Anesthesia E-ssential

AANA Anesthesia E-ssential, June 27, 2019, Tenth Anniversary Issue
 
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Vital Signs


Happy 10th Anniversary to the Anesthesia E-ssential!


It was June 30, 2009, when the very first issue of AANA's email newsletter was distributed to its members. The newsletter was then known as "eNews," and one of the news items featured in the issue revealed a contest to name the fledgling newsletter. The winning entry, Anesthesia E-ssential, took effect in August 2009.

Some items of interest that appeared in the first AANA email newsletter include:

  • The August 2009 launch of AANALearn
  • FY2008 AANA President Jackie Rowles' Off the Cuff taped talk (a podcast predecessor)
  • Election results - can you guess who was elected President-elect for FY2010?
  • Various federal initiatives - health reform, graduate nursing education, propofol sedation device, funding for military CRNAs, and more
  • Position Statement 2.14 "Securing Propofol" was released
  • The introduction of AANA's Twitter account: @aanawebupdates, and more.

Compiled and edited by AANA Managing Editor Linda Lacey for the first 9 years, eNews was first presented to the AANA members by AANA President Jackie S. Rowles. The newsletter was the recommendation of the Virtual Communities Task Force appointed by FY2006-07 President Brian Thorson.

Originally, eNews/Anesthesia E-ssential was published on the 15th and 30th of each month (depending on weekends and holidays), and was developed for five main reasons:

  1. To provide members with important news and information in as timely a manner as possible.
  2. To drive traffic to the AANA website.
  3. To provide abstracts of articles and research papers on topics of interest to nurse anesthetists, culled from thousands of periodicals and websites.
  4. To generate non-dues advertising revenue.
  5. To consolidate many of the blast emails sent by the AANA into one blast email—eNews!

Take a look back at the inaugural AANA eNews issue!

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AANA Sees Potential in Exec Order on Price and Quality Transparency


Following an in-depth review of President Donald Trump’s Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First, the AANA has identified the potential benefits to CRNAs, their patients, and the overall healthcare system, and will seek to work with the Department of Health and Human Services (HHS) and other agencies as they strive to meet the aggressive timeline laid out by the president.

To sum up, the executive order seeks to increase transparency in the health industry by:

  1. Directing the HHS secretary to issue a proposed rule within 60 days requiring hospital disclosure of negotiated rates in a format that is understandable and useable by patients;
  2. Directing HHS, Labor, and Treasury to issue a notice of proposed rulemaking within 90 days requiring insurance companies to provide information about cost-sharing and out-of-pocket costs to consumers up front before they receive services;
  3. Directing HHS, DoD, and VA to develop within 180 days a collaborative, comprehensive roadmap for ensuring consistent, consumer-centric quality metrics across Medicare, Medicaid, the Children's Health Insurance Program, the Health Insurance Marketplace, the Military Health System, and the Veterans Affairs Health System that can drive quality improvement;
  4. Directing federal agencies to release non-patient specific health data to researchers to improve health quality within 180 days;
  5. Directing the HHS secretary, in consultation with the attorney general and the Federal Trade Commission (FTC), to issue a report within 180 days that describes how the federal government and private sector are impeding healthcare price and quality transparency for patients, and provides recommendations for eliminating these impediments in a way that promotes competition.
  6. Directing the Treasury to amend Health Savings Account (HSA) rules to expand the range of products and services that can be covered during the deductible period as preventative services, allow money to be used for direct primary care service and health sharing ministries, and increase carry-over amounts for Flexible Spending Accounts (FSAs). The Treasury is required to propose these changes within 120-180 days.

Regarding the directive that the HHS secretary work with the attorney general and FTC to determine how governmental and private sector impediments to healthcare pricing and transparency can be eliminated, the AANA believes this report could be valuable in showing the effects of insurers refusing to recognize CRNA services and refusing to compensate CRNAs at the same rate as anesthesiologists for the same services. Inadequate networks offered by insurers are the result of discrimination against providers, including CRNAs and other APRNs, based on licensure or certification rather than safety, quality, and qualifications. Too often, patients receive out-of-network bills because insurers have refused to negotiate in good faith and have discriminated against providers, forcing the providers to go out of network.

The AANA hopes this directive will reinforce the AANA-supported “provider nondiscrimination” provisions signed into law in 2010, which requires insurers to not discriminate on the basis of licensure. The AANA also is optimistic that the report will bolster the association’s ongoing efforts to address pain management reimbursement issues with Medicare Administrative Contractors.

The AANA will be paying close attention as the executive order requirements are carried out by the various federal agencies over the next six months and will provide regular updates to the AANA membership.

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House Passes Labor-HHS-Education Appropriations Bill, Includes Major Increase to Title VIII Nursing Workforce Funding


In a major victory for CRNAs, the full House of Representatives voted last Wednesday to pass an appropriations bill that would greatly increase funding for Title VIII Nursing Workforce Development Programs.

The bill, H.R. 2470 is a minibus appropriations bill that includes Labor-HHS-Education appropriations as well as appropriations bills for four other departments. Multiple appropriations bills are often packaged together to ensure bipartisan support. The house bill contains several major victories for the AANA as well as the larger Nursing Community Coalition:

  • $279.472 million for Title VIII Nursing Workforce Development Programs: This is a $30.000 million (12.03%) increase over FY2019 funding levels and includes $10 million for existing Title VIII programs and $20 million in grants for an optional community-based nurse practitioner fellowship program.
  • $170.958 million for National Institute of Nursing Research (NINR): This is a $7.966 million (4.89%) increase over FY 2019 funding levels and reflects part of the $41.084 billion ($2 billion or 5.12% overall increase) for the National Institutes of Health (NIH).

The AANA worked with our coalition partners to lobby House appropriators to increase funding for Title VIII programs for Fiscal Year 2020, after FY2019 funding remained level. AANA staff and members met with representatives and signed on to coalition letters urging support for the increase. The package passed the house on a vote of 226 to 203. The Senate is still beginning their appropriations process, but the AANA has urged them to take up the same level of funding as the House.

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Happy Fourth of July!

The AANA Board of Directors and staff would like to wish everyone a safe and Happy Fourth of July! Due to the holiday, the AANA offices will be closed July 4-5. There also will be no Anesthesia E-ssential issue on July 4th. Publication will resume with the July 11th issue.

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Hot Topics


Open Comments: Postanesthesia Care, Practice Considerations


The draft practice document titled, Postanesthesia Care, Practice Considerations, is available for open comment through July 10, 2019. Please review and provide feedback to practice@aana.com. Download the draft document at www.aana.com/OpenComment.

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Young Skateboarder's Preventable Death Inspires Campaign To Zero


Six years ago, on June 29, 2013, Drew Hughes died. When the 13-year old skateboarder fell back and hit his head, no one dreamed he would not survive. He was alert, he was talking, he was animated. Yet a series of events played out where an unplanned extubation during a transport to a larger hospital, followed by a reintubation into his esophagus, left him without oxygen for the rest of the transport. He died from the complications of airway management.

This very preventable death has launched a movement. More than 33,000 patients in U.S. intensive care units alone, die from this preventable complication of the procedure that is supposed to keep them alive.

Major medical societies, the AANA included, along with several patient safety and quality improvement organization have banded together with the common goal of increasing awareness and prevention efforts to eliminate these preventable deaths from unplanned extubation. Help us honor Drew and those who have also died from unplanned extubation. Learn more about what you and your facility can do. http://bit.ly/2N2CG6L

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Class I Recall: Hudson RCI Sheridan and Sheridan Endotracheal Tubes by Teleflex Medical


Teleflex Medical is recalling multiple models of the Hudson RCI Sheridan and Sheridan Endotracheal Tubes due to complaints of the Sheridan connector disconnecting from the breathing circuit. Each tracheal tube includes an appropriately sized 15mm connector. Although the connector can be removed, it should not disconnect from the endotracheal tube without significant force. Use of the affected devices may cause serious adverse health consequences, including disconnection from the breathing circuit which may result in insufficient oxygenation, and death. Read the full recall.

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Teaching Anesthesia Diversity (TAD) Talk Comes to AANA Learn


The first Teaching Anesthesia Diversity (TAD) Talk is now available on AANA Learn. Originally presented during this year's Assembly of Didactic and Clinical Educators meeting, faculty members Johanna Newman, DNAP, CRNA and Jorge Valdes, DNP, MNA, CRNA, APNP discuss how nurse anesthesia programs can increase diversity and cultural competency.

This TAD Talk also explores the importance of a diverse nurse anesthesia workforce through analyzing statistics related to diversity in nursing, nurse anesthesia, and the United States population. Other topics discussed include strategies to improve the diverse student’s experience in a nurse anesthesia program and develop faculty cultural competence. View the TAD Talk.

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The Future of Nursing 2020-2030: Town Hall and Twitter Chat


In preparation for the next Town Hall meeting in Philadelphia, the Future of Nursing 2020-2030 Committee will be holding a Twitter chat on "Payment and Care for Complex Health and Social Needs" on Wednesday, July 17 from 3-4 p.m. ET. Follow @theNAMedicine and use the hashtag #Nursing2030Chat2 to participate.

For more information, visit:
https://nam.edu/publications/the-future-of-nursing-2020-2030
/

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Council on Accreditation (COA) Seeks Nomination for Director Opening


The COA is seeking nominations for a University Administrator Director. Candidates must be available to attend three-day COA meetings, typically held in January, May and October. The term of office is three years, beginning Fall 2019 through Fall 2022. The elected candidate then would be eligible to be considered for reelection to a second three-year term. The deadline to apply is July 15, 2019. For position criteria and application requirements, please visit www.coacrna.org.

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All of AANA’s Insurance Offerings in One Place


From malpractice to medical - and everything in between - visit the new AANA Insurance homepage to review all of the insurance options exclusive to members of the AANA. Learn more: https://direc.to/bFcN.

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NewsMaker: CRNA Maura McAuliffe Appointed to FDA Advisory Committee


Maura McAuliffe, PhD, MSNA, MSN, CRNA, FAAN, has been appointed to serve on the U.S. Food & Drug Administration (FDA)'s Anesthetic and Analgesic Drug Products Advisory Committee for three years. Her term began in March and will continue through 2022. McAuliffe is a professor and director of the Eastern Carolina University College of Nursing's nurse anesthesia program. 

The Anesthetic and Analgesic Drug Products Advisory Committee reviews and evaluates data concerning the safety and effectiveness of marketed and investigational drug products for use in anesthesiology and surgery, and provides recommendations to the FDA commissioner. This will include evaluations of drug products, including abuse-deterrent opioids and issues related to opioid abuse.

McAuliffe is one of 11 voting members on the committee. The committee members are selected by the commissioner or a designee from recommendations provided by authorities in the fields of anesthesiology, surgery, epidemiology or statistics and related specialties. Learn more.

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NewsMaker: CRNA Capt. Robert Hawkins to Serve as Commander of NMCPHC


The Navy and Marine Corps Public Health Center (NMCPHC) held a change of command and retirement ceremony on June 21 at Naval Medical Center Portsmouth in Portsmouth, Va. Capt. Robert Hawkins, DNP, PhD, MA, MBA, MS, CRNA, relieved Capt. Todd Wagner as commander of the NMCPHC. Hawkins served as deputy commander to Wagner prior to assuming this new role.

"Capt. Wagner leaves behind a tremendous legacy of success for Navy Medicine," said Hawkins. "He's been a tremendous leader and personal mentor. Big shoes to fill for sure! That being said, I look forward to following in his footsteps, helping to ensure that the Public Health Center continues to serve as a force multiplier and key contributor to Force Health Protection and Readiness." Learn more.

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NewsMaker: CRNA Stephanie Moore Administers Anesthesia to Chimp Named Burrito


Stephanie Moore, CRNA, ARNP, was put in touch with the operators of Chimpanzee Sanctuary Northwest in Cle Elum, Wash., when an opportunity arose to administer and monitor anesthesia for a chimpanzee named Burrito who has heart issues.

Contact between humans and chimps at the sanctuary is kept to a minimum due to the belief that the chimps shouldn't be put on display, and veterinary surgeons needed a different kind of expertise for the anesthesia. Chimps are also pretty big, strong, and can bite. Learn more about the challenges that both Stephanie and Burrito faced.

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Meetings and Workshops


SRNAs: Join Envision Physician Services for Anesthesia College Bowl Reception


On Monday, August 12, 2019, following the Anesthesia College Bowl at the AANA 2019 Annual Congress in Chicago, there will be a reception for student registered nurse anesthetists (SRNAs) in the Crystal Ball B&C rooms in the West Tower at Lobby Level in the Hyatt Regency hotel from 7:30-9:30 p.m.

Be sure to register for the Anesthesia College Bowl Reception with Envision Physician Services to receive an exclusive wristband for "no-wait" access at the reception. Space is limited. More information.

Supported by Envision Physician Services.
Envision Physician Services

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Evidence Based Treatments for Common Perioperative Emergencies Series (2-hour Course; Lecture and Lab) (2 Class A CE)


Evidence-Based Treatments for Common Perioperative Emergencies Simulation will involve learners in a two-hour, two-part educational experience. The first hour will be an interactive lecture/discussion of various cognitive aids and how they improve outcomes in emergencies. The second hour will involve small group simulations of select emergency situations with some of the nurse anesthesia profession’s leading simulation experts. Simulation sessions will be limited to 13 people per room and active participation is expected. This is a hands-on interactive experience.

Note: Attendees will need to participate in BOTH the lecture and one of the simulation lab options, to obtain credit for this series. This series is first come, first served. The 84 attendees will be accepted to participate for each 2-hour time block.

Sunday, August 11, 2019
7:45 am – 8:45 am—Lecture
(Attendees will receive a note card when entering that will have Lab Option 1 or 2 on it. Depending on the assignments, the attendee will then show up to that denoted time for the lab portion. This breaks up the attendee flow so that the sessions are not packed).

9:15 am – 10:15 am – Lab Option 1
10:45 am – 11:45 am – Lab Option 2

-AND-

Monday, August 12, 2019
7:45 am – 8:45 am—Lecture
(Attendees will receive a note card when entering that will have Lab Option 1 or 2 on it. Depending on the assignments the attendee will then show up to that denoted time for the lab portion. This breaks up the attendee flow so that the sessions are not packed).

9:00 am – 10:00 am – Lab Option 1
10:30 am – 11:30 am – Lab Option 2

Ultrasound Open Labs

Monday, August 12, 2019
10:00 – 12:00 pm – CRNA Only (1 Class A CE)
2:00 – 4:00 pm – SRNA Only (1 Class A CE)

Tuesday, August 13, 2019
8:00 – 10:00 am – Open to All (1 Class A CE)
Learning Objectives for all Labs:

  • Demonstrate proper ultrasound transducer orientation and application on models.
  • Identify anatomic structures with ultrasound on models.
  • Demonstrate how to use ultrasound guidance to perform various peripheral nerve blocks on models.

To learn more about the hands-on activities at Annual Congress visit aana2019.com. Select “Education” then “Full Schedule” and search for “Evidence Based Treatment” or “Ultrasound Open Lab.”

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Jobs


Certified Registered Nurse Anesthetist: The Green Technology Group, Las Vegas, Nevada


Certified Registered Nurse Anesthetist (CRNA) will provide medical assistance and support to the Defense Health Agency. The services that are required are under the following program and serves as consultant to Military Treatment Facilities. More specifically, the provider will perform these duties at Nellis AFB (Las Vegas). Learn more.

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CRNA: Envision Physician Services, Lake Havasu City, Arizona


Envision Physician Services has a full-time CRNA opportunity in our collaborative and well respected Care Team at Havasu Regional Medical Center in Lake Havasu City, Arizona. Live and work in a very desirable location of beautiful Arizona and experience 300 days of sunshine per year! Learn more about the opportunity, why CRNAs choose us, and all of the wonderful benefits of becoming a part of the Envision Physician services family. Learn more.

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CRNA: Littleton Regional Healthcare, Littleton, New Hampshire


Full-time (40 hour) position. Procedures to include General Surgery, ENT, OB/GYN, Orthopedics, GI, GU. Call frequency: 1:7 call (4 days per month), post call day off, and additional compensation over 1:7 call.

Skills required:

  • CRNAs are required to perform labor epidurals, spinals, LPs and ultrasound-guided regional anesthesia.
  • CPR, ACLS and PALS certification required

Learn more.

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Hospital-Employed CRNA Opportunity at Level I Trauma Center: Carle Physician Group, Urbana, Illinois


Carle Physician Group is seeking an additional CRNA to join our team of 50 CRNAs at our main campus in Urbana, Illinois. Position Details Include:

  • Join an autonomous and team-centered department of 50 CRNAs who perform over 19,500 cases annually at an established research and teaching hospital.
  • Call 1:20 (call included in 40-hour work week).
  • Positions available without call duties.
  • Three subgroups of 10 CRNAs cover OB, Pediatric, and Heart cases.
  • Perform a wide variety of cases and procedures to include: General, Spinal, Epidurals, IV Regionals, CVP, PA Invasive Monitors and A-lines.

Learn more.

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CRNACareers

How Does Your Career Grow?

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

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

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

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



 

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Healthcare Headlines

Healthcare Headlines is for informational purposes, and its content should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.


Prolonged Perioperative Use of Pregabalin and Ketamine to Prevent Persistent Pain After Cardiac Surgery

U.K. researchers, suspecting that use of pregabalin and ketamine would fend off persistent pain after cardiac surgery, tested their theory in a randomized controlled trial. They divided 150 adults with no history of chronic pain into three groups, according to their assigned treatment: usual care, 150 mg of pregabalin administered preoperatively and for two weeks post-procedure, or pregabalin plus a 48-hour postoperative infusion of intravenous ketamine. The main outcomes were prevalence of clinically significant pain at three and six months postoperatively, measured as a pain score of 4 or higher on a scale of 0 to 10. The results at both three and six months indicated that pain prevalence, compared with standard care, was lower for pregabalin alone and in conjunction with ketamine.

From "Prolonged Perioperative Use of Pregabalin and Ketamine to Prevent Persistent Pain After Cardiac Surgery"
Anesthesiology (Summer 2019) Vol. 131, No. 7, P. 119 Anwar, Sibtain; Cooper, Jackie; Rahman, Junia; et al.

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Association Between Anesthesia Exposure and Neurocognitive and Neuroimaging Outcomes in Long-term Survivors of Childhood Acute Lymphoblastic Leukemia

A study from St Jude Children's Research Hospital examined whether repeat anesthesia exposures as part of chronic disease management contribute to neurocognitive impairment and brain imaging abnormalities. The sample population for the research consisted of 212 survivors of childhood acute lymphoblastic leukemia, who were assessed for neurocognitive outcomes a median 7.52 years after diagnosis. That time frame was beyond the known outcomes associated with neurotoxic chemotherapies. The patients collectively underwent 5,699 procedures requiring general anesthesia during the period of 2000-2010. Analysis indicated that a high number of flurane exposures, greater cumulative doses of propofol, and longer anesthesia duration significantly contributed to neurocognitive impairment and neuroimaging abnormalities. The findings support limiting anesthesia exposures, when possible, in kids who undergo multiple medical procedures to manage chronic health problems.

From "Association Between Anesthesia Exposure and Neurocognitive and Neuroimaging Outcomes in Long-term Survivors of Childhood Acute Lymphoblastic Leukemia"
JAMA Oncology (06/20/2019) Banerjee, Pia; Rossi, Michael G.; Anghelescu, Doralina L.; et al.

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Peripartum Neuraxial Analgesia May Not Be Associated with Postpartum MS Relapse

Despite concern that neuraxial analgesia for childbirth could trigger a relapse in women with multiple sclerosis (MS), new research suggests that medical teams may be avoiding the technique unnecessarily. The fear that epidurals may have toxic effects on demyelinated fibers prompted a retrospective review of data from two prospective trials—PRIMS, which took place between 1992 and 1995 and POPARTMUS, conducted between 2005 and 2012. Both investigations tracked MS activity and relapse rates during pregnancy and for three months after delivery. There were 389 participants in all, 156 of whom received neuraxial analgesia. Roughly 24 percent of the expecting mothers suffered MS relapse while pregnant, with an additional 25 percent or so relapsing within three months of having the baby. After multivariable adjustment, researchers were unable to draw a correlation between neuraxial analgesia and relapse within three months of childbirth. They did, however, link postpartum relapse to the number of MS relapses that occurred during the gestation period. Patients who experienced relapses while pregnant had a 35.5 percent chance of relapse within three months of delivering versus a 21.6 percent risk in patients who went their entire pregnancy with no relapses. "Our study provides additional arguments toward the harmlessness of neuraxial analgesia in parturient women with MS, whatever their MS activity during pregnancy," noted the authors, who reported their findings in the Multiple Sclerosis Journal.

From "Peripartum Neuraxial Analgesia May Not Be Associated with Postpartum MS Relapse"
Clinical Pain Advisor (06/20/19) Rothbard, Gary

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PTSD Treatment: Researchers Test Stellate Ganglion Block for Effectiveness

Medical researchers are hopeful that a technique known as stellate ganglion block (SGB) can help veterans suffering from post-traumatic stress disorder (PTSD), many of whom commit suicide. SGB delivers pain-blocking medication into a bundle of nerves in the front of the neck through an ultrasound-guided injection. The procedure temporarily numbs those nerves and slows the release of norepinephrine—which is hyperactive in cases of PTSD, triggering fear memories that make the individual more vulnerable to PTSD and suicide. Because SGB downregulates norepinephrine, PTSD symptoms dissipate as well. There is a great deal of optimism that SGB could benefit the mental health of veterans on a mass level as they return to civilian life; however, the approach will have to become more common and accepted first.

From "PTSD Treatment: Researchers Test Stellate Ganglion Block for Effectiveness"
Medical Daily (06/24/19) Vatican, Johnny

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Outcomes of General Anesthesia Versus Conscious Sedation for Stroke Undergoing Endovascular Treatment

A meta-analysis examined how the choice of general anesthesia (GA) over conscious sedation (CS) affects acute ischemic stroke (AIS) patients undergoing endovascular treatment. A search of the literature yielded 23 relevant studies with a collective 6,703 participants. After pooled analysis, the researchers determined that the likelihood of favorable functional outcome was lower and mortality risk was higher in the CS patients than in the GA group. The disparity was erased, however, when looking only at a subgroup that included only the randomized controlled trials (RCTs). Because most of the studies in the meta-analysis were retrospective in nature, the investigators recommend that more multisite RCTs be undertaken to clarify the findings.

From "Outcomes of General Anesthesia Versus Conscious Sedation for Stroke Undergoing Endovascular Treatment"
Medscape (06/25/19)

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Paravertebral Blocks Urged for Mastectomy Procedures

A new study adds to the stack of evidence highlighting the benefits of regional anesthesia for oncology treatment, in this case breast cancer. The single-site chart review compared outcomes after mastectomy, stratified according to anesthetic approach. The 1,083 women in the review received monitored anesthesia care using propofol infusion with paravertebral block, volatile anesthesia plus paravertebral block, or volatile anesthetic with no regional anesthetic. Patients who underwent paravertebral block and propofol for their procedures had markedly lower rates of five-year mortality and cancer recurrence versus patients who were administered volatile anesthetics. Based on these findings, the researchers support making paravertebral block and propofol the first choice of anesthesia for mastectomies. Although it once was a difficult skill to learn, lead investigator Stuart Grant, MB, of Duke University Medical Center says ultrasound guidance has simplified it. "If you're determined to learn the paravertebral block, it's certainly something that can be taught to any practitioner, and the complication rate is extremely low," he remarks.

From "Paravertebral Blocks Urged for Mastectomy Procedures"
Anesthesiology News (06/13/19) Vlessides, Michael

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News summaries © copyright 2019 SmithBucklin

 



Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed weekly to AANA members.

Anesthesia E-ssential is for informational purposes, and its contents should not be interpreted as endorsements, standards of care, or position statements of the American Association of Nurse Anesthetists.

If you are interested in advertising in Anesthesia E-ssential contact HealthCom Media at 215-489-7000.

For more information on AANA and Anesthesia E-ssential, contact:

AANA
222 S. Prospect Avenue
Park Ridge, IL 60068
Phone: (855) 526-2262 (toll-free)/(847) 692-7050
Fax: (847) 692-6968

Attn: Cathy Hodson
E–ssential Editor
chodson@aana.com

 

June 27, 2019
Earn Your DNAP