Anesthesia E-ssential, November 15, 2013

Anesthesia E-ssential

Nov. 15, 2013


Vital Signs

Nominations for 2014 Elections Due Dec. 1
Nominations for members for elected office and consent forms from nominees are due in the AANA office by Dec. 1, 2013.
Each state association may submit one nominee for president-elect, vice president, and treasurer. In addition, state associations may submit one nominee for a director of their region. In 2014, directors from Regions 2, 3, 6, and 7 are eligible for election. Finally, state associations may submit one name of a member from their region for the AANA Nominating Committee and for the Resolutions Committee.
Also, remember that the AANA membership approved a proposed amendment to the Standing Rules which allows members to self-nominate or to nominate another member as long as the nominee meets the qualifications for office found in the AANA Bylaws and Standing Rules.
For information regarding the electoral process, please visit


The Pulse

  • NBCRNA is Seeking Feedback on CPC Program Recommendations
  • Certified Registered Nurse Anesthetists Support the American Academy of Nursing to Improve the Quality of Veterans’ Healthcare
  • Typhoon Haiyan
  • Article About Nurse Anesthesia Education Program Interviews Now Online
  • Help Us Serve You Better—Watch your Inbox for AANA Surveys
  • Volunteers Needed for Belize
  • Assembly of School Faculty: Achieving Excellence in Nurse Anesthesia Education
  • DANA’s Comments Incorporated into Delaware’s Proposed Office Rules
  • AANA Submits Letter of Support for Massachusetts Legislation
  • Associations for Nursing, Medical, and Pharmacy Boards Meet
  • FDA Takes Two Important Actions on Drug Shortages
  • FDA Issues Updated Recommendations to Decrease Risk of Spinal Column Bleeding and Paralysis in Patients on Low Molecular Weight Heparins
  • The Joint Commission Issues New Sentinel Event Alert
  • Story The Joint Commission Releases Annual Report on Quality and Safety
  • Nurse Anesthetists Week Materials Available Now

Healthcare Headlines

Healthcare Headlines is for informational purposes, and its content should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

Inside the Association
NBCRNA is Seeking Feedback on CPC Program Recommendations

Recertification for Nurse Anesthetists (NBCRNA) recently announced a series of recommendations for the Continued Professional Certification (CPC) Program. The NBCRNA is collecting feedback to allow all CRNAs to provide input on these recommendations. The survey will close on Nov. 25, 2013. Results from this survey will be provided to the NBCRNA Board of Directors to help them make determinations regarding the CPC program. Click here to provide your feedback to the NBCRNA.

Certified Registered Nurse Anesthetists Support the American Academy of Nursing to Improve the Quality of Veterans’ Healthcare
"Have You Ever Served?" is a new initiative that affects both healthcare providers and their patients. Various conditions can develop during the course of a soldier’s service, such as post-traumatic stress disorder and respiratory illnesses, that can affect his or her well-being and should be considered prior to undergoing anesthesia. The American Academy of Nursing is seeking to improve the quality of veterans' healthcare with this simple question and urges healthcare providers to ask it in order to identify and address any healthcare issues rising from a patient's service in the military.
The campaign is being launched in Alabama, California, Connecticut, Florida, Illinois, New Jersey, Ohio, Texas, Virginia, and Washington. The initial launch will benefit approximately one million veterans. Subsequently, "Have You Ever Served?" will be rolled out in all 50 states over a three-year period.
In addition to the American Academy of Nursing (AAN), "Have You Ever Served?" is sponsored by the Veterans Support Foundation and the Connecticut Department of Veteran's Affairs.
"Have You Ever Served?" represents the AAN’s commitment to First Lady Michelle Obama and Dr. Jill Biden’s Joining Forces campaign to mobilize all sectors of the community to support veterans and their families. Nurses, healthcare’s equivalent to boots on the ground, are uniquely positioned to facilitate this fundamental change of ensuring vital information is obtained and recorded in order to improve the quality of healthcare provided to our veterans and their families.
Typhoon Haiyan
The AANA offers its deepest sympathy to all those affected by Typhoon Haiyan in the Philippines. Visit the Current Events and Natural Disaster Preparedness page on the AANA website for links to information on how to help. 
Article About Nurse Anesthesia Education Program Interviews Now Online
Choosing the right nurse anesthesia educational program out of more than 100 accredited programs across the United States can be a daunting task, and possibly the most intimidating aspect is the interview process. If worrying about prerequisites, gathering information about each program, scheduling visits, and balancing a social life are not enough, potential students also have to prepare for an interview with the administrator of the program or a panel of professors. What Potential Students Need to Know about the Nurse Anesthesia Educational Program Interview Process, now posted on the AANA website, gives insight to how interviews differentiate, and what can help an applicant stand out from the rest. To read the full article, click here.
Help Us Serve You Better—Watch your Inbox for AANA Surveys
As part of the AANA’s ongoing commitment to better understand your needs so we may provide you with the benefits and services you value the most, the AANA is reaching out to the membership with online surveys. This week you have received or will receive one of the following surveys:
  • AANA Survey on Continuing Education (CE ) Credits and E-Learning
  • AANA Annual Meeting Preferences Survey
  • AANA Affinity Program Survey
Your completion of these survey questions will provide the AANA with the data needed to drive decisions that will help make membership in our professional association the most valuable experience possible for all CRNAs and student registered nurse anesthetists. Each survey takes approximately 5 to 10 minutes to complete. You will also have the opportunity to enter a drawing for a $100 gift certificate.
Volunteers Needed for Belize
Health Volunteers Overseas is looking for nurse anesthetist volunteers for 2-4 week assignments in the winter and spring in Belize. Contact Tony Li at for more information.
Assembly of School Faculty: Achieving Excellence in Nurse Anesthesia Education
The 2014 Assembly of School Faculty (ASF) is Feb. 18-20 in San Diego, Calif. This year only, the meeting will run midweek (Tuesday-Thursday), but the agenda will continue to tackle the issues faced by nurse anesthesia program administrators, anesthesia program faculty, and student registered nurse anesthetists, including: How will changes in healthcare policy affect education? What are the barriers to evaluating clinical performance? What effects do recent regulatory changes have on accreditation and certification? The goal of the ASF is to present you with the information you need to more effectively run and improve your program. If you are part of nurse anesthesia education, regardless of your role, you should be part of this meeting. This program provides 15 CEs. Register today.

DANA’s Comments Incorporated into Delaware’s Proposed Office Rules
On Oct. 1, 2013, the Delaware Department of Health and Social Services (DHSS) re-proposed office rules titled “Regulations Governing Medical Facilities.” The rules were re-proposed because the rules that were originally proposed in April 2013 received numerous comments which resulted in very significant changes to the proposed rules.  The Delaware Association of Nurse Anesthetists submitted comments on the first version of the proposed rules to ensure that CRNAs were included as a qualified anesthesia provider in the office setting and that the rules would not limit or restrict CRNA scope of practice in Delaware. Thanks to DANA’s hard work and open dialogue with DHSS, all of DANA’s comments were incorporated into rules proposed Oct. 1. The comment period for the proposed rules ended Oct. 31, 2013. 
AANA Submits Letter of Support for Massachusetts Legislation
AANA President Dennis Bless, CRNA, MS, sent a letter of support for Massachusetts HB 2009/SB 1079, which proposes to remove the involvement of the Board of Registration in Medicine in the regulations for advanced practice nurses and to remove the supervision requirement from the prescribing and ordering authority for CRNAs. President Bless stated that by removing the barriers to CRNA practice, this bill will improve access to care, promote competition, and decrease healthcare costs to the residents of Massachusetts. He emphasized the national trend toward removal of the barriers to practice and allowing advanced practice nurses to practice to the full extent of their education and training. He also encouraged the sponsors of this legislation to continue advocating for solutions that improve the quality of healthcare and reduce costs. Click here to view the full comment letter.
Associations for Nursing, Medical, and Pharmacy Boards Meet
The National Council of State Boards of Nursing (NCSBN), the Federation of State Medical Boards (FSMB), and the National Association of Boards of Pharmacy (NABP) met recently to discuss issues of interest to their professions. This interprofessional collaboration, known as the Tri-Regulator Leadership Collaborative (TRLC), was formalized in 2011. The professional boards represented by the TRLC regulate 5 million nurses, physicians, and pharmacists in the United States. Future efforts by the TRLC will include discussion of issues regarding interprofessional team-based care and encouraging and facilitating dialogue among state board members of the professions. For more information, see the press release at


Professional Practice


FDA Takes Two Important Actions on Drug Shortages
The Food and Drug Administration (FDA) is taking two actions to further enhance the agency’s ongoing efforts to prevent and resolve drug shortages. First, the FDA is releasing a strategic plan to improve the agency’s response to imminent or existing shortages as well as formulating longer-term approaches addressing the underlying causes of drug shortages. Second, the FDA issued a proposed rule requiring all manufacturers of certain medically important prescription drugs to notify the FDA of a permanent discontinuance or a temporary interruption of manufacturing likely to disrupt their supply. Access more information and links to the strategic plan and proposed rule here.


FDA Issues Updated Recommendations to Decrease Risk of Spinal Column Bleeding and Paralysis in Patients on Low Molecular Weight Heparins

In a Safety Announcement issued on Nov. 6, the U.S. Food and Drug Administration (FDA) recommended that healthcare professionals carefully consider the timing of spinal catheter placement and removal in patients taking anticoagulant drugs, such as enoxaparin, and delay dosing of anticoagulant medications for some time interval after catheter removal to decrease the risk of spinal column bleeding and subsequent paralysis after spinal injections, including epidural procedures and lumbar punctures. These new timing recommendations, which can decrease the risk of epidural or spinal hematoma, will be added to the labels of low molecular weight heparins, including Lovenox and generic enoxaparin products and similar products. Read the full Safety Announcement here.


The Joint Commission Issues New Sentinel Event Alert
The unintended retention of foreign objects, also called retained surgical items, after invasive procedures can cause death, and surviving patients may sustain both physical and emotional harm, depending on the type of object retained and the length of time it is retained. The Joint Commission has published Sentinel Event Alert 51 to address the prevention of unintended retained foreign objects. Access the full document here.
The Joint Commission Releases Annual Report on Quality and Safety
The Joint Commission has released its 2013 annual report on quality and safety, which also recognizes 1,099 hospitals as Top Performer organizations. The annual report summarizes the performance of 3,300 Joint Commission-accredited hospitals on 47 accountability measures of evidence-based care processes. The annual report can be accessed here.

Nurse Anesthetists Week Materials Available Now
Jan. 19-25, 2014, will be here before you know it. Plan to promote your profession and join in the fun by ordering your National Nurse Anesthetists Week promotional materials now. Visit for promotional ideas, sample press releases, proclamations, Spanish and English public service announcement scripts for radio, downloadable posters and brochures, and more. Brand new this year: customizable brochures! Ordering deadline: Jan. 14, 2014.


Using Morphine After Abdominal Surgery May Prolong Pain, CU Boulder Researchers Find
University of Colorado Boulder researchers report that while morphine is an effective painkiller, it can actually keep some surgical patients in pain twice or even three times as long. In animal studies, the team discovered that both abdominal surgery and morphine independently arouse glial cells in the nervous system, causing them to emit extra pain signals to the surrounding nerves. "After abdominal surgery—even without using any drugs to treat the pain—the glial cells would be activated and they would contribute to the postoperative pain," explained lead researcher Peter Grace. "What we're saying is, if you give them morphine, we also know that contributes to the pain. If you're putting both of those on top of each other, you're going to have a prolonged period of pain." However, using the morphine in tandem with the drug (+)-naloxone—which blocks the morphine from binding to the glial cells and exciting them—negates the extended postoperative pain effect.
From "Using Morphine After Abdominal Surgery May Prolong Pain, CU Boulder Researchers Find"
EurekAlert (11/12/13) Grace, Peter
Prescription Painkillers Can Up Risk of Depression
A new study out of Saint Louis University, published in the Journal of General Internal Medicine, suggests that chronic or long-term use of opioid painkillers can elevate patients' risk of developing major depression. In a review of the medical record data of some 50,000 veterans who had no history of either depression or opioid use but who were subsequently prescribed painkillers, researchers found that those who started and remained on opioids for 180 days or longer saw the risk of developing a new episode of depression escalate by 53 percent. Lead investigator Jeffrey Scherrer, PhD, said the "findings suggest that the longer one is exposed to opioid analgesics, the greater is their risk of developing depression." While there is no clear evidence why this phenomenon occurs, speculation points to a number of potential contributing factors. These factors include the opioid-induced resetting of the brain's reward pathway to a higher threshold; the long-term body aches that can linger after usage is stopped; and other side effects like adrenal, testosterone, or vitamin deficiencies as well as glucose dysregulation. The study also suggests that higher doses result in a higher risk of developing depression. Because of the growing use of opioid analgesics, Scherrer said, "even though the risk is not huge, there is enough exposure that we may have a public health problem."
From "Prescription Painkillers Can Up Risk of Depression"
Psych Central (11/01/2013) Nauert, Rick
Study Probes Anesthesia–Erection Link
Researchers in China examined the causes of involuntary erection in men undergoing urologic surgery—an occurrence that can delay the operation, or even lead to its cancellation. The study compared the rates of erection in nearly 300 men who were given isoflurane, propofol, or sevoflurane as the general anesthetic prior to elective urologic surgery. According to the results, a total of 5 percent of the men (16) developed an erection in the operating room—11 of whom received propofol, four of whom received sevoflurane, and one of whom received isoflurane. However, the investigators reported that administering isoflurane at an end-tidal concentration of 1 to 1.3 minimum alveolar concentration quickly reversed the erection. The results were presented at the 2013 annual meeting of the American Society of Anesthesiologists.
From "Study Probes Anesthesia–Erection Link"
Anesthesiology News (10/01/13) Vol. 39, No. 10
Automated System Promises Precise Control of Medically Induced Coma
A report in PLOS Computational Biology details the successful animal testing of a computer-controlled anesthesia system developed by researchers from Massachusetts General Hospital (MGH) and Massachusetts Institute of Technology. The system will automate the task of monitoring brain activity and adjusting anesthetic delivery for patients in a medically induced coma, making the process more efficient and exact. Emery Brown, MD, PhD, of MGH's department of anesthesia, critical care and pain medicine, led the research—which identified and studied patterns of brain activity representing various states of anesthesia. By adapting programs they had created to analyze neuron activity, the team developed algorithms to read and analyze EEG patterns in real time and identify the target level of brain activity. An automated control device then adjusts the flow of the anesthetic based on the target in order to achieve the desired brain state. MGH is seeking a patent for the technology, which Brown said would maintain medical coma at a more consistent and precise level using lower doses of anesthetic than can be achieved manually.
From "Automated System Promises Precise Control of Medically Induced Coma"
Science Codex (10/31/13)
Nerve Block Works for Stroke Shoulder Pain
With no effective treatment for stroke shoulder pain, which affected as many as a quarter of patients, researchers at Flinders University explored the use of nerve block for this purpose. They conducted a trial involving 64 patients—half of whom were randomly assigned to receive a single suprascapular nerve block, and half of whom were randomized to receive a placebo. The treatment was effective, although the researchers have not determined precisely how the pain reduction was achieved. They are employing transcranial nerve stimulation in hopes of discovering the mechanism through which the nerve block worked; and they also are considering the potential efficacy of the technique for other kinds of stroke, for frozen shoulder, and in cases of motor neurone disease.
From "Nerve Block Works for Stroke Shoulder Pain"
Rheumatology Update (10/29/13) Garrett, Nicola
Protein Shake During Labor Does Not Delay Stomach Emptying
According to new findings, drinking a high-protein shake during labor neither improves the rate of gastric emptying nor does it mitigate nausea or vomiting in women who have received epidural anesthesia. However, according to researchers who conducted a randomized trial at the University of Pittsburgh Medical Center, it does significantly improve patient satisfaction with oral intake. "Physicians should feel comfortable replacing ice chips or water with a high-protein liquid supplement" when vaginal delivery is expected, concludes lead researcher Manuel Vallejo, MD, an obstetric anesthesiologist at West Virginia University Health Sciences Center. In the study, he and colleagues evaluated 150 women—all of whom received ice chips and water as needed, with half also receiving 325 mL of protein shake in the 15 minutes after the epidural block. During labor and at one hour post-delivery, researchers measured the incidence of nausea and vomiting. Although it was hoped that the protein shake would reduce these side effects, there was no meaningful difference reported between those who received the shake and those who did not. The next day, study participants rated satisfaction with their oral intake during labor, with there being a statistically significant difference in the satisfaction ratings of those who received the shake over those who did not.
From "Protein Shake During Labor Does Not Delay Stomach Emptying"
Medscape (10/29/13) Louden, Kathleen
Health Matters: A New Prescription for Surgical Pain

The traditional treatment for managing postoperative pain has been based on narcotic painkillers, but doctors are moving away from that approach to a more comprehensive or "multimodal" strategy. This new protocol calls for the use of cocktails of medications given to patients before, during, and after surgery. The use of opioids is curtailed and so, therefore, is the constipation, grogginess, hallucinations, nausea, and addiction risk often associated with them. According to Dr. Martin Clark Jr., an orthopedic surgeon at Connecticut's Sharon Hospital, these new pain management protocols help patients stick to their physical rehabilitation regimens. University of Western Ontario researchers presented data in 2011 demonstrating that the use of an injection of a drug cocktail during surgery reduced patient pain and the need for pain medication while enhancing patient satisfaction. The cocktails are being used as an alternative to femoral nerve blocks in knee-replacement surgery, as studies have shown that femoral block can increase the likelihood that patients will fall following surgery.
From "Health Matters: A New Prescription for Surgical Pain"
Wall Street Journal (10/28/13) P. R8 Landro, Laura
Elderly Patients Who Have Diabetes Are More Likely to Suffer From Postoperative Delirium, Undergo Longer Surgery
Researchers say certain elderly patients are more prone to experience debilitating postoperative delirium—which, in turn, can mean extended hospital stays, poor recovery, and higher mortality rates. According to a team from the Department of Anesthesiology, Geriatrics and Palliative Care, and Neurosurgery at New York's Icahn School of Medicine, patients most at risk for disorientation, lethargy, inattention, agitation, and combative behavior include those who are diabetic, undergo longer procedures, or respond poorly to stress. They drew their conclusions from a study of 76 patients aged 68 or older, who were evaluated using the Confusion Assessment Method and Mini Mental Status Exam after having major non-cardiac surgery. "By understanding who may be at high risk for postoperative delirium, we can work on interventions for these patients, such as considering giving them antipsychotic medications before surgery, carefully monitoring the depth of anesthesia, and/or having patients see a geriatrics specialist prior to surgery," remarked researcher Stacie Deiner, MD.
From "Elderly Patients Who Have Diabetes Are More Likely to Suffer From Postoperative Delirium, Undergo Longer Surgery"
News-Medical (10/15/13)
Very Obese Patients Consume Greater Share of Hospital Resources
Two new studies indicate that morbidly obese patients drain more hospital resources while in surgery—because they require additional time in the operating room (OR) and need more time under anesthesia, for example. In one study, researchers examined the medical records of 131,541 patients undergoing anesthesia at New York Presbyterian Hospital from December 2007 to February of this year. Based on body mass index (BMI), patients were categorized as normal weight, overweight, obese, or morbidly obese. Heavier patients tended to have inpatient procedures, while normal-weight patients were more likely to undergo ambulatory surgery. Obese patients also spent longer periods in the operating room—a factor that has been linked to higher infection rates—and needed 176 minutes of anesthesia compared to 131 minutes for patients with normal BMI. Researchers in California, meanwhile, report that morbidly obese patients having primary hip arthroplasty required more total time in the OR than normal-weight patients, as well as longer operation times and longer anesthesia induction times. The investigators concede that more research is needed to understand the reason behind the differences; but, in the meantime, experts recommend that hospitals book extra OR time for morbidly obese patients or have more personnel on hand to help position these patients for surgery.
From "Very Obese Patients Consume Greater Share of Hospital Resources"
Anesthesiology News (10/01/13) Vol. 39, No. 10 Blum, Karen
Psychological Interventions for Needle-Related Procedural Pain and Distress in Children and Adolescents
Canadian researchers conducted a review of the efficacy of psychological interventions for needle-related procedural pain and distress among children and adolescents, updating a previous report on the topic. Their 2006 review found that several psychological techniques helped to manage pediatric needle pain, such as distraction, hypnosis, and combined cognitive behavioural interventions. For the new review, the authors looked at 39 trials involving nearly 3,400 participants, ages two to 19 years, who underwent needle-related procedures including immunization, venipuncture, and intravenous line insertion. As with the original review, the most commonly studied psychological interventions for needle procedures were distraction, hypnosis, and cognitive behavioral therapy (CBT); 19 of the 39 studies looked only at distraction. The researchers concluded that "there is strong evidence supporting the efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents, with no evidence currently available for preparation and information or both, combined CBT, parent coaching plus distraction, suggestion, or virtual reality."
From "Psychological Interventions for Needle-Related Procedural Pain and Distress in Children and Adolescents"
Cochrane Database of Systematic Reviews (10/13) Uman, L.S.; Birnie, K.A.; Noel, M.; et al.
Oral Celecoxib Effective for Pain After T & A in Peds
Celecoxib is an effective painkiller after adenotonsillectomy, according to the first study to evaluate the drug as a postsurgical painkiller in children. Results of the randomized controlled trial, from Children's Hospital of Eastern Ontario Research Institute, show that a short course of oral celecoxib (sold under the brand name Celebrex) reduced early pain and acetaminophen use in children who underwent adenotonsillectomy. The drug had no effect on functional recovery and did not appear to increase bleeding risk. In the study, 282 children between ages of two and 18 years were randomized to receive either a loading dose of 6 mg/kg of celecoxib or placebo before surgery. After the surgery, patients received either 3 mg/kg of celecoxib or placebo twice a day for five doses. Children also received morphine and acetaminophen as needed. Parents and children completed age-appropriate diaries to record recovery during the first week after surgery. Celecoxib significantly reduced "worst pain" and pain with swallowing on days 0 and 1 after surgery, but the results showed no significant difference on day 2. The Food and Drug Administration has only approved celecoxib in the pediatric population for juvenile idiopathic arthritis.
From "Oral Celecoxib Effective for Pain After T & A in Peds"
Anesthesiology News (10/01/13) Vol. 39, No. 10 Armitage, Mandy
Abstract News © Copyright 2013 Information Inc.