Anesthesia E-ssential

AANA Anesthesia E-ssential, August 22, 2019

Hot Topics

Important CRNA Fact Sheets Updated and Available on AANA Websites

Two essential documents used by the AANA, CRNAs, and state associations for advocacy and public education purposes have been updated and are available on the AANA website, and Future of Anesthesia Care Today microsite. The concise, bullet-point document CRNA Fact Sheet presents nurse anesthesia by the numbers; CRNAs at a Glance describes the five pillars of the Future campaign: access, safety, cost-effectiveness, education, CRNA roles and responsibilities.
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2019 Comps and Benefits Report is Now Available!

Whether you’re negotiating your salary, benchmarking salaries for your staff, or conducting research, the AANA provides a comprehensive and reliable source of CRNA-specific compensation and benefits data. Inside the report, you’ll find insights on CRNA employment trends, including:
  • Compensation cross-segmented by location, years in practice, and full-time/self-employed status
  • Benefits broken out by geographic region, years in practice and employment arrangement
  • Time off policies
  • Retirement benefits
  • And more!
AANA members receive 50% off! Order your copy of the report today!
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Future of Nursing 2020-2030 Releases Town Hall Videos, Presentations

The Future of Nursing 2020-2030's recorded videos and presentations from the Seattle, Chicago, and Philadelphia Town Halls are now available online.

See Seattle, Chicago, and Philadelphia resources.
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August 2019 AANA Journal Highlights

The August 2019 AANA Journal is online, a nice balance of clinical, research and educational/administrative offerings, including:

Ultrasound-guided Intravenous Line Placement Course for Certified Registered Nurse Anesthetists: A Necessary Next Step
Ultrasound-guided vascular access is an important skill set for difficult IV access cases and for central line placement. The authors, strong proponents of its utility, designed a structured, multimodality educational program that may provide a workable template for others. They believe that CRNAs can benefit from the routine use of ultrasound (US) for IV access. Although most institutions resort to US use for IV access as a rescue tool in difficult cases, the widespread availability of and familiarity with US will likely foster its evolution from rescue to routine use for IV access.

Accuracy of Visually Estimated Blood Loss in Surgical Sponges by Members of the Surgical Team
The authors describe the great importance that operating room personnel monitor the correct amount of blood loss during surgery in order to properly replace lost volume. Their study adds to the growing literature that describes the accuracy of operating room personnel in visually estimating blood loss in surgical sponges. They performed an observational study with a comparative descriptive design at a university hospital that included all members of the surgical team. Their findings are very illuminating and will be of interest to all readers.

Implications of Inspired Carbon Dioxide During Ophthalmic Surgery Performed Using Monitored Anesthesia Care
The author notes that the concentration of carbon dioxide (FICO2) in ophthalmic surgery performed under monitored anesthesia care (MAC) has been largely ignored in the recommended monitoring standards of professional anesthesia societies. Most ophthalmic procedures are performed using MAC with facial draping that has been shown to retain carbon dioxide in the ambient air surrounding the patient. The goal of this review is to encourage investigation of this underreported parameter. The author's arguments and findings are compelling and given the virtual absence of high-quality work directed at this important clinical issue, this paper may stimulate further needed work in the domain.

Preparing for Total Power Failure in the Operating Room
This article thoroughly explores something that each and every one of us may experience (or already have!) in rendering care in the OR, that is a total electrical power. There is much more that should be planned for here besides having a back-up flashlight. Though an uncommon event, when it occurs, it poses a major threat to patient safety. The purpose of this project undertaken at Duke University was to determine the internal battery-related capabilities and duration of function of site-specific anesthesia equipment during a total power failure and to develop a power failure protocol. This paper might well become the start of a guidance policy at our individual institutions.

Refusal of Epidural Anesthesia for Labor Pain Management by African American Parturients: An Examination of Factors
This article reminds us of the indispensable value of epidural anesthesia for labor pain management. The author illuminates somewhat uncomfortable terrain noting the disparity of use that exists along ethnic and racial lines, with African Americans less likely to accept epidural anesthesia. His qualitative study identifies the major factors that influence African American parturients to decline epidural anesthesia for labor pain management and offers suggestions to improve acceptance and compliance. Much needed research and kudos to Roberson for tackling this important clinical issue.

Use of a Double Gloving Technique to Decrease Cross-Contamination by Anesthesia Providers
The authors set out to determine the impact of double gloving during the induction of general anesthesia on the incidence of cross-contamination by the anesthesia provider. Their project greatly illuminates a common (but not universal) provider intervention designed to decrease the risk of nosocomial infection in the anesthesia workstation. Whether you are or are not a ‘double glover,’ you will find this very interesting reading.

Delayed Onset and Prolonged Horner Syndrome in Two Children After Single-Shot Ultrasound-Guided Infraclavicular and Subclavian Perivascular Brachial Plexus Blocks for Upper Extremity Surgery: Case Reports
This article notes that Horner syndrome is a well appreciated complication of cervical approaches to brachial plexus blocks due to local anesthetic-induced oculosympathetic paresis. In their case reports, the authors report delayed manifestations of Horner syndrome in 2 children in the aftermath of ultrasound-guided infraclavicular and subclavian perivascular blocks. A good deal of patient safety terrain is covered in this paper with important practice implications for those using regional anesthesia in the pediatric patient.

Anesthetic Management of a Patient with Severe Diastolic Dysfunction for Umbilical Hernia Repair: A Case Report
The author discusses the significant role that heart failure plays out in a surprisingly large percentage of adults and its tendency to play out lethally. Via a superbly chronicled case report, the author examines the anesthetic management of a patient with a known diagnosis of severe left ventricular diastolic dysfunction, with a life-threatening exacerbation of congestive failure, presenting with an incarcerated umbilical hernia.

The AANA Journal Course: Update for Nurse Anesthetists—Perioperative Management of the Direct-Acting Oral Anticoagulants
This article explores and advances on the current status of direct-acting oral anticoagulants (DOACs) that gained clinical traction in 2008 as replacements for warfarin, and yet remain somewhat obscure to many clinicians. Despite DOACs having an excellent safety profile, reversal agents for use in emergent/excessive hemorrhage did not exist. This Journal course reviews and updates the clinician on the perioperative management of patients on DOACs. And remember, valuable CEU credit is afforded with course completion.

Promoting Patient Safety Through an International Approval Process for Anesthesia Schools
This is an impressive accounting of 24 anesthesia programs located in Africa, Asia, the Caribbean, Europe, and North America that successfully incorporated patient safety programs in their curricula. Governments, educators, and practice authorities would be wise to incorporate nursing standards, developed by experts in the profession, in plans to solve the healthcare shortage with appropriately educated healthcare workers. Log-on and read this impressive and important document that describes what is going on in our domestic turf, and well beyond.

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NewsMaker: University of Wisconsin-Oshkosh Program Aims to Head Off Provider SUD, Addiction

The University of Wisconsin-Oshkosh is trying to stay ahead of the curve on the opioid crisis by providing more resources for those who are entering the nursing professions. The concern is not just for patients, but possible opioid misuse by health professionals themselves.

Kathleen Wren, PhD, CRNA, APNP, program director of the nurse anesthesia program, says that those in the medical field can be especially susceptible to addiction. The College of Nursing has added wellness and stress courses as part of its curriculum. Learn more.
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NewsMaker: CRNA Wendy Odell Promoted to National Chief Anesthetist Officer

Wendy Odell, DNP, CRNA, has been promoted to national chief anesthetist officer for NorthStar Anesthesia. A practicing clinician in the healthcare industry for more than 25 years, Odell most recently served as senior vice president of NorthStar Anesthesia and chief anesthetist officer for NorthStar's south division. Learn more.
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NewsMaker: CRNA Katie Hornbaker Receives Excellence in Health Care Services Award

Katie Hornbaker, CRNA, is one of two Excellence in Health Care Services award recipients. The award was presented at Grand County, Colorado's "Bulls, Boots and BBQ" fundraiser for the Grand County Rural Health Network.

Hornbaker, a CRNA at Middle Park Health, was one of six nominees for the excellence award. Learn more.
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Meetings and Workshops

Fall Anesthesia Business Seminar Begins September 9: Space is Still Available!

Do you feel limited in your practice? Do you dream of practicing independently? If you want to go out on your own, but don’t know the business side of anesthesia, here’s your chance to learn from Juan Quintana and Larry Hornsby, former AANA presidents, who both have launched multimillion-dollar anesthesia group practices.

University-level Curriculum for AANA Members Only
Quintana and Hornsby are bringing their university-level course to members only through AANA’s online education platform, AANALearn®. The average cost for online college-level courses is $300-$400 dollars per hour. This seminar is offered to AANA members for just $75 per hour. Participants will earn 16 CE credits and leave the course with an actionable business plan and a certificate of completion from AANA.

The next session will begin on September 9, 2019. Registration is now open, and seats are limited.

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Learn the Ins and Outs of Ultrasound-Guided Peripheral Nerve Blocks

The Ultrasound-Guided Peripheral Nerve Block Workshop, September 21-22, 2019, at AANA's headquarters provides expert lectures, hands-on instruction and group discussions of representative clinical cases. Learn more.
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Empower the Leader Within at AANA Leadership Summit

All CRNAs are leaders. Join your peers in Naples, Fla., for unparalleled networking and leadership development for CRNAs by CRNAs. State association leaders, chief CRNAs and administrators, practice owners and managers, federal political directors, state reimbursement specialists, facility leaders, and aspiring leaders, this is the meeting for you: AANA Leadership Summit, Nov. 8-10, 2019, Naples Fla.
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Save the Date for the Assembly of Didactic and Clinical Educators (ADCE) 2020

Join us in Braselton, Ga., for the leading nurse anesthesia educational program forum to discuss current educational requirements and how they will define the future of the CRNA profession. Topics include diversity, technology, health and wellness, research, and more.

Location: Chateau Elan Winery and Resort, Braselton, Ga.
Resort Reservations will include FREE airport shuttles to/from the Hartsfield Jackson International Airport.

Dates: February 19-22, 2020
Registration opens in October 2019.

Learn more.
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CRNA: Houston Methodist Hospital, Houston, Texas

Duties and Responsibilities
  1. Demonstrate ICARE values and Service Pride Standards through actions.
  2. Perform thorough and complete preanesthesia assessments and develop appropriate anesthesia plans.
  3. Administer anesthesia in accordance with clinical privileges, including induction, maintenance and emergence.
  4. Select, obtain and administer anesthetics, adjuvant drugs, accessory drugs and fluids necessary to manage the anesthetic, to maintain the patient’s physiologic homeostasis, and to correct abnormal responses to the anesthesia or surgery.
  5. Monitor, interpret and evaluate on-going data as appropriate for the type of anesthetic and specific patient needs.
  6. Provide expertise in airway management both in and out of the surgical suite.
  7. Place and maintain epidural catheters as adjuncts to anesthesia.
  8. Place and monitor arterial and central venous catheters including pulmonary artery catheters.
  9. Document pertinent information on the patient’s medical record.
  10. Respond to emergency situations by providing airway management, administration of emergency fluids or drugs, or using basic or advanced cardiac life support techniques.
  11. Act as investigators, collaborators, consultants, or assistants on research projects as needed.
  12. May provide clinical and didactic instruction to nurse anesthesia students with emphasis on the patient undergoing cardiac, thoracic and major vascular surgery.
  13. May evaluate and counsel nurse anesthesia students, making appropriate referrals when indicated.
  14. May assist in developing, implementing and evaluating didactic and clinical curricula for the nurse anesthesia students.
  15. May serve as a resource person to students and other health care professionals.
  16. May serve on a variety of institutional committees and participate as instructors in staff development and continuing education programs for both professional and non-professional staff members.
  17. Other duties as directed by the Chair of the Department, Sr. CRNA and other Anesthesiologists.
Learn more.
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Certified Registered Nurse Anesthetist: Memorial Health System, Springfield, Illinois

Status: Full-Time, Hospital employed.
Schedule: Convenient flexible schedule with 8-, 10- and 12-hour shift options available.
Basic Functions: This position embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values. Our CRNAs administer general, regional, and MAC anesthesia to patients of all ages and any ASA status. The CRNAs work in a collaborative team environment with 50 CRNAs, 21 Anesthesiologists and 12 Anesthesia Techs to assist with room turnover and stocking. The CRNAs serve as Clinical Instructors for SIUE and Millikin/Decatur Nurse Anesthesia programs.
Due to our continued growth, Memorial Medical Center has multiple needs for Certified Registered Nurse Anesthetists. Positions are available full time in the Main OR, CVOR or as a split 50/50 between Main OR and CVOR. Learn more.
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Nurse Anesthetist/CRNA: Loma Linda Univ Medical Center, Loma Linda, California

CRNA Anesthesiology - Eligible for $20k recruitment incentive w/ 2 years of recent and relevant experience!

Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, integrity, excellence, teamwork and wholeness.

The Certified Registered Nurse Anesthetist (CRNA): 
  • Provides comprehensive anesthesia care (general anesthesia, procedure-related sedation, and regional techniques) in collaboration with the supervising anesthesiologist who is directly available during the entire course of anesthesia at all LLUMC and LLUMC affiliated sites;
  • Partners with anesthesiologist to determine age-specific (neonatal through later adult) anesthesia plan and obtains approval for anesthesia plan from anesthesiologist prior to induction;
  • Communicates effectively with anesthesiologist to ensure course of anesthesia is adjusted based on the patient’s need and changing condition throughout anesthetic episode;
  • Applies theoretical concepts to clinical practice and continually expands knowledge base and clinical skills with a focus in anesthesia care;
  • Utilizes discretion and independent judgment in the delivery of whole-person care;
  • Practices within the CRNA scope of practice and follows LLUMC policies, protocols, techniques, guidelines, and state and federal regulations;
  • Utilizes interpersonal skills to maximize excellence in customer service, safe patient care, and professionalism;
  • Contributes to a work environment of caring and cooperation among a culturally diverse workforce and patient population. These services may be provided for both the LLUMC and LLUCH hospitals. Performs other duties as needed.
Completion of Registered Nursing (RN) program required. Graduate of Board of Registered Nursing approved American Association of Nurse Anesthetists program. Clinical experience providing anesthesia care as a CRNA or student registered nurse anesthetist within the last twelve months required. Learn more.
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CRNA II: Novant Health, Charlotte, North Carolina

Novant Health is seeking a CRNA to grow and develop within a professional setting. Team members utilize skills obtained through additional training, education and/or experience in the provision of anesthesia care to patients who present with complex and unique anesthetic requirements. Come join a remarkable team where quality care meets quality service, in every dimension, every time.

#JoinTeamAubergine #NovantHealth

Let Novant Health be the destination for your professional growth.

This position is located at our Center City Charlotte Orthopedic Hospital Location.

The schedule is a combination of 10- and 12-hour shifts, one day off per week. This position will cover 7 OR orthopedic suites and also cover a 7 OR outpatient surgery center (peds urology, peds general, outpatient ortho, GYN, robotic hysterectomies).

Highlights: No OB, No out of department, both facilities on the same floor located just down the hall from each other. Beeper call approximately 3 times per month. MDs currently do spinals/blocks. Weekend on-call cases urgent emergent only.

AANA dues paid, Current Reviews CE provided, paid education time, great benefits and retirement matching, surgical services bonus plan.

$15,000 Sign-on Bonus and Relocation Assistance!!

It is the responsibility of every Novant Health team member to deliver the most remarkable patient experience, in every dimension, every time. Learn more.

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Full-Time CRNA: Park Ridge Anesthesia Associates, Park Ridge, Illinois

Full-time CRNA position with a large stable Anesthesia group based out of Advocate Lutheran General Hospital. 3 12-hour shifts guaranteed 40hr W2 pay, No call, No weekends/Holidays, signing bonus, hourly rate plus time and a half, excellent benefits. Variety of cases including hospital and surgery center. New graduates welcome to apply. 6 weeks PTO. Ability to pick up extra shifts or work at other facilities if desired but not required. Learn more.
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How Does Your Career Grow?

Are you looking to further your career? CRNA Careers is a valuable resource to help you both in your job search and with your career advancement. It's more than a job board. CRNA Careers is where those searching for fulfillment, opportunity, and challenges go to find helpful career tips, search for jobs, and upload anonymous resumes to be found by recruiters and employers.

Here's how to grow your career on CRNA Careers:

  • Seek and find the best jobs in your industry.
  • Set up job alerts to be notified when the jobs you're looking for are posted on the site.
  • Upload your anonymous resume and allow employers to contact you.
  • Access career resources and job searching tips and tools.

Growing your career requires regular care and cultivation. CRNA Careers has the tools to move your career toward your goals. Learn more today!


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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.

Randomized Trial Comparing Early and Late Administration of Rocuronium Before and After Checking Mask Ventilation in Patients with Normal Airways

A randomized study examined whether the timing of neuromuscular blockade during general anesthesia induction influences the efficiency of mask ventilation and the time to tracheal intubation. Researchers in South Korea divided participants, all of whom had normal airways, into two cohorts. The 58 patients in the "early" group received intravenous rocuronium before a check of mask ventilation, while administration was delayed in the 56 patients making up the "late" group until after confirmation of mask ventilation. The primary outcome was the average of mask expiratory tidal volumes measured at 10-second intervals for the first minute after apnea during mask ventilation. The average proved to be greater in the early group than in the late group, signaling greater efficiency. The main secondary endpoint—time from apnea to tracheal intubation—also favored early administration of rocuronium, which took only 116 seconds compared to 195 seconds with late administration.

From "Randomized Trial Comparing Early and Late Administration of Rocuronium Before and After Checking Mask Ventilation in Patients with Normal Airways"
Anesthesia & Analgesia (08/19) Vol. 129, No. 2, P. 380 Min, Se-Hee; Im, Hyunjae; Kim, Bo Rim; et al.

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Effects of Peri-operative Intravenous Administration of Dexmedetomidine on Emergence Agitation After General Anesthesia in Adults

Chinese researchers undertook a meta-analysis of 12 randomized controlled studies in an effort to better understand the effect of dexmedetomidine on emergence agitation (EA) and other outcomes following general anesthesia. The included trials involved 824 adult participants, who received either intravenous dexmedetomidine perioperatively or placebo. The main endpoint was occurrence of EA, which the evidence showed was curtailed by dexmedetomidine, which also appeared to reduce the need for analgesia. However, patients receiving it also took more time to extubate and were more likely to develop hypotension. Other secondary recovery outcomes—including length of stay in the post-anesthesia care unit, postoperative residual sedation, bradycardia, and postoperative nausea and vomiting—were not meaningfully different between the two groups.

From "Effects of Peri-operative Intravenous Administration of Dexmedetomidine on Emergence Agitation After General Anesthesia in Adults"
Drug Design, Development and Therapy (08/15/19) Vol. 13, P. 2853 Zhang, Jian; Yu, Yang; Miao, Shuai; et al.

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UW Study Indicates Brain Bounces Back After Anesthesia

Despite what patients fear, a study led by the University of Wisconsin concludes that general anesthesia has only a slight effect on cognitive function. Researchers worked with more than 7,500 U.K. patients between the ages of 45 and 69, each of whom was hospitalized for two or more days following major surgery. In collaboration with scientists in London and Paris, they tested participants' cognitive abilities—using word recall, verbal ability, and mathematical logic—over the course of 19 years. Taking into account the natural deterioration that chips away at mental stamina starting in middle age, the team found the decline too small to be measured in individual patients. Across the sample, however, the researchers equated the deterioration to an average five months of brain aging. By comparison, primary investigator Robert Sanders, MD, of UW-Madison says stroke is associated with brain impairment in the range of 1 to 13 years of cognitive decline. The findings are reported in BMJ.

From "UW Study Indicates Brain Bounces Back After Anesthesia"
Wisconsin Public Radio (08/12/19) Mills, Shamane

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Usefulness of Intraoperative Neuromuscular Blockade Monitoring and Reversal Agents for Postoperative Residual Neuromuscular Blockade

Researchers in Argentina explored the role of patient monitoring and antagonist use in the occurrence of residual neuromuscular blockade (RNMB) after surgery. The retrospective, single-site study captured 240 consecutive patients who underwent NMB between June and December 2015, with or without intraoperative monitoring. All patients were subject to monitoring, however, after being admitted to the post-anesthesia care unit (PACU). Researchers documented RNMB in just 1.6 percent of patients who received quantitative NMB monitoring in the operating room, versus nearly a third of patients who did not. In addition, patients managed with sugammadex—as opposed to neostigmine—as a reversal agent were less likely to present with RNMB. The results indicate that intraoperative quantitative NMB monitoring and use of sugammadex reduce the incidence of RNMB in the PACU. The investigators back the argument that RNMB can be avoided by using quantitative monitoring in the operating theatre and eventually using reversal agents, as necessary, prior to anesthesia emergence.

From "Usefulness of Intraoperative Neuromuscular Blockade Monitoring and Reversal Agents for Postoperative Residual Neuromuscular Blockade"
BMC Anesthesiology (08/07/19) Vol. 19, No. 153 Domenech, Gonzalo; Kampel, Matías A.; García Guzzo, María E.; et al.

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Factors Associated with Spinal Anesthesia Failure During Hip, Knee Joint Arthroplasty Identified

Findings from a retrospective review provide insight into predictors of spinal anesthetic failure during knee and hip replacement. Investigators reviewed 3,542 cases of spinal anesthesia in this setting, including 135 times when delivery failed due to cerebrospinal fluid flowing back through the spinal needle. The analysis identified younger age and lower body mass index—but not height—as patient characteristics associated with risk of spinal anesthetic failure. The likelihood of failure was also greater when needle insertion occurred in the L4-5 space rather than at L2-3, when a 22-gauge needle was used instead of a 25-gauge needle, and with the use of hyperbaric versus isobaric bupivacaine. Additionally, patients undergoing hip arthroplasty appeared to be more vulnerable than patients having knee replacement surgery. “Further studies are needed to elucidate the reasons for these associations and the strategies to reduce the incidence of spinal failure,” noted the researchers, who reported their results in Anesthesia & Analgesia.

From "Factors Associated with Spinal Anesthesia Failure During Hip, Knee Joint Arthroplasty Identified"
Clinical Pain Advisor (08/06/19) May, Brandon

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Combined Ultrasound and Nerve Stimulator-Guided Deep Nerve Block May Decrease the Rate of Local Anesthetics Systemic Toxicity

Researchers studied how often local anesthetics systemic toxicity (LAST) occurs during deep nerve block of the lower extremity when performed under ultrasound guidance versus nerve stimulator guidance. The team from China also was interested in identifying risk factors associated with the complication. They randomized 300 patients to lumbar plexus block (LPB) or sciatic nerve block (SNB) with ultrasound guidance, nerve stimulator guidance, or dual guidance. The main outcome was incidence of LAST, which was documented in a total of 18 patients. The 12 percent occurrence rate was significantly higher in the ultrasound group compared with rates of 4 percent and 2 percent, respectively, in nerve stimulator group and the dual group. Risk factors associated with LAST in the setting of LPB and SNB, aside from ultrasound guidance, included female gender and presence of hepatitis B infection. The researchers, reporting in BMC Anesthesiology, recommend the use of ultrasound and nerve stimulator guidance together for these at-risk populations.

From "Combined Ultrasound and Nerve Stimulator-Guided Deep Nerve Block May Decrease the Rate of Local Anesthetics Systemic Toxicity"
Medscape (08/02/19)

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News summaries © copyright 2019 SmithBucklin

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.

If you are interested in advertising in Anesthesia E-ssential contact HealthCom Media at 215-489-7000.

For more information on AANA and Anesthesia E-ssential, contact:

222 S. Prospect Avenue
Park Ridge, IL 60068
Phone: (855) 526-2262 (toll-free)/(847) 692-7050
Fax: (847) 692-6968

Attn: Cathy Hodson
E–ssential Editor
August 22, 2019