Anesthesia E-ssential

AANA Anesthesia E-ssential
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AANA Election Slate Announced

The AANA Nominating Committee, after reviewing the nominations for elected positions for the upcoming election at its February meeting, has announced the slate of candidates for the 2018 election of the AANA Board of Directors, Nominating and Resolutions Committee members. You'll find the complete slate of candidates and further information about the upcoming elections on the member side of the AANA website. (Member login and password required.) The order of names was determined randomly on the ballot by the Nominating Committee. Those elected will begin their fiscal year 2019 terms of office at the conclusion of the AANA 2018 Nurse Anesthesia Annual Congress in Boston, Mass. 
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Hot Topics

Updated Management of Waste Anesthetic Gases, Policy Considerations

At the AANA Assembly of School Faculty, the Board of Directors has approved the updated Management of Waste Anesthetic Gases, Policy Considerations.  These policy considerations cover topics such as waste anesthetic gas (WAG) exposure risk, engineering and environmental controls to limit WAG exposure, environmental impact, clinical practice, and communication and training, as well include links to various other resources.
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Off-Duty CRNAs Recognized for Stepping Up During Emergencies

Recently CRNAs have been in the news for their selfless help of others in emergency situations. The American Association of Nurse Anesthetists would like to recognize our members for the work they do on and off duty, such as Katie Kineally, MSN, CRNA, in the story below; and three CRNAs from the Rochester, Minn., area who were on a United flight from Chicago to Phoenix and assisted an elderly woman on board: Sean Loughran, CRNA; Jeffrey Oberhansley, CRNA; and Jenna Steege, CRNA, APRN. Thank you all for what you do, every day, to help our patients survive whatever befalls them. The AANA is grateful for the dependable, safe, high quality anesthesia and healthcare services that our members provide. Thank you. #WeAreThere 
– Bruce Weiner, DNP, MSNA, CRNA, AANA President
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Ladan Eshkevari Invited to Join CMS Advisory Board

Georgetown Professor Ladan Eshkevari, PhD, CRNA, LAc has been invited to join the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). MEDCAC, which advises the Centers for Medicare & Medicaid Services (CMS), was established to “provide independent guidance and expert advice to CMS on specific clinical topics. The MEDCAC reviews and evaluates medical literature, reviews technology assessments, public testimony, and examines data and information on the benefits, harms, and appropriateness of medical items and services that are covered under Medicare or that may be eligible for coverage under Medicare.”
Eshkevari’s appointment to the MEDCAC board will give CRNAs a seat at the table and allow their voice to be heard on a number of critical CMS and federal healthcare related issues. 
The AANA congratulates Eshkevari on this amazing opportunity and thanks her for her service and advocacy on behalf of our profession. 
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February 2018 AANA Journal Highlights

Read on for highlights of the February 2018 issue of AANA Journal.
Team Communication
The authors further our understanding of pitfalls in communication in the genesis of patient safety concerns. This work is important to all aspects of our professional lives and will greatly enhance your appreciation of the importance of effective information transfer.
Temperature Monitoring in the Young
The authors performed a study assessing the validity of tympanic vs temporal temperature monitoring in the young patient. As a standard (Standard V of our AANA Standards) bringing research to bear on this vital element of our monitoring practice facilitates our understanding of how best to provide care with respect to temperature monitoring.
Identifying Patterns in the AANA Closed Claims Dataset
The AANA Foundation Closed Claim Research Team conducts comprehensive analyses of adverse anesthesia outcomes from medical malpractice claims. These data can be used to facilitate nurse anesthesia educational curricula and facilitate recommendations.
ERAS:  Total Knee and Hip Arthroplasty
Enhanced recovery after anesthesia and surgery found its roots in managing the patient after colorectal surgery. It has, predictably, moved into many other domains, and a natural setting is that of arthroplastic surgery. The authors review the essential elements we should be using in our care of these patients who undergo these increasingly common surgical procedures.
The TAPS Block:  Opioid Sparing for Hysterectomy?
The authors performed a meta-analysis regarding the efficacy of the transversus abdominis plane block in this common gynecological surgery. The use of the TAPS block as part of a multimodal regimen is reviewed from the perspective of statistically merging high-quality randomized controlled trials that addressed post-hysterectomy pain.

Harlequin Syndrome After an Interscalene Nerve Block
The authors describe a common anesthetic technique used for a variety of shoulder surgeries and an associated complication, harlequin syndrome, that occurred. This is a much less common complication than Horner syndrome and one that readers may be unfamiliar with. This article is a must-read for those of us caring for the patient undergoing shoulder surgery. 
Preventing the Itch from Intrathecal Opioids After Cesarean Delivery
The relentless, often debilitating, itching that can attend our use of intrathecal opioids is a major drawback of this approach. The author and colleagues shed much-needed light on the etiology and management of pruritus in their highly clinically relevant work.
Happy Puppet Syndrome (Angelman Syndrome)
This is a fascinating case report of Angelman syndrome that occurred in a child having an ENT surgical procedure. If you’ve not seen (or heard of) this syndrome, this is important reading and will forearm you for a possible future encounter.
Nitrous Oxide for the Parturient:  What Is Its Status?
Nitrous oxide is increasingly being offered to the patient undergoing labor. The risks and benefits and general safety concerns are discussed, as well as standards of use that will update you on this analgesic intervention in this important AANA Journal course offering.

The Doctoral Scholarly Project: Balancing Academic and Clinical Aims
The author tackles an issue that is of concern to every clinical doctoral student, as well as doctoral program faculty, administrators, and accreditation reviewers. Thought provoking points are raised that are bound to get us all thinking about achieving equipoise in what may be competing objectives.
Anesthesia Ready Time: How Do You Measure Up?
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Consider Nominating a Colleague for an AANA Award!
Deadline is March 15

Do you work with an outstanding program director, didactic instructor, or clinical instructor? Do you know someone who has spent a lifetime advancing the practice of nurse anesthesia as a practitioner, educator, clinician, or advocate? Consider nominating your colleague for one of the national AANA recognition awards. Visit Recognition Awards for details on the Agatha Hodgins Award for Outstanding Accomplishment, Helen Lamb Outstanding Educator Award, Alice Magaw Outstanding Clinical Practitioner Award, Ira P. Gunn Award for Outstanding Professional Advocacy, Clinical Instructor of the Year Award, Didactic Instructor of the Year Award, and Program Director of the Year Award. 
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AANA Member Advantage Program Partner Office Depot Hosts Webinar

On Thursday, March 1, at 2 pm EST, watch a brief information webinar to find out about the exclusive benefits Office Depot, an AANA Member Advantage Partner, offers AANA members. Register here for the webinar, which will discuss the program and its benefits, including:
  • Shop on-line and in-store
  • Savings of up to 80 percent off on over 93,000 products
  • Free shipping on orders over $50 (some exclusions apply)
The webinar will be recorded and available for viewing after the webinar date.

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Foundation and Research

AANA Foundation 2018 Award Nominations Deadline Extended to March 1

Each year the AANA Foundation presents awards at the AANA Annual Congress to individuals who have made a difference in the nurse anesthetist community. The extended deadline for Award nominations is March 1.
Nomination/application forms are available online for:
  • Advocate of the Year—presented to an advocate committed to supporting the AANA Foundation and encouraging others to do the same.
  • John F. Garde Researcher of the Year—Presented to an individual who has made a significant contribution to the practice of anesthesia through clinical research.
  • Rita L. LeBlanc Philanthropist of the Year—Presented to an individual who has donated time, talent and direct financial support to the AANA Foundation and other deserving organizations.
  • Janice Drake CRNA Humanitarian Award—Presented to a CRNA who wishes to volunteer and provide anesthesia, education, and training in underserved areas.
Forward the completed form to the AANA Foundation. Email to or mail to 222 S. Prospect Avenue, Park Ridge, IL 60068.
Thank you in advance for recognizing a member of the nurse anesthesia community. If you have any questions, please contact the AANA Foundation at (847) 655-1170 or
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AANA Foundation Student Scholarships Applications Now Available Online: Deadline March 1

The AANA Foundation is pleased to continue its long history of funding nurse anesthesia education. Applications for nurse anesthesia student scholarships are available online, and the application deadline is March 1, 2018. Scholarship awards range from $1,000 to $3,000 each. To apply for a scholarship, you must be enrolled in a program for at least six months prior to March 1, 2018.
Don’t delay! Access the Student Scholarship Application webpage on the AANA Foundation website,
Contact the AANA Foundation at (847) 655-1170 or with any questions. 
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Visit to view or place job postings

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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.

Apneic Oxygenation Improves Emergency Intubation

Based on evidence from eight relevant studies with more than 1,800 participants, apneic oxygenation through a nasal cannula could aid intubation in the emergency room. The process, recommended for management of difficult airways, is widely used but traditionally has been reserved for settings like the operating room and intensive care unit. According to the systematic review and meta-analysis, however, peri-intubation oxygen saturation improves and the incidence of hypoxemia declines with apneic oxygenation in emergency scenarios. Additionally, more intubation attempts are successful on the first try. Although senior study author M. Fernanda Bellolio, MD, of the Mayo Clinic says the analysis could not prove a long-term benefit, apneic oxygenation did cut ICU length of stay by nearly three days. Bellolio calls the approach a "low-cost universally available technique that can reduce the incidence of hypoxemia and increase first-pass intubation rates," with no associated adverse effects. The results of the review and meta-analysis appear in the Annals of Emergency Medicine.

From "Apneic Oxygenation Improves Emergency Intubation"
Anesthesiology News (02/19/18) Kronemyer, Bob

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Putting the Brain at the Center of Anesthesiology

Anesthesia providers typically monitor patients by keeping close watch over their movements and changes in their vital signs, but one researcher insists that more attention should be paid to the brain. MIT neuroscientist Emery Brown, MD, who also is an anesthesia provider at Massachusetts General Hospital, has spent the better part of a decade underscoring how various anesthetics affect different parts of the brain and how that knowledge can translate into improved care. Just recently, at the American Association for the Advancement of Science annual meeting, he explained how anesthesia produces specific brainwave patterns and how tracking them through electroencephalogram (EEG) readings can guide clinical decision making. By using real-time EEG data, for instance, he is able to keep patients sufficiently anesthetized without over-dosing them. Lower levels of anesthesia, in turn, can have important benefits for certain patient populations—older adults, for one. Another example comes from a 2016 study in which Brown and a colleague demonstrated how dopamine-producing neurons in the ventral tegmental region of the brain could rouse mice from general anesthesia—which suggests a potential strategy for waking humans in a way that could reduce adverse effects, accelerate return to normal brain function, and expedite the recovery process. Ultimately, Brown envisions a future model where doctors have a direct view of the patient's brain when monitoring and maintaining their consciousness during surgery.

From "Putting the Brain at the Center of Anesthesiology"
ScienceBlog (02/17/18)

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Safety and Efficacy of an I.V. Nanocrystal Formulation of Meloxicam for Pain After Bunionectomy

Evidence shows that an intravenous nanocrystal formulation of meloxicam is safe and well tolerated when used to treat pain after unilateral bunionectomy. Study participants—59 adults who underwent the procedure—were randomly assigned in a 1:1:1 ratio to receive once-daily I.V. injections of 30 mg of meloxicam, 60 mg of meloxicam, or placebo. With the only adverse events classified as mild to moderate in nature and occurring at comparable levels across all three groups, safety was not a concern. Efficacy was determined by differences in pain intensity over the first 48 hours. Both doses of I.V. meloxicam significantly reduced pain levels compared with placebo during all measurements taken within the first two days postoperatively. There were some differences between the meloxicam groups, however, with only the higher dose significantly prolonging time to first use of opioid rescue analgesics. At the same time, pain reductions of 30 percent and 50 percent from baseline were observed after 6 and 24 hours in the lower-dose group, but not in the higher-dose patients. Overall, the researchers found that I.V. meloxicam at 30 or 60 mg produced rapid analgesic onset in as quickly as 15 minutes and effectively alleviated moderate-to-severe pain after bunionectomy for two consecutive 24-hour periods.

From "Safety and Efficacy of an I.V. Nanocrystal Formulation of Meloxicam for Pain After Bunionectomy"
Journal of Pain Research (02/18) Vol. 11, P. 383 Gottlieb, Ira J.; Tunick, Deborah R.; Mack, Randall J.; et al.

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Factors Influencing Plasma Ropivacaine Concentrations After Local Infiltration Analgesia

A small, observational study examined whether safe ropivacaine concentrations are used during local infiltration analgesia for knee replacement. The prospective investigation enrolled 15 patients who received 300 mg ropivacaine and epinephrine 5 µg/mL for local infiltration analgesia. Measured using liquid chromatography-mass spectrometry, peak concentrations ranged from 0.32 µg/mL to 0.88 µg/mL, generally trending higher among women than men. In addition to female gender, body mass index, age, and creatinine level influenced peak ropivacaine concentrations. However, peak concentrations never approached 2.2 µg/mL—the level considered toxic—in any of the study participants. "A fixed dose of 300 mg ropivacaine 0.2% given as a single administration for [local infiltration analgesia] in the setting of [total knee arthroplasty] is a technique that produced peak ropivacaine concentrations less than half of the best available quoted toxicity threshold, suggesting it is a safe technique with an incidence of toxicity of 0% (0%-23.9%)," according to the researchers, who reported the findings in Regional Anesthesia and Acute Pain.

From "Factors Influencing Plasma Ropivacaine Concentrations After Local Infiltration Analgesia"
Clinical Pain Advisor (02/14/18) Martin, Jessica

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Impact of Intravenous Acetaminophen on Outcomes Following Radical Nephrectomy

A retrospective study aimed to show whether the high cost of intravenous acetaminophen (IVA) is justified by improved postoperative outcomes in the setting of radical nephrectomy (RN). A commercial hospital database was used to identify 9,809 Americans who underwent elective RN, with no complications, for a diagnosis of kidney cancer or renal mass between 2011 and 2015. Of that number, 1,147 received post-procedure IVA, which was shown to curb the likelihood of an extended hospital length of stay by 64 percent. The analgesic approach did not affect use of opioid pain medications, however, nor did it influence direct index hospitalization costs.

From "Impact of Intravenous Acetaminophen on Outcomes Following Radical Nephrectomy"
UroToday (02/13/2018) Goldberg, Hanan

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Lidocaine Seen as Useful Component for Balanced Anesthesia During Spinal Surgery

Researchers have demonstrated the ability to use lidocaine for balanced anesthesia during complex spine surgery, with no interference to spinal cord monitoring for potential motor- or somatosensory-evoked outcomes. The small Hospital for Special Surgery study involved 40 participants scheduled for multilevel posterior spinal fusion. Each patient received propofol and lidocaine in addition to isoflurane, ketamine, and diazepam—but the order in which the two anesthetic treatments were administered was randomized. The main endpoints, motor-evoked potential voltage thresholds and somatosensory-evoked potential amplitudes, were not significantly different between the groups. Looking at hemodynamic parameters, investigators also found estimated blood loss to be comparable between the two sets of patients.

From "Lidocaine Seen as Useful Component for Balanced Anesthesia During Spinal Surgery"
Healio (02/13/2018) Jaramillo, Monica

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Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed weekly to AANA members.

Anesthesia E-ssential is for informational purposes, and its contents should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

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Attn: Linda Lacey
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February 22, 2018
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