Anesthesia E-ssential

AANA Anesthesia E-ssential, April 26, 2018
AANA Member Advantage Program

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CMS Deputy Director Addresses National Health Policy Issues at AANA Mid-Year Assembly

Focused on anesthesia-related clinical standards and quality, Jean Moody-Williams, RN, MPP, gave the keynote speech at the AANA-Mid-Year, held April 21-25, 2018, in Washington, D.C.

Moody-Williams is the Deputy Director of the Center for Clinical Standards and Quality for the Center for Medicare & Medicaid Services (CMS). In addition, she is a member of the leadership team responsible for more than 400 employees and a $3 billion annual budget. Moody-Williams works with a team to lead policy activities for Quality Improvement Programs, End Stage Renal Disease Networks, Survey and Certification, Quality Measurement and Health Assessment, Clinical Standards, Coverage and Analysis, Quality Innovations Models and many of the agency’s Value Based Purchasing and public reporting programs for hospitals, physicians and ambulatory settings.

“This assembly brings together anesthesia professionals keenly interested in improving the quality of anesthesia care delivery in today’s healthcare system,” said AANA President Bruce Weiner, DNP, MSNA, CRNA. “Jean Moody-Williams’s critical role in clinical standards, quality measurement, health assessment, and other efforts at CMS will be valuable information for CRNAs to take back to their everyday anesthesia practice.”

The AANA Mid-Year Assembly is the largest advocacy meeting of CRNAs, with more than 1,000 nurse anesthetists expected to participate. The assembly educates attendees about the latest developments in healthcare policy and reimbursement

“CRNAs are perfectly suited to meet today’s healthcare challenge of delivering safe anesthesia, while helping to control rising healthcare costs,” said Weiner.
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AANA Recognizes Healthcare Advocate for Commitment to Anesthesia

Mary O’Brien, EJD, MSN, CRNA, ARNP, a resident of Swisher, Iowa, received the 2018 Daniel F. Vigness Federal Political Director of the Year Award from the AANA during the AANA’s Mid-Year Assembly held in Washington, D.C. O’Brien is the 17th recipient of the award.

The Daniel D. Vigness Federal Political Director of the Year Award was established in 2001 by the AANA Board of Directors to acknowledge the CRNA who makes the greatest strides in advancing the AANA’s federal healthcare agenda through grassroots political activities as a Federal Political Director. A CRNA for nearly 30 years, Daniel D. Vigness, MS, CRNA, was the first recipient of the Federal Political Director of the Year Award. A South Dakota native, Vigness lost his battle with cancer in 2013.

O’Brien is currently a staff nurse anesthetist at the University of Iowa Hospitals and Clinics, in Iowa City. “It is such an honor to be selected for this award. I wish to thank the members of the AANA Board of Directors and the many CRNAs across the country for taking the time to mentor and support me over the years as I have worked to advance our profession,” said O’Brien. “Dan was a friend and gave me the best sage advice as a new CRNA, and I am proud to have my name alongside his for this award.”

A nurse anesthetist for more than 15 years, O’Brien is well known to local, state, and federal legislators for her political involvement. Her efforts have helped make the Iowa Association of Nurse Anesthetists a well-known healthcare organization in the state of Iowa.

O’Brien received her master’s degree in nurse anesthesia and her bachelor’s degree in nursing from the University of Iowa in Iowa City, Iowa. She also graduated from Allen Memorial Hospital School of Nursing in Waterloo, Iowa. In addition, she earned her Executive Juris Doctorate from Concord Law School in Los Angeles, Calif.
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National Prescription Take Back Day on April 28

April 28 is National Prescription Drug Take Back Day. To find information on a safe, convenient, and responsible means of disposing of prescription drugs, as well as how to help prevent drug abuse and overdose for April 28 and any day of the year, see
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Resources for CRNAs Employed by a Hospital, Facility, or Group

How much do you know about the malpractice insurance coverage provided by your employer? Fill out our employed checklist and learn which questions to ask your employer to ensure you will have protection when you need it. Learn more.
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“WE ARE THERE” Merchandise Now Available

This year’s National CRNA Week theme, “Every Breath, Every Beat, Every Second WE ARE THERE” was a huge success on social media and with our members. The only complaint? A limited supply of product! Now you can order shirts, posters, and mugs to display your professional pride and give as gifts to colleagues and friends. All items are sans a date, so it’ll never be outdated!
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Looking for an AANA Volunteer Opportunity? Apply for a FY2019 AANA Committee Now!

President elect Garry Brydges, DNP, MBA, ACNP-BC, CRNA, is looking for volunteers to fill committee positions in fiscal year 2019. Many committees have positions available for CRNAs and student registered nurse anesthetists. Check out the committee page on the AANA website to read about the various opportunities. Deadline for submission of a committee request is May 15, 2018. Please note: If you currently serve on a fiscal year 2018 committee, you must reapply for fiscal year 2019.
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AbbVie Donates Vials of Mivacurium Chloride for Medical Missions

AANA Corporate Partner AbbVie has donated 15,500 vials of MIVACRON® (mivacurium chloride) injection, 2MG/ML, 10ML, expiration date Dec. 16, 2018, to AmeriCares for medical missions. Look for available products and make requests at the AmeriCares website while supplies last. Thank you to AbbVie for their support!
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AANA Member Benefits

Resources on Retirement Planning Available from ONE Advisory Partners

When it comes to retirement, the sooner you start planning for it, the better. By beginning at least a decade out (and preferably sooner than that), you gain the time to use strategies that can boost your retirement savings and reduce your taxes. One strategy recommended by One Advisory Partners, an AANA Member Advantage Program partner, is the backdoor Roth IRA. 

Read "Income Too High for a Roth IRA? Go Through the Backdoor"

Roth IRAs are valuable retirement planning tools for nurse anesthetists because of the tax benefits that these accounts offer, including tax-free growth and tax-free withdrawals. However, Roth IRAs have contribution limits—a modified gross income (MAGI) in 2018 of $135,000 for individuals and $199,000 for couples filing jointly. These limits effectively shut out high-income earners from contributing to a Roth. 
There is a workaround, however, and that’s the backdoor Roth IRA.
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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.

Periarticular Injection Plus ACB, IPACK Improves Pain Control in TKA

New evidence suggests that interspace between the popliteal artery and capsule of the posterior knee block (IPACK) plus adductor canal block (ACB), when coupled with periarticular injection, offers superior pain control for knee replacement. A total of 86 patients were involved in the study, which randomized them either to this intervention or to just the periarticular injection alone. The prespecified primary outcome was pain with walking on postoperative day 1—which was lower for the intervention group than for controls not only then but on days 0 and 2 as well. The IPACK/ACB patients also outperformed controls on secondary endpoints, reporting significantly lower pain scores, greater satisfaction, less interference from pain when walking, improved sleep, less opioid use, and less patient-controlled analgesia. The investigators from Hospital for Special Surgery, located in New York City, presented the findings at the World Congress on Regional Anesthesia & Pain Medicine.

From "Periarticular Injection Plus ACB, IPACK Improves Pain Control in TKA"
Healio (04/23/2018) Tingle, Casey

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Opioids Risky for Hemodialysis Patients

Prescribing opioids to hemodialysis patients places them at an elevated risk for complications, researchers report, with the threat escalating along with dosage. The University of California, San Francisco colleagues considered a sample of nearly 141,000 hemodialysis patients—a population largely affected by multiple comorbidities, inadequate clearance of active drug metabolites from the kidneys, uremia, and polypharmacy. Among the 64 percent of patients who received opioid analgesics, 11 percent experienced altered mental status, 5 percent suffered a fall, and 3 percent sustained a fracture. With each 60-mg increase in opioid dose, the investigators discovered, the likelihood of those outcomes increased 29 percent, 4 percent, and 4 percent, respectively. Moreover, while guidelines generally list fentanyl, methadone, and hydromorphone as safer opioid choices in the hemodialysis setting than hydrocodone, oxycodone, tramadol, morphine, and codeine, the UC study found that these three options were underprescribed. "Thus, opioid use in patients on hemodialysis may not be as safe as guidelines suggest, and the benefit-to-risk ratio of their use in this population should be carefully considered," according to Julie Ishida, MD, and her team, who reported their findings in the Clinical Journal of the American Society of Nephrology..

From "Opioids Risky for Hemodialysis Patients"
Renal and Urology News (04/20/18) Persaud, Natasha

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Perineural Dexamethasone Not Worth Adding to Interscalene Block

Research out of Canada took a closer look at interscalene block using dexamethasone, which has been shown to prolong the duration of analgesia in this setting. As part of a superiority study, they divided 280 shoulder surgery patients into four groups of equal proportions. All participants underwent preoperative ultrasound-guided interscalene block but were randomized to a higher or lower dose of dexamethasone as well as to administration as a perineural adjuvant or an intravenous one. The primary outcome was block duration, which was extended an additional two hours with perineural administration compared with IV delivery. Still, the difference between the two routes was less than 10 percent; and doubling the dexamethasone dose had little added effect on block duration. What the investigators also discovered is that the risk of neurological symptoms with perineural administration of dexamethasone was higher than anticipated, at 16 percent. Considering that perineural delivery is associated with poor neurological outcomes while providing only a marginal increase in block duration versus IV delivery, the team from the University of Manitoba could not justify further study into perineural dexamethasone as an adjunct to interscalene block. "Our conclusion is that clinicians should strongly consider the risks of administered perineural dexamethasone given its limited analgesic benefit and theoretical risks of neurotoxicity," they report.

From "Perineural Dexamethasone Not Worth Adding to Interscalene Block"
Anesthesiology News (04/20/18) Vlessides, Michael

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Femoral Nerve Block Alone or in Combination with Sciatic Nerve Block for TKA

Based on a systematic literature review, adding sciatic nerve block to femoral nerve block could benefit patients undergoing total knee arthroplasty (TKA)—especially those at risk for postoperative opioid use. The meta-analysis covered 10 prospective randomized trials that compared outcomes with femoral plus sciatic nerve blocks to outcomes with just femoral nerve block in the setting of TKA. Data from the 500-plus study participants indicated that the combination technique improved pain score at four hours, pain score at movement at 12 hours, use of patient-controlled opioids at 24 and 48 hours, and incidence of postoperative nausea. Duration of hospitalization, meanwhile, was comparable between the two treatment groups. "This meta-analysis provides evidence-based supports for the benefits of sciatic nerve block as a complement to femoral nerve block in total knee arthroplasty," concluded the review authors, who reported their findings in the Journal of Anesthesia. "The combination sciatic-femoral nerve block appears to be the optimal choice for patients [at] high risk [for] postoperative opioids consumption or acute pain after total knee arthroplasty."

From "Femoral Nerve Block Alone or in Combination with Sciatic Nerve Block for TKA"
Clinical Pain Advisor (04/19/18) Rice, Tyler

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Perioperative Gabapentin May Improve Pain Management in Head and Neck Cancer

Research findings indicate that perioperative gabapentin significantly improved visual analog scale (VAS) pain scores in patients undergoing head and neck mucosal surgery. However, the investigators say, the approach is unlikely to have much impact on total narcotic use. Among the 90 study participants, some were randomized to twice-daily oral gabapentin prior to surgery and for three days afterwards. Others were randomized to take a placebo. While the gabapentin group had markedly better VAS scores for resting, coughing, and swallowing pain, narcotics consumption in the first three postoperative days was similar for both sets of patients. Additionally, study participants reported comparable levels of daily pain and pain tolerance, as well as narcotic effectiveness. With similar rates of dizziness and sedation as placebo and only a slightly higher rate of nausea, perioperative gabapentin was deemed safe. While it also "may reduce perception of pain," the researchers agree that it is "unlikely to change narcotic use. They reported their evidence at the 2018 American Head & Neck Society Annual Meeting in National Harbor, Md.

From "Perioperative Gabapentin May Improve Pain Management in Head and Neck Cancer"
Cancer Therapy Advisor (04/19/18) Nam, James

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Study Finds No Evidence That Anesthesia in Young Children Lowers Intelligence

Based on a database study of children born from 1994 to 2007 in one Minnesota county, Mayo Clinic researchers doubt that kids who undergo anesthesia in early life are likely to have lower IQs than kids who do not. The 997 patients were selected to be as much alike as possible, but they were stratified into cohorts based on whether they had no anesthesia exposure by age three (411), a single exposure (380), or two or more exposures (206). Based on medical records of testing at ages 8-12 and 15-20, as well as on parental reports, all three cohorts presented similar levels of brain function—including intelligence and memory. However, those who experienced multiple anesthetic exposures by their third birthday did score modestly lower on tests involving fine motor skills. Additionally, according to the paper published in Anesthesiology, their parents were more likely to report behavioral and learning problems. More problems with executive function—but not other behaviors—were noted by parents whose child underwent anesthesia just once before age three. "For the majority of kids undergoing surgery, the results overall are reassuring," says lead author David Warner, MD. "Although we do have some concerns about the children who are receiving multiple anesthetics, it's important to note that our results don't allow us to conclude that anesthesia itself is causing problems. However, the fact that we found some problems in some of these children means that research in this area needs to continue, including further analysis of our data."

From "Study Finds No Evidence That Anesthesia in Young Children Lowers Intelligence"
Medicalxpress (04/18/2018)

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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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April 26, 2018
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