Proposed Evidence-based Practice Guidelines for Using Esmolol to Blunt the Sympathetic Stress Response to Laryngoscopy and Intubation

Direct laryngoscopy (DL) and endotracheal intubation (ETI) are standard procedures performed during general anesthetic induction, which provoke a sympathetic stress response that can result in intraoperative hemodynamic instability. Traditional agents like lidocaine and fentanyl, commonly used to mitigate the stress response, have limitations and can lead to adverse effects. Recent literature suggests that esmolol, an ultra-short-acting, cardio-selective beta-1 adrenergic receptor antagonist, may be an effective alternative due to its rapid onset, short duration, and minimal side effects. This final scholarly project (FSP) aims to develop evidence-based practice guidelines for using esmolol as an adjunctive induction agent. A systematic literature review identified the efficacy and safety of administering a 1.5 mg/kg esmolol bolus three minutes before DL. The FSP will engage an interdisciplinary team to implement and evaluate the developed guidelines in a central Ohio hospital system. Baseline and intervention data on blood pressure, heart rate, and rate pressure product will be collected on 150 patients to assess the impact of an esmolol bolus on stress response attenuation during induction relative to traditional agents. Achieving a statistically significant improvement in hemodynamic stability will support esmolol’s adoption as a preferred induction agent. The FSP will provide clinical insights into optimizing anesthesia practices to enhance intraoperative patient safety and reduce opioid reliance. Should the desired outcomes be unmet, further research will be initiated to identify influencing factors and refine the esmolol induction guidelines accordingly

Integrating the Transversus Abdominis Plane Block into an ERAS Protocol for Bariatric Surgery Patients

This Doctor of Nursing Practice (DNP) project investigates the integration of the Transversus Abdominis Plane (TAP) block into Enhanced Recovery After Surgery (ERAS) guidelines for bariatric surgery patients, aiming to improve postoperative outcomes by reducing opioid consumption, time to ambulation, and hospital length of stay (LOS). Bariatric patients who undergo sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) frequently encounter challenges with postoperative pain, increasing opioid use, delaying postoperative time to ambulation, and increasing postoperative hospital LOS. Prolonged postoperative hospitalization increases the financial impact on the healthcare system, and bariatric patients who have a longer postoperative LOS have a higher rate of readmission. While the TAP block has shown promise in enhancing postoperative analgesia and reducing reliance on opioids, it remains underutilized in clinical settings. This DNP project utilizes the Iowa Model of Evidence-Based Practice to guide the development, pilot implementation, and hospital-wide adoption of the TAP block within an ERAS guideline for bariatric patients. A multidisciplinary team has designed and implemented an intervention that could be evaluated by incorporating a small-scale pilot study to evaluate its impact on patient outcomes. The anticipated outcomes include a 20% reduction in opioid use, earlier ambulation, and shorter LOS, contributing to improved patient satisfaction and decreased healthcare costs. This proposed project can potentially standardize the TAP block as an integral part of and ERAS guideline, enhancing recovery for bariatric surgery patients in rural community hospitals

Evidence-Based Guidelines for Intraoperative Quantitative Neuromuscular Monitoring

Nondepolarizing neuromuscular blocking agents are routinely used medications vital to anesthetic care. When administering neuromuscular blocking agents, monitoring neuromuscular blockade depth and degree of recovery is a standard of nurse anesthesia practice to facilitate adequate recovery. If not adequately reversed, postoperative residual neuromuscular blockade can cause severe complications. Traditional qualitative neuromuscular monitoring practices largely contribute to the continuing high incidence of postoperative residual neuromuscular blockade, as supported by research that qualitative monitoring methods are insensitive to the depth of blockade and clinical situations, providing unreliable physiologic information. As recommended in practice guidelines by the American Society of Anesthesiologists, quantitative neuromuscular monitoring offers objective neuromuscular function measurements that are shown to reduce the incidence of postoperative residual neuromuscular blockade, hypoxemia, and muscle weakness. This proposed scholarly project focuses on implementing guidelines for reversing nondepolarizing neuromuscular blocking agents using intraoperative quantitative neuromuscular monitoring. During implementation, data will be collected on the incidence of postoperative residual neuromuscular blockade, hypoxemia, and muscle weakness. The quantitative data will be analyzed and compared to traditional qualitative monitoring data. The project team predicts a statistical decrease in the incidence of postoperative residual neuromuscular blockade, hypoxemia, and muscle weakness in patients monitored using quantitative monitoring. Therefore, standardization of quantitatively monitoring neuromuscular blockade into guidelines for routine practice is essential

Evidence-Based Practice Guidelines for Lung Protective Ventilation in Adult Patients Undergoing Abdominal Laparoscopic Surgery

The rise in abdominal laparoscopic surgeries has underscored the need for improved ventilation strategies to reduce postoperative pulmonary complications, such as atelectasis, ventilator-induced lung injury, and pneumonia. These complications can increase hospital stays, healthcare costs, and mortality. This final scholarly project investigates the impact of lung protective ventilation in adult patients undergoing abdominal laparoscopic procedures and proposes guidelines for implementation. Lung protective ventilation strategies, including low tidal volume ventilation, individualized positive end-expiratory pressure, and recruitment maneuvers. Current research shows potential in mitigating postoperative pulmonary complications by improving intraoperative oxygenation and lung compliance. Using the Johns Hopkins Evidence-Based Practice model, this project critically reviews current literature, identifies gaps in practice, and formulates an evidence-based framework tailored for the perioperative setting. The primary aim was to develop and standardize lung protective ventilation guidelines to enhance patient outcomes and minimize postoperative pulmonary complications’ clinical and economic impacts. The secondary aim was to increase adherence to lung protective ventilation practices among Certified Registered Nurse Anesthetists and anesthesia teams through education and structured implementation protocols. Findings from this project are intended to support the broader adoption of lung protective ventilation in clinical practice, setting a new standard for safer, more effective ventilation management during laparoscopic surgery

Hypothermia Prevention in Major Trauma Patients

Traumatic injuries present a significant health challenge for providers, often resulting in hypothermia, coagulopathy, and acidosis, referred to as the trauma triad of death. Hypothermia significantly impacts trauma patients\u27 outcomes and exacerbates morbidity and mortality rates, particularly in trauma cases with high injury severity scores who require immediate surgical intervention. Despite the detrimental effects of hypothermia, evidence-based approaches to treating hypothermia in this population are lacking. Traditional warming methods heavily rely on provider preference and can lead to inconsistent care. Rapid, reliable, and effective resuscitation interventions are essential in the immediate care of major trauma patients. The proposed project will create evidence-based guidelines for the prevention of hypothermia in trauma patients arriving to the emergency room and operating room. After receiving approval from hospital administration, the project team will gather data from previous major trauma patients and educate nursing and anesthesia staff on the new hypothermia guidelines. The trial period will last eight months. After completion of the trial period, data gathered will evaluate the effectiveness of the guidelines in preventing the incidence of hypothermia. The project team expects the implementation of practice guidelines will decrease the incidence of hypothermia in major trauma patients who require immediate surgery. Effective prevention of hypothermia in trauma patients necessitates a multifaceted approach. By integrating innovative temperature control solutions into trauma resuscitation protocols, healthcare providers can mitigate the detrimental effects of hypothermia, ultimately saving lives and improving patient care

Evidenced-Based Practice Guideline Development: The Addition of Adjunctive Dexmedetomidine in Brachial Plexus Blocks for Upper Arthroscopic Surgery

Dexmedetomidine (DEX) is an alpha-2 adrenergic agonist increasingly studied as an adjunct in brachial plexus blocks (BPBs) to enhance postoperative pain management. This project examines the efficacy of DEX as an adjunct in BPBs for upper extremity arthroscopic surgeries, focusing on its ability to extend analgesia duration, reduce opioid use, and enhance patient satisfaction. With analgesic and sedative properties, DEX can improve postoperative pain management with minimal side effects, providing shortened hospital stays, decreased costs, and better patient outcomes. Using the Iowa Model for evidence-based practice, baseline data on postoperative pain, analgesia duration, and opioid use will be collected from patients receiving standard BPBs, establishing control metrics. During the trial, 50 patients will be randomized to receive DEX-adjunct BPBs or standard BPBs with lidocaine. Key outcomes, including analgesia duration and opioid consumption, will be analyzed with two-sample t-tests, and logistic regression will be used to assess binary outcomes of opioid use. Patient satisfaction, measured via Likert scale surveys, will be evaluated using descriptive statistics and t-tests. Preliminary evidence suggests that DEX can significantly reduce pain and opioid consumption postoperatively. This study aims to confirm these benefits with a Quality Improvement (QI) review to ensure protocol adherence and data quality through chart audits and electronic medical record (EMR) reviews. Findings will be shared with stakeholders and published in medical journals to promote DEX’s use in BPBs. If successful, the project could lead to broader adoption of DEX in BPBs

Proposed Evidence-Based Practice Consideration: The Use of Remimazolam Tosilate Instead of Propofol for Endoscopic Procedures Under Monitored Anesthesia Care in the Elderly Population

Endoscopic procedures are essential for diagnosing and managing gastrointestinal conditions, particularly in a growing elderly population. The selection of sedative agents significantly influences patient safety and procedural outcomes. Propofol, the traditional choice, is successful but associated with risks such as hypotension, bradycardia, and respiratory depression, particularly in elderly patients. This hypothetical Doctor of Nursing Practice (DNP) project explores the use of remimazolam tosilate (RT), a novel ultra-short-acting benzodiazepine, as an alternative to propofol during monitored anesthesia care (MAC) for elderly patients undergoing endoscopic procedures. The project utilizes a randomized controlled trial (RCT) design to compare RT and propofol regarding hemodynamic stability, respiratory outcomes, recovery times, and patient satisfaction. The project team collects quantitative data via validated tools, including the Modified Observer’s Assessment of Alertness/Sedation Scale and Aldrete Scoring System, and gathers qualitative feedback through Likert-scale surveys. Findings highlight that RT maintains superior hemodynamic stability, reduces respiratory complications, and achieves comparable sedation success with shorter recovery times than propofol. These results suggest that RT is safer and more optimal for elderly patients, aligning with evidence-based practice goals to enhance patient outcomes and procedural efficiency. By addressing the limitations of traditional sedatives, this project underscores the potential of RT to improve clinical practices in geriatric anesthesia care. Future implementation of RT protocols could enhance patient safety, reduce healthcare costs, and optimize resource utilization

Evidence-Based Clinical Practice Guidelines for Postspinal Hypotension in Pregnant Women

Abstract Postspinal hypotension (PSH) in pregnant women undergoing a cesarean delivery is a common yet significant problem for the safety of the mother and fetus. The physiological effects of a spinal injection may compromise uteroplacental flow, predisposing the fetus to hypoxia and acidosis. Maternal consequences of prolonged hypotension include unstable hemodynamics, loss of consciousness, and nausea. Historically, healthcare providers have used crystalloid preloads and reactive phenylephrine boluses to correct hypotension. However, recent evidence suggests that these interventions have limited effectiveness. Thorough research led to the development of clinical guidelines that propose providing a 500 mL 6% hydroxyethyl starch preload or a 1000 mL Lactated Ringers coload in conjunction with a prophylactic variable-rate norepinephrine infusion immediately following the injection of the spinal anesthesia to avoid hypotension. For the project’s hypothetical implementation a hospital with a large obstetric unit will undergo pre- implementation measurements of several outcomes, including: incidence of hypotension, total vasopressor requirements, frequency of maternal bradycardia, and nausea. During a two-month trial implementation period, the proposed clinical guidelines will be implemented for all elective cesarean deliveries that meet the inclusion criteria. After two months, the Quality Improvement team and anesthesia leadership members will compare the new measurements to the baseline data. With the new guidelines in place, an anticipated decrease in the occurrence of postspinal hypotension, as well as the need for vasopressors, incidence of bradycardia, and nausea will occur in pregnant women undergoing cesarean deliveries

Dexmedetomidine and the Prevention of Emergence Agitation in Military Veterans with Post-Traumatic Stress Disorder

Emergence agitation (EA) is a post-anesthetic complication that occurs when the patient is in a self-limited, nonfluctuating state of excitement while transitioning into a state of consciousness. EA can lead to negative adverse outcomes including, accidental invasive line removal, bleeding, respiratory depression, unintentional extubation, and injury to the staff and the patient. EA is often observed in military veterans who have a medical history of post-traumatic stress disorder (PTSD). For patients with a history of military exposure undergoing elective general anesthesia who also have PTSD, anxiety, and or depression, the incidence of EA was estimated to be around 27%. The pathophysiology of EA is unknown; however, a collection of risk factors has been associated with a higher incidence of EA. These risk factors include pre-operative anxiety, history of pre-existing mental disorders like PTSD, use of volatile agents with low solubility, age, sex, invasive lines and tubes, and the use of premedications like benzodiazepines and anticholinergics.There are currently no evidence-based guidelines or policies in place to properly manage and prevent the incidence of EA in military veterans with a history of PTSD scheduled for general anesthesia. Dexmedetomidine is an alpha-2 adrenoceptor agonist that produces sedation that resembles a patient\u27s natural sleep without causing respiratory depression and allowing for patient arousal. The combination of high-risk identifying assessment tools including the DSM-5, the Richmond Agitation Sedation Scale (RASS), and the utilization of Dexmedetomidine in the peri-operative setting has been proven to decrease the incidence of EA in patients with a history of PTSD

Enhancing the Diversity and Number of Certified Registered Nurse Anesthetists: A Proposed Pipeline Program for Underrepresented Students

The underrepresentation of minority groups in the Certified Registered Nurse Anesthetist (CRNA) profession impacts healthcare providers’ diversity and cultural competence. This Final Scholarly Project (FSP) proposes a pipeline program to increase diversity within the CRNA field by providing academic support, mentorship, and clinical exposure to students from underrepresented backgrounds. Given the shortage of anesthesia providers, especially in underserved areas, improving access to the CRNA profession for minority students is critical for enhancing patient outcomes. This FSP suggests establishing mentorship and skill development concepts through a 12-month structured program that targets minorities, first-generation college students, or those from rural backgrounds. The program utilizes a mixed-methods approach, collecting quantitative and qualitative data to assess recruitment, retention, academic progress, and mentorship effectiveness. Quantitative data analysis includes descriptive statistics, paired t-tests, and ANOVA, while qualitative feedback is assessed through thematic analysis. Success is measured by a 15% average increase in academic assessment scores, 75% enrollment from target demographics, and a 25% CRNA program application rate among participants. Findings are expected to demonstrate that the program effectively supports minority students pursuing CRNA careers, addressing workforce shortages and the need for diversity. This FSP has broader implications for reducing healthcare disparities and advancing diversity in other medical professions by creating a replicable model for academic and professional support