Anesthesia E-ssential

AANA Anesthesia E-ssential
CRNA Week 2018

Vital Signs

Modern Healthcare: Advanced Practitioners Oppose AMA Effort to Limit Their Practice Authority

AANA President Bruce Weiner, DNP, MSNA, CRNA, spoke with Modern Healthcare about the American Medical Association (AMA) resolution to limit practice authority for non-physician healthcare providers. Read his comments in the Dec. 14, 2017, article, which discusses the push by advanced practice nurses to convince the AMA to rescind a recent decision to launch a campaign focused on limiting independent practice of non-physician practitioners across state lines. 
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Hot Topics

Off-duty CRNA Comes to Aid of Derailed Amtrak Train Passengers

Major Michael Livingston, CRNA, was off-duty from his anesthesia responsibilities at Madigan Medical Center in Tacoma, Wash., when the Amtrak train derailment happened on Dec. 19, 2017.

Livingston was on highway I-5, about 100 yards from the derailment, on his way to Lacey, Wash., with his daughter for a tour of a prospective high school. 
Livingston pulled his car over to the side of the road, and went to see if anyone needed help. With one of the train cars dangling from the bridge above I-5, “I just know that people needed help,” said Livingston at a local press conference. “These could have been our neighbors, people that we knew. I didn’t know that this was an inaugural train run. It was a train on I-5…how can I do something systematic and be beneficial to these people? You only think about ‘What can I do as fast as I can to help?’” 
He describes his experiences in helping to evacuate people from the dangling train car and the surrounding area in a local press conference video.
Other first responders who speak in the video include Lt. Robert McCoy and Lt Col. Chris Sloan. Sloan is the deputy commander of administration at Madigan Medical Center. All three are trained in crisis response.
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Happy Holidays—And See You Next Year!

Due to the holidays, Anesthesia E-ssential will not come out on Dec. 28, 2017, and will resume publication with the Jan. 4, 2018, issue. The E-ssential staff wishes all of our readers a joyous holiday season, and we look forward to serving you in 2018.
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CPC Program Two-Year Check-In Opens April 2018

The CPC Program two-year Check-in window will be open between April – July 2018 for those that recertified or originally certified in 2016. This is your next step in the CPC Program. What does this involve? It will be simple and quick, and include pre-populated fields for confirmation. By checking in, you will confirm current licensure and practice, update contact information, pay the same fee as in the past for the upcoming two years of certification, and check your CPC Program compliance progress (Class A, B, and optional Core Modules). 

Reminders will be sent with a link to the check-in portal. Regular updates on the two-year Check-in to ensure a seamless process are scheduled. Visit NBCRNA.COM/CPC for CPC Program resources, videos, a toolkit, and more information.
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ATTN 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 him or her for the Daniel D. Vigness Federal Political Director Award, which is presented during AANA Mid-Year Assembly in April 2018. Named for the late Dan Vigness, CRNA, of South Dakota, the first AANA FPD of the Year, 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 to submit a nomination.
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Call for Candidates: Delegate to Education Committee

The AANA Education Committee is seeking candidates interested in serving on the committee as a delegate. The deadline for receiving completed candidate packets is Jan. 15, 2018. The election will be held, and the winner announced, at the Assembly of School Faculty in February 2018.
The candidate information packet is available on the AANA website.
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Avoid a MIPS 2017 Penalty – Submit by Dec. 31

Eligible Clinicians (ECs) have until Dec. 31, 2017, to submit the minimum of one quality measure and one improvement activity in order to avoid an automatic 4 percent penalty on the 2019 Merit-based Incentive Payment System (MIPS) payment year. 
ECs may choose any measures, for any patient for 2017 in order to avoid a negative payment adjustment on their 2019 Medicare reimbursement. While there is no longer the opportunity to receive a payment bonus for 2017 performance, there is still time for providers to avoid the -4 percent penalty on their 2019 Medicare reimbursement by reporting data on at least one measure, one time, for at least one patient during the 2017 performance year. ECs who report at least one quality measure or improvement activity for a minimum of one patient by Dec. 31, 2017, will see a neutral payment adjustment in 2019. Take action now! The American Medical Association provides a useful video on how to submit your data in 2017.
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FDA Warns of Misbranding and Undeclared Drugs in Products that are Used as Street Drug Alternatives

The FDA has issued a warning letter to marketers and distributors of Legal Lean Syrup, a drink; and Coco Loko, a “snortable” chocolate powder; for selling unapproved new drugs and misbranded drugs. These products are being promoted as alternatives to illicit street drugs, claiming to mimic the effects of recreational drugs and affect a patient’s psychological state (e.g., to get high, to promote euphoria, or to induce hallucinations).

Coco Loko is described as a “snuff” to be snorted. Intranasal administration of a powder substance can trigger laryngospasm or bronchospasm and may also induce or exacerbate asthma. Coco Loko also includes taurine and guarana, neither of which have been evaluated for intranasal administration.
The FDA determined that Legal Lean Syrup contains doxylamine, which was not included in the product labeling, placing those who have been advised not to use or who have had adverse reactions at risk. 
During the preanesthesia assessment, anesthesia professionals ask the patient about their current medication history, which includes but is not limited to street drug alternatives, recreational drugs, and herbal supplements in addition to prescribed medications. Awareness of new medications, over the counter and street drugs, that a patient may be taking allows anesthesia and healthcare professionals to develop the unique patient specific plan of care to address all considerations necessary for patient safety and optimal outcome.
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The Joint Commission Issues Report Detailing Rationale and References for New and Revised Pain Standards

Effective Jan. 1, 2018, all Joint Commission-accredited hospitals must comply with new and revised pain assessment and management standards.

The Joint Commission has issued an R³ Report that provides the in-depth rationale and references used for the new requirements.  These requirements include identifying pain assessment and management, as well as safe opioid prescribing, as an organizational priority, actively involving medical staff in leadership roles in performance improvement activities, minimizing risks associated with treatment, collecting data to monitor performance, and analyzing the data.  The R3 Report also explains the process to develop the requirements, including an extensive literature and field review, learning visits at hospitals, and use of a technical advisory panel and a standards review panel.  
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Professional Practice

The Joint Commission Releases FAQs on New Pain Management Standards

The Joint Commission posted 10 responses to frequently asked questions (FAQs) addressing issues raised by its newly revised pain management standards, effective Jan. 1, 2018.

The responses address resources for staff education, leadership engagement, options for non-pharmacologic pain treatment modalities, facilitating Prescription Drug Monitoring Program access, identification of opioid treatment programs, patient education, pain assessment, and other requirements.   
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Diagnostic Testing Can Screen for Perioperative Myocardial Injury

Perioperative myocardial injury (PMI) refers to asymptomatic heart damage that can happen during or soon after any type of surgery.  The condition is easily missed because most of the affected patients have no chest pain or other symptoms.  Dr. Christian Puelacher’s research team found that 1 in 7 high-risk patients developed PMI after a non-cardiac surgery.   A high-sensitivity troponin test specific for heart troponin has been used in Europe and elsewhere for several years, but has only recently been approved by the U.S. Food and Drug Administration earlier this year.  This new diagnostic tool that can help better screen at risk patients after anesthesia for asymptomatic heart damage.  Read more about Dr. Puelacher’s research.
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Meetings and Workshops

Register Now for the Assembly of School Faculty
Feb. 15 - 17, 2018
The Scottsdale Resort at McCormick Ranch

Registration is now open for the only forum that brings all nurse anesthesia educational programs together in one place to discuss and define the future of the profession. If you are passionate about nurse anesthesia education, the Assembly of School Faculty is the must-attend meeting of the year. Find out more, and register now!
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Registration for the AANA Mid-Year Assembly is Now Open!

Join us April 21-25, 2018, at the Grand Hyatt Washington for the most important CRNA advocacy meeting. The AANA Mid-Year Assembly prepares nurse anesthetists to effectively advocate on Capitol Hill for protecting and advancing CRNA practice and reimbursement. You'll get briefings on the important issues facing CRNAs and hear from seasoned political pundits on how to communicate effectively with the legislators who can support the nurse anesthesia profession. 
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Federal Government Affairs

Applications to serve on the CRNA-PAC Committee are due Jan. 31, 2018

Are you a CRNA or SRNA with a strong interest in furthering the nurse anesthesia profession through federal political advocacy? If so, we invite you to apply for a position on the CRNA-PAC Committee beginning in fiscal year 2019.

Responsibilities of Committee members include setting and overseeing the CRNA-PAC expenditure and income policy, determining funding of open-seat and challenger candidates, fulfilling duties at CRNA-PAC events and AANA national meetings, participating in fundraising activities, and attending in-person meetings at the Mid-Year Assembly and Joint Committee Conference. A full job description can be found here.
Interested candidates should submit an application to the AANA Executive Unit at by Jan. 31, 2018. Student applicants should submit a letter of permission from their program director along with their application. Additional criteria for student applicants can be found at
If you have any questions, please contact Catharine Harris, AANA Associate Director of Political Affairs, at or (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 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 our 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. All contributors must be US citizens.
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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.

Alternative Induction Techniques Can Reduce Redistribution Hypothermia

Inducing anesthesia with inhaled anesthetics instead of propofol can minimize redistribution hypothermia—the transfer of heat away from the core—and the complications that often follow it, a new study concludes. The research involved 200 adult patients randomly assigned to anesthesia induction with 8 percent sevoflurane in 100 percent oxygen; 8 percent sevoflurane in 50 percent oxygen and 50 percent nitrous oxide; 2.2 mg/kg of propofol; or 2.2 mg/kg of propofol administered immediately after phenylephrine, a vasoconstrictor intended to offset the vasodilation effects of propofol. Core temperatures, measured every 15 minutes after induction, revealed that standard propofol induction produced significantly lower mean temperatures compared with the other three approaches. “People who received inhalation inductions were approximately 0.5 degree warmer at every time point, and people who received phenylephrine before propofol were 0.4 degree higher,” reported Jonathan Roth, MD, of Einstein Medical Center in Philadelphia. “These results clearly show that changing induction techniques keeps patients warmer, and we know that warmer patients tend to have fewer complications." Presenting the findings at the International Anesthesia Research Society 2017 annual meeting, he acknowledged that a major limitation of the work is that it is a process study and encouraged future outcome studies to validate the findings.

From "Alternative Induction Techniques Can Reduce Redistribution Hypothermia"
Anesthesiology News (12/19/17) Doyle, Chase

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Patients Should Be Offered Music During Surgeries to Reduce Pain and Anxiety, According to Top Doctor

Allowing patients to listen to music during surgery is an easy and affordable way to alleviate their pain and anxiety, U.K. researchers contend. A team led by prominent urological surgeon Bhaskar Somani of University Hospital Southampton NHS Foundation Trust analyzed 15 international studies involving 1,900 urology patients. "In the modern era, the volume of urological procedures delivered on an outpatient basis has risen and many of these are carried out under local anesthesia," he said. "However, from the patient perspective, the experience of undergoing such procedures—not just in urology but across medical and surgical specialties—while awake can cause pain and anxiety." In 90 percent of the studies included in the review, however, music reduced both. On top of that, overall satisfaction was better in 53 percent of enrollees who listened to music and willingness to undergo the procedure again was higher in 40 percent. "A clear strength of music is its low cost, non-invasive nature and ease of delivery," Somani remarked. "There is a very strong case for all patients to be offered the option of music as an additional therapy when undergoing procedures."

From "Patients Should Be Offered Music During Surgeries to Reduce Pain and Anxiety, According to Top Doctor"
Daily Mail (United Kingdom) (12/15/17)

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Fascia Iliaca Compartment Block Versus No Block for Pain Control After Lower Limb Surgery

Researchers undertook a meta-analysis in order to gauge the analgesic efficacy of fascia iliaca compartment block (FICB) compared with no block (NB) following lower limb surgery. In all, seven clinical trials with more than 500 participants were included for review. According to the evidence, FICB recipients had lower pain scores at 4, 12, and 24 hours after the procedure and were less likely to experience postoperative nausea and vomiting. Moreover, FICB curtailed the amount of morphine needed at 24 hours. The team from The Third Affiliated Hospital of Soochow University in Changzhou, China, concluded that high-quality randomized controlled trials are warranted to verify their finding that FICB delivers safe and effective pain relief after lower limb surgery.

From "Fascia Iliaca Compartment Block Versus No Block for Pain Control After Lower Limb Surgery"
Journal of Pain Research (12/17) Vol. 2017, No. 10, P. 2833 Yang, Linyi; Li, Min; Chen, Chen; et al.

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Smoking Cessation May Increase Postoperative Opioid Use

Evidence suggests that surgical patients who previously smoked but quit are prone to lower preoperative pain tolerance and higher postoperative opioid consumption relative to patients who never picked up the habit. The study involved 68 nonsmokers and 80 abstinent smokers scheduled for hepatic resection. Electrical pain thresholds measured pre-procedure were found to be lower in the former smokers than in the nonsmokers. Additionally, based on utilization of patient-controlled intravenous analgesia after the surgery, abstinent smokers required higher doses of extra morphine equivalent in the first 48 hours postoperatively and more of them requested additional rescue analgesics during that time frame. Nonsmokers, meanwhile, had lower pain scores than abstinent smokers at 6, 24, and 48 hours post-surgery. To explain the disparities, the investigators speculated that "abstaining from smoking can produce profound changes in physiology," although they conceded that more study is needed.

From "Smoking Cessation May Increase Postoperative Opioid Use"
Clinical Pain Advisor (12/14/17) Martin, Jessica

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Genetics May Explain Chronic Post-Surgery Pain

Research out of Asia points to genetics as a likely factor governing which patients develop chronic postoperative pain. Colleagues from the Chinese University of Hong Kong queried more than 1,150 patients one year after surgery, asking them to rate their pain on a scale of zero to 10. More than 20 percent reported chronic postoperative pain—severe for a third of them—that disrupted sleep, prevented participation in activities, impacted mood, and reduced overall quality of life. Analysis of blood samples gathered from study participants found that one genetic marker known as the brain-derived neurotrophic factor was most correlated with pain after surgery. Genetic variation accounted for 7 percent to 12 percent of a patient's risk for postoperative pain, the researchers reported in Anesthesiology. Factors such as male gender, age younger than 65 years, anesthetic technique, and smoking history also influenced the odds of post-surgical pain; however, their share of the risk was just 3 percent to 6 percent.

From "Genetics May Explain Chronic Post-Surgery Pain"
United Press International (12/14/17) Hays, Brooks

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Spinal Tap Needle Type Impacts the Risk of Complications

A Canadian study has found that performing lumbar puncture using atraumatic needles with a pencil tip instead of a conventional, beveled traumatic needle is equally effective but cuts the risk of post-dural headache in half. The joint investigation between Hamilton Health Sciences and McMasters University also documented a greater than 50 percent reduction in patient readmissions and repeat emergency room visits with atraumatic needles. The findings are based on pooled data from 110 clinical trials conducted around the globe over the past three decades. Senior study author Saleh Almenawer, MD, explained that the tip of an atraumatic needle leaves only a tiny hole in the thick membrane around the nerves known as the dura, making it less likely that cerebrospinal fluid will seep through and cause headaches or other problems. Although the design debuted about 70 years ago, most providers are unaware of it and continue to use conventional needles. "This study provides convincing high-quality evidence for people to change to the atraumatic needles for a better patient care," said Almenawer, a neurosurgeon with Hamilton. The study appears in The Lancet.

From "Spinal Tap Needle Type Impacts the Risk of Complications"
ScienceDaily (12/06/17)

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Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed bimonthly 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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December 21, 2017
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