Design of a Workshop for Focused Transesophageal Echocardiography During Noncardiac Surgery in Nurse Anesthesia Education.

OBJECTIVE: The use of transesophageal echocardiography (TEE) by certified registered nurse anesthetists (CRNAs) during noncardiac surgery is relatively uncommon despite its unique potential to diagnose causes of hemodynamic instability. To address this problem, educational endeavors designed to provide practical TEE skills to CRNAs are needed. The aim of the current study was to evaluate the feasibility, acceptability, efficacy, and utility of a 2-day focused TEE workshop in nurse anesthesia education that employed a protocol involving a limited number of views and used goal-directed, qualitative assessments of critical physiologic parameters. METHODS: This was a prospective, observational study involving 14 second-year nurse anesthesia students. The cohort was evaluated following completion of this workshop by simulator-based testing involving hypothetical clinical scenarios, and this test data was analyzed according to the percent successful acquisition and interpretation of TEE views to determine immediate objective teaching efficacy. The acceptability, perceived efficacy, and perceived utility of the workshop were assessed by online survey, and survey responses were qualitative and quantitative in nature. RESULTS: Participants acquired appropriate TEE views associated with clinical scenarios 99% of the time and correctly interpreted the pathology in those views 93% of the time. Participants uniformly perceived significant educational value in this workshop and intend to incorporate TEE in their future clinical practice. CONCLUSIONS: A 2-day workshop to teach focused TEE to nurse anesthesia trainees directed by a streamlined protocol is feasible, acceptable, and perceived as useful by participants, and provides practical experience and entry-level competency in this point-of-care ultrasound modality.

Cognitive Competence and Curriculum Development in Nurse Anesthesia Education: A Pilot Study.

Background: Advanced practice nursing in the United States is shifting toward doctoral certification, most commonly a Doctor of Nursing Practice degree. However, there is limited evidence that this transition improves clinical competence. Purpose: The aim of this study was to determine whether modifications in a nurse anesthesia curriculum that transitioned from a Master of Nursing to a Doctor of Nursing Practice program were associated with improved cognitive performance using an oral examination. Design: A prospective, comparative observational study of students from a single, university-based nurse anesthesia program. Methods: This study was a small-scale investigation (n = 22) that used a quantitative method to compare the performances of consecutive cohorts of Master of Nursing and Doctor of Nursing Practice nurse anesthesia students as rated by oral examinations designed to evaluate critical thinking skills and previously shown to demonstrate internal consistency and reliability. Results: After completing an expanded curriculum, Doctor of Nursing Practice nurse anesthesia students performed significantly better than Master of Nursing students on oral examination, with improvements in cognitive domains previously identified as areas of underperformance by Master of Nursing students. Conclusion: Targeted curricular additions in a Doctor of Nursing Practice program correlated with improvements in nurse anesthesia student cognitive competence as measured by oral examination.

A Cognitive Template for Management of Perioperative Adverse Events.

Perioperative crisis management commonly involves both rapid generic responses and slower abstract reasoning for the successful management of adverse events. A metacognitive approach to this process offers the potential for minimizing errors and thereby improving outcomes. One such metacognitive technique uses templates that guide dynamic decisionmaking. Because stressful circumstances impair memory and cognitive function, templates may be particularly useful during crises both to improve functional recall and to provide mental constructs that compel anesthesia providers to organize their thoughts and direct approaches to problem-solving that rely on critical thinking rather than solely on heuristics. A six-step cognitive template is proposed for formulating a working diagnosis and deciding appropriate therapy during a perioperative adverse event. The template utilizes overlapping differential diagnoses organized using principles of anatomy and/or physiology. It has been effective in nurse anesthesia training to promote a metacognitive approach to decisionmaking during such events, and the template can be widely utilized in nonacademic settings for similar purposes.

Sugammadex: Pharmacometrics, Clinical Utility, and Adverse Effects.

Sugammadex has been used clinically since 2008, and it represents the only cyclodextrin neuromuscular blocking reversal agent currently available for patient care. Sugammadex's unique mechanism of action allows it to reverse the effects of aminosteroid neuromuscular blockade rapidly, and pharmacodynamically predictable doses are selected based on quantitative neuromuscular monitoring. The drug has several potential adverse effects, predominantly related to immediate hypersensitivity reactions and bradyarrhythmias, and it can be costly. Overall, when employed appropriately, it represents an efficacious addition to the perioperative pharmaceutical armamentarium with significant utility.

Synchronous Screen-Based Simulation in Anesthesia Distance Education.

PURPOSE: The aim of the present study was to evaluate the feasibility, acceptability, and utility of synchronous online screen-based simulation (SBS) in anesthesia education. METHODS: The investigational cohort consisted of 12 second-year nurse anesthesia students enrolled in a Doctor of Nursing Practice (DNP) program. Pairs of students worked with a single instructor online using the same SBS employing a cloud-based peer-to-peer platform and high-fidelity software involving a graphical avatar. During each session, the instructor initially manipulated the avatar through the software scenario with educational pauses to communicate learning content. Thereafter, students proceeded through the same SBS by stating their desired actions, which were then implemented by the instructor. At the conclusion of each session, students were evaluated by an integrated software scoring system, and thereafter they completed a questionnaire rating their distance SBS experience. RESULTS: Synchronous online SBS was performed in this manner without difficulty; it was accepted by students as a valuable adjunct to their in-person mannequin-based simulation (MBS) training; and it was perceived as a useful addition to their anesthesia education. Students identified significant value in the isolation of the cognitive component of learning by this teaching methodology. Lack of haptic learning, however, also was seen as a disadvantage of SBS compared to MBS. Students' criticisms of SBS were largely unrelated to use of this technique with synchronous online education, but rather related to general limitations associated with SBS technology. There was a positive correlation between the students' mean post-SBS rating and the automated SBS score (r = 0.832). CONCLUSION: Synchronous online SBS can effectively supplement MBS in an anesthesia training program. Its major perceived advantage appears to be an ability to isolate and reinforce appropriate cognitive skills related to intraoperative care including crisis management. Students who had higher mean post-SBS ratings also had higher automated SBS scores.

Mock Oral Board Examination in Nurse Anesthesia Education.

BACKGROUND: Despite its widespread use in anesthesia residency training, mock oral board examinations (MOBEs) are not included in the pedagogy of most nurse anesthesia programs (NAPs). A small-scale study was conducted to assess the use of MOBEs in this setting. METHOD: The investigational cohort consisted of 10 second-year students in a master's program in nurse anesthesia. MOBEs were scored according to a common rubric, and final scores were reconciled by raters. Responses from pretest and posttest questionnaires, as well as scoring data, were analyzed. RESULTS: MOBEs were administered in a problem-free manner to nurse anesthesia students and was perceived by these students as a valuable addition to their curriculum. There was pass-fail agreement among the raters related to clinical analysis, fund of knowledge, and communication skills, and the scoring was characterized by elements of internal consistency. CONCLUSION: MOBEs are feasible in an NAP, and well accepted by students. MOBEs have significant evaluative potential in this setting. [J Nurs Educ. 2021;60(4):229-234.].

Anesthesiologists Have an Important Role in Preclinical Nurse Anesthesia Education.

Anesthesiologists do not participate regularly in the preclinical portion of nurse anesthesia training programs (NAPs). This practice is predicated on a historical separation of the early educational tracks of physicians and advanced practice nurses whose professions ultimately came to occupy overlapping niches within the field of anesthesia. The state of affairs has been bolstered by territorial friction between professional organizations, and by the lack of a perceived need for anesthesiologists to become involved at an early stage of nurse anesthesia education given the large number of qualified certified registered nurse anesthesia instructors available to perform this role. Anesthesiologists, however, have significant pedagogical assets to offer NAPs, including expertise in critical analysis and decision-making skills related to perioperative adverse events. In addition, introduction of anesthesiologists into preclinical NAP education has the potential to inject added academic rigor into NAPs currently transitioning to Doctor of Nursing Practice programs. Likewise, NAPs offer a professional haven for those anesthesiologists seeking new challenges in education, and a unique opportunity to shape the future of anesthesia. Most importantly, introducing anesthesiologists into the initial educational phases of the nurse anesthesia profession provides an opportunity to grow trust and understanding between these two professions that are critical for safe, healthy, and lasting partnerships in future years.

Distance Education in Anesthesia Using Screen-Based Simulation - A Brief Integrative Review.

Screen-based simulation (SBS) using digital technology has been demonstrated to improve the cognitive and psychomotor skills of anesthesia trainees. As a method of education and evaluation, this form of simulation offers multiple advantages related to cost, availability, simplicity, repeatability, and scorability. Online use of SBS with software employing standard cloud-based peer-to-peer platforms allows for instruction at a distance of important anesthesia-related critical thinking skills including crisis management. Despite the fact that there are no studies concerning the application of SBS in anesthesia distance education, this form of instruction has increased as a result of quarantine measures associated with the coronavirus-2 pandemic that have disrupted traditional in-person mannequin-based simulation, and its usage likely will continue through the post-pandemic era for multiple reasons. Several options exist for asynchronous and synchronous teaching of anesthesia skills at a distance with SBS, and there are useful techniques that can assist in achieving these educational goals with this process.

Enhanced fear memories and brain glucose metabolism (18F-FDG-PET) following sub-anesthetic intravenous ketamine infusion in Sprague-Dawley rats.

Ketamine is a multimodal dissociative anesthetic, which provides powerful analgesia for victims with traumatic injury. However, the impact of ketamine administration in the peri-trauma period on the development of post-traumatic stress disorder (PTSD) remains controversial. Moreover, there is a major gap between preclinical and clinical studies because they utilize different doses and routes of ketamine administration. Here, we investigated the effects of sub-anesthetic doses of intravenous (IV) ketamine infusion on fear memory and brain glucose metabolism (BGluM) in rats. Male Sprague-Dawley rats received an IV ketamine infusion (0, 2, 10, and 20 mg/kg, 2 h) or an intraperitoneal (IP) injection (0 and 10 mg/kg) following an auditory fear conditioning (3 pairings of tone and foot shock [0.6 mA, 1 s]) on day 0. Fear memory retrieval, fear extinction, and fear recall were tested on days 2, 3, and 4, respectively. The effects of IV ketamine infusion (0 and 10 mg/kg) on BGluM were measured using 18F-fluoro-deoxyglucose positron emission tomography (FDG-PET) and computed tomography (CT). The IV ketamine infusion dose-dependently enhanced fear memory retrieval, delayed fear extinction, and increased fear recall in rats. The IV ketamine (10 mg/kg) increased BGluM in the hippocampus, amygdala, and hypothalamus, while decreasing it in the cerebellum. On the contrary, a single ketamine injection (10 mg/kg, IP) after fear conditioning facilitated fear memory extinction in rats. The current findings suggest that ketamine may produce differential effects on fear memory depending on the route and duration of ketamine administration.

Effects of Subanesthetic Intravenous Ketamine Infusion on Corticosterone and Brain-Derived Neurotrophic Factor in the Plasma of Male Sprague-Dawley Rats.

Posttrauma anesthetic agents influence neuroendocrine responses that may affect fear memory. The effects of a subanesthetic intravenous (IV) ketamine infusion on mediators of stress and memory in rodents are unknown. Therefore, we used a clinically relevant method to administer a 2-hour subanesthetic IV ketamine infusion following a rodent fear-conditioning paradigm (paired tone plus foot shock) to evaluate the effects on corticosterone and brain-derived neurotrophic factor in the plasma of male Sprague-Dawley rats. We found that subanesthetic ketamine infusions (5 and 20 mg/kg/h) dose-dependently increased plasma corticosterone levels. Ketamine at 20 mg/kg/h significantly reduced plasma brain-derived neurotrophic factor measured 2 hours after the conclusion of the ketamine infusion. These results demonstrate that a subanesthetic IV ketamine infusion maintained a heightened neuroendocrine stress response after fear conditioning and reduced levels of a neurotrophin associated with memory, which may influence fear memory processing. The behavioral outcomes of these effects are unknown and warrant future investigation.

Communication in the Operating Room Setting.

Ideal and effective communication consists of a clear, audible, and focused message from a transmitter that is delivered to an attentive, undistracted receiver, and consists of both verbal and nonverbal types. Communication in the health care setting is highly complex and dynamic, involving multiple settings, participants, and unique challenges. Effective communication in the perioperative environment is a requirement for safe patient care delivery and an important element of teamwork. A message must be accurately delivered in a uniquely high-risk and time-sensitive location, beset with numerous distractions, barriers, and challenges. Surgical checklists and time-out procedures have promoted a standardized, "all-hands" approach to addressing some of the challenges to effective communication in the perioperative environment. Postoperative debriefing sessions have demonstrated effectiveness in improving team functioning in the simulated learning environment and hold promise as another strategy to address these challenges, but require further research and development. Other promising strategies to improve effective perioperative communication are focused on team building activities and minimizing distractions at critical time points within patient care delivery, but to date are not substantiated by evidence. Future research is necessary to examine these novel approaches to improving communication in the perioperative environment to influence the safety of patient care delivery in this highly challenging health care setting. Wise men speak because they have something to say; Fools because they have to say something. Plato.