Medicine and Health Sciences Commons^™

Final Scholarly Project: Evidence-Based Practice Guidelines For The Perioperative Management Of Blood Glucose Levels In The Cardiac Surgery Patient, Chelsey Benner

Doctor of Nursing Practice Scholarly Projects

Cardiovascular disease is the leading cause of mortality worldwide, necessitating a high demand for cardiac surgery. A unique stressor for cardiac surgery is an increased surgical stress response involving hyperglycemia. Perioperative hyperglycemia contributes to adverse postoperative outcomes following cardiac surgery. Current evidence examines blood glucose control and its effect on adverse postoperative outcomes, including sternal wound infections, acute kidney injury, prolonged mechanical ventilation, and an increased length of stay in the intensive care unit. Despite the link between hyperglycemia and poor postoperative outcomes, most facilities lack standardized guidelines for the perioperative management of blood glucose levels in cardiac surgery patients. …

Analysis Of Clinical Outcomes And Cost Effectiveness Of Neuromuscular Blocking Drug Reversal In Patients Classified As Obese, Trevor Mack

Doctor of Nursing Practice Scholarly Projects

Obesity predisposes patients to heightened risks of adverse outcomes following surgery, including residual neuromuscular blockade and postoperative complications. The administration of non-depolarizing neuromuscular agents (NMBAs) is fundamental for muscle relaxation and optimal surgical conditions. However, the subsequent reversal of these blockers with agents like sugammadex or neostigmine is crucial to mitigate these risks. While sugammadex is recognized as a clinically superior choice due to its rapid and more complete reversal, its extensive use is often limited by cost, presenting challenges in obese patients who already face increased susceptibility to complications. This project evaluates the cost-effectiveness of sugammadex versus neostigmine in …

Development Of Evidence-Based Practice Guidelines For Utilizing Erector Spinae Plane Blockade For Patients Undergoing Cardiac Surgery, Gabrielle Metoyer

Doctor of Nursing Practice Scholarly Projects

In the United States, the aging population and high rates of cardiovascular disease leads to increased cardiothoracic surgeries. Analgesia for cardiac surgeries often involves high-dose opioids. However, with an ever-increasing opioid epidemic and adverse effects on the postoperative healing process, recent literature seeks to decrease opioid consumption by utilizing alternative methods of analgesia. The American Association of Nurse Anesthetists recommends the use of regional anesthesia techniques to reduce the incidence of undertreated postoperative pain that can occur from opioid-sparing methods of analgesia. This project aims to create an evidence-based analgesia guideline for adult patients undergoing cardiac surgery. Interventions will include …

Development Of Evidence-Based Clinical Practice Guidelines For Pediatric Preoperative Anxiety, Whitney R. Stant

Doctor of Nursing Practice Scholarly Projects

Preoperative anxiety is a problem that occurs frequently in pediatric patients. Preoperative anxiety creates physical and psychological changes that impact a child’s surgical experience. Pediatric patients who experience preoperative anxiety may also experience prolonged postoperative care, long-term psychological complications, and increased postoperative pain. Sedating medications are often administered to prevent and treat preoperative anxiety. Commonly, midazolam is administered intranasally to prevent preoperative anxiety. Midazolam increases the risk of cognitive impairment and respiratory depression. Dexmedetomidine is an effective alternative to midazolam. Dexmedetomidine is a highly selective alpha-2 agonist and provides arousable sedation without respiratory depression. Dexmedetomidine is safe and effective at …

Implementation Of Guidelines For Preprocedural Ultrasound In Neuraxial Placement For Obstetric Patients With Scoliosis, Luther Nyirenda

Doctor of Nursing Practice Scholarly Projects

Neuraxial anesthesia including epidural, spinal, and combined spinal-epidural, is used with 65% of parturients in the United States for the management of pain and discomfort. Conventional landmark palpation has been the mainstay technique for neuraxial anesthesia, but unfamiliar spinal anatomy can lead to incomplete blockade or an increased incidence of complications. Scoliosis causes lateral curvature and rotation of the spine leading to arthritis and soft tissue changes that can present obscure anatomical landmarks, cause difficulty in needle passage, and result in inadequacy of local anesthetic efficacy. The literature illustrates that preprocedural ultrasound is recommended for needle placement in parturients with …

Development Of Clinical Practice Guidelines For Incorporating Paravertebral Blockade For Thoracic Surgery Adult Patients, India Hutchison

Doctor of Nursing Practice Scholarly Projects

Thoracic surgery is considered one of the most painful surgical procedures due to its severity and the duration of the procedure. Pain is detrimental to the patient experience, and poor patient satisfaction results in revenue loss for hospitals. Maintaining adequate pain control after surgery is crucial in preventing pulmonary complications such as atelectasis and respiratory failure that prolong patient recovery. It is the responsibility of the anesthesia provider to ensure adequate pain control throughout the perioperative experience. Although current evidence-based data shows that regional anesthesia provides superior thoracic postoperative pain control, the current practice continues to be the utilization of …

Using The Bispectral Index Monitor To Decrease The Incidence Of Unintended Intraoperative Awareness In The High-Risk Population, Bridget Hayes

Doctor of Nursing Practice Scholarly Projects

Unintended intraoperative awareness is a traumatizing complication of general anesthesia. This negative outcome affects 0.1-0.2% of all patients undergoing general anesthesia. Patients at higher risk for this experience include those undergoing emergency surgery, traumas, cesarian sections, those on cardiopulmonary bypass, those with substance use disorder, and those undergoing total-intravenous anesthesia (TIVA). This high-risk population is affected by unintended intraoperative awareness 1% of the time. The bispectral index (BIS) monitor has been proposed as a tool to decrease the incidence of unintended intraoperative awareness. There are several large, randomized controlled trials that demonstrate that using a BIS monitor decreases the incidence …

Final Scholarly Project: The Administration Of Transversus Abdominis Plane Blocks In Patients Undergoing Anesthesia For Open Ventral Hernia Repairs, Brennon Pinion

Doctor of Nursing Practice Scholarly Projects

Ventral hernia repairs are the only definitive treatment for umbilical or abdominal hernias. These procedures are prevalent and often lifesaving but also carry high risks of adverse effects. Some of the problems that follow include postoperative ileus, increased opioid use, and prolonged length of stay. Due to the rate of complications, there was a need to improve these outcomes. One way to improve outcomes is to implement superior anesthetic techniques. This Final Scholarly Project (FSP) followed the Plan-Do-Study-Act (PDSA) model to conduct evidence-based practice (EBP) and quality improvement (QI) sections. The plan phase included a thorough literature search and analysis …

Clinical Guidelines For The Perioperative Management Of Patients With Aortic Stenosis Undergoing Noncardiac Surgery, Owen Diehl

Doctor of Nursing Practice Scholarly Projects

Aortic stenosis (AS) is a common valvular disorder that causes left ventricular (LV) outflow obstruction. The prevalence of AS may increase with the aging population and the widespread availability of diagnostic capabilities like echocardiography. With the increasing patient population diagnosed with AS, the chance of encountering these patients during noncardiac surgery (NCS) increases. Performance of anesthesia is challenging in patients with AS due to the pathophysiological consequences of AS and the hemodynamic changes associated with anesthesia. The patient with AS presenting for NCS is at an increased risk of perioperative major adverse cardiac events (MACEs). This project aimed to determine …

Evidence-Based Practice Guidelines: Anesthesia For Total Knee And Hip Arthroplasty, Amanda Kleinfelder

Doctor of Nursing Practice Scholarly Projects

Abstract

Total knee and hip arthroplasty are the two most common orthopedic surgeries in the United States. Traditional perioperative practice is multidisciplinary, with each professional, including anesthesia, making decisions based on their current knowledge or past experience. Postoperative complications pose a threat to any patient undergoing a surgical procedure. Enhanced Recovery After Surgery (ERAS) protocols were developed to streamline best practice guidelines during the perioperative period. ERAS pathways aim to decrease postoperative complications, accelerate recovery after surgery, decrease narcotic use and promote early mobilization and discharge from the hospital. The aim of this project is the development of evidence-based practice …

Final Scholarly Project: Development Of Evidenced-Based Practice Guidelines For Female Patients Undergoing Anesthesia For Breast Cancer Surgery, Alexa High

Doctor of Nursing Practice Scholarly Projects

In the United States, the rate at which cancer is diagnosed is on the rise. In women, breast cancer is the second most common cancer diagnosis, following skin cancer, with approximately one in eight women developing breast cancer in their lifetime. When a patient receives a breast cancer diagnosis, the oncologic team will discuss the most suitable treatment plan for the patient, this often includes chemotherapy, radiation therapy, and surgery. Within the last few decades, research has shown that there may be a correlation between anesthetic medications and breast cancer metastasis. This project aims to create an evidence-based anesthesia guideline …

An Evidence-Based Strategy For The Use Of Simulation To Assess Situation Awareness In Applicants To Nurse Anesthesia Programs, Angela Lee

Doctor of Nursing Practice Scholarly Projects

Medical errors are considered one of the top causes of patient death. Closed claims analysis reveals an estimated 50% of claims are associated with preventable events by the anesthesia provider. Errors in anesthesia leading to critical incidents are associated with errors in situation awareness (SA). Identification of human factor variables, such as SA, provides an analysis of observable behavior and intuition necessary to guide crisis management, maintain clinical performance, and mitigate errors in patient safety. The human factor components of human error and SA play critical roles in patient safety and overall clinical anesthesia practice. The viability of simulation assessment …

Evaluating Nurses’ Turnover Intention And Organizational Commitment Following Stroke Unit Staffing Changes: An Evidence-Based Quality Initiative, Heather Tatusko

Doctor of Nursing Practice Scholarly Projects

Nurses are known to be overworked, overwhelmed, undervalued, and understaffed at dangerous levels throughout various inpatient hospital units across the United States (U.S.). Hospital registered nurse (RN) turnover is a significant issue that has accelerated since the COVID-19 pandemic, resulting in economic impacts and other burdens for organizations, individuals, and communities. Evidence suggests that evaluating Registered Nurses’ Turnover intention (NTI) and Organizational Commitment (OC) can help maintain a ready and capable team of skilled RNs; however, most healthcare organizations (HCOs) do not collect or analyze NTI and OC data and focus on staffing numbers and monetary incentives to get adequate …

Routine Evaluation With Gastric Ultrasound To Reduce Gastric Aspiration (Regurga), Joel Jackson

Doctor of Nursing Practice Scholarly Projects

When a patient undergoes anesthesia, there are inherent risks that the providers should protect the patient from. Despite adherence to fasting guidelines established by the American Society of Anesthesiologists (ASA), patients undergoing anesthesia continue to experience intrapulmonary aspiration of gastric contents. There are several factors that delay gastric emptying, including coexisting disease, trauma, pain, and opioid use. Gastric ultrasound assessment of the gastric antrum is a relatively new technology in anesthesia and can be used to assess the gastric antrum and provide information to anesthesia providers regarding the risk of aspiration in the perioperative period. The primary aim of this …

Development Of Evidence-Based Practice Anesthesia Guidelines For Brain-Dead Organ Donors, Kelly Dzialowski

Doctor of Nursing Practice Scholarly Projects

Organ donation is a gift of life for both donors and recipients that can come from living donors, donors after cardiac death, or brain-dead donors (BDDs). Treating the donors with optimal care throughout the entire donation process is crucial due to organ supply shortages. Organs from BDDs are a large contributor to the number of organs donated each year and require critical care from the time of admission, declaration of brain death, and throughout the organ procurement surgery. Although each BDD requires meticulous care for successful retrieval and donation, there is a lack of evidence-based practice (EBP) guidelines for anesthesia …

Development Of Evidence-Based Clinical Practice Guidelines For The Prevention Of Peripheral Neurological Injury During Robotic-Assisted Prostatectomies For Patients In The Steep Trendelenburg Position, Tyler Wolpert

Doctor of Nursing Practice Scholarly Projects

Robotic-assisted surgery (RAS) is becoming more prevalent in modern surgical practice and is currently being utilized in a range of surgical specialties from colorectal and gynecological procedures to bariatrics and orthopedics. Every surgical procedure has potential risk to patients, however robotic-assisted laparoscopic prostatectomies (RALP) in the steep Trendelenburg (ST) position poses unique risk for peripheral nerve injury (PNI). Despite attempts to reduce the incidence rate of PNI during RALP, injuries are still occurring to patients causing patient harm and anesthesia provider litigation. The implementation of a CRNA based safety checklist may reduce the incidence rate of PNI and provider litigation …

Viscoelastic Monitoring In Major Hepatic Surgery: An Evidence-Based Practice Project, Randy Kinietz

Doctor of Nursing Practice Scholarly Projects

Patients undergoing major hepatic surgery are at high risk for intraoperative transfusion of allogenic blood products. These patients are at increased risk due to pre-existing hepatic pathology, surgical stress, and the complexity of surgical procedures. While blood product transfusion may be necessary to support hemostasis and hemodynamics, it is not without risk. Current literature states that viscoelastic monitoring is superior to traditional laboratory values when guiding transfusion during major hepatic surgery. Viscoelastic monitoring is a term used to describe the measurement of change in viscoelastic properties of whole blood during clot formation. There are two readily available point-of-care types – …

Recommending An Eras Guideline For Patients Undergoing Total Joint Arthroplasty, Kahl Knapke

Doctor of Nursing Practice Scholarly Projects

Enhanced recovery after surgery (ERAS) is a comprehensive guideline that guides patients' care throughout their surgical journey. ERAS is intended to reduce the body’s response to the many stressors of surgery. ERAS is proven effective in various specialty surgical areas, including orthopedics. Orthopedic surgery rates increase parallel with the patient population ages, indicating a need for more joint replacements. Implementing an ERAS guideline reduces healthcare costs to the patient and hospital facility by reducing the length of stay (LOS) and complications postoperatively. The investigation revealed a lack of consistent direction of care, and the developed approach for patients undergoing joint …

Guidelines For The Optimal Assessment Of Airway To Predict Difficult Intubation, Morgan Kleinfelder

Doctor of Nursing Practice Scholarly Projects

Managing the airway is the cornerstone of anesthesia care. However, difficult airway or intubation is not clearly defined. A major complication with a difficult airway is a cannot intubate, cannot ventilate (CICV) situation, which is reported to be as high as 10%. In addition, according to the American Society of Anesthesiologists (ASA) Closed Claim Study, "Adverse respiratory events are the most common type of injury, with difficult intubation [DI] and ventilation contributing to most of the cases. Twenty-eight percent of all anesthesia deaths are related to a CICV situation. As anesthesia evolves, basic airway assessments were developed and include mallampati …

Development And Implementation Of An Evidence Based Practice Guideline Related To The Management Of Adult Angioedema, Megan Przybysz

Doctor of Nursing Practice Scholarly Projects

Angioedema (AE) is a potentially life-threatening medical condition that occurs with a higher frequency than medical providers may expect, with the emergency department (ED) serving as the usual first point of medical contact for patients. Any hesitation in recognizing AE or inconsideration of the disease process in differential diagnoses may lead to a dangerous delay of care. Due to the potential rapid progression of airway obstruction in AE, inexperienced providers should not attempt intubation, instead deferring to providers experienced in alternative airway techniques (i.e., anesthesia providers). The primary goal of this project is to develop an evidencebased practice guideline for …

Evidence-Based Practice Guidelines For The Surgical Patient With Obstructive Sleep Apnea, Aaron Mcneilan

Doctor of Nursing Practice Scholarly Projects

Obstructive Sleep Apnea (OSA) is a medical condition which many people may be affected by but may be unaware of the presence of the condition. The incidence of OSA has increased in direct correlation with the rising rate of obesity in the general population. While chronic conditions may arise if OSA goes untreated, patients with OSA also have an increased risk for acute complications following surgical procedures such as airway obstruction, hypoxia, brain damage, and death. Many anesthetic medications administered during surgery exacerbate the pathological consequences of OSA, predisposing patients to adverse respiratory events during the recovery period following a …

Development Of A Rotem-Guided Transfusion Algorithm In Cardiothoracic Surgery Patients, Kourtney Jane Snyder

Doctor of Nursing Practice Scholarly Projects

Abstract

Cardiothoracic surgical patients are at an increased risk for bleeding complications for various reasons, including induction of hypothermia, initiation of the coagulation cascade, degradation of the coagulation factors, mechanical destruction of platelets, and a systemic inflammatory response due to cardiopulmonary bypass (CPB). The American Society of Anesthesiologists recommends rotational thromboelastometry (ROTEM)-guided transfusion algorithms for perioperative blood management; however, there remains a heavy reliance on conventional coagulation laboratory values. Utilization of the following PICOT question will guide this project: In cardiothoracic surgical patients, how does the use of ROTEM versus traditional coagulation laboratory tests (PT, INR, aPTT, ACT, platelet count, …

Development Of An Evidence-Based Crna Preceptor Training Program, Emmanuel Mensah

Doctor of Nursing Practice Scholarly Projects

A preceptor is an experienced clinician who is expected to facilitate a student's learning experience. Preceptorship is the relationship between a staff nurse and student, focusing on the development of clinical skills and knowledge. Initially introduced by Florence Nightingale in the 1800s, the concept was quickly adopted by nurse anesthetists and is a staple of the anesthesia practice today. As it stands, many Certified Registered Nurse Anesthetists (CRNA) preceptors do not receive formal training in their role, which may lead to a decrease in teaching ability and confidence to face broad teaching-learning issues. A lack of preparation hinders preceptor outcomes …

General Anesthesia Clinical Practice Guidelines For Patients With Posttraumatic Stress Disorder, Bradley Closson

Doctor of Nursing Practice Scholarly Projects

General anesthesia is an induced state of unconsciousness administered by anesthesia providers to obtain patient amnesia, analgesia, and akinesia. Adult patients with posttraumatic stress disorder (PTSD) are at risk for general anesthesia-related complications throughout the perioperative setting. Emergence delirium is a clinically significant postoperative complication that patients with PTSD have an increased risk of developing. Postoperative complications of emergence delirium include patient or medical staff injury, surgical site damage, prolonged postanesthesia care unit (PACU) stay, and increased medical care costs. Evidence demonstrates that implementing preventive interventions decreases the incidence of emergence delirium. There are no standardized, evidence-based general anesthesia guidelines …

Preprocedural Ultrasound For Labor Neuraxial Anesthesia: Evidence-Based Practice Recommendations, Nicholas Anderson

Doctor of Nursing Practice Scholarly Projects

Central neuraxial blockade (CNB) is the most widely used method of anesthesia provided to laboring patients and includes epidural, spinal, combined spinal-epidural, and caudal techniques. Studies have shown that using preprocedural ultrasound is a safe and effective tool to facilitate the placement of neuraxial needles, especially in patients with predicted difficulty. With the prevalence of obesity increasing, laboring patients with predicted difficulty of neuraxial needle placement is increasing as well. In addition, the traditional method of palpation and visualization of anatomical landmarks to place neuraxial needles can produce inaccurate results due to inconsistencies between patients. Use of preprocedural ultrasound to …

Incorporation Of Mindfulness Application Use In Doctoral Nurse Anesthesia Curricula For Mitigation Of Stress And Anxiety In Student Registered Nurse Anesthetists, Kerrie Rodgers

Doctor of Nursing Practice Scholarly Projects

The nurse anesthesia specialty is highly stressful, with educational training being no exception. High didactic demands and intensive clinical experiences are placed on student registered nurse anesthetists (SRNAs), increasing stress and anxiety in their personal and professional lives. High levels of psychological distress can lead to inadvertent consequences in students’ mental, emotional, and physical health and can contribute to illness, burnout, substance use, and compromise in patient safety. Some degree of stress is necessary for motivation to succeed and perform at high levels, and encountering stress while enrolled in a doctoral nurse anesthesia program is expected and unavoidable. A search …

Evidence-Based Practice Recommendations For The Use Of A Cardiac Optimization Algorithm In Patients Undergoing A Whipple Procedure, Jarrod Genther

Doctor of Nursing Practice Scholarly Projects

A fundamental responsibility of a certified registered nurse anesthetist includes intraoperative fluid and hemodynamic management. While Enhanced Recovery After Surgery protocols advocate goal-directed fluid therapy, the methodology remains controversial. An algorithmic approach systematically optimizes cardiac function and fluid volume status based on stroke volume variation, cardiac index, and mean arterial pressure. This project aims to evaluate the effects of placing intraoperative guidelines for patients undergoing a Whipple procedure when using a cardiac optimization algorithm to guide fluid and vasopressor management. The outcomes evaluated included the amount of fluids delivered intraoperatively, vasoactive medication administration, urine output, amount of blood transfusions, cardiac …

Development Of Evidence-Based Clinical Practice Guidelines For Pediatric Patients At Risk Of Emergence Delirium, Christina Bensley

Doctor of Nursing Practice Scholarly Projects

Postoperative emergence agitation or emergence delirium (ED) is a phenomenon that can occur in patients who have undergone surgery requiring the administration of inhaled anesthetics. ED is a postoperative side effect of general anesthesia commonly experienced by pediatric patients that negatively impacts a patient’s overall postoperative experience. There is a lack of consistent standardized clinical practice guidelines for general anesthesia in pediatric or adult populations. The primary goal of this scholarly project is to develop and implement clinical practice guidelines focusing on the occurrence of postoperative ED and select adverse clinical outcomes in pediatric patients undergoing general anesthesia. The project …

Final Scholarly Project: Clinical Guidelines For The Perioperative Management Of Patients With Opioid Use Disorder Requiring Anesthesia, Jessica Kayla Joos

Doctor of Nursing Practice Scholarly Projects

Opioids have highly addictive properties that allow for high levels of misuse. Since the early 1990s, the misuse and deaths rates related to narcotics have steadily risen in the United States. Efforts to identify individuals using opioids prior to surgery have proven difficult. The number of patients misusing opioids and reporting for surgery can only be estimated due to under-reporting related to fear and self-stigma. With 50 million surgeries in the U.S. annually and 3.32 million people misusing opioids monthly, the chances of a patient with Opioid Use Disorder (OUD) presenting for anesthesia are exceptionally high. Moreover, patients who rate …

Evidence-Based Strategy To Improve Delirium Detection In Elderly Postsurgical Patients, Aimee Baker

Doctor of Nursing Practice Scholarly Projects

Postoperative delirium (POD) is a serious adverse outcome that frequently affects older adults. Patients experiencing POD are at greater risk for postoperative mortality, increased length of hospital stay, functional decline, and increased cost of care. Current global population trends indicate that the population of adults over the age of 60 years old will double over the next thirty years. Recent guidelines call for hospitals to implement routine delirium assessment to improve early intervention. Nursing delirium assessment tools are a critical resource for early delirium identification. Nursing delirium assessment tools are often highly sensitive and specific for delirium when used in …