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Novitas Update:
AANA Continues Challenge to LCD, Pursues Dialogue with CMS

On June 13, 2017, the AANA voluntarily filed to dismiss its litigation without prejudice, which leaves the AANA with the ability to revive its lawsuit under the right circumstances. In the time since the Local Coverage Determination (LCD) took effect on June 5 following the court's determination that AANA's lawsuit could proceed, the AANA Board of Directors, legal counsel, and staff have carefully deliberated on a course of action that would put the AANA in the best possible position to continue working with the Centers for Medicare & Medicaid Services (CMS), our strategic partners, and other stakeholders to achieve a more favorable result for CRNAs not only with regard to this LCD, but with regard to the LCD process going forward. For further information, read the statement by President Cheryl Nimmo, DNP, MSHSA, CRNA. (AANA member login and password required.)
 
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See You Next Week!
Welcome to the Weekly Anesthesia E-ssential

As part of our goal to deliver important news and information to members in a timely manner, the Anesthesia E-ssential will now be distributed each Thursday instead of twice monthly. Be sure to check your email inbox each Thursday afternoon for an informative digest of news about the AANA, the profession, and the healthcare industry. 

 

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There's a New Way to Participate in the Business of the AANA!

On Saturday, Sept. 9, 1 p.m. PDT, the AANA Business Meeting will be live streamed with access through AANA's website. On Sunday, Sept. 10, all eligible voting members of the association will receive an email allowing them to vote on the proposed bylaw amendments and resolutions. You will also have access to a recording of the debate on the specific issue. Voting will be open for 24 hours. Be sure to update your email address in AANA's records, and watch for your voting email on Sunday, Sept. 10.

 

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June AANA Journal Highlights

Read on for highlights of the June 2017 issue of AANA Journal.

ONLINE CONTENT at aana.com:
 
Guest Editorial:
You Are Needed—Service and the AANA
 
The senior director of Education and Professional Development at the American Association of Nurse Anesthetists, Bruce A. Schoneboom, PhD, CRNA, FAAN, COL(ret), ANC, USA, recounts his experiences regarding a career that spanned nearly 3 decades in the U.S. Army including more than 22 years as an Army Certified Registered Nurse Anesthetist (CRNA) and he encourages fellow CRNAs to get involved in their  profession.

Pulmonary Hemorrhage During Computed Tomography–Guided Percutaneous Lung Biopsy: A Case Report and Review of the Literature
This is a case report of a young male suffering from a potentially life-threatening pulmonary bleed during a percutaneous lung biopsy. It reminds us that vigilance and a worse-case-scenario plan are essential during even routine and generally “low-risk” procedures.
 
Bilateral Tension Pneumothoraces During Colonoscopy: A Case Report and Review of Literature
This fascinating case report of an extremely rare event, along with a literature review of other cases, demonstrates how important it is to be prepared for the unexpected. Vigilance and rapid diagnosis and intervention were critical in prevention a catastrophic outcome.
 
Ventilatory Management During Intraoperative Airway Obstruction due to Endotracheal Tube Kinking
A kinked endotracheal tube, if not rapidly recognized and corrected, can lead to a disastrous outcome. This case report highlights the clinically relevant manifestations of such an occurrence and uses a bench research model to reinforce our understanding of what to look for in such a scenario.
 
Intravenous Acetaminophen for Perioperative Pain Control in Adult Elective Neurospine Surgical Patients: A Retrospective Case-Control Study
IV acetaminophen is increasingly utilized by many as part of a perioperative analgesic strategy. Using a case-control design, this clinical study examines its use in a particular patient population and will be of great interest to providers who use, or are considering using, such an approach in their surgical anesthetic care plans.
 
Intravenous Dexamethasone for Prolonged Duration of Axillary Nerve Blockade
A case is reported of the use of a single, IV dose, of 8 mg of Dexamethasone as an alternative to perineural use of the drug, which is currently not FDA approved. Outcome is reported in terms of what the current literature reveals about its use. 
 
LiteratureSearching for Practice Research  
This practical approach to doing a professional and timely literature search when seeking the best evidence, provides a framework for those providers who may not have access to a resource biomedical librarian in their practice environments.
 
Self-Efficacy and Graduate Education in a Nurse Anesthesia Program: A Pilot Study
This study examined the role of self-efficacy as it relates to the phasic components (didactic vs clinical) of student evolution as they worked through their educational and training program. Results are surprising and will be of interest to educators and practitioners (and students!) alike.
 
Workforce Initiative for Current Predictors of CRNA Employment in the State of Florida
In a state with three types of anesthesia providers and a rapidly expanding patient population, this study assessed workforce requirements in the state relative to current and projected patient population needs. While the study is confined to one state, there are important implications for such research that apply to other practice locales.
 
AANA Journal Course: Update for Nurse Anesthetists—Part 2—A Review of Dental Anatomy and Dental Injury Associated With Anesthesia
This continuing education offering provides an update on a critically important, and all too common, area of practice— dental evaluation and injury as it relates to anesthesia care.  This is an important contribution to our specialty and will be of interest to all providers.
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AHIX Offers Small Business Health Plan

AHIX, an AANA Member Advantage Program Partner, offers affordable health coverage for small business owners and their employees. Perfect for companies with no current group health plan, this AHIX plan covers:

  • Hospital
  • Office visits
  • Emergency Room
  • Surgery
  • Ambulance
  • X Rays
  • Labs
  • RX card
  • Extended coverage for critical Illness and accidents
  • Dental optional
  • Visit www.aanahealthplans.com to find out more.


     
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    Professional Practice


    FDA Requests Removal of Opana ER from Market

    U.S. Food and Drug Administration (FDA) has requested that Endo Pharmaceuticals remove its opioid pain medication, reformulated Opana ER (oxymorphone hydrochloride), from the market. After careful consideration, the agency is seeking removal based on its concern that the benefits of the drug may no longer outweigh its risks. This is the first time the agency has taken steps to remove a currently marketed opioid pain medication from sale due to the public health consequences of abuse. Read more in the FDA’s press release.

     

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    MHAUS Recommendations Available for Public Comment

    The Malignant Hyperthermia Association of the United States (MHAUS) has released two recommendations for public comment. The comment period will close on July 6. The recommendations are titled:
    • Following treatment of acute MH, how much dantrolene should be administered and for how long? What criteria should be used to determine stopping treatment with dantrolene?
    • Can patients with a suspected personal or family history of MH be safely anesthetized prior to diagnostic testing?
    CRNAs are encouraged to review and leave professional, diplomatic, and concise comments directly on the MHAUS site.
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    The Joint Commission Updates Healthcare-Associated Infection National Patient Safety Goal

    Revised requirements for National Patient Safety Goal 7 "Reduce the risk of health care–associated infections," for hospitals and critical access hospitals (CAHs) effective Jan. 1, 2018, include: 
    • Allowing hospitals and CAHs to determine the timeframe for periodically educating staff and licensed independent practitioners about multidrug-resistant organisms and prevention strategies after initial education.
    • Allowing hospitals and CAHs to determine the timeframe for periodically educating staff and licensed independent practitioners about the importance of prevention of central line-associated bloodstream infections after initial education.
    • Requiring use of maximum sterile barrier precautions during central venous catheter insertion.
    • Requiring an alcoholic chlorhexidine antiseptic for skin preparation during central venous catheter insertion unless contraindicated.

     Read the revised standards.

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    Time Outs to Improve High Reliability

    With the Association of periOperative Registered Nurses' (AORN’s) National Time Out Day on June 14, The Joint Commission is reminding all perioperative healthcare providers about the importance of an effective time out in creating a safe environment for a patient undergoing surgery or an invasive procedure. Several impediments to effective time outs, as noted by The Joint Commission, include:

     

    • Time outs taking place without all staff members present, or before prep and drape occurs.
    • Time outs without the staff’s full participation.
    • Lack of senior leadership engagement in the time out.
    • Staff feeling too intimidated to speak up.
    • Inconsistent organizational focus on patient safety.
    • Policy changes made with inadequate or inconsistent staff education.
    • Distractions or insufficient time to conduct a proper time out.

    Read more about The Joint Commission’s efforts to highlight National Time Out Day, including safety culture resources and the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.

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    Foundation and Research


    AANA Foundation: Donate Today for Annual Congress Recognition

    Thank you to all AANA members who have supported the AANA Foundation in fiscal year 2017. Your support is so important in advancing nurse anesthesia education and research.

    If you haven’t made your donation yet, please do so by July 1, 2017, to be included in the AANA Foundation’s FY17 Annual Report (donations of $100 or more will be included). Visit the Foundation's secure donation page.

    Again, thank you for your support!
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    AANA Foundation Announces New Logo

    In September 2016, in conjunction with its 85th anniversary, the AANA rolled out a new branding initiative which included a new motto, imagery, and logo. Recently, a new logo has been created for the AANA Foundation. The new logo includes a column which the Board felt was an appropriate image to represent the Foundation. Pictured here is the old logo to the far left and two versions of the new logo – one rectangular and one square.

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    Jobs


    Visit www.crnacareers.com
    to view or place job postings
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    Featured Career Opportunities

    Full Time Certified Nurse Anesthetist - Hospital for Special Surgery (HSS)
    New York City
     
    The Hospital for Special Surgery has an excellent opportunity for either a new grad or experienced Certified Nurse Anesthetist with excellent clinical skills to join our Anesthesiology team!

    Read more about this position.


    Full Time CRNA - CompHealth
    Missouri
     
    $215K POTENTIAL, $25K BONUS and $6K ANNUALLY
    Offering 8 and 10 hour shifts, EXCELLENT schools, cost of living and benefits.
    90 Minutes to the city!  New Grad welcome!
     

     
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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.

    Success With Neurotropin in Treating Pediatric Lower Extremity Pain Induced by Spinal Cord Injury After Epidural Anesthesia

    Spinal cord injury (SCI) has been known to occur as a complication of epidural block, and treating the ensuing neuropathic pain continues to challenge the medical establishment. A 2015 case in China, however, now offers the first direct evidence that neurotropin—which is implicated in neuronal growth regulation—may represent a clinically effective approach to resolving neuropathic injury in children that occurs during epidural anesthesia. A seven-year-old female undergoing emergency appendectomy moved involuntarily during lumbar puncture, causing deep penetration of the anesthetic needle. After emerging from anesthesia, the patient complained of pain, numbness, muscle weakness, and difficulty walking. She was given gabapentin, diclofenac sodium, mecobalamin, ganglioside, and dexamethasone/methylprednisolone in an effort to discourage SCI and deliver pain relief. The analgesics gradually resolved most of her symptoms, but the pain continued unabated at postoperative day nine. After securing permission from the girl's parents, caregivers administered neurotropin. The patient's pain subsided little by little, dropping from a visual analog score of 7 to 4 over about two weeks and eventually falling to 0, with all myelomalacia of SCI virtually gone within 15 months. Although neurotropin to date has rarely been used in children, the authors believe it should be viewed as a promising candidate for pain relief in the pediatric population.

    From "Success With Neurotropin in Treating Pediatric Lower Extremity Pain Induced by Spinal Cord Injury After Epidural Anesthesia"
    Journal of Pain Research (06/17) Vol. 2017, No. 10, P. 1391 Zhu, Mengye; Zhou, Fuqing; Li, Lingchao; et al.

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    Chronic Pain Raises Risk of Dementia

    Researchers at the University of California, San Francisco claim that elderly people suffering from chronic pain lose their memory faster and are more vulnerable to dementia. The analysis, based on data from an ongoing study of Americans aged 60 years and up, reportedly is the first to suggest that chronic pain triggers changes in the brain. One possibility, according to lead author Elizabeth Whitlock, MD, of the university's anesthesia and perioperative care department, is that the emotional trauma caused by pain triggers stress-hormone pathways in the body that may play a role in cognitive decline. She and her team sifted through data on more than 10,000 older Americans who answered questions about their pain and cognition in 1998 and 2000. Respondents who complained of nagging pain were 7.7 percent more likely to develop dementia. They also declined 9.2 percent faster in tests of their memory and cognitive function over the next 10 years than did older adults not plagued by chronic pain. "Up to one in three older people suffer from chronic pain," Whitlock remarked, "so understanding the relationship between pain and cognitive decline is an important first step toward finding ways to help this population." The study appears in JAMA Internal Medicine.

    From "Chronic Pain Raises Risk of Dementia"
    Pain News Network (06/05/17) Anson, Pat

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    Pupillary Light Reflex Recovery From General Anesthesia Varies Greatly

    Researchers in Belgium have discovered that recovery of light reflex—which is depressed by general anesthesia (GA)—varies widely among patients, no matter what agent is used to put them under. Their study involved 80 adults, randomly allocated to receive either propofol target-controlled infusion or sevoflurane anesthesia in addition to remifentanil. Pupillary light reflex (PLR) was tested in an awake state before GA, serially between induction and emergence from GA, and in the post-anesthesia care unit once the patient was responsive again. The investigators had expected that older people might regain PLR more slowly; however, the time needed to recover a third or half of the pupillary relaxation velocity measured before GA induction was affected neither by age nor duration of anesthesia, time to extubation, PLR variation before GA, or pupillary reaction velocity. They were further surprised that recovery times also were not influenced by parameters at the end of GA—including heart rate, end-tidal carbon dioxide monitoring, bispectral index, and mean arterial pressure. PLR has long been used for neurologic evaluation of anesthetized patients; but, based on their findings, the researchers say physicians may want to reconsidering using it to measure brain stem function in patients who have been under GA.

    From "Pupillary Light Reflex Recovery From General Anesthesia Varies Greatly"
    Anesthesiology News (06/04/17) Covey, Ethan

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    Older Patients Have a Higher Pain Tolerance After Major Surgery—Or Do They?

    While previous research has indicated postoperative pain diminishes with increasing age, new findings suggest that geriatric patients simply do not own up to how much they hurt. The team from Germany's Jena University Hospital extracted data for nearly 2,400 patients from PAIN OUT, an international registry and study targeting outcome data on the first day following surgery. Investigators looked at age—an independent variable—and functional impairment—a dependent variable—in the patients, all of whom had total knee arthroplasty between February 2010 and November 2016. They noted that self-reported pain levels clearly declined with older people, although their functional impairment scores did not. "Our study confirms that the older the patients, the lower their reported maximum pain levels," according to researchers, who presented the evidence at the Euroanesthesia meeting in Geneva from June 3-5. "These findings suggest that elderly patients might tend to underreport their pain levels, and that asking about functional impairment might be a better tool for pain assessment."

    From "Older Patients Have a Higher Pain Tolerance After Major Surgery—Or Do They?"
    Medicalxpress (06/03/2017)

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    Caudal Block May Increase Intracranial Pressure in Children

    Although complications from caudal block occur at a low rate in pediatric patients, new evidence suggests the technique may carry a risk of elevated intracranial pressure. The anesthetic approach increasingly is being used for postoperative pain control in infants and children following abdominal procedures. The new study focused on 80 patients undergoing urological surgery at a single site in Korea. The participants, aged 6 months to 4 years old, were randomized to a high or low dose of ropivacaine during the block. Researchers measured optic nerve sheath diameter (ONSD)—a representation of intracranial pressure—before the block, immediately following it, 10 minutes afterwards, and 30 minutes afterwards. Caudal blocks using 1.5 ml/kg of local anesthetic appeared to raise intracranial pressure in pediatric patients more so than blocks using just 1.0 ml/kg; however, both dosages increased ONSD from baseline levels. The results "might raise safety concerns regarding caudal block . especially in children with intracranial pathologies or risk factors associated with increased intracranial pressure," the investigators report in the British Journal of Anaesthesia.

    From "Caudal Block May Increase Intracranial Pressure in Children"
    Clinical Pain Advisor (06/01/17) Melton, Christin

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    We Might Have Been Wrong About How Anaesthesia Blocks Consciousness All Along

    Anesthesia has been used safely and effectively for more than 100 years, but scientists are still largely in the dark about how it actually works. The predominant line of thought—that anesthetic agents block connections between different sectors of the brain, which in turn limits the volume of information that can be exchanged between them—is now being called into question. Researchers at Germany's Goethe University suspect that rather than disrupting information transfer, anesthetics instead may actually be changing brain connections. As they explain in PLOS Computational Biology, it is possible that the reduction in transferred information is due to the fact that the information is not there to be conveyed. "The decreases in information transfer could be related to less information being available in the source, rather than to a decoupling," they speculate. Rodent tests using isoflurane appear to support their hypothesis. Brain activity in ferrets given the drug showed the information transfer decreased the most at the prefrontal cortex, or the source of the information, rather than at the target area known as V1. That suggests that the prefrontal cortex is struggling to generate information to transfer. More research is needed to explore this theory, the investigators concede.

    From "We Might Have Been Wrong About How Anaesthesia Blocks Consciousness All Along"
    ScienceAlert (06/01/17)

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    Vibrating, Cold Device Enables Quick IV Insertion While Reducing Kids' Pain in Emergency Room

    Researchers at Children's Hospital of Philadelphia have endorsed a non-pharmacologic alternative to lidocaine for administering intravenous catheters to children in the emergency department (ED) setting. Based on a study of 251 patients aged 4–18 years, they say a vibrating cold device (VCD) delivers similar relief as does the topical anesthetic. Study participants were randomly assigned to receive one treatment method or the other during IV insertion, and self-reported pain and anxiety was no different between the two cohorts. Nurses and caregivers also were highly satisfied with both approaches; however, lead investigator Debra Potts, RN, suggested the shorter time of onset associated with VCD might be more advantageous in busy EDs. "We anticipate that using this device would enable nurses to insert an IV with little pain for the child at least 30 minutes sooner than using topical lidocaine," she noted, adding that larger follow-up studies are warranted.

    From "Vibrating, Cold Device Enables Quick IV Insertion While Reducing Kids' Pain in Emergency Room"
    Science Daily (06/01/2017)

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    General Anesthesia Linked to Postoperative Delirium in TKR Patients

    Researchers say patients having total knee arthroplasty (TKA) could be twice as likely to suffer postoperative delirium if they undergo general anesthesia versus neuraxial anesthesia. A team from the Hospital for Special Surgery in New York City used anesthesia billing information and surgical billing codes to identify more than 21,000 patients who had TKA at their facility from 2005-2014. Multivariable logistics regression analysis was then applied in order to flesh out predictors for postoperative delirium. After controlling for age, gender, and comorbidities like diabetes and sleep apnea, the colleagues determined that anesthetic approach had a significant influence on risk. Compared with general anesthesia, the likelihood of presenting with postoperative delirium after knee replacement was 0.52 for spinal, 0.45 for epidural, and 0.55 for combined spinal-epidural. "Given that other risk factors might not be modifiable, anesthesia type is especially important to consider as a way to reduce risk for delirium as well as other complications," said Sarah Weinstein, a research data analyst at the Hospital for Special Surgery.

    From "General Anesthesia Linked to Postoperative Delirium in TKR Patients"
    Anesthesiology News (06/01/17) Doyle, Chase

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    Visual Recognition Memory Impaired After Multiple Exposures to Anesthesia During Infancy

    As the medical community continues to pursue its understanding of anesthesia in the pediatric setting, recent research links multiple exposures to anesthesia during early life to impaired visual recognition memory. The finding comes from the Icahn School of Medicine at Mount Sinai and is based on animal models that closely mimic human neurodevelopment. Led by professor Mark Baxter, PhD, of the school's anesthesiology and neuroscience departments, the investigators exposed 10 young Rhesus monkeys to sevoflurane for four hours—roughly the time needed for major surgery in people. The exposures took place at 7 days postnatal, at 2 weeks, and at four weeks. Once the test subjects reached age 6-10 months, their visual recognition memory was evaluated and compared with healthy controls, with assessments taken again at 12-18 months and 24-30 months of age. While there was no obvious difference in memory function between controls and exposed infants during the first round of testing, the exposed monkeys exhibited significant memory impairment compared to their unexposed counterparts after the first year of life. "Our findings are consistent with epidemiological studies that show increased risk of long-term cognitive impairments after repeated exposure to anesthesia in infancy and early childhood," according to Baxter, "but perhaps most interestingly, we found that these deficits may emerge at later developmental stages, even when memory performance is unaffected earlier in development." The research was reported in the British Journal of Anaesthesia.

    From "Visual Recognition Memory Impaired After Multiple Exposures to Anesthesia During Infancy"
    Medical Xpress (05/31/17)

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    Intraoperative Ketamine for Prevention of Postoperative Delirium or Pain After Major Surgery in Older Adults

    A multinational research effort questioned whether the anesthetic agent ketamine prevents delirium, which often affects older adults after a major operation. The Prevention of Delirium and Complications Associated with Surgical Treatments (PODCAST) study recruited participants aged older than 60 years between Feb. 6, 2014, and June 26, 2016. Ultimately, 227 patients were randomized to receive 0.5 mg/kg of ketamine after anesthesia induction but before surgical incision; 223 were assigned to a higher dose of 1.0 mg/kg; and 222 were given placebo. Using the Confusion Assessment Method, investigators determined that delirium incidence did not differ between the ketamine cohorts and the control group, nor was there any disparity in adverse events. Postoperative hallucinations and nightmares were more common, however, with increasing doses of ketamine compared with placebo. Based on the trial results, the PODCAST researchers concluded that a single subanesthetic dose of ketamine does not decrease delirium in older adults during the first 3 days following major surgery and, in fact, may actually cause patient harm through negative experiences.

    From "Intraoperative Ketamine for Prevention of Postoperative Delirium or Pain After Major Surgery in Older Adults"
    The Lancet (05/30/2017) Avidan, Michael S.; Maybrier, Hannah R.; Jacobsohn, Eric; et al.

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    Study Aims to Find If IV Acetaminophen Can Lead to Lower Doses of Opioids After Hip Replacement Surgery

    A new study is getting underway to determine if intravenous acetaminophen can curb opioid demand following hip replacement surgery. In New York, the Hospital for Special Surgery team is hoping for an alternative to narcotic medications, which effectively manage postoperative pain but are linked to a host of adverse effects. IV acetaminophen is an viable candidate, according to lead researcher Geoffrey Westrich, MD, because it achieves a higher peak concentration in the blood much faster than pill form. Participants in the double-blinded study will be randomly assigned to receive oral acetaminophen, IV acetaminophen, or placebo. The researchers will evaluate whether pain in the IV acetaminophen patients is alleviated enough to significantly lower their opioid needs and reduce the associated side effects. Other outcomes they will be watching include sedation effects, pace of progress toward physical therapy goals, and length of hospital stay. "Because of its efficacy, general safety profile and lower risk of adverse effects compared to other pain medications, intravenous acetaminophen could be an attractive component of the overall pain management plan," Westrich predicts. "If we find that the IV form safely reduces the need for opioid medication, it would be advantageous for hip replacement patients."

    From "Study Aims to Find If IV Acetaminophen Can Lead to Lower Doses of Opioids After Hip Replacement Surgery"
    News-Medical.net (05/26/2017)

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    Sciatic Nerve Block Plus Femoral Nerve Block May Provide Superior Pain Relief After Total Knee Arthroplasty

    Pairing femoral nerve block (FNB) and sciatic nerve block (SNB) may offer more postoperative pain relief following total knee arthoplasty than would a combination of FNB and local infiltration analgesia (LIA). That is the conclusion of a systematic review and meta-analysis of five English-language studies published in between 1966 and 2017. According to investigators from China's Henan University, SNB plus FNB provided superior analgesia compared to LIA plus FNB in the first two days after surgery. They determined that sciatic-femoral nerve block also reduced opioid consumption on postoperative day 1 in addition to curtailing nausea and vomiting. The strength of the evidence was low, however, with a collective study population of only 240 participants and wide disparities in pain relief and adverse effects between groups. "Our confidence in the effect estimate is limited, and the true effect may be substantially different from our estimates," the researchers report. Previous work also has found that FNB and SNB together deliver superior pain control after knee replacement; however, LIA emerged as an alternative to avoid quadriceps weakness—which can result in postoperative falls—and other adverse effects associated with the approach. Additionally, LIA does not carry the risk of sciatic nerve injury.

    From "Sciatic Nerve Block Plus Femoral Nerve Block May Provide Superior Pain Relief After Total Knee Arthroplasty"
    Clinical Pain Advisor (05/24/17) Stiles, Laura

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    Abstract News © Copyright 2017 INFORMATION, INC.
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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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    For more information on AANA and Anesthesia E-ssential, contact:

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    Attn: Linda Lacey
    E–ssential Editor
    llacey@aana.com
    June 15, 2017
    Earn Your DNAP Nurse Anesthesia Annual Congress AANA Group Disability


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