) is a methodology designed to teach critical thinking, communication, and visual literacy. The Fine Art of Health Care is a VTS-based educational program that brings students from various health-care disciplines to the Lowe Art Museum at the University of Miami in Florida. Twenty-six nurse anesthesia, medical, physical therapy, nursing, and psychology students participated in the workshop during the 2016 fall semester. The students completed an anonymous survey to evaluate their experience. All participants agreed or strongly agreed that VTS helped them understand how to hone their observational and listening skills; 92% agreed that looking at and discussing art has merit with regards to collaborative practice; 96% agreed that VTS helped them improve their communication skills; and 93% found value in the VTS workshop because it provided opportunity to meet and have discussions with students from other disciplines. The arts and humanities have long been recognized as important tools for building multidisciplinary collaboration in health education. There is growing evidence that integrating the arts into the nursing curriculum can have powerful outcomes. These capabilities proved useful in the nurse anesthesia curriculum by allowing skillful conceptualization, and originality and leveling of the playing field for all health-care students.

Do You See What I See? The Role of Visual Arts in Health Care Education.

The universality of visual arts can be used to facilitate inventive and interdisciplinary approaches to open the lines of communication between learners, educators, and health care providers to improve patient outcomes. Arts-based training programs have been implemented successfully in higher education as part of a growing awareness of the need to develop interpersonal skills of health care professionals to be able to deliver respectful and compassionate patient care. Visual thinking strategies (VTS) is a student-centered methodology using facilitated art-based discussions to create inclusive discussions. VTS-based programs may be successfully developed for continuing multidisciplinary education of health care professionals with the goals of improving communication and team building. [J Contin Educ Nurs. 2020;51(8):367-370.].

Cardiovascular Collapse During Transurethral Resection of Bladder Tumor: A Case Report.

Despite innovative modalities, transurethral resection (TUR) procedures are the primary surgical intervention for bladder tumor and enlarged prostate. TUR syndrome, a major complication of TUR procedures, leads to derangement in electrolytes, hemodynamic compromise, and possible cardiac arrest. This case report describes cardiovascular collapse in a 60-year-old male during TUR of a bladder tumor under general anesthesia. The patient developed hypoxia, which progressed to cardiovascular collapse. Electrolyte analysis revealed acute hyponatremia. The patient was resuscitated successfully, transferred to intensive care unit, and discharged from the hospital without any complications. This case report of a cardiovascular collapse during transurethral resection of bladder tumor offers insight of the risks in urologic procedures and highlights the importance of clear communication as well as early recognition and successful management of complications.

Evaluation of a Low-Cost, High-Fidelity Animal Model to Train Graduate Advanced Practice Nursing Students in the Performance of Ultrasound-Guided Central Line Catheter Insertion.

INTRODUCTION: Ultrasound-guided central venous catheter insertion (UGCVC) is a commonly performed procedure taught through simulation. The aims of the study were to examine the utilization of an animal model and compare it with two currently used Blue Phantom central line models to determine whether an animal model provides good or better simulated conditions for the performance of UGCVC insertion. METHODS: Using a randomized cross-over study, 46 advanced practice nursing students were assessed using a task-specific performance tool in their performance of UGCVC insertion on both the animal model and the Blue Phantom models. The number of insertion attempts and time to performance was recorded. A preprocedure survey was used to ascertain their presimulation workshop experience, followed by a postprocedure survey. A cost comparison was completed as a secondary outcome. RESULTS: A comparison was conducted on the performance scores and the postsurvey results between the animal model and the Blue Phantom models. The number of venous access attempts was not significantly different when comparing the three models. A cost comparison showed the total cost of each animal model was US $15.66 as compared with the approximate cost for the Blue Phantom IJ model of US $1500.00 and the Gen I model of US $2700.00. CONCLUSIONS: Current Blue Phantom models lack the ability to fully perform all the necessary steps critical to the performance of UGCVC insertion. At a total cost of US $15.66 per model, this study showed that training with an alternative economical model was comparable with more expensive mannequin simulators. The results of this study may serve to guide clinicians and educators who are seeking alternative simulation models to provide skill acquisition.

Choosing the anesthetic and sedative drugs for supraventricular tachycardia ablations: A focused review.

This study provides a review of the contemporary literature for the effects of most commonly used anesthetic drugs for sedation and anesthesia during adult electrophysiologic (EP) studies where supraventricular tachycardias (SVT) need to be induced for diagnostic purposes and/or catheter ablation. Some medications may affect cardiac electrophysiology and conduction, altering the ability to induce the arrhythmia, and may have negative impact on mapping and ablation treatment. The objective of the study is to determine the best sedative choice during SVT ablations. The authors searched MEDLINE, PubMed, and Google Scholar databases for published articles within the past 20 years (1998-2018) that have evaluated the effects of common anesthetic drugs during SVT ablations. Further articles were identified through crossreferencing, discussion with electrophysiologists, and hand-searching key electrophysiology and anesthesia journals. Eight review articles, two randomized control trials, six prospective observational studies, one retrospective observational study, and two case reports were included in this review. Seven of the studies focused on the pediatric population. The findings about the effects of the commonly used anesthetics are discussed further in detail. Sevoflurane had no clinically important effects on sinoatrial (SA) node activity, or the normal atrioventricular (AV), or accessory pathway. Midazolam and fentanyl, alone or in combination, neither alter the inducibility of reentrant tachycardia nor have they shown to affect the SA node, refractory periods of AV conduction, or accessory pathways. Similar findings were reported by investigators with propofol, except for ectopic atrial tachycardia in children, which remained un-inducible in one of the studies. Remifentanil and dexmedetomidine lengthened both sinus cycle and AV conduction. Dexmedetomidine increased the atrial refractory period and diminished atrial excitability. Ketamine shortened atrial conduction and successfully returned prolongation of sinus node conduction due to dexmedetomidine. In conclusion, the current literature regarding sedation for SVT studies in the adult population is sparse. Midazolam, propofol, fentanyl, and remifentanil can be used safely in patients undergoing EP studies without significant interference with electrophysiological variables or the inducibility of reentrant tachycardias in usual clinical doses. Low-dose ketamine has potential use as an adjunctive medication in the EP lab and additional studies would be beneficial. The effects of dexmedetomidine on conduction and arrhythmia inducibility during SVT ablation is not as clear as studies have yielded conflicting results, and may not be the best choice for sedation in this patient population.

Changes in cerebral oxygen saturation during transcatheter aortic valve replacement.

Cerebral oxygen saturation (rSO2) is a non-invasive monitor used to monitor cerebral oxygen balance and perfusion. Decreases in rSO2 >20 % from baseline have been associated with cerebral ischemia and increased perioperative morbidity. During transcatheter aortic valve replacement (TAVR), hemodynamic manipulation with ventricular pacing up to 180 beats per minute is necessary for valve deployment. The magnitude and duration of rSO2 change during this manipulation is unclear. In this small case series, changes in rSO2 in patients undergoing TAVR are investigated. Ten ASA IV patients undergoing TAVR with general anesthesia at a university hospital were prospectively observed. Cerebral oximetry values were analyzed at four points: pre-procedure (baseline), after tracheal intubation, during valve deployment, and at procedure end. Baseline rSO2 values were 54.5 ± 6.9 %. After induction of general anesthesia, rSO2 increased to a mean of 66.0 ± 6.7 %. During valve deployment, the mean rSO2 decreased <20 % below baseline to 48.5 ± 13.4 %. In two patients, rSO2 decreased >20 % of baseline. Cerebral oxygenation returned to post-induction values in all patients 13 ± 10 min after valve deployment. At procedure end, the mean rSO2 was 67.6 ± 8.1 %. As expected, rapid ventricular pacing resulting in the desired decrease in cardiac output during valve deployment was associated with a significant decrease in rSO2 compared to post-induction values. However, despite increased post-induction values in all patients, whether related to increased inspired oxygen fraction or reduced cerebral oxygen consumption under anesthesia, two patients experienced a significant decrease in rSO2 compared to baseline. Recovery to baseline was not immediate, and took up to 20 min in three patients. Furthermore, baseline rSO2 in this population was at the lower limit of the published normal range. Significant cerebral desaturation during valve deployment may potentially be limited by maximizing rSO2 after anesthetic induction. Future studies should attempt to correlate recovery in rSO2 with recovery of hemodynamics and cardiac function, provide detailed neurological assessments pre and post procedure, determine the most effective method of maximizing rSO2 prior to hemodynamic manipulation, and provide the most rapid method of recovery of rSO2 following valve deployment.