Anesthesia E-ssential

AANA Anesthesia E-ssential, October 17, 2019

Vital Signs

SRNAs and CRNA Educators: Sign Up for the Student Mentoring Program at the Assembly of Didactic and Clinical Educators (ADCE)

Student Registered Nurse Anesthetists (SRNAs), are you interested in becoming a nurse anesthesia educator? CRNA didactic educators, are you interested in mentoring students with an interest in education? Sign up for the Student Mentoring Program at the February 2020 Assembly of Didactic and Clinical Educators (ADCE).

The program consists of a Student/Mentor Meet and Greet from 6:00 - 6:30 p.m. on Wednesday, February 19, for the mentor/mentee pairs to meet each other. Students are paired with an educator from a program other than their own. Thursday, February 20, is the one-day mentoring experience. Wherever the mentor goes throughout the day, the student will follow. The mentor introduces their mentee to their colleagues, involves them in their discussions, and takes them to lunch.

SRNAs: One student who has been nominated by their program director is accepted from each nurse anesthesia program, and a student may participate in the mentoring program only once. Let your program director know now if you would like your name submitted!

CRNA Didactic Faculty: Volunteers are needed to serve as mentors.

Please refer to the brochure for complete details about the program. Simply email the Education department at to nominate a student and/or sign up as a mentor by December 9, 2019. Provide your/the student’s name, nurse anesthesia program, e-mail address and phone number.
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Hot Topics

Seeking Candidates: Delegate to Education Committee

The AANA Education Committee is seeking candidates to serve a two-year term as a Delegate. The deadline for receiving completed candidate packets is January 6, 2020. The election will be held, and the winner announced, at the Assembly of Didactic and Clinical Educators (formerly called Assembly of School Faculty) meeting in February 2020.

Delegates must be CRNAs who spend at least 50% of their time in the didactic and/or clinical instruction of nurse anesthesia students at the time of application. During their tenure on the committee, they must:
  • Be continuously involved in the didactic and/or clinical instruction of nurse anesthesia students.
  • Attend the February Assembly of Didactic and Clinical Educators and Nurse Anesthesia Annual Congress during both years of their term.
  • Attend Education Committee meetings and conference calls for the two-year term which begins immediately following the AANA Annual Congress in the year elected.
The candidate information packet is available on the AANA website under CE & Education, Opportunities for Educators. Questions? Contact the Education department at 847-655-1161 or
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CRNAs/SRNAs - Do You Know How Much You Should be Getting Paid?

Whether you’re comparing offers, negotiating your salary, or conducting research on the profession’s outlook, stay up to date on the latest CRNA compensation, salary, and benefits trends! With the official 2019 Compensation and Benefits Report, you can better understand what your full compensation package should entail:
  • 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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LAST DAY! Call for Abstracts: Share Your Professional Knowledge by Presenting at AANA 2020 Annual Congress in San Diego

Deadline: TODAY! Abstracts due by 11:59 p.m. CST October 17, 2019!
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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NewsMakers: Three CRNAs Recognized for Excellence

The University of Santo Tomas Nurses Association International (USTNAI) recognized Phil Mangahas, DNP, CRNA, Sallie Poepsel, PhD, CRNA, and Tony Umadhay, PhD, CRNA, with awards of excellence during the USTNAI Annual Convention and Leadership Summit on September 26-29, 2019 in Brooklyn, N.Y. The conference theme was “Unifying Generations of Nurses with Excellence and Heart.” The CRNA recipients were honored for their significant contributions, exemplary work and outstanding achievements in the field of professional nursing:
  • Dr. Mangahas for his community service through surgical mission trips with Operation Care Abroad,
  • Dr. Poepsel for nursing service as a former Region Director and AANA Board Member, and
  • Dr. Umadhay for his contributions to nursing education at Barry University, College of Nursing & Health Sciences.
USTNAI is a professional organization of international nurses from the University of Santo Tomas (UST), Manila. Known as the Pontifical and Royal Catholic University of the Philippines, UST is a Dominican institution of learning and research founded in 1611, under the patronage of St. Thomas Aquinas. Mangahas (1971), Poepsel (1974) and Umadhay (1991) are all BSN alumni of the UST. 

Tony Umadhay, Sallie Poepsel, Phil Mangahas
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October 2019 AANA Journal Highlights

The October 2019 AANA Journal is online, a nice balance of clinical, research and educational offerings, including:

Intravenous Lidocaine for Relief of Chronic Neuropathic Pain
The authors systematically reviewed the literature regarding the use of lidocaine in the treatment of chronic pain. The work was performed in the context of the very real need for all of us to be thoughtful about the use of opioids, given the current related epidemic. Their works sheds light on new uses and new environments for this old, non-opioid intervention.

Evaluating a Quality Improvement Initiative to Increase Anesthesia Providers’ Use of and Understanding of Quantitative Neuromuscular Monitors
A quality improvement initiative regarding the use of quantitative monitoring to assess the use of muscle relaxants during clinical care is discussed, a topic getting much needed emphasis in the literature. The authors’ analysis of the program reveals the value of education and positive reinforcement in altering clinical practice that advances patient safety.

It’s Never Just a Block: An Analysis of Regional Anesthesia Closed Claims
Members of the AANA closed claims analysis team examined records of very poor outcomes involving regional anesthesia. Although this type of research is not amenable to define cause and effect, strong associations were found with respect to themes: errors in cognitive decision making, ineffective communication, and production pressure. Closed claims analysis continues to prove itself a worthy undertaking in defining practice patterns that place patients as risk, and help define where education and training may be most productive in enhancing patient safety.

Combined Interscalene Brachial Plexus and Superficial Cervical Plexus Nerve Block for Midshaft Clavicle Surgery: A Case Series
The authors report their case series on the use of regional anesthesia for the surgical repair of displaced clavicular fractures, a procedure for which we have generally provided general anesthesia. Here the authors report their use of combined interscalene brachial plexus block and superficial cervical plexus peripheral nerve block as the primary anesthetic (plus sedation) in 10 patients. Good patient follow-up and documentation provides the reader with an opportunity to evaluate if this might work in your practice.

Inclusive Recruitment and Admissions Strategies Increase Diversity in CRNA Educational Programs
This article describes individual and social-level recruitment strategies which occurred over a 12-month period that targeted the issue of increasing racial and ethnic diversity in providers as one component in a broad effort to eliminate health disparities and increase the quality of care. This broad domain of issues related to healthcare policy is of great national importance and is being discussed in virtually every academic and healthcare institutional setting. Readers will find this report illuminating and grounded in realistic and achievable outcomes.

Most Hemodynamically Stable Method for Change from High to Low Anesthesia Flow: A Randomized Controlled Trial Comparing State Entropy, High Fresh Gas Flow for 10 Minutes, and 0.8 Ratio of End-Expired Agent Concentration to Inspired Agent Concentration
The authors tackle issues and challenges related to adjusting inhaled gas concentrations during low-flow delivery with an emphasis on hemodynamic perturbations. This interesting randomized controlled trial involving 90 patients makes interesting reading with clinically important implications for the reader.

Nasal Ventilation Mask for Prevention of Upper Airway Obstruction in Patients with Obesity or Obstructive Sleep Apnea
This article describes the use of a relatively novel approach, use of a nasal ventilation mask, in managing patients at high risk of upper airway obstruction due to body habitus or pathophysiological factors. The authors focused their efforts on high volume, endoscopy clinics where 75% of the cases are EGD or colonoscopy procedures. Readers are provided with sufficient information related to use of such a device to determine if potential application to their own practice is merited.

Characterizing Anesthetic Management and Perioperative Outcomes Associated with a Novel, Fusionless Scoliosis Surgery in Adolescents
This interesting collaboration among physician and CRNA clinical researchers describes a novel fusion-less surgical procedure, and management considerations, for patients undergoing idiopathic scoliosis repair. Their report details the management and analgesic control concerns in 35 adolescents who underwent the procedure. The use of neuraxial was a critical factor in both reducing opioid use as well as accelerating hospital discharge.

Ketamine and Treatment-Resistant Depression
The use of ketamine has literally experienced a renaissance and in this AANA Journal Course, the authors describe the pharmacology and clinical use of the drug in treating depression, especially in those who have proved refractory with other approaches. This Journal Course informs the reader about its use in this setting and will prove valuable reading to all, even those not caring for patients who are specifically seeking treatment for depression.

AANA Journal Online content
Don't miss our online content in the letters-to-the-editor section that involve a recent book review (interesting exchange there between book author and a reviewer), as well as a back-and-forth about a paper we recently published on pharmacogenetics, and a commentary from a previous AANA President on a recent “From the Editor’s Desk.”
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Meetings and Workshops

New! Exclusive Opportunity! CRNA Delegation to Athens, Greece

Class A CE Credits: 12.00
When: March 14-20,2020
Location: Athens, Greece
Sign-up Deadline: December 19, 2019

Connect with fellow CRNAs and international advanced practice nursing colleagues in Greece through the World Learning CRNA delegation. Led by Debbie Malina, DNSC, MBA, CRNA, FY2012 AANA president, the World Learning program will give you a unique opportunity to learn about the state of healthcare and the role of nurse anesthetists and advanced practice nursing professionals in Greece.

Download the Professional Exchanges brochure for more information.
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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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AANA Leadership Summit: Empower the Leader Within

Class A CE Credits: 15.75
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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Assembly of Didactic and Clinical Educators (ADCE) 2020

When: February 19-22, 2020
Location: Château Élan Winery and Resort, Braselton, Ga.
Registration opens October 23, 2019

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

It Pays to be Prepared: Preorder 2020 CPC Core Modules and Save!

SAVE UP TO 25% on the innovative microlearning series being released in the fall of 2020. You'll have peace of mind knowing you're all set to meet CPC requirements through all four required knowledge domains. Offer expires December 31, 2019.

Be prepared. Preview modules and sign up today at

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CRNA: Banner University Medical Group, Tucson, Arizona

BANNER UNIVERSITY MEDICAL GROUP (BUMG) is seeking a CRNA to join our team at Banner University Medical Center – Tucson. BUMC-T values patient-centered care and healthcare innovation. We were named a U.S. News and World Report Best Hospital and ranked No. 3 Hospital in Arizona. Tucson, located in the Sonoran Desert surrounded by multiple mountain ranges, is a very friendly Southwestern town where you’ll have access to a multitude of yearlong outdoor activity options, from cycling to boating to golf, to simply sitting and enjoying some of Mother Nature’s most astounding creations. With resources and lifestyle opportunities like these, what you envision for your professional career and personal life environment can become your reality.

Details and requirements include:
  • Current Board, CPR, BLS, and ACLS certifications.
  • Current Arizona License.
  • Critical Care training and experience.
  • Responsible for performing general, regional, and monitored anesthesia services across a broad scope of the health continuum in a Directed Program.
  • Some weekends may be required.
Learn more.

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CRNA: Total Vascular Care, San Antonio, Texas

Total Vascular Care is pleased to expand their services and is seeking a qualified full-time CRNA for our downtown multi-specialty surgery center.

The candidate must be able to work independently, have a team-oriented attitude, and enjoy a fast-paced environment. 3 years related experience preferred. Must be proficient in axillary and supraclavicular blocks.

Position is M-F, no call or weekend required.
Competitive Compensation.
Established, professional and team-oriented practice.
NO Holidays.
FT Benefits Package, Paid Vacation, 401K.
Must be Proficient in axillary and supraclavicular blocks.
Vascular lab.

2 ORs.
EMR System.
CRNA model.
Board Certification Required.

Learn more.
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Certified Registered Nurse Anesthetist: Memorial Health System, Springfield, Illinois

Status: Full-Time, Hospital employed.

Schedule: Convenient flexible schedule with 8-, 10- and 12-hour shift options available

Basic Functions:
This position embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values. Our CRNAs administer general, regional, and MAC anesthesia to patients of all ages and any ASA status. The CRNAs work in a collaborative team environment with 50 CRNAs, 21 Anesthesiologists and 12 Anesthesia Techs to assist with room turnover and stocking. The CRNAs serve as Clinical Instructors for SIUE and Millikin/Decatur Nurse Anesthesia programs.

Due to our continued growth, Memorial Medical Center has multiple needs for Certified Registered Nurse Anesthetists. Positions are available full time in the Main OR, CVOR or as a split 50/50 between Main OR and CVOR. Learn more.
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CRNA: HSHS Medical Group, Springfield, Illinois

HSHS Medical Group is actively recruiting Certified Registered Nurse Anesthetists to join an existing team of 36 CRNAs at St. John’s Hospital in Springfield, IL. Practice in a setting that offers a wide variety of cases and procedures to include: General, Cardio-Thoracic, OB/ Pediatric/ NICU, Regional, Spinal, Epidurals, IV Regionals, CVP, PA Invasive Monitors and A-lines. 100% Medically Directed.

Position is employed with the HSHS Medical group which is a not-for-profit integrated network of healthcare services that is affiliated with St. John’s Hospital, Springfield, IL; a 431-bed Level I Trauma Center with Level III NICU.

Join an autonomous and team-centered department. With 1:5 weekend coverage. 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.

Effects of Depth of Neuromuscular Block on Postoperative Pain During Laparoscopic Gastrectomy

Hoping for clarity on whether depth of neuromuscular block (NMB) affects postoperative pain, researchers in South Korea assembled 100 patients for a randomized study. Participants, all of whom were undergoing laparoscopic gastrectomy, received either deep or moderate levels of NMB with a standard-pressure pneumoperitoneum. The main outcome was minimum effective analgesia dose (MEAD) of oxycodone, as measured in the post-anesthesia care unit. The median value was 8 mg for both sets of patients, indicating that deep NMB did not significantly lower the MEAD of oxycodone following laparoscopic gastrectomy compared to moderate NMB. While most secondary endpoints, including pain scores, also were not significantly different between the two groups, the research did show greater muscle relaxant use among the moderate NMB patients. The investigators also noted that duration of pneumoperitoneum was a significant variable in determining the MEAD of oxycodone.

From "Effects of Depth of Neuromuscular Block on Postoperative Pain During Laparoscopic Gastrectomy"
European Journal of Anaesthesiology (11/01/2019) Vol. 36, No. 11, P. 863 Choi, Byung-Moon; Ki, Seung-Hee; Lee, Yong-Hun; et al.

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IV Ketorolac May Cut Need for Opioids Following Orbital Surgery

New evidence supports the use of intravenous ketorolac for pain relief after orbital surgery. The study included 100 participants, half of whom received I.V. ketorolac and half of whom did not. While there were no bleeding complications in either group, postoperative pain scores were lower among patients who received ketorolac. They measured at 3.08 immediately after surgery and fell to 1.04 on postoperative day one for that group, while scores in the control group were 5.44 and 2.66 at the same intervals. In addition, fewer ketorolac patients than controls required postoperative antiemetics or opioids. "[Intravenous ketorolac] reduces postoperative pain in orbital surgery and the requirement for opioid analgesics, without increasing the risk of bleeding complications," the researchers reported at the 2019 American Academy of Ophthalmology Meeting in San Francisco.

From "IV Ketorolac May Cut Need for Opioids Following Orbital Surgery"
Monthly Prescribing Reference (10/12/19) Ernst, Diana

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Transversus Abdominis Plane Block May Improve Acute and Chronic Pain After Robotic Partial Nephrectomy

Renal surgeries are associated with acute postoperative pain, but researchers say ultrasound-guided transversus abdominis plane (TAP) block in combination with general anesthesia may deliver significant relief. Their optimism stems from the results of a prospective trial, which included 96 adults undergoing robotic partial nephrectomy. A randomized selection process separated the patients into two treatment arms, with 48 receiving standard general anesthesia only and the other 48 receiving standard general anesthesia with TAP block added. The main endpoint was morphine demand 24 hours after surgery, which was lower among the TAP block recipients. The results also correlated TAP block with improved intensity of acute somatic pain and lower incidence of chronic pain—although acute visceral pain was no better in one group than in the other. The study report appears in Pain Medicine.

From "Transversus Abdominis Plane Block May Improve Acute and Chronic Pain After Robotic Partial Nephrectomy"
Clinical Pain Advisor (10/11/19) Rothbard, Gary

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Mind and Machine: Updates From the Society for Technology in Anesthesia Annual Meeting

Presenters at the 2019 annual meeting of the Society for Technology in Anesthesia (STA) discussed the newest innovations in the field. Development in the area of simulation and learning was a key topic at the event, which was held under the banner of "Mind and Machine." Instead of high-fidelity, mannequin-based simulation, the field increasingly is employing lower-fidelity, screen-based simulation. Virtual reality and gaming for this purpose are becoming more popular, and STA attendees were able to get some first-hand exposure to the trend, compliments of an interactive station that simulated a liver transplant. The Internet of Things (IoT), or the addition of networking capabilities to small everyday devices, is also creating buzz in anesthesiology circles. IoT could help redesign adult monitors to work better with children undergoing anesthesia and allow for continuous wireless monitoring of postoperative patients on the ward, for example. Also causing excitement is the next generation of intraoperative anesthesia information management systems. Despite some nits that have yet to be solved, the technology permits easy visualization of data along with customizable reports and dashboards. Arguably the star of the STA meeting, however, was machine learning, which is using big data—including waveforms, imaging, environmental data, and genomics—to report research as well as to learn and predict. One session demonstrated how a deep neural net trained on intraoperative data (such as drugs, fluids, and medications) can predict postoperative in-hospital mortality as well as a logistic regression model, but better define nonlinear associations between intraoperative variables.

From "Mind and Machine: Updates From the Society for Technology in Anesthesia Annual Meeting"
Anesthesiology News (10/11/19) Levin, Matthew A.; Blake, Charlene M.

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Study Questions Strategy of Asking Patients to Self-Report Their Physical Fitness Before Surgery

Researchers are challenging the longstanding practice of using patient-reported fitness capacity to gauge their physical readiness for a noncardiac operations. Preoperative assessments always ask whether surgical candidates can climb a set of stairs and whether they can walk two blocks on flat land. Although every patient must check off these two items, anesthesia provider Daniel Rubin, MD, MS, of University of Chicago Medicine questions the accuracy of the responses. "We know that patients can both overestimate their physical abilities and underestimate their physical abilities," he remarks. To investigate, he and his team analyzed National Health and Nutrition Examination Survey data during 2003-2004 and also during 2005-2006, specifically from respondents who wore accelerators to record their physical activity over the course of one week. They report in Anesthesiology that the results were mixed. "The questions are pretty good at identifying patients who answer in the affirmative to whether they can climb stairs or walk two to three blocks and who actually have adequate functional capacity," Rubin explains. "Where it gets a little messy is classifying patients who don't respond yes. It's basically a coin flip as to whether they are functionally capable." The solution is to develop more rigorous methods of determining functional capacity, he adds. To this end, Rubin and his colleagues are currently developing a smart phone app that would enable providers to give patients The Duke Activity Status Index survey and conduct a six-minute walk test.

From "Study Questions Strategy of Asking Patients to Self-Report Their Physical Fitness Before Surgery"
Newswise (10/09/19)

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Study Targets 'Fingerprint' of Human Consciousness

Led by Western University neuroscientist Adrian Owen, researchers say they have learned more about the "fingerprint" of human consciousness. Owen's team performed functional magnetic resonance imaging on a group of participants while they were gradually sedated using propofol. The brain scans were then compared with those taken by University of Cambridge collaborators of a group of patients who were either in a vegetative state or a minimally conscious state. "Remarkably, we saw very similar results in the two groups of participants scanned on opposite sides of the Atlantic," Owen reports. "Specifically, loss of consciousness—whether due to propofol anesthesia or brain injury—was accompanied by reduced functional diversity and integrative capacity in similar brain networks, which may represent a neurobiological marker or 'brain fingerprint' for consciousness." While his earlier research has shown that functional neuroimaging can pick up conscious awareness in some patients presumed to be completely vegetative, the new discovery could help explain why some of those individuals can still communicate their thoughts while others cannot. "It is still early days, but these results are beginning to reveal how our brains generate our conscious experience of the world and what goes wrong when consciousness fails," Owen says. The study appears in Nature Communications.

From "Study Targets 'Fingerprint' of Human Consciousness"
Medicalxpress (10/11/2019) Renaud, Jeff

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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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Park Ridge, IL 60068
Phone: (855) 526-2262 (toll-free)/(847) 692-7050
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Attn: Cathy Hodson
E–ssential Editor
October 17, 2019