Anesthesia E-ssential

AANA Anesthesia E-ssential, June 14, 2018

Vital Signs

CRNA Pamela Wrobleski Seated as AANA Representative on The Joint Commission’s Ambulatory Care Advisory Council

As the AANA Representative to TJC’s Ambulatory Care Advisory Council, Pamela Wrobleski, DNAP, MPM, CRNA, CASC, will represent the interests of the AANA and CRNAs while offering her expertise obtained from more than three decades of administration and anesthesia leadership at Joint Commission-accredited Southwestern Ambulatory Surgery Center in West Mifflin, Pennsylvania, and at several other accredited ASCs and hospitals in Pennsylvania.

The council provides valuable input on ambulatory care accreditation products, services, and activities to promote patient safety and quality.

Pamela completed her Doctor of Nurse Anesthesia Practice from Saint Vincent College in Latrobe, Pennsylvania, and her Masters of Public Management, Healthcare Concentration from Carnegie Mellon University. Pamela also is a clinical site coordinator at Excela School of Nurse Anesthesia and the University of Pittsburgh School of Nursing Nurse Anesthesia Program. She serves on many boards and committees, including as the reimbursement specialist for the Pennsylvania Association of Nurse Anesthetists. Congratulations!
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Minnesota Daily: Nurse Anesthetists Learn Methods for Addressing National Opioid Crisis

A national conference held at the University of Minnesota Twin Cities School of Nursing taught Certified Registered Nurse Anesthetists, student registered nurse anesthetists, and educators how to be part of the solution to the national opioid epidemic.

Speaking at the conference were AANA President-elect Garry Brydges, DNAP, MBA, ACNP-BC, CRNA, and former AANA President Jackie Rowles, DNP, MBA, MA, CRNA, ANP, DAAPM, FAAPM, FAAN. Also quoted in the article were SRNAs Heidi Nichols and Anna Baker.

Read the article in the Minnesota Daily.
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Hot Topics

Naloxone Hydrochloride Injection Recall

Hospira, Inc. is voluntarily recalling lots 72680LL and 76510LL of Naloxone Hydrochloride Injection, USP, 0.4 mg/mL, 1 mL in 2.5 mL, Carpuject Single-use cartridge syringe system (NDC 0409-1782-69), due to the potential presence of embedded and loose particulate matter on the syringe plunger.  Read more in the company’s announcement.
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Malpractice Insurance Coverage Options to Fit Your Needs

For nearly 30 years, AANA Insurance Services has specialized in developing innovative malpractice insurance options for nurse anesthesia professionals. In fact, no other agency provides a wider range of coverage options for CRNAs. Caring has its risks. Learn how AANA Insurance Services can help safeguard your career.
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June 2018 AANA Journal Highlights

Read on for highlights of the June 2018 issue of the AANA Journal.

Emergent Bilateral Face-lift Hematoma: A Case Report
An all-too-common problem facing the anesthesia and surgical team is described as acute postoperative bleeding following an entirely elective surgical procedure. With an ever-increasing number of baby boomers undergoing cosmetic procedures, readers will find this highly relevant to their clinical practice. Airway concerns predominate and the author discusses the essential management approaches.

Should Continuous Subcutaneous Insulin Infusion (CSII) Pumps Be Used During the Perioperative Period? Development of a Clinical Decision Algorithm
An evidence-based, decision-making algorithm aids the use of an approach that may be unfamiliar to many nurse anesthetists, the use of a continuous subcutaneous insulin infusion system. Despite the large number of users in the U.S., approaches to perioperative glucose management vary like the weather, with evidence-based approaches not always in place. This paper details a multidisciplinary approach to dealing with the intervention in a patient-centered manner.

Improving Patient Outcomes Through Closed-Claims Analysis: Salient Characteristics and Patterns Associated with Respiratory Events
The article covers the use of a most valuable research approach: closed-claims analysis, in the quest to better understand and illuminate issues related to perioperative respiratory events that led to adverse patient outcomes. This is essential reading for all nurse anesthetists, given the important patient safety concerns associated with what CRNAs do in our practices every day.

Anesthetic Management of a Patient With Type 1 von Willebrand Disease and Uterine Placental Abruption: A Case Report
A case of a placental abruption in a patient with Von Willebrand disease is detailed. This is not as uncommon as one might suspect, and its management is complex and requires careful and meticulous decision making, based on best evidence.

Reexamining Metoclopramide’s Role in the Prevention of Postoperative Nausea and Vomiting: A Secondary Analysis
This article revisits the use of an older drug that has fallen out of its once common use. Metoclopramide’s administration, when stratified by an individual’s unique risk profile for postoperative nausea and vomiting, is explored in a secondary analysis of a dataset.

Subanesthetic-Dose Ketamine to Decrease Emergence Delirium in the Surgical Patient With Post-traumatic Stress Disorder
The author explores a novel, but increasingly widespread, use of ketamine to manage psychiatric and neurocognitive dysfunction; in this case, emergence delirium associated with post-traumatic stress disorder. Limited relevant research is available to inform best practice. This paper identifies the pathophysiological basis of the conditions and describes how ketamine may have efficacy in treating the conditions.

Investigation of the Anxiolytic and Antidepressant Effects of Crocin, a Compound from Saffron (Crocus sativus L), in the Male Sprague-Dawley Rat
This article sets out to determine if crocin, derived from a natural source, produces anxiolytic and/or antidepressant effects using rat models for anxiety and behavioral despair. This type of research exemplifies the basic science role of the nurse anesthetist in the discovery and development of new pharmaceuticals in dealing with common and uncommon problems.

AANA Journal Course: Update for Nurse Anesthetists—Herbal Medications and Anesthesia Case Management
This Journal Course examines the ever-growing litany of herbal medications used that many of us encounter daily. This state-of-the-review will empower the reader to deal with herbal medicines that have the potential to adversely react with medications used in the perioperative period.

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Vietnam Voices Needed

The AANA seeks to record the histories of our Certified Registered Nurse Anesthetists (CRNAs) who served in Vietnam. AANA hopes to share these experiences with our membership, legislators and the general public as a means of enlightening, healing, and reaching into a vibrant history so that the many accomplishments and sacrifices of CRNAs, soldiers, brothers, sisters, friends and loved ones are not forgotten.

If you are interested in contributing your experience as a nurse or nurse anesthetist who served during the Vietnam War, see the submission guidelines. Contact Cathy Hodson of the AANA staff with any questions.
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Professional Practice

Changes in Joint Commission Fluoroscopy Standards for Critical Access Hospitals

Effective July 1, 2018, The Joint Commission’s standards for hospitals, critical access hospitals, ambulatory care settings, and office-based surgery settings will include two new requirements relating to fluoroscopy to increase awareness of radiation exposure risks.

For all settings, proper shielding must be used for fluoroscopic procedures. In ASCs, hospitals, and CAHs, additionally, the radiation safety officer, diagnostic medical physicist, or health physicist must review the results of staff dosimetry monitoring at least quarterly to assess whether staff radiation exposure levels are “as low as reasonably achievable” (ALARA) and below regulatory limits. ALARA is defined in U.S. Nuclear Regulatory Commission federal regulation 10 CFR 20.1003.

Surveyors likely will review inspection records of all shielding devices to determine that there is a sufficient number of acceptable shielding devices. They also will review whether ALARA readings are posted in areas accessible to staff and what staff can do if they have questions about the ALARA readings.
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Upcoming FDA Risk Evaluation and Mitigation Strategies (REMS) Webinar

Register and join the U.S. Food and Drug Administration (FDA) on June 26 at 1:00 p.m. ET for a complimentary webinar which will introduce healthcare professionals to web resources about Risk Evaluation and Mitigation Strategies (REMS), including a REMS resource portal and the REMS@FDA website, and will focus on what type of information is available, where, and how to navigate these resources.  AANA members can apply for Class A credit for this webinar, through the Individual Nonprior Approval process.
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Meetings and Workshops

Pre-Congress Workshops: Maximize Your CE Opportunities

The Pre-Congress Workshops take place on Friday, September 21, 2018 prior to the AANA 2018 Annual Congress. Topics include:
  • Advanced Physical Assessment for Pain Management Practice Workshop - The workshop will provide CRNA knowledge and hands-on practice for advanced physical assessment useful for differential diagnosis in pain management.
  • Writers Workshop: Writing for Professional/Scholarly Publication - The workshop will include presentations and a discussion regarding what constitutes a good idea, the process of marshaling that idea to a tangible product that merits consideration for publication, and anticipating what will occur during the peer review process. Exemplars will be used to explore optimizing the process and the workshop will be led by senior leaders of the AANA Journal Committee.
  • Fundamentals in Perioperative Transesophageal Echocardiogram Workshop - The workshop will provide didactic and hands-on learning opportunities featuring individualized and group instruction using cardiac and TEE simulation tools and intraoperative recordings to improve the understanding of real-time monitoring of cardiac function.
  • Airway on Demand Workshop - Attendees of this program will be exposed to both didactic and hands-on learning opportunities aimed at reinforcing learned knowledge and skills, as well as providing the opportunity for new learning, related to airway management under both normal and emergent conditions.
  • Crisis Resource Management Simulation Course - The Center for Medical Simulation's Crisis Resource Management Simulation Course will allow nurse anesthetists to improve their skills in managing and debriefing routine and critical clinical events, particularly in the realm of acutely deteriorating clinical situations, and managing difficult conversations with colleagues.
  • Neuraxial Regional Anesthesia-Epidural Workshop - The core faculty of the popular “AANA Regional Anesthesia Workshops” offers an opportunity to update current knowledge of epidural anesthesia techniques and clinical applications.
  • Gateway to Debriefing with Good Judgment Course - The Center for Medical Simulation’s Gateway Debriefing Skills Workshop introduces healthcare education faculty to the foundational practices of the Debriefing with Good Judgment© method of debriefing. This innovative workshop combines an immersive, day-long, in-person learning experience with supplemental online learning that includes customized peer-to-peer and mentor feedback. Participants will have the opportunity to learn how to efficiently improve future performance, set high standards while holding high regard for the learner, treat learners as thinkers and not just doers and practice various debriefing phases.
  • Neuromuscular Block Monitoring Workshop - Attendees of this didactic and hands-on instruction program will: 1) Review the incidence and outcomes of residual paralysis. 2) Explore techniques to improve the management and reversal of neuromuscular block. 3) Examine current and developing technologies available to assess neuromuscular block and reversal.
Please note: There is an additional registration fee for these workshops, they are not included in the Annual Congress registration fee. Learn more or register for the Pre-Congress Workshops.
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Tap Into the Power of Technology at AANA 2018 Annual Congress

September 21 - 25, 2018, Boston, Massachusetts. The 85th AANA Annual Congress is being held at the Hynes Convention Center in one of America's most storied and historical cities: Boston.

Refresh and expand your knowledge with hands-on patient simulation workshops and expert speakers. Network with colleagues from across the nation at the biggest CE event in nurse anesthesia.

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Expand Your Knowledge and Skills at the Upper and Lower Extremity Nerve Block Workshop

August 18-19, 2018, Park Ridge, Illinois. The Upper and Lower Extremity Nerve Block Workshop is designed to enhance your knowledge in the clinical sciences related to upper and lower block anesthesia. This program will expand the CRNA’s skills and expertise in upper and lower extremity nerve block anesthesia. Included with registration, all attendees will receive Upper Extremity Blocks, written by featured speaker Charles A. Reese, PhD, CRNA.
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Practice Leadership Assembly Debuts

November 9-11, 2019, Rosemont, Illinois. Mark your calendar. Business owners as well as practice and facility leaders will gain insight and confidence to lead the way in a rapidly changing healthcare environment. Registration opens in July. Watch for details.

See all upcoming events on our AANA Meetings & Workshops page.
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Foundation and Research

MIPS Preliminary Performance Feedback Now Available

Clinicians who submitted 2017 Merit-Based Incentive Payment System (MIPS) data can review their Preliminary Performance Feedback data on the Quality Payment Program’s (QPP) website. Clinicians must input their Enterprise Identity Management (EIDM) credentials into the website to access their information. CMS notes that these scores are subject to change based on several factors that include but are not limited to: special status scoring; calculations of the All-Cause Readmission measure; CAHPS survey results; and Improvement Activities participation and results. For those without EIDM credentials please see the EIDM User Guide for instructions on how to obtain them. CMS anticipates that MIPS Final Scores will be published in July 2018.
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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.

Risk of Dementia Jumps 29 Percent for Seniors with Anesthesia Experience

The Journal of Alzheimer's Disease reports findings that point to an elevated risk of dementia in older patients who have undergone general anesthesia. Researchers at Samsung Medical Center in South Korea examined health insurance data from about 219,400 adults older than age 50, stratifying them according to their exposure to general anesthesia and tracking onset of dementia over more than a decade. They discovered that 8,890 of the patients received a new dementia diagnosis, and 76 percent developed Alzheimer's. The risk of dementia was 28.5 percent greater among those who had received general anesthesia than among those who had not—even after adjusting for age, gender, comorbidities, and other factors. "The study results do not mean that general anesthesia should be avoided because it is dangerous but signals the importance of evaluation and management of cognitive abilities before and after general anesthesia," notes investigator Prof. Kim Do-kwan.

From "Risk of Dementia Jumps 29 Percent for Seniors with Anesthesia Experience"
Korea Biomedical Review (06/12/18) Chu, Marian

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Acute Heart Failure Treatment Paradigm Challenged by Splanchnic Nerve-Block Studies

Two new preliminary studies raise the prospect of using splanchnic nerve block to treat certain patients with decompensated heart failure (HF). Some cases might be caused when fluid volume shifts from the intra-abdominal compartment to the heart and lungs. Splanchnic nerve block, however, relaxes the intra-abdominal vasculature, allowing intrathoracic fluid volume to offload. In a Polish study involving 10 patients, surgical ablation of the right greater splanchnic nerve was associated with significant improvement in cardiac filling pressures, exercise capacity, and quality of life over three months. Over six months, the patients also demonstrated reduced left ventricular mass and better diastolic function. A second investigation involving five patients with decompensated chronic HF found that intracardiac filling pressures, cardiac output, and self-reported dyspnea improved greatly within 90 minutes after following temporary total splanchnic nerve block. Both studies were presented at the European Society of Cardiology Heart Failure 2018 in Vienna last month. Duke University's Marat Fudim, MD, lead author of the Circulation paper reporting the results of the smaller study, notes that diuretics and ultrafiltration are appropriate first-line treatments for acute decompensation when caused by excess fluid and sodium. In cases where volume-redistribution is the culprit, however, "the trials that show that a lot of diuresis hurts your kidneys and does not improve outcomes." The fluid volume was not "excess," he explains. "It was just in the wrong place." He stresses that the novel treatment approach is far away from clinical application. But, he says, "we actually now have data to support that there is a different mechanism for heart failure decompensation."

From "Acute Heart Failure Treatment Paradigm Challenged by Splanchnic Nerve-Block Studies"
Medscape (06/08/18) Stiles, Steve

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Marginal Benefit for Neuraxial Over General Anesthesia in Noncardiac Surgery

New research from the Cleveland Clinic points to slightly better outcomes after noncardiac surgery under neuraxial anesthesia versus general anesthesia. Investigators used the American College of Surgeons-National Surgical Quality Improvement Program database to analyze information on orthopedic operations performed on adults using either of these anesthetic techniques between 2011 and 2015. They also matched the patients in a 1:1 ratio according to propensity score and procedure type. Based on results for 72,877 matched pairs, neuraxial anesthesia did not lower mortality compared with general anesthesia. It did, however, lower the risk of venous thromboembolism by 17 percent, shorten hospital stay, and curtail 30-day readmissions. Despite the findings, Cleveland Clinic research fellow Gausan Bajracharya, MD, cautions that "the effect of neuraxial anesthesia on long-term outcomes remains unclear, as there have been no large robust trials on this topic and available studies are either small or inconclusive." Based on those and other limitations, the researchers conclude that anesthesia providers can safely choose one technique or the other.

From "Marginal Benefit for Neuraxial Over General Anesthesia in Noncardiac Surgery"
Anesthesiology News (06/07/18) Vlessides, Michael

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The Effect of Passive Leg-Raising Maneuver on Hemodynamic Stability During Anesthesia Induction for Adult Cardiac Surgery

Because intravenous fluid loading before anesthesia induction is not universally tolerated by cardiac patients, researchers investigated the efficacy of passive leg-raising maneuver (PLRM) as an alternative. All 120 heart surgery patients involved in the study received 250 mL of fluid prior to anesthesia induction with midazolam, fentanyl, and cisatracurium. Half were arranged in a simple supine position for induction; while PLRM was performed on the other half, starting two minutes before anesthesia induction and lasting for 20 minutes after tracheal intubation. The results suggest the preinduction PLRM can foster more stable hemodynamic conditions in adult cardiac surgery patients. Hypotension, for example, affected 63.3 percent of the patients in the PLRM group versus 81.6 percent of patients in the control group. The PLRM patients also presented higher mean arterial blood pressure immediately before anesthetic injection, before laryngoscopy, and 20 minutes post-intubation. Additionally, the technique was associated with higher central venous pressure—which, in turn, helped to significantly lower the postinduction incidence of hypotension. The study was conducted at Tabriz University of Medical Sciences in Tabriz, Iran.

From "The Effect of Passive Leg-Raising Maneuver on Hemodynamic Stability During Anesthesia Induction for Adult Cardiac Surgery"
Integrated Blood Pressure Control (06/07/18) Vol. 11, P. 57 Fakhari, Solmaz; Bilehjani, Eissa; Farzin, Haleh; et al.

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Understanding How Drug Reduces Confusion in Older Patients After Surgery May Lead to Better Care

Although dexmedetomidine is used for sedation, researchers believe it actually curbs postoperative delirium by inhibiting overactivity of so-called GABAA receptors in brain cells. "We knew anesthetics target these receptors to cause the profound depression of brain function required for patients to tolerate surgery," explains primary investigator Beverley Orser, MD, PhD, who chairs the University of Toronto's anesthesiology department. "However, what we found surprising in our previous research was once the anesthetics were eliminated from the body, there was a subtle but continued increase in the activity of GABAA receptors in areas of the brain involved in memory and problem-solving." Orser and her team studied healthy young male mice, some given the anesthetic etomidate and others given both etomidate and dexmedetomidine. The lab subjects anesthetized with only etomidate had subtle impairment in memory and problem solving, and they presented with a greater number of GABAA receptors on the surface of brain cells. The etomidate/dexmedetomidine mice, meanwhile, exhibited no cognitive deficits; and GABAA receptor overactivity was calmed. "The findings may explain why this drug reduces the incidence and duration of postoperative delirium," Orser says. "While we used healthy young mice, we would expect to see the same results in older animals." She and her colleagues say the findings could foster more widespread use of dexmedetomidine as prophylaxis against postoperative delirium as well as accelerate development of new therapies for the condition with fewer adverse effects.

From "Understanding How Drug Reduces Confusion in Older Patients After Surgery May Lead to Better Care"
Medicalxpress (06/07/2018)

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Medical Marijuana Alleviates Pain in Older Patients

New findings suggest that medical marijuana alleviates pain and curtails analgesic use in the elderly. Researchers reached their conclusion after surveying 138 older users at two medical marijuana dispensaries. After one month of taking a cannabis-based product, with vaporized oil formulations an apparent favorite, pain scores fell to 5.6 from 9 on a scale of 0 to 10. Over the same period, medication-related adverse effects impacting daily activities dropped to 3.5 from 6.9. Additionally, 27 percent of patients stopped taking all other pain drugs after using medical marijuana for one month; 20 percent said they cut back on other pain medications by an "extreme" amount; and 18 percent said they reduced other analgesic use by a "moderate" amount. "Older adults tend to have more of an aversion toward the use of medical marijuana, so these findings were surprising," says Pauline Agornyo, MD, of New York-based Northwell Health. "Primary care physicians in states where medical marijuana has been legalized should present it as an option to qualifying patients who have not gained sufficient pain relief from their current pain medication regimen." She adds, however, that larger, randomized, long-term studies should be conducted to gauge the most effective applications and long-term outcomes of medical marijuana use as well as appropriate dosing guidelines.

From "Medical Marijuana Alleviates Pain in Older Patients"
Healio (06/05/2018) Miller, Janel

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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 14, 2018
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