Supporting CRNA Clinical Practice: A Review of New and Updated Professional Practice Documents

The American Association of Nurse Anesthesiology (AANA) Practice Committee, in collaboration with AANA Professional Practice staff, advisory panels, and subject matter experts, annually applies a standardized evidence-based process to review, evaluate, and revise clinical resource documents found in the Professional Practice Manual for the CRNA (Certified Registered Nurse Anesthetist) and on the AANA website. This article highlights several revised and newly developed documents, which include topics such as diversity, equity, and inclusion, anesthesia and analgesia for obstetric patients, and safe injection guidelines.

The Utility of BIS™ Monitoring in Anesthesia for Elderly Patients

Aging leads to anatomic and physiologic changes in the brain, making it more sensitive to the depressant effects of anesthetic medications and increasing the risk of postoperative neurocognitive complications such as postoperative delirium and postoperative cognitive dysfunction. This article explores the implications of anesthesia on elderly patients' brain health, emphasizing the heightened risk of postoperative neurocognitive disorders, and describes the BIS™ Monitoring System as a neuromonitoring tool for anesthesia professionals to assess the depth of anesthesia. The integration of the BIS Monitoring System into clinical practice can contribute to a more tailored and patient-centered approach to anesthesia management, ultimately improving perioperative outcomes and safety.

Analysis of a Needs Assessment Survey to Develop an Online Resource Repository Supporting Nurse Anesthesia Educators

BACKGROUND

Without highly qualified nurse anesthesia educators and administrators, the health care system will be threatened by the inadequate supply of certified registered nurse anesthetists (CRNAs).

PURPOSE

American Association of Nurse Anesthesiologists' Faculty Stabilization Task Force (FSTF) analyzed reasons for high faculty turnover and developed recommendations to support nurse anesthesia faculty and administrators.

METHODS

A survey evaluated participants' current role, leadership development opportunities, mentorship experiences, and resource needs.

RESULTS

Of 109 respondents, 87 (80%) were program administrators or assistant administrators with less than 5 years of experience in their role. Despite academic experience, 51% felt adequately prepared for their role.

CONCLUSIONS

The FSTF provided 2 recommendations: to create a robust faculty development program for all faculty at all levels of CRNA education and a repository of information needed for program administrators and faculty to oversee and educate students in a high-quality CRNA program.

The burden of skin and soft tissue, bone and joint infections in an Australian cohort of people who inject drugs

INTRODUCTION

There are currently limited data regarding the clinical and economic significance of skin and soft tissue infections (SSTI) and bone and joint infections in Australian people who inject drugs (PWID).

METHODS

Retrospective cohort study in adult PWID admitted to Monash Health, a large heath care network with six hospitals in Victoria, Australia. Inpatients were identified using administrative datasets and International Classification of Disease (ICD-10) coding for specific infection-related conditions. Cost analysis was based on mean ward, intensive care and hospital-in-the-home (HITH) lengths of stay. Spinal infections and endocarditis were excluded as part of previous studies.

RESULTS

A total of 185 PWID (61 female, 124 male, median age 37) meeting the study criteria were admitted to Monash Health between January 2010 and January 2021. Admitting diagnoses included 78 skin abscesses, 80 cellulitis, 17 septic arthritis, 4 osteomyelitis, 3 thrombophlebitis and 1 each of necrotising fasciitis, vasculitis and myositis. Pain (87.5%) and swelling (75.1%) were the most common presenting complaints. Opioids (67.4%) and methamphetamine (37.5%) were the most common primary drugs injected. Almost half (46.5%) of patients had concurrent active hepatitis C (HCV) infection on admission. Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV) were uncommon. The most significant causative organism was methicillin-susceptible Staphylococcus aureus (24.9%). In 40.0% (74/185) no organism was identified. Patients required a median acute hospital stay of 5 days (2-51 days). There were 15 patients admitted to the intensive care unit (ICU) with median duration 2 days. PICC line insertion for antibiotics was required in 16.8% of patients, while 51.4% required surgical intervention. Median duration of both oral and IV antibiotic therapy was 11 days. Almost half (48.6%) of patients were enrolled in an opioid maintenance program on discharge. Average estimated expenditure was AUD $16, 528 per admission.

CONCLUSION

Skin and soft tissue and joint infections are a major cause of morbidity for PWID. Admission to hospital provides opportunistic involvement of addiction specialty services.

The genomes of Hercules beetles reveal putative adaptive loci and distinct demographic histories in pristine North American forests

Beetles, despite their remarkable biodiversity and a long history of research, remain lacking in reference genomes annotated with structural variations in loci of adaptive significance. We sequenced and assembled high-quality chromosome-level genomes of four Hercules beetles which exhibit divergence in male horn size and shape and body colouration. The four Hercules beetle genomes were assembled to 11 pseudo-chromosomes, where the three genomes assembled using Nanopore data (Dynastes grantii, D. hyllus and D. tityus) were mapped to the genome assembled using PacBio + Hi-C data (D. maya). We demonstrated a striking similarity in genome structure among the four species. This conservative genome structure may be attributed to our use of the D. maya assembly as the reference; however, it is worth noting that such a conservative genome structure is a recurring phenomenon among scarab beetles. We further identified homologues of nine and three candidate-gene families that may be associated with the evolution of horn structure and body colouration respectively. Structural variations in Scr and Ebony2 were detected and discussed for their putative impacts on generating morphological diversity in beetles. We also reconstructed the demographic histories of the four Hercules beetles using heterozygosity information from the diploid genomes. We found that the demographic histories of the beetles closely recapitulated historical changes in suitable forest habitats driven by climate shifts.

Impact of changing from autopsy to post-mortem CT in an entire HM Coroner region due to a shortage of available pathologists

A significant problem facing routine medicolegal coroner-referred autopsies is a shortfall of pathologists prepared to perform them. This was particularly acute in Lancashire, where the coroner decided to initiate a service that relied on post-mortem computed tomography (PMCT). This involved training anatomical pathology technologists (APTs) to perform external examinations, radiographers to perform scans, and radiologists to interpret them. The service started in 2018 and now examines over 1,500 cases per year. This study outlines the PMCT process using NHS staff, with CT equipment and logistics managed by the commercial sector. It compares the demographics and outcomes of PM investigations for two 6-month periods: the autopsy service prior to 2018, and then the PMCT service. These data were then compared with previous UK PMCT data. Referrals for adult non-suspicious deaths were made in 913 cases of which 793 (87%) had PMCT between 01/10/2018 and 31/03/2019. Fifty-six cases had autopsy after PMCT, so 81% of cases potentially avoided autopsy. The PMCT service did not delay release of bodies to the next-of-kin. Comparing the cause of death given shows no difference in the proportions of natural and unnatural deaths. There was an increase in diagnosis of coronary artery disease for PMCT, with less respiratory diagnoses, a feature not previously demonstrated. These data suggest PMCT is a practical solution for potentially failing autopsy services. By necessity, this involves changes in diagnoses, as PMCT and autopsy have different strengths and weakness, but the ability to pick up unnatural death appears unaffected.

Impact of the COVID-19 pandemic on a post-mortem CT service for adult non-suspicious death

Due to the COVID-19 pandemic, the post-mortem computed tomography (PMCT) service was expanded from three to seven cases per day to help mortuary services and avoid invasive autopsy. Additional targeted angiography and pulmonary ventilation procedures were stopped and triage rules relaxed to allow more indications to be scanned, including those requiring toxicology. A service evaluation was performed for the first 3-months of the COVID-19 pandemic compared to the equivalent period the previous year to study the impact of these changes. It was found that, despite the increase in deaths regionally, coronial referrals remained about 100 per month, a reduction in referral rate. The number undergoing PMCT rose from 28% to 74% of cases. Turnaround time remained the same. For cases triaged to PMCT, the need for subsequent autopsy increased from 7.9% to 15.8%. No significant changes were seen in diagnosis rates, including cardiac or respiratory. There was an increase in patients with coronary death without severe coronary calcification who underwent autopsy after PMCT. These may have been diagnosed by targeted coronary angiography. Fifty-three cases requiring toxicology/biochemistry had PMCT, with 38 having PMCT only. In 8/11 (72.7%) cases with normal PMCT and toxicology as the key diagnostic test, autopsy was performed prior to results. This suggests the pathology team were reluctant to risk an "unascertained" outcome. This study shows that it is possible to increase PMCT services by widening referral criteria and by limiting the use of enhanced imaging techniques, without significantly changing diagnosis rates of key diseases; however, selectively restarting targeted angiography may help avoid autopsy in some cases.

Integrating the ASRA Pain Medicine Cannabis Consensus Guidelines into Certified Registered Nurse Anesthetist Clinical Practice

The American Association of Nurse Anesthesiology Practice Committee and subject matter experts recently evaluated newly published cannabis guidelines titled "ASRA Pain Medicine Consensus Guidelines on the Management of the Perioperative Patient on Cannabis and Cannabinoids." A summative review of the evidence-based guidelines provides essential recommendations, which are directly applicable to certified registered nurse anesthetist clinical practice.

Long-read sequencing data reveals dynamic evolution of mitochondrial genome size and the phylogenetic utility of mitochondrial DNA in Hercules beetles (Dynastes; Scarabaeidae)

The evolutionary dynamics and phylogenetic utility of mitochondrial genomes (mitogenomes) have been of particular interest to systematists and evolutionary biologists. However, certain mitochondrial features, such as the molecular evolution of the control region in insects, remain poorly explored due to technological constraints. Using a combination of long- and short-read sequencing data, we assembled ten complete mitogenomes from ten Hercules beetles. We found large-sized mitogenomes (from 24 to 28 kb), which are among the largest in insects. The variation in genome size can be attributed to copy-number evolution of tandem repeats in the control region. Furthermore, one type of tandem repeat was found flanking the conserved sequence block in the control region. Importantly, such variation, which made up around 30% of the size of the mitogenome, may only become detectable should long-read sequencing technology be applied. We also found that, although different mitochondrial loci often inferred different phylogenetic histories, none of the mitochondrial loci statistically reject a concatenated mitochondrial phylogeny, supporting the hypothesis that all mitochondrial loci share a single genealogical history. We on the other hand reported statistical support for mito-nuclear phylogenetic discordance in 50% of mitochondrial loci. We argue that long-read DNA sequencing should become a standard application in the rapidly growing field of mitogenome sequencing. Furthermore, mitochondrial gene trees may differ even though they share a common genealogical history, and ND loci could be better candidates for phylogenetics than the commonly used COX1.

Supporting the Foundation of Nurse Anesthesia Education: A Report of the Faculty Stabilization Taskforce

Without highly qualified educators and educational program administrators, the ability to provide anesthesia and pain management services throughout the healthcare system will be threatened by the inadequate supply of Certified Registered Nurse Anesthetists (CRNAs). The average turnover rate between the years 2016-2020, for CRNA program administrators, was 15% with some programs changing leadership as often as every two to four years. In response, the American Association of Nurse Anesthesiology (AANA) and the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) created the Faculty Stabilization Taskforce (FSTF) to review reasons for the high turnover rate and to develop methods and tools to support program faculty and administrators in their role of educating the future CRNA workforce. The FSTF provided two recommendations: 1) to create a robust faculty development program for all faculty at all levels of CRNA education, and 2) to create a repository of information needed to administrate, and educate students, in a high-quality CRNA program. This article summarizes the report made to the AANA Board of Directors (BOD) which was unanimously accepted and is already being implemented by AANA and COA staff. The full text of the report can be found on the AANA's website at www.aana.com/FSTF.

A Review of New and Updated Professional Practice Documents

The American Association of Nurse Anesthesiology (AANA) Practice Committee, in collaboration with AANA Professional Practice staff, advisory panels, and subject matter experts, applies a standardized evidence-based process to review, evaluate, and revise clinical resource documents found in the Professional Practice Manual for the CRNA (Certified Registered Nurse Anesthetist) and on the AANA website. This article highlights several revised and newly developed practice documents, which include topics such as the scope of nurse anesthesia practice, point of care ultrasound in anesthesia care, anesthesia for patients with substance use disorder, office-based dental anesthesia, workplace civility, and health disparities.

Incipient speciation and its impact on taxonomic decision: a case study using a sky island sister-species pair of stag beetles (Lucanidae: Lucanus)

Species delimitation can be difficult when the divergence between focal taxa is in the incipient stage of speciation, because conflicting results are expected among different data sets, and the species limits can differ depending on the species concept applied. We studied speciation history and investigated the impact on taxonomic decision-making when using different types of data in a Taiwanese endemic sister-species pair of stag beetles, Lucanus miwai and Lucanus yulaoensis, from sky island habitats. We showed that the two geographical taxa can be diagnosed by male mandibular shape. We found two mitochondrial co1 lineages with pairwise sequence divergence > 3%; however, L. miwai might not be monophyletic. The result of our multispecies coalescent-based species delimitation using five nuclear loci supported the evolutionary independence of the two sister species, but the calculated values of the genealogical divergence index (gdi) corresponded to the ambiguous zone of species delimitation. We also showed that post-divergence gene flow is unlikely. Our study demonstrates challenges in the delineation of incipient species, but shows the importance of understanding the speciation history and adopting integrative approaches to reconcile seemingly conflicting results before making evolutionarily relevant taxonomic decisions.

Experimental Observations of Laser-Driven Tin Ejecta Microjet Interactions

The study of high-velocity particle-laden flow interactions is of importance for the understanding of a wide range of natural phenomena, ranging from planetary formation to cloud interactions. Experimental observations of particle dynamics are sparse given the difficulty of generating high-velocity flows of many particles. Ejecta microjets are micron-scale jets formed by strong shocks interacting with imprinted surfaces to generate particle plumes traveling at several kilometers per second. As such, the interaction of two ejecta microjets provides a novel experimental methodology to study interacting particle streams. In this Letter, we report the first time sequences of x-ray radiography images of two interacting tin ejecta microjets taken on a platform designed for the OMEGA Extended Performance (OMEGA EP) laser. We observe that the microjets pass through each other unattenuated for the case of 11.7±3.2  GPa shock pressures and jet velocities of 2.2±0.5  km/s but show strong interaction dynamics for 116.0±6.1  GPa shock pressures and jet velocities of 6.5±0.5  km/s. We find that radiation-hydrodynamic simulations of the experiments are able to capture many aspects of the collisional behavior, such as the attenuation of jet velocity in the direction of propagation, but are unable to match the full spread of the strongly interacting cloud.

Creating a Cognitive Aid for Use During Intraoperative Power Failures

An intraoperative power failure (IOPF) is a complete or partial absence of the electrical power supply with or without the availability of a backup generator system during an operative or other invasive procedure. An IOPF can be stressful for the OR team and puts surgical patients at risk for adverse outcomes. To prepare providers for an IOPF, a CRNA piloted a project to create an evidence-based, facility-specific cognitive aid (CA) to guide decision making and enhance patient management and outcomes during an IOPF. The project team tested the battery-power capabilities of essential anesthesia equipment, including anesthesia gas machines, IV pumps, and vital sign monitors, and included the results in the CA. A needs assessment survey was sent to the anesthesia professionals at the facility to promote clinician buy-in and solicit feedback for creating the CA.

Basic Airway Management for the Professional Nurse

The registered nurse (RN) on a medical-surgical nursing unit may be the first health care professional to encounter a patient with the signs of impending respiratory failure. Importantly, the RN must recognize the signs of respiratory compromise and possess the competence and confidence to intervene without delay. Signs of respiratory deterioration, physical assessment, and respiratory laboratory studies are reviewed. Modes of oxygen therapy, basic airway management techniques, including bag mask ventilation, and use of oropharyngeal and nasopharyngeal airways are discussed. The assembly of equipment and medications frequently used for intubation are also outlined.

Faculty development workshop on gender-associated incivility in nursing education

BACKGROUND

Men comprise the minority of entry-level baccalaureate nursing students and are at increased risk of experiencing gender-associated incivility.

PROBLEM

Uncivil peer-to-peer behavior can negatively affect students' mental and physical well-being, and learning experience. Nursing faculty must be able to identify and address gender-associated incivility among students.

AIM

The purpose of this quality improvement program was to train nursing faculty to prevent, identify, and manage gender-associated incivility in the educational environment.

METHODS

A day-long interactive workshop utilizing trigger films, small group discussions, and interactive theater was developed to train nursing faculty to implement proactive and reactive techniques to address uncivil behavior which will enhance the learning environment for all students. Utilizing Kirkpatrick's Model of Evaluation, participants were surveyed at the conclusion of the workshop and four months postworkshop to evaluate their learning and its implementation.

RESULTS

Participants gained greater understanding of the impact of gender-associated incivility and felt both empowered and better prepared to manage gender-associated conflict.

CONCLUSION

Similar approaches may be useful for schools of nursing that wish to empower their nursing faculty to support an equitable nursing education environment free of gender-associated incivility.

Evolution of adult male horn developmental phenotypes and character displacement in Xylotrupes beetles (Scarabaeidae)

Character displacement that leads to divergent phenotypes between sympatric species has been hypothesized to facilitate coexistence and promote the accumulation of biodiversity. However, there are alternative evolutionary mechanisms that may also lead to the evolution of phenotypic divergence between sympatric species; one of the mechanisms is evolutionary contingency. We studied the evolution of the presence and absence of a major male horn phenotype, which may have ecological implications for promoting coexistence between sympatric beetles, across geographic populations from different Xylotrupes beetles. By using a previously published phylogeny with 80 Xylotrupes taxa, we estimated the transition rates between the two phenotypic states (i.e., presence vs. absence of a major male phenotype). Based on the estimated transition rates, we then simulated possible phenotypic outcomes between sympatric species. We found that sympatric species were equally likely to evolve the same versus distinct phenotypic states based on the estimated transition rates given the phylogeny. The empirically observed number of sympatric species showing different phenotypic states can be explained by evolutionary contingency alone. We discussed the importance of applying phylogenetic comparative methods when studying phenotypic evolution and more generally to investigate the effect of stochastic processes before making deterministic inferences.

Isolation by geographical distance after release from Pleistocene refugia explains genetic and phenotypic variation in Xylotrupes siamensis (Coleoptera: Scarabaeidae)

Consistent and objective species delimitation is crucial to biodiversity studies, but challenges remain when conflicting taxonomic decisions have been made because different data sets and analytical methods were used to delineate species. In the rhinoceros beetle, Xylotrupes siamensis, the use of different morphological characters has resulted in taxonomic disagreement between studies. We used three molecular loci (mitochondrial CO1 and nuclear ITS2 and H3) to investigate the genetic divergence between populations exhibiting different male horn phenotypes. We also applied an approximate Bayesian computation approach to test alternative historical hypotheses that might explain the present genetic diversity among geographical populations. Furthermore, we used species distribution models to estimate the temporal variation in the geographical distribution of suitable habitats. The results show that the two phenotypic taxa within X. siamensis are not genetically structured and that their genetic structure can be explained using isolation by geographical distance. The emergence of the two phenotypic taxa might have been associated with historical isolation in separate refugia. However, spatial expansion and genetic interchange between populations might have gradually eroded the spatial genetic structure. We demonstrate that understanding the historical processes responsible for phenotypic divergence and genetic diversity among current populations could help with making evolutionarily coherent taxonomic decisions.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Using a Retrospective Secondary Data Analysis to Identify Risk Factors for Pulmonary Complications in Trauma Patients in Pietermaritzburg, South Africa

BACKGROUND

The trauma burden in South Africa is significant. The objective of this project was to investigate the incidence of posttrauma pulmonary complications (PPCs) and to identify patient, health risks, and hospital factors, which predispose trauma patients to develop PPCs hospital in Pietermaritzburg, South Africa.

METHODS

The design was a retrospective secondary data analysis of patients who presented as a trauma admission via the health systems' Hybrid Electronic Medical Registry. The final data set included 6382 trauma admissions.

RESULTS

The PPC rate was 9.4% for patients with a surgical intervention versus 1.9% for those without a surgical intervention. Of the total 289 PPCs reported, the most common included pneumonia or atelectasis (46.4%) and prolonged ventilation (36.0%). The risk of developing a PPC was statistically significantly (P < 0.0001) associated with surgical intervention and the number of surgeries.

CONCLUSIONS

The trauma burden in South Africa requires complex medical and surgical interventions. The incidence of PPCs is significantly associated with surgical intervention. With the increasing demand to harness data and improve patient care, the Hybrid Electronic Medical Registry proves to be a driver for quality improvement.

Point-of-Care Ultrasound in Anesthesia Care: New AANA Practice Document Adopted by AANA Board of Directors

The American Association of Nurse Anesthetists recently released a practice considerations document titled, "Point-of-Care Ultrasound in Anesthesia Care," that clinicians, administrators, and other stakeholders are encouraged to download and read in their entirety, available at aana.com/PracticeManual.