AANA Anesthesia E-ssential
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Vital Signs

AANA Practice Management Initiative Website Up and Running

The AANA is pleased to announce the AANA Practice Management Initiative, which is dedicated to developing much-needed business of anesthesia and pain management resources and bringing them together in one place. This initiative coordinates the activities of several AANA Divisions for one point of contact for members. See www.aana.com/practicemanagement for valuable references from AANA Divisions, including new resources such as contract checklists, sample anesthesia services agreement, and other business resources.
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CPC Facts

CPC Program Overview—Animated

Are you looking for a quick overview of the CPC Program? The NBCRNA has posted on its website a three-minute animated video that provides an overview of the program and its components. For more information about the NBCRNA's Continued Professional Certification (CPC) Program, which will launch on August 1, 2016, go to the cpc-facts.aana.com and NBCRNA websites.
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Hot Topics

AANA Connect is Here—Join the Conversation!

AANA Connect is now up and running. Three online communities—General, Practice Management, and SRNA-Only—will allow you to connect with, learn from, and share with your nurse anesthesia colleagues from around the country. Click here and join the conversation now!
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National CRNA Week, January 24-30, 2016

Tell the world who you are during National CRNA Week, January 24-30, 2016. The theme for 2016 is "CRNAs: Making a Difference One Patient at a Time," which complements the ongoing public education campaign launched by the AANA in September 2014. In a fresh and innovative way, the theme delivers the message that CRNAs are highly educated and skilled professionals who provide safe, cost-effective anesthesia care and other essential healthcare services across the United States. Promotional materials for this year’s theme, “CRNAs: Making a Difference One Patient at a Time,” are available at http://www.aana.com/CRNAweek. AANA members can also find a myriad of other public relations and patient education materials at www.aana.com/future-today and patient education materials at www.aana.com/forpatients.
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Veterans Deserve More Than Just Another "Thank You"

Click here to read the Op-Ed from AANA President Juan Quintana, CRNA, DNP, MHS, on the issue of delays in healthcare for veterans.
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New CRNA Study Published in Nursing Economic$

The staff of the AANA Research and Quality Division published a study in Nursing Economic$ that demonstrated that anesthesia providers differ among populations of varied socio-economic conditions. After controlling for multiple variables in the correlational analysis, CRNAs were more correlated with the uninsured, unemployed, Medicaid, and Medicaid disabled. This study illustrates that CRNAs in both urban and rural environments are more likely to increase access to anesthesia service to the most vulnerable populations.
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AANA Research and Quality Division Offers Intro to Health Service Research Webinar

The AANA Research and Quality Division supports the AANA Foundation in their mission to advance the science of anesthesia through education and research. The health service research (HSR) webinar was created as an introduction for CRNAs who are interested in learning more about how to identify national priorities and framework from which nursing scholars can identify HSR topics, and to provide information on how the AANA Foundation supports HSR through fellowships and grants.
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Military Blood Transfusion Protocol for Severe Hemorrhaging May Help Save Combat and Civilian Patients

Improvements in military trauma care procedures related to hemorrhage and resuscitation on the combat zone front lines may lead to improvements in civilian trauma care as well, according to an article in the latest issue of the AANA Journal. Read “Far Forward Anesthesia and Massive Blood Transfusion: Two Cases Revealing the Challenge of Damage Control Resuscitation in an Austere Environment” here.
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Interested in Being a Speaker at Annual Congress?

Are you interested in being a new speaker at the AANA 2016 Nurse Anesthesia Annual Congress? The members of the AANA Professional Development Committee are inviting all CRNAs to apply for an opportunity to be a new speaker in a concurrent session.

The Nurse Anesthesia Annual Congress provides this opportunity for newer speakers to present evidence-based topics to an audience. Six individuals will be selected by the Professional Development Committee and given an opportunity to present their lecture on Saturday, Sept. 10, 2016.

For more information, and to apply by December 1, 2015, please visit here.
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Meetings and Workshops

Registration Open for Assembly of School Faculty

We're excited to announce that advance registration is now open for the 2016 Assembly of School Faculty. Join us in historic San Antonio on February 25-27, 2016, for the premier convergence of nurse anesthesia program faculty. Register Now!
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Foundation and Research

Fellowship Application Deadline is February 1, 2016

The fellowship application is now available on the AANA Foundation website at www.aanafoundation.com. The due date for all FY16 fellowship applications is February 1, 2016. Click on the link below to access the application and view the AANA Foundation Research agenda and sample applications:
. If you have any questions, please contact the AANA Foundation at (847) 655-1170 or foundation@aana.com.
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Proof is Power: Foundation Kicks Off Annual Giving Campaign

The AANA Foundation kicked off its 2016 Proof is Power Campaign. On the strength of tax-deductible gifts, the Foundation will continue to advance and support nurse anesthesia through research and education. When you receive your letter or phone call requesting your tax-deductible donation, please be a part of our success and donate generously. We need YOUR help to fund future studies and provide scholarships, fellowships and grants needed to secure the future of our profession.

To learn more about the Foundation’s Proof is Power campaign or to make your tax-deductible donation, please click here.

Thank you for your continued support of the CRNA profession!
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Federal Government Affairs

Senators Unveil Bipartisan Bill Supporting CRNA, APRN Full Practice Authority in the VHA

Efforts to promote veterans access to quality healthcare received a boost on Nov. 10, when Sens. Jeff Merkley (D-OR), Mike Rounds (R-SD) and five additional Senators introduced bipartisan legislation directing the Veterans Health Administration (VHA) to allow Certified Registered Nurse Anesthetists (CRNAs) and other advanced practice registered nurses (APRNs) to provide patient care to the full extent of their education and abilities.

The “Veterans Health Care Staffing Improvement Act” (S 2279) was unveiled at a U.S. Capitol news conference and is supported by AANA. In addition to directing the VHA to extend full practice authority to CRNAs and other APRNs, the bill also removes bureaucratic barriers to healthcare professionals’ privileging and credentialing within the VHA, and encourages former military healthcare personnel to join the VHA for healthcare services. Additional cosponsors include Sens. Jeanne Shaheen (D-NH), Thom Tillis (R-NC), Mark Warner (D-VA), Sherrod Brown (D-OH) and Ron Wyden (D-OR).

“Veterans are waiting too long for quality healthcare that they deserve and have earned,” said AANA President Juan Quintana, CRNA, DNP, MHS. “The AANA strongly supports this legislation which will reduce veterans’ wait times for high quality healthcare by recognizing CRNAs and other APRNs to their full practice authority.”

The legislation follows an independent assessment that Congress ordered of the VA and published last month, which recommended that allowing CRNAs and other APRNs to practice to the full extent of their education and abilities would increase veterans’ access to care, reduce wait times, and save money. The proposal is also consistent with recommendations made previously by the Institute of Medicine, and is supported by more than 40 Veteran and healthcare professional organizations, including the Vietnam Veterans of America, the Military Officers Association of America, the Veterans of Foreign Wars, and the Iraq and Afghanistan Veterans of America.

Sens. Thom Tillis (R-NC), Mike Rounds (R-SD), Jeff Merkley (D-OR) and Mark Warner (D-VA) unveiled the AANA-backed Veterans Health Care Staffing Improvement Act (S 2279) at a U.S. Capitol news conference on Nov. 10.

AANA President Juan Quintana, CRNA, DNP, MHS, (center) joined AANA members, including CRNAs, student registered nurse anesthetists and veterans, at the U.S. Capitol news conference unveiling the Veterans Health Care Staffing Improvement Act (S 2279).
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Following Two-Year Agreement, Congress Continues Work on Unfinished Budget Business Affecting CRNA Interests

A two-year budget agreement adopted by Congress and signed by the president at the end of October gives lawmakers until Dec. 11 to complete unfinished budget business, including arrangements for Title 8 nurse workforce funding. However, the measure also extends the out-years of certain budget sequestration cuts through the mid-2020s, keeping in place a problematic policy that has kept Medicare payments depressed by 2 percent since 2013.

The AANA and APRN organizations are urging Congress to complete its FY 2016 appropriations work, including strong funding for Title 8, nursing research and healthcare quality initiatives important to patient safety. In the additional years that the bill extends budget sequestration, CRNAs and physicians would see their sequestered-level payment continue, and not have a bounce-back of plus-2 percent to pre-sequestration levels.
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Update on AANA’s Efforts to Ensure Veterans Access to Quality Care

The AANA and its members continue to advocate for legislation and a Veterans Health Administration (VHA) proposal that would authorize all advanced practice registered nurses (APRNs), including CRNAs, to practice as full practice providers in the VHA and help improve access to quality healthcare for all veterans. Here is a status update:
  • The AANA continues urging the U.S. Department of Veterans Affairs to publish a regulatory proposal for public comment that supports strengthening Veteran access to quality healthcare by adopting full practice authority for CRNAs and other APRNs serving in VHA healthcare facilities. Take action here and encourage your friends and family to also take action through the Veterans Access to Quality Healthcare Alliance microsite.
  • Since mid-February, AANA members have sent more than 14,000 messages to their federal legislators expressing support for full practice authority for CRNAs and other APRNs in the VHA. Even more CRNAs are encouraging their colleagues, friends and family to take action by writing their member of Congress and the VA Secretary through the Veterans Access to Quality Healthcare Alliance microsite.
  • The AANA is supporting legislation in the House, HR 1247, the “Improving Veterans Access to Quality Care Act,” sponsored by Reps. Sam Graves (R-MO) and Jan Schakowsky (D-IL). The bill now has 41 bipartisan cosponsors, with Rep. Terry Sewell (D-AL) adding her support most recently. The AANA encourages members whose U.S. Representative has cosponsored this legislation to send a thank-you note (here). Please continue to contact your U.S. Representative and encourage co-sponsorship of this bill (here). View the AANA and APRN Workgroup letter of support here and also view the Nursing Community letter here.
  • An independent assessment of the VHA completed by the RAND corporation recommended the Agency move forward with the full practice authority proposal for APRNs in the VHA and touted the policy as a cost saving measure. To read the full recommendation starting on p. 266 of the document, see here. The AANA and APRN organizations have supported the independent assessment in a letter to the VA Secretary and Chair and Ranking Member of the House Veterans’ Affairs Committee, which can be read here (AANA member login required).
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AANA Requests, Medicare Corrects 2016 Anesthesia Fee Schedule, with $431 Boost for Average CRNA; Additional Updates on Recent Medicare Payment Rules

Major Medicare payment rules published earlier in November affecting CRNAs, physicians and hospitals included one error critical to CRNAs—a 0.5 percent additional cut to the Medicare anesthesia conversion factor. Following AANA’s request to Medicare to correct the error, the agency did so, boosting the 2016 anesthesia conversion factor to $22.4426 per unit, and benefiting the average CRNA by $431 in 2016 over the uncorrected funding level.

The AANA’s analysis of the rules, each of which exceeds 1,000 pages, continues. Some major findings affecting CRNAs include:
  • The physician fee schedule changes how Medicare calculates the malpractice expense portion of the anesthesia conversion factor, reflecting reductions in liability premiums CRNAs have paid over the years thanks to improved patient safety and outcomes. Relative to the 2015 mean anesthesia CF of $22.6093, the recalculation reduces the 2016 anesthesia CF slightly to $22.4426. In fee-for-service Medicare, Part B pays an anesthesia fee on the basis of the conversion factor times the sum of the service’s base and time units.
  • Medicare is proposing to include CPT codes 00740 and 00810, anesthesia codes associated with colorectal screening, as misvalued codes. CMS acknowledged the AANA recommendation that Medicare create a modifier to be used by surgeons providing moderate sedation, and stated that the agency will consider input from the community on this issue as it values services through future notice and comment rulemakings.
  • With AANA’s support, Medicare finalized its proposal to recognize CRNAs as telehealth providers.
Additional information about these important rules will be published for members on www.aana.com and in the AANA NewsBulletin.
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AANA Members Complete First-Ever Public Office Campaign School

Six AANA members on Nov. 9 completed the association’s first-ever educational program for CRNAs and student registered nurse anesthetists considering a run for public office.

Conducted by internationally recognized “democracy coach” and George Washington University Graduate School of Political Management lecturer Nancy Bocskor, the school educated CRNAs and one student registered nurse anesthetist about preparing a run for public office, political fundraising, messaging and social media, and building an effective campaign team. Participants also heard from AANA Regional Director Debra Barber, CRNA, DNP, who gave her first-person perspective from her 2014 run for the Kentucky statehouse. Though she came in second on election night, Barber said she benefitted a great deal professionally and personally from the skills and contacts developed during her campaign.

Participants in the AANA’s first-ever Campaign School for members considering a run for public office included AANA Past President Sharon Pearce, CRNA, MS, (left), who is a candidate for the North Carolina House of Representatives, Regional Director Debra Barber, CRNA, DNP, (second from left), and colleagues from around the country.
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Thanks for Celebrating Chicago with CRNA-PAC at the Fall Leadership Academy

AANA members participating in the Fall Leadership Academy Nov. 6-9 in Rosemont, Ill., learned valuable leadership perspectives, improved their skills and professional networks as Federal Political Directors (FPDs) and State Reimbursement Specialists (SRSs), and celebrated Chicago at a fundraising event benefiting CRNA-PAC.

Attended by AANA President Juan Quintana, CRNA, DNP, MHS, and members of the Board of Directors, CRNA-PAC Committee chair Angela Mund, CRNA, DNP, and her PAC Committee colleagues, and over a hundred CRNA leaders from around the country, “CRNAs Celebrate Chicago” raised more than $45,000 for the CRNA-PAC and helped to strengthen the voice of the profession in Washington for the 2016 national elections.

The CRNA-PAC Committee says “thank you!” If you missed the event and would like to contribute, click www.crna-pac.com and enter your AANA member login and password to give online safely and conveniently.
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  • Members of the U.S. House of Representatives elected Rep. Paul Ryan (R-WI) Speaker, and a key Republican majority panel named Rep. Kevin Brady (R-TX), current chair of the House Ways and Means Subcommittee on Health, to succeed Rep. Ryan as chair of the House Ways and Means Committee. The action by the Republican Steering Committee awaits expected approval by the full House Republican Conference, and creates a vacancy in the Health Subcommittee chairmanship important to CRNAs.
  • The AANA has been present for several Presidential debates featuring candidates from both sides of the aisle. AANA President Juan Quintana, CRNA, DNP, MHS, has attended one from each major party in-person, accompanied by leading CRNAs, to help promote the role and value of CRNAs among national leaders present. They included a Republican debate on Oct. 28 in Boulder, Colo., and a Democratic debate on Nov. 15 in Des Moines, Iowa. The AANA encourages CRNAs to engage with the presidential campaign of their choice, particularly in the early caucus and primary states of Iowa, New Hampshire, South Carolina and Nevada, plus the “Super Tuesday” states of Alabama, Alaska, Arkansas, Colorado (caucus), Georgia, Massachusetts, Minnesota (caucus), North Carolina, Oklahoma, Tennessee, Texas, Vermont and Virginia. Neither the AANA nor the CRNA-PAC support or endorse candidates for president. If you have any questions, contact your AANA team in Washington at info@aanadc.com. To see a full list of debates schedule, see here.
  • While the switch to the ICD-10 coding system took place Oct. 1, Congress is monitoring the transition and so is the AANA, which is backing legislation to ease the switch. If you or your facility encounters any issue with the ICD-10 transition, please email info@aanadc.com. To learn more, see an AANA compilation of CRNA-focused ICD-10 materials here.
  • Stay up to date on CRNA reimbursement issues by obtaining Version 3 of the AANA’s “Issues Briefs on Reimbursement and Nurse Anesthesia,” available only for AANA members here (requires AANA member login and password).
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The following is an FEC required legal notification for CRNA-PAC:

Gifts to political action committees are not tax deductible. Contributions to CRNA-PAC are for political purposes. All contributions to CRNA-PAC are voluntary. You may refuse to contribute without reprisal. The guidelines are merely suggestions. You are free to contribute more or less than the guidelines suggest and the association will not favor or disadvantage you by reason of the amount contributed or the decision not to contribute. Federal law requires CRNA-PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year. Each contributor must be a US Citizen.
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Visit www.crnacareers.com to view or place job postings
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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.

More Than 50 Percent of Women First Come in Contact With Opioids Through Prescriptions

New findings indicate that opioid analgesics prescribed by a doctor served as the gateway to opioid addiction for more than half of female abusers. In a study of 503 patients enrolled in methadone clinics in Ottawa, 52 percent of the women but just 38 percent of the men reported prescription pain pills as their first experience with opioid use. The researchers surmised that women are more likely to have medical conditions that result in severe long-term pain; that their higher levels of sex hormones may create hypersensitivity to pain; and that they seek medical attention more often than men, making them more likely to receive opioid prescriptions. "It is important that the issues we have identified are addressed when managing and treating addiction in women," said lead study author Monica Bawor. "Particular attention should be paid to opioid prescribing practices, where careful assessment and consideration of the benefits of opioids compared to the risks is exercised." The study results are published in Biology of Sex Differences.

From "More Than 50 Percent of Women First Come in Contact With Opioids Through Prescriptions"
Forbes (11/10/15) Arlotta, C.J.

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FDA Panel Backs Merck's Sugammadex

Sugammadex, a neuromuscular blockade antidote, has made some progress at the Food and Drug Administration. Although the recommendation is not binding, the agency's Anesthetic and Analgesic Drug Products Advisory Committee has voted to allow the product for the reversal of general anesthesia induced by rocuronium or vecuronium. FDA officials previously have challenged the drug, marketed as Bridion, over the risk of severe allergic reaction; but panel members agreed that Merck & Co. has provided adequate information on the risk of both cardiac dysrhythmias and hypersensitivity/anaphylaxis. With FDA approval, Bridion would be the first of a new class of drugs—called selective relaxant binding agents—to enter the U.S pharmaceutical market. Sugammadex is already available in more than 70 other countries.

From "FDA Panel Backs Merck's Sugammadex"
PharmaTimes (11/08/15)

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Laryngeal Mask for Keratoplasty Anesthesia Safe, Effective

While tracheal intubation is standard practice for general anesthesia (GA) during keratoplasty, it also threatens to increase intraocular pressure and promote coughing during recovery—which in turn could elevate intraocular tension and damage sutures. To gauge the efficacy of laryngeal mask airway (LMA) and supraglottic gel device (i-gel) for keratoplasty anesthesia, a team of French researchers studied 110 patients having ophthalmic surgery. The study participants were divided evenly into two groups, with each half undergoing one of the two processes. The results, published in Cornea, revealed less-frequent coughing during or after extubation in the i-gel cohort compared to the tracheal intubation cohort. Patients who received i-gel also took less time to recover. While patients prone to difficult airway and those at risk for aspiration are contraindicated for LMA, the researchers concluded the technique is safe and "applicable to the majority of patients having keratoplasty under GA."

From "Laryngeal Mask for Keratoplasty Anesthesia Safe, Effective"
Medscape (11/04/15) Barclay, Laurie

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Updated Malignant Hyperthermia Guidelines

While 80 percent of patients who presented with malignant hyperthermia (MH) in the 1970s and 1980s died as a result of the condition, which can be triggered by certain general anesthetics, most patients today survive. Some of the credit for the shift may belong to the European Malignant Hyperthermia Group's (EMHG) screening guidelines that were developed to identify vulnerable populations, including people carrying an autosomal dominant calcium channel mutation. The guidelines, used since 2001 to help thousands of at-risk persons, were updated earlier this year. Previously, EMHG recommended muscle biopsy and an in vitro contracture test (IVCT), followed by mutation screening if the IVCT came back positive. The revised guidelines, published in the British Journal of Anaesthesia, confirm DNA screening as a viable primary diagnostic approach to the IVCT. Additionally, while the older guidelines called for the use of caffeine or halothane to perform the IVCT, they did not distinguish between the two when classifying patients. Per the update, patients now receive separate designations for abnormal response to halothane or caffeine, thus widening the number of diagnostic groups to four.

From "Updated Malignant Hyperthermia Guidelines"
MD Magazine (11/04/2015) Wick, Jeannette Y.

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Hearing Loss From Dural Puncture Not Uncommon, But Is Improved With Epidural Blood Patch

Hearing loss can occur as a result of accidental dural puncture during spinal anesthesia, U.K. researchers report, but applying an epidural blood patch can provide relief. English anesthesiologist Caroline Borkett-Jones, MD, spearheaded a prospective study of 110 patients, 91 of whom believed that dural puncture impaired their hearing. Audio testing and evaluation of the patients one hour prior and 24 hours following epidural blood patch indicated significant improvement after its application, with all participants reporting a return to normal hearing levels within three to seven days. According to Borkett-Jones, the findings imply that hearing loss after accidental dural puncture may occur more often than thought. "Audiometric testing may place a role in the diagnosis and management of this problem in the future," she said. Meanwhile, Canadian anesthesiologist Naveen Eipe, MD, suggested that the research could have implications for women who receive epidurals during labor. "This study not only highlights a rather unknown anesthetic complication, it suggests a simple and effective remedy," according to Eipe.

From "Hearing Loss From Dural Puncture Not Uncommon, But Is Improved With Epidural Blood Patch"
Anesthesiology News (11/01/15) Vol. 41, No. 11 Vlessides, Michael

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Monitoring Tool Identifies Surgery Patients at High Risk for Opioid-Induced Respiratory Depression

A new monitoring tool promises to identify surgical patients with elevated risk for opioid-induced respiratory depression (OIRD), an outcome that is always possible when narcotic painkillers are used during an operation. The risk index tool was developed by clinicians in Michigan after studying the charts of 114 patients who suffered a respiratory emergency that required rescue with naloxone, an opioid antagonist. The team assessed a number of individual and iatrogenic risk factors, ultimately isolating five. According to the researchers, obstructive sleep apnea, renal dysfunction, hepatic dysfunction, upper abdominal surgeries, and being female point to increased risk for OIRD. Patients were categorized as very high risk, high risk, medium risk, or low risk. "We can now look at high-risk and very high-risk patients and monitor them more closely, and not have to look at everyone that closely," remarked lead study author Nicole Humbert, PharmD. "We are looking now how we are getting our risk assessment done in pre-op. This might include more frequent vital sign assessment and pulse oximetry monitoring, and of course looking at changes in opioids." The findings were presented recently at the PAINWeek meeting in Las Vegas.

From "Monitoring Tool Identifies Surgery Patients at High Risk for Opioid-Induced Respiratory Depression"
Pain Medicine News (11/01/2015) Vol. 13, No. 11 Pizzi, Donald M.

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Trends in Prescription Drug Use Among Adults in the United States From 1999-2012

A new survey shows significant increases in prescription drug use and polypharmacy in the United States. Using data from seven cycles of the National Health and Nutrition Examination Survey, researchers looked at data for about 38,000 noninstitutionalized adults from 1999 through 2012. The rate of overall prescription drug use increased from an estimated 51 percent in 1999–2000 to an estimated 59 percent in 2011–2012. Meanwhile, the prevalence of polypharmacy—using five or more prescription drugs—rose from about 8.2 percent to 15 percent during the study period. These increases persisted even after adjusting for age. The researchers report that of the 18 drug classes used by more than 2.5 percent of the population, the prevalence of use rose in 11 drug classes, including antihyperlipidemic agents, antidepressants, and muscle relaxants. Simvastatin was the most commonly used drug in 2011–2012, increasing in use from 2 percent at the beginning of the study to about 8 percent. The researchers say there are a number of possible explanations for the overall increase in prescription drug use—including large-scale policy changes such as the implementation of Medicare Part D, though they note the increase was not only seen among older adults.

From "Trends in Prescription Drug Use Among Adults in the United States From 1999-2012"
Journal of the American Medical Association (11/03/15) Vol. 314, No. 17, P. 1818 Kantor, Elizabeth D.; Rehm, Colin D.; Haas, Jennifer S.; et al.

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Staff Breaks Help Improve Outcomes

After studying data from a large cohort of patients undergoing non-cardiac procedures at Vanderbilt University Medical Center between 2005 and 2014, researchers have determined that staff breaks lead to better surgical outcomes. "We assume that well-rested individuals could be expected to perform better, or perhaps the break gives clinicians an opportunity to reassess what they were doing and how things were going when they left," speculated lead researcher Jonathan Wanderer, MD, who also suggested that experienced anesthesia providers who fill in during breaks may "find some things that are important for patient outcomes." Drexel University's Ashish Sinha, MD, who was not involved in the research, agreed. "I believe the 'fresh look' that colleagues provide when they come into the OR [operating room] helps create an atmosphere for catching inadvertent mistakes," he said. "In the world of anesthesia, problems can happen in the 'cruise control' part of the case ... and the level of vigilance may drop off just a bit. Not surprisingly, many anesthesia errors and negative outcomes occur during the middle of the case, not the beginning or end, as some might believe." The Vanderbilt study was building off a Cleveland Clinic investigation, which drew a correlation between intraoperative handoffs and poorer surgical outcomes. The Tennessee researchers were unable to replicate that finding, however.

From "Staff Breaks Help Improve Outcomes"
Anesthesiology News (11/01/15) Vol. 41, No. 11 Vlessides, Michael

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Constipation Drug Improves Survival in Palliative Cancer Care

A new study led by Jonathan Moss, MD, professor of anesthesia from the University of Chicago, suggests that methylnaltrexone, approved for the treatment of opioid-related constipation, may lengthen survival in people who take opioids for advanced cancer pain. Moss presented the findings at ANESTHESIOLOGY® 2015 in San Diego. There is a growing body of evidence to suggest that the life spans of patients with cancer may be shortened when they take opioids. "Somehow, the opiate receptor seems to be involved in the progression of tumors," he said. Methylnaltrexone blocks the receptor without reducing the analgesic effects. The study, a retrospective analysis of two clinical trials, looked at 229 patients, 117 of whom received methylnaltrexone for opioid-induced constipation and 112 of whom received placebo. Patients with advanced cancer who received opioids lived an average 20 days longer if they received methylnaltrexone compared with placebo. The drug is administered by subcutaneous injection every other day, in doses of 8 mg to 12 mg.

From "Constipation Drug Improves Survival in Palliative Cancer Care"
Medscape (10/27/15) Harrison, L

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Nitrous Oxide Shows Promise in Patients at Risk for Cardiovascular Disease

The results of the ENIGMA-II (Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia) study help "alleviate concerns raised in recent years about the effect of nitrous oxide on the heart and vascular system," reports lead author Kate Leslie, MD. ENIGMA-I had suggested that the gas could elevate the risk of heart attack, but the trial excluded high-risk patients. The new finding that nitrous oxide is, in fact, a safe option for surgery patients with cardiovascular disease or at risk for it is based on outcomes from nearly 6,000 patients meeting those parameters. All underwent non-cardiac surgery under general anesthesia, with half receiving a combination of nitrous oxide, oxygen, and a more powerful anesthetic such as sevoflurane or propofol. The remaining patients were anesthetized with a mix of nitrogen, oxygen, and stronger anesthetic agent. One year later, there was no difference in the rate of heart attack, stroke, disability, or death between the two cohorts. The discovery is "welcome news because nitrous oxide is inexpensive, simple to administer and helps with pain as well as anesthesia," Leslie, reporting in Anesthesiology.

From "Nitrous Oxide Shows Promise in Patients at Risk for Cardiovascular Disease"
News-Medical.net (10/26/2015)

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Study: Pediatric Patients Prescribed More Opioid Medication Than Necessary Following Surgery

Many pediatric patients are prescribed opioids for moderate to severe pain, but they may be prescribed more than they need after surgery. Research presented at the ANESTHESIOLOGY® 2015 annual meeting indicates nearly 60 percent of opioids dispensed to children after surgery went unused. "This is of particular concern, since almost half of the patients studied had adolescent siblings who are at a distinct risk of abusing prescription opioids," said Myron Yaster, MD, professor in the Departments of Anesthesiology and Critical Care Medicine and Pediatrics at Johns Hopkins University School of Medicine. The nonmedical use of prescription opioids is a major gateway to narcotic addiction in adolescents, possibly because of availability and the perception that they are "safer" than street drugs. The researchers examined 292 pediatric patients admitted to Johns Hopkins Hospital for surgery and who were prescribed opioids at discharge. Oxycodone was the most commonly prescribed opioid. The majority of parents did not receive any instruction about what to do or how to properly discard leftover medication.

From "Study: Pediatric Patients Prescribed More Opioid Medication Than Necessary Following Surgery"
News-Medical.Net (10/26/15)

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Update on Multistate Outbreak of Fungal Infections Associated with Contaminated Methylprednisolone Injections, 2012–2014

The Centers for Disease Control and Prevention (CDC) has released a follow-up report to the 2012 multistate outbreak of fungal meningitis and other infections caused by injections of contaminated methylprednisolone acetate solution (MPA). As of Oct. 23, 2013, 751 patients had been reported as infected (though two more were identified retrospectively.) Of these patients, nearly one-third had meningitis only, 20 percent had meningitis and parameningeal infections, 43 percent had parameningeal infections only, and 4 percent had peripheral joint infections. Most patients received antifungal treatment for at least six months after diagnosis. According to the data, by 12 months after the initial diagnosis, 42 percent of patients were considered cured. In addition, 41 percent were no longer receiving treatment but did not yet meet the definition of cured, 7 percent were still receiving treatment, and 8 percent (35 individuals) had died. CDC has received eight reports of relapse of fungal infection after antifungal treatment; the median time to relapse for six of those patients was 90 days. The researchers note that a recent report of relapse occurring 21 months later highlights the need for continued vigilance. "Clinicians and patients should remain watchful for symptoms of infection in patients exposed to contaminated MPA, because fungal infections can develop slowly and are difficult to eradicate," CDC said.

From "Update on Multistate Outbreak of Fungal Infections Associated with Contaminated Methylprednisolone Injections, 2012–2014"
Morbidity and Mortality Weekly Report (10/30/15) Vol. 64, No. 42, P. 1200 McCotter, Orion Z.; Smith, Rachel M.; Westercamp, Mathew; 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.

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November 13, 2015
Earn Your DNAP CME/CE Webcast Intubation is easy until it isn't

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