Anesthesia E-ssential

AANA Anesthesia E-ssential
Membership Matters

Vital Signs

President Nimmo Updates Membership on Healthcare Reform

In a letter dated June 30, AANA President Cheryl Nimmo, DNP, MSHSA, CRNA, updated the AANA membership on the latest healthcare reform efforts in Congress and the AANA's actions during negotiations. 

"The U.S. Senate recently unveiled draft legislation to repeal and replace the Affordable Care Act (ACA), but was unable to move forward with the bill this week after failing to find enough Republican senators or any Democratic senators willing to support it," the message began. "The legislation is likely to change frequently before the Senate holds a vote. During this time, the AANA will remain a voice offering positive solutions to healthcare reform."
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Hot Topics

MIPS 2017 CMS Approved QCDR List Released

The much-awaited Centers for Medicare & Medicaid Services approved Qualified Clinical Data Registry (QCDR) List has been released. The AANA Research and Quality division has identified at least seven QCDRs that specifically cater to anesthesia professionals. These entities have self-nominated and demonstrated that they meet the applicable requirements outlined by CMS at 42 CFR §414.1400 and in the CY 2017 Quality Payment Program final rule with comment period. Individual MIPS clinicians and groups wishing to submit MIPS data via a QCDR for the 2017 performance period are encouraged to review the list below before making a selection. Each of the 2017 QCDRs has provided detailed information, including their contact information, the measures, activities, and performance categories they support, services offered, and costs incurred by their clients. View the complete 2017 QCDR List today! For an QPP_2017_CMS_Approved_QCDRs-anesthesia, visit the AANA Quality-Reimbursement page
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New AHRQ Report Shows Sharp Rise Among Women for Opioid-Related Hospital Stays

Hospitalizations involving opioid pain relievers and heroin increased 75 percent for women between 2005 and 2014, a jump that significantly outpaced the 55-percent increase among men, according to a new report from the Agency for Healthcare Research and Quality (AHRQ). Learn more and download the entire report from AHRQ’s press release. 
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Pharmacy Executive Gets 9 Years for Deadly Meningitis Outbreak that Killed 76 People

Barry Cadden, president, part owner and chief pharmacist for the New England Compounding Center (NECC), the firm blamed for a fungal meningitis outbreak in 2012, was sentenced to nine years in prison after his conviction on racketeering and mail fraud charges. Cadden was one of 14 people indicted Dec. 16, 2014, after a two-year federal investigation of the fungal meningitis outbreak that sickened over 750 patients, killing 76, in 23 states. Read the USA Today article here.
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Professional Practice

Succinylcholine Recalls from Fagron and PharMEDium

The following secondary recalls have been announced as a result of Hospira’s June 15, 2017, recall announcement that microbial growth was detected during a routine simulation of the manufacturing process and therefore there was a lack of sterility assurance.
  • Fagron Sterile Services is voluntarily recalling three lots of Succinylcholine Chloride 20mg/mL 5mL syringe. 
  • PharMEDium Services is voluntarily recalling specific lots of Potassium Phosphate and Succinylcholine Chloride.
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The Joint Commission Revises Medication Management Standards

According to The Joint Commission, these standards, effective January 1, 2018, have been updated to reflect evidence-based practices and quality and safety issues identified in the field. The revisions include:
  • Adding wasting of medications to the policy addressing control of medication.
  • Implementing a policy describing automatic dispensing cabinet (ADC) medication override types that will be reviewed for appropriateness and frequency of review.
  • Recording the date and time of any medication administered in the patient’s clinical record.
  • Implementing a policy requiring emergency backup for essential medication dispensing equipment, such as ADCs.
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Meetings and Workshops

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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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.

Epidural Neostigmine Versus Fentanyl to Decrease Bupivacaine Use in Patient-Controlled Epidural Analgesia During Labor

Adding an agent like fentanyl to an epidural infusion can lower anesthetic use in laboring mothers, but opioids also elevate the risk of additional side effects. Because of this, researchers at Wake Forest School of Medicine posited that neostigmine—which also reduces anesthetic load—might be a better epidural adjuvant. To investigate, they compared total hourly bupivacaine consumption in women receiving epidurals who were randomly assigned to patient-controlled analgesia with either bupivacaine plus fentanyl or bupivacaine plus various doses of neostigmine. With 151 patients evaluated for the final analysis, the team discovered comparable levels of local anesthetic use between the different cohorts. Patients who received fentanyl consumed 16.0 ml per hour; while women in the neostigmine groups consumed 16.2, 15.3, or 14.6 ml based on the dosage. Although both fentanyl and neostigmine produced similar and adequate labor pain relief, fentanyl is the more affordable of the two options. Still, the researchers conclude, neostigmine may be the most prudent choice in cases when the patient wants to avoid opioid exposure because of previous addiction or other reasons.

From "Epidural Neostigmine Versus Fentanyl to Decrease Bupivacaine Use in Patient-Controlled Epidural Analgesia During Labor"
Anesthesiology (07/17) Vol. 127, No. 1, P. 50 Booth, Jessica L.; Ross, Vernon H.; Nelson, Kenneth E.; et al.

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New Anesthesia Dosing Models May Increase Safety of Remifentanil for Obese Patients and Children

Refined dosing models for remifentanil could make the anesthetic safer for certain patients, according to the researchers who developed them. Dosing volume traditionally has been determined by a patient's actual body weight, which can cause unnecessary pain in children who do not receive enough of the drug or potentially fatal complications in obese patients who are administered too much of it. A team led by Talmage Egan, MD, who chairs the anesthesiology department at the University of Utah Health Sciences Center, derived one of the new models from data extracted from nine previously published data sets. It provides calculations for accurate dispensing for both obese and normal-weight people. "We found that in very obese patients, we cannot simply calculate the amount of reminfentanil needed based solely on a patient's measured weight," Egan reports. "If you base the dose solely on total body weight for an obese patient, the dose will be much too high. A person who weighs five times as much as a lean person doesn't need five times the anesthetic dosage." The second new dosing model—the only one to date that is appropriate for both adults and children—considers age, weight, gender, and fat-free mass. The investigators discovered that infusion rates vary, depending on a child's age. Those younger than five years old need about 1.75 times the dose in adult patients, while patients between five and 20 years old only require about 1.5 times the adult dosage. "Having a single model for both children and adults is safer," according to Egan. "Our model appears to work better than adult-only or children-only models." He cautioned that both models require additional investigation.

From "New Anesthesia Dosing Models May Increase Safety of Remifentanil for Obese Patients and Children"
Medical Xpress (06/29/17)

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Study Finds Link Between New Opioid Use and Increased Risk of Cardiac Death in Older Adults With COPD

While opioids can calm symptoms of chronic obstructive pulmonary disorder (COPD)—including persistent cough and shortness of breath—evidence suggests that new use of the drugs elevates risk of cardiac death in geriatric patients. Canadian researchers reviewed the records of more than 130,000 community-dwelling residents and more than 14,000 residents of long-term care facilities in Ontario, all of whom were older than 65 years and diagnosed with COPD. The analysis showed that, compared with non-opioid use, recently initiated use of opioid analgesics increased coronary artery disease-related death by 215 percent among long-term care residents and by 83 percent among COPD patients living at home. Nicholas Vozoris, MD, who led the team from St. Michael's Hospital, noted that opioids can lower blood oxygenation levels and increase inflammatory factors in the blood vessels—both of which can hurt the heart. "One other important reason they might be linked to future risk of heart attacks is because they offer pain relief, which could reduce or take away chest pain that acts as a warning before a cardiac event," he added. Vozoris and colleagues reported their findings in the European Journal of Clinical Pharmacology.

From "Study Finds Link Between New Opioid Use and Increased Risk of Cardiac Death in Older Adults With COPD" (06/29/2017)

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Drugmakers Are Racing to Find Alternatives to Opioids

Drug manufacturers are giving new urgency to efforts to develop better pain medication. The potent efficacy of narcotic painkillers like morphine, fentanyl, and oxycodone has spawned a market that today is valued at $4 billion; but opioids also have cost the country dearly in terms of addiction, overdoses, and fatalities. With regulatory scrutiny on the rise, the pharmaceutical industry is exploring a number of possibilities. One is built on synthetic capsaicin, the active ingredient in chili peppers. In mid-stage testing, a single injection delivered up to six months of substantial relief to arthritic participants by reducing the ultra-sensitive nerve endings in the knee. Other candidate drugs designed to alleviate pain from osteoarthritis are classified as nerve-growth-factor inhibitors, which work by blocking pain signals in nerve cells in the skin, muscle, and other parts of the body besides the brain. Some drugmakers, meanwhile, are focusing on experimental treatments that channel the pain-modifying properties of cannabis. Also in the pipeline are Nav 1.7 sodium ion channel blockers, which modulate a newly discovered pathway in the body that affects pain. Yet another experimental pain drug uses a toxin found in cone snails as part of an intravenous injection. Even as some companies strive to create brand new analgesic options, others are bent on modifying existing opioids to render them safer and less addictive.

From "Drugmakers Are Racing to Find Alternatives to Opioids"
Bloomberg (06/28/17) Chen, Caroline

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Use of Fentanyl Patches in Nursing Homes Persists After FDA Warning

The Food and Drug Administration (FDA) has since 2005 warned about the risks of transdermal fentanyl patches, particularly among opioid-naive patients, but nursing homes have not completely phased out the long-acting analgesics. A study led by Camilla Pimentel, MPH, PhD, of the University of Massachusetts Medical School analyzed a sample of Medicare patients living in long-stay facilities in 2011. Of more than 12,250 patients who received the patch within 30 days of admission that year, 9.4 percent had not taken opioid analgesics in the prior 60-day period. The practice, according to Pimentel, is contrary to FDA recommendations, which indicate that the long-acting opioids "should only be given to patients who have developed tolerance to opioid medications through regular treatment with other opioids. Otherwise, they are at higher risk of unintentional fatal overdose because of respiratory depression." Although use of the patch persists in opioid-naive patients in nursing homes, Pimentel and colleagues report in the Journal of the American Geriatric Society, use of long-acting opioids overall is down in this setting, accounting for just 5 percent of all long-stay Medicare nursing home residents.

From "Use of Fentanyl Patches in Nursing Homes Persists After FDA Warning"
Pain Medicine News (06/28/2017) Rosenthal, Thomas

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Liposomal Bupivacaine, Dexamethasone Reduced Postoperative Pain After Shoulder Arthroplasty

New evidence links intraoperative liposomal bupivacaine and intravenous dexamethasone to positive outcomes in patients undergoing shoulder surgery. The study had two treatment cohorts—both of which included multimodal pain management with preoperative and postoperative opioids, gabapentin, nonsteroidal anti-inflammatory drugs, acetaminophen, and single-injection interscalene block. Patients in one group, however, also were administered liposomal bupivacaine during the procedure along with I. dexamethasone. Those participants reported significantly less pain on days 0 and 1 following shoulder arthroplasty, less overall opioid use, and shorter hospital stay compared to participants who received standardized treatment. The study, which included a total of 55 patients, appears in the Journal of Shoulder and Elbow Surgery.

From "Liposomal Bupivacaine, Dexamethasone Reduced Postoperative Pain After Shoulder Arthroplasty"
Healio (06/26/2017) Tingle, Casey

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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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