Anesthesia E-ssential

AANA Anesthesia E-ssential, October 10, 2019

Vital Signs

Executive Order: Protect and Promote Nursing's Role in Providing Care for Patients

President Trump's Executive Order sets out to protect and improve Medicare for those who currently, and will in the future, benefit from its services. Section 5 of the executive order offers, among other things, that within one year, the Secretary of Health and Human Services would "propose a regulation that would eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions, and all other licensure requirements of the Medicare program that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their profession".

Both CRNAs/APRNs/nurses and physicians have launched petitions - nurses in favor of the changes the executive order lays out; physicians against those changes. SIGN THE NURSING PETITION NOW - the physician petition response is outnumbering the nursing petition response by more than 3:1.

Nursing is the most trusted profession in America, for 17 consecutive years, according to the annual Gallup poll. We are the backbone of healthcare. We help keeps costs down, we provide access to care, and we ensure safe, quality and cost-effective care across this country. #WeAreTheAnswer! Support the removal of "additional federal red tape" and giving "the power back to the American people." Sign now!
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Thought Leaders on Nurse Anesthesia Education Present Keynote Addresses in China

The Fifth Sino-U.S. Nursing Forum was held at the Pine City Hotel Conference Annex in Shanghai, China, on September 27-28, 2019. The forum was focused on international collaboration and partnership within nursing and created opportunities for exchanging and sharing global nursing information and innovation.

Three U.S.-based CRNA thought leaders were invited to present keynote addresses at the conference. Bruce Schoneboom, PhD, MHS, CRNA, FAAN, Johns Hopkins School of Nursing, presented on the Health and Human Services' Pain Management Best Practices Inter-Agency Task Force report. Dru Riddle, PhD, DNP, CRNA, FAAN, Texas Christian University, presented ‘Evidence Overload and Impact on Patient Care’. John M. O’Donnell, DrPH, CRNA, CHSE, FSSH, University of Pittsburgh, presented on ‘Interprofessional Education: A Global Challenge’ as part of a Dean’s Panel focused on Multidisciplinary Global Collaboration. Their participation also highlighted the important role that CRNAs play in delivery of anesthesia care in the United States; a role that currently does not exist in China.

Keynote CRNA Speakers in China

The scientific presentations included talks on:
  • Geriatric care
  • Critical care
  • Nursing informatics
  • Leadership
  • Evidence-based practice
  • Translational science
  • Knowledge transfer
  • Pain management
  • The opioid crisis
  • Pediatric care
  • Multidisciplinary collaboration
  • Interprofessional education and knowledge transfer.
The opening keynote speaker for the conference was Dr. Eileen Sullivan-Marx from New York University. The meeting was hosted by Fudan University and Co-sponsored by other prominent Chinese Schools including School of Nursing Peking University, School of Nursing Peking Union Medical College, School of Nursing Central South University, School of Nursing SunYat-Sen University, School of Nursing Xi’an Jiaotong University, School of Nursing Sichuan University, School of Nursing China Medical University. The forum was also supported by the Shanghai Nurses Association. US Co-Sponsors included: University of Pittsburgh School of Nursing, New York University College of Nursing, Duke University School of Nursing, Johns Hopkins University School of Nursing and University of California at San Francisco School of Nursing.
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Hot Topics

USP Delays Revised USP 797 Official Date Until Further Notice

The United States Pharmacopeia (USP) has postponed the official date of the latest version of USP 797 – Pharmaceutical Compounding – Sterile Preparations because it is considering appeals of the revised standards. On June 1, 2019, USP published the revised standards that are currently under appeal. While those revised standards called for an official date of December 1, 2019, that date is no longer effective. There is no fixed date for when the revised USP 797 will be official. USP bylaws require postponing the official date while an appeal is pending. In the interim, the current USP 797 (last revised in 2008) is official.

It is important to note that USP plays no role in enforcement of its standards. It is up to state and other regulators, facilities through policy, and accreditors to determine whether and how they will follow USP 797 standards. Read the USP announcement.
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Update on CRNAs and Medication-Assisted Treatment for Opioid Use Disorder

The SAMHSA waiver application is now open for CRNAs to apply to prescribe buprenorphine within medication-assisted treatment (MAT) for opioid use disorder in states where CRNAs have prescriptive authority. See more information: Once you’re prescribing MAT, please email with feedback on your experience and practice setting. Thank you!
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Looking to Pick Up Work Outside of Your Full-time Position?

AANA Insurance Services has malpractice insurance coverage for that! Visit our Policy Options page to learn more about our short term coverage options, including daily, weekly, monthly, and moonlighting coverages. Learn more.
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Employers – When You Get Compensation Right, You Attract and Retain the Best CRNA Talent

How are your benefits and compensation packages stacking up against other programs and facilities? With the official 2019 Compensation and Benefits Report, review salary and benefit trends across the U.S., so you can remain competitive and compensate your staff fairly:
  • Review compensation by location, years in practice, and employment status.
  • Compare benefits by region and employment arrangements.
  • Evaluate time-off and retirement benefits.
  • And more!
AANA members receive 50% off! Order your copy of the report today!
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Call for Abstracts: Share Your Professional Knowledge by Presenting at AANA 2020 Annual Congress in San Diego

AANA Members are invited to submit an abstract for consideration to present at the AANA 2020 Annual Congress, in sunny San Diego, Calif., the biggest event in nurse anesthesia. Present your topics to thousands of CRNAs and SRNAs from all over the nation - from various practice settings and levels of leadership.

For more information on how to submit an abstract, abstract submission guidelines and a template of the grading rubric, please visit the abstract page. Abstract submissions will close on Thursday, October 17, 2019, at 11:59 p.m. CST. 
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Meetings and Workshops

Spinal Epidural with Obstetric Essentials Workshop

When: October 24-26, 2019
Location: AANA National Headquarters, Park Ridge, Ill.

Presentations include:
  • Normal and abnormal physiology of pregnancy.
  • Pharmacology.
  • Analgesia/anesthesia techniques.
  • Formal presentations.
  • Clinical applications of spinal and epidural anesthesia procedures.
  • Introduction to the application of ultrasound using live models.
View Workshop Program.
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Leadership Summit: Empower the Leader Within

When: November 8-10, 2019
Location: Naples Grande Beach Resort, Naples, Fla.

The AANA Leadership Summit is designed to meet the needs of all CRNAs — state association leaders, chief CRNAs and administrators, practice owners and managers, facility leaders, and aspiring leaders. This educational event will include an afternoon of tracks focused on federal political directors, practice and facility leadership (including state reimbursement specialists), president-elect and government relations. Of course, as with all AANA activities, students are welcome and encouraged to join the learning.

View Details.
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ADCE 2020: Wine, Spa Treatments, and the Latest in Nurse Anesthesia Education

When: February 19-22, 2020
Location: Château Élan Winery and Resort, Braselton, Ga.

Mark your calendar to join us next year in Braselton, Ga., at the Château Élan Winery & Resort, February 19-22, 2020. Château Élan Winery & Resort is located approximately 45 minutes from the Hartsfield-Jackson Airport. Transportation will be provided for AANA attendees, from the airport to the resort.

Save the Date.
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Mid-Year Assembly 2020: Advocate for Your Profession on Capitol Hill

When: April 18-22, 2020
Location: Renaissance Washington D.C. Downtown, Washington, D.C.

The Mid-Year Assembly is the most important nurse anesthesia advocacy meeting. Join us on Capitol Hill as we gather, rally, and impress the importance of nurse anesthesia on our legislators.

Save the Date

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AANA Member Benefits

New Course Available on AANA Learn: Integrating Multimodal Pain Management Techniques into My Practice

The course–Integrating Multimodal Pain Management Techniques into My Practice– is now live on AANA Learn. This is the recording of the second webinar in the Enhanced Recovery Webinar series sponsored by Pacira. You can find this course in the New!, Member Exclusives, Pain Management, and All Courses categories. This course is a Member Exclusive, so it is free to members, and it is worth 1 Class A credit and 1 Pharm credit.

The course fees are as follows:
  • Members: $0.00
  • Associate Members (students): $0.00
  • Non-Members: $50
Learn more.
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CRNA: Envision Physician Services, Lake Havasu, Arizona

Envision Physician Services has a full-time CRNA opportunity in our collaborative and well respected Care Team at Havasu Regional Medical Center in Lake Havasu City, Arizona. Live and work in a very desirable location of beautiful Arizona and experience 300 days of sunshine per year! Learn more about the opportunity, why CRNAs choose us, and all of the wonderful benefits of becoming a part of the Envision Physician services family.

Opportunity Highlights:
  • $10K Start Date Bonus!
  • This position includes a relocation allowance of up to $10K!
  • Competitive compensation and robust benefits starting day 1.
  • Anesthesia Care team is comprised of 8 CRNAs and 6 physicians.
  • Practice a wide variety of cases including regional blocks, epidurals, spinals, ortho, GI.
  • This practice covers 6 ORs, L&D, 1 Cardiac OR, and a 2 room ASC.
  • Reasonable schedule and call; if you are seeking a work/life balance, this is your opportunity!
  • CRNAs have a wide range of autonomy and are well respected.
Envision Physician Services offers a competitive compensation and benefits plan, bonus structure, CME, generous time off, 401K, relocation assistance, and paid malpractice with tail coverage. Learn more.
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Senior OR Nurse Anesthetist: University of California-Irvine, Orange, California

The Department of Anesthesia and Perioperative Care at the University of California-Irvine is seeking qualified CRNAs to join our team. We are located in beautiful and sunny Southern California. The CRNA team of over 35 CRNAs is an integral part of the perioperative care at UCI. With an anesthesia care team model, our CRNAs work collaboratively with our faculty anesthesiologist and physician residents in a positive culture to provide excellent quality clinical care for our patients. We are committed to the department’s core values of integrity, dedication and inclusivity. We strive to provide a rewarding working environment with flexibility, open communication, and work life balance.

We offer a wide variety of cases and locations to practice including the main OR, outpatient surgery, GI, IR, cath lab, and OB. Candidate will do general anesthesia, MAC, TIVA, epidurals, spinals, central and arterial lines, and ultrasound training. We are currently offering variable shifts. No Call and No major holidays! Come share in our positive and professional environment in one of the most beautiful places in our country to live! Learn more.
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CRNA: CHRISTUS St. Vincent Health System, Santa Fe, New Mexico

Our CRNAs work in a collaborative team environment with 18 CRNAs, 7 Anesthesiologists and 2 Anesthesia Techs. Primarily adult population, well-rounded case mix with no transplants and no hearts, a lot of autonomy with excellent support from care team.
  • Deliver anesthetics across 8 Main ORs, 6 Ambulatory surgery ORs, plus OB, GI, IR, and Cath Lab – all without major travel between facilities.
  • Newest technology available with state of the art equipment and Epic health record.
  • Hospital employed; competitive salary and benefits package.
  • Bonus of up to $40,000 for first three years of employment plus ongoing bonus opportunities.
  • Flexible scheduling.
  • Reimbursement for continuing education with educational leave time.
  • Paid occurrence-based malpractice and reimbursement for licensure and membership dues.
  • Relocation assistance.
Learn more.
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Certified Registered Nurse Anesthetist: UPMC Pinnacle, Harrisburg, Pennsylvania

Join UPMC Pinnacle — a growing, multisite health system with seven acute care hospitals — as a Certified Registered Nurse Anesthetist, an essential member of the UPMC Pinnacle healthcare team who is responsible for assessing, planning, implementing, evaluating, and coordinating the total anesthesia care of patients. Through collaboration with all members of the anesthesia care team, the nurse anesthetist diagnoses and treats the human response of the patient and family to the anesthesia process, continuously monitoring, analyzing, and improving the performance of clinical activities. The nurse anesthetist is self-directed, empowered, and accountable for the direct supervision of all team members delivering care to assigned patients.

Multiple opportunities are available including UPMC Pinnacle Harrisburg, Community Osteopathic, and West Shore hospitals.

CRNAs practice includes various case types including General, Pediatric, Vascular, ENT, GI, GU, GYN, EP, Robotics, Thoracic, Orthopaedics, OB, Transplant, and IR. Learn more.
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Ongoing CRNA Locums Opportunities: Alumni Healthcare Staffing, Illinois

Alumni Healthcare Staffing is working with a client searching for CRNA providers to assist with Ongoing Locum Tenens coverage. Please see below for details:
  • Monday-Friday (40 hrs guaranteed)
    • Weeknight and Weekend call
  • Combo Shifts - 8's, 10's, or 12's
  • Bread and Butter Cases
    • Must be comfortable with Regional Anesthesia
  • Level ll Trauma Center
  • 150 Bed Hospital
  • Weekly Direct Deposit
  • Coordinated and Paid Travel Service
  • Reliable and Responsive Consultant Service Available 24/7
  • Active and Unrestricted IL License
Learn more.
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CRNACareers - Exclusive AANA Member Job Board, connecting CRNAs with the top employers in the U.S.

  • Search and apply to locum tenens or permanent positions at industry-leading facilities.
  • Upload your resume anonymously and allow employers to contact you.
  • Set up job alerts to receive notifications on new openings.
  • Access free career resources to assist with resume and interview preparation.

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.

Association of General Anesthesia vs. Procedural Sedation with Functional Outcome Among Patients with Acute Ischemic Stroke Undergoing Thrombectomy

Because general anesthesia during stroke thrombectomy has been linked to unfavorable neurological outcomes, researchers wondered if procedural sedation is a better choice. They combed MEDLINE, going back about 40 years, for randomized clinical trials (RCTs) that compared the two techniques in this setting. The search produced three English-language RCTs populated by adults with anterior circulation acute ischemic stroke and a National Institutes of Health Stroke Scale score of 10 or greater. There were 368 participants in all—183 who underwent thrombectomy with general anesthesia and 185 who received procedural sedation. After analyzing data for the individual patients, the review authors found that functional disability was worse in the stroke population who received procedural sedation. Modified Rankin Scale scores—which measure the extent of disability, with lower numbers equating to less disability—averaged 2.8 for the general anesthesia group at three-month follow-up versus mean scores of 3.2 in the procedural sedation group. The investigators advise caution when interpreting the results, however, given the single-site design of the individual trials and the fact that only one specified disability as the main endpoint.

From "Association of General Anesthesia vs. Procedural Sedation with Functional Outcome Among Patients with Acute Ischemic Stroke Undergoing Thrombectomy"
Journal of the American Medical Association (10/01/19) Vol. 322, No. 13, P. 1283 Schönenberger, Silvia; Löwhagen Hendén, Pia; Simonsen, Claus Z.; et al.

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Transversus Abdominis Plane Block May Improve Opioid Use, Pain After Cesarean Section

Based on the findings of a retrospective review, transversus abdominis plane (TAP) block may provide clinical benefits after cesarean section, when paired with intrathecal morphine administration. The single-site study included 142 patients who had C-section, 43 of whom received TAP block to alleviate postoperative pain. The time until first opioid use after discharge from the operating room was 23.3 hours among the women who received TAP block versus just 12.1 hours for those who did not. Secondary outcomes—including postoperative pain scores and overall opioid consumption in the first 24 hours following surgery—also favored TAP over no TAP. The researchers reported their results in Regional Anesthesia and Pain Medicine.

From "Transversus Abdominis Plane Block May Improve Opioid Use, Pain After Cesarean Section"
Clinical Pain Advisor (10/02/19) May, Brandon

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No Association Between Induction Method and Perioperative Respiratory Adverse Events in Overweight Children

Contrary to earlier findings, researchers report no correlation between anesthesia induction technique and serious respiratory complications in overweight children with sleep-disordered breathing (SDB). This patient population is at risk for perioperative respiratory adverse events (PRAEs), including laryngospasm and bronchospasm. To determine if inhalational or intravenous induction is superior to the other in terms of these outcomes, the team retrospectively analyzed data from 2,110 children who matched the patient profile and underwent procedures requiring general anesthesia between 2007 and 2014. While younger age, bronchial asthma, and prolonged duration of surgery were identified as independent predictors of severe PRAEs, type of induction was not. "On univariate analysis, inhalational induction appeared to be advantageous," said Olubukola Olugbenga Nafiu, MD, of University of Michigan Hospitals-Michigan Medicine. "However, once patients were stratified into age groups, the induction technique was no longer a significant factor." The finding refutes prior research indicating that PRAEs were more common in children undergoing inhalation induction versus I.V. induction, suggesting a need for additional research. Nafiu presented the study results at the 2019 annual meeting of the Society for Pediatric Anesthesiology/American Academy of Pediatrics.

From "No Association Between Induction Method and Perioperative Respiratory Adverse Events in Overweight Children"
Anesthesiology News (10/02/19) Covey, Ethan

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Assessment of Common Criteria for Awake Extubation in Infants and Young Children

A study out of Wake Forest School of Medicine identifies the best predictors of extubation readiness in children after general anesthesia emergence. This period is a known critical juncture for pediatric surgery patients, when their vulnerability to complications is high. With this information in mind, the researchers worked with 600 children between the ages of 0 and 7 years old who underwent awake extubation after exposure to and emergence from general anesthesia with a volatile anesthetic. They took note during extubation of nine different patient markers, including oxygen saturation and movement other than coughing. Successful extubation, as defined by a standard set of criteria, was achieved in 92.7 percent of the cases—particularly those where facial grimaces, purposeful movement, conjugate gaze, eye opening, and tidal volume greater than 5 ml/kg occurred. In fact, the odds of successful extubation steadily improves as the number of these features increases.

From "Assessment of Common Criteria for Awake Extubation in Infants and Young Children"
Anesthesiology (Fall 2019) Vol. 131, No. 10, P. 801 Templeton, T. Wesley; Goenaga-Día, Eduardo J.; Downard, Martina G.; et al.

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Perioperative Dextrose Infusion and Postoperative Nausea and Vomiting

Researchers consulted the literature for evidence that intravenous dextrose infusions provide prophylaxis against postoperative nausea and vomiting (PONV). Their meta-analysis included 10 randomized controlled trials with nearly 1,000 participants in all. Among 465 patients who received intraoperative or postoperative dextrose infusion and 522 patients who did not, the incidence of PONV—both in the post-anesthesia care unit and within the first 24 hours postoperatively—was not significantly different. Postoperative antiemetic administration and serum glucose level, meanwhile, were specified as secondary outcomes. I.V. dextrose administration proved to markedly lower the former but raise the latter. Therefore, if clinicians do choose this approach, they are advised to also utilize plasma glucose monitoring.

From "Perioperative Dextrose Infusion and Postoperative Nausea and Vomiting"
Anesthesia & Analgesia (10/19) Vol. 129, No. 4, P. 943 Zorrilla-Vaca, Andres; Marmolejo-Posso, Diana; Stone, Alexander; et al.

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Does Programmed Intermittent Epidural Bolus Improve Childbirth Conditions of Nulliparous Women Compared with Patient-Controlled Epidural Analgesia?

Because epidural analgesia can affect childbirth, researchers investigated the effect on second-stage labor in women given programmed intermittent epidural boluses (PIEB) versus patient-controlled analgesia (PCA). The study took place at multiple sites in Paris and analyzed results from 249 nulliparous patients in spontaneous labor. All participants received epidural initiation with levobupivacaine containing sufentanil, with some receiving an hourly bolus of PIEB and others receiving a continuous rate infusion of PCA. The primary endpoint was a composite of objective labor events, including prolonged maternal active pushing and posterior occiput position in the second stage of labor. The results were not materially different between the two treatment arms for the main outcome, nor for the secondary endpoints of vaginal instrumental delivery rates and degree of motor blockade. However, analgesic conditions—another secondary outcome—were better with PIEB, especially at full dilation, even though those patients received the same volume of medication as the PCA group.

From "Does Programmed Intermittent Epidural Bolus Improve Childbirth Conditions of Nulliparous Women Compared with Patient-Controlled Epidural Analgesia?"
European Journal of Anaesthesiology (10/01/2019) Vol. 36, No. 10, P. 755 Morau, Estelle; Jaillet, Malaury; Storme, Brigette; et al.

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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
October 10, 2019