AANA Journal[JOURNAL]
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200 papers
Practice Model Trends in Medicare Payments Across States and Regions.
Hoyem RL, Jordan L, Lukyanova VV … +1 more , Legaspi T
AANA J · 2023 Oct · PMID 37788174
Anesthesia delivery models have long been shaped by workforce trends, state and federal regulations, economic incentives driven by reimbursement, and the normative preferences of provider and facility organizations. In r...
Anesthesia delivery models have long been shaped by workforce trends, state and federal regulations, economic incentives driven by reimbursement, and the normative preferences of provider and facility organizations. In recent years, there has been a significant shift toward greater use of more efficient certified registered nurse anesthetist (CRNA)-oriented delivery models observed at the national level Medicare data. However, given the wide range of these factors across states and regions, this shift has likely occurred at an uneven pace. This study analyzes the influence of provider workforce composition and CRNA scope of practice (SOP) regulations on usage of competing types of anesthesia delivery models, including anesthesiologist alone, care team, and undirected CRNA models. Results show that over the period from 2010-2019, anesthesia delivery models utilized under Medicare Part B have become increasingly oriented around the use of CRNAs. However, increases in the care team vs undirected CRNA model are highly uneven and inconsistent across states, even after adjusting for workforce and SOP. Speculation on additional normative or organization-driven reasons for persistent use of inefficient delivery models in some places is offered.
Inadvertent Perioperative Hypothermia.
Garceau C, Cosgrove MS, Gonzalez K
AANA J · 2023 Aug · PMID 37527171
Temperature regulation during the perioperative period plays an essential role in keeping patients safe while optimizing their recovery. The World Health Organization recommends preserving normothermia, identified as a c...
Temperature regulation during the perioperative period plays an essential role in keeping patients safe while optimizing their recovery. The World Health Organization recommends preserving normothermia, identified as a core body temperature greater than 36°C, to minimize morbidity and mortality. The etiology of inadvertent perioperative hypothermia (IPH) varies in origin. Preoperative exposure, decreased ambient operating room (OR) temperature, skin exposure during preparation, unwarmed skin preparation and washout solutions, and lack of warming devices all contribute to IPH. Moreover, general and regional anesthesia blunt the physiologic response to hypothermia which originates in the hypothalamus. Postoperatively, patients with temperatures < 36°C are at greater risk for surgical site infection, increased mortality, longer length of hospital stay, higher 30-day readmission rates, among other complications. Identifying preoperative risk factors and OR practices that contribute to IPH, monitoring temperatures, and use of warming devices during the perioperative period can help to prevent IPH.
Anesthetic Management of a Patient With Eagle's Syndrome: A Case Study.
Supsic B, Minzola D
AANA J · 2023 Aug · PMID 37527170
Eagle's syndrome is a condition characterized by elongation of the styloid process or calcification of the styloid ligament that can manifest as a constellation of symptoms including dysphagia, globus sensation, hoarsene...
Eagle's syndrome is a condition characterized by elongation of the styloid process or calcification of the styloid ligament that can manifest as a constellation of symptoms including dysphagia, globus sensation, hoarseness, headache, and neck pain. Anatomically, this can impinge neurovascular structures, distort the hypopharynx, and stiffen the epiglottis and other pharyngeal structures, increasing the difficulty of airway management. The objective of this case study was to discuss the features of Eagle's syndrome and anesthetic considerations in the management of the condition. Intubation may be challenging and presents a scenario where a glidescope is the preferred tool over direct laryngoscopy. Smooth emergence and extubation strategies, including the novel use of lidocaine and dexmedetomidine, are followed to minimize the risk of surgical complications.
Evidence-Based Practice Guidelines for Organ Procurement.
de Luzan IF, Vormbrock M, Merkel A … +1 more , Smith-Steinert R
AANA J · 2023 Aug · PMID 37527169
Organ procurement is a complex and unique procedure that warrants the creation of an evidence-based practice guideline. Anesthesia care of the donor may adversely impact the fate of organs once transplanted. The followin...
Organ procurement is a complex and unique procedure that warrants the creation of an evidence-based practice guideline. Anesthesia care of the donor may adversely impact the fate of organs once transplanted. The following article gives a brief review of the literature, and a guideline for providing anesthesia during an organ procurement which was created for a large, level-one, academic facility. Care of the organ donor during the preoperative phase is frequently discussed in the literature; however, there remains a need for further information on the care of the organ donor intraoperatively.
Accidental Intraarterial Placement of a Venous Cannula: When In Doubt Take It Out!-A Case Report.
Shah SB, Koul A
AANA J · 2023 Aug · PMID 37527168
An artery may be entered on the dorsum of the hand with the mistaken belief that it is a vein. Intraarterial injection of drugs is one of the dreadful consequences of accidental intraarterial cannulation. In this case of...
An artery may be entered on the dorsum of the hand with the mistaken belief that it is a vein. Intraarterial injection of drugs is one of the dreadful consequences of accidental intraarterial cannulation. In this case of a 3-month-old infant, we emphasize the fact that careful observation can prevent unintentional intraarterial drug injection via an 'assumed intravenous' cannula and prevent the associated morbidity. When there is a suspicion of an intraarterial placement of venous cannula, it is of paramount significance to confirm before the injection of medications. Aberrant arterial anatomy should be kept in mind, particularly in children on the dorsum of the hand, where placement of an intravenous cannula is usually considered safe.
The Impact of High-Fidelity Simulation on Nurse Anesthesia Students' Knowledge, Self-Confidence, and Psychomotor Skills.
Aguirre P, Amos VY, Mitchell JC
AANA J · 2023 Aug · PMID 37527167
The utilization of simulation has proved to be a valuable tool to train students in the academic setting in preparation for the clinical environment. Student registered nurse anesthetists (SRNAs) receive limited educatio...
The utilization of simulation has proved to be a valuable tool to train students in the academic setting in preparation for the clinical environment. Student registered nurse anesthetists (SRNAs) receive limited education and training on the use of powered air-purifying respirators when caring for patients with highly infectious diseases (i.e., COVID-19). The purpose of this pilot study was to assess SRNAs' knowledge, self-confidence, and psychomotor skills for the safe performance of donning and doffing of powered air-purifying respirators while managing the airway. A single group pretest and posttest descriptive study was conducted over 7 months which included 45 SRNAs. There was a statistically significant increase in knowledge (P = < .001) and self-confidence (P = < .001) on safe donning and doffing of powered air-purifying respirators for emergent intubation. Descriptive statistics on the psychomotor skills revealed that the SRNAs were able to demonstrate donning and doffing of powered air-purifying respirators for emergent intubation during simulation. Findings suggest that simulation is an appropriate strategy and is relevant for nurse anesthesia educators to consider when training SRNAs to don and doff while managing the airway for patients with COVID-19.
Certified Registered Nurse Anesthetists' Experience of Relocation to COVID-19 Intensive Care-A Qualitative Interview Study.
Sundblad H, Hommel A
AANA J · 2023 Aug · PMID 37527166
In spring 2020, a global SARS-Cov-2 pandemic was declared. The number of patients in need of intensive care exceeded the number of available care places at intensive care units (ICUs) and certified registered nurse anest...
In spring 2020, a global SARS-Cov-2 pandemic was declared. The number of patients in need of intensive care exceeded the number of available care places at intensive care units (ICUs) and certified registered nurse anesthetists (CRNAs) were relocated to ICUs to support the care during the pandemic. The aim of this study was to illuminate the experiences of the CRNAs regarding relocation to COVID-19 intensive care. An interview study based on qualitative content analysis was conducted. The participants were CRNAs who usually work in the operating unit, however, were relocated to work in the COVID-19 ICU at a university hospital in southern Sweden during the pandemic. Four themes emerge in the results: sense of pride, competence, work environment, and nursing. The results illuminate the CRNAs' experience of relocating from their usual working environment to caring for critically ill patients in a COVID-19 ICU. The CRNAs managed the relocation well, although sometimes it was difficult. The CRNAs showed great loyalty, dedication, competence, and flexibility in their professional capacity. The time they worked in COVID-19 intensive care was a challenging period, but it gave them a well-deserved sense of pride and competence.
Comparison of Mepivacaine 2% and Isobaric Bupivacaine 0.5% Spinal Anesthetics for Total Knee Arthroplasty.
Bettin NF, Crawford KL, Peterson JJ
AANA J · 2023 Aug · PMID 37527165
Spinal anesthesia is an option for patients during total knee arthroplasty (TKA) procedures. Spinal anesthesia can offer advantages and disadvantages to the patient's experience and outcomes. We conducted an evidence-bas...
Spinal anesthesia is an option for patients during total knee arthroplasty (TKA) procedures. Spinal anesthesia can offer advantages and disadvantages to the patient's experience and outcomes. We conducted an evidence-based, quality improvement project comparing mepivacaine 2% and isobaric bupivacaine 0.5% and retrospectively assessed specific intraoperative and postoperative outcomes that were of interest to the staff at the hospital where the project was completed. Primary outcome measures of interest included intraoperative heart rate, blood pressure, vasopressor use, fluid resuscitation, postoperative pain scores, use of opioid analgesic medications, and time to ambulation after administration of the spinal anesthetic. Compared with patients receiving isobaric bupivacaine 0.5% (n = 30), patients receiving mepivacaine 2% (n = 30) had greater intraoperative hemodynamic stability (defined as heart rate and blood pressure maintained within 20% of baseline values) during the first 30 minutes after anesthetic administration ( < .05 for multiple time points). They also required less opioid medication for postoperative pain management (25 vs 50 mcg fentanyl) and were able to ambulate sooner after the procedure (mean [standard deviation], 452.2 [218.5] vs 681.0 [476.6] minutes; = .006). In conclusion, mepivacaine 2% was the higher-performing local primary spinal anesthetic for patients undergoing TKA.
Racial And Ethnic Discrimination During Clinical Education and Its Impact on the Well-Being of Nurse Anesthesia Students.
Serrano Y, Dalley CB, Crowell NA … +1 more , Eshkevari L
AANA J · 2023 Aug · PMID 37527164
The effects of racial/ethnic discrimination in the clinical setting have been shown to cause psychological distress in populations of healthcare workers. However, there are currently no published studies that investigate...
The effects of racial/ethnic discrimination in the clinical setting have been shown to cause psychological distress in populations of healthcare workers. However, there are currently no published studies that investigate racial/ethnic transgressions in the clinical arena and their impact on the well-being of student registered nurse anesthetists (SRNAs). The current study aimed to investigate 1) the prevalence and nature of racial/ethnic bias during clinical education and 2) its impact on wellness in a cohort of SRNAs. Data were collected using a three-part 16-item electronic questionnaire distributed to a national sample of SRNAs. A significant association was found between race/ethnicity and an increased incidence of discrimination (χ [5] = 24.1, P < .001). SRNAs who described experiencing at least one discrimination encounter during their training had significantly higher mean Well-Being Index scores-associated with more distress-compared with those students who had never experienced discrimination (P < .05). Participant responses were categorized into five major themes: overt discrimination, covert discrimination, disparate treatment, barriers to reporting, and incivility/bullying. Addressing the distinctive challenges related to race/ethnicity in clinical sites is paramount to ensuring the success of minority SRNAs.
Anesthesia Management For A Patient Having Transoral Approach For Anterior Cervical Osteophyte Resection.
Silla MT, Bennetts P, Hollabaugh B
AANA J · 2023 Aug · PMID 37527163
Anterior cervical osteophytes (ACOs) are a common condition in the elderly, leading to dysphagia, odynophagia, aspiration, neck pain, dysphonia, and dyspnea. Transoral surgical resection is an approach to managing cervic...
Anterior cervical osteophytes (ACOs) are a common condition in the elderly, leading to dysphagia, odynophagia, aspiration, neck pain, dysphonia, and dyspnea. Transoral surgical resection is an approach to managing cervical (C1 and C2) ACOs where the endoscopic endonasal approach is contraindicated. Advantages of the transoral approach include it providing direct access to the cervical spine, limits injury to surrounding neurovascular structures, and eliminates scarring. Anesthesia considerations for transoral surgical resection of ACOs will be covered in the following case report. A review of the literature examines the prevalence of and anesthesia considerations for the transoral approach to anterior cervical osteophyte resection.
Downfolding of the Epiglottis Through the Vocal Cords: A Case Report.
Mouzannar S
AANA J · 2023 Aug · PMID 37527162
This report presents an unusual case of epiglottic downfolding through the vocal cords which occurred during direct laryngoscopy and loss of view with intubation. Few indicators of an issue were present postintubation, b...
This report presents an unusual case of epiglottic downfolding through the vocal cords which occurred during direct laryngoscopy and loss of view with intubation. Few indicators of an issue were present postintubation, but the providers' interest in one peculiar detail led to timely discovery of the issue avoiding any further injury or complications to the patient.
A Look To The Future.
Jordan L
AANA J · 2023 Aug · PMID 37527161
Abstract loading — click title to view on PubMed.
High O a Go To: Effects of Hyperoxia.
Gatti A, Wands B
AANA J · 2023 Jun · PMID 37227962
Current research on the optimal amount of oxygen delivery during general anesthesia is controversial. It is well described that anesthesia providers create supraphysiological arterial oxygen levels in patients with the d...
Current research on the optimal amount of oxygen delivery during general anesthesia is controversial. It is well described that anesthesia providers create supraphysiological arterial oxygen levels in patients with the delivery of supplemental oxygen. Over the past 20 years, hyperoxia has been studied more thoroughly and potential consequences are better understood. Atelectasis and radical oxygen species can lead to postoperative complications such as infection, prolonged respiratory support, and increased length of hospital stay. Anesthetists should consider the risk and benefit, potential effects, and differentiate the amount of oxygen dependent on the clinical situation. More research is needed in varying patient populations and surgical procedures to better understand the implications of hyperoxia in patients requiring general anesthesia.
Improving Small-Volume Antibiotic Administration for Surgical Prophylaxis: A Quality Improvement Project.
Thomas BL, Torres B, Curtis M … +1 more , Chen L
AANA J · 2023 Jun · PMID 37227961
No clear policy on administration methods for small-volume intravenous antibiotic bags (≤ 100 mL) for surgical prophylaxis lead to wide variation in anesthesia provider practice at a large academic medical center. Admini...
No clear policy on administration methods for small-volume intravenous antibiotic bags (≤ 100 mL) for surgical prophylaxis lead to wide variation in anesthesia provider practice at a large academic medical center. Administration via secondary tubing is the recommended practice to minimize significant medication losses from dead volumes. An observation of current practice and measurements of dead volumes was followed by an educational intervention on best practices for administration of small-volume antibiotics. Three postintervention cycles were conducted to evaluate change in practice and reductions in dead volumes over a 6-week period. Mean dead volume losses were evaluated using one-way ANOVA. Statistically significant ( = .0012) decreases in dead volume losses were observed postintervention, from 8.48 mL (SD 6.80) to 0.93 mL (SD 1.46). The most common pre- and postintervention tubing sets used were primary tubing (pre) and secondary tubing (post). Mean dead volume losses for these respective tubing sets were 13.45 mL (SD 4.74) and 0.79 mL (SD 1.40) ( < .0001). Preintervention administration methods resulted in incomplete antibiotic administration. Overall, there was a significant reduction in dead volumes of antibiotic by changing practice to secondary tubing. With strong provider acceptance and sustained reduction in medication wastage, this intervention has shown to be a beneficial new practice moving forward.
Examination of a Nurse Anesthesia Program's Teaching Assistant Model and Its Impact on Increasing Nurse Anesthesia Education Capacity.
Baker O, Sparks H, Dalley CB … +3 more , Everson M, Crowell N, Eshkevari L
AANA J · 2023 Jun · PMID 37227960
A nurse anesthesia educator shortage exists that is attributed to factors such as a lack of financial incentive and proper training to be an educator. Due to the faculty shortage, nurse anesthesia programs (NAPs) are for...
A nurse anesthesia educator shortage exists that is attributed to factors such as a lack of financial incentive and proper training to be an educator. Due to the faculty shortage, nurse anesthesia programs (NAPs) are forced to defer admission to qualified applicants which reduces the number of certified registered nurse anesthetists (CRNAs) that NAPs can produce. Research regarding students as teaching assistants (TAs) at the university level has shown benefits and challenges to students, professors, and the TAs themselves as well as the impact on the overall faculty capacity. Current research regarding TA programs does not pertain to NAPs, therefore, research regarding the impact of TA programs on increasing nurse anesthesia faculty merits further work. This study was conducted using quantitative surveys and qualitative interviews to bridge the gap in the literature on the potential impact of TA programs on NAP faculty shortages. A survey was sent via email to former TAs (n = 44) of the Georgetown University NAP to assess the impact that the TA program had on their decision to enter a role in academia after graduation. Interviews were then conducted on a voluntary basis via a video conferencing platform to add qualitative data to the survey results. The survey response rate was 45% (n = 20). Following proportional analysis, 80% of the survey respondents indicated that they participated in the education of student registered nurse anesthetists in the clinical or didactic setting as a CRNA. Eighty percent of respondents indicated that being a TA positively influenced their desire to become a faculty member. One hundred percent of CRNAs interviewed reported that the biggest barrier to becoming fulltime faculty was the lack of financial incentives offered by NAPs. Interviewees recalled their TA experience as the foundation for their enjoyment of teaching anesthesia. The results of this study indicate that TA programs in NAPs can be used as a method to increase faculty capacity.
Bupivacaine Dosing for Cesarean Delivery in Parturients of Short Stature: A Retrospective Case-Control Study.
Lange EMS, Toledo P, Stariha J … +3 more , LiMandri J, Morley D, Nixon HC
AANA J · 2023 Jun · PMID 37227959
The ED50 and ED95 of spinal bupivacaine for cesarean delivery has been well described in the literature; however, parturients with extremes of stature have been excluded. Parturients of short stature are a height of ≤ 14...
The ED50 and ED95 of spinal bupivacaine for cesarean delivery has been well described in the literature; however, parturients with extremes of stature have been excluded. Parturients of short stature are a height of ≤ 148 cm. This retrospective, case-control study evaluated anesthetic outcomes for parturients of short stature and controls who underwent cesarean delivery over a 10-year period. Women were matched for anesthetic type and body mass index. Data extracted included patient demographics and obstetric and anesthetic information. The primary outcome was dose of intrathecal bupivacaine. Categorical data were compared using a chi-squared test, continuous data were compared using a t-test or Mann-Whitney U test. Data for 26 women of short stature and 52 controls were evaluated. The mean dose of bupivacaine used for spinal anesthesia in parturients of short stature was 9.8 ± 1.0 mg ( <.0001). The mean intrathecal bupivacaine dose used in combined spinal epidural anesthesia was 10.5 mg (interquartile range, 9-10.9) in parturients of short stature ( = .002). All but one patient of short stature achieved an adequate surgical level; there were no instances of high spinal blockade. Adequate surgical anesthesia was achieved with reduced dosing of spinal bupivacaine in parturients of short stature without an increase in adverse outcomes.
Development and Validation of a Quantitative Grading Rubric for High-Fidelity Simulation Assessment.
Greenwood JE, Ledvina M
AANA J · 2023 Jun · PMID 37227958
High-fidelity simulation scenarios provide trainees the opportunity to demonstrate foundational anesthesia skills, complex prioritization, and decision making. One strategy used in trainee assessment is an objective stru...
High-fidelity simulation scenarios provide trainees the opportunity to demonstrate foundational anesthesia skills, complex prioritization, and decision making. One strategy used in trainee assessment is an objective structured clinical examination (OSCE). The purpose of this study was to design an OSCE with a reliable, quantitative grading rubric that could be used as part of a comprehensive assessment strategy to determine readiness for entry into clinical training for nurse anesthesia residents. An observational correlational study was developed to validate four high-fidelity simulation scenarios and accompanying quantitative grading rubrics. The rubrics were tested on junior nurse anesthesia residents and graded by program faculty members. Interrater reliability was tested using Krippendorff's alpha. Three cohorts of nurse anesthesia residents (n = 83) were assessed yielding 330 unique observations. Interrater reliability increased over the duration of the study with an overall reliability coefficient of 0.9092 (95% CI, 0.8509-0.9062), indicating a very high degree of interrater reliability among a variety of raters in complex simulated environments. Development of a quantitative rubric for high-fidelity simulation is achievable and should be considered as part of a summative assessment to differentiate individual student performance and readiness to proceed to clinical training within a front-loaded nurse anesthesia program.
Spinal Anesthesia with 2-Chloroprocaine and Dexmedetomidine for Cesarean Section: A Case Report.
Baribeault T, Suss S
AANA J · 2023 Jun · PMID 37227957
To our knowledge, there are currently no published articles discussing the use of 2-chloroprocaine plus dexmedetomidine in women undergoing cesarean section and only one article published on spinal anesthesia with these...
To our knowledge, there are currently no published articles discussing the use of 2-chloroprocaine plus dexmedetomidine in women undergoing cesarean section and only one article published on spinal anesthesia with these two medications for other types of surgery. 2-Chloroprocaine is a short-acting local anesthetic that helps patients ambulate more quickly after surgery due to its 60-minute average duration of action. Dexmedetomidine, when given in combination with local anesthetics, in spinal anesthesia, prolongs the effects of the local anesthetic. It is especially advantageous in obstetric anesthesia because of its wide safety margin, minimal ability to cross the placenta, and benefits that are unique to the parturient: dense visceral analgesia, anxiolysis without amnesia, reduced shivering, and lack of respiratory depression, nausea, and pruritis. We report a case of spinal anesthesia for cesarean section with 2-chloroprocaine plus dexmedetomidine and were able to achieve excellent surgical conditions and a more rapid recovery of motor function than with bupivacaine plus dexmedetomidine.
Use of Single-Dose Dexamethasone in Patients With Diabetes Undergoing Surgery: A Systematic Review and Meta-Analysis.
Sanders JC, Russell PK, Tubog TD
AANA J · 2023 Jun · PMID 37227956
The purpose of this review was to examine the effect of single-dose dexamethasone on perioperative blood glucose in diabetic patients. We used PubMed, Cochrane Library, MEDLINE, CINAHL, Google Scholar, and grey literatur...
The purpose of this review was to examine the effect of single-dose dexamethasone on perioperative blood glucose in diabetic patients. We used PubMed, Cochrane Library, MEDLINE, CINAHL, Google Scholar, and grey literature for our search. Only randomized controlled trials were included. Risk ratio (RR) and mean difference (MD) were used to estimate outcomes with suitable effect models. Quality of evidence was assessed using the Risk of Bias and GRADE systems. We analyzed seven trials involving 1,321 patients. Diabetic patients treated with single-dose dexamethasone had statistically significant changes in blood glucose levels from baseline by 33.61 mg/dL (MD, 33.61; 95% CI, 17.59 to 49.63; < .0001). Dexamethasone increased blood glucose levels 1-4 hours (MD, 29.02; 95% CI, 7.09 to 50.94; = .010), 8-24 hours (MD, 30.81; 95% CI, 9.21 to 52.41; = .005) after administration and increased risks of hyperglycemia. However, there was no difference in surgical site infection (SSI) (RR, 0.81; 95% CI, 0.59 to 1.11; = .19). Effect size imprecision, substantial heterogeneity, and publication bias was the study's limitations. We found that single-dose dexamethasone increased glucose concentration 24 hours after surgery with little to no effect on SSI. Extrapolation of these findings to clinical settings must take into consideration the review's limitations.
Understanding Pain in Alzheimer's Disease in Anesthesia.
Dabney C, Monroe T, Cowan R … +1 more , Carter M
AANA J · 2023 Jun · PMID 37227955
The primary risk factor for developing Alzheimer's Disease (AD) is increasing age, meaning that certified registered nurse anesthetists (CRNAs) will most likely encounter patients with AD with increasing frequency. Patie...
The primary risk factor for developing Alzheimer's Disease (AD) is increasing age, meaning that certified registered nurse anesthetists (CRNAs) will most likely encounter patients with AD with increasing frequency. Patients with AD are a challenge for CRNAs to quickly create a comprehensive anesthetic because of the difficulty with self-reporting and understanding how the brain responds to pain in AD. New research about how the brain processes pain in patients with AD is available, which could prove helpful. Published reports that outline a specific anesthetic plan are scarce, particularly considering each patient's own set of circumstances and where they are in the disease process. This article highlights helpful suggestions and considerations for CRNAs when assessing pain, understanding individual responses to pain, and developing a plan to help control pain when caring for patients with AD.
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