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FDA Issues New Warnings for Sedation and Anesthesia in Young Children and Pregnant Women

The US Food and Drug Administration (FDA) is warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains. Visit FDA.gov. To better inform the healthcare professionals and the public about this potential risk, the FDA is requiring warnings to be added to the labels of general anesthetic and sedation drugs and will continue to monitor the use of these drugs in children and pregnant women. Read the FDA drug safety communication for more information and a list of general and sedation drugs affected by this label change.
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Hot Topics


National CRNA Week: Safe and Effective Anesthesia Care for Every Patient

CRNAs and student registered nurse anesthetists are taking advantage of National CRNA Week to inform their communities, colleagues and patients how CRNAs provide “safe and effective anesthesia care for every patient.” This observance is intended to educate the public and other healthcare providers about the safe, compassionate anesthesia care CRNAs deliver to patients 24/7 for surgery, child birth, emergency situations, and pain management. This year, the annual event is celebrated Jan. 22-28, 2017.

National Nurse Anesthetists Week was established in 2000 and renamed National CRNA Week in 2015. Now in its 18th year, CRNA Week is promoted by individual CRNAs, state associations, nurse anesthesia schools, public relations departments for various healthcare facilities, and through other creative resources, to inform the public about the millions of safe, high-quality anesthetics delivered by nurse anesthesia professionals each year.

“Study after study shows that Certified Registered Nurse Anesthetists provide safe, effective anesthesia care for every patient,” said AANA President Cheryl Nimmo, DNP, MSHSA, CRNA. “The pride we take in this profession is evident whenever you speak with a CRNA, but it is especially on display during National CRNA Week. Our members work hard to make their communities aware of their unique profession, and the privilege it is to be of service to our patients at a challenging time in their lives.”

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Consider Nominating a Colleague for an AANA Award!

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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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 2017. 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. To learn more and to submit a nomination, visit the award page.
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Nomination Deadline for Service on the 2017-18 CRNA-PAC is Jan. 31

If you or a colleague would like to serve on the CRNA-PAC Committee, Jan. 31 is the deadline for submitting an application online. In September 2017, the nine-member committee will have two CRNA vacancies, each for three-year terms. One student registered nurse anesthetist vacancy will also open for a one-year term. Two members of the AANA Board of Directors serve on the CRNA-PAC Committee, each for a one-year term that may be renewed for one additional year while the member also serves on the Board. To learn more about the CRNA-PAC Committee and access applications for both the CRNA and student positions, visit the Federal Government Affairs page (AANA login required).
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Professional Practice


FDA Bans Powdered Medical Gloves

Recently, the US Food and Drug Administration (FDA) published a final rule banning powdered surgeon's gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon's glove because these products present unreasonable and substantial risk to healthcare providers, patients, and other individuals. This rule is effective Jan. 18, 2017.
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Recall: Nurse Assist Inc. Normal Saline Flush IV Syringes

Nurse Assist Inc. is recalling the normal saline flush syringes due to incidents of Burkholderia cepacia contamination. B. cepacia is a bacterium that can cause bloodstream infections, particularly in patients with weak immune systems. Learn more about affected product codes and distribution dates.
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State Government Affairs


Nomination Deadline for Award for Excellence in State Government Relations Advocacy is Feb. 15

Nominate your state association for the AANA's Award for Excellence in State Government Relations Advocacy! State associations are encouraged to describe their significant efforts in state government affairs advocacy and enter by Feb. 15, 2017, to win this award, which will be presented at the AANA Mid-Year Assembly in April 2017. This annual award is not tied to a specific "victory" in the state legislative or regulatory arena, but will be given based on the quality of the undertaken effort. Examples of state association efforts include successful lobby days, legislative/regulatory efforts, or increased member participation in grassroots or other efforts. For more information and to submit your state's application, go to the awards page.
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Meetings and Workshops


2022 is Closer than You Think

Students starting programs Jan. 1, 2022, must graduate with doctoral degrees. Is your program ready? Program administrators, faculty, and deans are encouraged to attend "2022 is Closer than You Think: Transitioning to the Doctoral Degree." The joint 1.5-day COA/AANA Education Committee workshop is designed to assist programs in their successful transition to entry-level doctoral degrees. Visit
COA.us.com for further details.
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Registration Open for these Popular Hands-On Workshops

Register now—space is limited for the following spring hands-on workshops: Upper and lower Extremity Nerve Block, the Essentials of Obstetric Analgesia/Anesthesia, Spinal and Epidural, and Jack Neary Advanced Pain Management Workshop Part I. Visit www.aana.com/meetings for further information and to register!

Upper and Lower Extremity Nerve Block Workshop
AANA Foundation Learning Center
March 18-19, 2017
The Upper and Lower Extremity Nerve Block Workshop is designed to enhance the practitioner's knowledge in the clinical sciences related to upper and lower block anesthesia. The program will include case studies and hands-on demonstration.

Essentials of Obstetric Analgesia/Anesthesia Workshop
AANA Foundation Learning Center
May 10, 2017
Refresh your knowledge of clinical applications of spinal and epidural anesthesia procedures at the three-day intensive Spinal and Epidural Workshop. An excellent complement to the Essentials of Obstetric Analgesia/Anesthesia Workshop, this workshop combines expert lecture with a guided hands-on approach to learning.

Spinal and Epidural Workshop

AANA Foundation Learning Center
April 21-23, 2016
Refresh your knowledge of clinical applications of spinal and epidural anesthesia procedures at the three-day intensive Spinal and Epidural Workshop. An excellent complement to the Essentials of Obstetric Analgesia/Anesthesia Workshop, this workshop combines expert lecture with a guided hands-on approach to learning.

Jack Neary Pain Management Workshop Part 1
Rosemont, IL
June 3-5-2017
This workshop will expand your knowledge of interventional pain management through scientific and theoretical bases of pain, pharmacology, and pain management considerations.
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Important Information about Mid-Year Assembly Travel and Hotel Accommodations

Before you make your travel and hotel arrangements for the AANA Mid-Year Assembly, please note that special hotel group rates are available April 5-10 at AANA's official conference hotel, the Renaissance Downtown Hotel (located at 999 9th Street NW) by reserving rooms through AANA's website. Dates outside of these dates are not guaranteed, as the Cherry Blossom festival attracts tens of thousands of tourists from around the world. Also, there is a large citywide convention taking place prior to the AANA Mid-Year Assembly, and hotel availability is extremely scarce for those planning to arrive before April 5. (Please note: Special hotel rates are through April 10.) Haven't registered yet? Get the preparation you need to advance CRNA policy interests on Capitol Hill and to effectively advocate for your profession. Then apply a broader knowledge of policy and reimbursement issues at meetings with state representatives and Congressional staff. Space is limited.
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Foundation and Research


Register Today for Sunset, Surf & Sand at ASF

If you’re planning to attend the AANA Assembly of School Faculty (ASF) meeting in February, you won’t want to miss the AANA Foundation’s Sunset, Surf & Sand event at Sun, Surf, Sand Restaurant in Fort Lauderdale.

Visit the AANA ASF registration page to learn more and purchase tickets for this event when you register for the meeting. If you’ve already registered for ASF and would like to purchase event tickets, please contact Margaret Brennan, AANA Registrar, at (847) 655-1180.

If you have any questions, please contact Luanne Irvin, AANA Foundation Development Officer, at (847) 655-1173. We hope to see you there!
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Foundation Awards Nomination Deadline is February 1

We all know those around us who practice excellence in all they do—please take the time to nominate someone you know who makes a habit out of excellence.

"We are what we repeatedly do. Excellence then, is not an act, but a habit."
—Aristotle


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 deadline for Award nominations is Feb. 1, 2017.

See AANA Foundation Applications and Program Information to access the nomination/application forms 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 needy areas.
Forward the completed form to the AANA Foundation – email to foundation@aana.com 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 foundation@aana.com.
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Post-Doctoral and Doctoral Fellowship Applications Due February 1

Attention Researchers: Post-Doctoral and Doctoral Fellowship applications are available on the AANA Foundation website. See www.aanafoundation.com. The deadline for submission is February 1, 2017.  If you have any questions, please contact the AANA Foundation at (847) 655-1170 or foundation@aana.com.
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Jobs


Visit www.crnacareers.com to view or place job postings
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Featured Career Opportunities

Certified Registered Nurse Anesthetist (CRNA) – U.S. Army Nurse Corps
Nationwide

The US Army Medical Recruiting Brigade Honors Certified Registered Nurse Anesthetists during National CRNA week. Click here for information on CRNA training and career opportunities.

Experienced CRNAs - Quincy Anesthesia
Quincy, IL

Quincy Anesthesia Associates in Quincy IL is offering a salary and benefit package of $260,000 for experienced CRNAs and $230,000 for graduating SRNAs.
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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.

Are Infections Associated With Analgesic Steroid Paste After Spinal Decompression?

Researchers conducted a single-site study that questioned if epidural steroid agents promote surgical site infection after posterior lumbar operations. Participants with similar demographic profiles were split into two cohorts, based on whether or not their surgeon applied analgesic steroid paste to ease pain and inflammation after the procedure. The difference in acute infections between the two groups was statistically significant, the investigators report in Spine, affecting six of 103 patients who were treated with steroid paste compared with just two of 180 patients who were not. All but one of eight patients who contracted serious infections presented preoperative red flags. "The present study confirms suspicions raised in preliminary studies, and we recommend caution when treating patients with identifiable, comorbid risk factors," the researchers concluded.

From "Are Infections Associated With Analgesic Steroid Paste After Spinal Decompression?"
Becker's Spine Review (01/09/17) Dryda, Laura

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Diphenhydramine for Acute Extrapyramidal Symptoms After Propofol Administration

Although rare, extrapyramidal symptoms have been known to occur after administration of general anesthesia in patients who have never had serious neurologic problems. Propofol is believed to drive these symptoms—including ballismus, dystonia, choreoathetosis, and opisthotonus—but caregivers lack consensus on first-line treatment. While published case reports suggest an important role for anticholinergic drugs and benzodiazepines, diphenhydramine has also been used effectively as a primary response to severe extrapyramidal symptoms. The first documented case occurred in a teenage male with ulcerative colitis who underwent colonoscopy under general anesthesia with propofol. The patient responded promptly to treatment with the antihistamine after presenting with ballismus, torticollis, tongue thrusting, and oculogyric movements.

From "Diphenhydramine for Acute Extrapyramidal Symptoms After Propofol Administration"
Pediatrics (01/05/17) Sherer, James; Salazar, Tomas; Schesing, Kevin B.; et al.

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Use of PVB Has No Effect on Cancer Survival

Evidence from a new study refutes earlier findings that credit paravertebral block (PVB) with improved outcomes in breast cancer patients. The new research, a retrospective analysis of 792 women who underwent mastectomy with and without PVB, was spearheaded by Juan Cata, MD, of the MD Anderson Cancer Center at the University of Texas. His team developed two propensity score models to create a matched sample of patients based on key clinical covariates. In the first, 191 patients who received a PVB were matched by age, body mass index, duration of anesthesia, surgery type, and hormone receptor status with a like number of patients who did not get the block. While block patients used much fewer opioids, there was no meaningful difference between the two cohorts in risk for cancer recurrence. The second model added opioid consumption as a covariate; and this time, risk for recurrence was lower, but not significantly so. "Hopefully, I'm wrong," Cata said. "But as of today, the data do not support a decrease in cancer recurrence with a paravertebral block, although it's possible we were underpowered to show an association." He still favors PVB in general because it can improve pain control, reduce opioid consumption, curtail nausea, and extend pain relief for a longer period of time.

From "Use of PVB Has No Effect on Cancer Survival"
Anesthesiology News (01/04/17) Doyle, Chase

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Stress as Predictor of Postoperative Pain

Brazilian researchers have developed a new questionnaire meant to predict moderate to intense postoperative pain (MIAPP) based on emotional state, which they recently tested in 150 hysterectomy patients. Prior to their operations, all of the women were counseled by an anesthesia provider on the use of patient-controlled analgesia (PCA). They also completed the brief measure of emotional preoperative stress (B-MEPS), along with a pain evaluation and other assessments. Study participants then underwent the procedure under epidural anesthesia, with PCA available for 24 hours postoperatively. According to visual analog scale scores recorded 6, 12, 18, and 24 hours after surgery, B-MEPS independently predicted MIAPP with an odds ratio of 1.20. The findings, reported in Pain, could help better detect patients at high risk for MIAPP and, as other research suggests, possibly improve outcomes.

From "Stress as Predictor of Postoperative Pain"
Psychiatry Advisor (01/03/17) Rodriguez, Tori

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Doctors Are Cutting Opioids, Even If It Harms Patients

A crackdown on opioid prescribing appears to have had the desired effect on physician behavior, according to a nationwide poll, but many doctors worry the retreat comes at the expense of chronic pain sufferers. Based on feedback from almost 3,000 U.S. physicians, more than one-half of the country's doctors have cut back on opioid prescribing and nearly 10 percent have abandoned the practice altogether as state and federal regulators targeted their role in the sweeping overdose epidemic. More than one-third of respondents, however, agree that patients who safely take a regular dose of opioid medication to maintain daily functioning are being hurt by the shift away from the drugs. The irony of the pullback, according to University of Alabama professor Stefan G. Kertesz, MD, is that heroin and street fentanyl—not opioid prescriptions—are now powering the crisis. Yet, he notes, "public discourse has been contaminated by aggressive and inflammatory language that frightens doctors." The survey was conducted last month by the SERMO physicians social network on behalf of the Boston Globe.

From "Doctors Are Cutting Opioids, Even If It Harms Patients"
Boston Globe (01/03/17) Freyer, Felice J.

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Obstetricians Balk at FDA Warning on Anesthesia in Pregnant Women

The American College of Obstetricians and Gynecologists (ACOG) is challenging the Food and Drug Administration's (FDA) recent safety advisory against repeat or prolonged use of anesthetics in expecting women. The nonprofit organization said it was surprised by the Dec. 14 alert, which was based primarily on animal research and was not supported by any actual evidence from pregnant humans. "These warnings may cause patients and providers to inappropriately reject the use of these medically indicated drugs," ACOG wrote in a practice advisory to its members. In addition to cautioning against anesthetic use during the third trimester, the FDA warning covered children aged three years or younger—although it stressed that a single, brief exposure was unlikely to do cognitive or behavioral harm. "This is something we have been looking at, and based on the information we have, we thought it was important to get the information to the public," said FDA spokesperson Sarah Peddicord, defending the agency's bulletin.

From "Obstetricians Balk at FDA Warning on Anesthesia in Pregnant Women"
Reuters Health (12/29/16) Cohen, Ronnie

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Post-Op Opioid-Sparing Effect of Ketamine Analyzed

Armed with fresh evidence, researchers aspired to update an earlier meta-analysis on the opioid-sparing capacity of ketamine in children and infants after surgery. A search of the existing literature turned up 11 studies, including four new ones, that assessed ketamine as a perioperative opioid-sparing agent in pediatric patients. The review found that the drug offered no global opioid-sparing effect to 48 hours post-surgery and also failed to curb postoperative pain intensity; however, it also was not associated with greater postoperative nausea and vomiting or psychotomimetic complications. More research is needed, according to the investigators, who reported in Pediatric Drugs.

From "Post-Op Opioid-Sparing Effect of Ketamine Analyzed"
Monthly Prescribing Reference (12/16) Han, Da Hee

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Opioid Drugs Make Pain Tolerable, Most Long-Term Users Say

Although opioid use and overdose have reached epidemic proportions in the United States, popular opinion suggests the drugs do effectively manage chronic pain. Centers for Disease Control and Prevention guidelines cast doubt on the benefits of opioids over the long term, yet responses to the Washington Post-Kaiser Family Foundation national poll indicate the vast majority of Americans who have taken them for two months or more get reasonable relief from their pain. According to survey results, more than one-half, or 57 percent, of 622 long-term users report that opioids have afforded them a better quality of life. Specifically, they indicate that using opioids to manage pain has had a positive impact on their health and their ability to perform at work. On the other hand, poll-takers acknowledge that long-term opioid use is problematic in terms of the potential for addiction and adverse effects including dry mouth, nausea, and indigestion. However, the share of respondents who said long-term opioid consumption had a positive impact on their mental health and personal relationships was comparable to the share who said the impact was negative.

From "Opioid Drugs Make Pain Tolerable, Most Long-Term Users Say"
Washington Post (12/20/16) Guskin, Emily

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IV Acetaminophen Reduces Need for Opioids in Burn Patients

Findings from a small study suggest intravenous acetaminophen could play an important role in managing one of the toughest types of acute pain to treat: burn. A multimodal strategy is needed to address nociceptive pain from tissue damage, mechanical pain after surgery, and compounding pain as well as to avoid depression and other psychiatric disorders that can follow inadequate pain management. While most providers start treating burn victims with large doses of opioids, the current study finds that IV acetaminophen can curb the amount of narcotic painkillers needed—and therefore limit the rate of adverse events—while still safely providing analgesia. The study—conducted from May 2013 to May 2016 at a single site—randomized participants to IV acetaminophen plus IV opioids over 24 hours postoperatively as well as patient-controlled analgesia (PCA), or to morphine and hydromorphone PCA only. There was no statistically meaningful difference in pain scores between the two sets of patients, indicating they received comparable analgesia; however, the PCA-only group used 30 percent more opioids than burn patients receiving IV acetaminophen.

From "IV Acetaminophen Reduces Need for Opioids in Burn Patients"
Practical Pain Management (12/16) Subieta, Gunar; Torres, Maria; Poulakidas, Stathis; et al.

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Duration of Analgesic Use and Risk of Hearing Loss in Women

In a recent prospective study, researchers investigated the relationship between duration of analgesic use and self-reported hearing loss among more than 55,000 women in the Nurses' Health Study. The authors note that while frequent use of analgesics has been linked to an increased risk of hearing loss, the association between duration of use and hearing loss risk is not clear. According to the data, 18,663 incident cases of hearing loss were reported over 873,376 person–years of follow-up. The researchers report that longer duration of regular use of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen—for more than six years, compared with less than one year—were independently associated with higher risks for hearing loss. There was no association, however, between long-term use of aspirin and hearing loss. The results were not significantly affected by adjusting for body mass index and waist circumference, nor for excluding individuals with a history of tinnitus. The researchers conclude, "Considering the high prevalence of analgesic use and the high probability of frequent and/or prolonged exposure in women of more advanced age, our findings suggest that NSAID use and acetaminophen use may be modifiable risk factors for hearing loss."

From "Duration of Analgesic Use and Risk of Hearing Loss in Women"
American Journal of Epidemiology (12/14/16) Lin, Brian M.; Curhan, Sharon G.; Wang, Molin; et al.

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Nerve Blocks Safe, Effective in Older Headache Patients

Researchers believe peripheral nerve blocks (PNBs) may work better than standard drug treatment in delivering headache relief to seniors. The technique was successful in 81 percent of patients studied with chronic migraine, 75 percent of those with episodic migraine, 67 percent of older adults with tension type headache or new daily persistent headache, and 60 percent of those with occipital neuralgia—for an overall 73 percent efficacy rate. The retrospective studied included 64 patients, average age of 71, followed over a six-year period ended in 2016. Patients underwent four PNBs, on average, during the study period, with no adverse effects reported. Researchers say more data is needed to answer questions such as what kinds of headaches respond to which medications and whether local anesthetics would have the same effect as injections. Even so, the Mayo Clinic's J.D. Bartleson Jr., MD, says, the findings "provide some basis for treating older chronic headache sufferers with local anesthetics chiefly directed at posterior scalp sensory nerves—the greater and lesser occipital and auriculotemporal nerves—on one or both sides."

From "Nerve Blocks Safe, Effective in Older Headache Patients"
MedPage Today (12/13/16) Jenkins, Kristin

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The Case for Case Reports: Significant Impact Found, Even in Guidelines

Case reports are highly influential in the medical literature, according to a systematic review—especially within the anesthesia specialty. Lidocaine toxicity, for example, was first explored in a case report, notes Ekta Khemani, MD, an assistant professor of anesthesia at Western University in Ontario. A team led by her measured how often case reports were cited in the anesthesia literature, and by whom. Their look at nearly 300 submissions appearing in two high-impact industry journals, Anesthesiology and Anesthesia & Analgesia, revealed that case reports were referenced in review articles 33 percent of the time—more than any other research material—and were even attributed 3 percent of the time in clinical guidelines. Type of anesthetic, unexpected airway complications, and adverse events all factored heavily in high citation frequency. While they achieved a median score of 20 out of 30 based on 2013 Case Report (CARE) standards, a rating that Khemani characterized as "not too bad," she acknowledged that there is room to improve the quality of these documents. "Given the trend toward standardization, we feel that the CARE guidelines represent a quality improvement opportunity for case reports," Khemani said, "and the bibliometric impact is still significant, especially since we see that so many review articles are citing them."

From "The Case for Case Reports: Significant Impact Found, Even in Guidelines"
Anesthesiology News (12/12/16) Vlessides, M

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

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Attn: Linda Lacey
E–ssential Editor
llacey@aana.com
January 13, 2017
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