AANA journal最新文献

Simulation manikins provide anesthetists a training modality to practice ultrasound-guided central venous catheter (CVC) insertion safely without the risk of patient harm. The goals of this quality improvement (QI) project were to increase technical skills and reduce procedure time among anesthesia providers during CVC placement by implementing an ultrasoundguided, simulated CVC insertion workshop. A primary benefit of simulation-based education is the provision of a safe learning environment-one in which learners and providers may practice and increase skillsets. This QI project utilized a pretest-posttest design for which anesthesia providers completed a CVC insertion educational session and three formally evaluated simulated CVC placements: preworkshop, immediate postworkshop, and 3 months postworkshop. CVC insertion skills were evaluated by two experienced raters who established interrater reliability using a validated checklist and recorded procedure time in minutes. When comparing preworkshop median checklist score (33.74/52 [65%]), significant improvement was found in the immediate postworkshop (46.32/52 [89%]) and 3-month follow-up (44.26/52 [85%]). Time for CVC insertion significantly improved immediately postworkshop (15.7 minutes) and 3-month follow-up (15.9 minutes) when compared with preworkshop (21.5 minutes). An ultrasound-guided CVC simulation workshop can appreciably advance anesthesia providers' technical skills and decrease procedure time when performing insertion of a simulated internal jugular CVC.

In 2016, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) launched a Continued Professional Certification (CPC) Program to promote lifelong learning and to facilitate ongoing professional competency checks for practicing certified registered nurse anesthesiologists (CRNA). The use of simulation-based assessment is currently being studied by the NBCRNA for potential use in the CPC Program. The aim of the pilot project was to create and validate simulation scenarios and assessment tools for potential incorporation into the CPC Program. Using the modified Delphi method, an expert panel of eight CRNAs evaluated the validity of four simulation scenarios and the content validity and reliability of four scenario-specific assessment tools. Each of the eight individual surveys assessing simulation scenario validity and assessment tool validity reached ≥ 75% agreement among the expert panelists. Overall content validity index values for the four assessment tools ranged from 0.960 to 0.993. There was a direct relationship between panelists' scores and level of performance on all returned assessment tools. The expert panel validated four simulation scenarios and four accompanying assessment tools. All scenarios and assessment tools were determined to have high content validity and reliability. Using these scenarios and assessment tools would provide unique advantages over standardized assessment methods.

Difficult and failed airway management remains a significant cause of anesthesia-related morbidity and mortality. Failed airway management guidelines include performing a cricothyrotomy as a final step. Correct identification of the cricothyroid membrane (CTM) is essential for safe and accurate cricothyrotomy execution. Ten certified registered nurse anesthetists were assessed for ultrasound-guided (USG) needle cricothyrotomy competency following an online and hands-on education session using a human cadaver and then assessed 60 days later, without additional education or preparation. Both knowledge and confidence improved significantly when assessed immediately after education (P < .05) and were maintained when assessed 60 days later. Overall skill performance declined slightly from post-training although the decline was not statistically significant (P = .373). Overall needle placement time and distance from the CTM improved, despite improper transducer and image orientation by most participants. A one-hour hybrid educational program can significantly improve ultrasound and cricothyrotomy knowledge and confidence for 60 days. Transducer orientation may not be a significant contributor to performing proper USG needle cricothyrotomy.

Cricothyrotomy proficiency is imperative for anesthesia providers; however, opportunities to perform this skill are infrequent making skill maintenance essential. Increased accessibility of three-dimensional (3D) printing allows for production of low-cost simulation models. The models used for simulation-based teaching and deliberate practice facilitate skill development and refinement. A cost-effective, 3D printed airway model was designed and allowed 47 anesthesia providers to complete hands-on practice during a cricothyrotomy simulation-based training program. Assessment and comparison of pre- to post- intervention was completed for self-efficacy, knowledge, time to skill completion, compliance of required steps checklist, Global Rating Scale score, and successful ventilation. Statistically significant improvement from pre- to posttest was demonstrated in: 1) self-efficacy survey scores (P < .001); 2) knowledge test scores (P < .001); and 3) decreased time (minutes:seconds) to task completion (P < .001). Time from initial posttest to 3-month posttest (P = .046) significantly increased, however, the time at 3 months posttest remained significantly lower than pretest (P < .001). Providers' ability to ventilate, compliance with procedural steps, and technical skills significantly improved. 3D printing can produce anatomically similar simulation airway models that allow providers to practice and improve cricothyrotomy knowledge and skills. Developing an affordable and accessible simulation model provides a sustainable tool that allows providers multiple cricothyrotomy practice attempts.

Tracheal mucosal inflammation and irritation caused by the endotracheal tube (ETT) may exacerbate symptoms of pain and discomfort which create challenges including ETT tolerance and postintubation emergence phenomena. Various sedative and analgesic agents are used to mitigate these symptoms, however, there is concern that such medications may contribute to prolonged duration of intubation, length of intensive care unit (ICU) stay, as well as increased morbidity. This randomized control pilot study explored the feasibility and potential efficacy of instillation of a buffered lidocaine solution as an ETT cuff medium in adult rapid recovery eligible cardiac surgical patients. Thirty-two patients were randomized to the intervention (1.8% lidocaine/0.76% sodium bicarbonate) or control (air) group. Data were analyzed using median, standard deviation (SD), Wilcoxon rank sum, mean ± SD, two-sample t-test, and Fisher's exact test. The intervention arm demonstrated a trend toward a reduction in the incidence of cough at ICU arrival (0 versus 22%), incidence of pharyngitis at all time intervals, and propofol requirement (345 ± 248 mg versus 1,158 ± 1,426 mg) with no difference in adverse events between groups. These results support the development of larger studies to confirm the efficacy and feasibility of buffered lidocaine as an ETT cuff medium in this population.

Patients with Treacher Collins syndrome have a known difficult airway particularly if intubation is required. In most institutions that perform full mouth dental restoration (FMDR) procedures the patient is nasally intubated to protect the airway from debris and irrigation fluid. For patients with Treacher Collins syndrome the actual intubation and securing the airway can be more difficult and traumatic than the actual dental restoration itself. However, there is an airway technique using nasopharyngeal airways combined with a dental technique called "dry prepping" that can provide those patients a safe way of receiving an FMDR without intubation. A recent case report of a 29-month-old child with Treacher Collins syndrome received an FMDR without intubation.

Currently, there are approximately 1.62 million instrumented spinal surgeries performed each year in the United States. Complex procedures such as wide exposures and composite osteotomies, compounded by the spine's extensive vascular network, often result in major blood loss and increased fibrinolysis. Substantial intraoperative blood loss often necessitates blood transfusion and is a significant predictor of postoperative morbidity. Antifibrinolytic medications have been utilized prophylactically to reduce perioperative blood loss, particularly in surgeries where excessive blood loss is common. Tranexamic acid (TXA), a lysine analog that reversibly binds to plasminogen, inhibits the activation of plasminogen to plasmin, delaying clot degradation. The intravenous and topical administration of TXA during the perioperative period safely and effectively reduces blood loss, transfusion requirements, and/or hospital length of stay in patients undergoing major or complex spine surgery. Although the use of TXA for multilevel spine surgery is increasing, there remains widespread equivocality regarding ideal dosing regimens. Recent evidence suggests that high-dose TXA significantly reduces perioperative blood loss when compared with low-dose TXA, with no increase in perioperative morbidity and mortality. Translating this evidence into sustained change in clinical practice has the potential to improve both outcomes and blood product utilization in patients undergoing major or complex spine surgery.

Video laryngoscopy is useful when direct laryngoscopy fails. However, should video laryngoscopy replace conventional laryngoscopy? We sought evidence updating previous systematic reviews examining whether video laryngoscopy should replace direct laryngoscopy for routine adult intubations performed by experienced anesthesia providers in the operating room. Six randomized controlled trials met the inclusion criteria. All trials compared the success of various video laryngoscopes to Macintosh laryngoscopes. The primary outcome was the first-pass success rate. The secondary outcomes were time to successful intubation and oropharyngeal trauma occurrence. Overall, the evidence suggests there is no difference between video laryngoscopy versus direct laryngoscopy in first-pass endotracheal success rate, time to tracheal intubation, and occurrence of oropharyngeal trauma for adult intubations performed in the operating room. However, an important consideration in interpreting the evidence is that the studies were not uniformly powered to measure the outcomes of interest. Anesthesia providers should consider continuing the use of conventional laryngoscopy for adults not suspected of being difficult to intubate however, a video laryngoscope should be readily available. Future large-scale studies examining the use of the video laryngoscope for all adult intubations are needed.