Anesthesia E-ssential

AANA Anesthesia E-ssential, April 12, 2018

Vital Signs

AANA 2018 Annual Congress Registration is Now Open!

Tap into the power of technology at the 85th AANA Annual Congress being held at the Hynes Convention Center in Boston. You’ll refresh and expand your knowledge with hands-on patient simulation workshops and expert speakers. We’re excited to welcome keynote speaker, Pablos Holman, a notorious hacker, inventor, entrepreneur and futurist on a quest to solve the world's problems through the innovation of technology. Don’t miss the biggest CE event in nurse anesthesia! Register today for early bird rates.

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Important Change to AANA Journal Course

Please review the following for details about an important change to the AANA Journal Courses:
  • Beginning with the April 2018 issue of the AANA Journal, Journal Course articles will no longer be numbered.
  • Courses will no longer be part of a series of six courses as in previous years. Specifically, courses will no longer be referenced as part of, for example, Journal Course No. 37. Additionally, courses will no longer be numbered 1-6. Each course will be a stand-alone continuing education opportunity without a number.
  • As always, each issue of AANA Journal will contain a Journal Course article. Each course will be worth one CE credit with successful completion of the corresponding examination and evaluation.
  • Individuals will have two attempts to pass an examination available at
  • Each exam is priced at $35 for members and $21 for students, but can be taken at no cost by using one of the six free CEs available annually to AANA members as a benefit of their membership.
  • Visit to view all of the available CE opportunities.
The following information will be published with each Journal Course article:

The AANA Journal Course is published in each issue of the AANA Journal. Each article includes objectives for the reader and sources for additional reading. A 10-question open-book exam for each course is published on and will remain live on the site for a period of 3 years.

One continuing education (CE) credit can be earned by successfully completing the examination and evaluation. Each exam is priced at $35 for members and $21 for students but can be taken at no cost by using one of the six free CEs available annually to AANA members as a benefit of membership. For details, go to This educational activity is being presented with the understanding that any conflict of interest has been reported by the author(s). Also, there is no mention of off-label use for drugs or products.

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Hot Topics

Surgeon General's Advisory on Naloxone and Opioid Overdose

The Surgeon General has posted an advisory on the use of naloxone on someone who is suffering from an opioid overdose. The advisory reads:

"I, Surgeon General of the United States Public Health Service, VADM Jerome Adams, am emphasizing the importance of the overdose-reversing drug naloxone. For patients currently taking high doses of opioids as prescribed for pain, individuals misusing prescription opioids, individuals using illicit opioids such as heroin or fentanyl, health care practitioners, family and friends of people who have an opioid use disorder, and community members who come into contact with people at risk for opioid overdose, knowing how to use naloxone and keeping it within reach can save a life." (Emphasis added.)

Read more about the Surgeon General's advisory.
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The Joint Commission Posts 2017 Top 10 Most Challenging Ambulatory Care Standards

New to the list this year of most challenging standards in the ambulatory care setting is the implementation of infection prevention and control activities.

Dropping off the list from 2016 is addressing the safe use of look-alike/sound-alike medications. The most challenging standards for Joint Commission-accredited ambulatory care practices are:
  1. IC.02.02.01 – The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
  2. MM.03.01.01 – The organization safely stores medications.
  3. HR.02.01.03 – The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
  4. EC.02.04.03: The organization inspects, tests and maintains medical equipment.
  5. EC.02.05.01: The organization manages risks associated with its utility systems.
  6. EC.02.02.01: The organization manages risks related to hazardous materials and waste.
  7. IC.02.01.01: The organization implements infection prevention and control activities.
  8. EC.02.03.05: The organization maintains fire safety equipment and fire safety building features.
  9. EC.02.05.07: The organization inspects, tests and maintains emergency power systems.
  10. MM.01.01.03: The organization safely manages high-alert and hazardous medication.
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April 2018 AANA Journal Highlights

Read on for highlights of the April 2018 issue of AANA Journal.

Perceived knowledge and attitudes of CRNAs and SRNAs on fire risk management during time-out in the OR
The authors examine an area of on-going patient safety risk, fire in the OR, assessing individual perceptions of the risk in a study that raises many questions about value inculcation, education and training.

Effect of epidural volume extension on quality of combined spinal-epidural anesthesia for cesarean delivery: a systematic review and meta-analysis
A powerful research methodology examines the efficacy of a commonly used technique in providing OB anesthesia and analgesia. While focusing on the OB population, it generates thoughtful consideration in its application in other surgical domains as well.

Using evidence based best practices of simulation, checklists, deliberate practice, and debriefing to develop and improve a regional anesthesia training course
A QA and improvement project examines a comprehensive education and training program to enhance knowledge and performance metrics in performing regional anesthesia. This intriguing project challenges certain beliefs, and enhances and extends others related to how to conduct a regional anesthesia curriculum.

Adverse events during cosmetic surgery: a thematic analysis of closed claims
The authors continue the AANA’s longstanding interest in interrogating closed claims to generate practical and clinical understanding about the genesis and prevention of adverse events occurring during anesthesia care. This eye-opening latest addition to the literature focuses on cosmetic surgery and will be of great interest to all readers.

Implementation of a standardized handoff of anesthetized patients
This article adds to the growing literature devoted to communication practices as patients experience transitions in their care. Focusing on a group of CRNAs, and using an innovative methodology, the author examined the value of a standardized approach to patient handoff.

Propofol drug shortage associated with worse postop nausea and vomiting outcomes despite a mitigation strategy
The authors describe an unintended opportunity to assess the impact of a propofol shortage on an important patient goal, the prevention of PONV. Their work is particularly timely as we continue to experience episodic shortages of many different anesthetic-related agents, and the work presented provides the reader with a greater appreciation of how shortages may affect clinical practice.

AANA Journal Course: Residual neuromuscular blockade
This article explores a vital patient safety domain, neuromuscular blockade that extends beyond the intended pharmacodynamic period. In this important CEU offering, the authors discuss the safe use of these agents and strategies to mitigate the occurrence of postoperative residual block from administered neuromuscular blocking agents.

Don’t miss our online content!!
In an Education News piece, entitled “Professional Socialization and Political Advocacy,” the author explores the CRNA and SRNA roles of advocating and becoming greatly involved at the state and federal levels to ensure traction of CRNA leadership in healthcare policy decision making.

In another Education News piece, the “Basics of the objective structured clinical exam” are described in the ever-expanding simulation domain, as both a testing and a teaching tool/methodology. Of particular interest to educators, this work also has great importance to the everyday clinician and will prove illuminating to all readers.

Imagining in Time provides a beautiful and heartfelt examination of the life of “An Unsung Hero: Anne Penland, Nurse Anesthetist.” The author describes a North Carolinian who served as the very first CRNA in battle during WWI.
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NewsMaker: Maria Sallie Poepsel Joins AAHHS Board of Directors

Maria Sallie Poepsel, PhD, MSN, CRNA, APRN, has joined the board of directors for the Accreditation Association for Hospitals/Health Systems Inc. (AAHHS).

Poepsel also is currently serving as director, Region 4, on the American Association of Nurse Anesthetists' board of directors (FY2018); and the advisory committee on Rural Health and Human Services Administration (2016-2020).
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NewsMaker: Ron Castaldo Details DANA Experience with APRN Consensus Model Language

Former AANA board member and past president of the Delaware Association of Nurse Anesthetists, Ronald R. Castaldo, PhD, MBA, MS, CRNA, APRN, CCRN, details Delaware's unique experience with passing APRN Consensus language in the April 2018 issue of The Journal of Nursing Regulation.

"I am thrilled that Delaware's pathway can be memorialized for other APRNs and Consensus Model stakeholders to view and potentially benefit from," says Castaldo. Read the article (subscription required).

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NewsMaker: Thomas Bloomquist Becomes Certified Hypnotist Trainer

Thomas Bloomquist, MSN, CRNA, CHT, FAAPM, of Beyond Your Best in Concord, N.H., has become a certified hypnotist trainer. Qualified applicants who have used hypnosis personally, can now train to become certified consulting hypnotists.

Bloomquist, a Certified Registered Nurse Anesthetist who is also a certified clinical hypnotist, brings his nearly 40 years of medical experience in the field of anesthesia and pain management to his clinical hypnosis practice.
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NewsMaker: Kelley C. Moore Spotlighted in the Worldwide Leaders in Healthcare

Kelley C. Moore, DNP, MSN, MA, BSN, CRNA, joins the International Nurses Association, effective with her upcoming publication in the Worldwide Leaders in Healthcare. Moore is an established Doctor of Nursing Practice and Anesthesia Master Clinician currently maintaining a position with the David Grant USAF Medical Center in Fairfield, California. Featuring more than three decades of experience in her field, she has a special expertise in administration, going over cases, and intensive care work. She also serves as an adjunct professor with Ohio University and the University of South Florida, where she teaches online.

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Foundation and Research

Are you a MIPS Eligible Clinician? CMS Releases 2018 MIPS Eligibility Tool

You can now use the updated CMS MIPS Participation Look-up Tool to check on your 2018 eligibility for the Merit-based Incentive Payment System (MIPS). Just enter your National Provider Identifier, or NPI, to find out whether you need to participate during the 2018 performance year. The look-up tool has been updated to address the changes to low-volume threshold for MIPS eligibility. CRNAs in alternative payment models (APMs) should be aware that the CMS will update the APM participants look up tool at a later time. For more information, visit AANA Quality Reimbursement to learn how CRNAs are impacted by the Quality Payment Program and MIPS today.
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MIPS APMs to Advanced APMs: How to Make the Valuable Transition

The Centers for Medicare and Medicaid Services (CMS) is hosting a webinar series with APG to assist clinician groups to better understand alternative payment models (APMs) under MACRA and provide some “how-to” insight into APM implementation. Subject matter experts from CMS will review the MIPS APM model and requirements for qualifying to become an advanced APM, while APG will offer their strategies behind how they made the transition for their organization/group and share any challenges/pitfalls during implementation. This webinar will be held on April 30, 2018 at 12:00 p.m. – 1:30 p.m. ET. Register for this CMS sponsored webinar today.
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New AANA Member Advantage Program - SCG Health QCDR

SCG Health specializes in making MIPS regulatory burdens more approachable so that you can plan how to respond with limited resources and time. AANA Members who become SCG Customers will receive a 10% discount off the retail base subscription of 2018 reporting at $275 per clinician for reporting Quality and Improvement Activities, which must include three or more SCG Health QCDR measures. The discounted base subscription includes submission of quality data to SCG Health, live on-shored call center and online support, data submission, data verification and communication to CMS as required. Contact for more information or visit Data entry support for calendar year 2018 Quality data is available for AANA members for an additional $500 per clinician (discount does not apply).
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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.

FDA Expands Exparel Nerve Block for Upper Extremity Procedure Indication

The Food and Drug Administration has approved new indications for bupivacaine liposome injectable suspension, which may now be used for analgesia following shoulder replacement surgery or rotator cuff repair. The first and only multi-vesicular liposome local anesthetic designated for perioperative or postoperative use, it initially was sanctioned for single-dose infiltration at the surgical site. With the new FDA nod, it now becomes the first long-acting, single-dose nerve block for upper extremity surgery. The regulator acted on new evidence that supports use of the agent, commercially known as Exparel. The Phase III study included 156 patients who were evenly randomized to single-dose Exparel or a placebo at least one hour before their procedures, administered via ultrasound-guided interscalene brachial plexus block. The results reflected superiority over placebo in terms of pain scores and opioid consumption in the first 48 hours postoperatively, with a similar safety profile as with use in wound infiltration. "The ability to provide effective regional analgesia with a single dose of Exparel is a tremendous victory for patients and advances the imperative need for low- or no-opioid pain management strategies," remarked Jeffrey Gadsden, MD, chief of orthopedic, plastics, and regional anesthesiology at the Duke University School of Medicine.

From "FDA Expands Exparel Nerve Block for Upper Extremity Procedure Indication"
MD Magazine (04/09/2018) Kunzmann, Kevin

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I.V. Aminophylline Is Effective for Post-Dural Puncture Headache, Study Finds

In China, intravenous aminophylline is being explored as a less-invasive option to epidural blood patches for managing post-dural puncture headache. The complication is linked to lumbar punctures performed for spinal anesthesia or neurological diagnostic purposes. To investigate, the randomized multisite study involved 126 patients who reported severe headache after lumbar puncture. Each received either I.V. aminophylline or a placebo within three hours of headache onset and once again the following day. The primary outcome was patient-reported visual analog scale score eight hours post-treatment, which was 2.98 on average for the aminophylline group and 5.34 for the controls. At the end of the two-day treatment period, meanwhile, 72.6 percent of the intervention patients reported score improvements on the Patient Global Impression of Change scale, compared with just 39.1 percent of placebo-takers. Lead study author Nanchang Xie, MD, of The First Affiliated Hospital of Zhengzhou admitted the three-hour interval following dural procedure could limit the practicality of I.V. in real-life settings, even as outside experts questioned whether the technique makes sense in American medicine. "Cost and inconvenience to the patient, scheduling time for the physician, and evaluation and treatment of potential adverse events for the two-day intravenous treatment may be significant factors in applying this study in the United States," remarked Randolph Evans, MD, of Baylor College of Medicine. "The aminophylline infusions were compared to controls, so we don't know the relative efficacy of I.V. aminophylline to other available treatments," including epidermal blood patches, I.V. hydrocortisone, oral gabapentin, sphenopalatine block, bilateral greater occipital nerve blocks, and others.

From "I.V. Aminophylline Is Effective for Post-Dural Puncture Headache, Study Finds"
Neurology Today (04/05/18) Vol. 18, No. 7, P. 46 Moran, Mark

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Study Finds Spinal Anesthesia Associated with Better Outcomes After Hip Fracture Repair Compared to General Anesthesia

Researchers offer evidence that spinal anesthesia has added benefit over general anesthesia for older people who undergo hip fracture repair. The University of Toronto colleagues compared matched pairs of patients over a 13-year period, 883 sets in all. They found that, after adjusting for other factors that could play a role in this setting, death within 90 days of hip fracture surgery was less likely to occur with spinal anesthesia than with general anesthesia. Patients who received spinal anesthesia also had fewer blood clots in the lung, lower rates of major blood loss, and shorter hospitalizations. The study abstract, which won an award from the American Society of Regional Anesthesia and Pain Medicine, will be presented on April 19 at the 2018 World Congress on Regional Anesthesia and Pain Medicine in New York.

From "Study Finds Spinal Anesthesia Associated with Better Outcomes After Hip Fracture Repair Compared to General Anesthesia"
Newswise (04/05/18)

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Dexmedetomidine Effective for Shivering in Parturients

Researchers in Ontario believe they have found a way to alleviate intense shivering in pregnant women who undergo neuraxial anesthesia for surgical delivery. The complication can be severe enough to create patient distress and disrupt monitoring of vital signs, according to University of Montreal resident Christina Lamontagne, MD. She and colleagues randomized 80 obstetric patients who experienced shivering after neuraxial anesthesia, with half receiving intravenous dexmedetomidine after childbirth and half receiving normal saline. They discovered that administering a single bolus of dexmedetomidine significantly lowered the incidence of shivering and shortened the duration when it did occur. Intense shivering lasted just 2.6 minutes in the dexmedetomidine recipients, with chills ceasing completely within 15 minutes for 90 percent of patients. In the control group, by comparison, intense shivering lasted as long as 17 minutes; and only 23 percent of women is this group were free of chills within 15 minutes of receiving saline.

From "Dexmedetomidine Effective for Shivering in Parturients"
Anesthesiology News (04/03/18) Vlessides, Michael

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Pain Treatment During Labor Does Not Increase Risk of MS Relapses After Delivery, Study Finds

Despite concerns from some anesthesia providers, new evidence indicates that multiple sclerosis (MS) patients who receive neuraxial anesthesia during childbirth are not more likely to experience disease relapse afterwards. Investigators analyzed data from two large studies—one including 215 women from 12 European nations and another including 174 women from France and Italy. All 389 had relapse-remitting or secondary progressive MS, and none were exposed to disease-modifying treatments while pregnant or in the three months post-partum. According to the analysis, 24 percent of the 156 study participants who underwent neuraxial analgesia relapsed during pregnancy; and 25 percent relapsed during the following three months. However, women who relapsed during pregnancy were more likely to suffer a post-delivery relapse whether they received neuraxial anesthesia or not. "Our study provides additional arguments toward the harmlessness of neuraxial analgesia in parturient women [those in labor] with MS, whatever their MS activity during pregnancy," the team wrote in the Multiple Sclerosis Journal. "It is important to inform MS women that the post-partum [post-delivery] period is associated with a greater risk of relapse, which is closely related to the pregnancy disease activity but not to the use of local/regional analgesia at the time of delivery."

From "Pain Treatment During Labor Does Not Increase Risk of MS Relapses After Delivery, Study Finds"
Multiple Sclerosis News Today (04/03/18) Lopes, Jose Marques

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Palliative Sedation a Valid Option for Refractory Symptoms in End-Stage Cancer

A study out of Colombia upholds palliative sedation (PS) as a viable option for patients with end-stage cancer, but only as a last resort. The practice, accepted in developed nations, is only just emerging in Colombia and other countries. The prospective investigation took place at a palliative care center and involved 66 occupants with cancer whose symptoms no longer responded to standard treatment. PS, which alleviates intense suffering by rendering patients unconscious, was induced with midazolam. The most common conditions that triggered PS were dyspnea, delirium, pain, and existential suffering, with about 60 percent of patients exhibiting more than one refractory symptom that qualified them for PS. Patients lived 44.9 hours on average after PS initiation, the researchers reported in Supportive Care in Cancer. According to the study authors, PS is a valid and useful therapeutic strategy for refractory symptoms among the terminally ill; however, "further development of strategies and clear indications towards the use of PS in Colombia are needed, given its still scarce use."

From "Palliative Sedation a Valid Option for Refractory Symptoms in End-Stage Cancer"
Oncology Nurse Advisor (04/02/18) Nam, James

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Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed weekly to AANA members.

Anesthesia E-ssential is for informational purposes, and its contents should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

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Attn: Cathy Hodson
E–ssential Editor
April 12, 2018
PAJUNK Medical Systems Earn Your DNAP AANA Group Disability