Commercially available hyperbaric ropivacaine 0.75% has recently been gaining clinical acceptance for spinal anesthesia. However, limited studies are available comparing hyperbaric ropivacaine 0.75% with hyperbaric bupivacaine 0.5%. We hypothesized that ropivacaine, a pure S-enantiomer of bupivacaine, has a better clinical profile. We therefore compared the efficacy and safety of the two drugs. In this prospective, randomized, double-blind trial, 60 patients who belonged to the American Society of Anesthesiologists physical status I and II, undergoing elective infraumbilical surgeries were allocated into two groups: Group B (0.5% hyperbaric bupivacaine) and Group R (0.75% hyperbaric ropivacaine), respectively. The primary objective of this study was to compare the time to onset and duration of both sensory and motor blockade between both groups. Chi-square test was used for qualitative variables and independent t-test for quantitative data. P < 0.05 was considered statistically significant. The mean time to sensory and motor onset was longer in Group R (5.93 ± 1.86 min and 10.53 ± 2.03 min) when compared with Group B (3.20 ± 1.24 min and 7.93 ± 2.13 min) while the mean sensory and motor duration was shorter in Group R (146.57 ± 15.60 min and 108.87 ± 25.33 min) as compared with Group B (179.30 ± 21.35 min and 135 ± 14.10 min), both of which were statistically significant. Hyperbaric ropivacaine 0.75% has a slower onset and longer time to maximum spread but faster recovery, making it a safe alternative to bupivacaine.
The journey from nurse anesthesiology resident (NAR) to certified registered nurse anesthetist (CRNA) is a profound transformation, one that extends beyond skill acquisition to the evolution of professional identity. Using the metaphor of a caterpillar's metamorphosis into a butterfly, this article explores how academic rigor, clinical immersion, and mentorship shape resilience, adaptability, and confidence in future CRNAs. Grounded in growth mindset theory, it highlights how embracing challenges, seeking feedback, and reframing setbacks as opportunities for learning build both competence and self-efficacy. As residents transition from novice learners to autonomous practitioners, engagement with professional organizations such as the American Association of Nurse Anesthesiology becomes essential to sustaining lifelong growth and leadership. The metamorphosis from NAR to CRNA, therefore, reflects more than a change in credentials, it signifies emergence into a profession defined by reflection, excellence, and service.
Despite advances in regional anesthesia and multimodal analgesia, pain disparities in perioperative and chronic pain populations persist, particularly among marginalized groups who experience higher postoperative pain and poorer recovery. Social determinants of pain (SDOP) link social adversity to nociceptive processing through biological pathways. Chronic stress and allostatic load induce epigenetic changes that accelerate aging and affect pain biology. Most clinicians lack understanding of how to apply this knowledge in daily practice. This review examines links between SDOP, allostatic load, and pain vulnerability, with implications for perioperative pain management. Racialized minorities and socioeconomic disadvantages predict greater stress and worse pain outcomes. Allostatic load, reflecting cumulative physiological wear from chronic stress, is associated with greater pain severity, epigenetic modification of genes in pathways that regulate stress and aging, leading to accelerated biological aging and pain vulnerability. For instance, individuals with chronic low back pain show accelerated biological aging compared to healthy controls, and the pace of biological aging mediates the relationship between chronic pain stigma and pain outcomes. Understanding these biological pathways enables CRNAs to adopt evidence-based strategies, including routine social screening, equitable access to regional techniques, and targeted care for high-risk groups. More studies are needed to inform equity-centered pain management.
This study aimed to determine whether nasopharyngeal suction reduces the incidence of perioperative respiratory adverse events (PRAE) after supraglottic airway (SGA) removal in children. Four hundred children (ages 1-6 years) undergoing general anesthesia using SGA, were randomized into two groups: combined nasopharyngeal and oral suction (Group N), and oral suction alone (Group O). Suction was performed under anesthesia prior to SGA removal. Patients were observed for coughing, breath-holding, airway obstruction, laryngospasm, bronchospasm, and desaturation--the incidence of any one or more of which was considered positive for PRAE. Subgroup analysis of patients with active or recent upper respiratory tract infection (URTI) was decided a priori. The incidence of PRAE was 21.8%, with no significant difference between Group N (21.2%) and Group O (22.3%). In children with active or recent URTI, the incidence of PRAE was significantly lower in group N (21.7%) compared with group O (44.7%); relative risk 0.486 (95% CI, 0.258 to 0.917), P = .019; number needed to treat = 4.4. In the general pediatric population, nasopharyngeal suctioning did not reduce the incidence of PRAE. However, in children with URTI, PRAE incidence was significantly lower in those who underwent nasopharyngeal suctioning prior to SGA removal.
A 57-year-old man with myotonia congenita underwent elective laparoscopic appendectomy after perforated appendicitis treated with two drainages. Quadratus lumborum blocks were preoperatively placed bilaterally under ultrasound guidance. Anesthetic gases and succinylcholine were avoided, and total intravenous anesthesia was used for maintenance. Neuromuscular blockade was minimized and reversed with sugammadex. The operative course was uneventful. In the postanesthesia care unit, the patient reported a pain level of zero throughout his stay, required no opioids, and was discharged the same day with unremarkable surgical follow-up.
Trauma-induced coagulopathy is a major cause of preventable morbidity and mortality in adult trauma patients. Thromboelastography (TEG) has been shown to reduce blood product waste, morbidity, and mortality when used to guide trauma resuscitation. The TEG 6s is a new cartridge-based device that shifts the utility of TEG to the point-of-care. The purpose of this integrative review is to synthesize the current evidence regarding the use of the TEG 6s device in adult trauma patients with an emphasis on anesthesia. A comprehensive literature search was conducted following PRISMA 2020 guidelines, with eight articles meeting the inclusion criteria. These studies demonstrated comparable diagnostic accuracy to the TEG 5000 platform with improved interdevice reliability. Validated reference ranges, early predictors of maximum amplitude, and trauma-specific algorithms support the integration of the TEG 6s device into intraoperative and trauma workflows. The TEG 6s represents a promising tool for anesthesia providers to guide blood product management during the acute resuscitation of trauma patients. Further research should focus on validating standardized algorithms and assessing outcomes related to mortality, blood product usage, and cost.
Substance misuse and drug diversion among anesthesiology professionals may begin during training and span decades of practice. Because treatment for substance use disorder (SUD) is often delayed, early recognition and structured education are essential. This national quality improvement study evaluated the effect on knowledge, perceptions, and the likelihood of reporting suspected substance misuse. A descriptive, comparative pre-post survey was conducted with resident registered nurse anesthetists and support people recruited from 32 randomly selected U.S. nurse anesthesia programs. The intervention was a dual-perspective presentation that integrated clinical content and lived experience. Pre-post perceptions, knowledge, and reporting intentions were analyzed among matched respondents using the Wilcoxon signed-rank test (SAS 9.4; P < .05). Of 1,397 attendees, 868 completed the presurvey and 678 the postsurvey (78.1% retention); 425 were matched for analysis. Significant postintervention improvements were observed in perceptions of SUD as a disease (P = .003), knowledge of safety measures (P < .001), confidence in recognizing symptoms (P < .001), and the likelihood of reporting suspected misuse (P < .001). This national educational intervention was associated with immediate improvements in awareness and reporting intentions, offering a reproducible model for anesthesia education and early prevention.
There is a paucity of research on the transition of Certified Registered Nurse Anesthetists (CRNAs) entering academia. Guided by Schlossberg's Transition Theory, the purpose of this qualitative descriptive study was to explore the experiences of CRNAs moving from clinical practice to academia. Seven focus groups were conducted with CRNA educators and program administrators across the United States. Transcripts were analyzed using inductive content analysis with iterative coding, key words in context, and thematic development validated through team consensus. Findings illuminate how CRNA faculty navigate academic entry, adjustment, and persistence. Three major themes were identified: "Natural Progression," "On My Own," and Staying Power. Themes reflected a gradual entry into academia through early teaching opportunities and professional connections, a general lack of formal mentorship and accessible resources during early transition, and a sustained commitment through legacy building, flexibility, and institutional benefits. Results underscore the need for effective mentorship and orientation, and faculty development pathways to enhance recruitment and retention of CRNA educators to safeguard the education pipeline.
The Pericapsular Nerve Group (PENG) block is a novel, ultrasound-guided regional anesthesia technique that provides analgesia for hip surgeries by targeting the articular branches of the femoral, obturator, and accessory obturator nerves, while preserving motor function. Unlike traditional blocks used for total hip arthroplasty and femoral neck fractures, the PENG is a motor sparing block, promoting early ambulation while reducing opioid use. Despite its advantages, variability in technique and lack of standardization result in inconsistent results. This study aimed to develop and validate a competency-based checklist for PENG block performance using the Modified Delphi Method. Twenty-five regional anesthesia experts were invited to participate; 16 responded to the first survey round. A consensus of over 75% was achieved on all checklist items, particularly those related to anatomic landmarks and post-block procedures. Variability in ultrasound image acquisition techniques highlighted the need for flexibility within a standardized framework. Expert feedback was integrated to refine the checklist, ensuring clinical relevance and educational value. Establishing a validated checklist will standardize PENG block administration, leading to enhanced provider competency, improved outcomes, and reduced incidence of complications.
Gabapentin is widely used in perioperative analgesic protocols. Many clinical studies supporting the safety and analgesic efficacy of gabapentin for postoperative pain have been published over the last two decades. Several studies, many recently, have questioned its effectiveness and safety for perioperative pain management in early recovery after surgery (ERAS) and non-ERAS protocols leading to the research question: Is the use of gabapentin in perioperative analgesic protocols efficacious and safe for all perioperative patients? An integrative review was performed to identify, analyze, and synthesize a carefully selected sample of the evidence surrounding the inclusion of gabapentin in perioperative pain management practice. Analysis of the literature showed that gabapentin was found to be effective and safe in multiple studies yet may not be an effective treatment to include in all opioid-free multimodal pain regimens for ERAS and non-ERAS surgical pathways. Instead, gabapentin appears safe and effective for some populations of surgical patients undergoing a variety of procedures, while for other populations the medication is less efficacious and potentially harmful because of its side effects, which include respiratory depression, ataxia, and sedation.
There is growing interest in utilizing deep sedation with a natural airway rather than general endotracheal anesthesia (GETA) for cardiac catheterization procedures due to the presumed hemodynamic benefits and faster postprocedural recovery, although a paucity of data supports these assumptions. We hypothesized that the periprocedural complication rate would be lower in patients undergoing transcatheter pulmonary valve implantation (TPVI) under deep sedation with a natural airway versus those under GETA. We performed a retrospective chart review of 85 patients undergoing isolated TPVI at a large academic medical institution. A logistical regression adjusting for age was performed. The primary outcome was periprocedural complication rate, including access site rebleeding, hematoma, conversion to GETA, arrhythmia requiring intervention, cardiac arrest, blood transfusion, and postoperative nausea and vomiting. Significantly more patients in the GETA group experienced complications compared with the deep sedation group (41.2% vs 14.7%, P = .015). The secondary outcomes included vasopressor use, recovery location, and procedural, anesthesia, and recovery times. The median procedure time was shorter in the sedation group by 38 minutes (P = .010), and anesthesia time was shorter by 50 minutes (P = .001). Overall, we found that deep sedation is feasible for TPVI and in this retrospective study was associated with decreased periprocedural complications.
Graduate students, including medical students, use cognitive enhancer (CE) medications with or without legal prescription to aid academic performance despite little evidence that they improve performance in individuals without a medical diagnosis and subsequent prescription. However, there is limited information on CE medication use, with or without legal prescription, by resident registered nurse anesthetists (RRNAs). This cross-sectional survey assessed prevalence of CE medication use with or without legal prescription and its potential predictors (depression, anxiety, Attention Deficit Hyperactivity Disorder [ADHD] symptoms, and demographic variables) in 421 RRNAs. Descriptive and binary logistic regression analyses were conducted. The prevalence of CE use with or without prescription was 27.3%, with 93% obtained by prescription. The prevalence of clinically significant symptoms of ADHD (25.7%), depression (26.9%), and anxiety (23.1%) were assessed among RRNAs. No significant differences in age, gender, or program years were observed between CE medication users with or without legal prescription and CE non-users. However, white respondents were more likely to be CE medication users with or without legal prescription compared with respondents of other racial groups (P = .020). In the full logistic regression model, ADHD (aOR, 1.17; 95% CI, 1.10-1.24) was associated with increased odds of CE use. The Backward stepwise selection model retained ADHD and anxiety as significant predictors.
General anesthesia increases the morbid risk for both mother and infant during a cesarean delivery. Failed or asymmetric blocks can force providers to turn to a general anesthetic precipitously. A true one-sided spinal block, with complete absence of anesthesia on one side despite correct subarachnoid technique, is rare and not well characterized in the literature. In this case, a 32-year-old multiparous woman presented for elective repeat cesarean delivery. After an uncomplicated spinal anesthetic, she developed a complete left-sided sensory and motor block, with no block on the right. A supplemental epidural catheter was placed and lidocaine 2%, 12 cc with fentanyl 100 micrograms was used, which successfully achieved bilateral surgical anesthesia. The remainder of the case and postoperative course were unremarkable. This case illustrates the possibility of a structurally confined subarachnoid space leading to true one-sided spinal anesthesia. Prompt recognition and epidural rescue preserved patient comfort and surgical conditions. Anatomic factors should be considered when assessing neuraxial block failures, particularly in patients with prior spinal procedures.
Over 700,000 total knee arthroplasties (TKAs) are performed in the United States annually. Long-term functional recovery following TKA depends heavily on early ambulation and rehabilitation, which requires effective pain management. Adductor canal blocks (ACBs) offer targeted analgesia while preserving quadriceps strength. However, postoperative pain often outlasts single-shot peripheral nerve blocks. This analysis evaluated whether perineural dexmedetomidine added to local anesthetics increased the efficacy and duration of ACBs in patients undergoing TKA. This systematic review and meta-analysis examined adult patients undergoing primary TKA under general or spinal anesthesia and ACB. Five randomized controlled trials examining 445 patients met inclusion criteria. Patient ages ranged from 18 to 85 years and demonstrated similar comorbidities. Pooled analysis showed that patients receiving dexmedetomidine reported lower pain scores at rest (mean difference [MD] -0.35; P = .009) and during activity (MD -0.40; P < .0001). Opioid consumption decreased by an average of 8.91 mg (P = .05). Time to first rescue analgesia increased by 1.54 hours, and ambulation outcomes consistently showed improvement in the dexmedetomidine group. This analysis supports the use of dexmedetomidine as an adjunct for ACB in TKA. However, significant heterogeneity among studies limits applicability of this analysis's findings. Clinicians are advised to consider this when making practice decisions.
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) were developed to treat type 2 diabetes mellitus and later became widely used for the management of obesity. Recent evidence includes off-label uses for substance use disorders; nicotine and alcohol dependence; neurodegenerative diseases; and cardiovascular, kidney, and liver diseases. Certified registered nurse anesthetists (CRNAs) are likely to encounter patients using GLP-1RAs for both Food and Drug Administration-approved and nontraditional purposes. This review explores the pharmacology and mechanisms of action of GLP-1RAs, with a focus on their relevance in the perioperative period. It covers their effects on blood glucose control, gastric motility, and central nervous system pathways. Special attention is given to delayed gastric emptying, concerns about pulmonary aspiration, and the metabolic benefits of glucose-dependent insulin secretion and reduced blood glucose fluctuations. Current professional guidelines emphasize personalized, patient-centered perioperative care. The increasing use of GLP-1RAs, combined with more off-label prescribing and unregulated peptide use, emphasizes the need for thorough preoperative screening, clear medication reconciliation, and effective interdisciplinary communication. As more evidence emerges, CRNAs must remain vigilant while recognizing that the expanding role of GLP-1RAs is important for optimizing perioperative safety and achieving optimal patient outcomes in modern anesthesia practice.
One in four clinicians who seek treatment for substance use disorder are anesthesia providers. However, there is a dearth of research on substance use behaviors of doctoral resident registered nurse anesthetists (RRNA). The purpose of this study was to determine the prevalence and patterns of substance use and perceived stress levels among RRNAs. Anonymous surveys were distributed to RRNAs enrolled in doctoral programs in the United States. Respondents self-reported four substance use behaviors. Problematic substance use and perceived stress were self-reported using the Drug Abuse Screening Test (DAST-10) and the Perceived Stress Scale (PSS-10). Overall, 26.5% of respondents reported engaging in nonprescription substance use behaviors since enrollment. The prevalence of anesthetic agent use was 7.4%. Nine percent of respondents reported use of focus-enhancing drugs, 15% reported increased alcohol consumption, and 22% required a new prescription since enrollment. Mean PSS-10 scores were significantly higher in respondents who reported substance use behaviors (19.8 [SD, 6.5] vs 16.5 [SD, 6.3] P < 0.001). Predictive factors for substance use include enrollment period greater than 24 months, male gender, and elevated PSS-10 and DAST-10 scores.
