Anesthesia E-ssential

AANA Anesthesia E-ssential

Vital Signs

AANA Election Results Announced

The AANA is pleased to announce the results of the election for open positions on the FY2018 Board of Directors, Nominating Committee and Resolutions Committee.
Open Positions on the FY 2018  Board of Directors
  • Garry Brydges, DNP, MBA, MSN, CRNA, ACNP-BC, President-elect
  • Randall Moore II, DNP, MBA, MSN, CRNA, MAJ(ret), Vice President
  • Robert Gauvin, MS, CRNA, Treasurer
  • Maribeth Massie, MS, CRNA, Director – Region 1
  • Maria Sallie Poepsel, PhD, MSN, CRNA, Director – Region 4
  • Steven Sertich, JD, MAE, CRNA, Director – Region 5
AANA Board of Directors FY 2018
  • Bruce Weiner, MS, CRNA, President
  • Garry Brydges, DNP, MBA, MSN, CRNA, ACNP-BC, President-elect
  • Randall Moore II, DNP, MBA, MSN, CRNA, MAJ(ret), Vice President
  • Robert Gauvin, MS, CRNA, Treasurer
  • Maribeth Massie, MS, CRNA, Director – Region 1
  • Dina Velocci, DNP, CRNA, APN, Director – Region 2
  • Christine Salvator, MSN, CRNA, APN, Director – Region 3
  • Maria Sallie Poepsel, PhD, MSN, CRNA, Director – Region 4
  • Steven Sertich, JD, MAE, CRNA, Director – Region 5
  • John Bing, BSN, CRNA , Director – Region 6
  • Heather Rankin, DNP, CRNA , Director – Region 7
FY 2018 Nominating Committee 
  • Thomas Nolan, CRNA – Region 1
  • Dennis McKenna, DNAP, MHS, CRNA – Region 2 
  • David Proffer, MSN, CRNA, Capt, USAF(ret) – Region 3
  • Paul Beninga, MS, CRNA – Region 4          
  • Michael Mackinnon, MSN, FNP-C, CRNA – Region 5
  • Mary Scott-Herring, MS, CRNA – Region 6
  • Jeanne Antolchick, PhD, CRNA, Region 7
FY 2018 Resolutions Committee
  • James Eads, MSN, CRNA 
  • Robert Campbell, MS, CRNA 
  • Angela Mund, DNP, CRNA 
  • Monique Bowersox, MNA, CRNA 
  • Ann Culp, DNP, MSN, CRNA 
To access the report from the election services coordinator, visit the election center . (Member login and password required.) 
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Hot Topics

Apply Now for AANA/MTSA Post-Graduate Fellowship in Acute Surgical Pain Management
Application deadline is June 19

The AANA, in partnership with Middle Tennessee School of Anesthesia (MTSA), will offer a postgraduate Acute Surgical Pain Management Fellowship (ASPMF) beginning in summer 2017. The objective of this new certificate program, a component of the AANA Pain Management Curriculum, is to advance the knowledge and skills of CRNAs in acute surgical pain management and prepare them to help meet the growing need for this evidence-based approach in the United States. Fellows will learn advanced techniques for managing patients' acute post-surgical pain through hands-on ultrasound-guided regional anesthesia (USGRA) training, online discussions and coursework, as well as clinical opportunities with mentors experienced in acute surgical pain management.

Application deadline: June 19
Interviews: June 21 - 22
Classes Begin: July 17

For more information, visit MTSA.EDU.
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AANA Communications Committee Recognizes MYA Student Mentoring Program Participants

On April 8, 2017, at the AANA Mid-Year Assembly (MYA) in Washington, D.C., 50 student registered nurse anesthetists (SRNAs) from around the country spent the day being mentored by practicing CRNAs as part of the Student Mentoring Program, coordinated by the AANA Communications Committee. Each year, SRNAs who demonstrate leadership qualities and skills are recommended by their educational program administrators to participate in this popular program. We congratulate the students and their CRNA mentors who made this year’s mentoring program a resounding success.
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Check Your MIPS Status on the CMS Quality Payment Program Website

The Centers for Medicare & Medicaid Services (CMS) has created a new website which allows CRNAs and other eligible clinicians (ECs) to input their National Provider Identifier (NPI) to check their MIPS participation status. If you have question about your eligibility MIPS status or believe that you are exempt from the MIPS program, you can verify your participation status using this tool. CMS will conduct a second review of eligible clinicians’ MIPS participation status again in Fall of 2017. CRNAs are encouraged to check the website sooner rather than later. If you have questions about your MIPS status, please email at or call 1-866-288-8292
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MIPS Improvement Activities – CMS Resources

Two updated lists related to the Improvement Activities (IA) performance category under the Merit-based Incentive Payment System (MIPS) Program are now available on AANA Quality-Reimbursement. CRNAs should review the comprehensive Re-Mediated MIPS Data Validation Criteria April 24th 2017 they may report as part of the IA performance category. The list includes a description of the Improvement Activity, its weight, validation and suggestions for documentation. An extensive list of Patient Facing Codes is also available to help you determine which HCPCS/CPT codes constitute a patient facing encounter. For more information about the IA requirements, please review our Improvement Activities Fact Sheet.
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List of MIPS Qualified Registries for 2017

A list of Qualified Registries for the Merit-based Incentive Payment System (MIPS) Program 2017 performance year is now available on the AANA Quality-Reimbursement website. CMS has determined that these Qualified Registries will be able to report data for MIPS quality measures only, in addition to Improvement Activities and Advancing Care Information MIPS performance categories if permissible. CMS has not released the approved 2017 Qualified Clinical Data Registry (QCDR) list yet; however, CRNAs interested in finding more measures to meet the MIPS requirements via a QCDR are eligible for a discount with the Anesthesia Business Group QCDR (ABG QCDR) through the AANA’s Member Advantage Program.
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Professional Practice

Joint Commission Announces 2016 Top Ten Most Challenging Requirements for Office-Based Surgery Accreditation Program

This list, used to identify trends and direct educational efforts, identifies the requirements most frequently identified as “not compliant” during 2016 surveys and reviews. Infection prevention and control and credentialing and privileging top the list. The full list includes:
  1. HR.02.01.03 – The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
  2. IC.02.02.01 – The practice reduces the risk of infections associated with medical equipment, devices, and supplies.
  3. EC.02.04.03 – The practice inspects, tests, and maintains medical equipment.
  4. IC.01.03.01 – The practice identifies risks for acquiring and transmitting infections.
  5. NPSG.07.01.01 - Comply with either the current CDC hand hygiene guidelines or the current WHO hand hygiene guidelines.
  6. IC.01.05.01 – The practice plans for preventing and controlling infections.
  7. IC.02.04.01 – The practice offers vaccination against influenza to licensed independent practitioners and staff.
  8. MM.03.01.01 – The practice safely stores medications.
  9. MM.01.01.03 – The practice safely manages high-alert and hazardous medications.
  10. WT.03.01.01 – Staff and licensed independent practitioners performing waived tests are competent.
More information is available in the April 2017 issue of The Joint Commission Perspectives newsletter.
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Foundation and Research

Donate Today for AANA Foundation Annual Report 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). Donate today through the Foundation’s secure donation page. Support the RISE Above campaign. Again, thank you for your support!
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AANA Foundation Friends for Life Deadline – June 15, 2017

Friends for Life help fund and sustain programs that further research and education in anesthesia and support the future of nurse anesthesia through meaningful, lasting gifts. The Friends for Life submission deadline for recognition at this year’s Annual Congress in Seattle is June 15, 2017. For further information, please contact Nat Carmichael at (847) 655-1175 or
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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.

Peripheral Nerve Block Periarticular Injection Relieved Pain Within 3 Days of TKA

Peripheral nerve block (PNB) as well as periarticular injection with either ropivacaine or liposomal bupivacaine are all solid choices for pain relief following total knee arthroplasty, according to a comparative analysis. Researchers led by Matthew Abdel, MD, randomized 165 patients undergoing knee replacement to one of the three modalities, taking note of differences in pain levels and opioid use between the cohorts. While maximum pain score differed slightly between PNB and periarticular injection with liposomal bupivadaine during the first postoperative day, any significant disparity between the three groups was eliminated by the next day. PNB patients also consumed far fewer opioids on postoperative day 0 than periarticular patients, but use was about the same among the three cohorts by postoperative day 2. Abdel told the American Association of Hip and Knee Surgeons annual meeting recently that "peripheral nerve block provided the best pain relief when looking at maximal pain relief, lowest mean pain scores and lowest use of opioid consumption and this was statistically better than periarticular injection with liposomal bupivacaine, but no significant difference when compared to periarticular injection with ropivacaine." All three approaches, however, provided "satisfactory pain relief," he said.

From "Peripheral Nerve Block Periarticular Injection Relieved Pain Within 3 Days of TKA"
Orthopedics Today (05/17) Tingle, Casey

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Perioperative Lidocaine Offers No Benefits in Patients Undergoing Spinal Fusion

With existing research producing mixed results, a new study has found no advantage to administering perioperative lidocaine to patients undergoing spinal fusion surgery. Belgian investigators conducted the randomized trial at a single hospital, selecting 70 patients aged 15-56 years old who were scheduled for spinal arthrodesis. Some participants received intravenous lidocaine, administered along with anesthesia and followed by a continuous infusion of lidocaine for 6 hours postoperatively. Patients assigned to a control group, meanwhile, received a placebo injection of saline. All participants were provided acetaminophen and a morphine pump to alleviate pain after the procedure. Although several previous meta-analyses have documented better analgesic control, faster gastrointestinal recovery, and other benefits with perioperative lidocaine, that evidence was based mainly on abdominal surgeries. With the spinal fusion patients, the technique failed to curb postoperative pain, reduce morphine consumption, or mitigate nausea and vomiting compared with placebo. "Multimodal analgesia with lidocaine is of limited or no value in orthopedic surgery," the researchers wrote in Pain.

From "Perioperative Lidocaine Offers No Benefits in Patients Undergoing Spinal Fusion"
Clinical Pain Advisor (05/22/17) Melton, Christin

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Johns Hopkins Study Shows Ventilator-Associated Events Are Preventable

Hundreds of thousands of Americans a year require mechanical ventilation, but the life-saving equipment that helps them breathe also can result in healthcare-associated infection and other complications. According to researchers at the Johns Hopkins Armstrong Institute of Patient Safety and Quality, however, medical personnel have the power to lower the risk of ventilator-associated events. From October 2012 to March 2015, the team instructed providers and staff at dozens of intensive care units (ICUs) on interventions such as suctioning a patient's mouth tube, maintaining oral hygiene, and performing spontaneous awakening and breathing trials by curtailing narcotics and sedatives. Following evidence-based practices, embracing unit teamwork, and promoting a culture of safety paid off, according to changes observed after 24 months. The overall number of ventilator-associated events fell nearly 40 percent during the study period, to 4.58 cases per 1,000 patient ventilator days from 7.34 cases. Meanwhile, the rate of ventilator-associated pneumonia, thought to be one of the most deadly hospital-acquired ICU infections, plummeted 78 percent to 0.31 cases per 1,000 patient ventilator days from 1.41 cases. The scope of the study, initially carried out at hospitals in Maryland and Pennsylvania, has been widened to include all 50 states.

From "Johns Hopkins Study Shows Ventilator-Associated Events Are Preventable"
Infection Control Today (05/22/17)

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Paravertebral Block for Percutaneous Nephrolithotomy

Anesthesia and urology experts from Chicago's Loyola University teamed up to study the efficacy of paravertebral block (PVB) for percutaneous nephrolithotomy (PCNL). The results pointed to improved pain outcomes with a fentanyl PVB compared to placebo. For instance, the intervention was associated with about 13 percent lower total intravenous morphine equivalent dose and PCA pump demand. PVB recipients also went roughly 120 minutes before first analgesic administration, versus just 20 minutes for placebo recipients. Additionally, only 30 percent of patients in the PVB group required supplemental postoperative narcotics compared to 62 percent in the control group. These and other findings from the randomized controlled trial were presented recently at the American Urological Association's 2017 annual meeting in Boston.

From "Paravertebral Block for Percutaneous Nephrolithotomy"
UroToday (05/21/2017) Lama, Daniel

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Worse Pain Outcomes After Knee Replacement for Patients Who Took Opioids Before Surgery

Patients who filled at least one opioid prescription in the two years prior to a total knee arthroplasty (TKA) suffered worse pain-related outcomes after the surgery, according to new research. Investigators at Brigham and Women's Hospital in Boston studied data from 156 patients who underwent knee replacement there between 2011 and 2013, nearly a quarter of whom had a recent history of prescription painkiller use. At six months postoperatively, the team compared pain scores and other outcomes in TKA patients who and did not use opioids before the procedure. Postoperative pain scores were significantly higher among previous opioid users, at 17 on average compared to 10.5 for opioid-naive patients. Preoperative opioid use also was associated with higher "pain catastrophizing" scores, which reflect the extent to which an individual has overblown negative responses to and concerns about pain. "Clinicians and policy makers may consider limiting the use of opioids prior to TKA to optimize post-TKA pain relief," the researchers wrote in the Journal of Bone & Joint Surgery.

From "Worse Pain Outcomes After Knee Replacement for Patients Who Took Opioids Before Surgery"
Medicalxpress (05/18/2017)

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Survey on IV Ketamine for CRPS Underscores Need for Consensus Protocols

With IV ketamine emerging as a popular strategy for managing complex regional pain syndrome (CRPS), there also is a growing need to establish universal treatment standards. As a starting point in the process, Cleveland Clinic researchers last summer surveyed anesthesia providers, rehabilitation specialists, orthopedic doctors, and other clinicians about their experience with the approach. The questionnaire inquired about respondent demographics, diagnostic criteria, treatment volume, infusion protocol, adverse effects, and outcome measure utilization; and it covered both adult and pediatric patients as well as inpatient and outpatient settings. According to the answers, netted from more than 300 medical professionals in eight different countries, protocols vary significantly from one provider and institution to the next. Very little information on pediatric cases was submitted, the investigators noted, especially from an inpatient perspective. While data on adverse events associated with IV ketamine for CRPS also was "extremely limited," hallucinations, vomiting, and headache appear to be the most common side effects based on what little feedback that was provided. "Based on these results, we've tried to generate a possible consensus protocol so that in the future, when we design a study, we can compare outcomes between centers," said lead researcher Jijun Xu, MD, PhD.

From "Survey on IV Ketamine for CRPS Underscores Need for Consensus Protocols"
Pain Medicine News (05/16/2017) Doyle, Chase

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New Study May Explain Why Obese Patients More Likely to Wake Up During Surgery

Research out of Canada offers new insight into why the heaviest patients are also the most likely to regain consciousness in the operating room, a rare but alarming event. The randomized study recruited 60 people having bariatric surgery to shrink their stomachs. For half, doctors relied on a standard formula—lean body weight, or the individual's weight minus fat—to calculate propofol induction dose. A bispectral index monitor (BIS) was used on the remaining patients to determine when adequate sedation was reached, based on brain activity. As published in the Canadian Journal of Anesthesia, the investigators reported that 29 of 30 patients in the intervention cohort were successfully sedated at the BIS target of 50. More than half of the 30 patients in the lean body weight group, however, were still responsive after an initial dose of propofol and needed supplemental doses to finally put them under. "Using the lean body weight formula probably isn't the best method to dose your propofol in the morbidly obese patient," concluded lead author Jean Wong, MD, of Toronto Western Hospital, "because it results in under-dosing." Because this analgesic is highly fat soluble, it gets stored in fat and makes sedation more difficult to achieve. Some in the medical community believe dosing should be based more on total body weight, while others speculate that somewhere in between lean body weight and total body weight might be optimal.

From "New Study May Explain Why Obese Patients More Likely to Wake Up During Surgery"
National Post (Canada) (05/16/17) Kirkey, Sharon

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Thoracic Epidural Analgesia Reduces Opioid Administration in the ERAS Setting

New evidence affirms the use of enhanced recovery after surgery (ERAS) during open hepatectomy, dispelling lingering concerns about hemodynamic complications and coagulopathy. ERAS, a perioperative protocol that takes a multimodal approach to controlling pain, has demonstrated opioid-sparing and pain-relieving effects in many kinds of surgeries. Researchers led by Cathy He, MD, of Johns Hopkins Hospital have now shown the technique to also be viable in liver resection procedures. A total of 90 patients undergoing open hepatectomy at the facility between January 2014 and February 2015 were enrolled in the study. The final 30 hepatectomy patients before ERAS was adopted made up one cohort; a second included 23 patients in the ERAS protocol who did not receive an epidural; and the remaining 37 patients were also included in ERAS but did receive an epidural. ERAS overall was associated with much shorter hospital stay as well as less postoperative nausea and vomiting. Additional benefits—improved pain scores at 24 and 48 hours and a major reduction in morphine equivalent needs at 24, 48, and 72 hours—were observed in ERAS participants who had epidurals. "Our study suggests that epidural use within the ERAS framework is associated with significant improvement in analgesia end points without associated hypotension, increased fluid administration or lengthened hospital stay," concluded He, an anesthesiology resident at the Baltimore institution. She and her colleagues intend to add 100 more patients to the study in order to better evaluate for adverse effects.

From "Thoracic Epidural Analgesia Reduces Opioid Administration in the ERAS Setting"
Pain Medicine News (05/15/2017) Doyle, Chase

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Levobupivacaine vs Ropivacaine for Brachial Plexus Block

New research explored the analgesic superiority of levobupivacaine over ropivacaine
after ultrasound-guided brachial plexus block. The prospective study enrolled 62 patients scheduled for orthopedic surgery, randomizing them in equal proportions to receive one analgesic or the other. Based on its advantages compared to ropivacaine during peripheral nerve block, including longer-lasting analgesia, researchers expected levobupivacaine to deliver similar results with brachial plexus block. To their surprise, however, there was no difference between the two cohorts in terms of time to first request for pain medication, duration of the motor block, pain scores, need for rescue analgesia, or rate of sleep disruption. As a result, they reported in Medicine, levobupivacaine and ropivacaine offer similarly effective postoperative analgesia following brachial plexus block.

From "Levobupivacaine vs Ropivacaine for Brachial Plexus Block"
Clinical Pain Advisor (05/12/17) Chaverneff, Florence

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Regional Anesthesia Offers Alternatives to Opioids for TJR

Regional anesthesia—especially paired with ultrasound guidance and in the setting of multimodal analgesia—is a safe and affordable alternative to opioids during total joint replacement, according to Sonia Szlyk, MD. Speaking at the 2017 Interdisciplinary Conference on Orthopedic Value-Based Care, the director of anesthesia at INOVA Fair Oaks Hospital in Virginia noted that neuraxial and peripheral nerve blocks have the potential to boost patient satisfaction; reduce overall costs; and improve outcomes, in part by avoiding opioid-associated adverse events. To support her remarks, she cited research showing that incorporating adductor canal catheters into an enhanced recovery after surgery (ERAS) protocol increases ambulation distance, reduces falls, and improves quadriceps strength after knee replacement surgery. In addition, ultrasound-guided fascia iliaca blocks have demonstrated value as part of ERAS pathways for total hip replacement, hip fracture, and hip arthroscopy—particularly in fracture patients at risk for delirium. Continuous fascia iliaca catheters in fracture patients, meanwhile, have been reported to lower pain scores and shorten hospital stays, Szlyk said. "The health care system is increasingly focused on value-based care, and patient satisfaction and pain management are at the heart of that," she noted. "Regional anesthesia makes it easy to do the right thing for our patients."

From "Regional Anesthesia Offers Alternatives to Opioids for TJR"
Anesthesiology News (05/12/17) Doyle, Chase

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Continuous Intrathecal Infusion of Cannabinoid Receptor Agonists Attenuates Nerve Ligation-Induced Pain in Rats

Aware that cannabinoid receptors (CB1R/CB2R) are implicated in pain transmission, researchers in Taiwan wondered if agonists targeting those receptors might alleviate pain stemming from nerve ligation. To test their theory, they administered continuous intrathecal infusions of CBR1/R2 agonists or saline in the L5/6 spinal region of rats for seven days after nerve ligation surgery. They found that the approach did indeed block pain compared to saline, possibly as a result of the agonists' actions on neurons and glial cells. It also appeared that CB2R helped to regulate neuroinflammation caused by nerve injury, although the same was not true for CB1R.

From "Continuous Intrathecal Infusion of Cannabinoid Receptor Agonists Attenuates Nerve Ligation-Induced Pain in Rats"
Regional Anesthesia & Pain Medicine (05/10/2017) Shiue, S.J.; Peng, H.Y.; Wang, S.W.; et al.

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A Predictive Model for Extended Postanesthesia Care Unit Length of Stay in Outpatient Surgeries

Outpatient surgery data from a single site was used to create a predictive model for patients at risk for an extended stay in the post-anesthesia care unit (PACU). Data spanning Jan. 1, 2014 to Oct. 1, 2015 were collected retrospectively from the University of California, San Diego Healthcare Systems, excluding procedures not requiring an anesthesia provider to be present. The final data set included 10,465 patients, and the primary outcome was PACU length of stay greater than or equal to the 75th percentile of time spent in the recovery area. To build a model that could measure risk before the day of surgery, researchers did not consider intraoperative or postoperative events but focused exclusively on predictive variables known ahead of time. Five were ultimately included in the model—including primary anesthesia type, general anesthesia specifically. Two variables—longer scheduled case duration and specialty—were surgical in nature, with many subspecialities lowering the odds of a prolonged PACU stay compared with general surgery. The last two predictive variables were grounded in demographics, with morbid obesity raising the chances of airway management problems—a common PACU complication—and comorbidity with hypertension increasing the likelihood of a longer stay due to hemodynamic challenges. The model promises to guide clinician decision-making during the preoperative period and also aid in the development of effective case-sequencing methodologies to help optimize recovery room staff scheduling, particularly in settings with few recovery beds.

From "A Predictive Model for Extended Postanesthesia Care Unit Length of Stay in Outpatient Surgeries"
Anesthesia & Analgesia (05/17) Vol. 124, No. 5, P. 1529 Gabriel, Rodney A.; Waterman, Ruth S.; Kim, Jihoon; et al.

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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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