Preliminary Investigation: Pilot Study of Program Directors' Perceptions of Wellness and Suicide Prevention for Student Registered Nurse Anesthetists.

The purpose of this pilot study was to investigate wellness and student suicidality in nurse anesthesia programs. Graduate students such as student registered nurse anesthetists (SRNAs) are at increased risk of suicide from environmental and educational stressors. Wellness interventions may help. An observational, anonymous online survey of all program directors (PDs) was conducted. Identical responses on a simultaneous pilot SRNA study were compared. Quantitative data were analyzed using Wilcoxon rank sum and Fisher's exact tests. Three PDs reported student suicides. Anxiety, depression, and emotional lability were warning signs. Student and PD responses to wellness program assessments were varied, with PD responses more positive and students more negative. PDs were as stressed as students and struggled to meet their own wellness needs. Most PDs reported no or insufficient training in suicide risk and prevention. Suggestions for improving wellness initiatives included to improve and standardize activities and make initiatives more accessible and seek innovative solutions to fit more content into an overcrowded curriculum. PDs and SRNAs need suicide prevention training and improved wellness efforts at local and national levels. Approaches are needed to counter stigma and reluctance to discuss mental health challenges. Suicide is multidimensional, but with proactive awareness, it may be preventable.

Preliminary Investigation: Pilot Study of Wellness and Suicide Prevention for Student Registered Nurse Anesthetists.

This pilot study investigated wellness and causes and prevention of suicide in student registered nurse anesthetists (SRNAs). A cross-sectional anonymous survey study was conducted of a sample of randomly chosen SRNAs. Data were analyzed with descriptive and inferential statistics. Responses to open-ended questions were summarized and presented. Results demonstrated elevated SRNA stress levels. There was an association between suicidal ideation in SRNAs and depression, lack of perceived agency, and elevated anxiety in the classroom. SRNAs reported mental health challenges, depression, and anxiety. Sixteen percent of SRNAs felt that classmates were at risk of suicide, and two SRNAs had lost a classmate to suicide. Twenty-nine percent of SRNAs reported suicidal thoughts prior to matriculation, and 35% reported suicidal thoughts during training. Students with suicidal ideation asked for help from friends and family, but not faculty, and some did not ask for help. Students gave existing wellness initiatives low ratings, and many felt faculty did not promote wellness. Involving student group leaders and appointing a student lead wellness point person may encourage students to ask for help. Faculty should continually prioritize, check-in on, and monitor student wellness. Wellness is a never-ending, essential, and continually evolving effort. Suicide is preventable with compassionate intervention.

Demystifying Buprenorphine with Current Evidence-Based Practice in Acute and Chronic Pain Management.

Buprenorphine has been widely used in opioid medication assisted treatment (MAT) in the past decade. However, due to misinterpretation of its intrinsic mu opioid receptor activity extrapolated from preclinical and animal data, buprenorphine's clinical application in pain management has been greatly limited. Buprenorphine acts as a full mu agonist with fewer side effects compared to traditional opioids and can be effectively used in the treatment of acute and chronic pain. A strong body of evidence demonstrates that buprenorphine is an effective analgesic agent in both adult and pediatric surgical patients. In addition, buprenorphine has been successfully used in treating chronic pain, particularly in cancer pain and neuropathic pain. In this Journal course, buprenorphine's receptor pharmacology and pharmacokinetics are reviewed. Specifically, misinterpretation of its intrinsic mu receptor activity, and both analgesic ceiling effect and efficacy are clarified. Differences between suboxone and buprenorphine, and specific applications are explained. Pain management options and guidelines for surgical patients on buprenorphine are discussed, as well.

Concept analysis of longitudinal assessment for professional continued certification.

BACKGROUND: This concept analysis presents a scholarly epistemological approach to defining the attributes, empirical referents, antecedents, and consequences of a knowledge maintenance approach-known as longitudinal assessment-to professional certification. AIM: The analysis reports on the efforts of the National Board of Certification and Recertification for Nurse Anesthetists to explore this educational method as an approach to meet requirements for continued professional certification. METHOD: Using the classical approach to concept analysis, the authors explore the structure and function of longitudinal assessment and define the characteristics of the concept in a way that is meaningful to the continued certification of nursing and medical professionals. CONCLUSION: This analysis establishes a link between the goal and outcome of the continued certification process, including continuing education in nursing and medical practice, and the desirable characteristics of longitudinal assessment, which include proven principles of educational psychology. Through exploring model and borderline cases, the authors seek to demonstrate that longitudinal assessment is the best approach to foster lifelong learning of continuously evolving scientific, theoretical, and clinical knowledge in support of safe care for patients.

α2-Adrenergic Receptor Agonist, an Attractive but Underused ERAS Component in Improving Fast-Track Recovery and Surgical Outcomes.

Enhanced Recovery After Surgery (ERAS) protocols have been implemented in many institutions to attenuate the stress of surgery and facilitate early recovery. Careful selection of multimodal analgesic medication plays an essential role in achieving the goals of ERAS protocols. Clonidine and dexmedetomidine are α2-adrenergic receptor (α2-AR) agonists that can greatly enhance various ERAS components owing to their unique pharmacologic properties: antinociception, anxiolysis, anti-inflammation, and renal protection. The α2-AR agonists exert supraspinal and spinal antinociceptive effects by potentiating descending pain modulatory pathways and inhibiting peripheral C fibers. These antinociceptive effects of α2-AR agonists are independent of opioid receptors and result in analgesic synergy with opioid agonists. Several meta-analyses and systematic reviews have reported that α2-AR agonists decrease opioid consumption and side effects in adult and pediatric surgical patients. Given the wide distribution of α2-ARs in the body, α2-AR agonists have been associated with a reduction in anxiety, perioperative stress, inflammation, postoperative nausea and vomiting, shivering, and cognitive dysfunction. This course describes the basic and applied pharmacology of the α2-AR agonists and provides emerging evidence to support their utility in acute pain management and ERAS protocols. Perioperative administration of α2-AR agonists can enhance pain management, decrease adverse effects, and promote surgical recovery.

The Opioid Crisis and the CRNA: Providing Emergency Care for Patients With Opioid Use Disorder.

Certified Registered Nurse Anesthetists (CRNAs) care for patients with opioid use disorder frequently. Goals are to support recovery, prevent relapse, and effectively and safely treat perioperative pain. During emergencies, care may be urgent to prevent patient harm, potentially interfering with helpful interventions. This article discusses care principles that CRNAs should follow to assure that the anesthetic care goals are achieved during emergent care of patients with opioid use disorder.

Scholarly Work for Practice Doctorate Nurse Anesthesia Programs: Current State and Guidance.

The Standards for Accreditation of Nurse Anesthesia Programs: Practice Doctorate was adopted by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) in January 2015. Balancing academic and clinical preparation for doctoral students, preparation for the National Certification Examination, and requirements for scholarly work represents a major challenge for students, faculty, and programs. With most nurse anesthesia programs having transitioned to the practice doctorate, the COA was in a pivotal position to examine the current state of scholarly work and to produce a white paper to guide programs' development of criteria for scholarly work. To inform the guidance contained in the white paper, nurse anesthesia educators provided input via a survey, a focus group at the 2019 Assembly of Didactic and Clinical Educators meeting, and an active discussion and question-and-answer session during the Assembly. A call for comments was also sent to stakeholders for review and comment on the draft white paper. The guidance set forth in the white paper in no way supersedes institutional and/or other accreditor requirements. The aim of this guidance is to aid nurse anesthesia programs in successfully managing scholarly project curriculum. This article provides an overview of the project.

Evidence-Based Use of Nonopioid Analgesics.

Analgesia is a necessary component of any anesthetic technique, and can be achieved with local anesthetics, opioid and nonopioid analgesics, and inhaled anesthetic agents. Risks and benefits are associated with each of the agents and techniques described here, including local anesthetic systemic toxicity, respiratory depression, nausea, and urinary retention. Implementation of Enhanced Recovery After Surgery (ERAS) protocols, use of preemptive analgesia techniques, and the national opioid crisis are fostering increased utilization of nonopioid analgesics, including local anesthetics, nonsteroidal anti-inflammatory medications, intravenous acetaminophen, neuromodulatory agents such as gabapentin, corticosteroids, centrally acting ⟨2 agonists, and ketamine. Certified Registered Nurse Anesthetists optimize the safety and quality of care they provide through use of evidence-based practice, including the drugs they select, order, and administer, such as opioid and nonopioid analgesics, when providing anesthesia care.

The Opioid Crisis and the Certified Registered Nurse Anesthetist: Caring for Patients With Opioid Use Disorder in Drug-Free Recovery.

Opioid Use Disorder (OUD), the diagnostic term for opioid addiction, is estimated to affect millions of Americans and cost those who suffer it enormously. Given that opioid analgesics are a common component of anesthesia, how can we deliver safe and effective care to those who are in drug-free remission? This editorial will provide a background of this disorder, and will focus specifically on recommendations and guidelines available to the nurse anesthetist on the appropriate anesthetic care for the surgical patient population with OUD in recovery and not on maintenance therapy.

Increased Central Nervous System Interleukin-8 in a Majority Postlaminectomy Syndrome Chronic Pain Population.

Background and Objectives: Multiple processes have been identified as potential contributors to chronic pain, with increasing evidence illustrating an association with aberrant levels of neuroimmune mediators. The primary objectives of the present study were to examine central nervous system cytokines, chemokines, and growth factors present in a chronic pain population and to explore patterns of the same mediator molecules over time. Secondary objectives explored the relationship of central and peripheral neuroimmune mediators while examining the levels of anxiety, depression, sleep quality, and perception of pain associated with the chronic pain patient experience. Methods: Cerebrospinal fluid (CSF) from a population of majority postlaminectomy syndrome patients (N = 8) was compared with control CSF samples (N = 30) to assess for significant differences in 10 cytokines, chemokines, and growth factors. The patient population was then followed over time, analyzing CSF, plasma, and psychobehavioral measures. Results: The present observational study is the first to demonstrate increased mean CSF levels of interleukin-8 (IL-8; P < 0.001) in a small population of majority postlaminectomy syndrome patients, as compared with a control population. Over time in pain patients, CSF levels of IL-8 increased significantly (P < 0.001). Conclusions: These data indicate that IL-8 should be further investigated and psychobehavioral components considered in the overall chronic pain paradigm. Future studies examining the interactions between these factors and IL-8 may identify novel targets for treatment of persistent pain states.

The Opioid Crisis and the Certified Registered Nurse Anesthetist: How Can We Help?

This guest editorial reviews the facts surrounding the current opioid overdose crisis in the United States, including the history of opioid use and abuse leading up to the current crisis, and the impact of the crisis on the healthcare system. The editorial concludes with concrete recommendations and actions that Certified Registered Nurse Anesthetists (CRNAs) can take to combat this deadly and tragic epidemic. As leaders in the healthcare system and experts in opioid use and pain management, CRNAs have a moral and professional obligation to help patients and families affected by opioid misuse in any way possible.

Cerebrospinal Fluid Cytokines and Neurotrophic Factors in Human Chronic Pain Populations: A Comprehensive Review.

Chronic pain is a prevalent and debilitating condition, conveying immense human burden. Suffering is caused not only by painful symptoms, but also through psychopathological and detrimental physical consequences, generating enormous societal costs. The current treatment armamentarium often fails to achieve satisfying pain relief; thus, research directed toward elucidating the complex pathophysiological mechanisms underlying chronic pain syndromes is imperative. Central neuroimmune activation and neuroinflammation have emerged as driving forces in the transition from acute to chronic pain, leading to central sensitization and decreased opioid efficacy, through processes in which glia have been highlighted as key contributors. Under normal conditions, glia exert a protective role, but in different pathological states, a deleterious role is evident--directly and indirectly modulating and enhancing pain transmission properties of neurons, and shaping synaptic plasticity in a dysfunctional manner. Cytokines and neurotrophic factors have been identified as pivotal mediators involved in neuroimmune activation pathways and cascades in various preclinical chronic pain models. Research confirming these findings in humans has so far been scarce, but this comprehensive review provides coherent data supporting the clear association of a mechanistic role of altered central cytokines and neurotrophic factors in a number of chronic pain states despite varying etiologies. Given the importance of these factors in neuropathic and inflammatory chronic pain states, prospective therapeutic strategies, and directions for future research in this emerging field, are outlined.

Chronic Pain and Decreased Opioid Efficacy: An Inflammatory Link.

Chronic pain is a devastating amalgam of symptoms that affects millions of Americans at tremendous cost to our healthcare system and, more importantly, to patients' quality of life. Literature and research demonstrate that neuroimmune cells called glia are not only responsible for initiating and maintaining part of the chronic pain disease process, but also release inflammatory molecules responsible for decreasing the efficacy of one of the most prominent treatments for pain, opioid analgesia. This article describes chronic pain as a disease process that has ineffective treatment modalities, explores the mechanisms of glial cell activation and inflammatory responses that lead to chronic pain and decreased opioid treatment efficacy, and hypothesizes novel chronic pain treatment modalities based on the glial cell inactivation and anti-inflammatory pathways.

Opioid treatment of experimental pain activates nuclear factor-κB.

OBJECTIVE: To determine the independent and combined effects of pain and opioids on the activation of an early marker of inflammation, nuclear factor-κB (NF-κB). DESIGN: NF-κB activation was compared within-subjects following four randomly ordered experimental sessions of opioid-only (intravenous fentanyl 1 µg/kg), painonly (cold-pressor), opioid + pain, and a resting condition. SETTING: University General Clinical Research Center. PARTICIPANTS: Twenty-one (11 female) healthy controls. INTERVENTIONS: Following exposure to treatment (fentanyl administration and/or cold-pressor pain), blood samples for NF-κB analysis were obtained. MAIN OUTCOME MEASURES: Intracellular levels of activated NF-κB, in unstimulated and stimulated peripheral blood mononuclear cells at 15 and 30 minutes. RESULTS: Neither pain nor opioid administration alone effected NF-κB levels in cell populations; however, the combination of treatments induced significant increases of NF-κB in stimulated peripheral blood mononuclear cell, lymphocytes, and monocytes. CONCLUSIONS: The combination of acute pain with opioids, as occurs in clinical situations, activates a key transcription factor involved in proinflammatory responses.

AANA introduces an evidence-based infection control guide.

The American Association of Nurse Anesthetists Infection Control Task Force applied a rigorous evidence-based process to the revision of the Infection Control Guide for Certified Registered Nurse Anesthetists. This article details the necessity of a current Professional Practice infection control document, including an expansion of infection control and prevention literature since the last revision of this document; a multitude of infectious outbreaks; and an overwhelming lack of adherence to principles of effective hand hygiene, asepsis, and safe injection practices. Specific areas discussed include preventive measures used by Certified Registered Nurse Anesthetists during patient care activities; infection control measures aimed at procedures involving the anesthesia delivery system; and infection control practices for cleaning, disinfecting, and terminal cleaning of the environment.

Acute painful stress and inflammatory mediator production.

BACKGROUND: Proinflammatory pathways may be activated under conditions of painful stress, which is hypothesized to worsen the experience of pain and place medically vulnerable populations at risk for increased morbidity. OBJECTIVES: To evaluate the effects of pain and subjective pain-related stress on proinflammatory activity. METHODS: A total of 19 healthy control subjects underwent a single standard cold-pressor pain test (CPT) and a no-pain control condition. Indicators of pain and stress were measured and related to inflammatory immune responses [CD8+ cells expressing the integrin molecule CD11a (CD811a), interleukin (IL)-1 receptor agonist (IL-1RA), and IL-6] immediately following the painful stimulus and compared to responses under no-pain conditions. Heart rate and mean arterial pressure were measured as indicators of sympathetic stimulation. RESULTS: CPT was clearly painful and generated an activation of the sympathetic nervous system. CD811a increased in both conditions, but with no statistically significantly greater increase following CPT (p<0.06). IL-1RA demonstrated a non-statistically significant increase following CPT (p<0.07). The change in IL-6 following CPT differed significantly from the response seen in the control condition (p<0.02). CONCLUSIONS: These findings suggest that CP acute pain may affect proinflammatory pathways, possibly through mechanisms related to adrenergic activation.

Neuroimmune activation and chronic pain.

Chronic pain is an extremely debilitating disease syndrome for which current treatment modalities are largely ineffective. This article presents the recently proposed contributions of neuroimmune activation to the maintenance of chronic pain. The theory of neuroimmune activation postulates a pathway that links peripheral neuronal injury/inflammation with the activation of central nervous system neuroglial cells, which contributes to sustained neuronal hyperexcitability. Literature generated by the emerging field of central nervous system glial cell research, including genetic therapies, was reviewed to provide empirical support for this pathway. The clinical implications of neuroimmune activation to improved treatment of chronic pain states are discussed.

Implications of immune function to anesthesia care.

Multiple aspects of perianesthesia care and the perioperative environment can influence the functions of the immune system. This course reviews basic immune system functions and potential sources of immune system-altering perioperative stress. The effects of commonly used anesthesia drugs, opioids, and adjunct drugs on immune function are discussed. Patient populations at risk for increased morbidity due to perioperative immune depression are identified, along with patient-specific measures nurse anesthetists can take to reduce postoperative immune dysfunction.