Anesthesia E-ssential

AANA Anesthesia E-ssential, June 13, 2019

Vital Signs


President Brydges Speaks About Enhanced Recovery, Partnership at International Opioid Conference


The International Conference on Opioids took place this week in Boston, June 9-11. AANA President Garry Brydges, DNP, MBA, CRNA, ACNP-BC, FAAN, spoke on "Opioid-Sparing Pain Management: The Healthcare Provider's Role."

Brydges spoke about the importance of partnership across the healthcare continuum. He spoke about recognizing what the importance of scientists, addiction specialists, chronic pain, and mental health specialists are to the perioperative team. He also highlighted the importance of relationships and defining our crucial work from economic perspectives and the impact on overall healthcare delivery.

Brydges emphasized that opioid-sparing strategies are transforming healthcare delivery and the need to further collaborate with many of the attendees to enhance our patient outcomes.

For more on the conference, visit:

AANA President Brydges Speaking
                                            at International Opioid Conference


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CEO Randall Moore Provides Business Acumen in HealthLeaders Interview

An in-depth article in HealthLeaders magazine, "Find the Hidden Dollars in Your Hospital (Without Reducing Labor), " explores how healthcare leaders can streamline their revenue: eliminate waste, fix inefficiencies, and gain revenue. AANA Chief Executive Officer Randall Moore, DNP, MBA, CRNA, spoke with a reporter at the magazine to provide his expertise in healthcare and financial administration.

"Moore says that through his experience in hospital leadership, one of the most important ways to cut costs in healthcare processes is to decrease clinical variation. " Learn more.

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Hot Topics

Looking for Facilities to Join New Cohort in AHRQ Safety Program for Improving Surgical Care and Recovery

Be a part of the AHRQ Safety Program for Improving Surgical Care and Recovery! Enroll your hospital TODAY and join the other hundreds of hospitals in the U.S. who are improving their patient’s surgical experience by adopting enhanced surgical recovery practices. Get access to evidence-based enhanced recovery pathways for gynecology, colorectal, hip fracture and joint replacement surgeries, data registry with benchmark reports, resources to engage stakeholders and so much more!

The program is funded and guided for AHRQ and led by the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and American College of Surgeons. A new cohort begins September 1, 2019. Visit the program’s website to registry for an upcoming informational webinar: or email us at to enroll!

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Hurry! Registration Pricing for Pre-Congress Workshops Increases Tomorrow (June 14)

The Pre-Congress Workshops take place Friday, August 9, in Chicago. The workshops are:

  • 2019 Peer Assistance and Wellness Workshop Program - Full Day; 7.25 Class A CE Credits
  • Ultrasound-Based Acute and Chronic Pain Procedural Workshop - there is a morning and an afternoon session to choose from; 4.00 Class A CE Credits
  • Ultrasound-Guided Peripheral Nerve Blocks: A Focused Review and Clinical Applications - Full Day; 7.25 Class A CE Credits
  • Obstetrical Regional Anesthesia - A Focused Review and Clinical Applications - Full Day; 7.25 Class A CE Credits
  • Fundamentals in Perioperative Transesophageal Echocardiogram (TEE) Workshop - there is a morning and an afternoon session to choose from; 4.00 Class A CE Credits

Learn more and register now before registration pricing increases on June 14.

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Inside the June 2019 AANA Journal: Burnout, Ketamine, Midazolam, and Beach Chair Position

The June 2019 issue of the AANA Journal is chock full of interesting and stimulating content. Here Editor in Chief Chuck Biddle, PhD, CRNA, summarizes what you can learn in this issue.

Effects of Midazolam on Postoperative Nausea and Vomiting and Discharge Times in Outpatients Undergoing Cancer-Related Surgery

In their retrospective analysis of over 4,000 cases, the authors help to define the role of midazolam in moderating PONV in a greatly at-risk patient population. Readers will find the analysis straightforward, clinically relevant, and the findings surprising, as they found associated effects of midazolam outside of those that we view as primary target outcomes.

Beach Chair Position in a Patient with Subclavian Steal Syndrome and Axillary Lymph Node Dissection: A Case Report
This article illuminates the potentially treacherous landscape of caring for the patient in the beach chair position (BCP), in the current case where a vascular steal syndrome was observed to create a clinically relevant decrease in cerebral perfusion.

Given the commonality of the BCP, reported cases of impaired cerebral perfusion, and the very real physiological and technological concerns that may be seen, this paper should be mandatory reading for all. The author also discusses the need for specific monitoring strategies given the unique physiological perturbations, and risks, associated with the BCP.

Use of Near-Infrared Spectroscopy to Measure Tissue Oxygen Saturation During Total Knee Arthroplasty with Use of a Tourniquet
An elegant ‘proof of concept’ study to determine tissue oxygen during tourniquet application in a common orthopedic surgery model is discussed. Comparing it to tissue sampling in a non-tourniquet location, the findings are interesting and go a long way in having us consider traditional recommendations about how long a tourniquet can remain in place and inflated during a surgical procedure.

Single Dose of Ketamine During Kyphoplasty Procedures Does Not Reduce Postoperative Narcotic Consumption
The authors determined the effect of single dose of ketamine on intraoperative and postoperative opioid use in a standardized monitored anesthesia care (MAC) setting. This paper joins a growing body of literature that explores the effect of non-opioid adjuncts on the use of, and need for, opioids. Some readers may find this paper not consistent with other observations reported, especially with regard to postoperative requirements, but as with any study, the contextual sensitivity of the surgical procedure likely has great influence.

Burnout and the Nurse Anesthetist: An Integrative Review
In this much-needed study, light is shed on a domain that has been poorly studied—burnout in nurse anesthetists. Terming the effects of the pressures and demands of practice as ‘collateral damage’ these investigators provide not only information that will be of interest to all of our readers, but provide a framework and impetus for other researchers to further describe, and offer management and preventive concepts, to this woe of professional practice.

Role of Alveolar-Arterial Gradient in Partial Pressure of Oxygen and PaO2/Fraction of Inspired Oxygen Ratio Measurements in Assessment of Pulmonary Dysfunction
This article nicely reviews the common, and important use of the PAo2 - Pao2 and the Pao2/FIo2 ratio as measures of pulmonary dysfunction. The widespread use of these parameters in the lab, intensive care unit, and the operating room testifies to their pragmatism in the clinical setting. The authors of this excellent paper present and discuss influencers of these clinical parameters in a straightforward and very meaningful way.

Use of Nalbuphine for Treatment of Neuraxial Opioid-Induced Pruritus: A Systematic Review and Meta-Analysis
The authors present us with a methodologically superb study involving dealing with a common, and in some patients utterly disabling, complication of neuraxial opioids—generalized pruritus. The use of nalbuphine is carefully assessed in their work and reading this paper and considering its excellent critique of the literature, will empower the reader in making an evidence-based decision in treating this complication.

Anesthesia Exposure in the Young Child and Long-term Cognition: An Integrated Review
In the expanding volume of literature regarding the relationship(s) of anesthetic exposure in the very young child and the potential neurotoxic effects that may ensue, the authors’ work is consistent with that of others suggesting that any correlations between anesthesia and negative neurocognitive outcomes may not be due to anesthesia drug exposure, at least in a single exposure. But rather, due to other factors, such as the baseline comorbid state of the child, a side effect of the combination of surgery and anesthesia (i.e., surgical stress or hypotension, or artifactual depending on how neurocognition is assessed and reported).

Journal Course: Clarifying the Confusion of Adult Emergence Delirium
In this issue’s continuing education offering, the authors tackle head on the complex issues associated with the clinically important and highly relevant syndrome of emergence delirium. Wading through the enormous body of literature on the topic and offering a critical assessment of our existing state-of-knowledge provides for an interesting and illuminating opportunity for our readers to be up-to-date on this common clinical issue. At the same time, we can earn valuable continuing educational units.

Online Content: Guest Editorial
And don’t miss our online content! The authors offer up a guest editorial entitled, The Opioid Crisis and the Certified Registered Nurse: Caring for Patients Receiving Medication-Assisted Treatment. Enough said. Read this very important and sobering piece by authors who manage to capture the gestalt of this public health crisis and how we fit into the big picture.

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CRNA: Banner Health, Fallon, Nevada

Join a Top 5 Large Health System in a charming, safe community with friendly folks, an established respected team of peers, and proximity to Lake Tahoe, Reno & International Airport!

With 28 hospitals in six western states, Banner Health is one of the nation's most respected and awarded health systems in the country. We have an exceptional opportunity for a qualified CRNA to join our expanding team at Banner Churchill Community Hospital (BCCH) in Fallon, NV.

BCCH is a 40-bed JCAHO-accredited hospital providing comprehensive and emergency care, serving 45,000+ including an ambulance service that covers more than 5,900 square miles. Fallon offers a moderate year-round climate and is just a short drive from both Reno and Lake Tahoe. Fallon offers a wealth of lifestyle advantages including a rustic, rural small-town charm of 45,000, along with a recreational wonderland of outdoor sports, such as boating, fishing, hiking, biking, skiing, hunting, horseback riding and off-roading and NO STATE INCOME TAX!

Join the Banner Health Team, where you’ll have the time to connect with your patients, your practice, your family and the great outdoors! We offer dedication to work/life balance unmatched in our industry. Meaning you get to spend more time doing what you love. That’s HEALTH CARE made easier, LIFE made better! Learn more.

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Certified Registered Nurse Anesthetist Faculty Position: University of North Carolina at Greensboro, Greensboro, North Carolina

The School of Nursing at the University of North Carolina at Greensboro is recruiting for a certified registered nurse anesthetist faculty position in the Doctor of Nursing Practice (DNP) program. We are seeking an innovative and talented individual who is actively engaged in evidence-based practice and education and who wants to advance their academic career by becoming part of our dynamic team supporting the teaching, practice, service and research mission of the UNCG School of Nursing. Learn more.

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Certified Registered Nurse Anesthetist: St. Jude Children’s Research Hospital, Memphis, Tennessee

Think of what you could achieve if the best possible care was all that mattered. If you had the encouragement and opportunity to truly bond with the patients in your care. And if you could collaborate with the world’s brightest scientists, in a bench-to-bedside environment that put you on the leading edge of clinical breakthroughs for children with cancer, sickle cell, and other life-threatening diseases. It’s possible at St. Jude Children’s Research Hospital. As a clinical professional with us, you’ll be part of a team that gives our all to make a difference in the lives of patients with the rarest of conditions. All while receiving the resources and support you need to advance your career and be the force behind the cures.

As a Certified Registered Nurse Anesthetist, you'll provide anesthesia services for surgical, diagnostic and therapeutic procedures for the patients of St. Jude Children's Research Hospital. You'll serve as an integral part of the MDA/CRNA Anesthesia Care Team, providing a broad spectrum of anesthesia services that include pre-anesthesia preparation and evaluation, anesthesia induction, maintenance and emergence, and post anesthesia care. In addition to facilitating hands-on service for complex pediatric oncology patients, you'll also lend support outside of the operating room, providing clinical and administrative services and educational support.

Here at St. Jude Children’s Research Hospital, we set the standard of the very best of patient care, and we encourage applicants whose aspirations match the caliber of our work. If you’re self-motivated and ambitious, driven to embrace challenges, and an uncompromising champion of quality work, we’d love to have you apply. Learn more.

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How Does Your Career Grow?

Are you looking to further your career? CRNA Careers is a valuable resource to help you both in your job search and with your career advancement. It's more than a job board. CRNA Careers is where those searching for fulfillment, opportunity, and challenges go to find helpful career tips, search for jobs, and upload anonymous resumes to be found by recruiters and employers.

Here's how to grow your career on CRNA Careers:

  • Seek and find the best jobs in your industry.
  • Set up job alerts to be notified when the jobs you're looking for are posted on the site.
  • Upload your anonymous resume and allow employers to contact you.
  • Access career resources and job searching tips and tools.

Growing your career requires regular care and cultivation. CRNA Careers has the tools to move your career toward your goals. Learn more today!


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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.

Analgesia, Anesthesia and Obstetric Outcome in Women with Inherited Bleeding Disorders

An Irish study examined how anesthesia influences obstetric outcomes in pregnant women with inherited bleeding disorders (IBD), which increase the risk for vertebral canal hematoma (VCH) during epidural. The sample cohort included 97 women with IBD who delivered 130 infants at a single institution from 2011 through 2016. Researchers wanted to know if hemostatic support, analgesia, mode of obstetric delivery, and maternal/fetal outcomes would differ among the 49 pregnancies in which women were advised against regional anesthesia compared with the 81 in which women were given the green light. Patients with a contraindication against epidural were significantly more likely to consult with an anesthesia provider ahead of labor, to need prophylactic hemostatic support for delivery, to receive an infusion of remifentanil, and to undergo general anesthesia for Caesarean section. There were no incidences of neonatal bleeding or VCH, however, in any of the women in either group. Contraindication to neuraxial blockade also did not affect mode of delivery in the study population, with vaginal births occurring at 71 percent in the contraindication group and at 65 percent in the epidural-approved group. This finding should reassure women who are anxious about going through childbirth without regional anesthesia.

From "Analgesia, Anesthesia and Obstetric Outcome in Women with Inherited Bleeding Disorders "
European Journal of Obstetrics & Gynecology and Reproductive Biology (06/19) Boyd, Sean C.; O'Connor, Anna D.; Horan, Maebh A.; et al.

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Wrong Side Surgical Errors Substantially Underreported and Totally Preventable

Wrong-side error (WSE) events during surgery are fairly uncommon but occur more often than reported, according to researchers in Spain. By some estimates, the incidence rate is 1 per 100,000 procedures for wrong-side surgery and 1.3 per 10,000 procedures for wrong-side nerve blocks. While WSEs are rare, the team from Madrid's Hospital Universitario Fundación Alcorcón finds no reason for them to happen at all. The investigators analyzed 81 WSEs documented across 100 large Spanish hospitals between 2007 and 2018, the bulk of them classified as orthopedic and ophthalmology procedures. A total of 45 cases involved administering anesthesia to the wrong side of the body, with incorrect nerve block performed in 91 percent of the cases. The remaining 36 incidents were related to the surgical procedure itself, which was actually performed 50 percent of the time. Severe harm resulted in three affected patients. Based on the analysis, inaccurate or nonexistent use of surgical checklists, poor communication among surgical team members, and rushing were implicated in WSE events. Reporting at Euroanaesthesia Congress earlier this month, lead investigator Daniel Arnal, MD, said, "Our findings highlight the need for adequate training and appropriate use of surgical check-lists, as well the creation of a standardized surgical site marking protocol, the correct revision of clinical history and imaging tests, and involving patients in their own safety. "

From "Wrong Side Surgical Errors Substantially Underreported and Totally Preventable "
Medicalxpress (06/01/2019)

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Massive Study Affirms Safety of Pediatric Regional Anesthesia

A review of more than 104,000 blocks has helped to cement regional anesthesia as overwhelmingly safe for kids. The large-scale, prospective study comes compliments of the Pediatric Regional Anesthesia Network (PRAN) and its massive database covering nearly two dozen U.S. children's hospitals. Looking at blocks performed during the period spanning April 1, 2007, to Sept. 30, 2015, investigators documented adverse events and complications including neurologic effects, mild or severe anesthetic toxicity, infection, hematoma, respiratory depression, catheter malfunction, and dural puncture. "We 've amassed an unprecedented amount of data to really narrow the confidence intervals for our risk assessment for these procedures," commented primary investigator Benjamin Walker, MD, an associate anesthesiology professor at the University of Wisconsin. "So much so that some might be tempted to say that pediatric regional anesthesia is even safer than adult practice, because we generally have fewer long-term neurologic complications than you'll see in most adult studies. However, I don 't think we can say this with certainty in light of the limitations inherent to a large database like the PRAN." Instead, the researchers concluded that performing blocks under general anesthesia is at least safe as conducting them in awake patients. The review results are reported in Anesthesiology.

From "Massive Study Affirms Safety of Pediatric Regional Anesthesia"
Anesthesiology News (06/03/19) Vlessides, Michael

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Shorter MRI Protocol Reduces Sedation for Scans of Kids

Emory University researchers have created an abbreviated MRI protocol for brain scans of young children experiencing headaches, significantly curtailing the need for sedation. A records review showed that 31 pediatric patients were exposed to the shorter protocol, which can be completed in as quickly as about five to eight minutes, from April to September 2017. Roughly three-quarters of those patients successfully underwent MRI with no sedation, particularly those between the ages of six and eight years. Meanwhile, those who did not complete their sedation-less scan tended to be five years old or younger. "Additional benefits ... included high patient satisfaction and ability of MRI staff to accommodate inpatient MRI studies when scheduled full MRI time slots (45 minutes) were not fully used for the abbreviated brain MRI studies," co-authors Anna Trofimova and Nadja Kadom wrote in the American Journal of Roentgenology.

From "Shorter MRI Protocol Reduces Sedation for Scans of Kids" (06/11/19) Forrest, Wayne

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Labor Epidural Analgesia to Cesarean Section Anesthetic Conversion Failure: A National Survey

There is no clear best practice in place for anesthesia providers in the event that conversion of labor epidural analgesia to cesarean delivery anesthesia fails, sparking researchers' curiosity. They invited all members of the U.K.-based Obstetric Anaesthetists ' Association to complete an online survey in May 2017. The questionnaire solicited information on factors that guide the decision to use an existing labor epidural for C-section. In addition, it asked about factors that influence the management and choice of anesthetic technique in cases where epidural top up fails to produce objective sensory block, bilateral T10 sensory block, or unilateral T6 sensory block. A total of 710 questionnaires were returned, with 89 percent of respondents reporting that they would consider topping up an existing labor epidural for a category-one cesarean section. The decision, according to survey-takers, hinges primarily on how effective the epidural had been for labor pain; however, providers also take the category of C-section and the dermatomal level of blockade into consideration. Once an epidural top-up fails, anesthesia providers' next moves are determined most often by the category of C-section. Dermatomal level of blockade and the assessment of maternal airway are also factors, however. Survey results reveal variations in the clinical management of a failed epidural top up for cesarean delivery, highlighting a need for uniform guidelines.

From "Labor Epidural Analgesia to Cesarean Section Anesthetic Conversion Failure: A National Survey"
Anesthesiology Research and Practice (06/02/19) Desai, Neel; Gardner, Andrew; Carvalho, Brendan; et al.

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The Effect of Etomidate or Propofol on Brainstem Function During Anesthesia Induction

A randomized study out of Shanghai compared outcomes in 40 adults who received an infusion of etomidate during anesthesia induction with those of 40 others who received a propofol infusion. The results indicated that etomidate infusion was less taxing on the hemodynamic profile of patients, as evidenced by a shorter time to loss of consciousness (LOC) and lower bispectral index at LOC. In addition, more patients the etomidate group exhibited spontaneous breathing and maintained corneal reflex.

From "The Effect of Etomidate or Propofol on Brainstem Function During Anesthesia Induction"
Drug Design, Development and Therapy (06/05/19) Vol. 13, P. 1941 Zheng, Huibao; Zhu, Yuexin; Chen, Kaizheng; et al.

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News summaries © copyright 2019 SmithBucklin


Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed weekly 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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June 13, 2019
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