Anesthesia E-ssential March 28, 2014

Anesthesia E-ssential

March 31, 2014


Board Update

Assessed CEs
The AANA Board of Directors, staff, and CE Committee members have been receiving "assessed CE" questions from CE providers. The concept of assessed CE was introduced by the NBCRNA as part of the CPC program and is defined as “an activity that promotes enrichment of knowledge and this knowledge is then measured.” Questions about assessed CE have been answered as received with information provided by the NBCRNA. The formal definition of assessed CE has been drafted by the NBCRNA. The assessed CE information will be reviewed and commented on by the AANA CE Committee. The final document needs agreement of both the AANA and NBCRNA. 
According to the AANA database, we have over 2,000 CE providers that will need information on assessed CEs. The AANA is working on plans to work with the NBCRNA to provide a joint webinar on assessed CEs for CE providers as well as state presidents. This webinar will be recorded and posted as an audio stream on both the AANA and the NBCRNA websites along with an FAQ document. Both groups will continue to address concerns and implications of the new NBCRNA CPC requirement of 15 assessed CE credits beginning in 2016.
Your AANA is working diligently to engage and ensure that stakeholders and members are fully informed of all CE implications as the transition to the new CPC Program is implemented in January 2016. We will be updating information as the webinar is developed.


The Pulse

  • New Online Resource Center Has What You Need to Know About Malpractice Insurance
  • New FTC Report Supports APRN Practice
  • Live Stream Registration Still Open for AANA’s Diversity Summit
  • Online Forum for Candidates for the AANA Board of Directors Now Available
  • Needed: Chief CRNAs
  • Lynn Reede Appointed to NQF Surgery Measures Steering Committee
  • Discounted “Opt-Out” course on AANALearn
Meetings and Workshops
  • Business of Anesthesia
  • NEW AANA Workshop: Foundations of Advanced Pain Management
  • AANA 2014 Nurse Anesthesia Annual Congress
  • AANA 2014 Fall Leadership Academy
  • AANA Foundation Fellowship Applications Due April 1
  • Orlando – The Stars Come Out Again
  • “State of the Science” Oral Poster Presentations





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

Hot Topics

New Online Resource Center Has What You Need to Know About Malpractice Insurance
AANA Insurance Services recently marked the company’s 25th anniversary by launching AANA Insurance Services Resource Center, its new online resource center created specifically for CRNAs with round-the-clock access to critical information and educational resources to navigate the complex world of malpractice insurance. This comprehensive library of information includes helpful FAQs, glossaries, checklists, and reports about important malpractice insurance issues such as the different kinds of policies available; coverage extensions and limitations; and how to identify any exposure to you under your employer’s insurance. The website also includes special sections dedicated to risk management, patient safety, wellness, and legal issues, as well as recent events in the news.
Be sure to visit the new resource center at, and call AANA Insurance Services at (800) 343-1368, or send an email to if you have any questions about your insurance.
New FTC Report Supports APRN Practice
A new Federal Trade Commission (FTC) policy paper titled “Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses” supports removal of unnecessary regulatory burdens on advanced practice registered nurses (APRNs). The FTC notes that “APRNs provide safe and effective care within the scope of their training, certification, and licensure” and that “effective collaboration among health care providers, including team-based care, does not always require physician supervision of APRNs.” The report includes an appendix of letters, comments, and amicus briefs issued by the FTC in support of APRN and CRNA legislative and regulatory efforts. The press release and the policy paper are available here.
Live Stream Registration Still Open for AANA’s Diversity Summit
The AANA sponsored "Diversity and Inclusion in Nursing Education: Excellence in Healthcare" summit will be broadcast live on April 4, from 9 a.m. to 3 p.m. EDT. Listen to presenters such as Jane Kirschling, PhD, RN, FAAN; John Bing, CRNA; and Wallena Gould, CRNA, EdD, among others. The meeting is approved by AANA for 4 CE credits. View the agenda and register for the live stream at All are welcome to attend. Space is limited, register today!
Online Forum for Candidates for the AANA Board of Directors Now Available
Take advantage of this opportunity to become better acquainted with the candidates seeking election to the AANA Board of Directors. The Online Forum for Candidates for the AANA Board of Directors became available to members for question submission Monday, March 24, 2014. This un-moderated forum is located in the members-only section of the AANA website at: The forum will be available for members to view until the voting cutoff date of May 20, 2014.
Needed: Chief CRNAs
CRNAs who lead their anesthesia practice, department, division, or facility are an important resource to the entire anesthesia community. In their leadership roles, they are at the center of all things anesthesia. The AANA would like to identify Chief CRNAs and CRNAs who hold similar administrative/leadership roles in their facilities to collaborate with the AANA in developing resources to support the challenging work of all Chief CRNAs and CRNA leaders. Please take a moment to update your member profile and provide more details about your practice. To do so, visit, sign in with your member username and password and click the Update My Member Profile link on the right side of the Member Center homepage.
Lynn Reede Appointed to NQF Surgery Measures Steering Committee
Lynn Reede, CRNA, DNP, MBA, AANA’s Senior Director of Professional Practice, has been appointed to the National Quality Forum (NQF) Surgery Measures Steering Committee. This committee will work to identify and endorse new performance measures for accountability and quality improvement that specifically address surgical care processes, including cardiac, thoracic, vascular, orthopedic, neurosurgery, and general surgery.
Discounted “Opt-Out” course on AANALearn
April brings cherry blossoms to our nation’s capital and our thoughts turn to the AANA Mid-Year Assembly and the ongoing importance of our advocacy efforts for the nurse anesthesia profession. In support of these efforts, AANALearn is featuring The Opt-Out Story for CRNAs at a 40 percent discount now through April 30.
You’ve heard some of the history, but would you be able to explain this issue to a student, a physician, other healthcare providers, or a legislator? Do you know how many states are currently listed as “opt-out” states? Do you understand how the past can influence or affect the future for CRNAs?
The Opt-Out Story for CRNAs (1 CE credit) provides a clear and concise review of the historical events surrounding decisions made by two previous presidential administrations. The speaker, Sandra Larson, CRNA, PhD, APN, provides an engaging historical description of the time period from the late 1990s through the early 2000s. This is an interesting and thorough account of the socio-political and policy issues that surrounded the AANA’s efforts with Health Care Financing Administration (now Center for Medicare and & Medicaid Services) to repeal the unnecessary supervision requirements for nurse anesthesia services contained in Medicare Part A.
Click here for more information about The Opt-Out Story for CRNAs.



Meetings and Workshops

Business of Anesthesia
The AANA Business of Anesthesia Workshop addresses critical business issues facing CRNAs and will be held July 12 in Chicago. Whether you are employed or have your own business, this workshop has the necessary information to help you navigate the changing business environment in healthcare. Register today.
NEW AANA Workshop: Foundations of Advanced Pain Management
AANA’s newest workshop—Foundations of Advanced Pain Management will be held June 6-9, 2014, at the Regional Medical Center, Manchester, Iowa. Interventional pain management is an area of practice that demands critical assessment and knowledge to provide proper and precise treatment interventions to maximize positive patient outcomes. The AANA’s newest pain management workshop, Foundations of Advanced Pain Management, offers CRNAs practical, didactic and hands-on content to support their practice in advanced pain management. Register now.
AANA 2014 Nurse Anesthesia Annual Congress
The AANA 2014 Nurse Anesthesia Annual Congress will be held September 13-16 in Orlando, Florida. The AANA Annual Congress will highlight new research, emerging technology, specialty practice, practice and business management and other topics important to your unique practice. Register today.
AANA 2014 Fall Leadership Academy
Save the Date. The AANA Fall Leadership Academy will be held Nov. 7-9 in Rosemont, Illinois.
Registration opens in July.


AANA Foundation Fellowship Applications Due April 1
Post-Doctoral and Doctoral Fellowship applications are due April 1, 2014. Applications are currently available on the AANA Foundation website at If you have any questions, please contact the AANA Foundation at (847) 655-1170 or
Orlando – The Stars Come Out Again
Last Call for Talent – Applications Due April 1, 2014
Talent applications continue to come in, but there still may be room for your special talent. Apply TODAY if you’d like to perform to a room full of fellow CRNAs/SRNAs and support the Foundation’s mission to advance the science of anesthesia through education and research.
Orlando – The Stars Come Out Again will be held Sunday, Sept. 14, at the AANA 2014 Nurse Anesthesia Annual Congress. The evening will include dinner, drinks, dancing, a DJ, and CRNA and SRNA talent acts. If you’re chosen to perform, your ticket to the event is complimentary, and you’ll have the opportunity to win fabulous prizes.
Click here to view a video recap of last year’s talent acts in Las Vegas. Click here to visit our event webpage, learn more about the event, and access the application.
If you have any questions, please contact Luanne Irvin at the AANA Foundation at (847) 655-1173 or
“State of the Science” Oral Poster Presentations
Last Call – Applications Due April 1
The deadline for “State of the Science” Oral Poster Presentations at the AANA 2014 Nurse Anesthesia Annual Congress is April 1. Click here to access the applications, which are currently available on the AANA Foundation website at Research, literature reviews, and innovative, creative techniques in anesthesia are appropriate topics. Up to $1,000 accompanies oral presentations.
The deadline for General Poster Presentations is May 1.
If you have any questions, please contact the AANA Foundation at (847) 655-1170 or


Antibiotics for Epidural-Related Fever in Labor?
Studies show that women who receive epidural anesthesia during labor are two to four times more likely than those who do not to develop fever; however, researchers so far have been unable to determine an underlying reason for this occurrence. One potential explanation is a link between epidural anesthesia and placental inflammation, and a team at the University of Texas Southwestern Medical Center set out to explore this specific possibility. The 400 study participants were randomly selected to receive either a dose of the antibiotic cefoxitin or a placebo just before placement of the epidural catheter for labor analgesia. The share of women who developed fever was statistically insignificant between the two groups, at 38 percent for the cefoxitin cohort and 40 percent for the placebo patients. Half of the mothers in each group were diagnosed with placental inflammation; and while fever was more common in those with the condition, there was no notable difference in placental inflammation between the two cohorts. Because neither fever nor placental inflammation abated with antibiotic prophylaxis, the findings suggest that a noninfectious inflammatory etiology—rather than infection—is likely the cause of epidural fever. The results are published in Anesthesia & Analgesia.
From "Antibiotics for Epidural-Related Fever in Labor?"
Medscape (03/21/14) Macario, Alex

For Tracheostomy, Better Late Than ... Early?
Tracheostomy is believed to enhance patient comfort level while reducing sedation and mechanical ventilation times and shortening length of stay in the ICU; however, clinicians are at odds over whether "early" or "late" intervention is best. A meta-analysis presented at this year's annual meeting of the Society of Critical Care Medicine found no proven benefit to early tracheostomy—defined as within seven days of intubation, for the purpose of this research. Because of the elevated risk of complications due to the increased procedure rate, however, U.K.-based anesthesia consultant and researcher Tamas Szakmany, MD, PhD, concluded that early tracheostomy should be avoided. A second study presented at the same meeting, meanwhile, arrived at the opposite conclusion. Those researchers, based in New York, determined that mortality goes up the longer clinicians wait before performing a tracheostomy after intubation for prolonged mechanical ventilation. To further complicate the debate, there is no standard in terms of the range of time that constitutes "early" and the range that is considered "late." The former definition has included intubation within 48 hours to as long as 10 days, while the latter has been described as anywhere from eight to 28 days.
From "For Tracheostomy, Better Late Than ... Early?"
Anesthesiology News (03/01/14) Vol. 40, No. 3 O'Rourke, Kate
Brains Remember Odors Smelled Under Anesthesia, Rat Study
A new study published in Anesthesiology reveals evidence that the brains of rats "remember" smells introduced to them while under deep anesthesia, even though the rats' behavior after waking indicates no memory of the scents. This suggests that the brain is able to take sensory input and register it at the cellular level while under anesthesia, whereas before it had been believed that the brain was unable to perceive any sensory information while in this state. Lead researcher Yan Xu, PhD, of the University of Pittsburgh School of Medicine's anesthesiology department, commented that the research posed the "question of whether our brains are imprinted during anesthesia in ways we don't recognize because we simply don't remember." The fact that the brain does process information while under anesthesia, Xu added, "suggests a need to re-evaluate how the depth of anesthesia should be measured clinically." Further research into the impact of general anesthesia on memory and learning is also needed, based on the study findings.
From "Brains Remember Odors Smelled Under Anesthesia, Rat Study"
Counsel & Heal (03/18/2014) Hsu, Christine
Ultrasound-Guided Multilevel Paravertebral Blocks and Total Intravenous Anesthesia Improve Quality of Recovery After Ambulatory Breast Tumor Resection
That regional anesthesia enhances quality of recovery (QoR) following ambulatory surgery has been demonstrated in numerous studies; however, research with paravertebral blocks (PVBs), specifically, has been limited by the high failure rate associated with landmark-guided techniques. As an alternative, investigators at the Women's College Hospital in Toronto conducted a study exploring the impact of ultrasound-guided PVBs on QoR after breast tumor resection. Participants were randomized either to a cohort that received PVBs in conjunction with total intravenous anesthesia or to a placebo group that received general anesthesia and sham subcutaneous injections. Results for the 64 patients whose data were analyzed reflected improved QoR—including but not limited to such factors as physical comfort, emotional state, and pain—for the PVB group compared to the control group, both at discharge and on postoperative day two. There was no noticeable difference in the two groups at days four and seven. However, the PVB group also outperformed the control group in terms of incidence of postoperative nausea and vomiting, need for additional opioids post-surgery, time until discharge from the postanesthesia care unit, and hospital discharge time.
From "Ultrasound-Guided Multilevel Paravertebral Blocks and Total Intravenous Anesthesia Improve Quality of Recovery After Ambulatory Breast Tumor Resection"
Anesthesiology (03/14) Vol. 120, No. 3, P. 703 Abdallah, Faraj; Morgan, Pamela; Cil, Tulin; et al.
Surgical Patients Show Higher Mortality From Harm, Study Finds
Surgical patients are at greater danger from harms during the post-recovery period than are other hospital inpatients, according to researchers at the Henry Ford Health System in Detroit. They performed a retrospective review of hospital records for 114,677 patients admitted to the system between 2009 and 2011, comparing mortality rates for 11 different harms. In all cases, the rates were higher for surgical patients. The findings showed that, overall, about 73 percent of patients recovering from an operation died after experiencing harms such as adverse reaction to medication, renal failure, hypoglycemia, and infection. By comparison, the mortality rate for nonsurgical patients who suffered the same harms was just 37 percent. Lead researcher Zachary Bauman, DO, said the disparity could be explained by the fact that surgical patients experience more pain and are more likely to be prescribed narcotics, which in turn could expose them to greater risk. Another possible factor, according to Martin Makary of Johns Hopkins—who was not involved in the research—is stress. He notes that even minor stressors have been tied to physical conditions like acne or cold sore outbreaks, and patients undergoing surgery are dealing with one of the "greatest physiologic stress events in medicine: an operation."
From "Surgical Patients Show Higher Mortality From Harm, Study Finds"
Anesthesiology News (03/01/14) Vol. 40, No. 3 Guarino, Ben
No Difference by Injection Approach for Low Back Pain
Steroid injections into the epidural space are widely used in the United States to treat chronic pain in the low back. While transforaminal injections generally are considered more effective for relieving pain, this approach also is more likely than interlaminar injections to produce severe side effects such as paraplegia, seizures, and even death. Now, researchers say they have evidence that transforaminal injections are not necessarily better in the first place. George Chang Chien, DO, of the Chicago-based Rehabilitation Institute led the study, which reviewed data from eight different clinical trials. More than 509 patients were analyzed in all, some receiving transforaminal injections and some receiving interlaminar injections. While the former modality was indeed about 15 percent more effective in delivering pain relief over the short term, the interlaminar group presented slightly better results at two weeks than the transforaminal group. Neither approach, meanwhile, was better than the other during long-term follow-up of one month or six months. "These results suggest that the difference in efficacy between these two modalities may be less significant than previously thought," remarked Chien.
From "No Difference by Injection Approach for Low Back Pain"
Medscape (03/10/14) Melville, Nancy A.
Improved Rapid-Sequence Intubation
At the American Society of Health-System Pharmacists 2013 midyear clinical meeting, University of California, San Francisco researchers reported that patients undergoing rapid-sequence intubation (RSI) are more likely to receive sedation if a pharmacist is present during intubation. Medical records from nearly 500 patients who underwent RSI at the university's emergency department between 2008 and 2012 were reviewed, with researchers discovering that many did not receive appropriate sedation and analgesia. Respectively, 60.8 percent and 28.3 percent of patients given rocuronium for RSI did not receive analgesia and sedation. By contrast, of those patients administered succinylcholine, 48.6 percent did not receive analgesia and 15.6 percent did not receive sedation. Lead investigator Zlatan Coralic, PharmD, an emergency medicine pharmacist at UCSF, said, "There may be a false sense that patients are sedated with rocuronium. It is a much longer-acting paralytic than succinylcholine but [...] does not provide any analgesia or sedation." In contrast, the effect of succinylcholine diminishes after five to 10 minutes, "prompting providers to administer analgesia and sedation much sooner than with rocuronium." Of the rocuronium recipients, only 19 percent were left unsedated when an ED pharmacist was present during RSI compared to 35 percent who were unsedated when a pharmacist was not present. Coralic attributed this to pharmacists' awareness of rocuronium's pharmacokinetics and duration, although he noted that pharmacist attendance did not correlate with analgesia use in rocuronium recipients or with either analgesia and sedation in succinylcholine recipients.
From "Improved Rapid-Sequence Intubation"
Anesthesiology News (03/01/14) Vol. 40, No. 3
Hormone Combo Reduces Pain, Opioid Dose in Intractable Pain
Results of a preliminary study evaluating a novel hormone therapy combining oxytocin and human chorionic gonadotropin (hCG) indicate that treatment may provide relief and reduce opioid doses in patients who have intractable pain. In the groundbreaking trial, lead researcher Forest Tennant, MD, studied the effects of simultaneous administration of the oxytocin and the hCG in nine patients with intractable pain who were being maintained on one or more long- and short-acting opioids. Seven out of nine patients reported improvements in pain reduction, length of time between pain flares, and opioid dosage at follow-up two or three months later; and the improvements even continued at month six. Joseph Rabi, MD, from the University of Chicago, Schwab Rehabilitation Hospital in Illinois, noted, "In essence, the hCG given to the patients in this study counteracted the opioid's suppression of the hypothalamic tract," a well-documented effect of opioids. Rabi noted, however, that "the way it caused the pain to decrease is still uncertain. It is an interesting study and further studies should be pursued."
From "Hormone Combo Reduces Pain, Opioid Dose in Intractable Pain"
Medscape (03/17/14) Melville, Nancy A.
Significant Increase in Emergency Room Opioid Prescriptions
A new study from George Washington University, reported in Academic Emergency Medicine, shows that from 2001 to 2010 the use of opioid analgesic prescriptions during emergency room visits spiked. However, the results were not explained by a similar increase in visit rates for painful conditions, which by comparison rose only 4 percent. Maryann Mazer-Amirshahi, MD, from GW's School of Medicine and Health Sciences, called the trend "concerning" and noted that the use of opioids for treating "acute painful conditions [...] might do more harm than good, as they can potentially lead to misuse and addiction." The 10-year study also found that prescribing rates increased across all all groups and payer categories, with the Midwest states recording the largest proportional increase and urban emergency departments and nonprofit hospitals prescribing opioids more commonly than other institutions.
From "Significant Increase in Emergency Room Opioid Prescriptions"
RedOrbit (03/17/14) Flowers, April
Medical Cocktail Gets Knee Surgery Patients Up Sooner
Dr. Brett Perricelli, an orthopedic surgeon at St. Clair Hospital in Mt. Lebanon, Pa., began using a new cocktail of medication during total hip and knee replacement surgeries in October 2013. Since beginning to use the drug combination, which features the long-acting local anesthetic Exparel, he has seen dramatic improvements in patients' pain levels and recovery time. To date, Perricelli has used the as-yet-unnamed combination on about 100 patients. The multi-modal analgesia treatment "has changed everything that I have previously learned about hip and knee replacement," he insists. The regimen provides several benefits: less need for narcotics, decreased use of nerve blockers, expedited return to mobility, and the ability to begin physical therapy sooner. In addition, early analyses at St. Clair show that the new protocol is more cost-effective because patients have shorter hospital stays, take fewer narcotics, and undergo more effective physical therapy.
From "Medical Cocktail Gets Knee Surgery Patients Up Sooner"
The Daily Gazette (NY) (03/15/14) Lindstrom, Lauren
Simple Online Tool Helps Predict Patient's Risk of Complications Following Surgery
Research published in JAMA Surgery finds that post-surgical complications, or a lack thereof, are strong indicators of which patients are likely to be readmitted to the hospital within 30 days of an operation. By analyzing more than 142,000 patients who underwent non-cardiac surgery, controlling for severity of disease and surgical complexity, the investigators discovered that most patients who had complications following discharge from the hospital had an unplanned readmission. For those who did not report complications, only a minimal number of patients experienced an unplanned 30-day readmission. The American College of Surgeon's Surgical Risk Calculator, an online tool, lets healthcare professionals enter patient information—such as smoking status and body mass index—to get an estimate of his or her risk of complications following surgery. This information, in turn, could guide decisions based on post-discharge monitoring and the number of high-risk patients handled by each nurse.
From "Simple Online Tool Helps Predict Patient's Risk of Complications Following Surgery"
News-Medical (03/07/14)
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