A flash back: Graduates of nurse anesthesia programs have an average of 9,369 hours of clinical experience, including 733 hours during their baccalaureate nursing program, 6,032 hours as a critical care registered nurse, and 2,604 hours during their nurse anesthesia program.

Sugammadex has been used clinically since 2008, and it represents the only cyclodextrin neuromuscular blocking reversal agent currently available for patient care. Sugammadex's unique mechanism of action allows it to reverse the effects of aminosteroid neuromuscular blockade rapidly, and pharmacodynamically predictable doses are selected based on quantitative neuromuscular monitoring. The drug has several potential adverse effects, predominantly related to immediate hypersensitivity reactions and bradyarrhythmias, and it can be costly. Overall, when employed appropriately, it represents an efficacious addition to the perioperative pharmaceutical armamentarium with significant utility.

Calcinosis universalis is a rare subtype of connective tissue diseases known as calcinosis cutis. The disease is described as diffuse calcium salt deposits in subcutaneous, fibrous muscle structures, and tendons. Calcinosis cutis typically occurs secondary to a tissue damaging disease such as dermatomyositis, systemic lupus erythematosus, and Sjogren syndrome, presenting before age 20 and predominantly affecting women. Calcinosis universalis presents challenges for anesthesia providers as joint calcification can make positioning difficult, vascular access becomes increasingly difficult over time as iatrogenic calcifications limit access sites, and pharyngeal and epiglottic structures can be involved leading to obstruction of the airway. However, anesthesia management of these patients has rarely been reported in the literature. We present a patient with calcinosis universalis with reported difficult airway who was scheduled for endoscopic ultrasound guided biopsy necessitating general anesthesia.

Preoperative anxiety occurs in many surgical patients and yet there are no clear recommendations on how to provide the best evidence-based care to these patients during a general anesthetic. The following case report describes a complex case of a 35-year-old female who presented for imaging under general anesthesia with high preoperative anxiety. She displayed fluctuations in hemodynamics, an increased induction dose of propofol, and vasopressor support throughout the intraoperative phase of care. This case report describes the current evidence for considerations of high anxiety operative patients, which may include an increased induction and total dose of propofol, increased analgesic requirement, and an individualized preoperative assessment to establish a baseline anxiety level and proper education.

Congenital cystic adenomatoid malformation is a rare malformation of the lungs, which can pose complex anesthetic challenges because of the pathology and the frequent need for one-lung ventilation. Large lesions can rapidly enlarge, leading to a mediastinal shift, cardiovascular compromise, and pneumothorax. The most common choice for one-lung ventilation in young infants is endobronchial intubation of the non-operative lung using a conventional uncuffed endotracheal tube. We are describing the use of a microcuffed endotracheal tube with a microthin polyurethane cuff membrane (Microcuff, Kimberly-Clark) for this purpose for the first time, along with its unique benefits in this regard for airway management of an infant with congenital cystic adenomatoid malformation scheduled for bilobectomy.

Raynaud phenomenon can be an idiopathic benign disease, or it can be associated with vascular insufficiency due to arterial disease caused by other processes. Medical management of Raynaud phenomenon can be difficult, and digital ischemia, gangrene, and ulcers may occur secondary to vascular insufficiency. This case report describes the anesthetic management of a patient with a diagnosis of Raynaud phenomenon who presented to the perioperative area for débridement and distal amputation of the right third finger, which had become necrotic and gangrenous. An ultrasound-guided supraclavicular nerve block was performed preoperatively with 15 mL of 1.5% mepivacaine and 15 mL of 0.5% bupivacaine. The block was performed without complication, and the patient tolerated the procedure. A review of literature related to the use of peripheral nerve blockade for the treatment of digital ischemia is discussed. Ultrasound-guided technique is considered the gold standard for the performance of peripheral nerve blocks because this technique provides better efficacy and safety. These same ultrasonographic skills can expand anesthesia providers' practice beyond nerve blockade for anesthesia and analgesia with the addition of treatment and management of digital ischemia.

The coronavirus disease 2019 (COVID-19) pandemic prompted profound shifts in the delivery of critical healthcare services. A mixed-methods study was conducted to explore the impact of the pandemic on Certified Registered Nurse Anesthetist (CRNA) practice. The quantitative component involved a survey of CRNAs during the initial period of the pandemic to determine changes in practice and any relationship to removal of state and federal barriers. Approximately 16% of 2,202 responding CRNAs reported practice expansion beyond their normal responsibilities, primarily outside the operating room and involving tracheal intubation, ventilator management, arterial line placement, and central line placement. CRNAs were more likely to experience an expansion of practice in states affected by removal of regulatory barriers. However, respondents also reported missed opportunities to use the full expertise of CRNAs because of state and institutional restrictions. Findings from the qualitative component of this study are reported in a separate article.

Surgical site infection (SSI) is a common preventable iatrogenic infection following surgery with an approximated overall occurrence of 2-4%. Despite numerous studies, controversies still exist regarding the efficacy, safety, and cost effectiveness of strategies to decrease SSI. The World Health Organization issued recommendations for the prevention of SSIs including oxygenation with 80% fraction of inspired oxygen (FiO2). The primary outcome of our systematic review and metaanalysis was the effect of high inspired FiO2 related to SSI in the colorectal surgery population. Secondary outcomes included incidence of anastomotic leaks and length of hospital stay. Eleven trials consisting of 8245 were included in the analysis. We found moderate quality of evidence that 80% FiO2 was not effective in reducing SSI (RR, 0.91; 95% CI, 0.74 to 1.13; P = .41) anastomotic leaks (RR, 0.75; 95% CI, 0.53 to 1.06; P = 0.10). Conversely, we found low quality evidence of no effect on length of stay measured in days (MD, 0.39; 95% CI -0.59 to 1.36; P = 0.44). Although additional studies are required to decrease heterogeneity of the studies, the current review showed high FiO2 does not decrease the incidence of SSI in the colorectal surgery population.

The second victim phenomenon occurs when healthcare providers experience emotional or physical distress as a result of traumatic clinical events. Few hospitals have formalized peer support programs for second victims to navigate the postevent experience and offload associated emotional labor. This article describes the implementation of a second victim peer support program in a large academic anesthesiology practice, with the goal of augmenting emotional support for anesthesia providers. Program activations were tracked in a shared mailbox. Following peer support, second victims completed an evaluation assessing support received; trained peer supporters completed 2 evaluations assessing their comfort level and peer support encounters. From July 2018 to June 2020, ninety-one program activations (179 affected individuals) were made. A total of 130 peer support encounters were documented. Trained peer supporters were able to provide helpful support to affected colleagues nearly all (98.8%) of the time. Nearly 97% of second victims (25 of 31 evaluation respondents) reported the support as extremely or very beneficial, and 96.8% would recommend the program to colleagues. A second victim peer support program was successfully deployed in a large anesthesia department. This program was effective at a departmental level, fostering providers' well-being.

Research is abundant on second victimhood (the provider who was involved in and traumatized by an adverse clinical event) but minimal about the experience in nurse anesthetists. Physical and psychological symptoms of second victimhood may have a deleterious effect on patient care. Recognizing the important aspects during the various stages of recovery will help guide recovery efforts. Inclusion of important curriculum domains in nurse anesthesia education will improve understanding of this issue. Organizations and departments need to be aware of the seriousness of the effects of second victimhood and how to develop a supportive compassionate recovery program. More research is needed in nurse anesthetists to better understand implications specific to the practice.