Anesthesia E-ssential

AANA Anesthesia E-ssential, May 30, 2019

Vital Signs

Oregon Governor Signs Two Bills Removing Practice Barriers for CRNAs

Oregon SB 128 has been enacted. This bill allows the Oregon Board of Medical Imaging to issue a permit to APRNs (including CRNAs) to supervise fluoroscopy. The Oregon Association of Nurse Anesthetists introduced this bill to create a path for CRNAs to supervise fluoroscopy.

OR SB 136 has been enacted. This bill expands CRNA prescriptive authority by removing the 10-day supply limitation, thereby giving CRNAs full prescriptive authority.

The AANA State Government Affairs division worked closely with ORANA to support ORANA's efforts in passing these bills. SGA's collaboration with ORANA included AANA letters of support sent to the bill sponsors, strategic calls with ORANA leadership and lobbying teams, and materials to help local CRNAs advocate for the passage of these bills.
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New AAP Guidelines Enhance Dental Anesthesia Safety, Recognize CRNAs

In response to growing concerns about the safety of deep sedation/general anesthesia for dental procedures involving pediatric patients, the American Academy of Pediatrics (AAP), in conjunction with the American Academy of Pediatric Dentistry (AAPD), has made significant changes to its 2016 sedation guidelines. The AANA applauds the AAP and AAPD for their efforts to ensure pediatric dental patient safety consistent with the AANA’s own Dental Office Sedation and Anesthesia Care Position Statement, which can be read here.

The revised AAP guidelines, outlined in the clinical report titled Guidelines for Monitoring and Management of Pediatric Patients Before, During and After Sedation for Diagnostic and Therapeutic Procedures, recommend that at least two qualified providers should be present with a pediatric patient undergoing deep sedation/general anesthesia for dental treatment in a dental facility or hospital/surgicenter. And for the first time, the guidelines define a qualified provider as a CRNA in addition to a “medical anesthesiologist,” dentist anesthesiologist, or second oral surgeon.

Writing in AAP News, lead author Charles J. Coté, MD, FAAP, noted that the clinical report replaces the “personnel section” of the 2016 version which called for the presence of only “one trained person with Pediatric Advanced Life Support (PALS) certification to constantly observe the patient during deep sedation without the specification of an anesthesia-trained provider.” By comparison, the revised guidelines for deep sedation/general anesthesia require an independent observer with no additional responsibilities who is trained in PALS and skilled to assist in any medical emergency, such as a CRNA. The new guidelines apply to both dental facilities and hospital/surgicenters.

The full 2019 report is available and will be published in the June issue of Pediatrics.

AANA continues to be committed to patient safety related to the administration for dental sedation and anesthesia and supports a multidisciplinary approach to advance ongoing efforts to increase pediatric dental safety.

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Hot Topics


AANA THRIVE is a new online Health & Wellness resource supporting various career stages and transitions. CRNAs and SRNAs face multiple challenges and opportunities during their career, such as transitioning from:
  • An RN to an SRNA,
  • A student to CRNA,
  • Career changes and growth,
  • Coping with job loss when it is not your choice, and
  • Approaching retirement age.
These resources can help CRNAs and SRNAs THRIVE not only professionally, but personally as well. Learn more.
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Here's Your Opportunity to Become a State Peer Advisor - Apply Now!

For CRNAs interested in applying to be a volunteer State Peer Advisor (SPA) in their state – see information and a link to the application from this FAQ page: About AANA Peer Assistance. The SPA role is outreach and participation at the state and local levels to build awareness of the peer support available and assist with education to encourage professional and personal well-being and prevent substance use disorder (SUD), an occupational risk for anesthesia professionals.

SPAs also offer ongoing post-crisis peer support for CRNAs/SRNAs in their state. It’s an ideal time to be an SPA with the upcoming 2019 Peer Assistance and Wellness Annual Pre-Congress Workshop. For any drug or alcohol related concerns, such as CRNA/SRNA impaired practice or suspicion of drug diversion, call the AANA Peer Assistance Helpline (800-654-5167) for 24/7 confidential live support and resources.
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Recent Grads: Save up to 50% on Malpractice Insurance Coverage Through AANA Insurance Services

As our way of welcoming you to the profession, AANA Insurance Services is offering you a 50% premium discount on full-time and supplemental malpractice insurance coverage. Caring has its risks. Learn how we can help safeguard your career.
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How Do You Say OSAEMER? Free EMR Now Available for iPad

After five years of development, the first free electronic medical record specifically for CRNAs is now available as a free download to an iPad from the Apple iOS App store

CRNAs Dan Simonson and Jack Hitchens developed the program first for use via FileMaker Go, a free downloadable app that, after proper setup, runs the file. With the advent of the iOS app version, users will no longer have to go through the mildly technical setup required for OSAEMR for FileMaker Go.

[Note that while OSAEMER iOS can be viewed on any web browser, it can only be downloaded to an iPad, as it is not designed to work on iPhones or Mac OS. The FileMaker Go version, however, works on all platforms (iPad, Mac OS, and Windows) except Android. It works on iPhone but looks terrible and is difficult to use.]

"Our non-profit mission is to make sure that every CRNA has the ability to digitally record their care and submit their quality data, no matter how small their practice or few their cases," says Simonson. "We were concerned that, without data, these solo, small, and often rural practices—which form the bedrock of CRNA advocacy efforts at both the state and federal level—would become essentially invisible to policy makers and legislators.

For more info, visit:
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One Week Left! Enter Now! PR Recognition Awards Deadline: June 7

Each year 15-20 entries are received from state associations, CRNAs or SRNAs, educational programs, businesses and others for the PR Recognition Awards competition coordinated by the AANA Communications Committee. Awards are presented in four categories:
  1. Best overall public relations effort for the past year, to be awarded to an individual, organization, or state association.
  2. Best promotional effort for National CRNA Week, to be awarded to an individual, organization, or state association.
  3. Best public relations effort by an individual, small group, organization or company not affiliated with a state association.
  4. Best use of “CRNAs: The Future of Anesthesia Care Today” campaign to promote the nurse anesthesia profession by an individual, organization, or state association.
All entries are judged by the committee onsite the day before the opening of the Annual Congress, and the winners are recognized during Opening Ceremonies. Detailed information about the competition, along with entry guidelines, can be found on the AANA website.

Winners will receive a plaque to commemorate their achievement, and their names will be added to a PR Awards exhibit on permanent display in the AANA Executive Office in Park Ridge, Ill.

Please note:

  • The deadline for entries is earlier than usual because this year’s Congress is taking place in August rather than September. The deadline is Friday, June 7. Late entries will not be considered.

For additional information or answers to questions about the PR Awards, please contact PR Department Administrative Associate Karen Sutkus at or 847-655-1140.

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NewsMaker: CRNA John Bing Earns UMSON Dean's Medal for Distinguished Service

The 2019 Dean’s Medal for Distinguished Service was awarded John Bing, BSN, CRNA, at the University of Maryland School of Nursing’s (UMSON) convocation ceremony on May 16.

Bing was honored as an outstanding leader and practitioner who has represented nurse anesthesia at the state, national, and international levels with a special focus on nurses of color. Recognizing a significant need for Certified Registered Nurse Anesthetists (CRNAs) throughout Maryland, he was instrumental in establishing the Nurse Anesthesia program at the school, celebrating its 15th anniversary this year. He secured the initial grant to open the program and personally championed its support from the state legislature and area hospitals. The program now has more than 240 graduates and reflects an unprecedented level of diversity, with 60% of students representing racial and ethnic diversity. Learn more.
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NewsMaker: CRNA Jeff Roos Became Better Leader Through Military Service

Jeff Roos, MSN, CRNA, LTC(ret), served for 20 years in the U.S. Army, eventually retiring as a lieutenant colonel in 2008. Over the course of his several deployments, Roos worked with military medical teams who revolutionized trauma care.

In an article in the StarNews online, Roos said his military service helped him become a better leader and he would never change it. "The military aspect of my career—that forged really who I am as an adult," he said. "It is what molded me to be able to do what I'm doing right now." Learn more.
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NewsMaker: CRNA Pamela Chapman Markle, Ultramarathoner, Setting Records

Pamela Chapman Markle, CRNA, began running ultramarathons in 2011, at the urging of a physician. According to Ultrarunning Magazine, Markle ran daily to relieve stress, and decided to run Rocky Racoon in Huntsville, Ala. She planned to sign up for a 50-mile race, but as it was full, decided to go for the 100-mile race. Learn more.
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Clinical Nurse Anesthetist: The Ohio State University Wexner Medical Center, Columbus, Ohio

U.S. News & World Report released its updated 2018-19 “Best Hospitals” rankings, and we are proud to tell you that The Ohio State University Wexner Medical Center is ranked in 10 specialties and named high-performing in two others. Only 26 hospitals out of nearly 5,000 in the nation were ranked in 10 specialties or more. This is our 26th consecutive year on the Best Hospitals list and one of our best yet – seven of our specialties landed in the Top 25, three new programs joined this year’s list and ENT rose to fourth in the nation! Our faculty and staff who are leading the way in improving health in Ohio and across the world. Ohio State Wexner Medical Center is again leading the way as the best hospital in central Ohio.

The CRNA is a registered, professional advanced practice nurse who demonstrates excellence in all areas of anesthesia practice including but not limited to anesthesia case management, staff education and clinical research. The CRNA manages complex, unpredictable anesthesia situations. The CRNA must be competent in technical, cognitive and interpersonal skills required to serve those patients receiving anesthesia care and services. The CRNA is expected to practice within the established Medical Center, anesthesia, and nursing standards of practice (policies, procedures, protocols), and adhere to the Intensive Caring Value Statements. The CRNA works as a member of the patient care team and collaborates with an MDA in the anesthetic care of each and every patient. Learn more.
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CRNA: WellSpan Health/Apple Hill Surgical Center, York, Pennsylvania

WellSpan Health, an integrated health system serving central Pennsylvania and northern Maryland, has openings for full time CRNAs to join Apple Hill Surgical Center in York. The organization is comprised of a multispecialty medical group of more than 1,500 physicians and advanced practice clinicians, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 19,000 employees, and 170 patient care locations.
  • Full time position - must be board certified
  • CRNAs with prior Ambulatory experience are encouraged to apply
  • Exciting opportunity to join an established surgical center
  • Case mix includes: GI, Plastics, Urology, General, ENT, Peds, Podiatry, Ortho and Ophthalmology
  • Enjoy a well-balanced lifestyle, excellent hours and schedule and no call
  • Competitive salary and outstanding benefits
Learn more.

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Certified Registered Nurse Anesthetist: Memorial Health System, Springfield, Illinois

This position embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values. Our CRNAs administer general, regional, and MAC anesthesia to patients of all ages and any ASA status. The CRNAs work in a collaborative team environment with 50 CRNAs, 21 Anesthesiologists and 12 Anesthesia Techs to assist with room turnover and stocking. The CRNAs serve as Clinical Instructors for SIUE and Millikin/Decatur Nurse Anesthesia programs.

Due to our continued growth, Memorial Medical Center has multiple needs for Certified Registered Nurse Anesthetists. Positions are available full time in the Main OR, CVOR or as a split 50/50 between Main OR and CVOR. Learn more.
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Certified Registered Nurse Anesthetist: Rush Oak Park Hospital, Oak Park, Illinois

The CRNA functions under the medical direction of the Anesthesiologist with regard to pre-anesthetic and post-anesthetic patient management functions. Good oral and written communication skills; time management/priority-setting; familiarity with basic body mechanics; flexibility with schedule to accommodate staffing needs; ability to transport equipment; work environment includes probability of exposure to adverse, hazardous, or unpleasant conditions; routinely comes in contact with potentially infectious patients and specimens. Master's Degree, Graduate of an accredited C.R.N.A. Program, current Illinois RN license, Current CPR and ACLS (from AHA). Learn more.
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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.

Postoperative Analgesia for Pediatric Craniotomy Patients

Researchers in China set out to identify the best approach to postoperative analgesia in the setting of pediatric neurosurgery. To accomplish their goal, they assembled a sample population of 320 patients aged one to 12 years old who were scheduled for craniotomy. Based on randomized assignment, enrollees received fentanyl, morphine, tramadol, or normal saline. According to the investigators, 56 of the patients experienced moderate to severe pain. Comparative analysis revealed that, out of the four options, morphine delivered through patient-controlled intravenous analgesia or nurse-controlled intravenous analgesia was the safest and most effective pain control protocol for children undergoing neurosurgical procedures. Pain scores one and eight hours after surgery were lower with morphine than with any of the three groups. Additionally, the technique demonstrated promise for managing postoperative pain without increasing the likelihood of nausea and vomiting, respiratory depression, and excessive sedation.

From "Postoperative Analgesia for Pediatric Craniotomy Patients"
Medscape (05/28/19)

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Breast Cancer Recurrence Not Linked to Anesthesia Administration Mode

Researchers in South Korea questioned whether choice of anesthetic approach for surgical tumor resection influences whether breast cancer resurfaces later. The retrospective study analyzed long-term outcomes in 5,331 patients, half of whom received intravenous anesthesia with propofol or remifentanil for their operation. The remainder received inhaled anesthesia with isoflurane, sevoflurane, desflurane, or enflurane for the procedure. The main outcome was recurrence-free survival five years after surgery, which was tallied at 93.2 percent for the IV patients and 93.8 percent for the inhalation patients. A Cox proportional hazards model developed by the research team further confirmed a similar likelihood of recurrence-free survival with both techniques. There also was no significant between-group difference in overall survival at five years, the review's secondary endpoint. Based on the findings, lead investigator Jin-Tae Kim, MD, of Seoul National University Hospital advised that "the choice of anesthetic agent should be made according to the characteristics of the individual patient." He and his colleagues reported their results in Anesthesiology.

From "Breast Cancer Recurrence Not Linked to Anesthesia Administration Mode"
General Surgery News (05/27/19) Bassett, Jenna

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Improving Intraoperative Handoffs for Ambulatory Anesthesia

Collaborators at the University of Iowa and the University of Miami offer guidance on how to avoid adverse events and deaths stemming from permanent transitions of care from one anesthesia provider to the next. The researchers studied data from an ambulatory surgery center to shape their recommendations, which include eliminating arbitrary shift durations. Rather, they reason, optimal shift durations can be determined through statistical forecasting incorporating months of historical data. As a second piece of advice, anesthesia providers who may have to work late should be assigned to the operating rooms (ORs) expected to finish the earliest—not than latest. Additionally, cases in the one or two ORs with the latest scheduled end times should be sequenced so that the cases with the shortest durations are finished last. Finally, if a supervising anesthesia provider must be relieved early for administrative duties, he or she should be assigned to an OR that finishes with a series of brief cases. The logic underpinning these recommendations is that they provide multiple opportunities for a different anesthesia provider to assume responsibility between cases, which can potentially eliminate the need for a patient handoff in the first place.

From "Improving Intraoperative Handoffs for Ambulatory Anesthesia"
Local and Regional Anesthesia (05/19) Vol. 12, P. 37 Dexter, Franklin; Osman, Brian Mark; Epstein, Richard H.

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Xenon Gas Revealed to Offer Long-Term Protection Following Traumatic Brain Injury

European researchers have discovered that xenon, an anesthetic that has demonstrated neuroprotective properties in animals, can deflect long-term damage from traumatic brain injury (TBI). In experiments with mice, those given xenon within a few hours of a TBI had a similar life expectancy 20 months later as healthy mice with no TBI. However, mice with TBI but no exposure to the noble gas ultimately developed late-life cognitive damage, according to the report in the British Journal of Anaesthesia. "Xenon appears to act in a variety of ways, but one of the most likely mechanisms to explain its protective effects on brain tissue is by inhibiting receptors in the brain known as NMDA receptors, that become over-activated following a brain injury," explains lead study author Rita Campos-Pires. The discovery has promising implications for real-world application, with first responders and emergency rooms potentially using xenon gas to treat patients who present with acute brain injuries. "We have looked at very long-term outcomes, up to 20 months after TBI in mice," says corresponding author Robert Dickinson, who compares the timeframe to following human TBI patients until their 80s. "The finding that only a short treatment with xenon can have beneficial effects on cognition, survival, and brain damage almost two years later suggests that xenon might in future prevent cognitive decline and improve survival in human TBI patients."

From "Xenon Gas Revealed to Offer Long-Term Protection Following Traumatic Brain Injury"
New Atlas (05/22/19) Haridy, Rich

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Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome

The ROSE randomized clinical trial investigated the effect of early continuous neuromuscular blockade in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Enrollees, all subjected to the same mechanical ventilation approach, were divided into two treatment groups. The first, with 505 patients, underwent standard care with routine neuromuscular blockade and light sedation. The second, with 501 participants, received a 48-hour continuous infusion of cisatracurium with deep sedation. The main outcome was in-hospital mortality from any cause at 90 days, by which time 216 of the control patients and 213 of the patients in the intervention group had died. Although there was no significant difference in 90-day, all-cause mortality between the two sets of patients, those receiving the 48-hour cisatracurium infusion experienced more adverse cardiovascular events than did controls. The trial, sponsored by the National Heart, Lung, and Blood Institute, was suspended at the second interim analysis for futility.

From "Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome"
New England Journal of Medicine (05/19/19) Moss, Marc; Huang, David T.; Brower, Roy G.; et al.

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Effect of Ketofol vs Propofol as an Induction Agent on Ease of Laryngeal Mask Airway Insertion Conditions and Hemodynamic Stability in Pediatrics

Ketofol is a viable alternative to propofol for laryngeal mask airway insertion in children, according to a study published in BMC Anesthesiology. Researchers made the determination after examining outcomes in 60 pediatric patients who underwent the process using ketofol, a blend of ketamine and propofol. The ease of insertion and the hemodynamic effects for general anesthesia induction in that group were compared against the same outcomes in 60 other children who underwent the process with propofol only. The evidence indicated that ketofol offers comparable laryngeal mask airway insertion conditions as propofol while maximizing hemodynamics, including blood pressure and heart rate. Ketofol also minimized apnea time, as measured by the seconds from mask airway placement to the return of spontaneous ventilation.

From "Effect of Ketofol vs Propofol as an Induction Agent on Ease of Laryngeal Mask Airway Insertion Conditions and Hemodynamic Stability in Pediatrics"
Medscape (04/23/19)

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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:

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Attn: Cathy Hodson
E–ssential Editor
May 30, 2019