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Military Veterans and their CRNA Caregivers Honored in USA Today

On November 11, to commemorate Veterans Day and help raise awareness of the VA's all-important proposed rule granting full practice authority to CRNAs and other APRNs, the AANA participated in a special insert titled "Empowering our Veterans" in USA Today's weekend edition. CRNAs were featured prominently in a full-page ad titled “Battle-Tested Anesthesia Care” and a full-page article based on interviews with AANA President Cheryl Nimmo, DNP, MSHSA, CRNA, and Treasurer Randall Moore II, DNP, CRNA, USAR, MAJ(ret), themselves military veterans.

More than 250,000 copies of USA Today included the special insert, reaching more than 750,000 readers in New York City, Los Angeles, the Carolinas, North and Central Florida, Washington, D.C., Baltimore, and Dallas. Additional distribution was through notable USA Today partners such as the Wounded Warrior Project and American Legion. The article and ad also enjoyed a digital presence, which expanded the campaign's reach exponentially.

Be sure to check out the insert and especially the AANA’s two-page spread on the AANA website. Thanks again to all of our military and veteran CRNAs, and to the countless military veterans who have given so much of themselves on behalf of the United States!
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Hot Topics

Membership has its Perks!

As a benefit of AANA membership, CRNAs receive a coupon with an exclusive code that can be used for up to 6 free online courses worth 1 Class A CE credit each at AANA Learn. Members can use this exclusive code up to 6 times during the membership year for courses such as the AANA Journal course. In other words, members can fulfill nearly one-fourth of their 4-year, 100-credit requirement free of charge through AANA Learn.. Note: Coupons are limited to single-CE online courses through AANA Learn. Coupon code can be used up to six times during the membership year for courses like the AANA Journal Course. CPC Core Modules and multiple-CE bearing courses are not included.
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National CRNA Week, January 22-28, 2017

Tell the world who you are during National CRNA Week, Jan. 22-28, 2017. The theme for 2017 is "Safe and Effective CARE for Every Patient" which complements the association's ongoing new motto. In a fresh and innovative way, the theme delivers the message that CRNAs are proud to provide safe and effective anesthesia CARE. Promotional materials for this year’s theme, “Safe and Effective Anesthesia CARE for Every Patient,” are available at CRNA Week. Check out National CRNA Week for downloadable public relations promotional materials such as a fill-in-the-blank proclamation and press releases, promotional art, etc. AANA members can also find a myriad of other public relations and patient education materials at The Future of Anesthesia Care Today and patient education materials at For Patients.
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MACRA Final Rule on the New Quality Payment Program Now Published

The Medicare Access and CHIP Reauthorization Act (MACRA) Final Rule was published by Centers for Medicare & Medicaid Services (CMS) in the Federal Register on Nov. 4, 2016. The 2,000+ page rule describes the new Quality Payment Program that most CRNAs will have to participate in (beginning in 2017) to avoid Medicare reimbursement penalties and possibly earn incentives. To learn more about the new program, visit our updated MACRA FAQ page on the Quality-Reimbursement or visit Quality Resources to read our latest AANA NewsBulletin viewpoint article “Preparing for MACRA—Transitioning From PQRS to MIPS in 2017.”
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November 30—Last Day to Submit an Informal Review Request for 2017 PQRS Payment Adjustments

Individual eligible CRNAs and/or group practices who chose not to participate or did not satisfactorily report for the 2015 program year will automatically receive a -2.0 percent payment adjustment on their 2017 Medicare reimbursement. If you received notification of a 2017 PQRS negative payment adjustment and believe that it was applied to you in error, you can submit an informal review request through Nov. 30, 2016, via a web-based tool on the CMS Quality Reporting Communication Support Page. We also encourage you to access and review your 2015 PQRS feedback report and/or Quality and Resource Use Report prior to submitting an informal review request. To learn more, please visit our PQRS Feedback Reports and Payment Adjustments FAQ page.
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Nominations for 2017 AANA Elections Due December 1

Nominations for AANA elected offices and consent forms from nominees are due in the AANA office by Dec. 1, 2016.

Each state association may submit one nominee for president-elect, vice president, and treasurer. In addition, state associations may submit one nominee for a director from their region. In 2017, directors from Regions 1, 4, and 5 are eligible for election. Finally, state associations may nominate one member from their region for the AANA Nominating Committee and one member for the Resolutions Committee.

Members are also allowed to self-nominate or nominate another member as long as the nominee meets the qualifications for office found in the AANA Bylaws and Standing Rules.

For information regarding the electoral process, please visit AANA Election Center. (Member login and password required.)
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Military Experience Inspires CRNAs to Continue Serving Fellow Veterans in VA

On November 11, the 78th observance of Veterans Day, military, veteran, and civilian CRNAs stood shoulder to shoulder with the veterans they serve, providing safe, high-quality anesthesia care in VA facilities across the country. “We are proud to stand with our veterans, and consider it an honor to care for those who have given so much of themselves on our behalf,” said Cheryl Nimmo, DNP, MSHSA, CRNA, AANA president, and a veteran herself. Read the AANA press release.
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Tangible and Informative: AANA Brochures Meet Patients’ Educational Needs

The digital universe is great for information and communication, but some people still appreciate receiving a tangible item such as a brochure to read, review, and share. Delivered to your patient in person or available for your patient to take from a display rack at the registration/check-out counter, AANA’s patient education brochures are perfect for meeting many patients’ educational needs. Covering a wide range of topics such as preparing for and recovering from anesthesia, anesthesia for labor and delivery, office-based anesthesia, and more, AANA brochures come in packets of 100 and are free of charge save shipping/handling. Recently, the popular “Moderate Sedation” brochure was updated, revised, and renamed “All about Sedation.” To check out the full line of patient education brochures and to order your packets for CRNA Week 2017 (January 22-28), visit the AANA Bookstore. AANA brochures are always popular items during the CRNA Week ordering period, so place your order today!
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Meetings and Workshops

Registration Open for Assembly of School Faculty
Feb. 23-25, Fort Lauderdale

The AANA Assembly of School Faculty is the only forum that brings all nurse anesthesia educational programs together in one place to discuss current educational requirements and how they will define the future of the profession. If you are passionate about nurse anesthesia education, the Assembly of School Faculty is the must-attend meeting of the year.
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Foundation and Research

Proof is Power: AANA Foundation Annual Giving Campaign

The AANA Foundation has kicked off its 2017 Proof is Power Annual Giving campaign. Your tax deductible donation will continue to advance and support nurse anesthesia through research and education. When you receive your letter, phone call, or email requesting your participation, 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.

Learn more about the Foundation's Proof is Power Campaign and make your tax-deductible donation today.

Thank you for your continued support of the CRNA profession!
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Fellowship Application Now Available Online: Deadline is February 1

The fellowship application is now available on the AANA Foundation. The due date for all FY17 fellowship applications is February 1, 2017. Access the application and view the AANA Foundation Research agenda and sample applications.

Questions? Please contact the AANA Foundation at (847) 655-1170 or foundation@aana.com.
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Sponsor a Student for 2017: Deadline is December 1

Scholarship sponsors are an important source of pride and encouragement to nurse anesthesia students. In 2016, 53 students received scholarships totaling $112,000.

Complete the application and email to foundation@aana.com or mail with your tax-deductible donation to the AANA Foundation, Scholarship Sponsor, 222 S. Prospect Ave., Park Ridge, IL 60068. Please note that the minimum donation to sponsor a student is $3,000 per scholarship.

Thank you in advance for impacting the life of a future nurse anesthetist.
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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.

Association of Anesthesia and Surgery During Childhood With Long-Term Academic Performance

While animal investigations have demonstrated neurocognitive setbacks after early-life exposure to anesthesia, the results of a large Swedish trial are reassuring with respect to humans. Researchers at the Karolinska Institute in Stockholm studied the relationship between surgical anesthesia at a young age and academic and cognitive performance in adolescence. All 2.17 million children born nationwide from January 1973 to December 1993 were included in the cohort study—which considered single exposures to anesthesia and surgery by age four years, no exposures, and multiple exposures. Cognitive skills and academic prowess were measured by school grades at 16 years and by IQ test scores for boys at military conscription. Comparing grades of 33,514 children with one anesthesia exposure and 159,619 children with none, researchers documented no difference among children exposed at age six months or younger, at 7–12 months, at 13–24 months, or at 25–36 months—although there was a slight difference of 0.79 percent in academic performance for those who were exposed at ages 37–48 months. Overall, academic marks were 0.41 percent lower and IQ scores were 0.97 percent lower in the exposed group. The disparity—less than the difference attributed to factors such as gender and mother's educational level—was similar when comparing the cohort of 3,460 children with multiple exposures with the controls. Thus, the researchers concluded, exposure to anesthesia and surgery prior to age four years has a negligible effect on academic or cognitive development by the teenage years.

From "Association of Anesthesia and Surgery During Childhood With Long-Term Academic Performance"
JAMA Pediatrics (11/07/2016) Glatz, Pia; Sandin, Rolf H.; Pedersen, Nancy L.; et al.

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Pediatric Post-op Nausea Identified With the BARF Scale

Researchers at Baylor College of Medicine in Houston believe use of the Baxter Retching Faces (BARF) scale can help clinicians better recognize and treat postoperative nausea and vomiting in pediatric patients. Their study centered around 327 children undergoing general anesthesia, all of whom received prophylactic antiemetics. Patients rated the severity of their symptoms before and after the procedure using the BARF scale, visual analog scale, and Likert scale. The results indicated that nausea scores spiked from preoperative values in nearly 35 percent of the study population, and 4.3 percent of patients suffered emesis while in the post-anesthesia care unit (PACU). Yet rescue antiemetics were administered to just 2.8 percent of the children. Diaries kept by 220 of the study participants also indicated that post-discharge nausea affected nearly 31 percent. "In summary, we found that this BARF scale is easy and feasible to use in children ages 5 years and older," said lead study author and Baylor associate anesthesiology professor Mehernoor Watcha, MD. "Equally important, we've demonstrated that children have nausea in the PACU, but for some reason, they're not being treated. We've also demonstrated that the nausea is not just limited to the OR [operating room] and PACU; it also occurs following discharge." He presented the findings at the 2016 annual meeting of the International Anesthesia Research Society.

From "Pediatric Post-op Nausea Identified With the BARF Scale"
Anesthesiology News (11/09/16) Vlessides, Michael

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Ketofol an Alternative Deep Sedative for Emergency Departments

A large study out of Australia has identified an alternative deep sedative appropriate for use in the emergency department (ED). Ketofol, a combination of propofol and ketamine, was shown to be equally effective as propofol alone in this setting. Anthony Bell, MD, co-lead on the trial, said EDs have tended to shy away from the approach because of concerns about adverse psychological reactions. The new findings, however, showed that study participants randomized to receive ketofol experienced similar outcomes as those who received propofol. The research "will give us more sedation options in the future," Bell remarked, "especially considering the pain relieving properties of ketamine, which may reduce the need for other opiate type medications." The trial, conducted at three Australian hospitals, was reported in the Annals of Emergency Medicine.

From "Ketofol an Alternative Deep Sedative for Emergency Departments"
EurekAlert (11/08/16)

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Researchers Find That Even Mild Pulmonary Complications After Surgery Can Pose Major Risks

New study results reveal that even mild postoperative pulmonary complications (PPCs) present grave risks for surgical patients. PPCs can stem from too-big breaths under anesthesia or giving patients too many fluids, for example, but they are often downplayed as mild. Research published online in JAMA Surgery, however, suggests that even common problems like partial lung collapse and requiring prolonged supplemental oxygen create significantly greater odds of poor outcomes. The multi-site study involved 1,202 patients who had surgery with mechanical ventilation and general anesthesia for two hours or longer. One-third experienced at least one PPC, usually not severe. "We found that patients with one or more PPCs, even mild, had significantly increased intensive care unit admission, ICU/hospital length of stay and early postoperative mortality," reports lead co-author Ana Fernandez-Bustamante, MD, PhD, a University of Colorado associate anesthesiology professor. She and fellow researchers at seven other institutions believe that preventing mild PPCs could improve the recovery of thousands of patients.

From "Researchers Find That Even Mild Pulmonary Complications After Surgery Can Pose Major Risks"
Medicalxpress (11/09/2016)

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New Guidance Issued for Sedating Pediatric Patients With Heart Disease

Experts from three professional associations worked together to draft new recommendations for protecting pediatric patients with congenital heart disease during surgery. The guidance—a joint effort by the Society for Cardiovascular Angiography and Interventions, Society for Pediatric Anesthesia, and Congenital Cardiac Anesthesia Society—is intended to support doctors and hospital administrators when diagnosing and treating kids in the catheterization laboratory. In addition to adverse events like post-operative nausea and vomiting, children who undergo surgery face a higher risk of anesthesia-related problems like airway obstruction and cardiovascular complications such as arrhythmias and cardiac arrest. The threat of cardiac arrest, especially, is elevated among young patients with congenital heart disease. With these risks in mind, the consensus statement offers guidelines for patient monitoring before, after, and during the operation—regardless of what approach to anesthesia is taken. A paper detailing the recommendations appears in Catheterization and Cardiovascular Interventions.

From "New Guidance Issued for Sedating Pediatric Patients With Heart Disease"
DOTmed.com (11/08/16) Nelson, Lee

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Topical Analgesics Result in Decreased Use of Other Pain Medications

Researchers have discovered that alleviating chronic pain with topical analgesics curtails the need for opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and other treatments. As part of the ongoing OPERA (Optimizing Patient Experience and Response to Topical Analgesics) study, they theorized that the approach—as opposed to oral medications—might minimize adverse events, lower pain severity scores, and enhance quality of life. The 631 adult participants, most already taking over-the-counter (OTC) medications or prescription drugs for pain, were started on a regimen of topical analgesics. After three months of taking diclofenac, gabapentin, bupivacaine, or similar agent, NSAID consumption decreased 64.1 percent, use of OTC analgesics fell 51.4 percent, and prescription opioid usage declined 27.5 percent. In addition, pain scores were markedly lower. NSAID, OTC analgesic, and opioid use decreased even more for those on topical therapy for at least five months. Satisfaction was high overall, with zero adverse events reported by 99.5 percent of participants. "With the extremely low rates of adverse events associated with topical analgesics used in this study, clinicians should consider these agents for patients with pain syndromes amenable to topical therapies," advised lead researcher Jeff Gudin, MD. "We are not sure, but would think it reasonable that there is some systemic absorption and efficacy based on these interim results." The findings were presented at PAINWeek 2016.

From "Topical Analgesics Result in Decreased Use of Other Pain Medications"
Pain Medicine News (11/07/2016) Kronemyer, Bob

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Adding Music to Pain Meds May Reduce Pain

Research suggests that music, when paired with drugs or other conventional treatments, can moderate acute and chronic pain. Jin Hyung Lee of Ewha Womans University in South Korea, reviewed 97 randomized controlled trials involving music therapy or music medicine. The studies—conducted over the last 20 years or so—assessed the impact of music on outcomes like vital signs, pain levels, and amount of pain medication consumed. Many of the investigations reported lower heart rate, blood pressure, and respiration rate among patients in music-exposed cohorts. Moreover, although the results were inconsistent from study to study, Lee found that enrollees who received music intervention generally scored their pain intensity about a point lower on a scale of 0 to 10 after music sessions compared to controls. Writing in the Journal of Music Therapy, Lee noted the strategy appeared to reduce use of anesthetics as well as opioid and non-opioid pain medications—although sedative use was unaffected. According to Lee, the soothing nature of music distracts attention away from pain receptors and stimulates other senses, thus relieving stress and anxiety.

From "Adding Music to Pain Meds May Reduce Pain"
Reuters (11/04/16) Doyle, Kathryn

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Laparoscopic Total Extraperitoneal Repair Under Spinal Anesthesia Versus General Anesthesia

A Turkish study compared surgical outcomes in patients undergoing laparoscopic total extraperitoneal (TEP) inguinal hernia repair under spinal anesthesia compared with general anesthesia. A total of 50 participants were randomly assigned to receive spinal anesthesia with hyperbaric bupivacaine and fentanyl or general anesthesia with propofol, fentanyl, rocuronium, sevoflurane, and tracheal intubation. Spinal anesthesia proved to be safe and effective, with similar surgery times, complication rates, recovery, and length of hospital stay as procedures done under general anesthesia. Moreover, spinal anesthesia resulted in lower pain scores and higher patient satisfaction.

From "Laparoscopic Total Extraperitoneal Repair Under Spinal Anesthesia Versus General Anesthesia"
Therapeutics and Clinical Risk Management (10/27/16) Donmez, Turgut; Erdem, Vuslat Muslu; Sunamak, Oguzhan; et al.

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Effect of Conscious Sedation vs. General Anesthesia on Early Neurological Improvement Among Patients With Ischemic Stroke

The Sedation vs Intubation for Endovascular Stroke Treatment (SIESTA) clinical trial compared neurological recovery in thrombectomy patients based on sedation approach. The study, conducted at Germany's Heidelberg University Hospital, involved 150 patients with acute ischemic stroke in the anterior circulation. Each participant was randomized to receive either general anesthesia with intubation or conscious sedation without intubation while undergoing thrombectomy. Early neurological improvement between the two groups was comparable 24 hours post-procedure, as indicated by similar score changes on the National Institutes of Health Stroke Scale. There also was no meaningful difference between the two sets of patients for 41 out of 47 secondary endpoints. The findings do not support the use of conscious sedation over general anesthesia in this setting.

From "Effect of Conscious Sedation vs. General Anesthesia on Early Neurological Improvement Among Patients With Ischemic Stroke"
Journal of the American Medical Association (10/26/16) Schönenberger, Silvia; Uhlmann, Lorenz; Hacke, Werner; et al.

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Women More Likely to Convert From Laughing Gas to Epidural for Pain Relief During Labor

Despite its growing popularity as a pain-relief option during labor, new research finds that most expecting mothers who receive nitrous oxide end up requesting an epidural. In the single-site study, investigators reviewed the medical records of nearly 4,700 patients who had vaginal births between September 2014 and September 2015. Only 148 of them decided on laughing gas to alleviate labor pains; but, on average, pain scores varied little after inhaling it. In the end, 60 percent of moms-to-be asked to switch to an epidural. "While nitrous oxide may be somewhat helpful, epidural anesthesia remains the most effective method for managing labor pain," according to the study, which was led by Stanford University's Caitlin Sutton, MD. "Future studies are needed to further determine which women in labor would most benefit from nitrous oxide." The research was presented at the ANESTHESIOLOGY 2016 annual meeting.

From "Women More Likely to Convert From Laughing Gas to Epidural for Pain Relief During Labor"
News-Medical.net (10/24/2016)

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Study Reviews Alternatives to Anesthesia for Pediatric MRI Exams

Research points to several options for keeping children still during MRI besides sedation or general anesthesia, which present a risk for respiratory depression and other complications. After reviewing two dozen relevant studies, Delaney McGuirt of the University of North Carolina Biomedical Research Imaging Center singled out eight effective alternatives. Most notably, she determined that practicing the procedure with the patient in a simulated environment is highly effective for kids between the ages of three and eight years. Allowing the use of magnetic resonance-safe headphones and goggles to view movies during the test, meanwhile, works well with children aged three to 10; and performing MRI at night during the normal sleep cycle provides successful results for pediatric patients up to age four. McGuirt suggested that hospitals use her paper, published in Radiologic Technology, as a reference for alternatives to sedation. "I think there's enough evidence that they do work and they can be implemented just from reading the review," she said.

From "Study Reviews Alternatives to Anesthesia for Pediatric MRI Exams"
DOTmed.com (10/24/16) Chamoff, Lisa

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Public Health Insurance May Be a Predictor of Pain in Post-Anesthesia Care Unit

How much pain surgical patients endure while recovering in the post-anesthesia care unit (PACU) hinges in part on what kind of insurance they have, a new study finds. A team from Boston Children's Hospital assessed more than 200 adult and pediatric patients after surgery to remove their tonsils and/or adenoids. "Our goal," according to lead researcher Nissa Askins, MPH, "was to see if any patient characteristic or factor affected our patients' experience during a short-term, single instance of anesthesia care." The investigation determined that participants who carried public insurance were in more pain during their time in the PACU than patients with private coverage. Although Latino and African-American patients were more likely than white patients to have public insurance, the researchers noted that the predictor applied regardless of race, gender, age, overall health, income, or differences in care such as perioperative opioid dose. The findings were presented at the ANESTHESIOLOGY 2016 annual meeting.

From "Public Health Insurance May Be a Predictor of Pain in Post-Anesthesia Care Unit"
Medical Xpress (10/24/16)

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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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