Anesthesia E-ssential

AANA Anesthesia E-ssential
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2016 Annual QRUR Webcast-October 19

The Centers for Medicare & Medicaid Services (CMS) has made the 2016 Annual Quality and Resource Use Reports (QRURs) available to all group practices and solo practitioners nationwide. This upcoming webcast provides an overview of the report and explains how to interpret and use the information. 2016 Annual QRURs show how groups and solo practitioners performed in 2016 on the quality and cost measures used to calculate the 2018 Value-Based Payment Modifier (Value Modifier) and how the Value Modifier will be applied to payments for physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. Learn more on the 2016 QRUR and 2018 Value Modifier webpage. This event will be more meaningful if you have your report in front of you to follow along. Visit How to Obtain a QRUR to access your report prior to the event.  Register for this Medicare webcast today!
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Hot Topics

October 2017 AANA Journal Highlights

Read on for highlights of the October 2017 issue of AANA Journal
Wellness and Thriving in a Student Registered Nurse Anesthetist Population
The authors reported on their study of students’ perceptions of wellness (a program construct the AANA has actively promoted for years now) and their general performance in the academic and training rigors they encounter.  Some of their findings correlate as expected, but readers may find quite interesting some outcomes that may not match up with preconceived notions.  
Development of an Online, Evidence-Based CRNA Preceptor Training Tutorial (CPiTT): A Quality Improvement Project
This article describes an online tutorial approach for better preparing clinical preceptors for the task they find themselves responsible for. The evidence-based approach described will be of great interest to CRNAs who would prefer to have a bit more direction and rationale for how they go about their day when assigned to a student.
Refractory Hypotension in a Patient With a History of Anabolic Steroid Abuse Taking an Angiotensin-II Receptor Blocker: A Case Report
The authors report on the challenging management of a patient taking an angiotensin-II receptor blocker who is a chronic user of anabolic steroids. Refractory hypotension manifested during the patient’s care and the authors’ approach to managing the patient provides valuable information for clinicians.
Norwegian Nurse Anesthetist Perceptions of Professional Development and the Influence of Production Pressure
Norway provides the reader with an intriguing perspective from a cultural, societal, and training domain that is different from what most of us know. Professional development as a construct may vary from one social/cultural locale to another. Readers will find this Scandinavian perspective illuminating and provocative.
Addition of Fentanyl to Ropivacaine Infusion in Continuous Thoracic Paravertebral Infusion Does Not Improve Its Analgesic Effect Following Modified Radical Mastectomy: A Randomized Controlled Trial
The authors, in a randomized controlled trial, examined the use of fentanyl added to a paravertebral infusion in patients undergoing modified radical mastectomy. Readers may be surprised by the findings here, but the importance of clinical research with ostensibly negative findings will be appreciated.
Inadvertent Massive Overdose of Lidocaine in an Infant with Arthrogryposis Multiplex Congenita Treated Successfully with Lipid Emulsion
The article describes a case where an infant’s life-threatening exposure to an excessive dose of lidocaine was successfully managed. Part of the management included use of 10% lipid emulsion that may have proved essential in achieving a successful outcome.
The Future of Certified Registered Nurse Anesthetist Practice in South Korea: Fading Into the Sunset or Breaking of a New Dawn?
A scholarly perspective on the role (and future) of CRNAs practicing in South Korea is provided. Many readers may not be aware of the use of nurse anesthetists in this country and will find the reading valuable in gaining insight not only on the practice there, but on our own domestic practice as well.
Ketamine as Part of a Multimodal Approach to Postoperative  Pain Management
A growing body of literature explores what appears to be the ever-expanding role of ketamine in the perioperative period. The focus here is on its use in modifying postoperative pain as the authors explore its use as one component in a multimodal approach.  
Anesthesia Medicare Trend Analysis Shows Increased Utilization of CRNA services
The researcher authors, using the Medicare Part B National Summary Data File, examine anesthesia workforce contributions to cost. Readers will likely not be surprised by how CRNAs fit into the economic equation and will find the results buoying to our collective professional future.
AANA Journal Course: Update for Nurse Anesthetists – Part 4 –
An Overview of Anesthetic Management for the Brain-Dead Donor and Organ Recovery 
In this timely and important article, the author describes key management tenets associated with organ and tissue harvesting from a brain-dead donor. The importance of multidisciplinary involvement and targeted interventions in optimizing outcome (i.e., successful transplantation to a recipient) will greatly benefit providers who are involved in such procedures.
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Your Membership Matters: Renew Today!

Support your profession, your state and national associations, and fellow CRNAs around the country, and avoid an interruption in your member benefits. If you haven't already done so, renew your membership for fiscal year 2018 by Oct. 31, so you don't incur an administrative fee or miss out on your member benefits. It’s not too late!
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AANA Learn Member Exclusives: Take Advantage of Free Sponsored Courses Soon

Two sponsored courses that are free to AANA members: Monitoring and Reversing Neuromuscular Block in the New Millennium and Advanced Monitoring of Neuromuscular Block: State of the Art Assessment using Qualitative and Quantitative Measures will expire in Mid-November. Visit AANALearn, and be sure to log in before taking the courses.
Monitoring and Reversing Neuromuscular Block in the New Millennium
2.5 Class A Credits
2.5 Pharm Credits
Course Expiration Date: 11/14/2017
Advanced Monitoring of Neuromuscular Block: State of the Art Assessment using Qualitative and Quantitative Measures
1.0 Class A Credits
0.5 Pharm Credits
Course Expiration Date: 11/16/2017
Both are supported by an educational grant from Merck. 
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Meetings and Workshops

Upcoming Meetings and Workshops

Register now for the following meetings and workshops.

Fall Leadership Academy 
November 3-5 Rosemont, IL
Jack Neary Advanced Pain Management Workshop, Part II 
November 5-6 Rosemont, IL
Assembly of School Faculty
February 15-17 Scottsdale, AZ Save the date!
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Federal Government Affairs


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 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 our 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. All contributors must be US citizens. 
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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.

Systemic Lidocaine May Be Effective for Postmastectomy Pain

New research may finally have identified a preventative treatment for pain tied to mastectomy: intraoperative systemic lidocaine. The study randomized patients to an infusion of either the interventional treatment or of normal saline, with surgery-related pain assessed six months later. At that time, 29 percent of participants who had received saline reported still having pain compared with just 13 percent of those who had received I.V. lidocaine. The investigators, who published their study results in Pain Practice, believe the findings are important given that as many as 60 percent of women undergoing breast surgery experience chronic persistent post-mastectomy pain, "with no established methods of prevention" currently in place.

From "Systemic Lidocaine May Be Effective for Postmastectomy Pain"
Clinical Pain Advisor (10/05/17) May, Brandon

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I.V. Meloxicam Effectively Reduces Opioid Use Following Major Surgery

Phase III study results are promising for the use of intravenous meloxicam, which was shown to safely and effectively manage pain and curtail opioid use following major surgery. The new formulation was tested as part of a study led by Sergio Bergese, MD, director of neurosurgical anesthesia at Ohio State University Wexner Medical Center. His team randomized 538 adult surgical patients to receive I.V. meloxicam and 183 to receive placebo. At a dose of 30 mg, I.V. meloxicam resulted in few serious adverse events and zero deaths. Mean opioid consumption was reduced significantly at 24, 48, and 72 hours compared with placebo—which likely also explains the lower rate of nausea and vomiting in the intervention group. Bergese noted that his research, added to findings from other Phase II and Phase III research, point to "a large body of evidence showing I.V. meloxicam appears to work faster and provide a longer duration of postoperative pain relief, and is generally well tolerated." The study results were presented at PAINWeek, held in September in Las Vegas.

From "I.V. Meloxicam Effectively Reduces Opioid Use Following Major Surgery"
Healio (10/05/2017) Demko, Savannah

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Prescribing Gabapentin With Opioids Could Increase Risk of Fatal Overdose, Study Finds

Concomitant use of gabapentin and opioid painkillers significantly elevates the risk of opioid-related death, Canadian researchers report. The team from the University of Toronto performed a case-controlled study involving 1,256 opioid users who died of an opioid-related cause and 4,619 who did not. Analysis showed that gabapentin, an anticonvulsant, had been prescribed in the previous four months to 12.3 percent of those who died due to opioid-related causes but to only 6.8 percent of the matched controls. The investigators, who reported the finding in PLOS Medicine, calculated that mixing gabapentin and opioids raises the risk of fatal opioid overdose by 49 percent. While the combination is often used to battle chronic pain, both medications are known to trigger respiratory depression—a potentially deadly complication. Researchers also suspect that gabapentin may amplify the volume of opioid absorbed by the body, thereby raising the opioid dose.

From "Prescribing Gabapentin With Opioids Could Increase Risk of Fatal Overdose, Study Finds"
Pharmaceutical Journal (10/05/17)

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Virtual Reality Videos May Alleviate Pre-Surgical Anxiety in Children

Virtual reality videos that familiarize pediatric patients with the operating room help to calm their preoperative jitters, researchers report in the British Journal of Surgery. Their study compared pre-procedure anxiety scores in children who took a virtual tour of the OR led by an animated penguin guide with children who were briefed on their upcoming OR experience in a more traditional way. Based on meaningfully lower Yale Preoperative Anxiety Scale scores in the group of kids who viewed the four-minute video, investigators concluded that the virtual reality tour effectively eased patient anxiety ahead of the operation and increased their compliance during anesthesia induction. "This study shows how medicine and ICT (information and communications technology) can be coordinated to achieve clinical significance," remarked Sung-Hee Han, MD, of Seoul National University College of Medicine.

From "Virtual Reality Videos May Alleviate Pre-Surgical Anxiety in Children"
United Press International (10/04/17) Wallace, Amy

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Efficacy of Naloxegol for OIC Not Influenced by Opioid Type, Dose

Investigators attempted to settle questions about how effectively naloxegol alleviates opioid-induced constipation (OIC) based on dose, type of opioid in the patient's system, and duration of opioid use. The post hoc analysis looked at data from a pair of randomized, controlled trials in which more than 1,300 patients total received either 12.5 or 25 mg of naloxegol or oral placebo every day for 12 weeks to treat OIC. "What we noticed is that for both dosing groups, naloxegol was superior to placebo," remarked senior author Sri Nalamachu, MD, of the Pain Management Institute in Overland Park, Kan. "But there was no significant difference that we could see between the two dosing groups, perhaps because the sample was too small." Efficacy was also similar regardless of the type of opioid involved, although researchers observed a slightly higher—but ultimately statistically insignificant—rate of adverse effects in patients taking methadone. There was, however, some variation in efficacy based on duration of opioid use at baseline. Even so, the researchers found that improvements from baseline in the number of spontaneous bowel movements per week were similar.

From "Efficacy of Naloxegol for OIC Not Influenced by Opioid Type, Dose"
Anesthesiology News (10/04/17) Kronemyer, Bob

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Femoral Nerve Block Effective for Endoluminal Laser Ablation-Associated Pain

A Saudi study has found that ultrasound-guided femoral nerve block (FNB) can minimize intraoperative pain during endoluminal laser ablation without the need for sedation. Patients often experience discomfort from tumescent anesthesia injections during the procedure, which aims to correct greater saphenous vein insufficiency. The research showed, however, that the 38 patients who underwent tumescent anesthesia with FNB reported lower pain scores than the 22 patients who had ablation without pre-procedural FNB under ultrasound guidance. In addition to alleviating injection pain, study investigator Abdullah M Al Wahbi, MD, said the approach allows for early mobilization. The findings are published in Vascular Health and Risk Management.

From "Femoral Nerve Block Effective for Endoluminal Laser Ablation-Associated Pain"
Clinical Pain Advisor (10/03/17) May, Brandon

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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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October 12, 2017
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