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    In Defense of P Values.
    AANA J 2016 Oct;84(5):305-308
    Research associate in statistical genetics at the Virginia Institute for Psychiatric and Behavioral Genetics in the Department of Psychiatry at Virginia Commonwealth University, Richmond, Virginia.
    P values have become the scapegoat for a wide variety of problems in science. P values are generally over-emphasized, often incorrectly applied, and in some cases even abused. However, alternative methods of hypothesis testing will likely fall victim to the same criticisms currently leveled at P values if more fundamental changes are not made in the research process. Read More

    AANA Journal Course: Update for Nurse Anesthetists-Part 5-Use of Tranexamic Acid in Preventing Postpartum Hemorrhage.
    AANA J 2016 Dec;84(6):427-438
    Department of Nurse Anesthetist Practice at Florida International University College of Nursing and Health Sciences, Miami, Florida.
    Postpartum hemorrhage (PPH) continues to be a serious complication in both developed and underdeveloped countries. It remains the leading cause of maternal mortality in underdeveloped countries. Implementation of the World Health Organization guidelines of PPH treatment has reduced mortality. Read More

    Laryngeal Mask Airway and Valsalva Maneuver During Ophthalmic Surgery: A Case Report.
    AANA J 2016 Dec;84(6):423-425
    Anesthesiology Department at Mayo Clinic in Jacksonville, Florida.
    The use of a supraglottic airway, also called laryngeal mask airway (LMA), is gaining in popularity for delivery of general anesthesia in certain situations and is shown to be safe. Use of infraglottic airways (tracheal tubes) allows for positive pressure ventilation and maneuvers, such as holding continuous positive pressure in the airway to check for pleural and dural leaks. We describe the successful use of the LMA (Teleflex Inc) for general anesthesia, in which continuous positive airway pressure of 15 cm H2O held for 20 seconds allowed the neurosurgeon to identify the site of a cerebrospinal fluid (CSF) leak and successfully repair the leak. Read More

    Laryngospasm as a Cause of Unsuccessful Placement of Laryngeal Mask Airway ProSeal: A Case Report.
    AANA J 2016 Dec;84(6):420-422
    Department of Anesthesiology and Critical Care at the University College of Medical Sciences.
    Laryngospasm is a potential complication encountered during anesthesia using a laryngeal mask airway (LMA). We report a case in which laryngospasm resulted in unsuccessful placement of an LMA ProSeal Airway (Teleflex Inc), and we discuss the various causes of unsuccessful placement of this type of airway device. Laryngospasm causes increased resistance to gas flow by inducing closure of vocal cords, aryepiglottic fold, and periglottic tissue. Read More

    Low-Dose Vasopressin and Analogues to Treat Intraoperative Refractory Hypotension in Patients Prescribed Angiotensin-Converting Enzyme Inhibitors Undergoing General Anesthesia: A Systematic Review.
    AANA J 2016 Dec;84(6):413-419
    University at Buffalo School of Nursing, Buffalo, New York.
    This review assessed the utility of vasopressin and vasopressin analogues for the treatment of refractory hypotension associated with angiotensin-converting enzyme (ACE) inhibitors in the perioperative setting. A systematic review of the literature was conducted using MEDLINE, Embase, and ProQuest. Six randomized controlled trials met eligibility criteria. Read More

    A Patient Safety Dilemma: Obesity in the Surgical Patient.
    AANA J 2016 Dec;84(6):404-412
    Duke University School of Nursing, Durham, North Carolina.
    Patient safety and the delivery of quality care are major concerns for healthcare in the United States. Special populations (eg, obese patients) need study in order to support patient safety, quantify risks, advance education for healthcare-workers, and establish healthcare policy. Obesity is a complex chronic disease and is considered the second leading cause of preventable death in the United States with approximately 300,000 deaths per year. Read More

    Exploring Strategies to Increase and Sustain Membership in the American Association of Nurse Anesthetists.
    AANA J 2016 Dec;84(6):396-403
    American Association of Nurse Anesthetists in Park Ridge, Illinois.
    The total numbers of Certified Registered Nurse Anesthetists (CRNAs) in the United States and members of the American Association of Nurse Anesthetists (AANA) have risen to an all-time high. However, the percentage of CRNAs who are AANA members has been slowly declining since 2006, particularly among newly certified nurse anesthetists. To develop new strategies to increase and sustain CRNA membership, the AANA conducted a translational research project that explored evidence-based determinants of individuals' decisions to join professional associations, current membership practices and patterns, results of a recent member needs survey, and socialization of student registered nurse anesthetists (SRNAs) into the AANA. Read More

    Consensus Bundle on Prevention of Surgical Site Infections After Major Gynecologic Surgery.
    AANA J 2017 Feb 6;85(1):1-12. Epub 2017 Feb 6.
    Health Policy and strategic Health Care Initiatives, American College of Obstetricians and Gynecologists, Washington, DC.
    Surgical site infections are the most common complication of surgery in the United states. Of surgeries in women of reproductive age, hysterectomy is one of the most frequently performed, second only to cesarean birth. Therefore, prevention of surgical site infections in women undergoing gynecologic surgery is an ideal topic for a patient safety bundle. Read More

    Tranexamic Acid in Anesthetic Management of Surgical Procedures.
    AANA J 2016 Jun;84(3):201-9
    Blood loss during surgical procedures poses a grave risk to the patient, but transfusion is costly and associated with adverse outcomes. Antifibrinolytics, however, offer an economical and effective means of decreasing blood loss associated with surgical procedures. Tranexamic acid (TXA) is an antifibrinolytic that blocks lysine-binding sites of fibrinogen and fibrin, preventing the breakdown of existing clots. Read More

    Unknown Pseudocholinesterase Deficiency in a Patient Undergoing TIVA with Planned Motor Evoked Potential Monitoring: A Case Report.
    AANA J 2016 Jun;84(3):198-200
    Pseudocholinesterase abnormalities are a genetic cause of aberrant metabolism of the depolarizing muscle relaxant succinylcholine. This article examines a case where succinylcholine was chosen to facilitate intubation due to its ultra short duration and the request of the surgeon to monitor motor evoked potentials. Following succinylcholine administration the neurophysiologist was unable to obtain motor evoked potentials. Read More

    Preventive Dorzolamide-Timolol for Rising Intraocular Pressure During Steep Trendelenburg Position Surgery.
    AANA J 2016 Jun;84(3):189-96
    The study purpose was to evaluate preventive use of dorzolamide-timolol ophthalmic solution (Cosopt) during laparoscopic surgery with the patient in steep Trendelenburg (ST) position. Periorbital swelling, venous congestion, and elevated intraocular pressure (IOP) may produce low ocular perfusion. Prompt IOP reduction is important because 30- to 40-minute episodes of acute IOP elevations can result in retinal ganglion cell dysfunction. Read More

    Anesthetic Considerations of Stiff-Person Syndrome: A Case Report.
    AANA J 2016 Jun;84(3):181-7
    Stiff-person syndrome (SPS) is a neurologic disorder characterized by painful involuntary episodes of severe muscle rigidity affecting the axial muscles and extremities. Although the etiology of SPS is unknown, it is suspected to involve the synthesis of γ-aminobutyric acid (GABA). Symptoms of SPS are precipitated by sudden unexpected movements, noises, and stress. Read More

    The Jehovah's Witness Population: Considerations for Preoperative Optimization of Hemoglobin.
    AANA J 2016 Jun;84(3):173-8
    Most members of the Jehovah's Witness community refuse blood transfusions, and there are variations in what alternatives they will accept depending on their personal decisions. To provide culturally competent care, healthcare providers need to be knowledgeable about substitutions for blood administration as well as the risks and benefits of available alternatives so that they can inform their patients. It has been recognized in the literature that preoperative optimization of hemoglobin levels with alternative treatment modalities through a multidisciplinary approach can improve clinical outcomes in patients who refuse blood products. Read More

    Venous Thromboembolism Prophylaxis in Plastic Surgery: A Literature Review.
    AANA J 2016 Jun;84(3):167-72
    Venous thromboembolism (VTE) is a major health concern because it increases morbidity and mortality after a surgical procedure. A number of well-defined, evidence-based guidelines are available delineating suitable use of prophylaxis to prevent deep vein thrombosis and pulmonary embolism. Despite the available literature, there are clear gaps between recommendations and clinical practice, affecting the incidence of VTE. Read More

    Effects of a 30-mL Epidural Normal Saline Bolus on Time to Full Motor Recovery in Parturients Who Received Patient-Controlled Epidural Analgesia With 0.125% Bupivacaine With 2 µg/mL of Fentanyl.
    AANA J 2016 Jun;84(3):159-65
    Previous research suggests that an epidural bolus of 30 mL of normal saline after vaginal delivery may decrease the time for recovery from motor block. A double-blind, randomized controlled study was conducted in 46 parturients to determine if a 30-mL normal saline bolus or sham administered via epidural approach after delivery reduces the time to full motor recovery and the time to 2-dermatome regression. No significant difference was found in time to full motor recovery (saline group 83. Read More

    Thromboelastography: Clinical Application, Interpretation, and Transfusion Management.
    AANA J 2016 Apr;84(2):129-34
    The coagulation cascade is a dynamic process dependent on many factors. It involves interaction between primary hemostasis, platelet clot formation, secondary hemostasis, thrombin generation, and fibrinolysis. The assessment of this process is particularly important in the surgical patient to properly manage hemostatic issues. Read More

    Using a Structured Assessment Tool to Evaluate Nontechnical Skills of Nurse Anesthetists.
    AANA J 2016 Apr;84(2):122-7
    Nontechnical skills are critical for good anesthetic practice but are seldom addressed explicitly in clinical training. The purposes of this study were (1) to evaluate the reliability and validity of the observation-based assessment tool Nurse Anaesthetists' Non-Technical Skills system (N-ANTS) and (2) to evaluate the effect of training nurse anesthetist supervisors in the use of N-ANTS. This system comprises a global rating score, 4 categories, and 15 elements to rate nurse anesthetists' nontechnical skills. Read More

    Design of an Evidence-Based "Second Victim" Curriculum for Nurse Anesthetists.
    AANA J 2016 Apr;84(2):107-13
    The "second victim" phenomenon--when a healthcare provider experiences adverse events because of the adverse events of a patient--is not well known or understood among healthcare professionals, including Certified Registered Nurse Anesthetists (CRNAs). No published research is currently available on the impact of second victim specifically in CRNAs, but it is known that second victim poses major challenges for healthcare professionals. Therefore, it is important to acknowledge its occurrence and to develop an educational curriculum based on the available evidence in order to promote peer and organizational support infrastructures. Read More

    Local Anesthetic Adjuvants Providing the Longest Duration of Analgesia for Single- Injection Peripheral Nerve Blocks in Orthopedic Surgery: A Literature Review.
    AANA J 2016 Apr;84(2):95-103
    Inadequate pain relief after surgery may delay surgical recovery, decrease patient satisfaction, increase length of stay, raise the risk of hospital readmissions, and increase overall healthcare costs. One way to decrease postoperative pain for patients undergoing orthopedic surgery is through the use of peripheral nerve blocks. Anesthesia providers can add many adjuvants to local anesthetics to improve quality and prolong duration of analgesia. Read More

    Effect of Ultrasound-Guided Placement of Difficult-to-Place Peripheral Venous Catheters: A Prospective Study of a Training Program for Nurse Anesthetists.
    AANA J 2016 Apr;84(2):86-92
    Patients with difficult intravenous access (DIVA) often experience discomfort because of failed attempts to place peripheral venous catheters (PVCs); however, ultrasound guidance may improve this problem with catheter placement. The aim of this study was to evaluate the use of ultrasound when operated by nurse anesthetists for these patients. This prospective observational study with a pre/post design focused on inpatients with DIVA referred for PVC placement, a service provided by nurse anesthetists in most Scandinavian hospitals. Read More

    Intrathecal Spread of Injectate Following an Ultrasound-Guided Selective C5 Nerve Root Injection in a Human Cadaver Model.
    AANA J 2016 Apr;84(2):80-4
    Ultrasound-guided selective C5 nerve root blocks have been described in several case reports as a safe and effective means to anesthetize the distal clavicle while maintaining innervation of the upper extremity and preserving diaphragmatic function. In this study, cadavers were injected with 5 mL of 0.5% methylene blue dye under ultrasound guidance to investigate possible proximal and distal spread of injectate along the brachial plexus, if any. Read More

    Residual Neuromuscular Blockade.
    AANA J 2016 Feb;84(1):57-65
    This article provides an update on residual neuromuscular blockade for nurse anesthetists. The neuromuscular junction, pharmacology for producing and reversing neuromuscular blockade, monitoring sites and methods, and patient implications relating to incomplete reversal of neuromuscular blockade are reviewed. Overall recommendations include using multiple settings when employing a peripheral nerve stimulator for monitoring return of neuromuscular function and administering pharmacologic reversal when the train-of-four ratio is below 0. Read More

    Anesthetic Considerations for the Patient With Cyclic Vomiting Syndrome.
    AANA J 2016 Feb;84(1):52-5
    Cyclic vomiting syndrome (CVS) is characterized by intense vomiting, recurrent emergency department visits, and return to usual health status between episodes. This syndrome was first described in 1882 in a case series of pediatric patients, but there is growing understanding that CVS may occur in other age groups. This case report describes a 23-year-old with a history of CVS diagnosed in adolescence presenting for revision of a tibial plateau fracture. Read More

    Effect of a Nontechnical Skills Intervention on First-Year Student Registered Nurse Anesthetists' Skills During Crisis Simulation.
    AANA J 2016 Feb;84(1):46-51
    Simulation-based education provides a safe place for student registered nurse anesthetists to practice non-technical skills before entering the clinical arena. An anesthetist's lack of nontechnical skills contributes to adverse patient outcomes. The purpose of this study was to determine whether an educational intervention on nontechnical skills could improve the performance of nontechnical skills during anesthesia crisis simulation with a group of first-year student registered nurse anesthetists. Read More

    Effective Ventilation Strategies for Obese Patients Undergoing Bariatric Surgery: A Literature Review.
    AANA J 2016 Feb;84(1):35-45
    Obesity causes major alterations in pulmonary mechanics. Obese patients undergoing bariatric surgery present mechanical ventilation-related challenges that may lead to perioperative complications. Databases were systematically searched for clinical trials of ventilation maneuvers for obese patients and bariatric surgery. Read More

    A Hypotensive/Bradycardic Episode Leading to Asystole in a Patient Undergoing Shoulder Arthroscopy in the Sitting Position With Interscalene Block and Intravenous Sedation: A Case Report.
    AANA J 2016 Feb;84(1):27-33
    Anesthesia for shoulder surgery is often accomplished by means of an interscalene block and intravenous sedation, with the patient subsequently placed in the sitting position for surgical access. Despite the advantages of this popular technique, sudden unheralded and severe hypotensive/bradycardic episodes have been reported in this population, with an incidence of 13% to 24%. Although these episodes are usually transient and resolve spontaneously, there are case reports of progression to asystolic cardiac arrest following hypotensive/bradycardic episodes. Read More

    Intrathecal Opioid-Induced Hypothermia Following Subarachnoid Block With Morphine Injection for Elective Cesarean Delivery: A Case Report.
    AANA J 2016 Feb;84(1):23-6
    Opioids have been administered intrathecally with subarachnoid block for postoperative pain relief in parturients undergoing elective cesarean deliveries. This case report presents the uncommon occurrence of intrathecal opioid-induced hypothermia in the latent phase of recovery following elective cesarean delivery. There are few case reports on the occurrence of latent-phase postanesthesia care hypothermia in patients receiving subarachnoid block with morphine sulfate injection (Duramorph). Read More

    Nonpharmacologic Neuraxial Interventions for Prophylaxis of Postdural Puncture Headache in the Obstetric Patient.
    AANA J 2016 Feb;84(1):15-22
    Postdural puncture headache due to accidental dural puncture during epidural catheter placement is a source of morbidity for new mothers. It can interfere with maternal-newborn bonding and increase the length of hospitalization. This evidence-based article examined the question: For obstetric patients experiencing an accidental dural puncture during epidural placement, which nonpharmacologic prophylactic neuraxial interventions safely and effectively decrease the incidence of postdural puncture headache? A search of online databases revealed 4 systematic reviews with meta-analysis and a randomized controlled trial meeting the inclusion criteria. Read More

    A Review of Nonsteroidal Anti-inflammatory Drugs.
    AANA J 2015 Dec;83(6):425-33
    It is essential that nurse anesthetists are aware of the potential side effects and interaction of drugs that patients are taking before administering an anesthetic. Among the most commonly taken medications are nonsteroidal anti-inflammatory drugs (NSAIDs). Because these drugs have become almost ubiquitous, there is a risk underestimating potential effects, which may be harmful for the patient undergoing anesthesia and surgery. Read More

    Influence of Patients' "Sense of Coherence" on Main Postoperative Variables in the Postanesthesia Care Unit: A Cross-Sectional Study.
    AANA J 2015 Dec;83(6):417-23
    The objective of this study was to investigate whether patients' sense of coherence (SOC)--ability to comprehend their whole situation and their capacity to use available resources--influences acute postoperative complications in the postanesthesia care unit (PACU). We hypothesized that patients' SOC would be negatively related to their experience of pain and nausea, consumption of opioids, and length of stay in the PACU--the higher the SOC, the lower the experience of pain and nausea, less consumption of opioids, and shorter PACU stay. Data were collected from the anesthesia and electronic medical records, and combined with a questionnaire. Read More

    Discovery of Modern Anesthesia: A Counterfactual Narrative about Crawford W. Long, Horace Wells, Charles T. Jackson, and William T. G. Morton.
    AANA J 2015 Dec;83(6):410-5
    The discovery of anesthesia occurred during a narrow time span in the mid-19th century, but there is no agreement about who deserves credit for this important American contribution to medicine. Based mostly on an examination of primary sources, we explore how formal and informal interactions between the principals affected their careers, lives, and attribution of credit for the discovery of anesthesia. There should be no controversy as to which individual deserves credit for the discovery of anesthesia if credit is ascribed for specific contributions. Read More

    Comparison of Successful Intubation Between Video Laryngoscopy View Before Attempted Intubation and Direct Laryngoscopic Intubation by Student Registered Nurse Anesthetists: A Pilot Study.
    AANA J 2015 Dec;83(6):403-8
    Airway management is a primary focus when student registered nurse anesthetists (SRNAs) begin clinical rotations in their nurse anesthesia program. Successful endotracheal intubation requires both knowledge of and experience with the airway and its structures. Lack of clinical maturity and unfamiliarity with the patient airway intensifies student anxiety in the clinical arena. Read More

    Malfunction of the Expiratory Valve During Spontaneous Ventilation.
    AANA J 2015 Dec;83(6):400-2
    The integrity of inspiratory and expiratory unidirectional valves is very important in the normal functioning of an anesthetic circle breathing system. We describe our experience of an emergency manipulation of a ceramic valve disk of a circle breathing system (Dräger Fabius GS, Dräger Medical Inc) that altered its characteristics and led to rebreathing only during spontaneous ventilation. Read More

    Methods to Improve Success With the GlideScope Video Laryngoscope.
    AANA J 2015 Dec;83(6):389-97
    Occasionally intubation of patients is difficult using a video laryngoscope (GlideScope, Verathon Medical) because of an inability to guide the endotracheal tube to the glottis or pass the tube into the trachea despite an adequate view of the glottis. We examined methods to improve success when this difficulty occurs. A literature search revealed 253 potential sources, with 25 meeting search criteria: 7 randomized controlled trials, 4 descriptive studies, 8 case series, and 6 case reports. Read More

    Process Improvement: Addressing Attrition from the Uniformed Services University of the Health Sciences Nurse Anesthesia Program.
    AANA J 2015 Oct;83(5):351-6
    This retrospective cohort study examined the Uniformed Services University of the Health Sciences Registered Nurse Anesthesia program to identify reasons for high attrition rates. Relevant data were examined for 180 students enrolled in classes from 2005 through 2011. During that period, 40 students were dismissed or disenrolled, with the highest attrition rate (35%) occurring in the class of 2010. Read More

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