Anesthesia E-ssential, July 31, 2013

Anesthesia E-ssential

July 30, 2013


Vital Signs

AANA Announces Corporate Partners Program
The AANA is pleased to announce the AANA Corporate Partners program. The AANA believes in forming transparent, collaborative relationships with corporate partners so that each of us can leverage the work of the other. By working together we create a synergy that allows both the AANA and its corporate partners to better serve and communicate with AANA members.
There are two levels of partnership, and we are excited to have three companies join us. Each partnership is for one year.
Premier Level - $100,000
  • Merck
Elite Level - $75,000
  • Baxter
  • PharMEDium
The AANA Corporate Partners program combines the collective assets and strengths of the AANA and the AANA Foundation to generate maximum exposure and interaction for participating companies. We work jointly to promote our partnership through official designations, recognition advertising, and special positioning at our Annual Meeting, in our publications and on our website.
Partnering with the AANA and the AANA Foundation provides companies with access to a specific niche market in anesthesia—the Certified Registered Nurse Anesthetist. With access to more than 45,000 members, the AANA is the ideal professional association through which companies can demonstrate their commitment to the nurse anesthesia market.
For more information on the AANA Corporate Partners program contact Carol Wargo, AANA Director of Development and Marketing, at


The Pulse

  • Annual Reports Available Online
  • Expanded Second Edition of Evidence Trumps Belief Available Now
  • Online Registration for 2013 Fall Leadership Academy is Now Available
  • Don't Miss Out on These Popular Fall AANA Workshops
  • AANALearn® - Continuing Education Credits Always Available
  • AANA Exhibiting at the National Conference of State Legislatures Legislative Summit
Professional Practice
  • Board of Directors Approves New Scope of Practice Document
  • Joint Commission Revises Standards for Ambulatory Care Organizations
PR, Publications and eCommunications
  • See You on August 30
  • August AANA Journal Features Answers to Journal Course Exam

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
AANA Annual Reports Available Online
The 2012-2013 Annual Reports of AANA committees and affiliates have been posted on the member side of the website at (AANA member login and password required).
Hot of the Press:
Expanded Second Edition of Evidence Trumps Belief Now Available
An expanded second edition of Evidence Trumps Belief: Nurse Anesthetists and Evidence-Based Decision Making, by AANA Journal editor-in-chief Chuck Biddle, CRNA, PhD, is available now through the AANA Bookstore. The book contains additional chapters that make the text more versatile and provide readers a better foundation for achieving statistical power, identifying biomedical betrayal, and spotting statistical errors in published reports. In revising and expanding the book, Biddle takes aim at some of the more prominent criticisms of evidence-based decision making, such as that it’s over-reliant on randomized trials, there is insufficient time to accomplish what is required, and the available evidence is flawed and contradictory.
Biddle is a tenured full professor and staff anesthetist at Virginia Commonwealth University, Richmond, Va. He earned his doctorate in the outcomes sciences of epidemiology. A nurse anesthetist for nearly 30 years, his research has always been grounded in the broad domain of patient safety and marshaling evidence-based decisions to the patient. He believes this approach maximizes the opportunity to engage in truly patient-centric care.
Evidence Trumps Belief is published by the AANA.
Online Registration for 2013 Fall Leadership Academy is Now
November 8-10, 2013
Eden Roc Miami Beach Hotel
Registering couldn’t be easier! Click here and make your session selections. Register before Oct. 18 and receive a $50 discount!
The Fall Leadership Academy general session program on Friday morning will feature a keynote speaker and various AANA reports and updates. Friday afternoon and all day Saturday will be devoted to six separate focused tracks. The entire meeting is open to all CRNAs and student registered nurse anesthetists who are interested in expanding their leadership skills and knowledge, networking with peers, meeting new colleagues, and connecting with members of the nurse anesthesia community who are interested in current and exciting learning opportunities.
Don’t Miss Out on These Popular Fall AANA Workshops
  • There is still room in the Sept. 28-29, 2013, AANA Upper and Lower Extremity Block Workshop. This fast-filling workshop being held in Park Ridge, Ill., will include discussion on anatomy, pharmacology, and techniques. Between the lectures, attendees can put into practice what they’ve learned in the “hands-on” sessions. Click here to register!
  • Register now for the Oct. 23, 2013, AANA Essentials of Obstetric Analgesia/Anesthesia Workshop, which will be held in the AANA Foundation Learning Center in Park Ridge, Ill. This workshop addresses clinical applications of obstetric analgesia/anesthesia. Lecture format will cover normal and abnormal physiology of pregnancy, pharmacology, and techniques, plus case presentations will enhance lecture material. Hurry, space is limited.
    Click here to register for the OB Workshop!
  • On Oct. 24-26, 2013, the AANA will be offering the popular Spinal and Epidural Workshop in Park Ridge, Ill. This program includes discussion on the pertinent anatomic knowledge necessary for performing spinal and epidural anesthesia, comparisons of the differences and similarities between spinal and epidural anesthesia, and review of the clinical use of various local anesthetic and adjunct drugs for spinal anesthesia. This workshop fills quickly so register today!
  • Exciting revisions have been made to the AANA Advanced Pain Management Workshops to better serve members and to respond to requests by past attendees. AANA’s fall lineup of workshops will focus on various aspects of importance to the pain practitioner. Each workshop can be registered for separately, but the biggest impact comes from taking them all together as a training plan. Workshop options:
    • AANA Jack Neary Advanced Pain Management I Workshop – Oct. 12-13, 2013
    • AANA Jack Neary Advanced Pain Management II Workshop – Oct. 14-15, 2013
    • Neuroanatomy Prosection Workshop – Oct. 16, 2013
Sign in as a member at to register now.
AANALearn® - Continuing Education Credits Always Available
Three AANALearn® courses are on now sale at half price for members. Choose from more than 50 courses with a wide variety of topics. An important benefit for AANA members is that credits earned from AANALearn courses transfer directly to the CE transcript within the same day*, so you never have to worry about when credits will be posted.
All courses are prior approved by the AANA and the credits will automatically transfer to the AANA transcript*. AANA members have an existing account with AANALearn® which is easily accessed from the AANA website using the AANA login username and password. Browse the AANALearn® catalogs now at
* CE credit transfer is only for AANA members or nonmembers with record-keeping contracts.

AANA Exhibiting at the National Conference of State Legislatures Legislative Summit
The AANA will be exhibiting at the upcoming National Conference of State Legislatures (NCSL) Legislative Summit, which will take place in Atlanta, Ga., Aug. 13-15, 2013. This will be the 21st year that the AANA will be exhibiting at the NCSL meeting. This meeting is an invaluable opportunity for local nurse anesthetists, student nurse anesthetists, and AANA state government affairs staff to visit informally with legislators and their staff from all 50 states.
The AANA exhibit booth will be staffed by Anna Polyak, RN, JD, senior director of State Government Affairs, Sarah Chacko, JD, assistant director of State Government Affairs, and several Georgia nurse anesthetists and student registered nurse anesthetists.

Board of Directors Approves New Scope of Practice Document
The AANA Board of Directors approved a new “Scope of Nurse Anesthesia Practice” document during the June 2013 board meeting. The Scope document integrates qualitative and quantitative analysis, including a Scope survey, numerous focus groups, and input from various stakeholders. View the new document on the AANA Professional Practice Documents webpage.
Joint Commission Revises Standards for Ambulatory Care Organizations
The Joint Commission has made revisions to certain ambulatory care standards to ensure that these accreditation requirements remain relevant. The changes, effective Jan. 1, 2014, were made to requirements, located in the “Human Resources” (HR), “Leadership” (LD), “Medication Management” (MM), “National Patient Safety Goals” (NPSG), and “Provision of Care, Treatment, and Services” chapters. A determination was made that these requirements needed clarification or contained language that may not be relevant to all ambulatory settings. The revisions can be accessed on the Joint Commission website.

See You on August 30
The Anesthesia E-ssential will not come out on Aug. 15, and it will resume publication on Aug. 30. Before and during the Annual Meeting, watch your inbox for the 2013 AANA Convention Daily. The Daily will once again be distributed via email to all AANA members, not just Annual Meeting attendees. The first preissue debuted on July 29 and is available online at You will receive the next preissue on Monday, Aug. 5 and daily issues Aug. 11 through Aug. 13 during the meeting.
August AANA Journal Features Answers to Journal Course Exam
Wondering how well you did on AANA Journal Course Exam #32 (ends July 31 at midnight central time)? Exam answers will be posted on the AANA Journal webpagealong with all other Journal content, in early August.


Study Reveals Using Right Tool to Measure Patient Satisfaction Can Improve Health Care Quality
Employing a multi-dimensional tool that examines patient satisfaction in multiple ways and is able to convert subjective information into objective data can help enhance the quality of anesthesia care, according to researchers. The team from London reviewed more than 3,000 anesthesia studies from the past three decades that cited patient satisfaction as an outcome measure. The questionnaires covered everything from general and regional anesthesia to pediatric and obstetric anesthesia to pre-operative anesthesia evaluation. Only 34, however, were deemed to have well-developed and validated data collection instruments. "Patient satisfaction is a key measure of health care quality," said study author Sarah Barnett of the Surgical Outcomes Research Center at London's University College Hospital. "However, there are many poorly constructed questionnaires out there; the results could be biased and inaccurate." Going forward, the researchers concluded in the August issue of Anesthesiology, patient satisfaction surveys should include both qualitative and quantitative data.
From "Study Reveals Using Right Tool to Measure Patient Satisfaction Can Improve Health Care Quality"
News-Medical (07/25/13)

MD Anderson Researcher Reveals Super-Selective Scalp Block Prolongs Analgesia in Awake Craniotomies
Administering local anesthetic via bolus injection during a scalp block instead of via infiltration keeps patients pain-free for a longer period of time during awake craniotomies, researchers have discovered. A team led by Anh-Thuy Nguyen, clinical associate professor of anesthesiology and perioperative medicine at the University of Texas MD Anderson Cancer Center, studied 37 patients who underwent a scalp block for cranial surgery. With the goal of boosting the concentration of drug near the small-diameter nerves that innervate the scalp, the patients were injected with a bolus of ropivacaine with epinephrine. The results indicated that analgesia lasted at least 10 hours, much longer than the two- to six-hour span that is typical for traditional infiltration scalp blocks. The super-selective scalp block approach also did not require clinicians to re-inject local anesthetic during surgery. Additionally, Nguyen said the technique helped maintain patients' speech and function—which, in turn, allowed for neuromonitoring during the surgery.
From "MD Anderson Researcher Reveals Super-Selective Scalp Block Prolongs Analgesia in Awake Craniotomies"
BioNews Texas (07/24/13)

High Rate of Early Delirium After Surgery in Older Adults
In a study of 91 elderly patients having surgery under general anesthesia, 45 percent were diagnosed with delirium while still in the post-anesthesia care unit (PACU). A state of impaired consciousness or attentiveness, delirium often persisted even after a patient was transferred from the PACU to a hospital ward. Those with early delirium also suffered from deterioration of cognitive function, the Johns Hopkins researchers reported. Moreover, 39 percent of those with persistent delirium were discharged to a nursing home or other facility rather than being allowed to go home; that compared to 26 percent of patients who experienced early delirium that cleared up by the next day. Overall, the investigators confirmed that about 75 percent of all delirium cases at the hospital began in the PACU. "Recognizing delirium in the PACU may be important for identifying patients at higher risk of in-hospital harms ... as well as cognitive impairment and institutionalization at hospital discharge," they wrote in the August issue of Anesthesia & Analgesia. They noted that many cases of delirium would have been missed if clinicians had waited until the day after surgery to start monitoring them, rather than doing so immediately. The researchers recommend further investigation into the rate and impact of early delirium after anesthesia and surgery, including evaluation of longer-term outcomes.
From "High Rate of Early Delirium After Surgery in Older Adults"
Medicalxpress (07/24/2013)

Patient-Warming Systems May Affect OR Ventilation, Study Suggests
Researchers suspect that forced-air systems, a relatively new resource for maintaining body temperature during surgery, may compromise the operating room's ventilation equipment and expose patients to more airborne contaminants. The team from the University of Minnesota compared ventilation airflow patterns from conductive warming techniques, which apply heat directly to a patient's skin, against those from forced-air systems, which distribute heated air under the surgical drapes and over the patient. "Neutrally buoyant detergent bubbles" allowed them to visualize the airflow patterns. While conductive warming did not disrupt ventilation airflows over the surgical site, the investigators reported that the forced-air approach "generated hot air convection currents that mobilized bubbles over the anesthesia site and into the surgical site." The finding raises concerns that bacteria and other contaminants could be carried from non-sterile areas or that the ventilation system may not properly filter the contaminants from the surgical site. "These finding warrant future research into the effects of forced air warming excess heat on clinical outcomes during contamination-sensitive surgery," the researchers write in the August issue of Anesthesia & Analgesia.
From "Patient-Warming Systems May Affect OR Ventilation, Study Suggests"
Infection Control Today (07/24/13)
Pediatric Anesthetic Risk: Ketamine May Damage Children's Learning Ability and Memory
Recent research has determined that use of the drug ketamine in pediatric anesthesia may damage the developing neurons in children's brains, resulting in behavioral abnormalities as well as learning and memory disorders. In a clinical retrospective study looking at children younger than three years who had undergone a long-time surgery, or who had been administered ketamine repeatedly, it was found that they exhibited these abnormalities and disorders once they reached school age. Researchers now suspect that these effects may be linked to the potentially neurotoxic nature of ketamine, which was illustrated in another study published in Neural Regeneration Research. That animal research showed that tau phosphorylation and neuronal toxicity could be induced in the development of neurons by the presence of ketamine. The findings suggest that ketamine induces tau hyperphosphorylation at serine 404, which then causes damage to axonal transport and microtubule, which subsequently can lead to neurotoxicity and neuronal death in neonatal rats.
From "Pediatric Anesthetic Risk: Ketamine May Damage Children's Learning Ability and Memory"
Science Daily (07/19/2013)
Backache Following Epidural Analgesia in Labour
Researchers with Great Britain's North Staffordshire Hospital (NHS) Trust studied 369 primigravid women in spontaneous labor at term, and with a normal obstetric and medical history, to gauge any significant difference in complaints of backache in women receiving epidural analgesia in labor versus those who received non-epidural analgesia. Of those tracked, 184 received epidural analgesia while the remaining 185 received a non-epidural form of analgesia, generally intramuscular pethidine. The study results produced no significant differences between the two groups' reports of backache at three or 12 months following delivery. The researchers noted that while epidural analgesia likely provides more effective pain relief, two other studies conducted recently have shown that intramuscular analgesia is still overwhelmingly the preferred choice.
From "Backache Following Epidural Analgesia in Labour"
The Almagest (07/19/13) Watkins, Sienna

Effectiveness of Device-Assisted Ultrasound-Guided Steroid Injection for Treating Plantar Fasciitise
A recent study concluded that device-assisted ultrasound-guided injection results in better therapeutic outcomes than palpation-guided injection does when treating plantar fasciitis. Researchers came to that conclusion after selecting a group of plantar fasciitis patients and randomly dividing them into two groups: a device-assisted ultrasound-guided group and a palpation-guided group. Pain intensity evaluations were performed before injecting betamethasone and 1 percent lidocaine into the inflamed plantar fascia, as well as at three weeks and three months after the injection. The intensity of pain was measured using a visual analog scale and tenderness threshold. Patients in both groups exhibited significantly lower visual analog scale scores and higher tenderness threshold following the injection. However, patients in the device-assisted group had higher tenderness threshold, lower visual analog scale scores, and lower hypoechogenicity incidence in the plantar fascia after three months than did patients in the other group. Researchers also observed that the heel pad was significantly thin in the palpation-guided group following the injection.
From "Effectiveness of Device-Assisted Ultrasound-Guided Steroid Injection for Treating Plantar Fasciitis"
American Journal of Physical Medicine & Rehabilitation (07/13) Vol. 92, No. 7, P. 597 Chen, C.M.; Chen, J.S. ; Tsai, W.C.; et al.

Modular PALS Course More User-Friendly for Clinicians
A customized modular Pediatric Advanced Life Support (PALS) program developed by the Children's Hospital of Philadelphia may help make renewing PALS certification easier for anesthesia providers. Noting that PALS certification had some shortcomings, Aditee Ambardekar, MD, clinical assistant professor of anesthesiology at the facility, and her team reformatted a PALS refresher to be more relevant and user-friendly by splitting it into four sessions of one hour each that would be delivered every three months. After completing the modular course, a sample of 29 anesthesia providers took a survey to compare their experience with the modular format against their experience under the traditional program. The clinicians reported that the new format was both more satisfactory and more helpful than the traditional course. Ambardekar said the new format "is largely simulation-based scenarios that are anesthesia-specific and allow people to use their hands," and because it is broken into four parts, it is easier to fit it into a busy schedule. The researchers next plan to perform a randomized controlled trial where they will compare participants' learning outcomes between the traditional and modular courses. Ambardekar noted that there might be some criticism of the course given that it is anesthesia-specific but adds that "the foundation is there, and developing specialty-specific scenarios wouldn't be too difficult."
From "Modular PALS Course More User-Friendly for Clinicians"
Anesthesiology News (07/01/13) Vol. 38, No. 7 Vlessides, Michael
FDA Can't Allow Execution Drug to Be Imported
U.S. appellate judges have upheld a lower-court decision that blocks the Food and Drug Administration (FDA) from allowing the import of sodium thiopental into the country. The anesthetic, which is not approved in the United States, is used as part of a drug cocktail administered to condemned inmates as part of the lethal injection process. The FDA's policy of bringing the drug in from foreign nations "was not in accordance with law," the three-member panel determined. It did, however, reverse the lower court's ruling that state correctional departments could not retain supplies of sodium thiopental already in their possession.
From "FDA Can't Allow Execution Drug to Be Imported"
Associated Press (07/23/13) Frommer, Frederic J.

Anesthesia Alert: Anesthesia for the Pregnant Patient
In an article for Outpatient Surgery, Paloma Toledo offers tips for when expectant mothers undergo non-obstetric surgery. He first comment is that it is vitally important for mothers to understand and manage the unique risks that elective surgery poses for both mother and unborn child, no matter how early in the pregnancy the operation occurs. Approximately one in 50 pregnant women require such surgery each year in the United States, and many of those procedures are performed in outpatient settings. Although the American Society of Anesthesiologists' statement on non-obstetric surgery during pregnancy says that none of the anesthetic agents currently in use have been linked to teratogenic effects in humans when administered at standard concentrations, Toledo suggests that several other factors should be considered a surgical patient is also expecting. These include the importance of monitoring oxygen levels during the surgery to ensure adequate pre-oxygenation and selecting an appropriately sized endotracheal tube to prevent intubation failures from the upper airway edema and decreased internal tracheal diameter that many women develop as they gain weight during their pregnancy. Failed intubations are eight times higher in pregnant patients than in those who are not expecting. Other factors affecting pregnant surgical patients are decreased functional residual capacity, uncompensated respiratory alkalosis from increased alveolar ventilation, and the importance of maintaining the associated relative hypocapnea to prevent maternal hypercapnea and the possibility of fetal acidosis.
From "Anesthesia Alert: Anesthesia for the Pregnant Patient"
Outpatient Surgery (07/01/13) Toledo, Paloma

Pill Mill Crackdown Saving Lives, Changing Prescription Habits, Studies Find
According to a recent Workers' Compensation Research Institute (WCRI) report, the number of doctors writing prescriptions for addictive opioids since the 2011 ban on pill mills has fallen, with doctors more likely to prescribe anti-inflammatory drugs and less powerful pain medications. Another study released by Jim Hall, an epidemiologist with the Center for Applied Research on Substance Use and Health Disparities at Nova Southeastern University, found a 17 percent drop in Florida deaths attributed to prescription painkiller abuse in the first half of 2012 over the previous six months, amounting to eight fewer deaths a week. However, he says the state has a long way to go in reducing these types of deaths, as before the law, Florida saw 48.8 deaths a week from prescription opioid abuse. Hall says the decline in deaths is related to the tougher regulations on pill mills, drug enforcement raids on clinics, stricter prescription-writing guidelines, and a prescription drug database. Meanwhile, the WCRI report credited the physician-dispensing ban with changes in doctors' approaches to pain management. Within six months of the ban's implementation, the number of prescriptions written for the strongest, most highly addictive opioids fell 4.1 percent to 22.6 percent of pain meds prescribed to injured workers across Florida, the study said.
From "Pill Mill Crackdown Saving Lives, Changing Prescription Habits, Studies Find"
Fort Lauderdale Sun-Sentinel (FL) (07/19/13) Brochu, Nicole
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