Glucagon-like peptide-1 receptor agonists (GLP-1RAs) were developed to treat type 2 diabetes mellitus and later became widely used for the management of obesity. Recent evidence includes off-label uses for substance use...Glucagon-like peptide-1 receptor agonists (GLP-1RAs) were developed to treat type 2 diabetes mellitus and later became widely used for the management of obesity. Recent evidence includes off-label uses for substance use disorders; nicotine and alcohol dependence; neurodegenerative diseases; and cardiovascular, kidney, and liver diseases. Certified registered nurse anesthetists (CRNAs) are likely to encounter patients using GLP-1RAs for both Food and Drug Administration-approved and nontraditional purposes. This review explores the pharmacology and mechanisms of action of GLP-1RAs, with a focus on their relevance in the perioperative period. It covers their effects on blood glucose control, gastric motility, and central nervous system pathways. Special attention is given to delayed gastric emptying, concerns about pulmonary aspiration, and the metabolic benefits of glucose-dependent insulin secretion and reduced blood glucose fluctuations. Current professional guidelines emphasize personalized, patient-centered perioperative care. The increasing use of GLP-1RAs, combined with more off-label prescribing and unregulated peptide use, emphasizes the need for thorough preoperative screening, clear medication reconciliation, and effective interdisciplinary communication. As more evidence emerges, CRNAs must remain vigilant while recognizing that the expanding role of GLP-1RAs is important for optimizing perioperative safety and achieving optimal patient outcomes in modern anesthesia practice.
Graduate students, including medical students, use cognitive enhancer (CE) medications with or without legal prescription to aid academic performance despite little evidence that they improve performance in individuals w...Graduate students, including medical students, use cognitive enhancer (CE) medications with or without legal prescription to aid academic performance despite little evidence that they improve performance in individuals without a medical diagnosis and subsequent prescription. However, there is limited information on CE medication use, with or without legal prescription, by resident registered nurse anesthetists (RRNAs). This cross-sectional survey assessed prevalence of CE medication use with or without legal prescription and its potential predictors (depression, anxiety, Attention Deficit Hyperactivity Disorder [ADHD] symptoms, and demographic variables) in 421 RRNAs. Descriptive and binary logistic regression analyses were conducted. The prevalence of CE use with or without prescription was 27.3%, with 93% obtained by prescription. The prevalence of clinically significant symptoms of ADHD (25.7%), depression (26.9%), and anxiety (23.1%) were assessed among RRNAs. No significant differences in age, gender, or program years were observed between CE medication users with or without legal prescription and CE non-users. However, white respondents were more likely to be CE medication users with or without legal prescription compared with respondents of other racial groups ( = .020). In the full logistic regression model, ADHD (aOR, 1.17; 95% CI, 1.10-1.24) was associated with increased odds of CE use. The Backward stepwise selection model retained ADHD and anxiety as significant predictors.
Gabapentin is widely used in perioperative analgesic protocols. Many clinical studies supporting the safety and analgesic efficacy of gabapentin for postoperative pain have been published over the last two decades. Sever...Gabapentin is widely used in perioperative analgesic protocols. Many clinical studies supporting the safety and analgesic efficacy of gabapentin for postoperative pain have been published over the last two decades. Several studies, many recently, have questioned its effectiveness and safety for perioperative pain management in early recovery after surgery (ERAS) and non-ERAS protocols leading to the research question: Is the use of gabapentin in perioperative analgesic protocols efficacious and safe for all perioperative patients? An integrative review was performed to identify, analyze, and synthesize a carefully selected sample of the evidence surrounding the inclusion of gabapentin in perioperative pain management practice. Analysis of the literature showed that gabapentin was found to be effective and safe in multiple studies yet may not be an effective treatment to include in all opioid-free multimodal pain regimens for ERAS and non-ERAS surgical pathways. Instead, gabapentin appears safe and effective for some populations of surgical patients undergoing a variety of procedures, while for other populations the medication is less efficacious and potentially harmful because of its side effects, which include respiratory depression, ataxia, and sedation.
One in four clinicians who seek treatment for substance use disorder are anesthesia providers. However, there is a dearth of research on substance use behaviors of doctoral resident registered nurse anesthetists (RRNA)....One in four clinicians who seek treatment for substance use disorder are anesthesia providers. However, there is a dearth of research on substance use behaviors of doctoral resident registered nurse anesthetists (RRNA). The purpose of this study was to determine the prevalence and patterns of substance use and perceived stress levels among RRNAs. Anonymous surveys were distributed to RRNAs enrolled in doctoral programs in the United States. Respondents self-reported four substance use behaviors. Problematic substance use and perceived stress were self-reported using the Drug Abuse Screening Test (DAST-10) and the Perceived Stress Scale (PSS-10). Overall, 26.5% of respondents reported engaging in nonprescription substance use behaviors since enrollment. The prevalence of anesthetic agent use was 7.4%. Nine percent of respondents reported use of focus-enhancing drugs, 15% reported increased alcohol consumption, and 22% required a new prescription since enrollment. Mean PSS-10 scores were significantly higher in respondents who reported substance use behaviors (19.8 [SD, 6.5] vs 16.5 [SD, 6.3] < 0.001). Predictive factors for substance use include enrollment period greater than 24 months, male gender, and elevated PSS-10 and DAST-10 scores.
This study explored job satisfaction and turnover intentions among certified registered nurse anesthetists (CRNAs) in a prominent Southern California health system. Job satisfaction and turnover intentions were measured...This study explored job satisfaction and turnover intentions among certified registered nurse anesthetists (CRNAs) in a prominent Southern California health system. Job satisfaction and turnover intentions were measured using the Misener Nurse Practitioner Job Satisfaction Scale and Turnover Intention scales, respectively. Of the 60 CRNAs who completed the survey, 30% expressed turnover intentions, which was higher among new practitioners. Marital status emerged as a significant influence on both job satisfaction and turnover intentions. Overall job satisfaction was high, with male CRNAs scoring slightly higher. Principal components and regression analyses unveiled key factors regarding job satisfaction including satisfaction with supervisors, peer interactions, and flexibility in practice. The findings highlight the specific factors that influence CRNAs' career choices, stressing the importance of providing targeted support, particularly for those new to practice. The correlation between job satisfaction and specific factors is highlighted, offering healthcare organizations actionable insights. Addressing these dynamics can enhance job satisfaction, particularly among new CRNAs, and ultimately contribute to stable healthcare services. Findings from this study provide valuable insight that could guide development of strategies that mitigate turnover intentions and improve job satisfaction in the CRNA workforce.
Over 700,000 total knee arthroplasties (TKAs) are performed in the United States annually. Long-term functional recovery following TKA depends heavily on early ambulation and rehabilitation, which requires effective pain...Over 700,000 total knee arthroplasties (TKAs) are performed in the United States annually. Long-term functional recovery following TKA depends heavily on early ambulation and rehabilitation, which requires effective pain management. Adductor canal blocks (ACBs) offer targeted analgesia while preserving quadriceps strength. However, postoperative pain often outlasts single-shot peripheral nerve blocks. This analysis evaluated whether perineural dexmedetomidine added to local anesthetics increased the efficacy and duration of ACBs in patients undergoing TKA. This systematic review and meta-analysis examined adult patients undergoing primary TKA under general or spinal anesthesia and ACB. Five randomized controlled trials examining 445 patients met inclusion criteria. Patient ages ranged from 18 to 85 years and demonstrated similar comorbidities. Pooled analysis showed that patients receiving dexmedetomidine reported lower pain scores at rest (mean difference [MD] -0.35; = .009) and during activity (MD -0.40; < .0001). Opioid consumption decreased by an average of 8.91 mg ( = .05). Time to first rescue analgesia increased by 1.54 hours, and ambulation outcomes consistently showed improvement in the dexmedetomidine group. This analysis supports the use of dexmedetomidine as an adjunct for ACB in TKA. However, significant heterogeneity among studies limits applicability of this analysis's findings. Clinicians are advised to consider this when making practice decisions.
There is growing interest in utilizing deep sedation with a natural airway rather than general endotracheal anesthesia (GETA) for cardiac catheterization procedures due to the presumed hemodynamic benefits and faster pos...There is growing interest in utilizing deep sedation with a natural airway rather than general endotracheal anesthesia (GETA) for cardiac catheterization procedures due to the presumed hemodynamic benefits and faster postprocedural recovery, although a paucity of data supports these assumptions. We hypothesized that the periprocedural complication rate would be lower in patients undergoing transcatheter pulmonary valve implantation (TPVI) under deep sedation with a natural airway versus those under GETA. We performed a retrospective chart review of 85 patients undergoing isolated TPVI at a large academic medical institution. A logistical regression adjusting for age was performed. The primary outcome was periprocedural complication rate, including access site rebleeding, hematoma, conversion to GETA, arrhythmia requiring intervention, cardiac arrest, blood transfusion, and postoperative nausea and vomiting. Significantly more patients in the GETA group experienced complications compared with the deep sedation group (41.2% vs 14.7%, = .015). The secondary outcomes included vasopressor use, recovery location, and procedural, anesthesia, and recovery times. The median procedure time was shorter in the sedation group by 38 minutes ( = .010), and anesthesia time was shorter by 50 minutes ( = .001). Overall, we found that deep sedation is feasible for TPVI and in this retrospective study was associated with decreased periprocedural complications.
General anesthesia increases the morbid risk for both mother and infant during a cesarean delivery. Failed or asymmetric blocks can force providers to turn to a general anesthetic precipitously. A true one-sided spinal b...General anesthesia increases the morbid risk for both mother and infant during a cesarean delivery. Failed or asymmetric blocks can force providers to turn to a general anesthetic precipitously. A true one-sided spinal block, with complete absence of anesthesia on one side despite correct subarachnoid technique, is rare and not well characterized in the literature. In this case, a 32-year-old multiparous woman presented for elective repeat cesarean delivery. After an uncomplicated spinal anesthetic, she developed a complete left-sided sensory and motor block, with no block on the right. A supplemental epidural catheter was placed and lidocaine 2%, 12 cc with fentanyl 100 micrograms was used, which successfully achieved bilateral surgical anesthesia. The remainder of the case and postoperative course were unremarkable. This case illustrates the possibility of a structurally confined subarachnoid space leading to true one-sided spinal anesthesia. Prompt recognition and epidural rescue preserved patient comfort and surgical conditions. Anatomic factors should be considered when assessing neuraxial block failures, particularly in patients with prior spinal procedures.
Chronic pain is a complex and disabling condition that significantly impairs quality of life. It often arises from central sensitization, an amplified response to pain stimuli driven by neuroinflammatory changes in both...Chronic pain is a complex and disabling condition that significantly impairs quality of life. It often arises from central sensitization, an amplified response to pain stimuli driven by neuroinflammatory changes in both the peripheral and central nervous systems. Emerging evidence highlights the gut microbiome's crucial role in the process because it modulates inflammation, immune function, and neurotransmitter production via the gut-brain axis. An imbalance in gut flora, known as dysbiosis, can exacerbate neuroinflammation by altering intestinal barrier integrity, facilitating the release of pro-inflammatory mediators, and activating microglia within the central nervous system. These changes contribute to increased pain sensitivity and the progression of chronic pain states. Consequently, strategies promoting a healthy gut microbiome, such as targeted dietary measures and microbiota-focused therapies, represent promising adjuncts to conventional chronic pain management. This journal course evaluates current research on the connection between the gut microbiome and chronic pain, offering a novel perspective on holistic, microbiome-centered interventions for alleviating pain disorders. As certified registered nurse anesthetists increasingly participate in pain management, understanding this emerging approach is vital for improving patient outcomes in chronic pain conditions.
Resident registered nurse anesthetists (RRNAs) face high levels of depression, anxiety, and stress (DAS) due to the academic, clinical, and financial demands of graduate anesthesia education. Nature-based mindfulness, wh...Resident registered nurse anesthetists (RRNAs) face high levels of depression, anxiety, and stress (DAS) due to the academic, clinical, and financial demands of graduate anesthesia education. Nature-based mindfulness, which integrates nature exposure with mindfulness practices, has shown promise in reducing psychological distress but remains underexplored among RRNAs. This single-arm pilot, pre-/posttest study evaluated the effectiveness of a nature-based mindfulness intervention (NBMI) on DAS in a cohort of third-year RRNAs in the southeastern United States. The 8-week intervention included guided nature walks, box breathing exercises, and gratitude journaling. Depression, anxiety, and stress were measured pre- and postintervention using DASS-21. Focus groups explored participants' experiences postintervention. Quantitative analysis revealed a statistically significant reduction in anxiety levels (P = .039). Stress and depression scores decreased but did not reach statistical significance. Qualitative findings reflected improved mental clarity, emotional well-being, and peer connection. Findings suggest that NBMI is an effective, feasible, low-cost strategy to enhance well-being in RRNAs. Larger, randomized studies are warranted to examine the broader applicability of NBMI in nurse anesthesia education.
This study aimed to develop an evidence-based perioperative assessment tool for anesthesiology professionals to supplement standard preoperative assessments, targeting the unique health needs of transgender and gender-di...This study aimed to develop an evidence-based perioperative assessment tool for anesthesiology professionals to supplement standard preoperative assessments, targeting the unique health needs of transgender and gender-diverse (TGD) patients to enhance the perioperative experience. Many TGD patients express dissatisfaction with their care, while numerous healthcare professionals report feeling inadequately prepared to care for this population effectively. Using a modified Delphi design, a consensus-based Perioperative Gender-Diverse Assessment Tool (PGDAT) was developed to assist anesthesiology professionals in sensitively engaging with TGD patients and creating evidence-informed, patient-focused anesthetic plans. Fourteen expert panelists from the United States appraised the quality and clinical readiness of the PGDAT through iterative online surveys. Consensus was defined as 0.8 agreement among raters, and a thematic analysis was conducted following Braun and Clarke, with three core themes emerging. The interrater reliability was 0.75707 and 0.83977 using Gwet's AC2. The 0.8 consensus threshold was achieved after two survey rounds, which content-validated the PGDAT and established an evidence-based resource that future research opportunities can use to bring about systemic changes that promote safe and inclusive healthcare environments for all.
This secondary data analysis used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), logistic regression (Method 1), Xtreme Gradient Boosting (Method 2), and a 12-member expert pa...This secondary data analysis used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), logistic regression (Method 1), Xtreme Gradient Boosting (Method 2), and a 12-member expert panel (Method 3) to develop and validate a predictive model to identify patients undergoing thoracic surgery at risk for postoperative pneumonia (POP). Twenty-three covariates associated with POP were selected from the 2013-2022 ACS NSQIP dataset filtered for thoracic surgeries. Method 1 and Method 2 were assessed through area under the receiver operating characteristic curve (AUC ROC) using 10-fold cross-validation. Method 3 evaluated the 23 covariates for relevance to POP and relevant predictors were assessed through AUC ROC. Method 1 identified nine significant predictors ( < .05) with a 10-fold cross-validated AUC ROC = .72 (fair classifier). The significant preoperative predictors and their effect size were, sepsis (1.43), systemic inflammatory response syndrome (1.04), male gender (.77), bleeding disorder (.57), current smoker within 1 year (0.39), disseminated cancer (.39), hypoalbuminemia (.33), history of severe chronic obstructive pulmonary disease (.31), and anemia (.05). Method 2 achieved a 10-fold cross-validation AUC ROC = .75 (fair classifier). Method 3 had an AUC ROC = .6 (poor classifier). The nine significant predictors from Method 1 were used to develop a risk-based calculator.
This project aimed to reintroduce and evaluate a pediatric ketamine sedation protocol at a Zonal Referral Center in Mwanza, Tanzania, where nonanesthesia clinicians provide sedation when trained anesthesia personnel are...This project aimed to reintroduce and evaluate a pediatric ketamine sedation protocol at a Zonal Referral Center in Mwanza, Tanzania, where nonanesthesia clinicians provide sedation when trained anesthesia personnel are unavailable. The objectives were to assess knowledge retention, confidence, and protocol compliance. The study design used a pre- and postintervention design. Nonanesthesia clinicians at a > 1,000-bed hospital were surveyed to assess their knowledge and confidence about ketamine sedation. Over 10 days, 50 clinicians received training that included lectures and cognitive aid resources in English and Swahili (the local language). Knowledge and confidence were measured using paired surveys. Clinicians were observed for compliance, skill demonstration, and feedback during postimplementation sedation encounters. Results showed significant improvements in knowledge (M = 6.93-8.77; = .001) and confidence (M = 5.94-8.98; = .001). Seven sedation encounters were observed over a 7-day period, and compliance with the presedation assessment was 100% for last food or drink intake, allergy history, and medication history. Reintroducing this protocol in a low-resource setting led to improvements in knowledge, confidence, and skills among nonanesthesia clinicians.
Subarachnoid block, colloquially referred to as spinal anesthesia, is a commonly employed method of anesthesia for most of the lower limb orthopedic procedures. Patients in preoperative hypovolemic states are more prone...Subarachnoid block, colloquially referred to as spinal anesthesia, is a commonly employed method of anesthesia for most of the lower limb orthopedic procedures. Patients in preoperative hypovolemic states are more prone to post-spinal anesthesia hypotension (PSAH). Most orthopedic patients present in a preoperative fluid deficit state, thus, its recognition and appropriate correction are prudent. Ultrasonographic measurement of the inferior vena cava collapsibility index (IVCCI) is a tool to detect and correct hypotension secondary to hypovolemia. We hypothesized that pre-spinal IVCCI measurement is a reliable predictor of PSAH in patients undergoing elective lower limb orthopedic procedures. Ninety-nine participants, ASA grade I and II, aged 18-60 years, undergoing elective lower limb orthopedic surgeries were enrolled. Preoperative ultrasound inferior vena cava evaluation was performed and IVCCI was calculated. Preloading was done with intravenous crystalloid and subarachnoid block was administered in lateral position. Participants were placed supine and thereafter, level of sensory block was ascertained, and noninvasive blood pressure was measured every 2.5 min for 30 min. One hundred patients were screened and one was excluded due to failure of block. Mean IVCCI was 47.33 ± 9.62%. The receiver operating characteristic curve showed IVCCI has satisfactory predictive validity for predicting hypotension with AUC of 0.829 and < 0.001. The sensitivity and specificity of IVCCI was found to be 87.36% and 83.3% at a cut-off value of 51.67%. Preoperative ultrasound evaluation of IVCCI is a reliable predictor for PSAH at a value of 51.67%.
The aim of this study was to identify and assess factors associated with nurse anesthetist competency in Finland, South Korea, Taiwan, and the United States. A cross-sectional design was used. The Anesthesia Nursing Comp...The aim of this study was to identify and assess factors associated with nurse anesthetist competency in Finland, South Korea, Taiwan, and the United States. A cross-sectional design was used. The Anesthesia Nursing Competence Scale consisting of seven competencies was utilized: ethics, patient risk management, technological skills, collaboration, medication, optimizing anesthesia care, and anesthesia knowledge (0 = not competent at all, 10 = excellent competence). The data were collected via an online survey (N = 582) in 2024. Data analysis included correlation tests, t-tests, and linear regression analysis. The highest-rated competencies varied by country: collaboration in Finland (9.31 ± 0.68), medication in Taiwan (9.01 ± 1.19), and ethics in the United States (9.58 ± 0.84). However, anesthesia knowledge was the lowest-rated competency across all countries. Age, educational level, and work experience showed a positive correlation with competency and education level was identified as the most important factor influencing anesthesia nursing competency. Assessing these competencies as outcomes of nursing education in an international context remains crucial for promoting global standards in the education and practice of nurse anesthetists. Strengthening international collaboration in anesthesia nursing education and establishing standardized competency assessments could further promote high quality practices and ensure quality patient care.
Buprenorphine's unique pharmacologic profile and safety characteristics make it a first-line treatment for opioid use disorder (OUD). While buprenorphine is increasingly used in opioid dependence treatment, transitioning...Buprenorphine's unique pharmacologic profile and safety characteristics make it a first-line treatment for opioid use disorder (OUD). While buprenorphine is increasingly used in opioid dependence treatment, transitioning patients from full opioid agonists to buprenorphine remains a clinical challenge, particularly due to limited familiarity and complexities of induction of buprenorphine in managing OUD. Traditional clinical guidelines recommend initiating buprenorphine following a period of mild-to-moderate prerequisite opioid withdrawal. However, during the transition, inadequate equianalgesic dosing and inappropriate timing and routes of buprenorphine administration may precipitate withdrawal symptoms. Two primary induction strategies, microdosing and bridging, have currently demonstrated success in minimizing withdrawal and improving patient comfort. This journal course examines these two strategies when switching patients from common opioids to buprenorphine. Additionally, this article reviews the pharmacologic mechanisms of buprenorphine, compares the two induction techniques, and explores regulatory and practical considerations with current, evidence-based guidance on initiating buprenorphine in opioid-dependent patients for safer and more effective OUD care.
Dexmedetomidine is known to prolong sensory and motor blockade by local anesthetics. In this study we compared the efficacy of dexmedetomidine given intramuscularly and perineurally as an additive to supraclavicular brac...Dexmedetomidine is known to prolong sensory and motor blockade by local anesthetics. In this study we compared the efficacy of dexmedetomidine given intramuscularly and perineurally as an additive to supraclavicular brachial plexus block. Sixty-two patients requiring upper limb surgeries were randomly assigned to two groups. All patients received 2% lidocaine (10 mL) + 0.5% levobupivacaine (10 mL) + normal saline (5 mL). In the perineural group (PN), 0.5 µg/kg dexmedetomidine was administered perineurally in the block whereas in the intramuscular group (IM), 0.5 µg/kg dexmedetomidine was administered intramuscularly in the blocked arm. Onset and duration of sensory and motor blockade, time taken to request analgesia, sedation, and overall patient satisfaction were noted. Onset of sensory blockade occurred at 5 min in both groups. Onset of motor blockade (mean ± SD) occurred at 16.93 ± 6.91 min and 17.25 ± 6.93 min, in Group PN and Group IM, respectively. Sensory blockade (mean ± SD) lasted for 773.71 ± 222.6 min and 701.29±233.34 min, while motor blockade (median) lasted for 275 and 300 min in Group PN and Group IM, respectively. The onset and duration of blockade were comparable between the two groups. Onset and duration of brachial plexus block are comparable whether dexmedetomidine is given perineurally or intramuscularly as an adjunct to local anesthetic.
As the number of individuals identifying as transgender and gender nonbinary (TGNB) rises, the amount of TGNB patients requiring surgery increases in tandem. However, there are gaps in proficiency for certified registere...As the number of individuals identifying as transgender and gender nonbinary (TGNB) rises, the amount of TGNB patients requiring surgery increases in tandem. However, there are gaps in proficiency for certified registered nurse anesthetists and anesthesiologists which, compounded by a dearth of literature on TGNB-focused perioperative education, limit curricular implementation. Given the important need for improved perioperative care of TGNB patients, this study evaluates the impact of providing a 50-minute lecture to first-year resident registered nurse anesthetists (RRNAs) and second-year anesthesiology residents regarding their attitude, comfort, and perceived ability to care for TGNB patients. Participants completed prelecture and postlecture surveys, which were analyzed descriptively and using either chi-square tests or Fisher's exact tests. Based on our results, improvements were identified in areas such as the participants' understanding of TGNB patients' feelings, comfort interacting with TGNB patients, comfort in addressing transphobia, and perceived ability to care for TGNB patients. These results highlight the positive impact of TGNB-focused education on RRNAs and anesthesiology residents and emphasizes the importance of integrating instruction into anesthesia curricula.