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All APRNs are registered nurses who have earned a graduate degree that certifies them to practice advanced and specialized care. There are four classes of APRNs: certified nurse midwife (CNM), clinical nurse specialist (CNS), certified nurse practitioner (CNP), and certified registered nurse anesthetist (CRNA). Though all APRNs undergo extensive training to achieve their advanced degree, each type obtains a different skillset, with CRNAs focused on anesthesia care.

Prospective CRNAs must complete a master’s degree from a certified nurse anesthesia educational program and complete courses that focus on pharmacology, physiology, professional practices, and pain management. Comparatively, RNs must complete a Master of Science in nursing (MSN) to become a CNP and are recommended to do so to practice as a CNS. In most cases, both the CNS and CNP will subspecialize in a specific population, such as gerontology or pediatrics. Similarly, the CNM provider will obtain an MSN and then pass the midwifery exam offered by the American Midwifery Certification Board.¹ According to the Nurse Journal, CRNAs are the highest-paid APRNs, with an average annual take-home salary of $195,610, while CNMs earn $112,830 a year on average. The highest-paid CNP is a psychiatric CNP who earns $113,100 annually on average, whereas family and pediatric CNPs earn up to $98,000 annually on average.  Finally, the CNS provider can make up to $133,000 per year.²

With a highly attractive income potential and the ability to gain advanced skills, many RNs are motivated to earn a CRNA certification to meet the growing demand for anesthesia providers. In contrast to other APRNs, CRNAs are specially trained to provide anesthesia to patients in settings such as hospitals, clinics, private practices, and doctors’ offices. They also monitor vital signs throughout anesthesia, assist patients with recovery and side effects, and conduct post-procedure evaluations. The level of independence that CRNAs have varies according to state regulations, with some able to independently lead anesthesia care, while others require physician supervision.

In addition to their role in treating and diagnosing patients within their area of expertise, a CNS provider has a key role in education. CNS providers are often involved in educational programs to improve nurse performance, patient outcomes, and bedside nursing. This process involves the mentorship of nursing students and new nurse staff. They will also oversee evidence-based research and counsel patients and families when they act as resident experts on medically complex cases.^3,6

CNPs provide comprehensive care in their area of expertise. Their roles can include performing physical examinations, ordering prescriptions and procedures, ordering and interpreting laboratory and diagnostic results, and providing family planning services, prenatal care, health risk assessment, psychological counseling, healthcare service coordination, and/or health education.⁴

Finally, CNMs support patients in all areas of menarche, pregnancy, birth, and menopause. As providers, they can perform physical examinations independently, order prescriptions, and expedite patient therapy by admitting, managing, and discharging patients. They can interpret laboratory and diagnostic tests, order medical devices and equipment, and provide home health services.⁵

References

1. “NP vs. RN vs. CRNA (& More).” Adaptive Medical Partners, 23 May 2022, adaptivemedicalpartners.com/np-vs-rn-vs-crna-more/. Accessed 14 May 2024.
2. “Nurse Practitioner vs Clinical Nurse Specialist.” NurseJournal, 4 Dec. 2021, nursejournal.org/resources/np-vs-cns/.
3. “Medicare and CRNA Education – ProQuest.” Www.proquest.com, www.proquest.com/scholarly-journals/medicare-crna-education/docview/222116607/se-
4. AANP. “The Path to Becoming a Nurse Practitioner (NP).” American Association of Nurse Practitioners, 2020, www.aanp.org/news-feed/explore-the-variety-of-career-paths-for-nurse-practitioners.
5. “Nurse Anesthetists, Nurse Midwives, and Nurse – ProQuest.” Www.proquest.com, www.proquest.com/reports/nurse-anesthetists-midwives-practitioners/docview/2396587784/se-2. Accessed 14 May 2024.
6. “The Role of the Clinical Nurse Specialist in the – ProQuest.” Www.proquest.com, www.proquest.com/trade-journals/role-clinical-nurse-specialist-acute-care-setting/docview/3032757053/se-2. Accessed 14 May 2024.

Artificial Intelligence, or AI, is an umbrella term that encompasses technologies including deep learning, large language models, and natural language processing, that analyze large data sets in depth and learn from them, enabling the identification of subtle patterns¹. As AI technologies evolve, the potential applications of AI in medicine become increasingly versatile.

There are many potential applications for AI in medicine, with implementation of AI-powered tools in healthcare operations estimated to cut costs by $150 billion by 2026³. The most obvious application for AI is in streamlining and digitizing administrative tasks such as scheduling appointments, making reminder calls for pediatric immunizations and prenatal visits, and generating drug dosage algorithms and adverse effect warnings for patients on multiple drugs². Studies show that physicians who use documentation support tools such as voice-to-text dictation or medical scribe services have more face time with their patients³. Using AI to lessen the documentation and administrative burden therefore may improve patient care and satisfaction³. Additionally, AI may improve the precision of medical therapies by tailoring treatment to each patient based on a variety of patient factors such as age, gender, geography, race, family history, immune profile, metabolic profile, microbiome, and environment vulnerability³. This can be accomplished using complex algorithms that can take large datasets with patient information and analyze them for prognostic outcomes, in conjunction with patient information provided through health apps that monitor metrics such as food intake, vital signs, physical activity etc³. With improved genetic testing, AI can also incorporate patient genetic information to optimize treatment plans³. 

While the implications for AI use in clinical support tools are far-reaching and important, it is also a valuable technology for direct clinical work. Radiology and imaging diagnostics are one such area where AI can improve provider efficiency². While much work remains before AI can independently infer a diagnosis within complex clinical contexts with proven safety and accuracy, it can be used as a data point in provider decision-making, especially in distinguishing normal scans². This capability can be extremely helpful in places of high clinical volume, helping to reduce physician burnout². From a quality and safety standpoint, AI-driven video analysis is surprisingly effective at performing root-cause analysis³. One video analysis of a laparoscopic procedure was 92.8% accurate, not only in elucidating the steps of the procedure, but also in establishing missing or incorrect steps³. Finally, AI has been used to improve surgical robotics. Johns Hopkins University has developed a surgical robot called STAR (smart tissue autonomous robot), which has been shown in animal tissue to be able to consistently outperform human surgeons in tasks such as creating connections in bowel, suturing, and tying surgical knots³. While a fully autonomous robot surgeon still belongs to science fiction, implementing AI in surgery can enhance patient safety and successful surgical outcomes³.

Overall, the field of AI is exploding in terms of new technologies, and learning how to work with AI has the potential to enhance human endeavors in many disciplines. Advancements in AI have vast implications in medicine specifically, including improving clinical efficiency, reducing provider burnout, and improving surgical outcomes through diverse applications.

References

1. Alowais SA, Alghamdi SS, Alsuhebany N. et al. Revolutionizing healthcare: the role of artificial intelligence in clinical practice. BMC Med Educ 23, 689 (2023). doi:10.1186/s12909-023-04698-z.
2. Amisha MP, Pathania M, Rathaur VK. Overview of artificial intelligence in medicine. J Family Med Prim Care. 2019 Jul;8(7):2328-2331. doi:10.4103/jfmpc.jfmpc_440_19. PMID: 31463251; PMCID: PMC6691444.
3. Bohr A, Memarzadeh K. The rise of artificial intelligence in healthcare applications. Artificial Intelligence in Healthcare. 2020 Jun;25–60. doi:10.1016/B978-0-12-818438-7.00002-2. PMCID: PMC7325854.

Tranexamic acid (TXA) is an antifibrinolytic agent, a medication that reduces bleeding by preventing the lysis of a blood clot.¹ Originally developed for patients with hemophilia undergoing oral surgery, TXA is now also administered to reduce heavy menstrual bleeding, treat trauma patients at risk for hemorrhage, and to preoperatively minimize the need for blood transfusions during surgery.² TXA is an analog of the amino acid lysine and it functions by blocking the conversion of plasminogen to the enzyme plasmin, which breaks down blood clots by attacking fibrin.² TXA was first synthesized in 1962 and is currently on the World Health Organization’s Model List of Essential Medicines. ^3,4

In the surgical setting, TXA is commonly used for major orthopedic surgery, which often involves significant blood loss and requires transfusions.⁵ Specifically, a little less than a third of patients undergoing total joint arthroplasty require postoperative blood transfusions for anemia.⁶ Studies^7,8 have shown that intravenous TXA reduces blood loss and transfusion requirements for both total knee and hip arthroplasties. The safety and efficacy of topical and intra-articular TXA for total joint arthroplasty has also been established in the literature.⁹

In addition to orthopedic surgery, spine surgery can often entail a large volume of blood loss and is likewise often accompanied by the administration of TXA. Blood loss during posterior instrumented spinal fusion was found to be reduced by as much as 30% in patients given TXA before the operation.¹⁰ The efficacy of TXA for pediatric and adolescent patients has also been established in some situations: studies have shown that younger patients who receive intravenous TXA before scoliosis surgery demonstrate a dramatic decrease in blood loss.¹¹ While some studies, such as one investigating the perioperative use of TXA for fusion of the thoracic and lumbar spine,¹² have not found a significant difference in blood loss for patients given TXA, most clinical trials are in fact indicating that TXA can effectively control blood loss during spinal surgery.¹⁰

The use of TXA, while known to prevent the lysis of blood clots, may concurrently increase the risk of thromboembolism, the obstruction of a blood vessel by a blood clot dislodged from another site.  The 2012 “MATTER” study, which investigated the use of TXA in combat injury, demonstrated higher rates of thromboembolism in patients receiving TXA.¹³ Similarly, a 2018 study concluded that TXA administration was an independent risk factor for thromboembolism.¹⁴

However, these studies may be misleading. Myers et al.¹⁵ note that in those studies, TXA is only given to the sickest patients, who may already be at a much higher risk for thromboembolism, thus confounding any potential results. Many of these retrospective studies do not routinely screen for thromboembolism, which may present another methodological problem. Many more studies, in fact, have found that TXA does not present a significant risk for thromboembolism. For example, a recent systematic review and meta-analysis of hundreds of studies did not reveal an increased risk of thromboembolic events in any patient group.¹⁶ While patients should certainly be made aware of the potential for developing thromboembolic events upon receiving TXA, the risk appears to be quite low, and most researchers believe it should not prevent physicians from administering this vital drug.

References

1. McEvoy, M. “Tranexamic Acid (TXA): Drug Whys.” EMS1, Lexipol, 29 June 2015, www.ems1.com/ems-products/ambulance-disposable-supplies/articles/tranexamic-acid-txa-drug-whys-JHdJgbiQRX2zqonO/.

2. Thomas, J. “The Benefits of TXA.” EMS World, 5 Feb. 2015, www.emsworld.com/article/12042127/tranexamic-acid-for-prehospital-hemorrhage.

3. “TXA: History.” TXA Central, London School of Hygiene & Tropical Medicine, txacentral.lshtm.ac.uk/?page_id=98.

4. Gill, R., et al. “WHO Essential Medicines for Reproductive Health.” BMJ Global Health, vol. 4, no. 6, 2019, doi:10.1136/bmjgh-2019-002150.

5. Davey, J. Roderick, et al. “Tranexamic Acid for the Prevention and Management of Orthopedic Surgical Hemorrhage: Current Evidence.” Journal of Blood Medicine, 2015, p. 239., doi:10.2147/jbm.s61915.

6. Blumberg, N., et al. “A Cost Analysis of Autologous and Allogeneic Transfusions in Hip-Replacement Surgery.” The American Journal of Surgery, vol. 171, no. 3, 1996, pp. 324–330., doi:10.1016/s0002-9610(97)89635-3.

7. Ekbäck, G., et al. “Tranexamic Acid Reduces Blood Loss in Total Hip Replacement Surgery.” Anesthesia & Analgesia, vol. 91, no. 5, 2000, pp. 1124–1130., doi:10.1097/00000539-200011000-00014.

8. Good, L., et al. “Tranexamic Acid Decreases External Blood Loss but Not Hidden Blood Loss in Total Knee Replacement.” British Journal of Anaesthesia, vol. 90, no. 5, 2003, pp. 596–599., doi:10.1093/bja/aeg111.

9. Wong, J., et al. “Topical Application of Tranexamic Acid Reduces Postoperative Blood Loss in Total Knee Arthroplasty.” The Journal of Bone and Joint Surgery-American Volume, vol. 92, no. 15, 2010, pp. 2503–2513., doi:10.2106/jbjs.i.01518.

10. Yoo, J. S., et al. “The Use of Tranexamic Acid in Spine Surgery.” Annals of Translational Medicine, vol. 7, no. S5, 2019, doi:10.21037/atm.2019.05.36.

11. Verma, K., et al. “The Relative Efficacy of Antifibrinolytics in Adolescent Idiopathic Scoliosis.” Journal of Bone and Joint Surgery, vol. 96, no. 10, 2014, doi:10.2106/jbjs.l.00008.

12. Farrokhi, M. R., et al. “Efficacy of Prophylactic Low Dose of Tranexamic Acid in Spinal Fixation Surgery.” Journal of Neurosurgical Anesthesiology, vol. 23, no. 4, 2011, pp. 290–296., doi:10.1097/ana.0b013e31822914a1.

13. Morrison, J. J. “Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study.” Archives of Surgery, vol. 147, no. 2, 2012, p. 113., doi:10.1001/archsurg.2011.287.

14. Johnston, L. R., et al. “Evaluation of Military Use of Tranexamic Acid and Associated Thromboembolic Events.” JAMA Surgery, vol. 153, no. 2, 2018, p. 169., doi:10.1001/jamasurg.2017.3821.

15. Myers, S. P., et al. “Venous Thromboembolism after Tranexamic Acid Administration: Legitimate Risk or Statistical Confounder?” ANZ Journal of Surgery, vol. 90, no. 4, 2020, pp. 425–426., doi:10.1111/ans.15670.

16. Taeuber, I., et al. “Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality.” JAMA Surgery, vol. 156, no. 6, 2021, doi:10.1001/jamasurg.2021.0884.

Restless Leg Syndrome (RLS) is a common neurological disorder that affects approximately 5-10% of the population (1). It is characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations, such as tingling, itching, or crawling. These symptoms typically worsen during periods of rest or inactivity, leading to sleep disturbances and a significant impact on patients’ quality of life (2). For patients with restless leg syndrome undergoing anesthesia, the involuntary leg movements and discomfort can pose challenges for anesthesiologists, requiring specialized techniques and considerations to ensure safe and effective anesthesia administration. Additionally, certain medications commonly prescribed to manage RLS symptoms may interact with anesthetic drugs, necessitating a thorough understanding of potential drug interactions and adjustments in dosage (3). By addressing these challenges, anesthesiologists can provide optimal care for patients with RLS and ensure a smooth and successful anesthesia experience.

One way that anesthesiologists can adapt their techniques for patients with restless leg syndrome is by utilizing regional anesthesia. Regional anesthesia involves using nerve blocks to numb specific areas of the body, such as the legs, while the patient remains awake. This can help minimize the discomfort caused by RLS and reduce the risk of involuntary leg movements during surgery (3). Another technique that can be employed is the use of sedatives or muscle relaxants prior to anesthesia administration. These medications can help relax the muscles and reduce the severity of RLS symptoms (1).

Additionally, anesthesiologists should carefully review a patient’s medication history and consult with their primary care physician or neurologist to ensure that there are no potential interactions between RLS medications and any anesthetic drugs that may be used. For instance, dopamine agonists (pramipexole, ropinirole, etc.), which are commonly prescribed for RLS, may interact with anesthetic drugs, leading to increased sedation or hypotension (2). On the other hand, certain opioids used during anesthesia may worsen RLS symptoms or trigger an RLS episode. Anesthesiologists should be aware of these potential interactions and make necessary adjustments in medication dosages or choose alternative medications to ensure patient safety and optimize anesthesia outcomes.

In addition to the challenges during surgery, patients with RLS may also experience difficulties with post-operative pain management (1). The discomfort and restlessness associated with RLS can make it challenging for patients to find a comfortable position or to stay still, which can impede the healing process. Anesthesiologists and other healthcare providers must take this into consideration when developing a pain management plan for these individuals. By tailoring pain relief strategies to address both the surgical and RLS-related discomfort, patients can experience a smoother recovery and better overall outcomes (3). This may involve adjusting medication dosages or using alternative pain management techniques such as physical therapy or acupuncture. In some cases, it may be necessary to involve a multidisciplinary team of healthcare professionals, including neurologists or sleep specialists, to ensure comprehensive care. By addressing both the surgical and RLS-related pain, patients can not only recover more comfortably but also reduce the risk of complications and improve their overall quality of life (1). It is crucial for anesthesia providers to have open communication with patients regarding restless leg syndrome and to work together to develop an individualized pain management plan that meets the unique needs of each patient.

References

1. Gossard TR, Trotti LM, Videnovic A, St Louis EK. Restless Legs Syndrome: Contemporary Diagnosis and Treatment. Neurotherapeutics. 2021;18(1):140-155. doi:10.1007/s13311-021-01019-4
2. Amir A, Masterson RM, Halim A, Nava A. Restless Leg Syndrome: Pathophysiology, Diagnostic Criteria, and Treatment. Pain Med. 2022;23(5):1032-1035. doi:10.1093/pm/pnab253
3. Raux M, Karroum EG, Arnulf I. Case scenario: anesthetic implications of restless legs syndrome. Anesthesiology. 2010;112(6):1511-1517. doi:10.1097/ALN.0b013e3181de2d66

Bronchoscopy is an investigative or therapeutic procedure that involves inserting an instrument into the lungs via the airway and is often performed under anesthesia. Rigid bronchoscopy generally warrants general anesthesia, while flexible bronchoscopy can be carried out under sedation supplemented with topical anesthesia [1]. It is critical for the practicing anesthetist to use the best method for each individual patient [2].

Prior to any procedure, since patients may be of American Society of Anesthesiologists III-IV physical status given the conditions that typically call for bronchoscopy, appropriate pre-operative tests need to be carried out. This will inform the best approach to anesthesia for the bronchoscopy depending on the context [3].

For rigid bronchoscopy

The ideal anesthetic regimen involves analgesia, an appropriate decrease in awareness or consciousness, and muscle relaxation. General anesthesia is usually used for rigid bronchoscopy. Anesthesia may be induced with propofol, etomidate or ketamine, with fentanyl or remifentanil in adults, or with inhalational agents in children. The patient’s vocal cords should be treated with lignocaine in order to prevent the occurrence of post-operative laryngospasm. In addition, fentanyl boluses and short acting beta blockers can be administered in order to prevent a pressor response.

Anesthesia is then maintained with remifentanil and an intravenous or inhalational agent. Target controlled infusion as part of a total intravenous anesthesia (TIVA) protocol may also be used.

The reversal of a patient’s neuromuscular block is carried out postoperatively, with neostigmine, glycopyrrolate or atropine based on the clinical situation and physician choice. It is important to completely reverse the block since most patients undergoing a bronchoscopy will not have the respiratory reserve to tolerate any residual block [3].

Following completion of the procedure and prior to the administration of a reversal agent, it is best to implement a cuffed endotracheal tube or a laryngeal mask airway. An endotracheal tube is generally preferred as an emergency flexible bronchoscopy may be needed.

For flexible bronchoscopy

In most cases, sedation is sufficient for flexible bronchoscopy. Depending on state regulations and facility protocol, light to moderate sedation may be provided directly by the proceduralist. A moderate level of sedation allows the patient to respond to verbal commands and recover more quickly compared to deeper anesthesia. The dose of sedative should generally be decreased in elderly patients. As there is always a small risk of bradycardia, patients need to be monitored for any signs of hypotension or respiratory depression. Additionally, the American College of Clinical Pharmacology has published detailed guidelines for the administration of anesthesia for flexible bronchoscopy [3].

Topical anesthesia is critical in flexible bronchoscopy since it helps with patient comfort. To this end, the nostrils, oropharynx and hypopharynx are anesthetized, and anesthesia beyond the glottis can also blunt the cough reflex and allow for the bronchoscopy procedure to take place as smoothly as possible. Lignocaine is the most common agent used for topical anesthesia, but topical anesthesia regimens tend to vary across clinics [3].

Providing sedation and anesthesia for patients undergoing a bronchoscopy requires a thorough understanding of pulmonary anatomy and physiology, clear communication between the anesthesia provider, proceduralist, and patient, and a patient-tailored anesthetic regimen in order to ensure the best possible patient outcomes [4].

References

1. Lentini, C. & Granlund, B. Anesthetic Considerations for Bronchoscopic Procedures. StatPearls (2023).

2. Galway, U. et al. Anesthetic considerations for bronchoscopic procedures: a narrative review based on the Cleveland Clinic experience. J. Thorac. Dis. 11, 3156–3170 (2019). doi: 10.21037/jtd.2019.07.29

3. Chadha, M., Kulshrestha, M. & Biyani, A. Anaesthesia for bronchoscopy. Indian J. Anaesth. 59, 565 (2015). doi: 10.4103/0019-5049.165851

4. Goudra, B. G., Singh, P. M., Borle, A., Farid, N. & Harris, K. Anesthesia for Advanced Bronchoscopic Procedures: State-of-the-Art Review. Lung 193, 453–465 (2015). DOI: 10.1007/s00408-015-9733-7

Breast cancer is one of the most commonly diagnosed cancers and the second leading cause of cancer-related death in women. [1] As surgical resection is the primary method of treatment for these patients, there is a high risk of blood-borne metastasis. This occurs when trauma to the central tumor causes tumor cells to shed and enter the bloodstream, circulating and then exiting into distant regions of the body. [2] Additionally, surgical operations have been shown to decrease natural killer cell function and T cell response for one to four weeks after surgery. These immunosuppressive effects put cancer patients in the postoperative state at a higher risk of developing metastases. As a result, there is significant interest in potential modifications to breast cancer surgery that decrease the risk of negatively affecting a patient’s cancer status with minimal side effects. One area of interest is the effect of lidocaine on breast cancer cells.

Several retrospective studies have suggested regional anesthesia may have a positive effect on cancer relapse and recurrence. Regional anesthesia is administered by injecting local anesthetic at a target location to temporarily disrupt pain signals from a specific region of the body. Potential benefits include reducing surgical stress from neuroendocrine and immunological disturbances, reducing the use of systemic anesthesia and opiates (which have been shown to hinder cell immunity), as well as having a direct inhibitory effect on cancer cells. [1]

In an in vitro experiment, three human breast cancer cell lines were isolated and grown in culture plates. These breast cancer cells were treated with increasing doses of lidocaine, an anesthetic that is commonly used for regional anesthesia. Lidocaine significantly reduced cell viability in all three cell lines, as measured by the MTT colorimetric assay. The anesthetic was also shown to inhibit cell migration, as exposed cells demonstrated reduced wound closure compared to control cells. The same researchers then conducted an in vivo experiment in mice to further assess the effects of lidocaine on human breast cancer cells. Cancer cells were injected intraperitoneally, and the global tumor volume was measured. Mice injected with lidocaine exhibited prolonged survival times and developed significantly smaller tumors than control mice. [3] At the conclusion of these molecular and preclinical experiments, these researchers suggest lidocaine may have a protective effect against human breast cancer cells.

Lidocaine is an amide anesthetic routinely administered for topical or surface anesthesia, and is injected into the subarachnoid and epidural spaces to block sensory and motor neural transmission. [4] Cytotoxicity assays performed on natural killer (NK) cells demonstrated that clinically relevant concentrations of lidocaine increases performance of NK cells, which are a crucial pillar of the immune response. [4,5] One in vitro study on human hepatocellular carcinoma cells found cancer cells treated with lidocaine exhibited a decrease in Bcl-2 levels with a concurrent increase in Bax concentrations. These two molecules are part of the Bcl-2 family, a group of regulatory proteins modulating cell death, composed of inhibitors (Bcl-2) and promoters (Bax). It was further observed that treated cultures with cancer cells exhibited a significant increase in caspase-3, a “death protease” catalyzing the cleavage of many key cellular proteins. [6] Matrix-metalloproteinase 9 (MMP-9) is a proteolytic enzyme which plays a crucial role in tumor metastasis by regulating pathological remodeling processes involving inflammation and fibrosis. [7] Another in vitro study demonstrated lidocaine can significantly decrease the secretion of MMP-9 by repressing the activity of tumor necrosis factor ɑ (TNF-ɑ), a proinflammatory cytokine. [8]

The cancer microenvironment is extraordinarily complex, involving many molecular cascades and organ systems. Although lidocaine has been shown to have a protective effect against human breast cancer cells, the extant literature has thus far been restricted to artificial and preclinical experimentation. As such, further clinical research is needed to determine lidocaine’s true benefit. What’s more, there is a lack of research on the specific mechanisms by which lidocaine takes effect on cancer cells. Investigating these can help explain the beneficial properties of lidocaine in cancer progression.

References

1. Li, Ru, et al. “Effects of Local Anesthetics on Breast Cancer Cell Viability and Migration.” BMC Cancer, vol. 18, no. 1, June 2018, p. 666. BioMed Central, https://doi.org/10.1186/s12885-018-4576-2

2. Choy, A., and P. McCulloch. “Induction of Tumour Cell Shedding into Effluent Venous Blood Breast Cancer Surgery.” British Journal of Cancer, vol. 73, no. 1, Jan. 1996, pp. 79–82. www.nature.com, https://doi.org/10.1038/bjc.1996.14

3. Chamaraux-Tran, Thiên-Nga, et al. “Antitumor Effects of Lidocaine on Human Breast Cancer Cells: An In Vitro and In Vivo Experimental Trial.” Anticancer Research, vol. 38, no. 1, Jan. 2018, pp. 95–105. ar.iiarjournals.org, https://ar.iiarjournals.org/content/38/1/95

4. Zhang, Caihui, et al. “Local Anesthetic Lidocaine and Cancer: Insight Into Tumor Progression and Recurrence.” Frontiers in Oncology, vol. 11, 2021. Frontiers, https://www.frontiersin.org/articles/10.3389/fonc.2021.669746

5. Ramirez, Maria F., et al. “The Effect of Clinically Therapeutic Plasma Concentrations of Lidocaine on Natural Killer Cell Cytotoxicity.” Regional Anesthesia & Pain Medicine, vol. 40, no. 1, Jan. 2015, pp. 43–48. rapm.bmj.com, https://doi.org/10.1097/AAP.0000000000000191

6. Xing, Wei, et al. “Lidocaine Induces Apoptosis and Suppresses Tumor Growth in Human Hepatocellular Carcinoma Cells In Vitro and in a Xenograft Model In Vivo.” Anesthesiology, vol. 126, no. 5, May 2017, pp. 868–81. DOI.org (Crossref), https://doi.org/10.1097/ALN.0000000000001528

7. Yabluchanskiy, Andriy, et al. “Matrix Metalloproteinase-9: Many Shades of Function in Cardiovascular Disease.” Physiology, vol. 28, no. 6, Nov. 2013, pp. 391–403. PubMed Central, https://doi.org/10.1152/physiol.00029.2013

8. Piegeler, T., et al. “Clinically Relevant Concentrations of Lidocaine and Ropivacaine Inhibit TNFα-Induced Invasion of Lung Adenocarcinoma Cells in Vitro by Blocking the Activation of Akt and Focal Adhesion Kinase.” British Journal of Anaesthesia, vol. 115, no. 5, Nov. 2015, pp. 784–91. DOI.org (Crossref), https://doi.org/10.1093/bja/aev341

The relationship between physical therapy (PT) and recovery from surgery is complicated; whether there is a need for it after surgery is informed by several factors such as age, type of surgery and type of PT. Many types of surgery don’t need PT after at all, in fact. The need is larger when the surgery affects the musculoskeletal system in particular.

Orthopedic surgery often benefits from PT to assist with recovery. In their study, Hankins and Moloney attempt to delineate the best time to initiate physical therapy for optimized recovery from hip surgery in elderly patients. Earlier enrollment in physical therapy was directly linked to shorter hospital stays. If physical therapy began the day after the surgery, Hankins and Moloney explain that the patient was discharged two or three days earlier. Delaying physical therapy increased patient postoperative complications like delirium and pneumonia. Hankins and Moloney further found that delayed physical therapy was linked to poor mobility two months post-surgery and high mortality six months after the surgery. Thus, patients, especially elderly patients, need PT after hip surgery, with the most benefit coming from started physical therapy as soon as possible.¹

Villalta et al.’s findings not only agree with but also examine a wider demographic than the study by Hankins and Moloney. In the general population, early movement after orthopedic surgeries enhances recovery. Furthermore, aquatic physical therapy is superior to land physical therapy. Different types of orthopedic surgical procedures benefit from postoperative physical therapy. These include rotator cuff repair, anterior cruciate ligament reconstruction, hip replacement, and knee replacement. They demonstrated a key aspect of patient outcome – the early onset of physical therapy did not have adverse effects on patient wounds or wound healing time.

Compared to land physical therapy, aquatic physical therapy optimized patient recovery from hip and knee replacement surgeries not by reducing swelling or pain but by reducing the likelihood of adverse events on wound healing. Although aquatic physical therapy has been demonstrated to improve recovery from rotator cuff repair surgery because muscle activity is reduced, clinicians still hesitate to implement it because the limbs need to be immersed. Physicians fear this will delay wound healing. Aquatic physical therapy began on postoperative day 6 or 14 for the two groups making up the study cohort. Post-op day 14 participants had fewer complications from aquatic physical therapy compared to post-op day 6, suggesting that aquatic PT may be better after the surgical site has more time to heal. ²

Patients emerging from orthopedic surgery are not the only ones who benefit from physical therapy. In a study published by Hulzebos et al., it was found that cardiac surgery patients who participated in preoperative physical therapy enjoyed protection from postoperative pneumonia. This result is consistent with previous studies. This is an important benefit since the geriatric population easily succumbs to pneumonia. This vulnerability is an ever-present concern for physicians.³ Hoogeboom et al. explains that physical therapy strengthens lung capacity and reduces the onset of pneumonia. Their study agrees with the preceding body of work that PT both before and after the surgery reduces length of hospital stay as well as the associated risks of surgical complications following cardiovascular, abdominal, thoracic, and orthopedic surgery, with a need for starting PT early in the postoperative period specifically.

To refine current research into the benefits of physical therapy, more researchers need to consider how physical therapy can serve the general population and not just the geriatric population.⁴

References

1. Hankins ML, Moloney GB. Early initiation of physical therapy after geriatric hip fracture surgery is associated with shorter hospital length of stay and decreased thirty-day mortality. Injury. 2022 Dec;53(12):4086-4089. doi: 10.1016/j.injury.2022.09.040. Epub 2022 Sep 25. PMID: 36192201.
2. Villalta EM, Peiris CL. Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults after orthopedic surgery: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2013 Jan;94(1):138-48. doi: 10.1016/j.apmr.2012.07.020. Epub 2012 Aug 7. PMID: 22878230.
3. Hulzebos EH, Smit Y, Helders PP, van Meeteren NL. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev. 2012 Nov 14;11(11):CD010118. doi: 10.1002/14651858.CD010118.pub2. PMID: 23152283; PMCID: PMC8101691.
4. Hoogeboom TJ, Dronkers JJ, Hulzebos EH, van Meeteren NL. Merits of exercise therapy before and after major surgery. Curr Opin Anaesthesiol. 2014 Apr;27(2):161-6. doi: 10.1097/ACO.0000000000000062. PMID: 24500337; PMCID: PMC4072442.

A looming shortage of anesthesiologists globally may affect the accessibility of healthcare in the next ten years. The American Association of Medical Colleges predicts that there will be a workforce gap of as many as 12,500 anesthesiologists in the United States by 2033 (3). Similarly, a study from the UK suggests that there will be a shortage of 11,000 anesthetic staff members by 2040, preventing 8.25 million operations from taking place (3). Growing shortages of anesthesiologists globally could significantly impact the availability of surgeries and other medical procedures, especially in rural and low-income areas. The COVID-19 pandemic has pushed many healthcare workers to exit the workforce in the past few years by creating a more stressful working environment in hospitals and clinics (3). A changing world population and limited training opportunities in anesthesiology are other factors to consider. In order to recruit and retain skilled anesthesiologists, healthcare systems worldwide need to evolve to support the well-being and work-life balance of both the profession’s older and newer members.

Various factors have contributed to the growing workforce gap for anesthesiologists. An aging population has correlated with an increasing demand for surgical and anesthesia services that has outpaced the number of anesthesiologists entering the profession (5). Furthermore, the uneven distribution of anesthesiologists across regions means that rural and lower-income areas face more significant challenges in ensuring that anesthesiologists are available to provide perioperative care (5).

Additionally, the limited number of residency slots and lack of funding for medical education in the United States have restricted the number of anesthesiologists entering the field yearly (2). In 2022, 43% of medical students who applied for an anesthesiology residency did not match with a residency program (2). Although the US Congress has started working toward creating more residency positions, accredited institutions that can provide residencies may not receive federal funding for these spots, disincentivizing them from making more residencies available (2). Education and clinical training is crucial globally to address anesthesiologist shortages.

In the United Kingdom, a study published by the Association of Anaesthetists found that more anesthesiologists were retiring early in the last few years (3). The top factors contributing to the decision to retire included health and well-being, workload, and burnout, suggesting that anesthesiologists’ working environments fail to prioritize clinicians’ health and well-being (3). In particular, the study argues that anesthesiology departments must provide more significant support for older clinicians experiencing health issues, fatigue, or hearing and vision loss (3).

Creating systems and structures that allow anesthesiologists to “pace their careers” may help retain experienced anesthesiologists, who can help mentor younger members of the field (3). For example, anesthesiology departments can create policies that support older doctors experiencing menopause and ensure that equipment is easily accessible for older anesthesiologists experiencing hearing or vision loss (3). Furthermore, increasing residency positions in anesthesiology is critical for maintaining the anesthesiology workforce in the coming years (2). A study on anesthesiology residency programs found that expanding residency programs resulted in significant cost savings for healthcare organizations, considering that the cost per hour of clinical coverage for residents is far lower than that of paying nurse anesthetists overtime (2). Accordingly, the study suggests that institutions might consider expanding their residency programs even if they do not receive additional federal funding (2).

Improving recruitment and retention strategies for anesthesiologists and offering more robust support to clinicians is imperative to ensure that there will be enough anesthesiologists for necessary medical procedures in the upcoming years. It is also important to distribute existing anesthesiologists, as low resource areas tend to experience exacerbated shortages of skilled healthcare providers. Drawing providers to such areas can increase equitable access and improve anesthesiologist shortages globally.

References

1. “Action needed to avert anesthetist shortage of 11,000 by 2040, which could affect over 8 million operations.” Medical Xpress, Sept 28 2022,
2. “Additional anesthesiology residency positions may help hospitals save costs, address projected workforce shortages of anesthesia care professionals.” ASA Monitor, Jan 27, 2023, https://www.asahq.org/about-asa/newsroom/news-releases/2023/01/additional-anesthesiology-residency-positions-may-help-hospitals-save-costs
3. Davies, et al. “Age and the anaesthetist: considerations for the individual anaesthetist and workforce planning.” Anaesthesia, 29 Sept 2022, vol. 77, no. 11, pp. 1259-1267.
4. “How Physician Shortages Could Change the Future of Anesthesiology.” Anesthesiology News, Sept 19 2020, https://www.anesthesiologynews.com/Policy-and-Management/Article/01-20/How-Physician-Shortages-Could-Change-The-Future-of-Anesthesiology/59531
5. Simoneaux, Richard. “Are We Facing an Anesthesiologist Shortage?” ASA Monitor, January 2022, https://pubs.asahq.org/monitor/article-abstract/86/1/1/118103/Are-We-Facing-an-Anesthesiologist-Shortage?redirectedFrom=fulltext
6. “The Anesthesia Provider Shortage.” Medicus, June 7, 2023, https://medicushcs.com/resources/the-anesthesia-provider-shortage

Mepivacaine is a local anesthetic that is used to block sensation and pain during surgery, often as spinal anesthesia. It is also used in dental surgery. There are several local anesthetics available that fulfill the same roles, such as bupivacaine, but each has a specific pharmacological profile. 

Research conducted by Schwenk et al. found that mepivacaine is superior to bupivacaine in hip arthroplasty (joint surgery of the hip). The former enables earlier ambulation during recovery from spinal anesthesia. This difference is observed because bupivacaine causes greater sensory impairment, thereby delaying ambulation and discharge. ¹  

Another study compared mepivacaine and bupivacaine during egg retrieval. Spinal anesthesia can be used for oocyte retrieval since there is an increased chance for fertilization (27%) compared to general anesthesia (15%). During transvaginal oocyte retrieval, patients received the spinal mepivacaine–fentanyl combination instead of the traditional bupivacaine—fentanyl combination.  Menshawi & Fahim found that the cocktail of mepivacaine was superior to the one with bupivacaine as the primary agent. Recovery from mepivacaine was faster than bupivacaine. Both the sensory and motor block resolved quickly enough to reduce the time to ambulation and hospital discharge.  

Calkins et al. arrived at the same conclusion as both of the previous studies. Their research also showed that mepivacaine leads to faster recovery in patients following hip arthroplasty. In addition to shorter stays in the post-acute care units, patients did not experience complications, like urinary catheterization, or require overnight stay. On the other hand, the bupivacaine group experienced more neurologic complications like spinal headache. This data agrees that using mepivacaine spinal anesthesia improves surgery results. 

Mepivacaine is also used in dental surgery and is typically administered as a 3% solution without any vasoconstrictors or as a 2% solution with vasoconstrictors such as 1:20,000 levonordefrin and 1:100,000 adrenaline. Lidocaine, another local anesthetic commonly used in dental procedures, is always available as a 2% solution with 1:100,000 or 1:50,000 adrenaline. Su et al. found that the 2% solution of mepivacaine with 1:100,000 adrenaline was far superior to its counterpart lidocaine with 1:100,000 adrenaline. This may be because mepivacaine’s low vasodilation reduced bleeding and systematic toxicity while improving the depth and duration of anesthesia. Milder vasodilation facilitates higher concentrations of mepivacaine. Although the superior effects of mepivacaine to lidocaine was in the context of its combination with vasoconstrictors like adrenaline, the results are still notable. Because anesthesia tends to use cocktails during surgery, examining the drug of impact within its cocktail mixture makes for a more accurate representation of how its results will play out in the field. ³ 

In dental surgeries, articaine has been proven to produce anesthesia more swiftly compared to mepivacaine. Articaine’s thiophene ring allows for enhanced lipid membrane permeability and metabolism in the plasma of cells enhances the efficacy of the drug. ⁴ On the other hand, mepivacaine is an amide so needs to be initially metabolized in the liver. Both mepivacaine and articaine block sodium channels on nerve membranes, thereby blocking the transmission of nerve impulses. The literature agrees that the following advantages of mepivacaine make it the number one choice for surgeons: rapid onset so that anesthesia is delivered in a short time, intermediate duration for faster recovery, less vasodilation thereby reducing toxicity, less cardiotoxicity than bupivacaine and it is usable without epinephrine for patients who have contraindications to vasoconstrictors (e.g., certain heart conditions). 

References 

1. Schwenk ES, Kasper VP, Smoker JD, Mendelson AM, Austin MS, Brown SA, Hozack WJ, Cohen AJ, Li JJ, Wahal CS, Baratta JL, Torjman MC, Nemeth AC, Czerwinski EE. Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation. Anesthesiology. 2020 Oct 1;133(4):801-811. doi: 10.1097/ALN.0000000000003480. PMID: 32852904. 

2. Menshawi, M.A., Fahim, H.M. Spinal mepivacaine versus bupivacaine for ultrasound guided transvaginal oocyte retrieval. A comparative study. Ain-Shams J Anesthesiol 12, 22 (2020). https://doi.org/10.1186/s42077-020-00068-9 

3. Su N, Liu Y, Yang X, Shi Z, Huang Y. Efficacy and safety of mepivacaine compared with lidocaine in local anaesthesia in dentistry: a meta-analysis of randomised controlled trials. Int Dent J. 2014 Apr;64(2):96-107. doi: 10.1111/idj.12087. Epub 2014 Jan 16. PMID: 24428507; PMCID: PMC9376404. 

4.Gazal G. Is Articaine More Potent than Mepivacaine for Use in Oral Surgery? J Oral Maxillofac Res. 2018 Sep 30;9(3):e5. doi: 10.5037/jomr.2018.9305. PMID: 30429965; PMCID: PMC6225598. 

Healthcare providers interface with patients of all ages, ethnicities, genders, and sexual orientations, and thus it is important that the demographic makeup of these providers reflects the patients they care for and that patients feel comfortable and understood by their providers. This claim is backed by data; multiple studies have shown that female patients have better outcomes when treated by female physicians, across all specialties³. Another retrospective analysis of 1.8 million hospital births found that pairing a newborn with a physician of the same race reduces in-hospital mortality by 50%, as well as decreasing communication barriers between patients and physicians, and increasing healthcare utilization by these patients². Anesthesiology providers, in particular, interact with patients during some of their most vulnerable moments: immediately before and immediately after surgery, managing their perioperative pain, and caring for them in the ICU setting. Thus diversity, equity and inclusion initiatives are even more important in the field of anesthesia, for patient safety and satisfaction.  

Despite the well-demonstrated importance of diversity in medicine, there are still significant disparities in many specialties, including anesthesia. For example, even though gender parity is much better in matriculants to medical schools in the United States in modern times, there remains a large gender gap in practicing anesthesiologists¹. 64.3% of all anesthesiologists are men, with only 36.6% being women and no data on other gender identities¹. Women are also largely overlooked for leadership positions. For example, only 13% of department chair positions are held by women¹. Furthermore, in 2020, anesthesiology residents who identified as American Indian/Alaskan Native, Black/African American and Hispanic/Latino combined made up less than 15% of all anesthesiology residents across the country¹. The barriers to increased diversity in anesthesia are in large part like the barriers in medicine as a whole; they are historic and institutional in nature¹. For most of their history, higher education institutions denied admission to minorities and women¹. While that is not the case today, standardized testing and legacy admissions have been shown to overwhelmingly benefit wealthy, White applicants¹. Despite both departmental and national DEI initiatives, these historic barriers have been difficult to overcome¹.  

Nonetheless, there is important work being done to overcome these barriers. For example, a national imitative, Raising Anesthesiology Diversity and Antiracism (RADAR), launched in 2022⁴. This program is a joint effort from the departments of anesthesiology at University of Michigan and Washington University in St. Louis, and it aims to engage and support historically marginalized medical students, trainees, and early faculty in the field of anesthesiology⁴. It also aims to address the problem from the top: RADAR provides anti-racism training and resources to senior leadership⁴. There is also a call to action for departments across the country to join in this initiative, so it becomes and remains a widespread and sustainable effort⁴. While this program is too new to study the outcomes of it, national initiatives are an important way to keep improving diversity in the field of anesthesias⁴.  

References 

1. Estime SR, Lee HH, Jimenez N, Andreae M, Blacksher E, Navarro R. Diversity, equity, and inclusion in anesthesiology. Int Anesthesiol Clin. 2021 Oct 1;59(4):81-85. doi: 10.1097/AIA.0000000000000337.  

2. Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci U S A. 2020 Sep 1;117(35):21194-21200. doi: 10.1073/pnas.1913405117.  

3. Tsugawa, Y., Jena, A.B., Figueroa, J.F., Orav, E.J., Blumenthal, D.M., Jha, A.K., 2017. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Internal Medicine 177, 206.https://doi.org/10.1001/jamainternmed.2016.7875 

4. Wixson MC, Mitchell AD, Markowitz SD, Malicke KM, Avidan MS, Mashour GA. Raising Anesthesiology Diversity and Antiracism: Launching a National Initiative. Anesth Analg. 2022 Jun 1;134(6):1185-1188. doi: 10.1213/ANE.0000000000005817.