AANA Anesthesia E-ssential

Vital Signs

Make VHA Full Practice Heard on Social Media with a Thunderclap – Enroll by July 20

To make our VHA full practice authority issue heard on social media, AANA coalition partners are organizing a social media thunderclap, and AANA invites CRNAs and student registered nurse anesthetists to participate.

A social media thunderclap allows a single message to be mass-shared all at once to be heard in a coordinated way across social media. In this case, the American Nurses Association is coordinating a single message to be broadcast over participants’ social media accounts at the same time — 11 a.m. ET/10 a.m. CT. You can view the Thunderclap effect on Twitter by following AANA (@aanawebupdates) or searching on the #APRNs4Vets hashtag at the time of the event, or any time thereafter. Advance enrollment is required.

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CPC Facts

Got Four Minutes? CPC Program Class B Credits Explained in New Video

Find out more about the Continued Professional Certification (CPC) Program's Class B requirement in the new four-minute NBCRNA video.This short animation provides an overview of the Class B requirement of the Continued Professional Certification (CPC) Program. It includes examples of various activities that may be considered for Class B credit, as well as information about what documentation is needed. Nearly 20,000 CRNAs are already in the CPC Program earning Class A and Class B credits and registering for Core Modules. AANA members can self-report Class B credits at AANA Learn.

For more information and resources about the NBCRNA's CPC Program, which will officially launch on Aug. 1, 2016, go to the cpc-facts.aana.com and NBCRNA websites.

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Hot Topics

Your Membership Matters!

Enrollment is now open for the membership period of September 1, 2016, through August 31, 2017. Renew today and continue to be part of the nearly 50,000 members-strong voice of the American Association of Nurse Anesthetists. Installment payments and automatic renewals now available!

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Medscape Separates Anesthesia Evidence from Politics in Two Comprehensive Articles

Two important articles have been published recently by Medscape that are worth your attention. The first provides a closer look at the Veterans Administration's proposed rule in a spirited exchange between AANA President Juan Quintana, DNP, MHS, CRNA and American Society of Anesthesiologists President Daniel Cole, MD. The second takes a deep look at the research on APRN/CRNA safety and how it measures up to physician care. Medscape, which is part of the WebMD healthcare network, is geared toward specialists, primary care physicians, and other health professionals.

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Open Session of July 16 AANA BOD Meeting to be Live Streamed

Pre-registration is required for the live stream of the Open Session of the AANA Board of Directors Meeting, which will be held on Saturday, July 16, 2016, at 9 am Central Time. The registration deadline is July 15. All AANA members are welcome to attend the Open Session, to be held at the AANA office, 222 S. Prospect Avenue, Park Ridge, IL.

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AANA Offers Online Research Resource Hub

As a reminder, Research Resources features valuable information for aspiring and seasoned investigators including literature on Hot Research Topics such as health workforce, quality and safety, reimbursement and alternative payment models, and healthcare delivery systems. In addition, the section includes links to the Research Webinar Series and the new Research Dataset Resources. CRNAs and students who are interested in conducting nurse anesthesia research can access this site using their AANA member login.

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36th Annual PR Recognition Awards: Call for Entries

The deadline is quickly approaching to submit your 2016 PR Recognition Award entries. These prestigious awards– five in all – are judged by the AANA Communications Committee and presented during the Opening Ceremonies at the Nurse Anesthesia Annual Congress.

Guidelines for entries can be found at Recognition Awards.

All entries need to be submitted electronically by end of business on Aug. 5, 2016.

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Quality Viewpoint Articles Available Online

Every other month, the AANA Research and Quality Division posts a new Viewpoint Article on the myAANA Quality website. These editorial-style articles are also published in the AANA News Bulletin and feature timely information and perspectives on pertinent issues and challenges related to quality reporting and health payment policy reform. Be sure to check out the latest article on the “PQRS Report Card for CRNAs”.

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#AANA2016: Reserve Your Hotel Room Soon!

#AANA2016 will held at the historic Washington Marriott Wardman Park—be sure to book your room by August 19 to take advantage of conference rates. The largest hotel in D.C., the Wardman is conveniently located next to the Woodley Park Metro station. Also, if you haven’t booked your flight, take advantage of our special airline and car rental discounts promo codes.

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AANA Press Release Corrects Misperceptions About CRNAs

A new press release from the AANA titled “Five Things You Might Not Know About CRNAs” provides the facts and answers some incorrect claims about CRNAs.

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Professional Practice

Health Volunteers Overseas in Need of CRNA Volunteers

Health Volunteers Overseas (HVO) has a pressing need for volunteers. Contact Chelsea Dascher, at c.dascher@hvousa.org if interested.

  • Laos - Seeking volunteers for 2016 and 2017 to provide clinical and didactic instruction to students enrolled in Laos Friends Hospital for Children nurse anesthetist training program.
  • Bhutan - Nurse educators needed to provide education for nurse anesthesia students, residents, and professionals in the areas of informatics, statistics, teaching methods, evidence-based practice, health promotion, and health policy.
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Joint Commission Dispels Myths about Sharing Information with Patients and Families

The Joint Commission has issued a white paper promoting open communication with patients and families with the aim of improving the transparency, cost effectiveness, and safety of healthcare. This paper, developed with input from its Patient and Family Advisory Council, dispels myths healthcare providers commonly have about sharing information with patients and their caregivers and families. Myths addressed include misinterpretations of the HIPAA Privacy and Security regulations, concern about the threat of lawsuits, views that patients aren’t willing or able to discuss their healthcare, misperceptions that patients and healthcare providers don’t define quality care the same way, and beliefs that patient engagement does not lead to improved outcomes. The Joint Commission busts these myths and provides examples and recommendations for improving patient engagement.

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Meetings and Workshops

#AANA2016: Get Inspired, Connect with Colleagues, Grow Your Knowledge

Join us in our nation's capital September 9-13 for our profession's premier educational, professional, and social event! Highlights include:

  • Keynote speaker LTG Patricia Horoho, ANC, USA(ret), 43rd U.S. Army Surgeon General, detailing her experiences during the 9/11 attack on the Pentagon
  • Two additional educational tracks: Continued Professional Certification (CPC) Program Review and Enhanced Recovery After Surgery (ERAS)
  • Neuraxial Regional Anesthesia-Epidural Pre-Congress Workshop
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Registration Open Now for Fall Leadership Academy

Learn to lead at any level, in all practice settings, at the Fall Leadership Academy: November 11-13, 2016, in Rosemont, Ill. Featuring more than 20 expert speakers and five educational tracks, Fall Leadership Academy is designed to expand your leadership skills as well as your network of colleagues.

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Save the Dates for These Popular Hands-On Workshops

Visit Meetings for further information and to register!

Upper and Lower Extremity Nerve Block Workshop

  • AANA Foundation Learning Center
  • September 24-25, 2016

Jack Neary Pain Management Workshop II

  • Rosemont, IL
  • October 29-30, 2016

Essentials of Obstetric Analgesia/Anesthesia Workshop

  • AANA Foundation Learning Center
  • November 2, 2016

Spinal and Epidural Workshop

  • AANA Foundation Learning Center
  • November 3-5, 2016
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Foundation and Research

AANA Foundation Fundraiser to Feature Capitol Steps

Capitol Steps will be performing at the AANA Foundation fundraiser Stepping Out in DC on Sunday, September 11, 2016, from 7 – 11:45 pm at Washington Marriott Wardman Park. Ticket includes dinner, drinks, entertainment, and the Dance Party. We’re in DC during an election year with the Capitol Steps, so for this patriotic event wearing red, white or blue seems appropriate, or you can even dress as your favorite politician!

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Don’t Forget to Buy Tickets to Shake It for a Cause Dance Party

Plan to “celebrate” with us on Sunday, September 11, 2016, from 9:30 – 11:45 pm at the Shake It for a Cause Dance Party at Washington Marriott Wardman Park. Tickets are $50 for CRNAs and $25 for students. If you’re planning to attend Stepping Out in DC, the dance party ticket is included. In the meantime, check out our Foundation board members preparing for the dance party… http://bit.ly/JibJab11

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Federal Government Affairs

Blue-Ribbon Federal “Commission on Care” Supports Full Practice for VHA APRNs; Issue Status Update in Washington

In its July 7 report to the Obama administration, the Commission on Care, a federal blue-ribbon panel planning the future of the Veterans Administration, recommended full support of the VA’s proposed rule authorizing full practice authority for CRNAs and other APRNs in VHA facilities.

“The evidence cannot be denied,” said AANA President Juan Quintana, DNP, MHS, CRNA, in a statement. “The commission’s final report, delivered to the White House Tuesday evening, is one more data-driven document that highlights the need for allowing APRNs, including CRNAs, to have full practice authority as a major step toward increasing veterans access to quality healthcare.” The report is the fourth major federal advisory report recommending full practice for CRNAs and other APRNs, the other three being the National Academy of Medicine report The Future of Nursing, a Federal Trade Commission report on APRN regulation, and the 2015 Independent Assessment of the VA.

Read the Commission on Care’s full report.
In addition:

  • Regulation: Less than two weeks remain before the public comment period expires July 25 on the Department of Veterans Affairs proposed rule on APRN full practice authority. As of July 11, the Federal Register reported having more than 56,000 comments submitted to the rule; more than 25,400 comments have been submitted through the AANA’s Veterans Access to Care campaign.
  • Legislation: The AANA continues to encourage members of the U.S. House of Representatives to cosponsor the “Improving Veterans Access to Quality Care Act” (H.R. 1247) and members of the Senate to cosponsor the “Veterans Health Care Staffing Improvement Act” (S. 2279), which have 57 and 11 bipartisan cosponsors respectively, including Congresswoman Karen Bass (D-CA) who joined as a cosponsor on July 6. Be sure to thank your U.S. Senators and Representatives who have supported expanding veterans access to care through full practice authority for CRNAs and other APRNs.
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Less Than Two Weeks Remain before VHA APRN Rule Comment Period Ends July 25; Have You Taken Action Yet?

Time is short, with less than two weeks remaining before the VHA APRN full practice authority proposal comment period ends on July 25, so be sure you and your colleagues, friends, and family members are heard on this critical issue! The Federal Register reports over 56,000 comments filed, and more than 25,400 comments have been submitted through the AANA’s Veterans Access To Care campaign site.

Already, 16 states have met or exceeded their goal of 33 percent of membership submitting comments through the campaign. Further, CRNAs who are VA employees have been given the go-ahead by their employer to submit comments, provided that they comment as private citizens, and professionals and do not use their VA office or title in the comment. More than 83 media outlets have covered the issue, many driven by AANA public relations efforts. Most recently the issue was covered extensively in a Medscape interview with AANA President Juan Quintana, DNP, MHS, CRNA, and American Society of Anesthesiologists (ASA) President Daniel Cole, MD, with the AANA’s evidence clearly trumping the ASA’s politics. Opposition to the proposal continues being aggressively organized by ASA, which has kept wrongly accusing the VA of promoting a lower standard of care and putting veterans’ health and safety at risk.

To help make this proposed rule a final rule and the law of the land, every AANA member is being asked to:

  1. Submit a comment through Veterans Access To Care.
  2. Share with family, friends and colleagues, especially veterans.
  3. Watch for AANA CRNAdvocacy alerts to contact your members of Congress and be heard on Capitol Hill as needed.
  4. Spread our message for increasing veterans access to care and reducing their wait times by sharing news articles and personal experiences on your Facebook and Twitter social media platforms, using the hashtags #CRNAs4Vets and #ForOurVets. You can also share content from the AANA Facebook and Twitter feeds.
  5. Consider making a contribution to your CRNA-PAC at CRNA-PAC. Governed by AANA members and funded solely by members’ voluntary contributions, our CRNA-PAC helps make CRNAs heard on Capitol Hill as it supports federal candidates and campaigns that are CRNA-friendly and influential on CRNA issues.
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House Appropriations Committee to Consider Legislation Funding HHS, Title VIII Nurse Workforce Development Programs

The full House Appropriations Committee will mark up its FY 2017 Labor, Health and Human Services, and Education legislation on July 13. The legislation previously cleared by the House Labor-HHS Subcommittee on July 7 helps fund Title 8 nurse workforce development programs supported by AANA and other nursing organizations.

The legislation includes $73.2 billion for HHS, which is an increase of $2.6 billion from last year and about $3.5 billion more than President Obama’s request. Included is funding for the Title VIII Nursing Workforce Development programs. In written testimony provided to the committee in March, AANA President Juan Quintana, DNP, MHS, CRNA, expressed support for nurse anesthetist traineeships and other CRNA programs and recommended that the committee increase overall nurse educational funding to $244 million. The AANA and other members of the nursing community continue to work with members of the Appropriations Committee to support funding for this important initiative.

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Government Accountability Office (GAO) Issues Report on Drug Shortages

Drug shortages continue to be a challenge for CRNAs. The reasons are spelled out in a new publication released by the Government Accountability Office (GAO) on July 7, titled “Drug Shortages: Certain Factors Are Strongly Associated with This Persistent Public Health Challenge.”

Of note to CRNAs, the report found that: “Shortages of sterile injectable anti-infective and cardiovascular drugs in 2012, 2013, and 2014 were strongly associated with certain factors GAO examined. Two factors—a decline in the number of suppliers and failure of at least one establishment making a drug to comply with manufacturing standards resulting in a warning letter—suggest that shortages may be triggered by supply disruptions. A third factor—drugs with sales of a generic version—suggests that due to relatively low profit margins for generic drugs, manufacturers are less likely to increase production, making the market vulnerable to shortages.” The report also said that though the overall number of drug shortages has remained stable after years of significant increases, the number of new shortages has been declining, but the number of existing shortages not resolved from one year to the next has been increasing.

The AANA supported enactment of a federal statute expanding the FDA’s ability to combat drug shortages, which expires in 2017. The AANA will be working closely with Congress to reauthorize this statute during the coming year. Read the new GAO report.

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Medicare Proposes 2017 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Rule; AANA Preparing Comment by September 6 Deadline

The Centers for Medicare & Medicaid Services (CMS) on July 6 released a preview of the CY 2017 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs (HOPPS) proposed rule.

Of specific interest to CRNAs, the proposed rule includes a request for comment on a quality measure of note. For the Hospital Outpatient Quality Reporting (OQR) program beginning in CY 2020, CMS is proposing to add a measure which assesses variations in patient outcomes following surgery at a hospital outpatient department. CMS is also seeking comment on a future clinical quality measure that addresses concerns associated with overlapping or concurrent prescribing of opioids and benzodiapines. For the Ambulatory Surgical Center Quality Reporting (ASCQR) Program, CMS is requesting comment on adding one anesthesia-related outcome measure beginning in CY 2020: the Normothermia Outcome, which assesses the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration who are normothermic within 15 minutes of arrival in the post-anesthesia care unit. The AANA is reviewing this proposal closely for possible impacts on or opportunities for CRNA practice and reimbursement, and to inform the profession’s response during the public comment period ending Sept. 6, 2016.

Read the fact sheet on the proposed rule provided by CMS.

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AANA Preparing Comment on Medicare’s Physician Fee Schedule Proposed Rule

On July 7, the Centers for Medicare & Medicaid Services (CMS) released a preview of the CY 2017 Physician Fee Schedule proposed rule with comments due Sept. 6.

In the proposed rule, CMS estimates that the CY 2017 national anesthesia conversion factor (CF) will be $21.9756, down about 0.1 percent from $21.9935 in 2016. The regular physician CF for CY 2017 is estimated to be $35.7751, also down about 0.1 percent from $35.8043 in 2016. Medicare continues to pay fee-for-service anesthesia according to the formula (base units + time units) x (anesthesia CF). Certain non-anesthesia services commonly provided by CRNAs, such as line insertions, are paid under the regular physician CF. According to its Table 43 on p. 788, allowed 2017 charges for anesthesiology are $1.977 billion, a zero percent increase in the combined impact on total allowed charges of all the proposed relative value (RVU) changes. For nurse anesthetists/anesthesiologist assistants, allowed 2017 charges are $1.211 billion, also a zero percent increase in the combined impact on total allowed charges of all the proposed RVU changes. (Though the overall allowed charge for anesthesiology is different than for CRNAs, they remain subject to the same anesthesia CFs.) Total Medicare PFS estimated allowed charges are $89.467 billion for 2017, with no change year over year.

Of interests to CRNAs, the agency:

  • Proposes a uniform methodology for valuation of procedural codes that currently include moderate sedation as an inherent part of the procedure (pp. 107-109, p. 352 and Table 22 pp. 356-367).
  • Seeks public comment on several new, revised, and potentially misvalued CPT codes. This is a new process which the AANA advocated for in previous PFS and which allows an opportunity for all types of healthcare professionals, including CRNAs (p. 235 and Table 23 pp. 374-394).
  • Is not proposing any changes to the valuation of CPT codes 00740 and 00810 (anesthesia for lower GI procedures), but noted that these codes are potentially misvalued and is looking forward to receiving input from interested parties during future notice and comment rulemaking (p.287 and p. 374).
  • Proposes values for new epidural injection codes (p. 322).
  • Notes that the AMA CPT Editorial Committee created separate codes for the reporting of moderate sedation and seeks public comment on values for these codes (pp. 353-354).
  • Notes that the Value Modifier (VM) will apply to CRNAs in the CY 2018 payment adjustment period (p. 726).

The AANA is analyzing this proposed rule further and is preparing comments.

See the fact sheet with a link to the rule.

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Making CRNA Voices Heard: AANA Participating in Republican and Democratic National Conventions

Policy leaders and influencers from around the country will be present in Cleveland, Ohio, for the Republican National Convention, July 18-21, and in Philadelphia, Pa., for the Democratic National Convention, July 25-28. The AANA and CRNAs will be present to represent the voice of the nurse anesthesia profession on site.

Led by President Quintana, an AANA delegation will attend political events and policy forums with leaders from inside and outside the healthcare industry, and from both major political parties.

The highlight of AANA’s activities will be health policy luncheons on July 19 at the RNC and July 26 at the DNC, developed in partnership with the American Nurses Association, Walgreens, the American Podiatric Medical Association, and our media partner, Real Clear Politics. Both events take place from noon-2 p.m. Eastern, and will be live-streamed online at Real Clear Politics.

Stay tuned for more information and be sure to engage with AANA’s national convention activities on Facebook and Twitter (hashtags #AANA and #CRNA).

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  • The House and Senate are in session during the week of July 11, before breaking July 15 for political conventions and the August recess. You can access the House calendar and the Senate calendar to see where your members of Congress will be this summer and fall. If you plan to see your legislators in Washington or at home, let us know by emailing info@aanadc.com.
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The following is an FEC required legal notification for CRNA-PAC

Gifts to political action committees are not tax deductible. Contributions to CRNA-PAC are for political purposes. All contributions to CRNA-PAC are voluntary. You may refuse to contribute without reprisal. The guidelines are merely suggestions. You are free to contribute more or less than the guidelines suggest and the association will not favor or disadvantage you by reason of the amount contributed or the decision not to contribute. Federal law requires CRNA-PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. Each contributor must be a US Citizen.

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Visit www.crnacareers.com 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.

Research Finds Childbirth Education Program Dramatically Reduces Medical Interventions at Birth

A novel study in Australia has demonstrated the value of childbirth classes focused on pain management. The randomized controlled trial found that teaching moms-to-be how to use acupressure, relaxation, massage, breathing techniques, and other strategies for pain relief significantly lowers the rate of medical interventions during labor and delivery. For example, only 23.9 percent of expecting mothers exposed to these complementary medicine-based disciplines required epidurals—markedly fewer than the 68.7 percent of women in the control group who needed the block. Women in the study group also experienced fewer cesarean deliveries, were less likely to have perineal trauma, spent less time in the second stage of labor, and were less likely to have their labor accelerated through artificial means. Also, newborns in the study group were less likely to require resuscitation at birth. The study was reported in the medical journal BMJ Open.

From "Research Finds Childbirth Education Program Dramatically Reduces Medical Interventions at Birth"
Medical Xpress (07/13/16)

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Peri-op Clonidine: Benefits Not There, But Hypotension Is

Although the blood pressure drug clonidine has long been used for sedation and analgesia, a new study from the Cleveland Clinic cautions that the practice actually could harm patients by causing hypotension. Researchers recruited 624 patients having noncardiac surgery under general or spinal anesthesia. Participants were randomized to receive clonidine or placebo orally before surgery and then through a patch on the skin kept in place for 72 hours postoperatively. Comparisons revealed no meaningful difference in pain levels or opioid use between the two sets of patients. Meanwhile, a meta-analysis of five existing studies determined that clonidine has no impact on pain at 24 or 48 hours following surgery. The Cleveland Clinic's Alparslan Turan, MD, advised clinicians to "bear in mind that by giving clonidine you are not going to decrease pain scores or opioid consumption, but at the same time you may increase the risk of intraoperative hypotension."

From "Peri-op Clonidine: Benefits Not There, But Hypotension Is"
Anesthesiology News (07/12/16) Vlessides, Michael

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Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period

A recent study sought to characterize the risk of chronic opioid use among opioid-naive patients following various surgical procedures compared with nonsurgical patients. The retrospective analysis used health insurance claims between 2001 and 2013 for 11 procedures, including total knee arthroplasty (TKA), laparoscopic cholecystectomy, and open appendectomy. In all, about 641,900 opioid-naive surgical patients and more than 18 million opioid-naive nonsurgical patients were studied. The researchers found that among those undergoing surgery, the incidence of chronic opioid in the first preoperative year ranged from 0.119 percent for Cesarean delivery to 1.41 percent for TKA. For nonsurgical patients, the baseline incidence of chronic opioid use was 0.136 percent. Seven of the procedures were associated with a higher risk of chronic opioid abuse. Patients who may be particularly at risk include men and those with a preoperative history of drug abuse. Further research should investigate whether these findings apply to other surgical procedures and patient populations, the researchers suggest.

From "Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period"
JAMA Internal Medicine (07/11/16) Sun, Eric C.; Darnall, Beth; Baker, Laurence C.; et al.

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5 Insights on Pain Management Following Outpatient ACL Reconstruction

A new study analyzed results from 77 randomized controlled trials investigating pain management following ACL reconstruction in the outpatient setting. Based on the literature, they concluded that early mobilization helped calm pain symptoms. They also determined that regional nerve blocks and intra-articular injections successfully provided post-surgical analgesia. The same was true for cryotherapy-compression, but only when intra-articular temperatures were adequately lowered. Additionally, it was found that gabapentin, ibuprofen, ketorolac, and zolpidem curbed the need for opioids. Reporting in The American Journal of Sports Medicine, the review authors emphasized that "further research is needed to determine the optimal multimodal approach that can maximize recovery while minimizing pain and opioid consumption."

From "5 Insights on Pain Management Following Outpatient ACL Reconstruction"
Becker's ASC Review (07/16) Vaidya, Anuja

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New Pain Control Option Identified for Gynecologic Cancer Surgery

An enhanced recovery after surgery (ERAS) pathway using bupivacaine hydrochloride is the go-to pain protocol for women with gynecologic cancer, but researchers say better results can be achieved by pairing ERAS with liposomal bupivacaine instead. The approach, which has been successful with a number of other procedures, curtailed the need for narcotic pain medication and reduced nausea and ileus in patients following staging laparotomy or complex cytoreductive surgery. Overall narcotic use in the first 48 hours after surgery declined 55 percent compared with ERAS with bupivacaine hydrochloride, while patient-controlled analgesia (PCA) was cut from 30 percent to 4 percent. "The results of the study have a huge potential to change practice," suggests Gregg Nelson, MD, from the Department of Gynecologic Oncology at the Tom Baker Cancer Centre in Calgary. The doctor, who was not involved in the research, believes that incorporating liposomal bupivacaine into an ERAS approach using multimodal analgesia could ultimately supplant PCA—which can cause fatigue, nausea, and ileus—and epidurals, which have high failure rates.

From "New Pain Control Option Identified for Gynecologic Cancer Surgery"
Clinical Oncology (07/16) O'Rourke, Kate

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Study Finds Preoperative Falls Common Among Adults of All Age Groups

Preoperative falls—which have been associated with surgical complications and poor outcomes—are quite common, based on an observational study reported in Anesthesiology. Researchers at Washington University School of Medicine in St. Louis followed 15,000 adults undergoing a variety of procedures, finding patients with arthritis, incontinence, dizziness, impaired mobility, and poor perceived health most prone to falls. Moreover, they discovered that such accidents are not limited to the elderly and, most surprisingly, that they actually occur most frequently among the middle-aged. Because falls also were correlated with a lower quality of life and inability to perform everyday tasks—such as using the bathroom without help—the study also suggests that patient history of tumbles could be a valuable tool for evaluating overall health prior to an operation. "Falls before surgery have not been rigorously studied, but our results point to the need for further exploration," remarked medical student and lead author Vanessa Kronzer.

From "Study Finds Preoperative Falls Common Among Adults of All Age Groups"
News-Medical.net (07/04/2016)

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The Effect of Intrathecal Morphine Dose on Outcomes After Elective Cesarean Delivery: A Meta-Analysis

Researchers conducted a meta-analysis to determine whether a low dose (LD) or a high dose (HD) of intrathecal morphine provides adequate duration and intensity of analgesia with fewer side effects during cesarean delivery. A literature search identified 11 randomized controlled trials that satisfied the inclusion criteria; all compared LD morphine with HD morphine in women undergoing elective cesarean delivery under spinal anesthesia. The resulting study population included 480 patients—233 in the HD cohort and 247 in the LD cohort. Mean time to first analgesic request—the primary outcome—was longer in the HD group compared with the LD patients, but nausea/vomiting and pruritus occurred less frequently in the LD group. The research shows that HDs of intrathecal morphine prolong analgesia after cesarean delivery compared with lower doses. Clinicians must weigh the benefits of that extended relief, however, against the potential for side effects.

From "The Effect of Intrathecal Morphine Dose on Outcomes After Elective Cesarean Delivery: A Meta-Analysis"
Anesthesia & Analgesia (07/16) Vol. 123, No. 1, P. 154 Pervez, Sultan; Halpern, Stephen H.; Pushpanathan, Ellile; et al.

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Risk of Blindness From Spine Surgery Down Significantly

The risk of blindness caused by spinal fusion has declined about 60 percent since the late 1990s, reports anesthesiology professor Dr. Steven Roth and colleagues at the University of Illinois at Chicago. Based on data from the Nationwide Impatient Sample, the team estimated that 2,511,073 spinal fusions were performed between 1998 and 2012, resulting in 257 instances of ischemic optic neuropathy—or 1.02 per 10,000 surgeries. While the threat is down nearly three-fold over that time span, the researchers did observe a significantly increased risk among men, anyone older than 50, patients who received a blood transfusion during the procedure, and obese individuals. Roth attributes the lower risk to greater use of minimally invasive surgical techniques but also believes that changes in anesthesia practice may be contributing to the trend. Many anesthesia providers now set a stricter limit for how low they will allow blood pressure to fall during surgery, which may help reduce the risk for ischemic optic neuropathy.

From "Risk of Blindness From Spine Surgery Down Significantly"
Science Codex (07/01/16)

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The Use of Electrical Impedance to Identify Intraneural Needle Placement in Human Peripheral Nerves

Researchers believe that, like ultrasound imaging and electrical stimulation, electrical impedance (EI) can play a role in detecting intraneural needle placement during peripheral nerve blockade. To demonstrate the technique's potential, they compared differences in EI measurements between intraneural and extraneural needle placements on recently amputated limbs. No more than 45 minutes after amputation, ultrasound imaging guidance was used on the specimens for extraneural placement of an insulated peripheral block needle connected to a nerve simulator. The needle was then advanced intraneurally. Researchers repeated the process on the same nerves, the tibial nerve for below-the-knee amputations and the sciatic nerve in the popliteal fossa for above-knee amputations, after exposure by surgical dissection. Intraneural impedance was significantly higher than extraneural EI, both before and after surgical dissection. The study concluded that measurement of EI in conjunction with nerve simulation could be a simple and valuable way to identify intraneural needle placement—and avoid resulting neural injury—during peripheral nerve blockade.

From "The Use of Electrical Impedance to Identify Intraneural Needle Placement in Human Peripheral Nerves"
Anesthesia & Analgesia (07/16) Vol. 123, No. 1, P. 228 Vydyanathan, Amaresh; Kosharsky, Boleslav; Singh, Nair; et al.

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Justice Department to Make $40 Million Available for Victims of Deadly Meningitis Outbreak

Officials from the U.S. Department of Justice expect to make $40 million available to victims of a fungal meningitis outbreak that was linked to contaminated steroid injections. The outbreak affected more than 770 people, and there were 76 deaths. Two years ago, federal prosecutors charged more than a dozen people in a 131-count indictment, asserting that employees at the New England Compounding Center (NECC) were aware they were producing medication in an unsafe and unsanitary way and still shipping it to customers. The company's owner and supervisory pharmacist were charged with 25 acts of second-degree murder and will head to trial later this year. According to Justice officials, the money will come from the Office for Victims of Crime's Crime Victims Fund. They will work with authorities in Massachusetts, where NECC is located and where the criminal case was brought, on a grant award to help affected individuals across the United States receive compensation.

From "Justice Department to Make $40 Million Available for Victims of Deadly Meningitis Outbreak"
Washington Post (07/07/16) Zapotosky, Matt

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Surgery for Kids: Send in the Clowns!

Adding to earlier work showing that medical clowns soothe kids during blood draws, sexual abuse exams, and other procedures, new research finds this to also be true for surgery-related pain. For the study, published online in the Journal of Paediatrics and Child Health, researchers enrolled 80 boys aged two to 16 years who were scheduled for penile meatotomy. Half were randomized to have a clown—knowledgeable about surgical anatomy, the medical condition being treated, and operating room (OR) function—accompany them through the process. Those children exhibited lower stress levels, did not need as long to induce anesthesia, spent less time in the OR, and resumed normal activities faster. As an added benefit, overall medical costs were lower for these patients. Based on the positive impact on preoperative anxiety, postoperative pain, and speed of anesthesia induction in this small subset of kids, the researchers recommend further research involving larger surgical patient populations.

From "Surgery for Kids: Send in the Clowns!"
MD Magazine (06/30/2016) Wick, Jeannette

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An Exploratory Human Laboratory Experiment Evaluating Vaporized Cannabis in the Treatment of Neuropathic Pain From Spinal Cord Injury and Disease

Researchers conducted a randomized laboratory experiment involving the administration of vaporized cannabis in patients with neuropathic pain related to spinal cord injury and disease. A total of 42 participants underwent a standardized procedure for inhaling four puffs of vaporized cannabis containing placebo, 2.9 percent concentration, or 6.7 percent concentration delta-9-tetrahydrocannabinol (9-THC) on three different occasions. The researchers report that vaporized cannabis positively affected all of the neuropathic pain descriptors, and there was significantly more pain relief with active cannabis compared to placebo. Because the two active doses did not significantly differ from each other in terms of analgesic potency, the weaker formulation appears to offer the best risk-benefit ratio in patients with neuropathic, spinal cord-related pain.

From "An Exploratory Human Laboratory Experiment Evaluating Vaporized Cannabis in the Treatment of Neuropathic Pain From Spinal Cord Injury and Disease"
The Journal of Pain (06/07/2016) Wilsey, Barth; Marcotte, Thomas D.; Deutsch, Reena; 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.

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July 15, 2016
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