Anesthesia E-ssential

AANA Anesthesia E-ssential

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Vital Signs

AANA Journal Online Presence to Increase with February Issue

In an effort to increase the number of case studies and research papers published in the print issue of the AANA Journal, beginning with the February 2017 issue, Journal departments such as Research News, Education News, Legal Briefs, Imagining in Time, Guest Editorials, as well as letters, book reviews, and the annual index of articles, will be published solely online at AANA Journal. Additional articles may also be published only online as well.

By publishing this content online only, the Journal will be able to accommodate additional case studies and research papers in each print issue. All online content will be accepted for publication using the same stringent, double-blinded process used for the content published in the print edition of the Journal. The online content will also be indexed by PubMed/MEDLINE and be highly visible to researchers and scholars.

In March 2008, the Journal transitioned to an online manuscript submission and peer-review tracking system called Editorial Manager. In the 8+ years since, manuscript submissions to the Journal more than doubled from 70 to 145. However, this positive outcome of moving to Editorial Manager created a backlog of articles approved for publication. A subsequent analysis of Journal content in the six issues published in 2016 found approximately 60 pages devoted to departments, letters, book reviews, the annual index, and non-case study/non-research articles. On its annual conference call in April 2016, the Journal Editorial Committee and Journal staff supported an increased online presence for the Journal to assist in managing surging submissions and speed their time to publication; CEO Wanda Wilson, PhD, MSN, CRNA, approved a more robust digital presence for the Journal in December 2016.

Online content will be posted on at the same time the print edition arrives in member mailboxes.

The print issue and online-only content will continue to be published on the following schedule: February, April, June, August, October, and December. The Journal app will still be available so readers can access the AANA Journal on their mobile devices. The digital (flip-page) edition of the Journal will continue to be posted at for each print issue.

The first article to be published via the AANA Journal online will be “The Consensus Bundle on Prevention of Surgical Site Infections After Major Gynecologic Surgery.” This article is being published concurrently in the January 2017 issue of Obstetrics & Gynecology, the January 2017 issue (vol. 124, no. 1) of Anesthesia & Analgesia, and the January/February 2017 issue of Journal of Obstetric, Gynecologic, & Neonatal Nursing. Teaming with these respected publications to disseminate this crucial information regarding surgical site infection raises the visibility of the AANA Journal.
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Hot Topics

2017 MIPS Reporting Year Begins

The new Quality Payment Program established under MACRA started Jan. 1, 2017, and has replaced the PQRS and Value Based Modifier. Most CRNAs will have to participate in the Merit-based Incentive Payment System (MIPS) track to avoid the -4 percent Medicare reimbursement penalty. CRNAs should begin to learn about MIPS and the Pick Your Own Pace reporting to avoid the penalty and possibly earn a modest incentive in 2019. The AANA Research and Quality Division has created a MACRA video as well as other MACRA resources including FAQ and fact sheets, which are all available on the AANA Quality-Reimbursement website.       
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2016 PQRS Reporting Coming to an End

The 2016 PQRS performance year ended Dec. 31, 2016. If you have been diligently gathering your PQRS measures for the 2016 reporting year, it is still not too late to report via a registry as some registries are still accepting quality data for submission to CMS. The CMS deadline for data submission for registries and QCDRS (using XML format) is March 31, 2017.
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Open Positions on the COA

The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is seeking nominations for two CRNA Educator directors, one CRNA Practitioner director, and one Public Representative. Candidates must be available to attend three-day COA meetings, typically held in January, May, and October. The term of office for the CRNA Educators and Public Representative is three years, beginning fall 2017 through fall 2020. The individuals then would be eligible to be considered for reappointment to a second term. The CRNA Practitioner will complete the remaining term of the upcoming vacancy, i.e., fall 2017 through fall 2018, and then would be eligible to be considered for reappointment to a full term of three years. For more information please visit the COA’s website.
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2017 MIPS Measure Specification Released

The Centers for Medicare & Medicaid Services (CMS) has released the final specifications for the 2017 MIPS measures on Dec. 29, 2016. To view the measure specifications please visit CMS’ Quality Payment Program website under Education and Tools. The measure specifications found within this website can only be used for claims or qualified registry reporting only and do not include QCDR measures.
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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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Meetings and Workshops

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 (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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Registration Open for these Popular Hands-On Workshops

Register now—space is limited for the Essentials of Obstetric Analgesia/Anesthesia and Spinal and Epidural workshops. Visit for further information and to register!

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
May 11-13, 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.
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Visit to view or place job postings
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Featured Career Opportunities

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

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.

Full-Time CRNA – Danbury Hospital
Danbury, CT

Western Connecticut Medical Group is seeking a full-time CRNA to join us at Danbury Hospital in Danbury, Connecticut, located 70 miles from New York City. Part-time and per diem options available.

CRNA Opportunity – Anesthesia Associates of Southern Illinois
Southern Illinois

Anesthesia Associates of Southern Illinois is expanding to new locations and we are seeking additional CRNAs for our growing group. Our locations are eligible for Federal Student Loan Repayment!
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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.

SONORIA and PPAHS Partner on Safety Initiative

The Society for Non OR Intervention and Anesthesia (SONORIA) and the Physician-Patient Alliance for Health & Safety (PPAHS) are working together to make procedures performed outside of the operating room safer than ever. "Both of our organizations believe that improving patient safety requires collaborative effort," declared SONORIA President Wendy Gross, MD. Her group counts as members anesthesia providers, nurses, physicians assistants, interventional medicine practitioners, and other practitioners who want to improve non-OR safety. PPAHS, meanwhile, strives to develop and identify best practices in opioid administration in hopes of eliminating patient harms. "Suboptimal outcomes and untoward events such as those chronicled in the PPAHS blog are powerful reminders of why we all need to be involved in promoting collaborative practice and better interdisciplinary communication," Gross added.

From "SONORIA and PPAHS Partner on Safety Initiative"
Healthcare Risk Management Review (01/26/2017)

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Preoperative Epidural Steroid Injections Linked With Postoperative Infection After Fusion

Study results published in Spine reveal a significant risk for postoperative infection among patients who received a cervical epidural steroid injection (CESI) ahead of fusion surgery. Researchers reviewed data from a national insurance database to compare 90-day infection rates in people who underwent CESI prior to anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). Investigators stratified patients based on when they received an injection: within 3 months of surgery, between 3 and 6 months, and between 6 and 12 months. After controlling for age, gender, obesity, diabetes, and smoking, investigators used multivariate binomial logistic regression analysis to gauge how preoperative injections may influence postoperative infection rates. The findings indicated markedly higher infection rates among patients who underwent CESI within 3 months of fusion surgery. Specifically, the risk was elevated for those receiving an injection 3 to 6 months before PCF or within 3 months of undergoing ACDF.

From "Preoperative Epidural Steroid Injections Linked With Postoperative Infection After Fusion"
Healio (01/25/2017) Jaramillo, Monica

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Use of Standardized Analgesia Protocol Linked With Less Pain Among Neurosurgical Patients

A prospective, interrupted time-series study sought to assess the impact of a standardized analgesia protocol designed for neurosurgery. Adoption of the protocol was associated with a 32 percent reduction in pain on the first postoperative day for neurosurgical patients and an even greater reduction, 43 percent, for those undergoing spine surgery. The decrease in pain levels, meanwhile, was linked to significantly fewer monthly naloxone doses as well as compliance with the analgesia protocol.

From "Use of Standardized Analgesia Protocol Linked With Less Pain Among Neurosurgical Patients"
Healio (01/23/2017) Jaramillo, Monica

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Intra-op Beta Blockers Lower Post-op Opioid Use, Nausea and Length of Stay

Canadian researchers believe continuous infusion of beta blockers during surgery can promote patient recovery afterwards. Lead investigator Stephen Yang, MD, of McGill University Health Centre, identifies the primary benefit as a reduction in opioid requirements, which then produces other positive impacts. Effectively managing postoperative pain shortens hospital stay, for example, but curbing the amount of opioids needed lowers the incidence of associated side effects. To support their position, Yang and colleagues cite results from five high-quality trials that evaluated the effect of the intraoperative beta blocker esmolol on postoperative pain outcomes. Systematic review of the studies indicates that compared with patients who did not receive beta blockers, patients undergoing esmolol infusion used significantly less postoperative opioid medication, spent less time in the post-anesthesia care unit, and were less likely to experience postoperative nausea and vomiting. "In addition to the mechanisms proposed by the authors," notes Girish Joshi, MD, MBBS, a professor of anesthesiology and pain management at the University of Texas, "I think that the use of intraoperative esmolol allows avoidance/reduction of intraoperative opioid administration, which may prevent/limit acute opioid tolerance and/or opioid-induced hyperalgesia, clinically relevant phenomena that are often underappreciated by anesthesiologists."

From "Intra-op Beta Blockers Lower Post-op Opioid Use, Nausea and Length of Stay"
Anesthesiology News (01/20/17) Vlessides, Michael

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Patients Accept Same-Day Consent for Low-Risk Clinical Trials

Same-day consent for participation in low-risk anesthesia studies may not be as much of an ethical quandary as some perceive, based on patient feedback in a new survey. All respondents were enrolled in either a clinical trial of dexamethasone in gynecologic patients or one focused on neuromuscular monitoring in the operating room. Participant permission was required for both studies on the day of surgery, but patients in the neuromuscular trial were notified the day before that they would be solicited for research purposes. Among the 129 patients who filled out the 25-question survey, the overwhelming majority agreed they were able to grasp the aim, benefits, and risks of the trial—even if only approached for the first time in the preoperative holding area. Lead study author Glenn Stephen Murphy, MD, of NorthShore University HealthSystem, admits that higher risk could have skewed the responses in another direction. "I think the low level of anxiety is a reflection of the fact that patients were undergoing lower-risk procedures," he speculates. "If we were investigating a new experimental drug, the results might be different."

From "Patients Accept Same-Day Consent for Low-Risk Clinical Trials"
Pain Medicine News (01/19/2017) Doyle, Chase

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Study: UVA Slashes Opioid Use While Improving Pain Scores

A study at the University of Virginia (UVA) Health System has found that pain levels for surgical patients there fell even as doctors administered fewer opioids. Investigators reviewed 101,484 operations that took place under general anesthesia between March 2011 and November 2015. During that span, the average amount of opioids given per surgery decreased 37 percent. Additionally, on a scale of 0 to 10, patients' self-rated pain scores in the recovery unit declined from an average 5.5 to 3.8—an improvement of 31 percent. "There is very clear evidence that people can become opioid dependent because of the drugs they get during and after surgery," remarked UVA anesthesiologist Marcel Durieux, MD, who conducted the study with two colleagues. "I think that by substantially limiting opioids during surgery, we've made an important step in addressing that problem." He cited two factors in how UVA was able to alleviate patients' pain while using fewer opioids. Because research has shown that opioids actually make people more sensitive to pain, for one, curbing the amount of these drugs given to patients might in itself improve pain scores. The second factor was a significant increase in the use of non-opioid pain medications, such as lidocaine and acetaminophen.

From "Study: UVA Slashes Opioid Use While Improving Pain Scores"
Augusta Free Press (01/19/17)

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Updated Guidelines on Intrathecal Therapy for Pain

In light of changes in the field of intrathecal therapy (IT) over the past five years, the Polyanalgesic Consensus Conference (PACC) guidelines have been revised to reflect new understanding of the practice. Specifically, an expert panel has presented 32 consensus points involving the treatment of pain through IT. Additionally, algorithms were developed for "intrathecal medication choices to treat nociceptive and neuropathic pain for patients with cancer, terminal illness, and noncancer pain, with either localized or diffuse pain," they wrote in Neuromodulation, where the recommendations have been published. Lead author Timothy Deer, MD, a clinical professor of anesthesiology and pain medicine at West Virginia University, offered a summary snapshot of the changes. The guidance, he noted, includes new recommendations on significantly cutting or eliminating opioids in patients taking intrathecal medications, on using conopeptides more effectively to avoid narcotic painkillers, on dosing, on diagnosing and treating complications, and on trialing to streamline the process. The PACC guidelines, first introduced in 2000, were last updated in 2012.

From "Updated Guidelines on Intrathecal Therapy for Pain"
Neurology Advisor (01/19/17) Rodriguez, Tori

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Longer Duration of Block Analgesia Seen With Steroids Added to Local Anesthetic

Research involving 910 shoulder surgery patients showcased the benefit of using steroids in addition to local anesthesia during interscalene brachial plexus blockade. The prospective study randomized 574 participants to receive an injection of local anesthesia with triamcinolone acetonide added, with the other 336 receiving local anesthesia only. Block duration—based on telephone interviews 36 hours after surgery, patient journals maintained during the first two postoperative days, and office followup on the 10th day—lasted for a significantly longer period of time in patients who received steroids. Otherwise, overall success rates and side effects were similar between the two treatment arms.

From "Longer Duration of Block Analgesia Seen With Steroids Added to Local Anesthetic"
Healio (01/18/2017) Jaramillo, Monica

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Analgesic Effects of Opioids Can Be Mediated Via Immune Cells

While opioid receptors in the brain are recognized for their role in pain-killing medication, German researchers have discovered that the analgesic effects of opioids can also be unlocked by activating receptors in immune cells. Their work, published in the journal Brain, Behavior, and Immunity, demonstrates that pain reduction in mice was mediated this way. Using an animal model of neuropathic pain and three different opioid receptor agonists, the team demonstrated that all three agonists alleviated pain. However, animals with fewer immune cells experienced significantly weaker analgesia—which was fully restored once the numbers of immune cells were increased. This effect was only mediated by immune cells containing opioid receptors. "We were able to show that opioid agonists activate opioid receptors on immune cells, which triggered the release of endogenous painkillers (opioid peptides) and produced analgesia in a mouse model of neuropathic pain," reported researcher Prof. Halina Machelska. "This led us to conclude that opioids can exert enhanced analgesia when they act directly in painful tissue—providing that this tissue is inflamed and contain immune cells." The findings are relevant for many pain conditions, including arthritis, nerve damage, post-surgical, and cancer pain—all of which are associated with an immune response.

From "Analgesic Effects of Opioids Can Be Mediated Via Immune Cells" (01/17/2017)

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Spinal Anesthesia Offers Another Choice for Young Children

While it has long been standard procedure to put infants and young children to sleep for surgery, more parents are being given the option to skip general anesthesia. Instead, the tiny patient is allowed to remain in an awake state but is numbed from the mid-chest down via spinal anesthesia. Going this route can especially benefit babies—who are less prone to stranger anxiety than older kids and are calmer in the OR setting, according to Nationwide Children's Hospital anesthesia provider Emmett Whitaker, MD. Because the block fends off pain for roughly 90 to 100 minutes, it also is most suitable for shorter surgeries. Whitaker emphasizes that general anesthesia is still considered safe but notes that spinal anesthesia does a better job of stabilizing patient temperature and eliminates the need for the use of breathing tubes or narcotic drugs like morphine. It also is associated with good post-surgery pain control and abbreviated recovery time. Finally, spinal anesthesia offers parents some reassurance at a time when experts are still trying to determine if early exposure to general anesthesia poses developmental harms. "If we can do something that may even be a little bit safer—may be safer, we don't know yet—it's certainly worth it," said Nationwide Children's Hospital surgeon Rama Jayanthi, MD. "And the concept that we can put these little babies through an operation with no medication whatsoever that goes into their bloodstream . is very attractive."

From "Spinal Anesthesia Offers Another Choice for Young Children"
Columbus Dispatch (01/14/17) Viviano, JoAnne

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Use of Pulse Oximetry Recommended to Monitor for Hypoxia During Transport From the OR to the PACU

New findings indicate that almost 7 percent of surgical patients develop hypoxia, a serious postoperative complication, while being taken to the recovery area. "In large hospitals, transport from the operating room to the PACU (post-anesthesia care unit) can be quite lengthy, resulting in the patient having inadequate oxygenation for an unacceptable period of time," explains anesthesia provider Olga Eydlin, MD, of New York University Langone Medical Center. She and her team reviewed data from 3,440 patients who received anesthesia for a procedure and were monitored with a pulse oximeter before departing the OR, during transport to the PACU, and upon arrival in the recovery unit. In all, 231 cases of hypoxia were identified—the vast majority of them moderate in nature and documented in patients who had received general anesthesia. Analysis also revealed a higher risk of hypoxia during transport in patients with cardiac or pulmonary disease as well as in heavier patients. The findings suggest the complication occurs during transport more often than believed, prompting Eydlin and colleagues to recommend using portable pulse oximeters during transport and making supplemental oxygen available to the anesthesia provider during the move. "By no means are we suggesting that the pulse oximeter is replacing the anesthesia provider closely watching the patient," emphasizes Eydlin, who says the device is simply "an additional modality to provide information to the anesthesia provider."

From "Use of Pulse Oximetry Recommended to Monitor for Hypoxia During Transport From the OR to the PACU"
Anesthesiology News (01/11/17) Vlessides, Michael

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Recovery Profile and Patient Satisfaction After Ambulatory Anesthesia for Dental Treatment

Researchers at Tokyo Dental College performed a crossover comparison in an effort to identify which agent—propofol or sevoflurane—was favored for ambulatory anesthesia. They enrolled 20 patients, all with severe anxiety about dental procedures, who were scheduled for two or more separate days of extensive dental work under general anesthesia. Each study participant was exposed to both anesthetics, in different sessions in randomized order, with no other drugs co-administered to maintain anesthesia. They were then observed as they emerged and recovered from anesthesia. Additionally, a questionnaire—distributed at discharge and relayed via telephone interview 24 hours later—helped to gauge patient satisfaction and preference. Time to extubation, eye opening, and response to verbal command—as well as most other emergence recovery profiles—was faster after exposure to sevoflurane than after exposure to propofol. Recovery profiles during the recovery phase, however, were similar with both anesthetic methods; and the questionnaires reflected greater satisfaction with and a clear preference for propofol over sevoflurane. Upon completing their second treatment, patients also expressed a preference for propofol for future dental procedures.

From "Recovery Profile and Patient Satisfaction After Ambulatory Anesthesia for Dental Treatment"
Anesthesia Progress (Winter 2017) Vol. 63, No. 4 Ohkushi, Keita; Fukuda, Ken-ichi; Koukita, Yoshihiko; et al.

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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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Attn: Linda Lacey
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January 30, 2017
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