Anesthesiology Commons^™

Developing A Clinical Practice Guideline For Surgical Diabetic Patients, Barbie Denise Harbaugh, Diane Whitehead

Walden Faculty and Staff Publications

Diabetes is a recognized risk factor for postoperative infection, acute renal failure, ileus, and lengthy hospital stay. Optimal screening, management, and scheduling of elective surgery for diabetic patients has been shown to improve quality care, decrease complications, and increase the efficiency and lower the costs of preoperative patient care. However, surgery cancellations are common due to inadequate preoperative glycemic control and poor intraoperative glycemic control, which is a recognized risk factor for perioperative or postoperative complications. There were no clinical practice guidelines or optimization protocols for elective surgery patients at a small rural hospital in the Northeast United States. The …

A Quality Improvement Project To Determine The Incidence And Prevalence Of Obstructive Sleep Apnea, Best Practice Anesthesia Guidelines, And The Incidence Of Perioperative Cardiac And Respiratory Complications After The Implementation Of The Stop-Bang Questionnaire, Bradly Diamond, Gregory Guerrier, Cody Holliman, Robert Marrero, Tyler Nelson

Doctoral Projects

Patients with obstructive sleep apnea (OSA) are at risk for perioperative respiratory and cardiovascular compromise (Opperer et al., 2016). Unfortunately, almost 90% of patients with moderate-to-severe OSA are not diagnosed and unaware of their disorder; however, they remain at increased perioperative risks (Singh et al., 2015). The STOP-BANG questionnaire was developed to meet the need for a reliable, concise, and efficient screening tool for OSA risk. The facility at which this project was conducted did not utilize a prescreening OSA risk tool. The facility not using a prescreening OSA risk tool is especially important because the State of Mississippi currently …

Impact Of Best Practice Guideline Statement On Anesthesia Practice In Rural Mississippi Hospitals With Obese Patients Undergoing Total Knee Arthroplasty, Steven Hodnett

Doctoral Projects

The aim of this best practice guideline (BPG) was to be a resource for anesthesia providers practicing with obese patients undergoing total knee arthroplasty (TKA) and to measure the knowledge of these providers. After dissemination of an executive summary to anesthesia providers in two hospitals in rural Mississippi, an anonymous online survey was provided via Qualtrics software for voluntary participation. The survey consisted of 10 questions. The data collection period was five weeks. Respondents are noted at N=2, and the data was reviewed and categorized into one of three domains (i.e., knowledge, practice, and safety). In the domain of knowledge, …

Developing A Local Anesthetic Systemic Toxicity Protocol In A Mississippi Hospital, James Dearman, Terry J. Tieman

Doctoral Projects

Local anesthetic systemic toxicity (LAST) is a rare complication of administering local anesthetic medications. However, this complication is potentially deadly, especially without prompt and correct treatment. Due to the rarity of LAST and the fact that its treatment differs from the conventional treatment of cardiac arrest, the authors sought a best practice recommendation to guide its treatment. While the most effective treatment for LAST has been well established, a thorough review of literature and survey of clinical preceptors demonstrated that most providers have not encountered LAST in clinical practice. Additionally, lipid emulsion therapy is a somewhat controversial treatment among some …

A Market Analysis Of Pay Rates For New Graduate Certified Registered Nurse Anesthetists, Zachary Halliwell

Doctoral Projects

The profession of Certified Registered Nurse Anesthetists (CRNA) is a thriving occupation. In their national Occupational Outlook Handbook, the Bureau of Labor Statistics (U.S. Department of Labor, 2018), reported the national market for CRNAs is predicted to continue its steady growth through 2026. The Bureau of Labor Statistics (BLS) provides numerous statistics, as previously mentioned, on their website. However, the stats available include CRNAs of varying experience levels. The Mississippi Department of Employment Security (MDES) has a few statistics, online, regarding the market for CRNAs. The data provided by MDES, while appreciated, is lacking in numerical significance, given the minuscule …

Evidence-Based Best Practice Policy Recommendation For Postoperative Sore Throat, Corey Gambrell

Doctoral Projects

Airway management is a fundamental aspect of patient care when general anesthesia is being administered. Unfortunately, tracheal intubation can lead to the development of postoperative sore throat (POST) in the recovery room. POST is a minor yet preventable consequence of manipulation and injury of the airway mucosa. POST is routinely considered a minor postoperative complication; however, the occurrence of POST can have a negative influence on patient satisfaction as well as their perception of the perioperative experience. The etiology of POST is multifactorial, but evidence indicates that prevention is possible when evidenced-based practices are employed by anesthesia providers. A targeted …

General Anesthetic Induction Sequence High Fidelity Simulation: Determining Efficacy Among Novice Student Registered Nurse Anesthetists, Alex Wilkie, Steven Urbick, Kenn B Daratha

Books, Presentations, Posters, Etc.

Background High Fidelity Simulation (HFS) is used across multiple health professions. Despite the wide variety of clinical experiences that Student Registered Nurse Anesthetists (SRNA) possess prior to training, the induction sequence to a General Anesthetic (GA) is a daunting task. Although the efficacy of HFS has been widely studied within undergraduate nursing programs, there are no studies published determining the efficacy of HFS on SRNA training. The purpose of this study was to determine the efficacy of simulation training amongst entry-level SRNA’s and examine any individual participant factors that may influence clinical performance within HFS.

Methods • Human subjects were …

Comparisons Of Preoperative Blood Pressures In Surgical Patients, Brian Stacy, Kenn B Daratha

Books, Presentations, Posters, Etc.

Background Surgical patients expect anesthesia providers to provide high quality care. Blood pressure variability must be mitigated by establishing the patient’s blood pressure baseline and sustaining it through surgery. A consensus has not been established on which blood pressure measurement should be used as the patient’s baseline. Blood pressures before surgery in multiple care settings have been shown to vary. This may result in differences in drug and fluid administration, depending on the blood pressure considered baseline by the anesthesia provider. The purpose of this observational evidence-based practice project was to compare mean blood pressures leading up to surgery among …

Intraoperative Hypotension In Non-Cardiac Surgery Patients At Providence Sacred Heart Medical Center, Genna Ledrew, Kenn B Daratha

Books, Presentations, Posters, Etc.

Background Intraoperative Hypotension (IOH) during non-cardiac surgery is a common side effect of anesthesia that is associated with acute kidney injury (AKI), myocardial injury (MI), mortality, and other adverse outcomes1,3,4. These risks increase as the duration and severity of IOH exposure increase3,4. Blood pressure is a modifiable risk factor of mortality and organ damage that can be readily treated by the anesthesia provider2 . Limiting IOH can improve patient outcomes and produce monetary savings5 . The objective of this project is to report the incidence of IOH at a large tertiary teaching hospital, and extrapolate the risks of mortality and …

Hyperoxia: Current Practice Of Oxygen Delivery During General Anesthesia, Christa Kirby, Kenn B Daratha

Books, Presentations, Posters, Etc.

Background While supplemental oxygen is routinely administered during anesthesia to prevent oxygen desaturation and optimize tissue oxygenation, oxygen delivery practices after intubation are largely unknown. Compiled evidence suggests limiting intraoperative fraction of inspired oxygen (FiO2) to below 60%. The deleterious effects of hyperoxia and the mortality benefit of conservative oxygen administration are being demonstrated in contemporary critical care literature. The lack of consensus guidelines and high level evidence on the topic of intraoperative oxygen delivery begs the question to what degree are patients being exposed to hyperoxia during general anesthesia. The purpose of this evidence-based practice project was to better …

Sugammadex Versus Neostigmine: Operating Room Time And Cost, Annie Benscheidt, Kenn B Daratha

Books, Presentations, Posters, Etc.

Background The choice of neuromuscular blockade reversal agents impacts cost and operating room time. Currently, the two medications used to reverse neuromuscular blockade are Neostigmine and Sugammadex. These medications differ in both cost and pharmacologic profiles which effect the time and predictability of reversal (Carron, Zarantonello, Tellaroli, & Ori, 2016). Evaluating cost and time differences in reversal using Sugammadex and Neostigmine helps anesthesia providers select the appropriate medication. This evidence based practice project examined the difference in case length and operating room and reversal agent costs in cases using Sugammadex and Neostigmine at Providence Sacred Heart Medical Center.

Methods • …

Comparison Of Ondansetron, Dexamethasone, And Its Combination In The Prevention Of Postoperative Nausea And Vomiting, Alina Palanchuk, Kenn B Daratha

Books, Presentations, Posters, Etc.

Background Postoperative nausea and vomiting remains a common and unpleasant side effect for patients following surgery. Uncontrolled PONV can result in prolonged hospital stays, unanticipated hospital readmissions, and decreased patient satisfaction. The Apfel score identifies and counts independent risk factors for PONV; females, non-smokers, postoperative opioid use, and history of PONV or motion sickness. Rates of PONV increases as the number of risk factors increase. The primary intervention to decrease PONV is administration of prophylactic antiemetics. Research supports the use of combination antiemetic therapy for patients with a high number of risk factors. The purpose of this evidence based practice …

Ultrasound Simulation For Regional Anesthesia, Kayla Brown, Kenn B Daratha

Books, Presentations, Posters, Etc.

Background Regional anesthesia is an essential skill in the practice of Nurse Anesthesia, and future employment demands expertise. Literature supports the addition of simulation training to existing didactic and apprenticeship education to improve clinical expertise. The purpose of this project was to trial simulation training, focused on anatomical visualization with ultrasound for regional anesthesia, as a means to improve student performance and confidence.

Methods • Facility project approval and exemption determination by IRB. • Hands-On Test: Ultrasound to obtain visualization for axillary (cohort 1), interscalene (cohort 2) block on live-model. Expert CRNA observed performance to determine if image was clinically …

Intraoperative Opioid Administration Among Cancer Patients, Amanda Barrett, Kenn B Daratha

Books, Presentations, Posters, Etc.

Background Cancer prevalence continues to rise. In vitro and in vivo studies have demonstrated that opioid receptor agonists may be associated with poor outcomes for cancer patients. Laboratory studies have shown that opioids cause immunosuppression; tumor cell progression, recurrence and metastasis. The surgical environment further decreases immune function, causes an inflammatory response and promotes cancer cell mobilization. Anesthesia providers are in a unique position to influence postoperative outcomes. Opioid free anesthetic delivery is a growing trend amongst anesthesia providers and is supported by the literature. The purpose of this project is to compare intraoperative opioid administration rates for patients with …

Transfusion Ratios Following Activation Of A Massive Transfusion Protocol: An Evidence Based Practice Project, Cody Woodbury, Kenn B Daratha

Books, Presentations, Posters, Etc.

Background Accidental injury is one of the leading causes of death in the United States and worldwide. Severe hemorrhage from injury is the leading cause of preventable death. Effective management of hemorrhaging trauma patients has been evolving since the early 1900’s. Recent studies have demonstrated the benefits of using a balanced resuscitation technique, revolving around the goal of recreating whole blood. The purpose of this project was to identify what ratios of blood products are being transfused at Providence Sacred Heart Medical Center (PSHMC) and Providence Holy Family Hospital (PHFH).

Methods A literature review was performed identifying seven high quality …

Aortic Stenosis Poster, Katonya Lawson

Nursing Student Class Projects (Formerly MSN)

Aortic stenosis is the narrowing of the aortic valve secondary to calcification and fibrosis. It is the most common valve disorder and the second most frequent reason for cardiac surgery. As the elderly population increases, the number of patients presenting with aortic stenosis will increase. RNs and APRNs need to be aware of the pathophysiology and clinical manifestations of aortic stenosis because the disease can progress quickly and be fatal if mismanaged. Patients with aortic stenosis have an increased risk of morbidity and mortality during the peri-operative period during non-cardiac surgery. Therefore, CRNAs must remain vigilant when caring for this …

Anesthetic Considerations For Patients Under The Influence Of Marijuana And/Or Cannabidiol: Anesthesia Interactions And Implications, Alexa Schimmel

Nurse Anesthesia MSNA Student Capstones

This manuscript investigates the use of marijuana, including edibles and cannabidiol (CBD), and its effects on anesthesia. This topic of research is very recent without an abundance of information. Various articles discuss the route of marijuana use including inhalation, ingestible and extracts of the plant, including CBD. For this manuscript, the term marijuana will pertain to both inhaled and ingested marijuana unless otherwise noted; ingestible marijuana is also known as edibles. This manuscript explains the mechanism of action of marijuana and CBD, the general guidelines for the use and how each affect the administration and impact of anesthesia.

Augmented Mean Arterial Blood Pressure And Vasopressor Selection In Patients With Spinal Cord Injury, Jayme Schroeder

Nurse Anesthesia MSNA Student Capstones

Blood pressure management in the acute period following spinal cord injury is a critical concern; one that anesthesia and critical care providers are often able to directly measure and regulate. It has been hypothesized that supraphysiologic blood pressure maintenance during this acute phase may improve recovery, however there is limited high-quality evidence to reinforce and guide management. Based on included prospective and retrospective studies, which provide the highest level of evidence available, The American Association of Neurologic Surgeons does provide the following level III recommendation: MAP goals of 85–90 mm Hg for 5–7 days post-injury should be considered. With regard …

Carbon Dioxide Embolisms During Laparoscopic Surgery, Leanne M. Jobin

Nurse Anesthesia MSNA Student Capstones

With the advancement of technology over the past few decades, laparoscopic surgery has significantly increased in popularity among many surgical subspecialties including: general surgery, gynecology, and urology. Many procedures that traditionally required open access with large incisions have been replaced with laparoscopic approaches as it offers many advantages such as, faster recovery, less postoperative pain, and shorter hospital stays. Despite its many advantages, it creates numerous anesthesia challenges and considerations when caring for patients undergoing laparoscopic procedures. Among these challenges, are carbon dioxide embolisms. This manuscript involves research and previous case studies that were conducted on carbon dioxide embolisms during …

Amniotic Fluid Embolism In The Parturient Patient, Vanessa Pasquariello

Nurse Anesthesia MSNA Student Capstones

An amniotic fluid embolism (AFE) occurs when amniotic fluid enters maternal circulation, causing a physical obstruction or an anaphylactoid reaction, both of which are often detrimental to the parturient patient. This paper reviews a series of studies to examine the incidence, risk factors, presentation, and management of an AFE in the healthcare setting. Diagnosing an AFE remains difficult as a universal diagnostic criterion does not exist (aside from in reported research); thus, its identification is often made when another differential diagnosis fails to manifest. The presentation of the following biomarkers: squamous cell carcinoma antigen, CK13, and CK10/13 can aid in …

Robotic-Assisted Versus Video-Assisted And Open Thoracic Surgery: Outcomes, Advantages, And Costs, Ananth Thitte

Nurse Anesthesia MSNA Student Capstones

Thoracic surgery via video assisted thoracoscopic surgery (VATS) began in the early 1990s, as a minimally invasive alternative to open thoracotomy for performing lobectomies, wedge resections, and segmentectomies. It initially showed improved morbidity and mortality, decreased pain, and decreased length of stay when compared to traditional open thoracotomy (Zhang & Gao, 2015). To its detriment, VATS has a steep learning curve and manipulation of instruments has been described as non-intuitive. The video camera used provides a two-dimensional image, with limited depth perception compared to the naked eye in an open procedure. Due to these shortcomings, and in spite of its …

Vaping And Anesthesia, Wen Wang

Nurse Anesthesia MSNA Student Capstones

Electronic cigarettes (ECs) are a fast-growing class of Electronic Nicotine Delivery Systems (ENDS) which were first put on the market 15 years ago. These devices have been advertised as safer alternatives to conventional cigarettes and a tool for smoking cessation by their manufacturers regardless of inadequate safety data (Kalkhoran, 2016). Since ECs have only been on the market for one and half decades, data on short-term health effects from inhaling EC aerosols are inadequate, and data regarding long-term health effects are very limited. Despite insufficient safety data, the use of ECs has increased exponentially since they were put on the …

Delirium In Long Term Care Rehabilitation Residents: A Correlational Retrospective Study, Rebecca Lerma-Kjonegaard

Dissertations

Abstract Background: Delirium is associated with devastating outcomes, cognitive loss,

decreased function and an increase risk of mortality which affects patients and places a heavy burden on family and the healthcare system. The purpose of this study was to describe the relationship between select demographics, clinical characteristics, CHART- DEL-derived delirium diagnosis and ICD-10 coded discharge delirium diagnoses among Long Term Care (LTC) rehabilitation residents.

Method: A retrospective correlational design from174 LTC rehabilitation residents age 65 years or older using EMR and hard copy charts. The setting was a Southern California community hospital-based 100-bed LTC. Abstracted data included demographic characteristics (age, …

The Effect Of The Implementation Of A Quarterly Triad Tool In The Pain Clinic Setting On The Assessment And Mitigation Of Risks In Patients On Chronic Opioid Therapy, Caroline Asava

Evidence-Based Practice Project Reports

The concurrent use of opioids and benzodiazepines (BZDs poses a formidable challenge for clinicians who manage chronic pain. While the escalating use of opioid analgesics for the treatment of chronic pain and the concomitant rise in opioid-related abuse and misuse are widely recognized trends, the contribution of combination use of BZDs, alcohol, and/or other sedative agents to opioid-related morbidity and mortality is underappreciated, even when these agents are used appropriately. Patients with chronic pain who use opioid analgesics along with BZDs have a defined increase in rates of adverse events, overdose, and death, warranting close monitoring. To improve patient outcomes, …

Improving Nurse Anesthetist Intraoperative Handoff Process By Developing And Implementing An Evidence-Based, Facility-Specific Cognitive Aid, Jason Silva, Myron Arnaud

Journal of Nursing & Interprofessional Leadership in Quality & Safety

Miscommunication or non-transfer of pertinent patient information during intraoperative handoffs between anesthesia providers creates patient safety risks. An evidence-based facility-specific cognitive aid was developed and introduced to nurse anesthetists in an anesthesiology department of a large academic hospital with the aim of improving the intraoperative patient handoff process. The program used a handoff cognitive aid that addressed five pertinent patient information points. A secondary measure was evaluation of provider satisfaction. Twenty-four nurse anesthetists utilized the handoff cognitive aid during handoffs in the course of a 4-week pilot program. Eighty-eight nurse anesthetist handoffs were observed (23 with and 65 without the …

Improving Perioperative Warming Of Surgical Patients: Implementation Of A Warming Protocol, Maghy Schrage

Doctor of Nursing Practice Projects

Despite the ample amount of knowledge and interventions available to keep patients warm in the operating room, the issue of inadvertent perioperative hypothermia continues to be a problem affecting surgical patients. Unfortunately, even a mild degree of hypothermia can increase a patient’s chance for negative outcomes such as surgical site infections, bleeding, and higher risk for mortality. The project involved development of a warming protocol/guideline for a small community hospital. The implementation process consisted of two separate presentations tailored to educate both nursing and anesthesia staff about the importance of warming patients, reimbursement initiatives, and appropriate interventions.

The project study …

Changing Healthcare Provider And Parent Behaviors In The Pediatric Post‐Anesthesia‐Care‐Unit To Reduce Child Pain: Nurse And Parent Training In Postoperative Stress (Np‐Tips), Brooke N. Jenkins, Michelle Fortier, Robert S. Stevenson, Mai Makhlouf, Paulina Lim, Remy Converse, Zeev N. Kain

Psychology Faculty Articles and Research

Background

Children who undergo surgery experience significant pain in the post anesthesia care unit. Nurse and parent behaviors in the post anesthesia care unit directly impact child postoperative pain. Therefore, we have developed and evaluated (Phase 1) and then tested (Phase 2) the feasibility of a new intervention (Nurse and Parent Training in Postoperative Stress) to alter parent and nurse behaviors in a way consistent with reducing child postoperative pain.

Methods

In Phase 1, a multidisciplinary team of experts (physicians, nurses, and psychologists) developed an empirically‐based intervention which was then evaluated by experienced nurses (N = 8) and parents …

Perioperative Antimicrobial Prophylaxis In Vascular Surgery: A Quality Assessment And Improvement Project, Brian Torres

Dissertations

Introduction: Prophylactic antimicrobial selection and administration for the prevention of surgical site infections in vascular surgery is a recommended best practice. Non-adherence to published guidelines on the selection and administration of antimicrobials has been observed and may lead to reduced efficacy of antimicrobial prophylaxis.

Methods: An observational, descriptive design was used to study clinician knowledge and behavior and included a retrospective patient record review and provider knowledge survey. A clinical education intervention targeting providers responsible for the selection and administration of antimicrobial prophylaxis was conducted. A repeat patient record review and knowledge survey was completed following the education intervention.

Results: …

Adaptation And Validation Of The Situation Awareness Global Assessment Technique For Student Registered Nurse Anesthetists, Deniz Dishman

Theses and Dissertations

Anesthesia is a health care specialty fraught with high workload demands, stressful work environments, increased production pressure, work areas with many distractions, an increasing use of advanced technology, and the constant need to prioritize work actions. Effective clinical judgment in this dynamic environment necessitates that the provider demonstrate the ability to project what may occur secondary to actual or potential condition changes. These key elements operationalize situation awareness (SA).

High level SA is an important characteristic for the successful development of student registered nurse anesthetists (SRNAs). With Endsley’s “Theory of Situation Awareness” as the foundation, the goal of this study …

Perceived Impact Of Ambient Operating Room Noise By Certified Registered Nurse Anesthetists, Marianne S. Cosgrove

Theses and Dissertations

It is widely acknowledged that elevated levels of noise are commonplace in the healthcare environment, particularly in high acuity areas such as the operating room (OR). Excessive ambient noise may pose a threat to patient safety by adversely impacting provider performance and interfering with communication among perioperative care team members. With respect to the certified registered nurse anesthetist (CRNA), increased ambient OR noise may engender distractibility, diminish situation awareness and cause untoward health effects, thereby increasing the possibility for the occurrence of error and patient injury.

This research project analytically examines the perceived impact of ambient noise in the operating …