Consensus Guidelines for Assessment and Comprehensive Outcomes Evaluation in Rural Pain Clinics.

Recent advancements in nurse anesthesiology fellowship training programs have helped to establish advanced pain management services for rural communities. Consensus guidelines to direct the rural provider toward the most valid and reliable measures for pain assessment and functional outcomes evaluation are not presently available. The primary aim of this initiative was to establish consensus guidelines for a comprehensive outcome evaluation program with specific time intervals for assessments that can be utilized by all rural pain clinics. The American Association of Nurse Anesthesiology Nonsurgical Pain Management Advisory Panel members provided formative and expert feedback for this initiative. The Delphi model was utilized to achieve consensus through multiple rounds of surveys. Items achieving >70% agree/strongly agree were kept; items with >70% disagree/strongly disagree were rejected; items meeting neither advanced to the following round for evaluation until consensus was met. During round I, consensus was reached for: (1) the use of the Numerical Rating Scale for pain severity; and (2) timing of pain severity & functional pain outcomes on each office visit and before/after each intervention. Round II, consensus was achieved for: (1) the use of Wong-Baker FACES Pain Rating Scale as a suitable instrument when literacy or communication pose a barrier but not as a primary assessment; and (2) the use of the Brief Pain Index-Short Form for functional outcome measures. During round III, consensus was reached for: (1) the use of the Oswestry Disability Index as a functional outcome measure; and (2) pain reassessment being performed within 14 days of intervention. This initiative provides rural pain clinics with a comprehensive outcome evaluation program with specific time intervals for assessments.

Assessing the Quality of Postoperative Recovery: A Guide for Making Adjustments in Anesthesia Delivery.

PURPOSE: The purpose of this project was to develop a plan and then implement a process for improving anesthesia delivery at a surgery center in the Southeast United States over a 2-month period. DESIGN: The design of the project was based on utilization of the instrument QoR-15 (Quality of recovery - 15 item questionnaire). This tool is a valid and reliable instrument for the measurement of postoperative outcomes. The QoR-15 includes 15 questions that can each be scored on a 10-point scale. METHODS: Methods included a literature search, collecting pre-assessment data, making phone calls to patients utilizing QoR-15 tool, analyzing data, presenting findings to stakeholders, creating a plan of future anesthesia care adjustments. FINDINGS: The results revealed the following outcome data: a total of 183 postoperative phone calls were successfully performed. The calls were completed on the first postoperative day during the months of July and August 2021. There were 459 total cases during this 2-month period with 113 successful patient contacts (24.6 % successful contact rate). Mean scores of the QoR-15 data for the total population were above 9 for all 15 items. The data was then analyzed according to surgical specialty. The category of moderate pain scores in patients from the General and Ophthalmology surgical specialties were 7.9 and 7.8 respectively. General surgery patients also had one of the highest scores in severe pain with a mean of 8.7. CONCLUSIONS: In conclusion, the leadership team at the ASC received a formal presentation of the results and recommendations for future adjustments that could be potentially implemented in anesthesia care. The benefits of regional anesthesia were suggested to help achieve better patient pain outcomes in both the General and Ophthalmologic surgical populations.

The applications of cryoneurolysis for acute and chronic pain management.

BACKGROUND: Cryoneurolysis is a term used to describe the application of extreme cold to targeted nerve tissue. The primary goal of the application of a thermal neurolytic technique is to disrupt the conduction of pain signals from the periphery to the central nervous system and eliminate or diminish the experience of pain. Recent advancements in ultrasound technology coupled with the development and approval of handheld devices specifically designed to deliver cryoneurolysis has expanded the use of this modality in the perioperative setting. APPLICATION: Surgical procedures including total knee arthroplasties, shoulder arthroplasties, thoracotomies, and mastectomies have all demonstrated long-term pain relief benefits when cryoneurolysis has been administered days to weeks prior to the planned procedure. In addition, the newly designed handheld device allows for office-based clinical use and has been utilized for various chronic pain conditions including neuropathic and phantom limb pain. CONCLUSION: The evidence clearly demonstrates that cryoneurolysis has a low risk profile and when administered appropriately, provides prolonged analgesia without promoting motor blockade. This narrative review article describes the unique mechanism of action of cryoneurolysis for prolonged pain relief and provides emerging evidence to support its applications in both acute and chronic pain management.

Perioperative Pain Management for Surgical Patients with Opioid Use Disorder: A Program Development Initiative.

PURPOSE: Over the last decade an increased number of individuals have been diagnosed with Opioid Use Disorder (OUD) and state-level regulatory pressure has mounted to develop the capability to provide opioid-free anesthesia (OFA) on clinical indication or at patient request. DESIGN: A program initiative for OUD patients who require OFA was developed and implemented in two phases. METHOD: Phase I assessed the needs and knowledge of licensed nurse anesthetists in the state of Florida. Phase II recruited volunteers for a day-long event which involved both didactic and simulation training. Data collection for phase II included: demographics, knowledge, evidence-based practice belief scale (EBPBS), and evidence-based practice implementation scale (EBPIS) which measures the perceived ability to implement those beliefs. Phase II training was divided into three domains: Preoperative, Intraoperative and Postoperative with didactic and simulation experiences for each domain. FINDINGS: The phase II participants pre-simulation median total knowledge assessment score was 9 with median scores of 5 for questions 1 to 6 and 4 for questions 7 to 12. After participating in simulation, median knowledge assessment scores increased to 11, with median scores of 6 for questions 1 to 6 and 5 for questions 7 to 12. Before simulation training, median scores for the EBPBS and EBPIS were 66 (IQR 8) and 22 (IQR 24) respectively. After simulation, the median EBPBS score increased to 76 (IQR 7.5), a significant improvement from pre-simulation (P = .002). CONCLUSION: There is a lack of knowledge and training of anesthesia providers on how to manage the growing population of patients with OUD. This program initiative increased perceived ability to provide OFA care to patients with OUD presenting for surgery.

Evaluation of postprocedure cognitive function using 3 distinct standard sedation regimens for endoscopic procedures.

The primary purpose of this investigation was to evaluate postprocedure cognitive function associated with 3 distinct standard sedation regimens used for endoscopic procedures. A secondary aim was to identify complications requiring provider interventions. Subjects scheduled for colonoscopies were approached for enrollment the day of their procedure. A convenience sample of 96 subjects was randomly assigned. Cognitive function was recorded on the day of surgery using the Mini-Mental State Examination (MMSE) and 24 and 48 hours postoperatively using the Telephone Interview of Cognitive Status (TICS). The propofol plus fentanyl group had a mean TICS score of 34.53 at 24 hours compared with 34.96 at 48 hours (P = .017). The midazolam plus fentanyl group had a mean TICS score of 34.76 at 24 hours compared with 36.26 at 48 hours (P = .004). The propofol-alone group had a mean TICS score of 35.09 at 24 hours compared with 35.98 at 48 hours (P = .924). The results of this investigation indicate that the sedation regimen of propofol alone has the least impact on postprocedure cognitive function. Additionally, the number of jaw lift interventions was significantly higher in both groups who received fentanyl.

Lateral Femoral Cutaneous Nerve Cryoneurolysis for Meralgia Paresthetica: A Case Report.

Meralgia paresthetica (MP) is a disorder of lateral femoral cutaneous nerve mononeuropathy caused by entrapment or compression of the nerve. It is characterized by numbing, tingling, and burning pain in the lateral aspect of the thigh. The current treatments for MP include conventional medical management, peripheral nerve blocks, and surgical interventions. Some patients who suffer from MP can experience intractable pain and medical management of MP is often inadequate to provide satisfactory pain control. Although regional anesthesia provides excellent pain relief, the analgesic effects of peripheral nerve block are short-lived. Emerging evidence suggests that cryoneurolysis has a low-risk safety profile and can provide prolonged pain relief of superficial nerves when administered appropriately. We present a successful case of a patient with intractable neuropathic pain resulting from MP treated with cryoneurolysis therapy. The patient demonstrated immediate pain relief by 100% after the procedure followed by 80% and 60% pain reduction at 1-month and 3-months follow-up, respectively. Cryoneurolysis may be an alternative modality for patients who fail at conventional medical treatments of neuropathic pain.

Update for nurse anesthetists evidence-based anesthesia: The use of preprocedural ultrasonography during labor to facilitate placement of an epidural catheter.

Placement of an epidural catheter in parturients can be challenging because the anatomic changes of pregnancy may make it difficult to palpate an ideal insertion point or detect loss of resistance. Preprocedural ultrasonography (U/S-P) is reported to facilitate placement of epidural catheters in parturients. U/S-P provides information on the ideal insertion point, angle of needle insertion, and estimated depth to the epidural space. The purposes of this course are to describe the technique, systematically review the literature, and discuss techniques for integrating U/S-P into practice. It provides evidence demonstrating that U/S-P is a useful adjunct for placement of epidural catheters in obstetrical patients, especially patients with presumed "difficult backs" or obesity.

Perioperative administration of gabapentin for shoulder arthroscopy: a prospective, randomized, double-blind, placebo-controlled study.

Recent studies suggest gabapentin has opioid-sparing effects and may reduce acute postoperative pain. However, there is limited research on the efficacy of gabapentin when combined in a multimodal approach after shoulder arthroscopy under general anesthesia with an interscalene block. We conducted prospective, double-blind study of 70 patients who were randomized to receive either 300 mg of gabapentin or placebo 1 hour before surgery, then twice a day for 2 days. The primary outcome was average pain scores. Secondary outcomes included differences in morphine equivalents, adverse effects, and sleep patterns. No significant differences in pain scores were found on day 1 (gabapentin mean [SD], 4.23 [2.61], vs placebo, 4.61 [2.57]; P = .58) or day 2 (gabapentin, 4.26 [2.39], vs placebo, 4.03 [2.34]; P = .71). Total morphine equivalents on day 1 (gabapentin, 9.75 mg [6.58 mg], vs placebo, 9.52 mg [4.75 mg]; P = .88) and day 2 (gabapentin, 9.21 mg [6.66 mg], vs placebo, 6.93 mg [5.44 mg]; P = .17) were similar. Adverse effects and sleep patterns were similar (P > .05). These results suggest this dosing regimen of gabapentin is not efficacious in improving outcomes in patients undergoing shoulder arthroscopy under general anesthesia with an interscalene block.

Determining the relationship of acute stress, anxiety, and salivary alpha-amylase level with performance of student nurse anesthetists during human-based anesthesia simulator training.

Managing stress for student nurse anesthetists represents a multifaceted educational concern for anesthesia educators. Our purpose was to determine the relationship between physiologic measures of stress and performance of student nurse anesthetists during anesthesia simulator training. Following institutional review board approval, 78 students were enrolled from a nurse anesthesia program. A prospective descriptive design was used to compare baseline, acute, and recovery measurements of stress with performance scores of students during an induction and intubation sequence in a patient simulator. Performance scores were stratified into low-, moderate-, and high-performing groups based on scores received from trained observers. A statistically significant difference in physiologic measures of stress was detected between baseline and acute levels of salivary a-amylase (P = .017), heart rate (P = .003), and anxiety levels (P = .001). No significant differences were found when measures of stress were compared with performance of low, moderate, or high performers. This investigation revealed remarkable findings regarding the relationship between stress and student performance. Analysis of the descriptive statistics and means of each group suggests that low performers have increased stress and perform poorly, whereas high performers have increased stress and perform superbly, and moderate performers have modest stress and perform moderately.

Effects of guided imagery on postoperative outcomes in patients undergoing same-day surgical procedures: a randomized, single-blind study.

The purpose of this investigation was to evaluate the effects of guided imagery on postoperative outcomes in patients undergoing same-day surgical procedures. Forty-four adults scheduled for head and neck procedures were randomly assigned into 2 groups for this single-blind investigation. Anxiety and baseline pain levels were documented preoperatively. Both groups received 28 minutes of privacy, during which subjects in the experimental group listened to a guided imagery compact disk (CD), but control group patients received no intervention. Data were collected on pain and narcotic consumption at 1- and 2-hour postoperative intervals. In addition, discharge times from the postoperative anesthesia care unit (PACU) and the ambulatory procedure unit and patient satisfaction scores were collected. The change in anxiety levels decreased significantly in the guided imagery group (P = .002). At 2 hours, the guided imagery group reported significantly less pain (P = .041). In addition, length of stay in PACU in the guided imagery group was an average of 9 minutes less than in the control group (P = .055). The use of guided imagery in the ambulatory surgery setting can significantly reduce preoperative anxiety, which can result in less postoperative pain and earlier PACU discharge times.

A Review of the Analgesic Benefi ts and Potential Complications Related to Epidural Corticosteroid Injections.

The Institute of Medicine has reported that greater than 115 million adults in the United States are living with some form of chronic pain. Back pain is the most prevalent and is associated with high individual morbidity and increased healthcare costs. One approach for the management of chronic back pain involves the injection of corticosteroids in the epidural space.This interventional approach requires advanced training with techniques that vary according to the level of the vertebral column where the injection is to be performed. The primary rationale for epidural steroid injection is to reduce the inflammation surrounding the spinal nerve root as it exits the neuroforamen.Injections are performed at levels that correspond most appropriately with the patient's clinical presentation,physical findings, and radiographic findings. Epidural steroid injections are considered safe and effective, and are supported by evidence for the treatment of radicular pain. Complications from epidural steroid injections are rare but can be catastrophic, including permanent disability and death. The focus of this article is to understand how technique and selection of specific corticosteroids used for epidural injection can manage chronic back and radicular pain effectively while minimizing risk that leads to unnecessary harm.

Opioid Overdose and Naloxone Kit Distribution: A Quality Assurance Educational Program in the Primary Care Setting.

PROBLEM: In 2014, there were approximately 200,000 incidents of an unintentional opioid overdose nationwide. The 2016 Centers for Disease Control and Prevention opioid prescription guidelines identified a knowledge deficit regarding opioid prescribing among primary care providers as a contributing factor to this epidemic. PURPOSE: The purpose of this quality assurance project was to provide education on opioid overdose and distribution of naloxone kits through a presentation to primary care providers at Veterans Administration facilities in the southeast region of the United States. METHODS: A convenience sampling strategy was utilized for this project. Primary care providers who prescribe opioids or care for patients at risk of an opioid-related event or death were invited to participate. A Likert scale survey was used to determine the effectiveness of the presentation. RESULTS: The results of the survey showed a potential for improving medical providers' perceptions and comfort with prescribing naloxone kits. The mean score at pretest was 32 of 50 (64%) in contrast to 42 of 50 (84%) after attending the presentation. Attending this quality assurance presentation was related to an increased awareness of naloxone kit availability and Centers for Disease Control and Prevention recommendations regarding the safe administration of opioids. CONCLUSION: This educational presentation can assist providers in identifying patients who are prescribed opioids and at risk for accidental overdose and death.

The Last State to Grant Nurse Practitioners DEA Licensure: An Education Improvement Initiative on the Florida Prescription Drug Monitoring Program.

Nurse practitioners (NPs) now have prescriptive authority for controlled substances in all 50 states in the United States. Florida, the last state to grant NPs DEA licensure, has been wrought with prescription diversion practices for a number of years as pill mills, doctor shopping, and overprescribing proliferated. Prescription Drug Monitoring Programs (PDMPs) help curb drug diversion activity and play a key role in reducing the abuse of controlled substances. The primary objective of this education improvement initiative was to increase knowledge of actively licensed NPs in the state of Florida regarding the state's PDMP. The main themes included the drug abuse problem, description and progression of the PDMP, and how to use the Florida PDMP. Upon approval from the institutional review board, this education improvement initiative gauged NP knowledge of the PDMP and main themes before and after an educational PowerPoint intervention. A pretest/posttest questionnaire was administered for assessment of all knowledge questions. One hundred forty-five NPs with active advanced registered NP licenses in Florida completed both the pretest and posttest questionnaires. Descriptive statistics and paired t tests were used for statistical significance testing. Knowledge of the PDMP and the main themes of the education improvement initiative significantly increased (p < .001) from pretest to posttest results. This education improvement initiative had positive effects for NPs on the knowledge of the Florida PDMP and the main themes. This indicated that Florida NPs are able to acquire greater comprehension of the PDMP by an education intervention.

The effect of transdermal scopolamine on the incidence and severity of postoperative nausea and vomiting in a group of high-risk patients given prophylactic intravenous ondansetron.

Specific risk factors place patients at greater risk for postoperative nausea and vomiting (PONV). Routinely, these patients are treated prophylactically with intravenous (IV) ondansetron or transdermal (TD) scopolamine. No study has examined what effect using a combination of these prophylactic treatments would have on the incidence of PONV in a group of high-risk patients. A total of 56 patients at high risk for PONV were treated prophylactically with IV ondansetron and randomized to receive a TD scopolamine patch or placebo. Demographics, incidence, and severity of PONV and side effects and antiemetic requirements were measured. Nausea was measured using a 0 to 10 verbal numeric rating scale. Descriptive and inferential statistics were used for analysis. No difference in demographics or the incidence of side effects was noted between groups. Patients in the scopolamine group had a lower incidence of PONV (P = .043), longer time to first reported nausea (P = .044), longer time to first episode of emesis (P = .031), and decreased supplemental antiemetic requirements (P = .016) compared with the placebo group. Based on this study, we recommend using a combination of TD scopolamine and IV ondansetron to prevent PONV in patients identified as high risk for PONV.

Postoperative respiratory depression and unresponsiveness following epidural opiate administration: a case report.

The profound segmental antinociception that epidural opioids offer has increased their use over the last 2 decades. Though side effects may accompany the use of epidural opioids, clinicians have found that the advantages far outweigh the disadvantages. The following case report outlines a patient's postoperative course in which she experienced respiratory depression while receiving epidural opioids. The pharmacokinetics of lipophilic vs hydrophilic opioids in relation to the occurrence of respiratory depression is discussed.

Severe intraoperative hyponatremia in a patient scheduled for elective hysteroscopy: a case report.

Hysteroscopy is a minimally invasive procedure that may result in potentially disastrous complications. A hysteroscopy requires the insertion of a hysteroscope into the uterine cavity and the installation of a suitable distention medium for visualization of the endometrium. Potential risks include fluid volume overload, uterine perforation, hemorrhage, infection, and the need for immediate hysterectomy. Solutions most commonly used for distention of the uterine cavity are 1.5% glycine and sorbitol. Hypotonic, electrolyte-free distention media have the potential to be absorbed in volumes large enough to cause hyponatremia and hypervolemia, complications initially described as transurethral resection of the prostate (TURP) syndrome. Hyponatremia and hypervolemia have been associated with hysteroscopic surgical procedures. The following is a case report detailing the perioperative events of a 40-year-old woman in whom severe hyponatremia developed during an elective hysteroscopy.

Acute fatty liver of pregnancy: a case report.

The third trimester of pregnancy has several unique disease entities that challenge the anesthetist. Acute fatty liver of pregnancy (AFLP) is an increasingly recognized metabolic disorder found late in pregnancy. Current research estimates the incidence of AFLP at 1 per 6,659 births. Improved maternal morbidity and mortality is credited to early recognition and termination of the pregnancy. The decline in hepatic cellular activity is evident by the deterioration in metabolic, synthetic, and excretory functions of the liver. This obstetrical emergency can lead to death of both mother and child if not diagnosed in time to prevent coagulopathic complications.

The addition of clonidine to bupivacaine in combined femoral-sciatic nerve block for anterior cruciate ligament reconstruction.

Clonidine has been shown to prolong sensory analgesia when given as an adjunct to peripheral nerve blocks but has not been evaluated when given in conjunction with a femoral-sciatic nerve block. The purpose of this investigation was to determine whether the addition of clonidine to a femoral-sciatic nerve block would prolong the duration of sensory analgesia in groups of patients undergoing anterior cruciate ligament (ACL) reconstruction. This prospective, randomized, double-blind investigation was performed on 64 subjects undergoing ACL reconstruction. Patients were assigned randomly to receive a femoral-sciatic nerve block using 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine (control group) or 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine and 1 microg/kg of clonidine (experimental group). Variables measured included demographics, timed pain intensity measurements, postoperative analgesic consumption, duration of analgesia, and patient satisfaction. No significant differences were noted between groups for pain intensity scores, duration of sensory analgesia, postoperative analgesic requirements, or overall patient satisfaction. Both groups reported minimal amounts of postoperative pain and high analgesic satisfaction scores. Based on our results, we do not recommend the addition of clonidine to a femoral-sciatic nerve block when given to facilitate postoperative analgesia in patients undergoing ACL reconstruction.

Hand ischemia associated with profound hypotension and radial artery catheterization in a pediatric patient: a case report.

Direct arterial blood pressure monitoring via the radial artery is a relatively common method employed during the perioperative period. Complications attributed to radial artery catheterization are extremely rare but can include thrombosis, ischemia, infection, and aneurysm formation at the site of catheter insertion. This report describes an episode of hand ischemia in a pediatric patient. The patient experienced a brief period of hypotension secondary to blood loss. A pallor hand was noticed after the patient had been adequately resuscitated. Appropriate treatment was administered, and the patient was eventually discharged to home without any further complications.