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CRNAs, Veterans Make Themselves Heard for Expanding Veterans Access to Care Rule, while ASA Ramps Up Opposition; Have You Taken Action Yet?

Thousands of AANA members and veterans have taken action to make their voices heard for expanding veterans’ access to quality healthcare – and reducing veterans wait times for care – through support for a proposed rule for full practice for CRNAs and other APRNs in Veterans Health Administration (VHA) facilities. But much more must be done – and AANA is making it easy for every CRNA voice to be heard if only every CRNA and student registered nurse anesthetist will join in taking action.

Already, seven states have met or exceeded their goal of 33 percent of membership submitting comments through the www.VeteransAccessToCare.com campaign six weeks before the July 25 public comment period deadline, and seven more states are 90 percent or more of the way towards the goal. 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. Nearly 3,000 AANA members joined President Juan Quintana, DNP, MHS, CRNA, and other elected and staff leadership for a live tele-town meeting on June 8 to learn more about the issue. More than 40 news publications have appeared on the issue, many driven by AANA public relations efforts, including op-eds by leading CRNAs in the Louisville Courier-Journal and the Las Vegas Sun.

But opposition to the proposal is being aggressively organized by the American Society of Anesthesiologists. In a Washington news conference June 1, its leaders inaccurately accused the VA in a news conference of promoting a lower standard of care and putting veterans’ health and safety at risk. And at its national meetings June 12-13, members of the American Medical Association were advancing policy statements attacking CRNAs and other APRNs as well as the Veterans Administration proposed rule.

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 www.VeteransAccessToCare.com;
  2. Share with family, friends and colleagues, especially veterans, our www.VeteransAccessToCare.com site where they can also take action;
  3. Be alert for AANA CRNAdvocacy alerts to contact your members of Congress and to be heard on Capitol Hill as needed; and,
  4. Spread our message for advancing veterans access to care and reducing their wait times by promoting news articles and strong stories on your Facebook and Twitter social media platforms, using the hashtags #CRNAs4Vets and #ForOurVets, and including www.VeteransAccessToCare.com. You can also forward content from the AANA Facebook and Twitter feeds.
  5. Consider making a contribution to your CRNA-PAC at www.CRNA-PAC.com. 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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CPC Facts


New CPC Program Overview Video Now Available

Watch the latest overview video on the Continued Professional Certification (CPC) Program to become more familiar with the program, components, timelines, and next steps. Watch the video here. For more information and resources about the NBCRNA's CPC Program, which will launch on Aug. 1, 2016, go to the cpc-facts.aana.com and NBCRNA websites.
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Hot Topics


Register for #AANA2016 by June 17 and Save $100!

Annual Congress Early Bird Registration ends June 17: Register now to join us September 9-13 at the Washington Marriott Wardman Park for nurse anesthesia's premier educational, professional, and social event! Just take a look at the AANA Nurse Anesthesia Annual Congress lineup of top-notch sessions and unparalleled networking events on the schedule at a glance. Register now!               
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AANA Research and Quality Facilitates New Research

The AANA Research and Quality Division facilitates the development of key research initiatives as determined by the AANA and AANA Foundation. The recent AANA and AANA Foundation Joint Research Program Overview highlights issues of import to nurse anesthesia for future research. Through AANA Foundation funding, the AANA Research and Quality Division is proud to have made possible two independently authored publications by the Lewin Group. A leading health policy journal (Medical Care) just published findings that found that there was no evidence that the odds of an anesthesia complication differ by CRNA scope of practice or anesthesia delivery model. To learn more about this ground breaking study, visit the June 2016 issue of Medical Care. Additionally, a new white paper found that regardless of anesthetizing location (i.e., inpatient, outpatient, ASC) the CRNA independent delivery model is the most cost effective. To learn more about the update to anesthesia cost effectiveness, visit the most recent May 2016 Lewin Publication.
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Class A CE Credit Can Now be Attained From Outside Providers

AANA members now have the option of earning Class A CE credit in the Continued Professional Certification (CPC) Program through the nonprior approval process. Previously, Class A CE credit could only be attained by attending AANA prior-approved meetings and activities, i.e., those that were assessed to meet specific anesthesia learning requirements, or by completing academic courses and life support courses. The new option gives CRNAs the ability to earn Class A CE credit by participating in programs that focus on nurse anesthesia practice or other specialties such as pain management as long as the learning opportunities are accredited by a recognized entity such as the American Nurses Credentialing Center’s Commission on Accreditation, American Medical Association, American Association of Critical Care Nurses, etc. These other opportunities must still go through the AANA’s nonprior approval process to insure that the accredited educational activity has an assessment standard that is equivalent to the AANA CE Program and NBCRNA CPC Program standards.

The change came about through a mutual agreement between the AANA and National Board of Certification and Recertification for Nurse Anesthetists and is effective immediately. For further information and instructions visit www.aana.com/ceportal.
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Veterans Radio Interviews AANA President Quintana on Proposed VA Rule

Advanced practice registered nurses (APRNs) and CRNAs can achieve excellent care for veterans and help avoid the tragic outcomes that can result from excessive wait times in the VA system, said AANA President Juan Quintana, DNP, MHS, CRNA, in an exclusive interview with Veterans Radio. In regard to the VA’s proposed rule to expand the role of APRNs, including CRNAs, in the VA system, Quintana said, “Sometimes the wait times at the VA service centers are and can be fairly terrible. We know…that sometimes veterans are waiting for their services to their detriment, and potentially in some cases, have lost their lives because of it.” Read more in the AANA Press Release and listen to the episode on Blog Talk Radio.
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15 Days Left to Register for 2016 PQRS GPRO

Will you be reporting to PQRS as part of a group practice for the 2016 performance period? Is so, your group needs to register your Group Practice Reporting Option (GPRO) with CMS—whether be it qualified registry, QCDR, EHR, or Web Interface—by June 30, 2016 via their Physician Value-PQRS Registration System. As a reminder a group practice is defined as two or more eligible professionals (EPs) who have reassigned their billing rights to a single Taxpayer Identification Number (TIN). CRNAs belonging to one or more group practices also have the option of reporting as individual EPs. For more information on GPROs, please visit our 2016 PQRS Reporting Mechanisms FAQ page on the AANA Quality-Reimbursement website.
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AANA Chronic Pain Management Fellowship Accepting Applications through July 1

The Chronic Pain Management Fellowship Program through Texas Christian University and the AANA is now accepting applications for the class that begins in August 2016. The application deadline is July 1, and candidates will be notified of admission status by August 1. The 12-month program is composed of online classroom discussions and course work, along with clinical hands-on apprenticeships with experienced pain practitioners. For more information, see the AANA Chronic Pain Management Fellowship Program webpage and the TCU Pain Management Fellowship website.
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President Quintana Among Healthcare Leaders Interviewed at Becker’s Hospital Review Meeting

Becker's Hospital Review, at their 7th Annual Meeting in April, conducted video interviews with healthcare leaders about healthcare's ever-changing landscape. Former Hospital CEO Dan Nielsen spoke with AANA President Juan Quintana, DNP, MHS, CRNA, about what was on his mind: See the interview at https://vimeo.com/169043588
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CPC Core Modules: Learn and Earn Class A CE Credits at Your Own Pace

Launched this spring through AANA Learn, the AANA Continued Professional Certification (CPC) Core Modules provide CRNAs and students with the highest quality, interactive online learning experience. Purchased together, these four modules offer 17 Class A CE Credits for recertification at an attractive, members-only price of $299. Visit the AANA Learn CPC Core Modules webpage to find out more.
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Professional Practice


AANA Submits Comments to SAMHSA Regarding Proposed Rule on Medication-Assisted Treatment

The AANA has submitted a letter to the Substance Abuse and Mental Health Service Administration (SAMSHA) in response to a proposed rule that would increase access to treatment for opioid use disorder while reducing the opportunity for diversion of the medication to unlawful use. This proposed rule works to increase the highest patient limit for providers to treat opioid use disorder from 100 to 200. Read the letter here.
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AANA Submits Comments to the FDA regarding the ER/LA Opioid Analgesics REMS Blueprint

The AANA has submitted comments to the US Food and Drug Administration (FDA) regarding the Extended-Release and Long-Acting (ER/LA) Opioid Analgesics Risk Evaluation and Mitigation Strategy (REMS) Blueprint. These comments include recommendations for patient engagement in pain management; incorporating a multimodal, multidisciplinary approach to pain management; incorporating immediate release opioid medications; and continued engagement with professional organizations, such as the AANA. Read the letter here.
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State Government Affairs


New State Government Affairs Webinar – Available Now!

View the latest webinar, “Selecting an Attorney or Lobbyist for your State Association,” now posted on the AANA State Government Affairs webinar page. View the webinar here. Take advantage of this opportunity to hear experienced members of the AANA Government Relations Committee and other experts provide valuable information and resources important to CRNAs and state nurse anesthetist associations
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Meetings and Workshops


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. Reserve your spot today!
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Save the Dates for These Popular Hands-On Workshops

Visit www.aana.com/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


Donate to the AANA Foundation Today for Annual Congress Recognition

Your support is so important: If you haven’t donated yet, please do so by July 1, 2016, to be included in the AANA Foundation’s FY16 Annual Report (donations of $100 or more will be included). Thank you to all AANA members who have supported the AANA Foundation in fiscal year 2016. Click here to access the Foundation’s secure donation page.
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Don’t Miss Out on the Fun: Stepping Out in DC

Register for Stepping Out in DC and Shake It for a Cause Dance Party and get out on the dance floor with friends and colleagues from around the country! Check out the dance moves on AANA Foundation Board Chair Wilma Gillis and Trustee Chuck Griffis and join the fun on Sunday, September 11, 2016, from 7 – 11:45 p.m. at Washington Marriott Wardman Park. Ticket includes dinner, drinks, entertainment featuring Capitol Steps, and the Dance Party. For those who only want to attend the Dance Party, tickets are $50 for CRNAs and $25 for students.
Click here to register for Annual Congress and purchase your tickets today. You’re sure to have a fun time, and a portion of your donation is tax deductible and supports nurse anesthesia education and research. See you in DC!
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Federal Government Affairs


VHA Full Practice Authority Issue Status Update

The AANA continues to work with a broad coalition of groups in support of improving veterans access to care through full practice authority for CRNAs and other APRNs at the VHA. Here is a brief rundown of activities to keep members apprised of current actions.
  • Regulation: The Department of Veterans Affairs published its proposed rule on APRN full practice authority in the Federal Register on May 25, triggering a 60-day public comment period that will end on July 25. AANA continues urging all members to use www.Veterans-Access-to-Care.com to submit regulatory comments as soon as possible in support of improving veterans access to quality healthcare through CRNA and APRN full practice authority. AANA members can also share the site with colleagues, friends, and family—especially veterans—to take action. As of June 14, the Federal Register reported having 28,925 comments submitted to the rule. AANA members had submitted over 11,000 comments through our veterans Access to Care campaign. AANA members can expect to receive a weekly email specific to the proposed rule throughout the comment period.
  • 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). The bills are up to 56 and 11 bipartisan cosponsors respectively. 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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Do’s and Don’ts for CRNAs Supporting Expanded Access to Care for our Veterans and CRNA Full Practice Authority in the VHA

What can CRNAs do to advance veterans access to quality care and support CRNA and APRN practice?
  • Do use www.VeteransAccessToCare.com to submit a comment and make your voice heard!
  • Do share www.VeteransAccessToCare.com with your friends, colleagues and family – especially those who are Veterans – and ask them to submit comments and make their voices heard, too.
  • Do keep all of your comments and social media postings factual and professional.
  • Don’t submit a comment if you feel it would put your job at risk. If you are uncomfortable submitting a comment, share www.VeteransAccessToCare.com with your colleagues, friends and family and multiply your voice effectively.
  • Don’t use the ASA-backed site to submit comments, even if you rewrite comments to favor the AANA’s point of view. There is no reason to trust the ASA site to faithfully submit CRNA-friendly comments to the Veterans Administration.
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AANA to HHS: CRNAs Should Not be Penalized for Not Being Incentivized to Adopt Certified EHR Technology

In a letter to the Office of the National Coordinator for Health Information Technology (ONC) on its request for information (ROI) on health information interoperability for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the AANA told the agency that CRNAs should not be penalized for not being incentivized to adopt meaningful use of certified Electronic Health Record (EHR) technology. For CRNAs, potential Medicare payment changes, as well as information technology standards affecting anesthesia practice, are at stake.

The AANA letter from President Juan F. Quintana, DNP, MHS, CRNA, also says the focus on measurement of interoperability should include exempt or ineligible providers who are not considered to be “meaningful EHR users” (such as CRNAs). AANA’s comments also emphasized the use of cost-effective anesthesia care provided by the CRNA non-medically directed model in advancing the interoperability of health information. The letter further said that for anesthesia, interoperability of health information should communicate across the continuum of patient care and EHR should use standardized taxonomies across technology platforms.

View AANA Comments here. View the RFI here.
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AANA Supports Increased Access to Treatment for Opioid Use Disorder

In a letter to the Substance Abuse and Mental Health Services Administration (SAMHSA), the AANA expressed support for increased access to treatment for opioid use disorder and encouraged broader availability of high-quality medication assisted therapy (MAT) by an increasing number of healthcare professionals who can provide this treatment, including CRNAs.

The letter, sent by AANA President Juan Quintana, DNP, MHS, CRNA, was in response to a SAMHSA proposed rule which seeks to increase the highest patient limit from 100 to 200 for qualified healthcare professionals to treat opioid use disorder. The purpose of the proposed rule is to increase access to treatment for opioid use disorder while reducing the opportunity for diversion of the medication to unlawful use.

The letter states that the AANA supports efforts for improving access to treatment for substance and opioid use disorders, which may include:
  • Increased use of CRNAs providing anesthesia care and pain management services with a holistic perspective for the patient, in a manner that reduces the need for opioids intra-operatively and postoperatively;
  • Increased use of non-pharmacologic and non-opioid management of acute and chronic pain;
  • Safe, responsible use of MAT to assist with comprehensive addiction treatment, including close medical supervision, behavioral therapy or counseling, patient education, evaluation for individualized treatment with consideration of co-occurring disease and disorders, ability to refer patients to higher levels of care as necessary, and drug screening to minimize the risk of relapse and maximize the benefit of treatment to support the patient’s long-term recovery.
The letter also voiced concerns that MAT would replace or not be used in combination with other important treatment modalities (e.g., counseling, drug screen) and would be used without appropriate supervision and monitoring.

View the AANA letter here.

View the proposed rule here.
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Senate Appropriations Committee Clears Legislation Funding Title 8 Nurse Workforce Development Programs

On June 9, the Senate Appropriations Committee approved its Labor, Health and Human Services (HHS), and Education Appropriations bill for fiscal year 2017, clearing it to go to the floor for a vote by the full Senate. The bipartisan legislation was approved on a committee vote of 29-1. Overall, the FY 17 bill includes $161.9 billion in discretionary spending, which is $270 million less than the FY 16 level and $2 billion less than the President’s budget request. HHS is funded at $76.9 billion, which is $1.4 billion more than the FY16 level. The following funding levels are of particular interest to CRNAs:
  • Nursing Workforce Development Programs: The legislation provides $229 million for Title VIII Nursing Workforce Development Programs, level with FY 16 funding. 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.
  • Opioid Abuse Prevention and Treatment Programs: The legislation provides $261 million to the Centers for Disease Control and Prevention (CDC), Substance Abuse and Mental Health Services Administration (SAMHSA), and Health Resources and Services Administration (HRSA) for programs related to opioid abuse prevention and treatment, a 93 percent increase over the FY16 level.
  • Rural Health Programs: The legislation provides $152.6 million toward programs that help rural communities. This is an increase of $3 million over the FY16 level.
The next step for the legislation is a vote by the full Senate, which has not yet been scheduled.

In the House of Representatives, the Appropriations Subcommittee on Labor, HHS, Education, and Related Agencies is yet to schedule its markup of a bill. Once this takes place, it will be up to the full committee to approve the bill prior to a vote on the House floor before the end of the fiscal year on September 30.

A summary of the full Senate legislation is available here.
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Upcoming Presidential and Congressional Elections

The AANA encourages CRNAs to vote and be active in primary elections this spring in support of candidates of their choice. If you are involved in one of the following primary or caucus campaigns, AANA DC would be delighted to hear from you. Tell your story or send your pictures to info@aanadc.com with “CRNAs in Campaigns” in the subject line.
  • June 28, congressional primaries in Colorado, New York, Oklahoma, and Utah
For an up-to-date list of 2016 election dates by state and by date, go here.
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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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Jobs


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.

Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood

A single exposure to general anesthesia appears to pose no cognitive risks to children younger than age three years, according to new research. The sibling-matched cohort study involving 105 sibling pairs was conducted between 2009 and 2015 at four university-based pediatric tertiary care hospitals in the United States. Researchers compared a single exposure to general anesthesia during inguinal hernia surgery in one sibling with no anesthesia exposure in the other sibling, before age three years. Global cognitive function (IQ) was tested in both the exposed and unexposed siblings at mean ages of 10.6 and 10.9 years, respectively. The exposed children all received inhaled anesthetic drugs, and anesthesia duration ranged from 20–240 minutes. There were no statistically significant differences in the mean IQ scores between exposed and unexposed siblings, the researchers report. Additionally, there were no statistically significant differences in mean scores between sibling pairs for memory, attention, visuospatial function, executive function, language, motor and processing speed, or behavior. Further study should look at repeated exposure, extended exposure, and vulnerable subgroups, the researchers said.

From "Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood"
Journal of the American Medical Association (06/07/16) Vol. 315, No. 21, P. 2312 Sun, Lena S; Guohua, Li; Miller, Tonya L.K.; et al.

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New Opioid Limits Challenge the Most Pain-Prone

State and federal restrictions have tightened access to opioids, with University of Maryland School of Pharmacy professor Mary Lynn McPherson noting that people "have to jump through more hoops" to fill prescriptions. Not only that, they can expect to be dispensed fewer tablets and pushed harder toward nonpharmacological alternatives. The crackdown is especially affecting older adults, who are more exposed to conditions and procedures that may warrant opioid therapy. At the same time, this demographic is more apt to experience the adverse effects of such medications—including nausea and vomiting, constipation, kidney or cardiac damage, and impaired cognitive function, among others. To complicate matters, alternatives—including NSAIDs such as ibuprofen or naproxen—present their own set of perils for older adults, including bleeding and reduced kidney function. Physicians are left struggling to balance the need to ease suffering with the need to avoid worrisome adverse effects, including the possibility of addiction. Although overdose and addiction traditionally have been lower among older adults, public health experts suspect the trend could reverse with Baby Boomers.

From "New Opioid Limits Challenge the Most Pain-Prone"
New York Times (06/07/16) Span, Paula

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Reduced Cancer Risk, Improved Survival With Neuraxial Anesthesia

Based on an analysis of 21 existing studies, use of neuraxial anesthesia (NA) is tied to improved overall survival (OS) and lower risk for disease recurrence in cancer patients. Reviewers looked at the effects of NA, NA with or without general anesthesia (GA), and GA by itself in surgeries for tumor resection. "For recurrence-free survival (RFS), a significant association between neuraxial anesthesia and improved RFS was detected compared with GA," they wrote in Oncotarget. "Our meta-analysis suggests that neuroaxial anesthesia may be associated with improved OS in patients with cancer surgery, especially for those patients with colorectal cancer." Despite the emphasis on colorectal cancer, favorable outcomes from NA were also documented in surgeries for prostate cancer, ovarian cancer, gastro-esophageal cancer, and laryngeal and hypopharyngeal cancer. First author Meilin Weng, MD, of Fudan University in China noted that NA "can reduce anesthetic requirements, decrease the release of endogenous opioids, improve tissue oxygenation and promote innate antitumor factors through the effects of local anesthetic. It can also bring early survival benefit by reducing the incidence of thrombotic events, infection, cardiovascular and pulmonary complications."

From "Reduced Cancer Risk, Improved Survival With Neuraxial Anesthesia"
Anesthesiology News (06/02/16) Dreyfuss, John Henry

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Reducing Pain During Postop Pediatric Strabismus Surgery

Based on a study including 50 patients at the Duke Eye Center, bupivacaine can alleviate pain in children having strabismus surgery. The research targeted kids between one and eight years, who were randomized to receive different forms of anesthetic pain relief: sub-tenons bupivacaine with topical control, sub-tenons control with topical lidocaine, or sub-tenons control with topical control. Pain was evaluated every five minutes after surgery for the first half-hour, every 15 minutes for the next two hours, and hourly until discharge. Lead researcher Laura Enyedi, MD, reported markedly lower 30-minute pain scores in the bupivacaine patients compared with the control group; scores were also lower compared to the lidocaine group, but not enough to impart statistical significance. There were fewer bilateral cases in the bupivacaine group than in the other two cohorts, however; and any difference in pain control lost statistical significance when scores in the bilaterality group were re-assessed. The finding suggests bilaterality may be correlated to pain, according to Enyedi, who said the best approach is a multimodal plan that integrates narcotics with local anesthetics, NSAIDs, and acetaminophen.

From "Reducing Pain During Postop Pediatric Strabismus Surgery"
Opthalmology Times (06/01/16) Dalton, Michelle

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'Immobilization' Blanket Replaces Sedation for Infant Medical Procedures

Duke University Children's Hospital is using a special med-vac blanket during procedures that normally would require newborns to be put under. To avoid the risk of adverse events from anesthesia and sedation, the tiny patients are instead wrapped inside an "immobilization" blanket filled with air and foam beads. The air is then sucked out with a hand pump, explains Christine Hiller of Duke's Pediatric and Congenital Heart Center, leaving the beads to conform to the infant. The technique keeps the child confined, but comfortable, during MRIs and other procedures by holding him or her "in their physiologic natural sleeping position," she adds. Hiller says the approach was tested, with great success, on 10 babies at the hospital. "They were completely functionally still so that we could get quality brain imaging," she reports.

From "'Immobilization' Blanket Replaces Sedation for Infant Medical Procedures"
WRAL.com (06/01/16) Mask, Allen

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Combination Dexamethasone Reduces Pain, Enhances Nerve Block Duration Compared With Systemic Dex Alone

Adding perineural dexamethasone to systemic intravenous dexamethasone extends postoperative pain relief after thoracic surgery and adds a pulmonary benefit, a new study finds. Bupivacaine with systemic dexamethasone typically yields about 20 hours of pain control; but that period can be prolonged up to eight hours more, according to researchers, if perineural dexamethasone is added to the equation. Dermot Maher, MD, MS, of Massachusetts General Hospital and Harvard Medical School led the investigation, which involved 40 patients undergoing the same thoracic procedure by the same surgeon. Half of the participants received bupivacaine plus saline, with the remainder receiving a combination of bupivacaine and dexamethasone. The dexamethasone group reported lower pain scores at eight, 20, and 24 hours postoperatively; and those patients needed fewer opioids at 32 hours. In addition, combined dexamethasone improved breathing patterns by a statistically significant margin compared to the control group. Maher called for additional research to determine optimal doses of systemic and perineural dexamethasone as well as to compare the approach against newer, more expensive analgesics, including liposomal bupivacaine.

From "Combination Dexamethasone Reduces Pain, Enhances Nerve Block Duration Compared With Systemic Dex Alone"
Pain Medicine News (05/31/2016) Doyle, Chase

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Narcotic Painkillers Prolong Pain in Rats, Study Says

Based on animal studies, researchers at the University of Colorado Boulder suspect opioids actually may cause pain to linger rather than diminish. As they report in the Proceedings of the National Academy of Sciences, rats given morphine for five days to treat a peripheral nerve injury continued to experience pain for several months. Investigators suspect the effect of opioid-based drugs on the spinal cord and immune cells could play a role in longer-term chronic pain conditions in humans, but they say more research is warranted. "The implications for people taking opioids like morphine, oxycodone and methadone are great, since we show the short-term decision to take such opioids can have devastating consequences of making pain worse and longer lasting," notes university professor Linda Watkins, MD. "This is a very ugly side to opioids that had not been recognized before."

From "Narcotic Painkillers Prolong Pain in Rats, Study Says"
United Press International (05/30/16) Feller, Stephen

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Opiate-Free Anesthesia Linked to Fewer Painkillers Later

Breast cancer patients need fewer postoperative narcotics if the anesthesia they receive during surgery is free of opioids, report researchers from the Jules Bordet Institute in Brussels. Their study included 64 patients, divided according to opiate-based or non-opiate anesthesia. The results, reported at Euroanesthesia 2016, indicated that patients in the non-opiate group required fewer painkillers 24 hours after their mastectomy or lumpectomy than patients who received opiate analgesia during the procedure. The level of pain relief was sufficient in the non-opiate group, said study author Dr. Sarah Saxena, even with less pain medication. "Non-opiate anesthesia in breast cancer surgery might avoid several opiate-related side effects such as postoperative nausea and vomiting," she added. "It might also reduce cancer recurrence." Her team is continuing its research in order to build on the findings.

From "Opiate-Free Anesthesia Linked to Fewer Painkillers Later"
Nursing Times (United Kingdom) (05/30/16) Ford, Steve

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Listening to Relaxing Music Reduces Anxiety in People Undergoing Eye Surgery, Allows for Less Sedation

A French study of elective eye surgeries adds to mounting evidence that the therapeutic benefits of music curtail the need for analgesia and anesthesia in the operating room. The 62 participants either listened to relaxing instrumentals—composed specifically to alleviate stress—or no music at all during the 15 minutes prior to cataract surgery. According to a questionnaire administered before and after the procedure, patients who did not listen to music were more anxious. Those who did, however, required fewer sedatives and were significantly more satisfied with their experience. "Music listening may be considered as an inexpensive, non-invasive, non-pharmacological method to reduce anxiety for patients undergoing elective eye surgery under local anesthesia," concluded lead study author Gilles Guerrier, MD. "We intend to assess the procedure in other types of surgeries, including orthopedics where regional anesthesia is common. Moreover, post-operative pain may be reduced by decreasing post-operative anxiety, which is another study we intend to perform."

From "Listening to Relaxing Music Reduces Anxiety in People Undergoing Eye Surgery, Allows for Less Sedation"
Medical Daily (05/28/16) Bushak, Lecia

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Poor Compliance by Hospitals Places Patients at Risk for Opioid-Induced Respiratory Depression

The first 48 hours after an operation present the greatest threat for opioid-induced respiratory depression, yet research indicates almost three-quarters of surgical patients are not adequately monitored for this byproduct of overdose. Spearheaded by University at Buffalo assistant nursing professor Carla Jungquist, PhD, the study recorded whether nurses at eight U.S. hospitals followed protocol to track blood oxygen saturation, respiratory rate, and level of sedation every two to four hours during the first 24 hours of recovery. Of more than 4,000 records reviewed, the analysis revealed that just 8 percent of patients receiving intravenous infusions of opioid medication underwent all three assessments every two hours; and slightly less than 27 percent were evaluated every four hours. The research also noted that more than 1 percent of patients needed rescue with naloxone—which reverses the effects of opioid overdose—but none of the patients monitored every two hours were among them. Jungquist and colleagues published the study in the Journal of Nursing Administration.

From "Poor Compliance by Hospitals Places Patients at Risk for Opioid-Induced Respiratory Depression"
Medical Xpress (05/27/16) Robinson, Marcene

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Use of Neuraxial, General Anesthesia Found Dependent on Patient, Provider Characteristics

Patient and provider characteristics guide decisions on what type of anesthesia to use for total hip replacements, research finds. Investigators analyzed more than 107,000 surgeries, with patients receiving general anesthesia (GA) in a little more than two-thirds of the operations and neuraxial anesthesia in just under a third. Among provider traits, the review indicated attendance by a certified registered nurse anesthetist was more frequent in the GA group; while the presence of an anesthesia resident or board-certified anesthesiologist was associated with neuraxial anesthesia. Among patients, those with greater comorbidities were less likely to undergo neuraxial anesthesia. Better candidates for this option exhibited decreased postoperative nausea/vomiting, and decreased inadequate pain control, among other traits. Patients classified as American Society of Anesthesiologists I or II also were more likely to receive neuraxial anesthesia. Even facility type played a role in anesthesia decisions. University hospitals were the least likely, for example, to employ neuraxial anesthesia as the primary anesthetic.

From "Use of Neuraxial, General Anesthesia Found Dependent on Patient, Provider Characteristics"
Healio (05/26/2016) Tingle, Casey

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Ketamine Better Than Haloperidol for Sedation Onset But Not Much Else

Researchers in Minneapolis say their study finds ketamine to be a much more effective agent than haloperidol for sedating agitated patients prior to hospitalization. A pair of studies they conducted over the course of one year included 146 participants, 64 of whom were given ketamine during transport to the hospital and 82 of whom were administered haloperidol. Sedation was achieved in just 5 minutes, on average, in the ketamine recipients; while it took about 12 minutes longer for the haloperidol to kick in. The ketamine group, however, also experienced significantly more intubations and complications than the haloperidol group. Despite the drug's inferiority in these aspects and despite weaknesses in the study design—including that it was neither randomized nor blinded—the researchers say the results point to a need for a deeper look into ketamine's use for rapid onset sedation. Safer formulations might be developed, they surmise, by adjusting doses. The study is reported in Clinical Toxicology.

From "Ketamine Better Than Haloperidol for Sedation Onset But Not Much Else"
American Council on Science and Health (05/25/16) Abassi, Lila

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The End of the Open Market for Lethal Injection Drugs

Seven years after Hospira halted production of sodium thiopental—an anesthetic used to put prisoners under while carrying out capital punishment sentences—Pfizer has taken steps to restrict the use of its drugs for executions. Lethal injections—accomplished with a cocktail of drugs to render the inmate unconscious, cause paralysis, and stop the heart—were embraced in the late 1970s as a gentler alternative to firing squads, gas chambers, and electrocutions. However, a spate of flubbed procedures in recent decades has demonstrated that drugs cleared for medical purposes do not necessarily make for a humane execution. Moreover, the growing objections of drug manufacturers morally opposed to having their products used in this manner has created a procurement problem for correctional authorities. Unable to legally obtain drugs needed for lethal injections, even from overseas suppliers, state prison systems have turned to loosely regulated compounding pharmacies—which carry their own risks—and substituted other drugs on an experimental basis. The supply of drugs for executions will dry up at some point, leaving states to choose a different method to serve death sentences or to wrestle with the issue of capital punishment itself—and whether it can ever even be carried out in a fair and constitutional fashion.

From "The End of the Open Market for Lethal Injection Drugs"
New Yorker (05/21/16) Caplan, Lincoln

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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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June 15, 2016
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