Anesthesia E-ssential

AANA Anesthesia E-ssential, May 31, 2018
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Vital Signs

New Research Confirms Safety of Nurse Anesthetists, Raises Questions about Anesthesiologist Assistants

New research published online in the journal Anesthesiology confirms the quality and safety of anesthesia provided by Certified Registered Nurse Anesthetists (CRNAs) while raising questions about the role and value of anesthesiologist assistants (AAs) in patient care.

The study, title "Anesthesia Care Team Composition and Surgical Outcomes," was funded by the American Society of Anesthesiologists.

"The value of healthcare professionals is measured in different ways, one of which is the safety and quality of the care they provide," said Bruce Weiner, DNP, MSNA, CRNA, president of the 52,000 member American Association of Nurse Anesthetists. "But in today's healthcare system, other measurable factors that are critically important to meeting the growing patient demand for healthcare services are the cost-effectiveness of the provider and the provider's ability to ensure patients have access to the care they need."

Read more.

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Directive Threatens to Impose New Barriers to CRNA Practice, Patient Access to Care

The AANA recently became aware of Veterans Health Administration (VHA) Directive 1123 which updates the policies, procedures, and responsibilities for Department of Veterans Affairs (VA) Anesthesia services, and appears to create new practice barriers for CRNAs that further jeopardize veterans’ access to timely anesthesia care. The AANA Federal Government Affairs Division recognizes several major problems and is carefully reviewing the 14-page directive. They will work with stakeholders to ensure that veterans will not be harmed by additional, onerous supervision requirements that create burdensome wait times for needed healthcare. The AANA will keep members apprised of this situation as it develops.

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Be Sure to Vote in the AANA 2018 Election! Voting Ends June 5, 2018 at noon CT

The AANA 2018 election started on May 8, 2018, and will continue until June 5, 2018, 12:00 noon CDT. To date, only 9 percent of eligible members have voted. Vote today so we can meet our minimum goal of 15 percent member participation.

By now, active AANA members should have received their ballot materials, including their election passcode and voting instructions, electronically or in the mail from Survey & Ballot Systems (SBS), the AANA's election coordinator. The email with the voting credentials originates from Please make sure this email did not end up in your spam or junk mail folder.

To vote online and view candidates’ biographical information and position statements visit the election site: and enter your member number and the election passcode provided to you by SBS.

If you do not have your election login information, click on the “Email me my login information” link on the login page and enter the email address on file with AANA, and your election login information will be emailed to you. SBS can be reached by phone at (952) 974-2339 (Monday through Friday, 8 a.m. to 5 p.m. CDT) or by email at

If it’s more convenient, please feel free to contact, and SBS will be asked to re-send your voting credentials.

View Board Candidates’ Video Speeches
Board candidates’ speeches presented at the April Mid-Year Assembly are available on the AANA website through the Video Speeches page. 

2018 Board Candidate Forum: Interact with the Candidates!
The AANA Connect 2018 Board Candidate Forum closed on May 23, 2018. The forum will remain open to view until the end of the voting cycle (June 5, 2018) but members won't be able to post additional questions.

If you have questions or need assistance, please email We look forward to your participation.

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Hospira Issues Safety Letter Regarding Cracked Needle Hubs

Hospira has issued an Important Safety Information Letter to alert Health Care Providers to the potential of cracked needle hubs and particulate in multiple products manufactured in the Carpuject™ Luer Lock Glass Syringe Products. In order to minimize the potential risk of adverse events with these products, special handling directions, as described in the letter, are required prior to administering the affected products to patients.

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Hot Topics

TODAY: Live Streaming Inaugural Meeting of the HHS Pain Management Best Practice Inter-Agency Task Force

The inaugural meeting of the HHS Pain Management Best Practices Inter-Agency Task Force is being held both Wednesday, May 30 and Thursday, May 31. Thursday's meeting is in session from 9 a.m. to 3:30 p.m. EST.

AANA Chief Learning Officer Bruce Schoneboom, PhD, CRNA, FAAN, is AANA's representative on the task force. Join the live stream.

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Practice Documents for Open Comment: Code of Ethics and Patient Transportation

Two practice documents are currently available for open comment:

  • Code of Ethics for the Certified Registered Nurse Anesthetist
  • Discharge After Sedation or Anesthesia on the Day of the Procedure: Patient Transportation With or Without a Responsible Adult, Policy Considerations

We appreciate your time, expertise, and feedback in the review of these documents. Please send your comments to by June 22, 2018. More information on each document can be found at Open Comment Opportunity.

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NewsMakers: Diane Miller, Aisha Allen Featured on Slice of Healthcare Podcasts

A brand new website called Slice of Healthcare, created by Jared Taylor, features podcasts with healthcare professionals. The first podcast, which aired on April 29, 2018, included an interview with Diane Miller, MHS, CRNA, who has invented a new device for pediatric induction.

Aisha Allen, BSN, CCRN, an SRNA from Duke University, also was interviewed in a separate podcast on May 13, 2018, about school, innovation, and social media.

Download the Slice of Healthcare podcasts on iTunes or listen on the Slice of Healthcare website.

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Meetings and Workshops

Learn the Business of Anesthesia From Two Successful CRNA Entrepreneurs

Do you feel limited in your practice? Do you dream of practicing independently? If you want to go out on your own, but don’t know the business side of anesthesia, here’s your chance to learn from Juan Quintana and Larry Hornsby, former AANA presidents, who both have launched multimillion-dollar anesthesia group practices.

Access to Instructors, Quintana and Hornsby
Juan Quintana, DNP, MHS, CRNA, and Larry Hornsby, CRNA, of International Anesthesia Seminars, have partnered with AANA to offer an eight week online seminar to teach CRNAs how to lead and succeed in starting and operating an anesthesia practice.

Opportunities Are There for CRNAs Who Are Ready
“With so much transition in healthcare, business opportunities are out there for CRNAs, but you don’t get a business education in anesthesia school,” said Quintana and Hornsby. “There is no book or manual out there, and we’ve built successful businesses through trial and error. We are passionate about helping other CRNAs mitigate their risk and succeed.”

University-level Curriculum for AANA Members Only
Quintana and Hornsby are bringing their university-level course to members only through AANA’s online education platform, AANALearn®. The average cost for online college-level courses is $300-$400 dollars per hour. This seminar is offered to AANA members for just $75 per hour. Participants will earn 16 CE credits and leave the course with an actionable business plan and a certificate of completion from AANA.

The first cohort will begin on July 9. Registration is now open and seats are limited. The second cohort will begin in fall 2018.


Course Curriculum

Week 1 - Business of Anesthesia and Practice Models

Week 2 - Reimbursement and Productivity

Week 3 - Negotiations, Cost Effectiveness

Week 4 - Contracts, Request for Proposal

Week 5 - Responding to RFPs, Value vs. Volume

Week 6 - Revenue Cycle Management, Rules

Week 7 - Business at the 30K-Feet Level

Week 8 - Present your RFP response

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Practice Leadership Assembly - NEW!

November 9-11, 2018, Rosemont, Illinois
Building on the popularity of the “Business of Anesthesia & the Fundamentals of Practice Management” track at the AANA 2017 Annual Congress, Practice Leadership Assembly is designed to give CRNA business owners as well as practice and facility leaders the insight and confidence to lead the way in a rapidly changing healthcare environment.

We're excited to share some news about a long-term plan for a deep dive into CRNA leadership enrichment opportunities for our members. We took a fresh look at the various needs for leadership development to design relevant and productive educational opportunities, including live events and webinars.

Practice Leadership Assembly
The first area of innovation is the new Practice Leadership Assembly, taking the place of Fall Leadership Academy in November 2018. Building on the popularity of the “Business of Anesthesia & the Fundamentals of Practice Management” track at the AANA 2017 Annual Congress (standing room only), Practice Leadership Assembly is designed to give business owners as well as practice and facility leaders the insight and confidence to lead the way in a rapidly changing healthcare environment. Topics include contract negotiation, optimizing staff engagement and performance, practice models, mitigating risk, change management, business acquisition, and more. Check the AANA Meetings & Workshops page in July for registration details.

State Leadership Workshops
The newly introduced State Leadership Workshops provide state leaders with conveniently located educational opportunities and feature a robust and focused program, intimate group size, and networking opportunities. The feedback from the first meeting in Las Vegas this February was overwhelmingly positive, with most attendees responding in evaluations that they were "very likely" to recommend the meeting to their colleagues. The next regional workshop is in Baltimore on June 23-24.

Federal political directors, state reimbursement specialists, pain reimbursement specialists, and AANA Foundation state advocates are key to fighting legislative and regulatory battles. New and innovative approaches for learning are being evaluated and will be communicated as soon as they are available.

These changes in our leadership development offerings will provide our members with the resources, mentorship, and expert advice you need for success. We strive to take positions of leadership so that when opportunities arise, WE ARE THERE!

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Foundation and Research

AANA Foundation Receives NBCRNA Donation and Match for Student Emergency Grant Program

The AANA Foundation’s Student Emergency Educational Grant Program supports student nurse anesthetists during times of financial hardship and natural disasters. Many students affected by hurricanes Harvey, Irma, and Maria and the California wildfires requested and received funds that aided them during this time of need.

The National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) generously donated $50,000 to assist with this effort and is offering an additional match to donations made by CRNAs and SRNAs. NBCRNA will match CRNA donations $1 for $1 and will match SRNA donations $10 to $1 up to $50,000 total.

When you take advantage of this matching gift, as a CRNA, your $500 donation becomes a $1,000 donation. As an SRNA, your $100 donation receives an additional $1,000 donation from NBCRNA. We ask that you take advantage of this generous match, and make a donation today by visiting the AANA Foundation.

For more information, contact the AANA Foundation at (847) 655-1170 or

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AANA Foundation’s Back Bay Bash in Boston

Purchase Your Tickets Today for Annual Congress Fundraising Event!

Join us Sunday, September 23, 2018, at McGreevy’s – America’s First Sports Bar. This fun event includes dinner, drinks, entertainment featuring DJ Mike Pearce, and CRNA and SRNA lip sync battles. Purchase your tickets when you register for the AANA 2018 Annual Congress. Contact Luanne Irvin, AANA Foundation Development Officer, at (847) 655-1173 or with questions or to register a song you or your group would like to perform at the event.

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AANA Foundation: Make Your FY18 Donation Today for Annual Report Recognition!

Access the Foundation’s secure donation page and make your tax-deductible gift to AANA Foundation’s Proof is Power Annual Fund today. Donations of $100 or more made by July 1, 2018 will be included in the AANA Foundation Fiscal Year 2018 Annual Report and Recognition booklet. Thank you in advance for your contribution and support of nurse anesthesia education and research.

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Are you a MIPS Eligible Clinician on the Hook for a 5 Percent Penalty? Verify Today!

To check whether you need to participate in 2018 Merit-Based Incentive Payment System (MIPS) to avoid the 5 percent penalty in 2020, CMS now offers two ways to verify your MIPS participation status. To check your individual eligibility status, go to the MIPS Status Lookup tool with your National Provider Identifier (NPI) to find out. You may learn that you are excluded from participation based on the 2018 MIPS low-volume threshold criteria.

For authorized users with Enterprise Identity Management (EIDM) credentials, you also may choose to log in to the CMS Quality Payment Program new portal to review group level data for all clinicians under a Taxpayer Identification Number (TIN). 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). The quality payment program helpdesk is prepared to answer questions about both look-up tools and participation status by email ( or phone (1-866-288-8292).

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AANA Member Benefits

MIPS QCDRs - AANA Member Advantage Program

If you or your group are Merit-Based Incentive Payment System (MIPS) eligible, it is not too late to start registry shopping. Through the AANA Member Advantage Program, discounts are available to AANA members for SCG Health QCDR (Quality Clinical Data Registry) and ABG QCDR. To learn more, visit the AANA QCDRs and Registry Reporting FAQs today. SCG Health specializes in making MIPS regulatory burdens more approachable so that you can plan how to respond with limited resources and time.

AANA members who become SCG Customers will receive a 10 percent discount off the retail base subscription of 2018 reporting at $275 per clinician for reporting Quality and Improvement Activities, which must include three or more SCG Health QCDR measures. ABG QCDR offers 13 ABG measures and AANA members can receive a $10 discount off the base QCDR subscription of $150 per provider.

Through Insight Medical Data Services (IMDS), an affiliate ABG partner, IMDS-QCDRapp offers additional services for $30 per month per provider (discount does not apply and price subject to change). For additional information about the MIPS and the Quality Payment Program visit the AANA Quality-Reimbursement website 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.

Epidural Compared with Non-epidural Analgesia and Cardiopulmonary Complications After Colectomy

Researchers undertook a retrospective cohort study to compare cardiopulmonary complications after open colectomy with and without epidural analgesia. Collaborators from the Cleveland Clinic and from University Hospitals Cleveland Medical Center studied 2014-15 data on nearly 4,200 patients who received epidural pain relief during their procedure and more than 16,700 propensity-matched patients who did not. Overall, there was no correlation between epidural analgesia and the primary outcome—a composite of cardiopulmonary complications. Looking at the 8,500 open colectomies, however, the data supported a strong correlation between epidural analgesia and fewer complications. In this setting, epidural analgesia was also associated with shorter hospital stays. The researchers involved in the observational study believe their findings may help guide analgesia-related decisions when planning open colectomy.

From "Epidural Compared with Non-epidural Analgesia and Cardiopulmonary Complications After Colectomy"
Journal of Clinical Anesthesia (06/01/2018) Vol. 47, P. 12 Cummings III, Kenneth C.; Zimmerman, Nicole M.; Maheshwari, Kamal; et al.

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Awake Video-Assisted Surgery Option for 'Inoperable' Lungs

Awake video-assisted thoracic surgery may be an option for patients whose vulnerability during endotracheal intubation and/or general anesthesia might otherwise preclude them from having an operation. Good candidates include patients with early-stage lung cancer and compromised lung function, for example. Ara Klijian, MD, from Sharp Grossmont Hospital in La Mesa, Calif., and Scripps Mercy Hospital in San Diego, has had experience with more than 500 awake video-assisted thoracic surgeries. Procedures including wedge resection, segmentectomy, and lobectomy can be conducted under local anesthesia and sedation, "with outcomes comparable or better than those done under general anesthesia," according to Klijian, who acknowledges that even anesthesia providers doubted the approach at first. "They said, 'are you serious? You really want to try this?' Now they love doing it this way." The benefits include the absence of central lines or arterial, urinal, or epidural catheters—which mitigates the likelihood of infection. The risk of postoperative morbidity is also lower, plus there is the potential to lower hospital costs and create a more comfortable recovery for patients. Still, Klijian concedes, the approach is still fairly novel. "It's not for everybody. You have to carefully pick the right patients and do a lot of preplanning," he cautions.

From "Awake Video-Assisted Surgery Option for 'Inoperable' Lungs"
Medscape (05/24/18) Hein, Ingrid

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Hospital Sedation Program a Success for Children with Needle Phobias

Vaccine recently reported on the use of nitrous oxide to sedate children who become agitated and/or distressed during the immunization process. The Royal Children's Hospital in Melbourne, Australia, uses the approach with patients who are developmentally disabled or who have a fear of needles—but only as a last resort. If books, television, and other distractions do not work, clinicians move on to specialized cold devices, numbing creams, or vibrating toys. When all else fails, a pediatric patient may receive a combination of nitrous oxide and midazolam. Royal Children's has attempted 213 vaccinations of children under sedation since 2012 and, according to the paper in Vaccine, did so successfully in 95 percent of those cases.

From "Hospital Sedation Program a Success for Children with Needle Phobias"
Pharmacy News (05/24/2018)

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Pre-op Fluid Fasting Before Anesthesia Called Unnecessary

New evidence suggests that limiting fluids before surgery, though widely accepted and practiced, may be unnecessary. The conclusion is based on an examination of patient data from November 2013-February 2016 at England's Torbay Hospital Day Surgery Unit, which in October 2014 began allowing patients to drink clear liquids until entry into the operating room. The retrospective study compared the rate of postoperative nausea and vomiting (PONV) in patients who had surgery under the new policy and in patients whose procedures were performed under the old guideline, which stipulated no fluids for two hours preoperatively. Nausea 24 hours post-surgery occurred in 5.2 percent of patients who were subjected to fluid restrictions, versus 3.8 percent for patients who were not. A similar pattern was documented with the rate of vomiting, at a respective 2.8 percent and 2.2 percent. The association between no fluid restrictions and less PONV was further supported by multivariate regression analyses. "We controlled for different surgical specialties and anesthetic techniques, including use of volatile anesthesia versus total intravenous anesthesia, spontaneous ventilation versus intermittent positive pressure ventilation and tracheal tube versus supraglottic airway device,” explained Graham McCracken, MB, an anesthesia provider who worked at Torbay until recently. In addition to the improved clinical outcome, patients permitted to have fluids on the day of surgery reported higher levels of satisfaction, according to results published in the European Journal of Anaesthesiology.

From "Pre-op Fluid Fasting Before Anesthesia Called Unnecessary"
Anesthesiology News (05/23/18) Kronemyer, Bob

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Ketamine Eliminated Pain in Patient with Fibromyalgia and RA, Case Study Says

According to a report in the Journal of Medical Cases, intravenous ketamine successfully delivered pain relief to a 49-year-old woman with rheumatoid arthritis (RA) and fibromyalgia. The approach was tested after the patient did not adequately respond to multiple previous treatment options, including traditional RA regimens such as analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and disease-modifying therapies. The 10-day protocol included IV ketamine infusion for four hours daily, with an initial dose of 428 mg that was gradually escalated to 1,063 mg. The patient reported reduced pain with the very first session and was nearly pain-free after the final treatment. RA symptoms, including joint pain and morning stiffness, were resolved as well. According to lead study author Ashraf Hanna, MD, “ketamine appears to possess unique immunomodulatory and analgesic properties that effectively [reduce] inflammation and reduce pain without the use of opioid/NSAID analgesics.” He and his co-authors acknowledge that their case study was highly limited. Going forward, however, "we are hopeful that future adequately powered and placebo-controlled clinical trials may confirm that ketamine is safe and effective for the treatment of autoimmune diseases such as RA,” they write.

From "Ketamine Eliminated Pain in Patient with Fibromyalgia and RA, Case Study Says"
Fibromyalgia News Today (05/22/18) Lopes, Jose Marques

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New Form of Local Anesthetic Does Not Reduce Opioid Use or Complications After Knee Surgery

Researchers say a long-acting anesthetic failed to curtail in-hospital opioid use or opioid-related complications when included in a multimodal protocol for postoperative pain relief. When injected into the tissue surrounding a surgical wound, a single dose of liposomal bupivacaine theoretically can control pain for up to three days; but investigators said that was not the case. "When we tested this hypothesis in a real-world setting where state of the art pain procedures such as peripheral nerve blocks were used, we were unable to show benefit," said senior author Stavros Memtsoudis, MD, PhD, from the anesthesiology department at the Hospital for Special Surgery in New York. He and colleagues reviewed data from more than 88,800 total knee replacements done from 2013-2016 under general or regional anesthesia with peripheral nerve block. Slightly more than a fifth of the patients were given liposomal bupivacaine in conjunction with the block; but opioid-related complications, inpatient opioid prescriptions, length of stay, and cost of hospitalization were no different for these individuals than for the general study population. "The routine use of liposomal bupivacaine should be carefully examined, especially given its relatively high cost. It does not seem to be the silver bullet physicians have been hoping for," Memtsoudis said. The findings appear online in Anesthesiology.

From "New Form of Local Anesthetic Does Not Reduce Opioid Use or Complications After Knee Surgery"
Medicalxpress (05/21/2018)

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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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May 31, 2018
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