Anesthesia E-ssential

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AANA Submits Comments to FDA Regarding Provider Education on Pain Management and Safe Opioid Use

The AANA has submitted a comment letter to the US Food and Drug Administration supporting a patient-centered approach to provider education on pain management and safe opioid use. The Letter emphasized that acute and chronic pain management should utilize a multimodal, patient-focused multidisciplinary team approach. Additionally, it encouraged the use of enhanced recovery after surgery (ERAS) protocols and advocated for the valuable role CRNAs play in acute and chronic pain management. 
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Hot Topics

Alternative Payment Model Fact Sheets Available on AANA Website

New fact sheets for Advanced Alternative Payment Models and MIPS Alternative Payment Models are now available that detail the Quality Payment Program (QPP) participation requirements for CRNAS in the 2017 performance year/2019 payment year. The Advanced APM Fact Sheet includes information on how Qualified Participant (QP) status is determined; the Medicare 2017 QP and Partial QP threshold requirements; and the dates when QP status determinations are made. The MIPS APM Fac Sheet includes a list of MIPS APMS and a table detailing the scoring methodology for the four MIPS performance categories. The table is organized by MIPS performance categories, and it includes information on how a CRNA’s final MIPS performance score will be calculated if one participates in a Medicare Shared Savings Accountable Care Organizations (ACOs), Next Generation ACOs, or Other MIPS APMs. The fact sheets are located and can be accessed on the AANA Quality-Reimbursement.  
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CDC Vital Signs: Opioid Prescribing is Still High and Inconsistent across the US

The amount of opioids prescribed in the US peaked in 2010 and then decreased each year through 2015. However, prescribing remains high and varies widely from county to county. Higher opioid prescribing puts patients at risk for addiction and overdose. The wide variation among counties suggests a lack of consistency among providers when prescribing opioids. Read more in CDC’s July Vital Signs Report.
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Free CE Series on Infection Prevention and Control from CDC & Medscape

The Centers for Disease Control and Prevention (CDC) has partnered with Medscape to offer free CE Series on Infection Prevention and Control. The latest module on Infection Transmission Risks Associated with Nonsterile Glove Use will be available on July 17, 2017. Check out all of their offerings, and register now!
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Attention CRNAs: Last Chance to Join the #AANA2017 Anesthesia College Bowl Challenge Team
Deadline extended to July 17

Bring your knowledge of anesthesia and your best game! Be warned, the SRNAs are hard to beat - but the CRNAs did it in 2016! With your participation, the CRNA Challenge Team can make it two in a row! Represent your program and have fun at this exciting annual event. The deadline to submit your application has been extended to July 17.
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Meetings and Workshops

#AANA2017: Get Inspired, Connect with Colleagues, Grow Your Knowledge

Join us Sept. 8-12 in the heart of Seattle for unparalleled networking and evidence-based education featuring seven educational tracks and critical topics like non-opioid anesthesia and pain management. Earn up to 27.25 Class A CE credits with 13.75 pharmacology credits.
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Register Now for the Fall Leadership Academy
November 3-5, Rosemont, Ill.

AANA Fall Leadership Academy features expert speakers in five educational tracks including Business and Facility Leadership, Federal Political Director, State Grassroots Advocacy, State President-elect, and State Reimbursement Specialist. Hone and develop leadership skills for your practice, state, and business. Plus, you'll expand your network of colleagues around the country.
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Registration Open for Upper and Lower Extremity Block Workshop

Expand your skills and expertise in upper and lower extremity block anesthesia through this hands-on workshop, to be held Oct. 7-8, 2017, in Park Ridge, Ill. The program will include case studies, hands-on demonstrations, return demonstrations, and skill validation. 
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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.

Effectiveness of Non-Steroidal Anti-Inflammatory Drugs for the Treatment of Pain in Knee and Hip Osteoarthritis

Swiss researchers performed a network meta-analysis in order to compare the efficacy of various types and doses of non-steroidal anti-inflammatory drugs (NSAIDs) in relieving pain related to knee and hip osteoarthritis. Their search parameters included randomized trials and relevant articles published Jan. 1, 1980–Feb. 24, 2015 that compared NSAIDs, paracetamol, or placebo for joint pain in groups of 100 participants or more. The final analysis included 76 studies involving more than 58,450 patients and seven NSAIDs or paracetamol in several different dosages. Diclofenac at a dose of 150 mg per day proved to be the most effective NSAID currently, in terms of both improved pain and greater physical function, followed by etoricoxib at 60 mg daily. Single-agent paracetamol, meanwhile, was considered a basically ineffective treatment for osteoarthritis pain, no matter the dose.

From "Effectiveness of Non-Steroidal Anti-Inflammatory Drugs for the Treatment of Pain in Knee and Hip Osteoarthritis"
The Lancet (07/08/2017) Vol. 390, No. 10090, P. E21 da Costa, Bruno R.; Reichenbach, Stephan; Keller, Noah; et al.

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Comparison of PCIA With Sufentanil vs. Tramadol in Post–Cesarean Section Pain Management and Lactation After General Anesthesia

A Chinese study of 146 women undergoing general anesthesia for cesarean section allowed researchers to compare sufentanil with tramadol for postoperative pain management in this population. Participants were randomly assigned to patient-controlled intravenous analgesia with one of the two drugs, to determine if either worked better than the other to control acute maternal pain and, thus, allow the mother to care for her baby sooner. Both cohorts experienced similar pain levels while at rest at all intervals checked; but movement-evoked pain—triggered by changing positions—was more pervasive in the sufentanil group at 4, 8, and 12 hours after c-section. The tramadol patients, meanwhile, achieved higher Quality of Recovery scores at 24 hours postoperatively as well as higher postpartum prolactin levels, which translated into an earlier start of lactation versus sufentanil patients. Based on the evidence, the team from Huazhong University of Science and Technology suggests that tramadol may be preferable to sufentanil for post-surgical pain control in women who undergo general anesthesia for c-section.

From "Comparison of PCIA With Sufentanil vs. Tramadol in Post–Cesarean Section Pain Management and Lactation After General Anesthesia"
Journal of Pain Research (07/17) Vol. 2017, No. 10, P. 1521 Chi, Xiaohui; Li, Man; Mei, Wei; et al.

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General Anesthesia No Safer Than Sedation for TAVR

More and more evidence is finding no difference in the safety and efficacy of sedation versus general anesthesia for transcatheter aortic valve replacement (TAVR), but those conclusions have been built around comparisons of outcomes. A retrospective study from the University of Miami Hospital, however, approached the question from a different angle. The focus of this investigation instead was on variables that affect anesthetic management while the surgery is still ongoing. Michael Fabbro, DO, and Richard Epstein, MD, reviewed the records of 150 patients who underwent TAVR via the transfemoral approach. A total of 92 patients received general anesthesia using a standard induction technique; and 58 were sedated, primarily with dexmedetomidine. Contrary to what the researchers expected, general anesthesia patients were not characterized by fewer cardiorespiratory perturbations; less administration of epinephrine, norepinephrine, or dobutamine to control blood; or lower volume resuscitation. Although the study was unable to establish superior safety with general anesthesia during the intraoperative period, Fabbro concedes that clinicians may take time to warm up to sedation for TAVR.

From "General Anesthesia No Safer Than Sedation for TAVR"
Anesthesiology News (07/04/17) Vlessides, Michael

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Safety and Acceptability of Patient-Administered Sedatives During Mechanical Ventilation

Mechanically ventilated patients often need sedatives to relieve their anxiety, prompting researchers to investigate the safety and acceptability of allowing them to administer the drugs to themselves as needed. The approach has persevered in 24-hour studies, but its safety is unknown at longer periods of time. The pilot trial, conducted in three intensive care units, involved 37 intubated patients who were expected to remain on ventilation for at least another 48 hours. Twenty participants were randomized to routine care, with sedative doses and frequencies dictated by the primary care team and administered by nurses; while 17 were randomized to dexmedetomidine delivered through patient-controlled analgesia (PCA) pumps. In the PCA group, five patients experienced blood pressure and heart rate levels lower than safety parameters; but none were removed from the study due to safety concerns. Some 92 percent of the dexmedetomidine patients were satisfied or very satisfied with their ability to self-administer medication, and 62 percent were happy with their ability to control anxiety. The results suggest that sedative self-administration is safe and appropriate for select patients undergoing mechanical ventilation, easing their anxiety but keeping them in a more alert state where they can participate in their own care.

From "Safety and Acceptability of Patient-Administered Sedatives During Mechanical Ventilation"
American Journal of Critical Care (07/01/2017) Vol. 26, No. 4, P. 288 Chlan, Linda L.; Skaar, Debra J.; Tracy, Mary F.; et al.

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Reducing Stress, Optimizing Coping Strategies May Diminish Need for Opioids Following Ankle Surgery

Researchers believe opioid use can be kept to a minimum after ankle fracture surgery when clinicians coach patients on coping mechanisms related to pain and help them better manage stress. The team from the University of Texas enrolled 99 adults in the study, surveying them about disability, satisfaction with surgery, and pain relief during suture removal one to two weeks following the operation. Of that number, 59 were also queried during followup five to eight months later. A total of 84 participants were taking opioids at the time of the suture-removal appointment, as were 14 of the 59 patients who participated in the longer-term followup. There was no correlation found between opioid consumption and disability or satisfaction with either the surgery or postoperative pain management. However, opioid use was independently tied to more reported pain with activity as well as with more catastrophic thinking—which, in turn, was associated with greater disability and poor response to both surgery and pain. "This is the latest in a series of studies demonstrating that pain relief after surgery or injury has more to do with calm and reassurance [self-efficacy] than with medication," said first study author David Ring, MD, PhD. He and his co-authors report in the Journal of the American Academy of Orthopaedic Surgeons that their findings indicate the need for a comprehensive approach to postoperative pain control that might involve social workers, psychologists, and psychiatrists in addition to medical doctors.

From "Reducing Stress, Optimizing Coping Strategies May Diminish Need for Opioids Following Ankle Surgery"
Medical Xpress (07/06/17)

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Surgeons Are Ditching Opioids for Ibuprofen and Novocain in the OR

In the wake of a crisis that has wreaked havoc across America, surgeons and anesthesia providers increasingly are adopting opioid-sparing techniques in the operating room. The pharmaceutical industry is working on a new generation of opioid-free painkillers; but until these innovations make it to market, existing options include established pain relievers like Novocain and intravenous acetaminophen, nerve blocks that numb only specific parts of the body, and use of massage and meditation in conjunction with pain drugs. Nerve blocks, often called regional anesthesia, are especially growing in popularity; and there is a great deal of demand for professionals who have the training and expertise needed to use ultrasound imaging to place catheters that flood the nerves with anesthetic. While the approach is seen most often in orthopedic surgeries, work is underway to apply it to kidney transplants and possibly additional complicated procedures.

From "Surgeons Are Ditching Opioids for Ibuprofen and Novocain in the OR"
Bloomberg (07/06/17) Lauerman, John

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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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July 13, 2017
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