Ketamine Use for Palliative Care in the Austere Environment: Is Ketamine the Path Forward for Palliative Care.

The goal of palliative care is to focus on the holistic needs of the patient and their family versus the pathology of the patient's diagnosis to reduce the stress of illness. U.S. servicemembers deployed to austere environments worldwide have significantly less access to palliative care than in military treatment facilities in the U.S. Preparation for future conflicts introduces the concept of prolonged medical management for an environment where urgent casualty evacuation is impossible. Ketamine is currently widely used for analgesia and anesthesia in the care of military service members and its use has increased in combat zones of Iraq and Afghanistan due to the favorable preservation of respiratory function, minimal changes in hemodynamics, and lower pain scores compared to opioids. Ketamine acts as a non-competitive antagonist on N-methyl-D aspartate (NMDA) receptors. Its anesthesia and analgesic effects are complex and include both presynaptic and postsynaptic neurons in brain and spinal cord. The use of palliative care to minimize suffering should not be withheld due to the logistical boundaries of austere military environments or lack of guidelines for recommended use. The use of ketamine for palliative care is a new clinical management strategy to provide both sedation and pain management for an acute pain crisis or comfort measures for the terminally ill. This makes ketamine an attractive consideration for palliative care when managing critically wounded patients for an extended time.

Workforce Initiative for Current Predictors of CRNA Employment in the State of Florida.

The challenging Florida anesthesia workforce has 3 different types of anesthesia providers competing in the same market and a growing population ranked number 2 in the United States. This study attempted to forecast changes in supply and demand of nurse anesthetists in Florida between 2014 and 2018 by surveying hospitals and ambulatory surgical centers; 17% (87/511) responded. Current anesthesia workforce and projected needs in 1, 2, and 5 years were included in the survey. Projected numbers of nurse anesthetist graduates from 2014 to 2018 were obtained from nurse anesthesia programs and schools in Florida. Respondents projected 73 new full-time openings through 2018, representing an 18% growth rate. Florida nurse anesthesia schools projected graduating 1,394 new Certified Registered Nurse Anesthetists (CRNAs) through 2018. This study estimated that 85% of new graduates will find full-time positions. A 22% growth in full-time positions would be required to absorb all new graduates expected to enter the Florida workforce. A projected surplus of 15% (114 positions) is in line with recent projected simulated models. The predicted CRNA surplus depends on current staffing models. Nonetheless, 633 new full-time positions would represent an increase in the proportion of fulltime CRNAs in the Florida workforce.

AANA Journal Course: Update for Nurse Anesthetists-Part 5-Use of Tranexamic Acid in Preventing Postpartum Hemorrhage.

Postpartum hemorrhage (PPH) continues to be a serious complication in both developed and underdeveloped countries. It remains the leading cause of maternal mortality in underdeveloped countries. Implementation of the World Health Organization guidelines of PPH treatment has reduced mortality. In addition, the prophylactic administration of tranexamic acid with uterotonic agents may contribute to the reduction of PPH. This evidence-based literature review of tranexamic acid will examine its mechanism of action as well as its effectiveness in prevention of PPH and blood loss reduction in elective surgery, obstetrics, and trauma.

Healthcare Utilizing Deliberate Discussion Linking Events (HUDDLE): A Systematic Review.

The phenomenon, "huddle moments," can be described as a preparatory briefing among healthcare providers for the purpose of collaborating, exchanging information, and bringing awareness to patient safety concerns. A historical background of huddle communication is described and a systematic literature review was conducted on preoperative briefing and huddle communication. The article also describes a need for increased interprofessional collaboration education in anesthesia and a need for leadership to support initiatives that improve patient safety. The purpose of this article is to provide a systematic review of huddle communication and give future evidence-based recommendations on how the huddle can be used in healthcare as well as how to roll out use of the HUDDLE acronym: Healthcare, Utilizing, Deliberate, Discussion, Linking, Events.

Bivalirudin in off-pump coronary artery bypass graft in a patient with heparin-induced thrombocytopenia: a case report of its use.

Heparin-induced thrombocytopenia (HIT) is an antibody-mediated reaction in which heparin administration causes a person to enter a pathological and highly prothrombotic state. When patients with known HIT undergo coronary artery bypass and grafting procedures, they must be appropriately anticoagulated. The dangers of heparin administration in this population necessitate the use of an alternative anticoagulant. The case describes the successful use of bivalirudin for procedural anticoagulation during an off-pump coronary artery bypass and grafting.

Objective Structured Clinical Examination as an educational initiative for summative simulation competency evaluation of first-year student registered nurse anesthetists' clinical skills.

The use of simulation to imitate real-life scenarios reaches back many centuries. In the last decade, the use of simulation in healthcare has gained acceptance as a valuable tool for teaching and learning technical and nontechnical skills in healthcare. The use of simulation technology has moved medical education from the standard of pen and paper examinations to the assessment of clinical competency before caring for patients. The old thinking of "see one, do one, teach one" is behind us as healthcare works to create a culture of safety that holds healthcare personnel accountable. A current use of testing clinical competence is the use of Objective Structured Clinical Examination (OSCE) by physician training programs. As a testing tool, the OSCE has great potential to assess the clinical competence of students before they enter the clinical setting. The nurse anesthesia program at the authors' university has moved toward creating a formal assessment to ensure clinical competence of their student registered nurse anesthetists. In this article, we describe the development and implementation of an OSCE to ensure clinical competence of first-year student registered nurse anesthetists before they begin their clinical training.