Hemoglobin Louisville: A Case Report.

This case study examines a patient undergoing an elective procedure who had a past medical history of Hemoglobin Louisville and presented with baseline oxygen saturation levels (SpO2) in the 80s as measured by noninvasive pulse oximetry. It presents the anesthetic provided, a brief review of physiology, and a discussion pertaining to this particular genetic mutation. Understanding the physiological implications of these types of hemoglobinopathies and their anesthetic management is key to managing patients' care throughout the perioperative period. With new hemoglobin variants continuing to emerge, reviewing some of the rare hemoglobinopathies is prudent to support the anesthesia community in their assessment and care of patients who present with unexpectedly low SPO2.

Synthetic Cannabinoid Use in the Trauma Patient: A Case Study.

This case study examines the management of a trauma patient brought emergently to the operating room following a motor vehicle collision with concomitant oropharyngeal and carotid artery injuries caused by tree branches. The patient stated that he had used cannabis and synthetic cannabinoids a short time before the accident, and his behavior was dangerously erratic at the scene as well as upon arrival to the emergency room. Understanding the pharmacologic and physiologic effects of these illicit substances is key to managing any patient undergoing anesthesia, particularly when requiring emergent vascular repair.

Active Shooter Preparedness: Is Your OR Ready?

Active shooter events, including those in health care facilities, are expected to increase in incidence. Perioperative personnel may be underprepared for such an event. Understanding how to make the best decision regarding whether to escape, hide, or fight, and being aware of the communication channels during these types of events are crucial to adequate preparation. Health care facilities and critical areas such as the OR should be prepared for an active shooter event. This article briefly describes a firsthand shooting event experience at Johns Hopkins Hospital and includes a review of the literature on active shooter events in health care settings to determine the most practical application of event preparedness for staff members working in the OR. It also discusses the highly relevant concept of patient abandonment.

Cut to Air.

A "cannot ventilate, cannot intubate" scenario is a rare, high-risk anesthesia event. Cricothyrotomy is the final step, but anesthesia training and maintenance of surgical airway skills is variable. The ability to "cut to air" when one performs a cricothyrotomy may be all that prevents a patient from experiencing anoxic brain injury or death. Forty-three Certified Registered Nurse Anesthetists (CRNAs) performed emergency cricothyrotomies on a simulation manikin. Three techniques were available: (1) cricothyrotomy kit, (2) scalpel and tracheostomy, and (3) scalpel/bougie/endotracheal tube. Technique selection and performance were recorded until successful confirmation of placement was achieved in less than 2 minutes. Confidence levels performing cricothyrotomy were also measured before and after simulation. Most CRNAs (53.5%) selected the cricothyrotomy kit, and all but 1 completed the cricothyrotomy in under 2 minutes. The scalpel/bougie/endotracheal tube combination was the fastest, with an average completion time of 86.6 seconds. The confidence of CRNAs in performing a successful cricothyrotomy in less than 2 minutes was significantly increased (P ≤ .001). Simulating airway skills improved performance, speed, and confidence. Because not all CRNAs have had extensive education in performing surgical airways and practicing these skills, simulation may have additional value in developing and maintaining skills and confidence.

Advanced Prehospital Trauma Resuscitation With a Physician and Certified Registered Nurse Anesthetist: The Shock Trauma "Go-Team".

OBJECTIVE: The R Adams Cowley Shock Trauma Center (STC) is Maryland's primary adult resource center for trauma care. The Shock Trauma "Go-Team" is a specialized component of Maryland's emergency medical system and is composed of a physician and certified registered nurse anesthetist. They are dispatched when advanced prehospital resuscitation is required. The purpose of this study is to describe the capabilities and historic epidemiology outcomes of the Go-Team. METHODS: A retrospective case series review of recoverable Go-Team records was performed from 2011 to 2018. Go-Team call logs/records were identified from multiple sources. Medical records were reviewed for patient demographics, mechanisms of injury, and treatments in the field. There was a total of 61 activations, with 22 deployments to the scene of injury. RESULTS: The majority of deployments were via helicopter (73%) and lasted 2 hours. The most common indications for deployment were motor vehicle entrapment (41%), trench collapse (14%), and building collapse (9%). Of the 22 patients treated by the Go-Team, 50% received at least 1 blood transfusion in the field, and 23% required an advanced airway. No field amputations were required. CONCLUSION: The STC Go-Team is a unique multidisciplinary specialized component of a statewide emergency medical system.

Education News.

First responders need hands-on experience with pediatric airway management, but the impact of a learner program in the operating room (OR) is unknown. We developed, implemented, and evaluated a pediatric airway "rotator" (PAR) program for 8 multidisciplinary groups to obtain this experience. This quality improvement pilot was conducted in the pediatric ORs from November 2017 to January 2018. We surveyed learner group leaders and anesthesia teachers about their PAR airway management expectations and developed a universal set of prerequisites, objectives, and simulation experiences. Airway management skills were assessed in a group of PARs at baseline. During implementation, another group of PARs completed prerequisites and reviewed objectives before coming to the OR for simu-lation using an infant mannequin. Then they entered the OR for "live" airway management. A comparison of preintervention and postintervention skills suggested an improvement in performance for most airway management domains except laryngeal mask airway insertion, which stayed about the same, and intubation, which decreased in the postintervention group. In the postassessment surveys, the PARs indicated that the interventions were helpful to their learning, and the anesthesia teachers' responses indicated that the primary goals to improve PARs' preparedness, airway management, and communication skills were achieved.

Development, Implementation, and Evaluation of a Certified Registered Nurse Anesthetist Preceptorship-Mentorship Program.

Little evidence exists to support the effects of a preceptor-mentor program for orienting newly hired certified registered nurse anesthetists (CRNAs). The literature suggests that participation in a preceptorship-mentorship program will increase the satisfaction, confidence, and comfort of both preceptors and newly hired orientees. The purpose of this project was to determine the effects of these outcomes. This program was developed based on best evidence and implemented as a quality improvement project. Three sessions were held to educate preceptors (N = 12) in the following areas: communication skills, providing constructive feedback, and assessing learner's styles and needs. The results suggested that participation significantly increased CRNA preceptor satisfaction and comfort in the precepting experience. The newly hired CRNAs answered that they were mostly or very much satisfied and confident at the completion of their orientation period. This program can be expanded to include additional preceptors and be sustained with future new hires. J Contin Educ Nurs. 2017;48(10):464-473.

A CRNA Preceptor Workshop to Increase Preceptor Satisfaction, Confidence, and Comfort: A Quality Improvement Project.

The purpose of this quality improvement project was to determine whether a 4-hour Certified Registered Nurse Anesthetist (CRNA) preceptor workshop would significantly increase staff CRNA preceptors' satisfaction, confidence, and/or comfort, to better prepare CRNAs to precept. A review of the literature, interviews with experienced CRNA preceptors, and a needs assessment survey were completed and used to develop the workshop's curriculum. For evaluation of the impact of this quality improvement project, attendees were asked to complete preworkshop and postworkshop surveys. Because scores were skewed, the significance of the differences from presurvey to postsurvey was determined with the Wilcoxon signed-rank test for the median difference. The median for all scores increased significantly from presurvey to the postsurvey. Because 94% of attendees had never attended a CRNA preceptor education course and 82% had never participated in any type of preceptor education or preparation, the results from this project suggest that this program fulfilled an unmet need for CRNA preceptors at this institution.