Routine Evaluation with Gastric Ultrasound to Reduce Gastric Aspiration (REGURGA)

When a patient undergoes anesthesia, there are inherent risks that the providers should protect the patient from. Despite adherence to fasting guidelines established by the American Society of Anesthesiologists (ASA), patients undergoing anesthesia continue to experience intrapulmonary aspiration of gastric contents. There are several factors that delay gastric emptying, including coexisting disease, trauma, pain, and opioid use. Gastric ultrasound assessment of the gastric antrum is a relatively new technology in anesthesia and can be used to assess the gastric antrum and provide information to anesthesia providers regarding the risk of aspiration in the perioperative period. The primary aim of this project was to develop evidence-based practice (EBP) guidelines for using point-of-care ultrasound (POCUS) of the stomach as a preoperative aspiration risk stratification tool. In addition to the primary aim, secondary objectives included developing a comprehensive plan to implement the guidelines as established, a comprehensive plan to monitor and measure the guidelines\u27 effect, and a comprehensive plan to adjust the guidelines if the outcomes are less than desirable. A literature search, review, and synthesis were conducted to establish the background of gastric ultrasound in anesthesia and to determine if the measurements were accurate. Guidelines were developed for theoretical implementation at a level-one trauma center in the midwestern United States. Following the implementation of the guidelines, a retrospective review will be conducted with measurement and analysis of outcomes, and adjustments will be made, if necessary, as described by the comprehensive adjustment plan. By using POCUS preoperatively, the risk of perioperative aspiration is reduced

University Presidential Update- January 2024

This is an Otterbein University presidential update to the staff and faculty, informing them on changes to campus

Guidelines for the Optimal Assessment of Airway to Predict Difficult Intubation

Managing the airway is the cornerstone of anesthesia care. However, difficult airway or intubation is not clearly defined. A major complication with a difficult airway is a cannot intubate, cannot ventilate (CICV) situation, which is reported to be as high as 10%. In addition, according to the American Society of Anesthesiologists (ASA) Closed Claim Study, Adverse respiratory events are the most common type of injury, with difficult intubation [DI] and ventilation contributing to most of the cases. Twenty-eight percent of all anesthesia deaths are related to a CICV situation. As anesthesia evolves, basic airway assessments were developed and include mallampati (MP), thyromental distance (TMD), upper lip bite test (ULBT), and interincisor distance (IID). However, not one basic airway assessment accurately predicts a DI. The problem is inappropriate or inadequate airway management because a difficult airway can lead to an emergency, such as an anoxic brain injury, respiratory compromise, or even cardiac arrest. The DNP project aims to implement a standardized guideline for the preoperative assessment tool, the LEMON law, as the standard of care for preoperative airway assessment in patients undergoing surgical operations requiring endotracheal tube (ETT) intubation. Theoretical implementation plan at a medical center in the Midwest utilizing a direct supervision anesthesia model to enact the Plan-Do-Check-Act (PDCA) model to evaluate the effectiveness and outcomes relating to the prediction of difficult airway, the prevalence of hypoxia, and effect on patients. Keywords: anesthesia, airway assessment, LEMON law, difficult airwa

Development of Evidence-based Clinical Practice Guidelines for the Prevention of Peripheral Neurological Injury During Robotic-assisted Prostatectomies for Patients in the Steep Trendelenburg Position

Robotic-assisted surgery (RAS) is becoming more prevalent in modern surgical practice and is currently being utilized in a range of surgical specialties from colorectal and gynecological procedures to bariatrics and orthopedics. Every surgical procedure has potential risk to patients, however robotic-assisted laparoscopic prostatectomies (RALP) in the steep Trendelenburg (ST) position poses unique risk for peripheral nerve injury (PNI). Despite attempts to reduce the incidence rate of PNI during RALP, injuries are still occurring to patients causing patient harm and anesthesia provider litigation. The implementation of a CRNA based safety checklist may reduce the incidence rate of PNI and provider litigation for these procedures. The overall purpose of this quality improvement project is to reduce the risk of PNI to patients undergoing anesthesia during RALP. The primary aim of the project is to create, implement, and evaluate the effects an evidence-based clinical practice safety checklist for use in conjunction with the surgical timeouts will have on the incidence rate of PNI. The following objectives have been established to achieve the aim of this project: 1) create and incorporate a practice safety checklist for CRNAs to use during surgical timeouts, using best practice evidence from the literature, 2) compare pre-and post-implementation outcome findings using clinical observations audits and lastly 3) provide project findings, identified barriers, and recommendations for sustainment and continued monitoring, using a SWOT analysis briefing and discussion format to the key stakeholders

Recommending an ERAS Guideline for Patients Undergoing Total Joint Arthroplasty

Enhanced recovery after surgery (ERAS) is a comprehensive guideline that guides patients\u27 care throughout their surgical journey. ERAS is intended to reduce the body’s response to the many stressors of surgery. ERAS is proven effective in various specialty surgical areas, including orthopedics. Orthopedic surgery rates increase parallel with the patient population ages, indicating a need for more joint replacements. Implementing an ERAS guideline reduces healthcare costs to the patient and hospital facility by reducing the length of stay (LOS) and complications postoperatively. The investigation revealed a lack of consistent direction of care, and the developed approach for patients undergoing joint arthroplasty has led to the research and recommendation of an ERAS guideline. The primary goal of this scholarly project is to recommend an evidence-based ERAS guideline for patients undergoing total joint arthroplasty to decrease the LOS at the hospital facility of interest. This educational project utilizes the Edward Deming Plan-Do-Study-Act (PDSA) cycle model, commonly called the Deming Cycle. The team then identified a focal point of the ERAS guideline to assess the effectiveness of the recommended guideline. The recommended ERAS guideline emphasizes patients receiving regional anesthesia before their total joint arthroplasty for its benefits of decreasing surgical stress on the body. It is a multimodal analgesic technique reducing opioid requirements and decreases postoperative pain to allow early ambulation. This project can be seen as a significant cost-saving guideline for the hospital and the patients. The outcomes from this scholarly project can be vital to recommending an ERAS guideline to other surgical specialty areas

Viscoelastic Monitoring in Major Hepatic Surgery: An Evidence-Based Practice Project

Patients undergoing major hepatic surgery are at high risk for intraoperative transfusion of allogenic blood products. These patients are at increased risk due to pre-existing hepatic pathology, surgical stress, and the complexity of surgical procedures. While blood product transfusion may be necessary to support hemostasis and hemodynamics, it is not without risk. Current literature states that viscoelastic monitoring is superior to traditional laboratory values when guiding transfusion during major hepatic surgery. Viscoelastic monitoring is a term used to describe the measurement of change in viscoelastic properties of whole blood during clot formation. There are two readily available point-of-care types – thromboelastography (TEG) and rotational thromboelastometry (ROTEM). For the purpose of this project, ROTEM will be referred to as viscoelastic monitoring. Although the literature supports the use of viscoelastic monitoring during major hepatic surgery, some facilities’ guidelines and policies may not be up-to-date with the most current evidence. The lack of an evidence-based approach to standardize transfusion utilization may lead to misinterpretation of viscoelastic monitoring, which may result in over- or under-resuscitation. This Doctor of Nursing Practice (DNP) project aims to develop an evidence-based practice guideline, utilizing the Rosswurm and Larrabee conceptual model, to assess a need for change, identify gaps in practice, implement the guideline, and evaluate the outcome. Successful implementation and dissemination of this DNP project could lead to changes in the standard of practice, hospital policy, or a revision of current guidelines. The work of this DNP project will be limited to the perioperative setting. Further scholarly work can explore the utility of viscoelastic monitoring in the pre-and postoperative settings

Development of a ROTEM-guided Transfusion Algorithm in Cardiothoracic Surgery Patients

Abstract Cardiothoracic surgical patients are at an increased risk for bleeding complications for various reasons, including induction of hypothermia, initiation of the coagulation cascade, degradation of the coagulation factors, mechanical destruction of platelets, and a systemic inflammatory response due to cardiopulmonary bypass (CPB). The American Society of Anesthesiologists recommends rotational thromboelastometry (ROTEM)-guided transfusion algorithms for perioperative blood management; however, there remains a heavy reliance on conventional coagulation laboratory values. Utilization of the following PICOT question will guide this project: In cardiothoracic surgical patients, how does the use of ROTEM versus traditional coagulation laboratory tests (PT, INR, aPTT, ACT, platelet count, and fibrinogen) affect blood product utilization, patient mortality, and overall cost peri-operatively and post-operatively? The literature review encompasses the highest level of current evidence to determine if there is a statistically significant difference in the number of blood products administered, mortality, and cost associated with utilizing ROTEM technology. The proposed project site would be a large urban hospital with an anticipated sample of 240 cardiothoracic cases over six months. Outcome data will be examined to help the project team explore and compare the impacts of a ROTEM-guided transfusion algorithm versus traditional coagulation laboratory tests. Overall, this project aims to develop a blood product management algorithm utilizing ROTEM technology to enhance the identification of coagulopathies, thereby limiting inappropriate blood product administration, lowering mortality rates, and providing a cost-effective method for coagulation management. Keywords: cardiothoracic, anesthesia, rotational thromboelastometry (ROTEM

Evidence-Based Practice Guidelines for the Surgical Patient with Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is a medical condition which many people may be affected by but may be unaware of the presence of the condition. The incidence of OSA has increased in direct correlation with the rising rate of obesity in the general population. While chronic conditions may arise if OSA goes untreated, patients with OSA also have an increased risk for acute complications following surgical procedures such as airway obstruction, hypoxia, brain damage, and death. Many anesthetic medications administered during surgery exacerbate the pathological consequences of OSA, predisposing patients to adverse respiratory events during the recovery period following a procedure. As advancements in medicine and the methods of anesthesia delivery continue to be made, there are certain techniques which can be included in the care plan of a patient with OSA to mitigate the risks associated with the disease. This project aims to create evidence-based practice guidelines (EBP) for the care of patients with OSA who may be at an increased risk for developing respiratory complications following surgical procedures. It was developed utilizing The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare. Although many of the postoperative complications seen in patients with OSA are preventable, updated guidelines for the care of this patient population have not been published since 2014. As a current nurse anesthesia graduate student, this scholar aims to explore the topic and to identify the safest way to provide anesthetic care for patients with OSA

An Evidence-Based Strategy for the Use of Simulation to Assess Situation Awareness in Applicants to Nurse Anesthesia Programs

Medical errors are considered one of the top causes of patient death. Closed claims analysis reveals an estimated 50% of claims are associated with preventable events by the anesthesia provider. Errors in anesthesia leading to critical incidents are associated with errors in situation awareness (SA). Identification of human factor variables, such as SA, provides an analysis of observable behavior and intuition necessary to guide crisis management, maintain clinical performance, and mitigate errors in patient safety. The human factor components of human error and SA play critical roles in patient safety and overall clinical anesthesia practice. The viability of simulation assessment delivers a consistent evaluation of learner progression and identifies areas of improvement to provide safe clinical practice and minimize adverse outcomes during patient interaction. Incorporating high-fidelity simulation into a multimodal admissions process for nurse anesthesia programs may provide a vital assessment of candidate SA in managing stressful scenarios and predict overall program progression and success. The evidence-based project serves to evaluate current literature for evidence-based strategies to provide a direct assessment of SA on prospective applicants during applicant interviews to nurse anesthesia programs

Development of Evidence-Based Practice Anesthesia Guidelines for Brain-Dead Organ Donors

Organ donation is a gift of life for both donors and recipients that can come from living donors, donors after cardiac death, or brain-dead donors (BDDs). Treating the donors with optimal care throughout the entire donation process is crucial due to organ supply shortages. Organs from BDDs are a large contributor to the number of organs donated each year and require critical care from the time of admission, declaration of brain death, and throughout the organ procurement surgery. Although each BDD requires meticulous care for successful retrieval and donation, there is a lack of evidence-based practice (EBP) guidelines for anesthesia for BDDs during organ procurement surgery. This project encompasses the development, implementation, and evaluation plan of EBP anesthesia guidelines for BDDs. The problem was identified through an introduction to and background information regarding the organ donation process, from the declaration of brain death to organ procurement surgery, organ rejection, financial impact, and the significance of the problem to anesthesia. Next, a clinical person, intervention, comparison, outcomes, and time (PICOT) question was introduced which drove the objectives of the project and facilitated a thorough literature review. With the results from the literature search and recommendations from the Lifeline of Ohio Organ Procurement Agency (LOOP), guidelines for anesthesia for BDDs were created. The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model was used to guide the development of and plan to implement the EBP anesthesia guidelines. Monitoring of outcomes will be completed by the QI department. Barriers, limitations, guideline improvement strategies, project timeline, and project budget are discussed, followed by a dissemination of the findings