Anesthesia E-ssential

AANA Anesthesia E-ssential, May 17, 2018
AANA Member Advantage Program

Vital Signs

Prescription Gabapentin - Caution Needed

Increasing use and misuse of prescription gabapentin is putting opioid-using patients at risk of overdose. Previously thought to be a safe alternative non-narcotic pain reliever, gabapentin has an abuse potential in high doses and, used with heroin, can impair breathing and reverse tolerance to opioids. Since identification of this risk in 2015, some states have taken action to use caution and controls to prevent a new prescription drug epidemic.
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Dräger Medical Recalls Fabius Anesthesia Machines Due to Production Step Error

Dräger Medical is recalling Fabius anesthesia machines due to excessive oil that was not removed at the time of production. Such excess oil may interfere with the position detector of the ventilation motor during operation and may cause ventilation to fail. A halt in ventilation may lead to serious adverse health consequences, including patient injury or death. For affected models and product numbers, visit the FDA website.
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Hot Topics

NewsMaker: CRNA Joe Powell Honored as Advanced Practice Provider of the Year

Joe Powell, BS, CRNA, was honored as the first recipient of the Phoebe Advanced Practice Provider of the Year Award.

The award is meant to honor an APP who exemplifies a commitment to improving the health and well-being of southwest Georgians, according to Phoebe officials. Powell works in the operating room at Phoebe Putney Memorial Hospital, Albany, Georgia. Read more.
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NewsMaker: CRNA Sarah Sellers Rocks Sports Illustrated

A Sports Illustrated story, "Sarah Sellers Offers Advice on Training Like an Elite While Working a Full-Time Job," highlights training tips by CRNA Sarah Sellers, who placed a surprise second in the Boston Marathon this past April.

SI also covered Sarah in an April article ("Who is Sarah Sellers, the Boston Marathon Runner-Up?"), shortly after the Boston Marathon.
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NewsMaker: CRNA Walter Laesch Named to School Board Oversight Panel

Walter Laesch, BSN, CRNA, APN, was named to a citizens' committee in the Champaign, Illinois, school board district. The Referendum Oversight Committee oversees the Champaign school district's various facilities projects. Read more.
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Professional Practice

Nominate Your Facility for an APSF Safety Recognition Award

The Anesthesia Patient Safety Foundation (APSF) seeks to recognize organizations that have made significant advances in safe medication administration during anesthesia care. Best practices in any of the areas of safe medication administration covered by the STPC paradigm – Standardization, Technology, Pharmacy, Culture – will be considered for the award. The submission deadline is June 15, 2018.  Visit the APSF website for more information about the submission process. 
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Open Comment Opportunity - AIUM Use of Ultrasound to Guide Vascular Access Procedures

The American Institute of Ultrasound in Medicine (AIUM) draft Practice Parameter for the Use of Ultrasound to Guide Vascular Access Procedures is currently out for open comment though May 25. Please review the linked document and send any comments you have to We will then compile all of the comments and provide them to AIUM. For more information, visit Open Comment Opportunity.

The AIUM is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of parameters, and accreditation. AIUM developed the draft Practice Parameter for the Use of Ultrasound to Guide Vascular Access Procedures collaboratively with many organizations, including AANA, whose members perform vascular access. Patrick Moss, DNAP, CRNA represents AANA on this initiative.

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Meetings and Workshops

Tap Into the Power of Technology: AANA 2018 Annual Congress

Join us in Boston on September 21 - 25, 2018 at the Hynes Convention Center for the biggest CE and networking event in nurse anesthesia. We’re excited to introduce new research and best practices in anesthesia at the AANA 2018 Annual Congress. You’ll earn up to 25.25 Class A CE credits with 9.0 Pharmacology credits, while meeting CPC requirements. Plus, you can make new connections and reconnect with your colleagues from around the nation at one of several networking events.

New this year, the call to all AANA members for abstract submissions will ensure quality educational programming based on medical and scientific significance, timeliness, and quality of data. “Abstract submissions will strengthen our Annual Congress program by allowing nurse anesthetists throughout the country to showcase their work, talents, skills, and expertise as they share best practices pertaining to a diverse set of topics with our colleagues,” stated Michael Greco, DNP, CRNA, Abstract Submission Team Lead on the AANA Professional Development Committee.

We’re excited about our 85th Annual Congress at the Hynes Convention Center in Boston — with new patient simulation workshops and a robust program. You’ll go back to your practice refreshed and energized by the synergy of thousands of your colleagues from around the nation.

Please consider giving back to the next generation of CRNAs. Consider sponsoring a student during the registration process and help support the future of the nurse anesthesia profession. For details, email


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Upper and Lower Extremity Nerve Block Workshop

August 18-19, 2018, Park Ridge, Illinois
Expand your knowledge and skills in peripheral nerve blocks with didactic and hands-on training.

The Upper and Lower Extremity Nerve Block Workshop is designed to enhance your knowledge in the clinical sciences related to upper and lower block anesthesia. Featuring didactic and hands-on training, this program will expand the CRNA's skills and expertise in upper and lower extremity nerve block anesthesia.

Bonus: Included with registration, all attendees will receive Upper Extremity Blocks, written by featured speaker Charles A. Reese, PhD, CRNA.

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

MIPS Payment Adjustment Follows Individual Clinician NPI under new TIN

In recognizing that MACRA changed the way performance would be scored under the MIPS program, the Centers for Medicare & Medicaid Services (CMS) will continue to address the issues impacted by the MIPS payment adjustments in 2019 and beyond (see CMS slides 45-49 published 4/23/2018).  In CY2017 Final Rule CMS-5517-FC ( pages 77330 – 77332), CMS recognized the payment adjustment challenges faced by individual clinicians (i.e., NPIs) associated with more than one group, clinicians using multiple submission mechanisms, and an NPI billing under a new taxpayer identification number (TIN) after the performance period. In their final rule making, CMS determined that performance will follow the NPI even if they leave the group (i.e., TIN) before the payment adjustment. CMS intends to “use the TIN/NPI's historical performance from the performance period associated with the MIPS payment adjustment, regardless of whether that NPI is billing under a new TIN after the performance period. In the event that an NPI bills under multiple TINs in the performance period and bills under a new TIN in the MIPS payment year, [CMS will take] the highest final score associated with that NPI in the performance period.” Unlike PQRS, CRNAs should now be aware that their best MIPS score will follow them into a new TIN. To learn more about how to participate in the MIPS program visit the AANA Quality Payment Program.
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New 2018 MIPS Eligibility Group Level Tool– Look up all NPIs Under a TIN

CMS now offers two ways to verify your MIPS participation status. Individual clinicians can continue to go to the MIPS Participation Status Lookup website to verify whether they met the 2018 eligibility criteria using their individual National Provider Identifier (NPI). For authorized users who want to view group level data, you now may choose to log in to the CMS Quality Payment Program website using your Enterprise Identity Management (EIDM) credentials to check your group’s 2018 eligibility for MIPS. If you don’t have an EIDM account, start the process now by referring to the EIDM User Guide for instructions, noting that the portal still refers to the Physician Quality Reporting System (PQRS). After logging into this new feature with your EIDM credentials, browse to the taxpayer identification number (TIN) affiliated with your group, and you will be able to click into a details screen to see the eligibility status of every clinician based on their NPI within your group to verify whether you or your group members need to participate in the 2018 MIPS performance year. The quality payment program helpdesk is prepared to answer questions about the look-up tools and participation status by email ( or phone (1-866-288-8292).
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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 of an Opioid Standard of Practice Intervention with Intravenous Opioid Exposure in Hospitalized Patients

The results of a new pilot study suggest that adopting a new standard of inpatient opioid prescribing that prefers oral and subcutaneous over intravenous administration may be associated with reduced I.V. opioid exposure. At the same time, effective pain control is maintained. For the study, conducted by researchers at Yale School of Medicine and Yale New Haven Hospital, use of opioids was compared between a six-month control period and three months following education for the prescribers on opioid routes of administration. The two-part quality improvement initiative included the adoption of a local opioid standard of practice for the general adult inpatient unit at a large academic medical center and targeted education for medical and nursing staff. The data show that I.V. opioid dosing was reduced by 84 percent after an opioid standard of practice was adopted. In addition, doses of all parenteral opioids decreased by 55 percent. The researchers also note that while there were no significant post-intervention differences in mean reported pain scores for patients receiving opioid therapy during the first three hospital days, compared with the preintervention period, substantial improvement was seen in the intervention group on days four and five.

From "Association of an Opioid Standard of Practice Intervention with Intravenous Opioid Exposure in Hospitalized Patients"
JAMA Internal Medicine (05/14/18) Ackerman, Adam L.; O'Connor, Patrick G.; Doyle, Deirdre L.; et al.

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Transversus Abdominis Plane Blockade as Part of a Multimodal Postoperative Analgesia Plan in Patients Undergoing Radical Cystectomy

A retrospective comparison sought to identify the benefits of using continuous transversus abdominis plane (TAP) blockade as part of an enhanced recovery after surgery (ERAS) regimen following radical cystectomy (RC). Over the study period of four years, the Northwestern University researchers considered 100 patients who underwent RC before an ERAS protocol was put in place and 71 who had the procedure after program implementation. The ERAS plan was associated with multiple benefits compared with traditional post-RC pain control. For example, patients who received multimodal analgesia with TAP block used a total of 89 mg of postoperative narcotics, versus 336 mg for patients who received standard care. Additionally, ERAS was associated with shorter time to flatus, bowel movement, and discharge from the hospital. According to investigators, patients in the ERAS cohort were more likely to be female, tended toward higher body mass index scores, and were more likely to have received neoadjuvant chemotherapy.

From "Transversus Abdominis Plane Blockade as Part of a Multimodal Postoperative Analgesia Plan in Patients Undergoing Radical Cystectomy"
Uro Today (05/14/18)

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Simple Trick May Reduce Procedural Pain

Injection-associated procedural pain can be easily alleviated, researchers report, by dripping lidocaine onto a patient's skin just before lidocaine injection. The randomized study, reported in Chest, included nearly 500 patients scheduled for lumbar puncture, peripheral insertion of a central catheter, or another bedside procedure involving subcutaneous injection. The intervention group included 244 participants, who had 1 mL to 2 mL of lidocaine dripped onto their skin right before receiving an injection of the anesthetic. Another 237 participants received the injection via standard practice. Based on reported visual analogue scale scores, patients in the intervention group experienced lower levels of procedural pain. Among the various procedures covered in the investigation, subgroup analysis indicated that the intervention patients who received optimal relief versus control patients were those who underwent peripheral insertion of central catheters. "Lidocaine dripped onto the skin from the syringe is water soluble and has no direct anesthetic effect; rather, we hypothesize that it is the room temperature solution on the skin (cooler temperature than skin body temperature) that generates sensory nerve traffic within the spinal cord dorsal horn that can 'gate' or inhibit the noxious signal from the lidocaine injection," the researchers explain.

From "Simple Trick May Reduce Procedural Pain"
Clinical Pain Advisor (05/11/18) May, Brandon

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Vertebroplasty No Better Than Local Anesthetic for Pain

Research out of the Netherlands suggests that undergoing percutaneous vertebroplasty provides no greater pain relief than do local anesthetic injections in older patients suffering from osteoporotic vertebral fractures. As part of the VERTOS IV randomized trial, 180 participants aged 50 years or older were assigned to either vertebroplasty—a bone cement treatment—or to a dummy procedure. All, however, received local anesthetic injections first. The primary outcome was pain at various intervals between postoperative day one and 12 months after surgery. Pain declined significantly from baseline levels at all assessments in both cohorts, with no meaningful between-group differences. Patients in both treatment arms also markedly reduced opioid or other painkiller use but, again, with no significant disparity between them. In addition, they did not differ in terms of quality of life or disability. "These results do not support percutaneous vertebroplasty as standard pain treatment in patients with acute osteoporotic vertebral compression fractures," according to the researchers, who report online in BMJ. Rather, they note, the evidence suggests "that factors aside from instillation of polymethylmethacrylate [bone cement] might have accounted for the observed clinical improvement after vertebroplasty; for example, the effect of local anesthesia, expectations of pain relief (placebo effect), [and] natural healing of the fracture." The positive response to sham treatment was unexpected, they conclude, and warrants additional study.

From "Vertebroplasty No Better Than Local Anesthetic for Pain"
Medscape (05/10/18) Busko, Marlene

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Mepivacaine Is Found to Be an Effective Spinal Anesthetic for Knee Replacement Surgery

Mepivacaine, a numbing medication that vanished from operating rooms decades ago, may get new life as a spinal anesthetic for knee replacement surgery. A pair of trials—a retrospective review and a small, randomized study—suggest that the agent manages pain as effectively as bupivacaine but with fewer adverse effects. Moreover, patients who received mepivacaine recovered normal function more quickly, accelerating their recovery and shortening their length of stay in the hospital. Contrary to past concerns that shifted favor to bupivacaine, the team at Henry Ford Health System found that patients given mepivacaine were no more vulnerable to nerve complications, pain control, nausea, or other side effects than were patients who received bupivacaine. "Our studies suggests that mepivacaine has multiple advantages and few drawbacks compared to bupivacaine as a spinal anesthetic in knee replacement surgery," says senior study author Jason Davis, MD. "It shows promise as an ideal anesthetic by working long enough for most knee replacements without the excessive duration that can delay patients' recovery." Shorter-acting pain drugs, he speculates, could even emerge as the new normal for regional anesthesia during outpatient joint replacement. Whether mepivacaine is equally effective for medium-length operations will require additional research, however.

From "Mepivacaine Is Found to Be an Effective Spinal Anesthetic for Knee Replacement Surgery"
News-Medical (05/09/18)

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Psychological Factors as Predictors of Early Postoperative Pain After Open Nephrectomy

The medical community sees great promise in the ability to predict how an individual patient will react to analgesics and surgical pain, prompting an investigation into possible psychological contributors. European researchers built their prospective observational cohort study around the setting of kidney removal, a common operation. Participants, 150 of whom were included in the final analysis, underwent a battery of psychological tests ahead of their procedure. Postoperatively, their pain intensity was measured on the numerical rating scale at three different intervals. In the "immediate early" time period up to eight hours after surgery, "expected pain" was the only psychological predictor. The dominant contributing factor during the "early" phase 12-24 hours post-surgery, meanwhile, was "anxiety." Finally, for the "late early" time frame 48-72 hours following the procedure, pain was tied predominantly to catastrophizing, preoperative analgesic consumption, and "APAIS [Amsterdam Preoperative Anxiety and Information Scale] anxiety." The findings show that after the first 24 hours following open nephrectomy, psychological variables take on an increasing role in predicting pain intensity—even more so than choice of analgesic.

From "Psychological Factors as Predictors of Early Postoperative Pain After Open Nephrectomy"
Journal of Pain Research (05/18) Vol. 11, P. 955 Mimic, Ana; Bantel, Carsten; Jovicic, Jelena; et al.

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

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

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Attn: Cathy Hodson
E–ssential Editor
May 17, 2018
Pacira Exparel