AANA Anesthesia E-ssential, December 20, 2018
 
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Open Comments for Analgesia and Anesthesia for the Substance Use Disorder Patient

The AANA has posted another document for open comment. Analgesia and Anesthesia for the Substance Use Disorder Patient is a new document which offers practice considerations for the anesthesia professional to provide safe care of the patient with substance use disorder. The open comment period closes on Jan. 10, 2019.

To guide your review and response, please consider the following:
  • Are there any gaps in the document?
  • Is the information described reflective of current practice?
  • Are there any unintended consequences that may occur as a result of this document?
  • Are there other relevant resources to include in the document?
Comments can be submitted directly to practice@aana.com.
  • Include the line number when making comments.
  • Phrase changes as statements, rather than questions, and suggest alternative language.
  • Provide a rationale for changes and cite literature or other evidence to support the change.

Additionally, the Standards for Nurse Anesthesia Practice and Guidelines for Core Clinical Privileges for Certified Registered Nurse Anesthetists are currently available for open comment. More information can be found on the AANA Open Comments webpage.

We appreciate your time, expertise and feedback in the review of practice documents.
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Season's Greetings! and Anesthesia E-ssential Publishing Schedule

The staff at the American Association of Nurse Anesthetists (AANA) would like to wish everyone a very safe and happy holiday season!

The Anesthesia E-ssential will not be published on Dec. 27 or Jan. 3, but will return on Thursday, Jan. 10, 2019, with more news about what is important in the world of nurse anesthesia. We also will feature an article on the Top 10 news items you may have missed in 2018.

The AANA will be closed Dec. 24, 2018-Jan. 1, 2019.* AANA will re-open for business on Wednesday, Jan. 2, 2019.

*AANA Insurance Services has different closure dates. Please see next item.

See you in 2019!


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AANA Insurance Services Holiday Hours

Just a reminder that AANA Insurance Services will be closed Dec. 24-26, Dec. 31-Jan. 1. However, we will be open Thursday, Dec. 27 and Friday, Dec. 28.

At any time, you can view your individual policy, or download and print a copy of your certificate of insurance by visiting AANA.com/Insurance and navigating to the My Policy tab.

We wish you the happiest of holidays and health, happiness, and success in the coming year!
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Hot Topics


Be Safe and Well this Holiday Season!

AANA, the AANA Peer Assistance Advisors Committee and the AANA Health & Wellness Committee wish you and your families all the best this holiday season! Take this time to catch up on sleep, be physically active, avoid germs, help those in need, and celebrate in moderation.

This time of the year may not be a joyous occasion for everyone and can increase stress and create emotional unbalance. Maintaining wellness and proper self-care is vital. The holiday season, and winter in general, is especially difficult for anyone facing seasonal depression, emotional crisis, or recent loss; challenging to those in recovery to maintain sobriety; perilous for those contemplating suicide and battling active addictions. Seek help and support - talk to a loved one, your healthcare professional or clergy. Other available options may include access to a workplace employee assistance program or university counseling services.

Remember, there is always help available:
  • Drugs or alcohol concerns, call the AANA Peer Assistance Helpline for 24/7 confidential live support and resources: 800-654-5167
  • Suicidal thoughts, American Foundation for Suicide Prevention Hotline: 800-273-TALK
  • Sexual assault, RAINN National Sexual Assault Hotline: 800-656-4673
  • When life threatening or potential for immediate risk or harm to self or others, call 911
See also: Holiday Tips from Anesthetists in Recovery (AIR).
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Seeking Candidates for Delegate to the Education Committee

The AANA Education Committee is seeking candidates who are interested in serving on the committee as a Delegate. The deadline for receiving completed candidate packets is Jan. 7, 2019. The election will be held, and the winner announced at the Assembly of Didactic and Clinical Educators (formerly called the Assembly of School Faculty) meeting in February 2019.

Delegates must be CRNAs who spend at least 50 percent of their time in the didactic and/or clinical instruction of nurse anesthesia students at the time of application. During their tenure on the committee, they must:
  • Be continuously involved in the didactic and/or clinical instruction of nurse anesthesia students.
  • Attend the February Assembly of Didactic and Clinical Educators and Nurse Anesthesia Annual Congress during both years of their term.
  • Attend Education Committee meetings and conference calls for the two-year term which begins immediately following the AANA Annual Congress in the year elected.
The candidate information packet is available on the AANA website under CE & Education, Opportunities for Educators. Questions? Contact the Education department at 847-655-1161 or education@aana.com.
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Attention State Presidents! Nomination Deadline for Daniel D. Vigness Federal Political Director Award is Jan. 15

Is your state's Federal Political Director (FPD) awesome? Then nominate her or him for the Daniel D. Vigness Federal Political Director Award, which will be presented during the AANA Mid-Year Assembly in April 2019.

Named for the late Dan Vigness, CRNA, of South Dakota, who was also the first recipient of the AANA Federal Political Director of the Year Award in 2001, this honor recognizes a CRNA who has been involved in federal political campaigns, developed close working relationships with federal officials, led successful CRNA advocacy efforts, helped contribute and raise funds for the CRNA-PAC, and helped recruit CRNAs to participate in political campaigns. Learn more and submit a nomination through the AANA website. Deadline is Jan. 15, 2019
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The Joint Commission Issues Sentinel Event Alert: Developing Reporting Culture to Improve Health Care Safety Systems

Sentinel Event Alert #60 - Developing a reporting culture: Learning from close calls and hazardous conditions, together with the infographic, The 4 Es of a Reporting Culture, guides healthcare organizations and leaders in establishing a psychologically safe environment for reporting. It addresses eliminating fear of adverse repercussions for reporting mistakes and urges learning from “close calls” in patient care. Reporting “close calls” provides critical information on persistent and potential weaknesses in healthcare safety systems. Recommendations from the Sentinel Event Alert include:
  • Reviewing the alert and The Joint Commission’s Sentinel Event Alert #57 - The essential role of leadership in developing a safety culture for basic guidance and resources.
  • Communicating leadership commitment to building trust and reporting through a safety culture.
  • Developing a system that encourages reporting incidents, including close calls and hazardous conditions.
    • Integrating a recognition program in the system, such as a “good catch” system.
    • Giving the staff feedback to show that action is being taken to address or fix the identified issue and to provide quality improvement education.
    • Eliminating fear of punishment so that organizational learning and quality improvement can occur.
    • Consoling those making a human error.
    • Coaching those responsible for at-risk behavior.
    • Fairly and equitably disciplining those committing reckless acts.
    • Holding all, regardless of position, to the same standards.
  • Examining data to identify:
    • Error-prone situations, including their frequency and severity.
    • Successes of the staff and system.
    • Issues needing addressing, systems needing strengthening, and contributing factors for staff education.

The Alert includes resources, such as examples of objective accountability evaluation/assessment tools and decision trees for distinguishing between human errors and at-risk or reckless actions and examples of videos explaining a just reporting and learning culture. 

As with all Joint Commission Sentinel Event Alerts, Joint Commission-accredited facilities should consider this information when designing or redesigning processes and should consider implementing relevant suggestions or reasonable alternatives.

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Now available! 2019 CRNA Week Social Media Graphics

Get ready to share your passion for your profession on Jan. 20-26, 2019! With CRNA Week just around the corner, you can start to spread the word that “Every Breath, Every Beat, Every Second – WE ARE THERE!” 

Help educate America about the important work CRNAs do every day, for every patient. We’ve created social media graphics that you can download to use on your personal and professional Facebook, Twitter, and Instagram pages.

Be sure to add the following hashtags to your post: #CRNAWEEK and #WEARETHERE. Also, don’t forget to tag your state legislators and hospital administration (example: @senatorjohndoe) and @aanawebupdates.
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NewsMaker: CRNA Jeff Scheidt Mentors Daughter on Medical Trip to Kenya

Jeff Scheidt, CRNA, and his daughter, Megan, a senior in high school, went to Kenya, Africa, last month for an 11-day medical mission with Kenya Relief. "Jeff was a part of 60-plus surgeries, and Megan was right there in the operating room with him, helping out however possible despite no medical experience," reports the LaCrosse Tribune. Read more.
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NewsMakers: CRNAs Donate $10,000 to Pennsylvania Ronald McDonald Houses

The Pennsylvania Association of Nurse Anesthetists (PANA) is donating $10,000 to Ronald McDonald House Charities in Pennsylvania to help families with housing near a hospitalized child. The grant will support each of the houses in Danville, Hershey, Pittsburgh and Scranton, and both houses in Philadelphia. Read more.



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December 2018 AANA Journal Highlights

Editor-in-Chief Chuck Biddle, PhD, CRNA, spotlights articles of interest in the December 2018 issue of the AANA Journal:

Understanding Bone Cement Implantation Syndrome (BCIS), offers valuable, state-of-the-art clinical information about a complication of a select group of orthopedic procedures. BCIS is often seen, though its mechanisms and preventive strategies may not be well appreciated. Read this excellent paper and you will be in the know.

In the paper, Complications Related to Laryngeal Mask Airway Use and a Postoperative Diagnosis of Reinke Edema: A Case Study, the authors describe a case of airway difficulty in a patient with an LMA. Reinke edema, a complication of the glottic structure, is well described, but rarely encountered. The astute management of this case demonstrates the importance of being a well-read, thoughtful practitioner.

A Certified Registered Nurse Anesthetist’s Transition to Manager describes the evolution of the CRNA manager. Barriers, strategies that tend to work, and other elements of career transition are expanded upon in this interesting, and unique contribution to our literature.

Using a standardized and widely respected tool, the authors in their paper, Methylene Blue as an Adjunct to Treat Vasoplegia in Patients Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass: A Literature Review, detail the use of methylene blue in treating refractory hypotension as a result of vasoplegia. The pathway involves the unique role of the inorganic molecule nitric oxide and provides important clinical treatment information that enhances patient care in the operating room.

More clinical insight and patient safety information is provided with yet another paper emerging from the AANA’s Closed Claims Team work. This paper entitled, Thematic Analysis of Obstetric Anesthesia Cases From the AANA Foundation Closed Claims Database, makes for uncomfortable (bad outcomes prevail) but absolutely invaluable insight into how catastrophic outcomes can occur in obstetrical anesthesia practice, taxonomizing the complex mechanisms into four discrete categories with which many readers will identify.

Mobile Computing Devices in the Perioperative Environment: A Survey Exploring Uses and Experiences Among Certified Registered Nurse Anesthetists explores an important domain of controversy in our current practice environment. The work is important, as it illuminates a currently poorly studied area of our clinical work life. This is essential reading for those who do, and do not, use mobile devices in the workplace.

Ultrasound guided regional anesthesia is now a foundational component of patient care. The application of the TAP block, increasingly used as part of the surgical pain relief is explored in the article entitled, Implementation of an Education Program for an Ultrasound-Guided Liposomal Bupivacaine Transversus Abdominis Plane (TAP) Block Protocol for Open Abdominal Procedures. The paper particularly critiques the use of liposomal bupivacaine with the TAP block procedure.

Those interested in the multimodal pain management (as we all should be) will find intriguing reading in this article, Intravenous Dexamethasone as an Analgesic: A Literature Review. Dexamethasone is a fascinating drug, recently widely embraced in anesthetic practice as a sedative agent, with intriguing properties that suggest it has analgesic actions or perhaps as an opioid-sparing agent, preventing hyperalgesic-related phenomena.

Each issue of the AANA Journal offers members an opportunity to earn valuable continuing education credit with cutting edge information. This issue’s offering, Update for Nurse Anesthetists—Cryoneurolysis for the Treatment of Sensory Nerve Pain, describes a minimally invasive and nonpharmacological approach with a proven track record in dealing with certain types of acute and chronic pain. Don't forget you may take the Journal Course online through AANA Learn for 1 Class A CE Credit.

The AANA Journal provides online-exclusive work with each issue. The current offering includes Education News, Hippocrates to Nightingale: Converging or Diverging Concepts in Patient Management and Decision Making; and a Letter to the Editor, Prevention of Prospective and Current Certified Registered Nurse Anesthetist Second Victims. Also, don’t forget to check out the 2018 Index of Volume 86 of the AANA Journal.
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Meetings and Workshops


Improve Your Business Acumen with AANA/IAS Anesthesia Business Seminars

If you’ve ever dreamed of owning or expanding your own anesthesia practice, you know it’s hard to find trusted resources. AANA members can now get valuable insights from two highly successful CRNAs. Larry Hornsby, BSN, CRNA, and Juan Quintana, DNP, MHS, CRNA, will guide you through an eight-week online seminar that will give you the skills and confidence to grab the brass ring.

Earn 16 Class A CE credits and get one-to-one feedback. From developing request for proposal (RFP) responses to increasing your negotiation skills, you’ll get a personalized experience that you can’t get anywhere else. Choose a Winter or Spring course. Learn more.
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Foundation and Research


AANA Foundation: Support Nurse Anesthesia Research and Education
Make Your Tax-Deductible Year-End Donation Today!

It’s the season of giving. Help us strengthen the nurse anesthesia profession by supporting the AANA Foundation’s Annual Fund and the RISE Above campaign. Make your gift today by visiting the Foundation’s secure donation page. To maximize your 2018 tax benefits, please submit your gift no later than December 31, 2018.

The AANA Foundation is grateful for your support this year and would like to wish you and yours a very happy holiday season!
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Federal Government Affairs


Interested in Serving on the CRNA-PAC Committee? Applications are due Jan. 31

CRNAs and SRNAs interested in serving on the CRNA-PAC Committee beginning in the 2020 AANA fiscal year are encouraged to submit an application by Jan. 31.

Responsibilities of Committee members include:
  • Setting the CRNA-PAC income and expenditure policy;
  • Participate in fundraising duties;
  • Reviewing open-seat and challenger candidates for federal office; and
  • Volunteering at CRNA-PAC events and national meetings.
Committee members are expected to attend two in-person meetings per year (Joint Committee Conference in August/September and Mid-Year Assembly in April) and conference calls on an as-needed basis. Read the full job description.

Applications should be submitted to Mary Scheuermann at committees@aana.com by Jan. 31, 2019. (Students, please see specific criteria and instructions here). The full slate of candidates will be approved for nomination by the AANA Board of Directors at the Assembly of Didactic and Clinical Educators in February, and new members will be elected by the CRNA-PAC Committee at Mid-Year Assembly.

If you have any questions, please contact Catharine Harris, AANA Associate Director of Political Affairs, at charris@aanadc.com or call (202) 741-9087.



The following is an FEC required legal notification for CRNA-PAC: Gifts to political action committees are not tax deductible. Contributions to CRNA-PAC are for political purposes. All contributions to CRNA-PAC are voluntary. You may refuse to contribute without reprisal. The guidelines are merely suggestions. You are free to contribute more or less than the guidelines suggest, and the association will not favor or disadvantage you by reason of the amount contributed or the decision not to contribute. Federal law requires CRNA-PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. Each contributor must be a U.S. Citizen.
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AANA Member Benefits


Nationwide
What Do You Know About the Shortest Day of the Year?

The winter solstice is the shortest day and longest night of the year in the Northern Hemisphere. Check out these 10 things you may not know about it!

December Winter Solstice
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Jobs


CRNA: St. Vincent Anderson Regional Hospital, Anderson, Indiana

St. Vincent has an opportunity for a full-time Certified Registered Nurse Anesthetist at St. Vincent Anderson Regional Hospital! Learn more.
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CRNA Jobs: Locum Tenens and Permanent Placement Opportunities Across the Country

United Anesthesia – Various Locations. United Anesthesia has been a leading CRNA and Anesthesiologist Locum Tenens and Permanent Placement firm in the country for 40 years. By specializing in only anesthesia placement, we can partner with you to find the ideal situation to suit your strengths, your priorities, your dreams. Your dedicated personal coordinator is looking forward to your call! Learn more.
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CRNACareers

Looking to Grow Your Career?

Visit CRNA Careers today, the official career center of the AANA. Job searching that is catered to meet your needs. Here's what we offer:

  • The Best CRNA Jobs: Connecting you to top employers in anesthesia.
  • Targeted Email Alerts: You can automate your search by setting up email alerts that match your criteria. Plus, search through CRNA positions that fit your needs.
  • Post Your Resume Anonymously: You're in control. Make your profile confidential and respond to employers with the best opportunities.

Start Your Search 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.

OR Handovers, Particularly During Long Surgeries, Increase Post-op Adverse Outcomes

An analysis shed new light on the relationship between intraoperative handovers between anesthesia providers and adverse postoperative outcomes while also confirming previous findings. Researchers looked at data from more than 114,000 adults who underwent operations at Harvard Medical School between 2007 and 2015. A total of 11.4 percent of the sample developed adverse events, defined as a composite of 30-day mortality, readmission, and serious postoperative complications. A meaningful association was found between anesthesia handovers during surgery and poor postoperative outcomes. There was a meaningful correlation between intraoperative handovers between anesthesia providers and all three components of the primary endpoint. "So, we were able to confirm the finding of [an earlier study], showing that handovers are indeed associated with adverse patient outcomes in an adjusted model," said researcher Paul Rostin. Meanwhile, data related to secondary objectives indicated that the unfavorable effects are worsened during operations lasting longer than 150 minutes and during transfers between less experienced practitioners. "We looked into handovers among CRNAs and residents, and found very similar associations," Rostin explained at the 2018 annual meeting of the American Society of Anesthesiologists. "We also found that handovers are a bidirectional issue: There are two people involved, and the experience level of both people matters." Rostin and his colleagues believe that hospitals should adopt local guidelines that consider the various risk factors to ensure that anesthesia handovers do not put patients at risk.

From "OR Handovers, Particularly During Long Surgeries, Increase Post-op Adverse Outcomes"
Anesthesiology News (12/14/18) Vlessides, Michael

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New Guidance Outlines Recommendations for Anesthesiology-Related Infection Prevention and Control

The Society for Healthcare Epidemiology of America (SHEA) has produced infection-prevention guidance that specifically targets the anesthesia work area in operating rooms. A correlation has been shown between contamination of anesthesia equipment and healthcare-associated infections that can put patients in danger. "Even though the demands on anesthesia providers make infection prevention best practices more challenging, there are opportunities for improvement," says lead author Silvia Munoz-Price, MD, PhD. "We describe how the anesthesiology team and hospital leaders can optimize infection prevention in operating room anesthesia, and we give suggestions for the future, including the need for better equipment design." Among the recommendations, SHEA advises double-gloving during airway management; cracking down on hand hygiene, with strategic placement of alcohol-based hand sanitizer dispensers; disinfecting reusable laryngoscope handles or switching to single-use laryngoscopes; disinfecting keyboards, monitors, and other high-touch surfaces on anesthesia machines; and adopting single-use syringes and vials for intravenous drug administration. SHEA drafted the guidelines with input from representatives of the American Association of Nurse Anesthetists, the American Society of Anesthesiologists, and the Anesthesia Patient Safety Foundation.

From "New Guidance Outlines Recommendations for Anesthesiology-Related Infection Prevention and Control"
Infection Control Today (12/11/18); et al.

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VA Uses Ketamine to Treat PTSD Effectively

As ketamine gains momentum in the treatment of depression, even the federal government is buying into the concept. A two-year-old program at the San Francisco Veterans Affairs Medical Center offers ketamine infusions to military veterans who suffer from post-traumatic stress disorder and depression but have not responded to first, second, and third lines of treatment. Tobias Marton, who runs the center's ketamine infusion program, says results with the drug—which is approved only as an anesthetic and pain reliever—have been "impressive." Cautious uptake of the treatment by VA comes nearly two decades after ketamine first emerged as a potential option for treating mental health disorders. According to Marton, efforts are underway to shift the therapy from off-label status to a sanctioned use. He says a company is working toward Food and Drug Administration approval of an intranasal ketamine product, with a decision from the regulator expected around March of next year. If it gets a stamp of approval, Marton says other VA clinics in rural communities would likely start offering ketamine treatments, too.

From "VA Uses Ketamine to Treat PTSD Effectively"
Eureka Times-Standard (California) (12/14/18) Santos, Philip

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Exparel May Improve Economic, Clinical Outcomes After TKA

New evidence points to benefit from using liposomal bupivacaine (Exparel) for knee replacement surgery. Researchers compared outcomes in tens of thousands of patients who underwent total knee arthroplasty (TKA) with Exparel with a propensity-matched cohort who had the same procedure without liposomal bupivacaine. The hospitalization period for the Exparel group was abbreviated by 0.6 of a day compared to the controls, and these patients also were 1.6 times more likely to be discharged home. In addition, recipients of liposomal bupivacaine incurred lower total hospitalization costs for their procedure and used fewer opioids. "Our analysis shows the utilization of Exparel supports optimized patient outcomes after TKA procedures, allowing for hospitals to provide high-quality care while controlling costs," says lead researcher Carl V. Asche, PhD. The findings appear in the Journal of Medical Economics.

From "Exparel May Improve Economic, Clinical Outcomes After TKA"
Healio (12/11/2018) Tingle, Casey

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National PDPH Rates, Clinical Practice Strategies Analyzed

Researchers conducted a large-scale analysis of data on postdural puncture headache (PDPH) after epidural in the United States. Using 2008-2015 claims information on more than 1.75 million deliveries, they studied the rate of neuraxial labor analgesia for vaginal delivery and the rate of PDPH after neuraxial anesthesia/analgesia. Investigators also tracked rates of single and multiple epidural blood patch placement—the first-line treatment for PDPH—and the rate of PDPH follow-up care within 90 days. The data revealed that nearly three-quarters of patients who had vaginal deliveries received neuraxial anesthesia, with use of the technique growing over the study period. PDPH occurred at a rate of 0.59 percent after neuraxial analgesia, whether for vaginal childbirth or cesarean section, with a downward pattern emerging between 2008 and 2015. Among women who developed PDPH, meanwhile, 62.2 percent were treated with epidural blood patch and 10.6 percent sought follow-up care. Overall, the research dovetails with results from earlier, smaller investigations, with a couple of surprise discoveries. "These findings support what has been described in the literature in terms of incidence rate of PDPH and epidural blood patch," said Carlos Delgado, MD, an assistant professor of anesthesiology and pain medicine at the University of Washington in Seattle. "We found it quite interesting that 60% of women with PDPH required a blood patch, but 40% required just conservative care. Interestingly enough, we saw a decreased incidence of repeat blood patches compared to the literature, which likely represents academic practices or are linked to efficacy." He presented the research at the 2018 annual meeting of the International Anesthesia Research Society.

From "National PDPH Rates, Clinical Practice Strategies Analyzed"
Anesthesiology News (12/11/18) Vlessides, Michael

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The Military Pushed It for the Battlefield. FDA Went Along. Is the Newest Opioid Any Better?

The Food and Drug Administration's (FDA) recent approval of a sufentanil sublingual tablet, marketed under the brand name Dsuvia, has sparked heavy debate. Critics wonder why regulators would approve a product 10 times stronger than fentanyl at a time when the country is already struggling to address opioid addiction, abuse, and overdose. They worry that the tiny size of the tablets—useful when a patient has trouble swallowing or intravenous placement is cumbersome—could facilitate diversion for misuse. The FDA believes that Dsuvia's calibrated dosing and the fact that it cannot be obtained from pharmacies will counter that risk. It also appears to agree with the U.S. military's perspective: that Dsuvia may provide tremendous benefit in combat zones. A deeper look at the data underpinning this belief, however, raises questions about the drug's use on the battlefield. While a key study found that the first signs of pain relief with Dsuvia materialized in abdominal surgery patients after just 15 minutes, lesser-reported data clocked the time to meaningful relief at almost 1 hour. "You want to be able to control pain very quickly in these types of patients and it doesn’t appear we’re seeing that in the data,” says Dr. Gregory Sugalski, vice chair of clinical operations at the Department of Emergency Medicine at Rutgers New Jersey Medical School. Still, he adds, it could be another tool in the military's medical arsenal and prove useful in some scenarios. "It might be enough to take the edge off when transporting someone, but it may not be enough for big injuries — amputations, gunshot wounds," Sugalski says.

From "The Military Pushed It for the Battlefield. FDA Went Along. Is the Newest Opioid Any Better?"
STAT (12/11/2018) Silverman, Ed

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News summaries © copyright 2018 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:

AANA
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
chodson@aana.com
December 20, 2018
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