Efficacy of addition of the anti-inflammatory, IV glutathione to standard ketamine IV therapy in major depressive disorder.

Ketamine, a N-methyl-D-aspartate (NMDA) antagonist, is used for treatment-resistant depression (TRD). Recent studies have shown that there are increased levels of pro-inflammatory cytokines in individuals with major depressive disorder (MDD) and those with higher levels of oxidative stress markers have a decreased or null response to conventional antidepressants. Glutathione (GSH) as an antioxidant adjuvant to ketamine has not been well studied. This double-blind study with 30 patients divided into 2 groups of 15 each, aimed to determine if GSH, added to standard ketamine infusion (GSH+K), rendered better outcomes in MDD patients versus patients receiving ketamine infusions with a normal saline placebo (K+NS). There were significant drops in BDI-II scores from day 1 to day 14, PHQ- scores from day 1 to day 14 and PHQ-9 scores day 14 to day 28, suggesting the overall treatment was effective. There were no statistically significant differences between the groups over time. However, a sustained improvement in depressive symptoms was observed for 14 days post-infusion in both groups.

A Retrospective Study: Multimodal Analgesia Quality Measure Implementation and Patient Outcome Assessment.

Current research has demonstrated that nonopioid multimodal analgesia decreases perioperative opioid consumption, postoperative nausea and vomiting (PONV), and pain scores. However, no research has been conducted to examine the patient outcomes of Merit-based Incentive Payment System (MIPS) 477. This study evaluates those outcomes following implementation of MIPS 477. The medical records of 400 adult patients who underwent elective and urgent laparoscopic gynecological procedures at a facility in the Mid-Atlantic region were reviewed. Data collection included patient characteristics, analgesics administered, pain scores at postanesthesia care unit (PACU) arrival and discharge, and antiemetic administration in PACU. This study's primary outcomes were postoperative pain scores, total intraoperative and postoperative opioid consumption, and PONV. Twenty-nine patients (7.8%) met the criteria as a control group, and 341 patients (92.2%) met the criteria as a treatment group. Pain scores were higher upon PACU arrival among the control group (P = .001). The total intraoperative morphine milligram equivalents (MMEs) administered was less among the treatment group (P = .04). The treatment group had reduced total intraoperative MMEs and pain scores at PACU arrival. However, there was no statistical significance in PACU discharge pain score, total PACU MMEs, and PONV in both groups.

Assessing CRNA Knowledge of Local Anesthetic Systemic Toxicity Treatment.

Local anesthetic systemic toxicity (LAST) is a rare life-threatening adverse event. Due to the potential for devastating patient outcomes, it is crucial for anesthesia providers to understand appropriate LAST management. The primary aim of this study was to assess certified registered nurse anesthetist (CRNA) knowledge of the 2020 American Society of Regional Anesthesia and Pain Medicine (ASRA) LAST treatment guidelines. The secondary aim was to determine whether there was a relationship between the frequency of CRNAs' exposure to perioperative local anesthetic use and their knowledge level. A quantitative descriptive study and national American Association of Nurse Anesthetists electronic survey solicited practicing CRNAs. Survey findings revealed knowledge scores averaging 47.3% among 184 respondents. Almost all (97.8%) recognized the importance of early lipid emulsion administration. Over half (54.3%) were unaware of the recommended epinephrine dosing during LAST. No relationship was found between knowledge level and CRNAs' exposure to local anesthetics. Those who reported having immediate access to written or electronic guidelines in the event of LAST had significantly higher knowledge scores than those without access (P = .049). Implementing cognitive aids may help bridge knowledge gaps identified in this study and ensure critical steps are not missed. Further studies examining the use of cognitive aids to improve CRNA knowledge of LAST management may be beneficial in the future.

Mobilizing nurses to address the opioid misuse epidemic.

BACKGROUND: The opioid epidemic is a major health challenge in the United States. PURPOSE: Members from the American Academy of Nursing joined to write a consensus paper about nurses' role in the opioid epidemic. METHODS: The panel reviewed the history of the opioid epidemic and policies to care for patients with opioid use disorder (OUD) and how registered nurses (RNs) and advanced practice nurses (APRNs) could increase care for people with OUD. DISCUSSION: Recommendations are presented to advance policies that empower RNs and APRNs to abate the opioid epidemic. CONCLUSION: Recommendations include (a) advance legislation that supports RNs and APRNs full scope of practice and expands professional role in pain management and addiction prevention; (b) evaluate effective policies that promote RN and APRN care; support federal elimination of X-waiver with state law alignment; (c) sustain the use of nurses in telemedicine; (d) support nursing research on nurse involvement in all aspects of OUD.

Racial And Ethnic Discrimination During Clinical Education and Its Impact on the Well-Being of Nurse Anesthesia Students.

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 (χ2 [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.

Examination of a Nurse Anesthesia Program's Teaching Assistant Model and Its Impact on Increasing Nurse Anesthesia Education Capacity.

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.

Certified Registered Nurse Anesthetists' occupational exposure to inhalational anesthetic agents: a survey of anesthetic gas safety.

BACKGROUND: Anesthetic gases have been known to cause damage when inhaled over long periods of time. Modern safety measures have been put in place to reduce the risk to anesthesia providers, however there is continued lack of information on providers experiencing short term effects (lethargy, fatigue, headache, slowed cognitive ability, nausea, and mucosal irritation) thereby leading to long-term sequalae (sister chromatid exchanges, micronuclei, chromosomal aberrations, and comet assays). METHOD: A thirteen item, multiple choice survey was sent to 3,000 anesthesia providers, of which 463 completed the survey. A Chi-square test of independence was used to determine the association between gas exposure and participant self-reported symptoms. A Spearman's Correlation test was also utilized to interpret this data since both frequency of smelling gas and frequency of symptoms were ordinal variables for which Spearman's rho correlation was the appropriate measure of association. RESULTS: The major findings were that as the frequency of smelling anesthetic gas increased, so too did the frequency of self-reported headaches and fatigue. Spearman's rho = .148 and .092. P value = .002 and .049, respectively. CONCLUSION: There have been many efforts to decrease the risk of exposure of anesthesia providers to anesthetic gases. While there is a decrease in reported exposures, indications of possible long-term effects remain a concern in anesthesia providers. Potential implications of exposure could lead to chromosomal aberrations, sister chromatid exchanges, comet assays, spontaneous abortions, and genotoxic effects.

Chronic Opioid Use After Surgery: An Exploratory Study Examining Rural Certified Registered Nurse Anesthetist Strategies to Mitigate Chronic Opioid Use and Their View of Their Role in the Opioid Crisis.

Certified registered nurse anesthetists (CRNAs) provide most of the anesthesia care in the rural United States. Rural regions of the US also have the highest opioid prescribing rates and opioid-related hospital admissions and deaths. Although CRNAs are the primary anesthesia providers in these regions, little research examines the strategies CRNAs may use to mitigate the development of chronic opioid use after surgery. The purpose of this study was to assess the views of rural CRNAs regarding their role in mitigating chronic opioid use after surgery and to determine what, if any, preventative strategies they may use. A survey was developed and distributed to CRNAs practicing in rural areas of the US with the highest opioid prescribing rates. Of the 160 CRNAs who responded, 73% agreed that they could influence whether their patient developed chronic opioid use after surgery. Those who agreed were more likely to be involved in policy development to decrease opioid use. The survey also found that CRNAs with a doctoral degree, compared with those with master's level preparation, were more likely to report that they could influence whether their patient developed chronic opioid use after surgery.

The Experience of Burnout in the SRNA Population and Association With Situational and Demographic Factors.

There is limited research regarding student registered nurse anesthetist (SRNA) burnout. To our knowledge there is no recently published work that has explored the associations between characteristics of SRNAs and burnout. Addressing this gap could establish the SRNA experience of burnout, identify demographic characteristics and situational factors that may correlate with burnout, and lay the foundation for future research. The purpose of this exploratory descriptive study was to assess the SRNA experience of burnout and any relationship between burnout to demographic or situational factors via the Oldenburg Burnout Inventory-S and demographic questions.The research questions were: 1) Do SRNAs experience different levels of burnout during the didactic curricula and/or clinical training element of nurse anesthesia school? 2) Is there an association between SRNA burnout and demographic or situational factors? Power analysis set the minimum n at 421. Five hundred thirty SRNAs responded to the randomized survey through the American Association of Nurse Anesthesiology. Data analysis was conducted using one-way ANOVA, Spearman's rho, 2-tailed t-test, and Chi square analysis. More hours in class per week correlated with lower exhaustion scores. Higher disengagement scores were reported by SRNAs further in their training, while more hours per week in clinical correlated with both higher disengagement scores and increased total burnout scores.

Minimum Atropine Dosing in Pediatric Patients: Does CRNA Practice Reflect Current Recommendations?

The purpose of this study was to evaluate certified registered nurse anesthetist (CRNA) current pediatric atropine dosing practices. Emphasis was placed on rationale for dosing and knowledge regarding current literature and guidelines. An electronic survey was deployed by the American Association of Nurse Anesthetists (AANA)'s survey department to a total of 2,905 CRNAs who are current AANA members. The survey was completed by 98 CRNAs, of which 67 selected that they do not administer anesthesia to pediatric patients weighing less than 5 kg and were excluded from further survey participation. The responses from the remaining 31 CRNAs were utilized for data analysis (n = 31). Approximately two thirds of participants (64.5%) were unaware of available guidelines pertaining to pediatric dosing of atropine within the last 5 years. A statistically significant difference existed when analyzing whether awareness of guidelines was associated with knowledge of the correct American Heart Association recommended pediatric atropine dose. Providers who were aware of guidelines reported the correct dose 100% of the time, whereas those unaware of guidelines reported the correct dose only 65% of the time (P = .03). Variability in clinical practices and sources guiding practice should be addressed to avoid potential overdosing in the vulnerable neonatal population.

Certified Registered Nurse Anesthetists' Management of the Perioperative Do-Not-Resuscitate Order: Evaluating Trends in Required Reconsideration.

Required reconsideration or review of do-not-resuscitate (DNR) orders perioperatively is recommended by the American Association of Nurse Anesthesiology and other organizations instead of automatic suspension of the DNR. A survey on perioperative DNR orders developed for a 2000 study by Coopmans and Gries was amended, reviewed by an expert panel, reformatted for web-based layout, and emailed to a random sample of 3,000 practicing Certified Registered Nurse Anesthetists (CRNAs) in the United States. From 207 returned responses, most CRNAs (63.5%) initially reported unfamiliarity with required reconsideration. After receiving a definition of the term, more CRNAs reported familiarity and past education on the concept. Chi-square analyses showed that familiarity with required reconsideration was associated with potential refusal to care for patients with active DNR orders (P=.004). CRNAs reported education or training on required reconsideration as uncommon and often informal. The survey found significant changes in reported perioperative DNR orders at practice institutions between the original survey by Coopmans and Gries and the present study. CRNAs' responses from the present survey indicate significant increases in policies of required review with patient involvement and policies of informed routine suspension (P<.001). Findings also revealed a significant decrease in reported policies of uninformed routine suspension (P<.001).

Impact of COVID-19 Pandemic on Certified Registered Nurse Anesthetist Practice.

The coronavirus disease 2019 (COVID-19) pandemic prompted profound shifts in the delivery of critical healthcare services. A mixed-methods study was conducted to explore the impact of the pandemic on Certified Registered Nurse Anesthetist (CRNA) practice. The quantitative component involved a survey of CRNAs during the initial period of the pandemic to determine changes in practice and any relationship to removal of state and federal barriers. Approximately 16% of 2,202 responding CRNAs reported practice expansion beyond their normal responsibilities, primarily outside the operating room and involving tracheal intubation, ventilator management, arterial line placement, and central line placement. CRNAs were more likely to experience an expansion of practice in states affected by removal of regulatory barriers. However, respondents also reported missed opportunities to use the full expertise of CRNAs because of state and institutional restrictions. Findings from the qualitative component of this study are reported in a separate article.

Acupuncture and Chronic Pain Management.

According to National Institute of Health Pathways to Prevention Workshop (2014), chronic pain affects an estimated 100 million Americans, with approximately 25 million people experiencing moderate to severe chronic pain, which negatively impacts their ability to function leading to a diminished quality of life. Pain is the primary reason Americans are on disability, which adds to the economic and social burden of suffering for the nation. Chronic pain costs are estimated to be between 560 and 630 billion per year. An estimated 5 to 8 million Americans use opioids for long-term management of chronic pain, which can have deleterious effects on their lives including addiction. Recent evidence suggests that acupuncture, a treatment modality that has been used worldwide for over 2,000 years, may provide a useful pain management option for those who suffer from chronic pain. The investigation into its mechanism of action and efficacy remains elusive, but promising.

Effects of Acupuncture, RU-486 on the Hypothalamic-Pituitary-Adrenal Axis in Chronically Stressed Adult Male Rats.

We have recently reported that pretreatment with electroacupuncture (EA) at stomach meridian point 36 (St36) prevents the chronic cold-stress increase in the hypothalamus-pituitary-adrenal axis (HPA), an action that may be under central control. Given that treatment for stress-related symptoms usually begins after onset of the stress responses, the objectives of the present study were to determine the efficacy of EA St36 on HPA hormones when EA St36 is given after stress was initiated, if the results are long lasting, and if blocking the glucocorticoid receptor (GR) using RU-486 had the same effects as EA St36. Adult male rats were placed in 4 groups of animals, 3 of which were exposed to cold and 1 of which was a nontreatment control group. After exposure to the cold stress, 2 groups were treated with either EA St36 or sham-EA, repeated over 10 days. The increase in ACTH and corticosterone observed in stress-only rats was prevented in EA St36 animals, and the effects remained intact 4 days after withdrawal of EA but continuation of cold stress. When the GR was blocked with RU-486, the efficacy of EA St36 remained unchanged. GR blockade did significantly elevate ACTH, which is not seen with EA St36, suggesting that EA St36 does act centrally. The elevated HPA hormones in stress-only rats were associated with a significant increase in depressive and anxious behavior; this was not observed in the stressed EA St36 animals. The results indicate that EA specifically at St36 vs sham-EA is effective in treating chronic poststress exposure.

Acupuncture blocks cold stress-induced increases in the hypothalamus-pituitary-adrenal axis in the rat.

Electroacupuncture (EA) is used to treat chronic stress; however, its mechanism(s) of action in allaying stress remains unclear. The interplay of stress hormones of the hypothalamus-pituitary-adrenal axis (HPA) and the sympathetic nervous system (SNS) is critical in the stress response. Our objective was to determine whether EA at acupoint, stomach 36 (EA St36) is effective in preventing chronic cold stress-induced increased hormone levels in the rat by examining four groups of animals, three of which were exposed to cold and one of which was a non-treatment control group. Before exposure to the cold, two groups were treated with either EA St36, or Sham-EA, before 10 days of cold stress. The EA St36 animals demonstrated a significant decrease in peripheral HP hormones (ACTH and CORT) compared with stress animals (P<0.05). These effects were specific; rats receiving Sham-EA had elevation of these hormones, similar to the stress-only animals. These effects were mirrored centrally in the brain; CRH levels were significantly (P<0.05) reduced in EA St36 animals compared with the other animals. Finally, EA effect on peripheral and adrenal SNS hormones (norepinephrine (NE) and neuropeptide Y (NPY) respectively) was examined, with no significant difference noted in adrenal tyrosine hydroxylase or circulating NE in any of the groups. However, EA St36 was effective in preventing stress-induced elevation is adrenal Npy mRNA. These results indicate that EA St36 blocks the chronic stress-induced elevations in the HPA and the sympathetic NPY pathway, which may be a mechanism for its specific stress-allaying effects.

Management of postpartum pain.

Following the physiologic challenge of birth, many women will experience pain during the postpartum period. The goal is to achieve the right complement and dosing schedule of medications and nonpharmacologic comfort measures to successfully relieve pain, while at the same time allowing the woman to remain fully awake and aware to care for her newborn. Many of the common modalities used for nonpharmacologic pain relief in particular are based on anecdotal evidence, cultural ritual, or outdated studies. In this article, the most common sources of postpartum pain are reviewed as well as evidence-based pain management strategies, including both pharmacologic and nonpharmacologic methods.

Acupuncture at ST36 prevents chronic stress-induced increases in neuropeptide Y in rat.

Chronic stress, as seen in post-traumatic stress disorder, can exacerbate existing diseases. Electroacupuncture (EA) has been proposed to treat chronic stress, although information on its efficacy or mechanism(s) of action is limited. While many factors contribute to the chronic stress response, the sympathetic peptide, neuropeptide Y (NPY), has been shown to be elevated in chronic stress and is hypothesized to contribute to the physiological stress response. Our objective was to determine if EA at acupuncture point stomach 36 (ST(36)) is effective in mitigating cold stress-induced increase in NPY in rats. Both pretreatment and concomitant treatment with EA ST(36) effectively suppressed peripheral and central NPY after 14 d of cold stress (P < 0.05). The effect was specific, as NPY in Sham-EA rats was not different than observed in stress-only rats. Additionally, the effect of EA ST(36) was long-lasting, as NPY levels remained suppressed despite early cessation of EA ST(36), while exposure to cold stress was continued. In the paraventricular nucleus (PVN), it was notable that changes in NPY mirrored plasma NPY levels, and that the significant elevation in PVN Y1 receptor observed with stress was also prevented with EA ST(36). The findings indicate that EA ST(36) is effective in preventing one of the sympathetic pathways stimulated during chronic stress, and thus may be a useful adjunct therapy in stress-related disorders.

Occurrence and removal of a knotted pulmonary artery catheter: a case report.

The challenge of treating older, obese patients with various comorbidities has become a mainstay of anesthetic practice. In order to monitor and provide anesthesia safely, the nurse anesthetist must weigh the risks and benefits of all types of monitoring when these patients undergo major invasive procedures. One such option is the Swan-Ganz pulmonary artery catheter. During the last decade an estimated 2 million pulmonary artery (Swan-Ganz) catheters were sold annually in the United States. Although the pulmonary artery catheter is a useful and popular monitoring tool, the potential for complications does exist, with some estimates suggesting a mortality rate of 0.02% to 1.5%. These figures, along with other complications, warrant consideration when evaluating the risks and benefits of this method of monitoring. The following case report describes one potential complication, a knot, and its management by the anesthesia care team in coordination with interventional radiology.

Use of acupuncture for chronic pain: optimizing clinical practice.

Increasingly, individuals are turning to complementary therapies to reduce or cope with chronic pain. Acupuncture, one of the oldest complementary therapies, originated from China more than 2500 years ago. It has steadily gained popularity in the United States over the last few decades as a modality for pain relief among both practitioners and patients. A 1997 National Institutes of Health consensus conference concluded that acupuncture needling releases endorphins and other neurotransmitters in the brain and should be considered as an appropriate pain treatment option. This article will provide an overview about acupuncture principles, discuss current clinical evidence, and identify acupuncture resources to optimize practice for chronic pain management.