Anesthesia E-ssential

AANA Anesthesia E-ssential
CRNA Week 2018

Vital Signs

AANA Launches IV Saline Solution Shortage Webpage

In light of the current IV saline solution shortage and its effects on AANA members and their patients, the AANA has been in contact with an FDA representative in the 2017 Atlantic Hurricane Incident Management Group.  

The IV saline shortage has been an ongoing issue since 2014 and has been exacerbated by the impact of Hurricane Maria on Puerto Rico. The FDA continues to work within its authority to increase IV saline solution supply levels in the United States.
The AANA continues to monitor this issue and will post relevant information related to the IV saline solution shortage on a new webpage IV Saline Shortage and other AANA communication channels.  If your facility is experiencing a shortage, it can be reported to to help the FDA gauge the extent of the shortage. Please note, this email address is to provide information to the FDA and may not result in an immediate response or resolution.
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Hot Topics

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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HFAP Releases 2017 Quality Report

The Healthcare Facilities Accreditation Program (HFAP) released its review of 2016 standard deficiencies, including those for hospitals, critical access hospitals (CAHs), and ambulatory surgical centers (ASCs).  Facilities can use this report to help prepare for initial accreditation surveys, reaccreditation surveys, and continuous quality assessment and improvement. The report includes frequently cited standards, examples of surveyor findings, tips for improvement, and resources to support compliance. For hospitals and CAHs, the most common deficiency area was physical environment, including absence of evidence of monitoring waste anesthesia gas. Other frequently cited deficiencies were emergency management, including no written business continuity plan and incomplete emergency supply plans. For hospitals, areas of deficiency also included ongoing professional practice evaluation (OPPE).  Hospitals were cited for not defining the OPPE plan and process in the medical staff bylaws, not including quality measures in the OPPE process, or not implementing the OPPE process.  For ASCs, top deficiencies included credentialing/privileging and infection prevention/control. 

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December 2017 AANA Journal Highlights

Read on for highlights of the December 2017 issue of AANA Journal.

Examination of Hospital Policies Regarding Certified Registered Nurse Anesthetist Attire in the Operating Room
The authors report on their study examining what we wear in the OR and associated infection control issues. Their work will be of interest because our general behaviors are now known to be associated with surgical site infections in some cases, but the role of attire remains contentious.
Propofol Disposal in the Anesthesia Setting: Overcoming Barriers
The authors examine a domain where little evidence-based literature is available. The environmental impact, economics, and diversion-related concerns associated with how we dispose of unused propofol during normal clinical duties are discussed. Their work illuminates terrain greatly in need of light.
An Unusual Complication After Ganglion Impar Block for Chronic Cancer Pain Management
A rare neurologic complication after a fluoroscopic-guided ganglion impar block is reported by the authors in their interesting case report. The authors were treating a patient with chronic cancer pain, and safety concerns associated with this commonly performed procedure are explored.
Lyme Disease and Anesthesia Considerations
The author provides a thorough and evidence-based look at concerns related to caring for the patient with Lyme disease, a condition that is nearly epidemic in some areas of the country, but even in less affected locales, this work proves clinically relevant as the likelihood of encountering such patients is significant in our practices.
A Needs Assessment for Development of the TIME Anesthesia Handoff Tool
The authors assess the need for a systematic handoff in daily clinical practice and help to define just what constitutes an evidence-based, clinically relevant handoff tool. They import solid research in their description of what essential elements should be included in the anesthesia handoff.
Perceptions of Certified Registered Nurse Anesthetists on Factors Affecting Their Transition From Student
The author explores a topic that is rarely systematically explored: the time in one’s career when one evolves from student to credentialed practitioner. Whether one is a seasoned practitioner, a student just beginning his or her training, or on the threshold of completing their program, this work will be of interest and is likely to generate a dialogue among colleagues and peers.
A Randomized, Blinded, Clinical Study of Injury Incidence During Endotracheal Intubation: Comparison of GlideScope Video Laryngoscopy and Direct Laryngoscopy
The authors used a strong research design to evaluate patient injury secondary to airway management using either traditional laryngoscopy or GlideScope video laryngoscopy. The findings have important patient safety implications for the nurse anesthetist.
Anesthetic Implications of Superior Vena Cava Syndrome in Interventional Radiology: A Case Report
This case report brings us up to date on the essential management considerations for patients with superior vena cava syndrome. The author provides the reader with vital information to optimize the delivery of safe and effective care for what can be a very challenging set of management decisions.
Conductive Skin Warming and Hypothermia: An Observational Study
The authors used a retrospective design involving over 900 patients to assess the impact of conductive skin warming (CSW) and the association of subsequent thermoregulatory indices. The findings add to our understanding of the role of CSW in our clinical care interventions.
AANA Journal Course: Update for Nurse Anesthetists—Part 5—Maxillomandibular Fixation and Anesthesia Management
Anesthetic considerations involved in caring for the patient in need of maxillomandibular fixation are detailed by the authors in this continuing education offering. They report from a platform of great experience and evidence-based care that will be of interest to all clinicians, as we may encounter such patients frequently.
Guest Editorial: The authors fact check the ASA’s reported training hours and compare this to those of the nurse anesthetist in-training in this provocative and illuminating guest editorial.
Education News: The author describes the Quality and Safety Education for Nurses project and how it relates to student registered nurse anesthetist performance evaluation in the complex domain of clinical care. The use of this tool to detect suboptimal performance is assessed. Assessing clinical performance of trainees remains poorly defined and this work helps to focus on what some of the major challenges are.
Anesthesia & Analgesia Reprint: The authors, in a reprint from Anesthesia & Analgesia, provide a compelling and thought-provoking paper on distractions in the OR based on work sponsored by the Anesthesia Patient Safety Foundation. This article is a must-read for all of us in a domain sorely in need of evidence-based recommendations, because it relates powerfully to issues of patient safety.
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The Joint Commission Posts Four 2018 National Patient Safety Goals for Ambulatory Healthcare

The four goals include identifying patients correctly, using medications safely, preventing healthcare associated infections, and preventing mistakes in surgery and invasive procedures. Specific actions include: Use two methods to identify a patient, label medications and solutions that are not immediately administered, use Centers for Disease Control and Prevention (CDC) or World Health Organization hand hygiene guidelines, comply with evidence-based policies and practices for the prevention of surgical site infections, verify that the correct invasive procedure is performed on the correct patient and on the correct site on the body, mark the procedure site, and follow a time out before an invasive procedure to make sure a mistake is not being made.  Read the full details.   

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Professional Practice

The Joint Commission Offers Workplace Violence Resources

The Joint Commission recently posted questions and answers concerning accreditation standards and workplace violence. This resource compiles all Joint Commission standards relating directly or indirectly to workplace violence prevention, discusses surveyor focus areas involving workplace violence prevention, and outlines how The Joint Commission’s sentinel event policy relates to workplace violence.  In addition, The Joint Commission posted a page providing National Safety Council resources, as well as an additional resource relating to active shooter situations and workplace violence prevention. 

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AAAHC Safe Injection Practices Study Indicates Compliance Concerns

The Accreditation Association of Ambulatory Health Care (AAAHC) Institute for Quality Improvement’s Safe Injection Practices Benchmarking Study for January – June 2017 shows that some AAAHC-accredited organizations are having challenges complying with national guidelines on safe injection practices. The study was based on self-reported responses from 110 AAAHC-accredited ambulatory organizations. The AAAHC noted that the results are similar to other recent studies indicating that reuse of syringes and absence of hand hygiene before injections remain problematic.  Ninety study participants were ambulatory surgery centers or office-based surgery organizations. A key finding for these organizations is that less than 60 percent conducted a safe injection practices (SIP) assessment in the last year.  In addition, 84 percent perform at least one of the following hand hygiene techniques before accessing supplies and preparing and administering injections: wash with soap and water, or use antiseptic hand wash, hand rub or surgical hand antisepsis.  Read the AAAHC press release for more information about the study.

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State Government Affairs

The Enhanced Nurse Licensure Compact will be implemented Jan. 19; Is your license affected?

The enhanced nurse licensure compact (eNLC) will be implemented Jan. 19, 2018.

This implementation may affect the RN licenses of CRNAs who practice in any compact state, and may particularly affect those licensed  and practicing in existing compact states Colorado, New Mexico, Rhode Island, and new compact states Florida, Georgia, Oklahoma, West Virginia, and Wyoming.  See the relevant eNLC FAQs

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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. Register here.
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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.

Virtual Reality Simulator Improves Intubation Success

Fiber-optic bronchoscopic (FOB)-guided intubation is a taught skill, and new research suggests that it can be improved with virtual reality. David Wong, MD, of the University of Toronto led the investigation, which supplemented the traditional "see one, do one" teaching methodology with FOB simulator instruction. A total of 34 anesthesia providers with relative inexperience in this practice were recorded and timed while performing the procedure during two separate sessions. First, they watched a 15-minute presentation featuring anatomy lessons, teaching materials, and demonstration videos. All participants then conducted an initial post-training FOB intubation in the operating room on a patient under general anesthesia. Some patients subsequently received FOB simulator training before doing a second intubation within a week of the first one; while others received no further instruction. Anesthesia providers were able to perform FOB intubation much faster after the virtual reality learning experience, while there was no meaningful change in intubation times for the control group. Addressing the Society of Airway Management 2017 annual meeting, Wong said, "Based on these results, I think there is a role for simulators as a training tool before people undergo their first intubation." However, citing the high cost of the simulation equipment, he acknowledged that "the decision to use them may ultimately be determined by practical and economic concerns."

From "Virtual Reality Simulator Improves Intubation Success"
Anesthesiology News (12/05/17) Doyle, Chase

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Nonopioid Analgesic Combination and Opioid Combinations Provide Similar Analgesic Effects for Acute Extremity Pain

Non-opioid analgesic combinations appear to work as effectively as opioids plus acetaminophen against acute extremity pain, study results out of New York City show. Patients seeking emergency care for moderate-to-severe pain at two locations there were evenly randomized into one of four interventions: ibuprofen plus acetaminophen, oxycodone plus acetaminophen, hydrocodone plus acetaminophen, or codeine plus acetaminophen. Two hours after treatment, participants in the ibuprofen/acetaminophen group achieved a 4.3-point decline from baseline pain scores. The reduction was on par with pain relief observed in the opioid/acetaminophen groups—whose pain scores dropped 4.4 points with oxycodone, 3.5 points with hydrocodone, and 3.9 points with codeine. "The findings support the inference that there are no clinically meaningful differences between the analgesic effects of these 4 analgesics and suggest that a combination of ibuprofen and acetaminophen represents an alternative to oral opioid analgesics for the treatment of acute extremity pain in the [emergency department]," the researchers concluded.

From "Nonopioid Analgesic Combination and Opioid Combinations Provide Similar Analgesic Effects for Acute Extremity Pain"
Clinical Pain Advisor (12/04/17) May, Brandon

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Comparison of Dexmedetomidine and Fentanyl as Local Aesthetic Adjuvants in Spinal Anesthesia

Chinese researchers undertook a systematic review and meta-analysis designed to compare the use of dexmedetomidine versus fentanyl as adjuvants to local anesthetics for spinal anesthesia. The team mined publication databases, ultimately identifying and focusing on nine randomized controlled trials involving 639 participants. With dexmedetomidine, the investigators found, patients achieved longer-lasting stable sensory block, sensory block, motor block, and pain-free period than with fentanyl. Moreover, dexmedetomidine was associated with a reduction in pruritus. These improved outcomes were achieved, the researchers added, without delaying the onset of sensory and motor block, slowing the time to peak sensory level, increasing the incidence of hypotension and bradycardia, or producing more adverse effects.

From "Comparison of Dexmedetomidine and Fentanyl as Local Aesthetic Adjuvants in Spinal Anesthesia"
Drug Design, Development and Therapy (12/01/17) Vol. 2017, No. 11, P. 3413 Sun, ShuJun; Wang, JiaMei; Bao, NaRen; et al.

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Regional Nerve Block May Provide Effective Pain Relief in Hip Fracture

According to the results of a systematic review, researchers believe that regional nerve block is beneficial for hip fracture. They identified 31 randomized studies that collectively compared more than 1,700 patients who did and did not undergo regional nerve block. Those who did experienced the equivalent of a 3.4-unit reduction in pain on movement based on a 10-point scale, possibly indicating faster mobilization. Additionally, investigators reported in the Annals of Emergency Medicine, these trial participants were at a lower risk for pneumonia than patients who did not receive nerve block; used fewer opioids; and expressed greater satisfaction with their experience. Still, the researchers concede, more study is needed to investigate the relationship between specific types of nerve block and improved outcomes related to fracture-related pain.

From "Regional Nerve Block May Provide Effective Pain Relief in Hip Fracture"
Clinical Pain Advisor (12/01/17) May, Brandon

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Intranasal Ketamine or Fentanyl for Children: Similar Analgesia, Disproportionate Side Effects

In pediatric patients presenting with single-extremity fractures, new findings show that intranasal ketamine delivers comparable pain relief to intranasal fentanyl—but also more adverse events. A total of 82 children were included in the study, which randomized half to ketamine and half to fentanyl. All 41 of the kids who received ketamine analgesia experienced minor adverse events, versus 61 percent of those who were given fentanyl. Additionally, the cumulative number of side effects—including unpleasant taste in mouth, dizziness, and sleepiness—was 2.2 times higher in the ketamine group. "There is less information about ketamine available than is needed to determine its role as first-line pain therapy in children," remarked James R. Miner, MD, professor of emergency medicine at the University of Minnesota. "This study starts to give us the information necessary to determine ketamine's place as a pain medication and its potential to replace opioids."

From "Intranasal Ketamine or Fentanyl for Children: Similar Analgesia, Disproportionate Side Effects"
Pain Medicine News (11/30/2017)

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Lumbar Plexus Nerve Block, Liposomal Bupivacaine Led to Modest Improvement for Opioid Use After THA

Researchers comparing pain-relief techniques following total hip arthroplasty (THA) observed modestly better outcomes in patients who received posterior lumbar plexus nerve block (PNB) or periarticular infiltration (PAI) with liposomal bupivacaine as opposed to periarticular infiltration with ropivacaine. The team randomly allocated 51 patients to PNB; 54 patients to periarticular infiltration with ropivacaine, ketorolac, and epinephrine (PAI-R); and 54 to periarticular infiltration with liposomal bupivacaine, ketorolac, and epinephrine (PAI-L). The primary endpoint—maximum pain on the morning of postoperative day one—was not significantly different among the treatment groups, the investigators found. However, patients in the PNB and PAI-L groups reported lower maximum pain on the second postoperative day than the PAI-R patients. One of the researchers, Mark Pagnano, MD, stressed that "all three strategies provided good pain relief and required relatively little supplemental use—useful information in the context of today's opioid epidemic."

From "Lumbar Plexus Nerve Block, Liposomal Bupivacaine Led to Modest Improvement for Opioid Use After THA"
Healio (11/29/2017) Tingle, Casey

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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 7, 2017
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