AANA Anesthesia E-ssential
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Vital Signs

No Trick: Halloween is the LAST Day to Renew Your Membership Before Grace Period Expires

If you have not yet renewed, your membership status will automatically switch in the AANA database to non-member after October 31. Renew now to avoid a $25 fee and a loss of benefits.

AANA membership pays for itself!

  • Members receive an exclusive code that can be used for up to six online courses worth 1 Class A CE credit each (a $300 value) on www.AANALearn.com.
  • Enjoy up to 30 percent off AANA educational opportunities including workshops and meetings, the AANA Nurse Anesthesia Annual Congress, and online learning.
  • Save up to 50 percent (a $296 value) when purchasing the four-part interactive AANA CPC Core Modules series on www.AANALearn.com.
  • And much more!

Renew Now.

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Hot Topics

National CRNA Week Materials Available Nov. 1—Celebrate Your Profession!

It’s time to start gearing up for the 19th annual National CRNA Week, Jan. 22-28, 2017. Look to the AANA for materials and resources you need to educate and inform your patients, healthcare colleagues, hospital administrators, policymakers, and others about the role and value of nurse anesthetists in today’s healthcare system. This year’s theme, “Safe and effective anesthesia CARE for every patient,” highlights the AANA’s new motto.

To speak with a PR Department representative, email pr@aana.com, or call (847) 692-7050 and ask for Chris Bettin, Marlene McDowell, or Cathryn Hodson.

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Free Enhanced Recovery eBook Available Now

Enhanced Recovery for Major Abdominopelvic Surgery, an eBook published for the American Society for Enhanced Recovery (ASER) is available now, free of charge. Supported by a grant from Pacira Pharmaceuticals, this comprehensive 397-page clinical manual provides detailed, expert guidance for surgeons, anesthesia professionals, nurses, and hospital administrators. To view or download the eBook, go to AANA Connect. For additional information about ERAS practice, see the AANA Professional Practice Department's Enhanced Recovery Resource Page.

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History Channel Airs "The WarFighters," Features CRNA's Son

On April 7, 2004, CRNA Mike Morel and his wife, Molly, learned that their son, Captain Brent Morel, a member of the U.S. Marines' 1st Reconnaissance Battalion, Bravo Company, had been killed in Fallujah. AANA covered the story in the July 2004 AANA NewsBulletin. For Veteran's Day, Nov. 11, 2016, the History Channel will air "The WarFighters," featuring Captain Morel's final battle, as told by the men who served with him. The Morel family cooperated with the production, and Captain Morel's men recount the events leading up to and following Morel's mortal injury.

"It definitely felt wrong. That we were so highly trained, so well equipped, so cohesive as a unit, to be in such a bad position. This shouldn't be happening," says Nate Self, U.S. Army Ranger. "I think it's important that we tell these stories, and that we remember these men gave their lives for another man. That is a very special thing about who we are."

View the trailer. The special airs at 8 p.m. ET/7 p.m. CT on Nov. 11, 2016, on the History channel. Check your local listings.

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Steve Alves, Normalynn Garrett, Michael Neft, Joseph Pellegrini, and Kathryn White Inducted as Fellows of the American Academy of Nursing

The AANA congratulates five CRNAs on their recent induction as Fellows of the American Academy of Nursing (AAN). Steve Alves, PhD, CRNA, FNAP, FAAN; Normalynn Garrett, PhD, CRNA, FAAN; Michael Neft, DNP, CRNA, FAAN; Joseph Pellegrini, PhD, CRNA, FAAN; and Kathryn White, DNP, CRNA, APRN, FAAN, were among 164 nurse leaders inducted during the AAN’s Annual Policy Conference in Washington, D.C., Oct. 20-22, 2016. They joined ranks of an elite group of more than 2,400 nursing professionals, and only 30 CRNAs, who have been selected as AAN fellows since the academy was established in 1973.

The AAN is an organization of distinguished nursing leaders who are recognized for their outstanding contributions to the profession through publications, research, awards and honors, professional activities, and community service. The academy’s Fellows represent all 50 states, the District of Columbia, and 24 countries.

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CMS Releases MACRA Final Rule on the New Quality Payment Program

The Medicare Access and CHIP Reauthorization Act (MACRA) Final Rule, which will affect quality reporting for CRNAs beginning in 2017, was submitted to the Federal Register on Oct. 14, 2016. The AANA Research and Quality Division has reviewed the 2,398-page document and has updated our MACRA FAQ page accordingly. Additional tools and resources for 2017 quality reporting will be posted on Quality-Reimbursement as more information is released by Centers for Medicare & Medicaid Services (CMS). In the meantime, you can visit the Quality Payment Program website to learn about the new program.

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Physician Compare Preview Period Ends November 11

The Physician Compare 30-day preview period will be open through Nov. 11, 2016, to allow CRNAs and/or their group practices to review their performance on select 2015 PQRS measures before they are publicly reported on the Physician Compare website later this year. A User Guide is available to help you access the secured preview site through the PQRS Provider Quality Information Portal (PQIP). If you have any questions regarding your data, please contact PhysicianCompare@Westat.com or visit the Physician Compare Initiative page.

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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, at 11:59 p.m. EST via a web-based tool on the Centers for Medicare & Medicaid Services (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 PQRS Feedback Reports and Payment Adjustments.

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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 the Election Center (member login and password required).

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Member Benefit: 6 Free CE Class A Credits on AANALearn.com

Take advantage of your member benefit! Enter promo code MEMBER upon checkout to receive 1 free Class A CE credit. Your code can be used for up to six online courses worth 1 Class A CE credit each (a $300 value) on AANA Learn.

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. Offer expires 08/31/2017.

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Professional Practice

CDC Issues Health Advisory: Stöckert 3T Heater-Cooler Device Likely Contaminated with Rare Bacteria

The Centers for Disease Control and Prevention issued a Health Advisory advising hospitals to notify patients who underwent open-heart (open-chest) surgery involving a Stöckert 3T heater-cooler that the device was potentially contaminated with the rare bacteria Mycobacterium chimaera during manufacturing. According to the advisory, hospitals should advise potentially exposed patients to seek medical care if they are experiencing symptoms such as night sweats, muscle aches, unexplained weight loss, fatigue, or unexplained fever. In addition, hospitals that use or have used this device are strongly encouraged to make and execute a plan to communicate with potentially exposed patients and to increase awareness among healthcare providers.

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Meetings and Workshops

Enhance Your Leadership Skills at Fall Leadership Academy

With more than 20 expert speakers in 5 specialty tracks, this year's meeting is designed for attendees to walk away with tangible skills to improve your approach to leading change in the workplace, in state associations, and in the community. Fall Leadership Academy is designed for CRNAs by CRNAs. Expand your leadership skills as well as your network of colleagues. www.aana.com/leadership. Reserve your spot today!

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Spokesperson Training for State Association Leaders

If you are a spokesperson for your state association, business, or some other entity, hone your skills at the popular Spokesperson Training for State Association Leaders, Nov. 13-14, 2016, immediately following the Fall Leadership Academy. Conducted by The Coaching Group, a Chicago-based firm that has a long history of working with the AANA Board of Directors, state association leaders, and AANA members, the Spokesperson Training program combines discussion, exercises, role play, and lecture to deliver and reinforce the skills needed to be an effective spokesperson. The program teaches life skills that work in any setting, from media interviews to testifying, negotiations to difficult conversations.

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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

AANA Foundation Sponsor a Student for 2017 Deadline is December 1

In 2016, the AANA Foundation’s Student Scholarship Program awarded 53 scholarships totaling $112,000. Thank you to all those who sponsored a student!

We are once again seeking sponsors to support nurse anesthesia students through their nurse anesthesia program. The deadline for sponsoring a student scholarship for 2017 is Dec. 1, 2016.

If you wish to be part of this important program,  see Ways to Give and access the Sponsor Application Form.

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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Support the FY17 Proof Is Power Annual Giving Campaign

Please make your FY17 donation to the AANA Foundation today! Your support is critical to advancing the nurse anesthesia profession through education and research that validates quality and cost-effective anesthesia care.

  • Visit AANA Foundation to make an online donation, or
  • Mail your donation to AANA Foundation, 222 S. Prospect Avenue, Park Ridge, IL 60068

All donations of $100+ will be recognized in print and on the website. AANA members who make donations of $250+ to both the AANA Foundation and CRNA-PAC will be recognized as Triple Crown members.

Thank you in advance for your support. It is greatly appreciated!

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Your Support Needed!
Proof Is Power Annual Fund and RISE Above Campaign

Watch the video message from the AANA Foundation Board to find out more about the RISE Above Campaign, which focuses on large-scale health policy research studies that support the practice of all CRNAs. Watch the video here. The Proof is Power Annual Fund focuses on research and education funding of our fellow CRNAs. Please support both of these important campaigns in 2017. For more information, visit www.aanafoundation.com and crnasriseabove.org.

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Visit www.crnacareers.com to view or place job postings

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Featured Career Opportunity

Director, Nurse anesthesia DNP Program – Marquette University
Milwaukee, WI

Marquette University College of Nursing invites applications for the position of Director, Nurse Anesthesia DNP Program. Requires doctoral degree, strong teaching skills and leadership ability in nurse anesthesia.


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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.

Combining Dental, Medical Procedures May Safely Limit Children's Anesthesia Exposure

According to research reported at the ANESTHESIOLOGY 2016 annual meeting, it is in the best interest of children to have medical and dental procedures requiring general anesthesia performed all at once. Taking care of a tooth extraction and a tonsillectomy or MRI at the same time, for example, improves patient safety and satisfaction while reducing expenses, the investigators conclude. Their study involved 55 pediatric patients who underwent dental work as well as a non-dental medical procedure during a single anesthetic session. Nearly 90 percent experienced no complication of any kind, and combining the procedures saved 30 percent on average. "It can be logistically complex to schedule several procedures at once, but combining them can decrease costs and pleases parents because their children don't have to undergo multiple recoveries, and can return to school and activities faster," said lead study author Vidya Raman, MD, of Nationwide Children's Hospital.

From "Combining Dental, Medical Procedures May Safely Limit Children's Anesthesia Exposure"
Medical Xpress (10/25/16)

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Dopamine May Help Surgery Patients Wake Up Easier From Anesthesia, Mice Study Says

Lab studies conducted by MIT and Massachusetts General Hospital researchers unveil the mechanism through which dopamine brings mice back from general anesthesia. The tests demonstrate the importance of the ventral tegmental area (VTA) of the brain in this process. "Dopamine neurons in the VTA are traditionally thought of as playing a key role in reward, motivation, and drug addiction but had not really been well characterized in the context of arousal," explains senior study author and anesthesiologist Ken Solt, MD. "But we discovered that by activating dopamine neurons in this very specific part of the brain, we were able to reverse the state of general anesthesia and wake up the animals." The results, published in the Proceedings of the National Academy of Sciences, provide fuel for additional studies. Solt et al. intend to test the cognitive functions of mice awakened by dopamine and also to perform clinical studies of Ritalin—a stimulant known to elevate dopamine levels—in humans undergoing anesthesia. The findings, if positive, could herald a new direction in postsurgical care.

From "Dopamine May Help Surgery Patients Wake Up Easier From Anesthesia, Mice Study Says"
Medical Daily (10/25/16) Cara, Ed

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Research Finds Rise in Number of Americans Who Undergo Procedures Involving Anesthesia Outside of O.R.

Research indicates that a growing share of Americans are heading to radiology suites or other settings—rather than the operating room (OR)—for procedures that require anesthesia. Based on data from the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry, the analysis documented 12.4 million OR cases between 2010 and 2014. It also found that 36 percent of procedures involving anesthesia, or 5.9 million cases, were performed outside of the OR. The increase, representing a jump from 28 percent over the five-year period, "reflects a shift toward safer, less-invasive procedures and tests," according to lead researcher Richard Dutton, MD, of U.S. Anesthesia Partners. While OR procedures typically entail general anesthesia, non-OR care more often is performed with intravenous sedation or regional anesthesia. The use of catheters, small incisions, and oral or rectal scopes in non-OR settings also may be less risky for some patients, making it a popular option for older people and those in poorer health. The findings were reported at the ANESTHESIOLOGY 2016 annual meeting.

From "Research Finds Rise in Number of Americans Who Undergo Procedures Involving Anesthesia Outside of O.R."
News-Medical.net (10/24/2016)

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Placebos Ease Back Pain, Even If You Know It Is a Placebo

New research in the journal Pain highlights the benefits of placebos for chronic back pain. For the study, more than 80 people with back pain were recruited, and researchers explained placebos to them. The participants were then randomized to receive either treatment as usual (in most cases an analgesic) or treatment plus the placebo. The medication was clearly labeled with: "Placebo pills. Take 2 pills twice a day." Over the course of the three-week trial, patients receiving their regular treatment reported an average 9 percent reduction in usual pain and a 16 percent reduction in maximum pain. People in the placebo group, however, reported an average 30 percent reduction in both measures of pain. In addition, the placebo group reported a 29 percent reduction in disability, compared with no reduction in the usual treatment group. The lead author of the study, Cláudia Carvalho of the ISPA Instituto Universitário in Lisbon, Portugal, noted the complex mechanism, explaining that "it encompasses the empathetic and trusting relationship between the doctor and the patient, the medical rituals that surround this therapeutic encounter, the positive expectation, and the engendering of hope in getting better."

From "Placebos Ease Back Pain, Even If You Know It Is a Placebo"
New York Times (10/21/16) Bakalar, Nicholas

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Low-Dose Sublingual Fentanyl Safe, Effective in Patients Receiving Lower Opioid Doses

Researchers have found a new use for sublingual fentanyl: treating breakthrough pain in the subset of cancer patients who can withstand only low doses of opioids for background analgesia. The drug is already indicated for this purpose in patients tolerant to and already receiving opioid therapy for underlying cancer pain. To determine if a smaller amount of it might help those taking 60 mg or less of opioids or oral morphine equivalents to alleviate their background pain, investigators looked at 51 cancer patients meeting this criteria and also experiencing breakthrough pain episodes. They discovered that pain intensity weakened noticeably at 5 minutes, 10 minutes, 15 minutes, and 30 minutes after sublingual fentanyl was administered. Many patients achieved 50 percent pain reduction at all four time intervals. Any adverse effects were classified as mild and, in most cases, were already present before receiving low-dose sublingual fentanyl. The study was reported in Supportive Care in Cancer.

From "Low-Dose Sublingual Fentanyl Safe, Effective in Patients Receiving Lower Opioid Doses"
Oncology Nurse Advisor (10/19/16) Hoffman, Jason

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Exposure to General Anesthesia in Young Children Not Linked to Long-Term Effects on Brain Development

Exposure to general anesthesia (GA) in the first two years of life does not appear to cause developmental harm by the time a child reaches kindergarten, a Canadian study has found. Researchers from the University of Manitoba compared developmental testing results from more than 4,000 kids exposed to GA before age four and more than 13,000 with no exposure. Kindergarteners who received GA between birth and two years old—whether once or on multiple occasions—performed comparably to those who never received GA. Single exposure between ages two and four, meanwhile, was associated with slight deficits in language and cognition testing results; but there was no greater risk with multiple exposures during that same age span. The findings, published in Anesthesiology, buck the common belief that risk of developmental problems increases the earlier in life and the more times a child is exposed to GA. "These results suggest that the concerns raised by animal studies may not be directly applicable to children," noted lead study author Ruth Graham, MD. "Rather, the combination of biological and social factors that are responsible for the need for surgery and anesthesia may also account for the small deficits seen in the developmental testing in kindergarten in the 2- to 4-year-old age group."

From "Exposure to General Anesthesia in Young Children Not Linked to Long-Term Effects on Brain Development"
News-Medical.net (10/18/2016)

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Remimazolam Safe, Effective for Outpatient Colonoscopy Sedation

A multi-center study demonstrated the safety and efficacy of remimazolam in achieving conscious sedation during outpatient colonoscopies. Researchers at Indiana University Hospital randomized 461 patients to receive the benzodiazepine, open-label midazolam, or placebo for the procedure; all participants also received fentanyl. The rate of successful colonoscopy was 91.3 percent for the remimazolam group, compared with 25 percent for the midazolam group and 1.7 percent for the placebo group. Adequate sedation was reached for 94 percent of the remimazolam patients, 46 percent of the midazolam patients, and 27 percent of the placebo patients. Additionally, 97 percent, 35 percent, and 5 percent of the study participants, respectively, did not require an alternative sedative as rescue medication. Other findings showed that colonoscopy patients who received remimazolam required a lower initial dose of fentanyl, reached and completely recovered from adequate sedation faster, and experienced fewer treatment emergent adverse events. The results were presented at the American College of Gastroenterologists 2016.

From "Remimazolam Safe, Effective for Outpatient Colonoscopy Sedation"
Healio (10/18/2016) Leitenberger, Adam

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GI-Administered Sedation for Colonoscopy Prompts Respiratory Depression

An observational study has uncovered a pattern of potentially unsafe levels of respiratory depression in colonoscopy patients under gastroenterologist-led sedation. Using a noninvasive ventilatory monitor, a team led by Karl Kristiansen, MD—a medical student at the University of Vermont at the time—tracked respiratory rate, minute ventilation, and tidal volume in 25 patients. Roughly three-quarters of them experienced periods of minute ventilation below the 40 percent threshold that is considered unsafe. Of those 19 patients, five dipped below 20 percent of baseline and two dropped below 10 percent. "It is interesting that 76 percent of patients fell below 40 percent and that routine care and monitoring in these patients resulted in only one intervention," Kristiansen remarked. "This study raises a few important questions, including the utility of noninvasive ventilatory monitoring." The procedural nurses as well as the gastroenterologist were blinded to device feedback, and the investigators wondered if attending physicians or anesthesia providers would change their medication administration if they were not blinded. The research was named a top poster presentation at "Driving Change in Ambulatory Anesthesia," a joint meeting held this year by the Society for Ambulatory Anesthesia and the American Society of Anesthesiologists.

From "GI-Administered Sedation for Colonoscopy Prompts Respiratory Depression"
Anesthesiology News (10/18/16) Crist, Carolyn

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Transcarotid TAVR Safer Under Local Anesthesia

French researchers report that transcarotid aortic valve replacement (TAVR) is a viable option, but one that bears a greater risk of stroke when performed under general anesthesia (GA) as opposed to local anesthesia with conscious sedation. Their study, published in JACC: Cardiovascular Interventions, involved 174 consecutive patients for whom transfemoral TAVR was not appropriate. While other clinical outcomes were comparable a year later, type of anesthesia notwithstanding, only TVAR patients who received GA suffered stroke or transient ischemic attack (TIA) within 30 days of the procedure. The incidence rate was 8.1 percent for that group, while no such episodes occurred among patients who underwent transcarotid TVAR with local anesthesia with conscious sedation. "The main findings from this study are that transcarotid TAVR appears safe and feasible, with a 30-day TIA rate of 5.7 percent, and that it may be managed with minimally invasive or general anesthesia strategies," according to the investigators.

From "Transcarotid TAVR Safer Under Local Anesthesia"
MedPage Today (10/17/16) Lou, Nicole

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Dexmedetomidine for Prevention of Delirium in Elderly Patients After Non-cardiac Surgery

Older adults commonly experience delirium after surgery, making them potentially vulnerable to other adverse events. A Chinese study investigated whether administering dexmedetomidine might safely lower delirium occurrence in this patient population. The trial randomly assigned 700 participants recovering from non-cardiac operations, all aged 65 years or older, to take either dexmedetomidine or placebo. Based on twice-daily evaluations during the first 7 days after surgery, researchers determined that postoperative delirium developed less frequently in the dexmedetomidine group. Those patients also experienced hypertension and tachycardia less often than the placebo group.

From "Dexmedetomidine for Prevention of Delirium in Elderly Patients After Non-cardiac Surgery"
The Lancet (10/15/2016) Vol. 388, No. 10054, P. 1893 Su, Xian; Meng, Zhao-Ting; Wu, Xin-Hai; et al.

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New Early Mobilization Program PICU Up! Gets Pediatrics Patients Moving

Research out of Johns Hopkins University shows that focusing less on sedation and more on mobility is safe and beneficial for patients in the pediatric intensive care unit (PICU). "The prevailing belief is that children in the PICU should be heavily sedated to protect them from all of the stressors, such as the tubes, the strangers and the physical pain," notes senior study author Sapna Kudchadkar, MD. "But fluctuating between a state of awareness and sedation can cause delirium, physical weakness, and post-traumatic stress disorder." In an effort to play down sedation, she and her colleagues developed a pilot program that concentrates more on maintaining or restoring musculoskeletal strength and function by sitting on the edge of the bed, standing up, moving from the bed to a chair, walking, and playing with toys. The PICU Up! Early Rehabilitation and Progressive Mobility Program, which tailors activities according to each patient's individual limitations, was tested out last spring. Among 100 children at the Johns Hopkins PICU, the share who walked by their third day in the ward jumped to 27 percent from 15 percent, the share who received at least one in-bed activity increased to 98 percent from 70 percent, and the median number of mobilizations per patient by day three doubled to six from three, among other results. The research can be found online in Pediatric Critical Care Medicine.

From "New Early Mobilization Program PICU Up! Gets Pediatrics Patients Moving"
Science Daily (10/13/2016)

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Local Anesthesia for Pain Control During Transrectal Ultrasound-Guided Prostate Biopsy

Researchers in China conducted a literature review to gauge the safety and efficacy of different approaches to local anesthesia during transrectal ultrasound (TRUS)-guided prostate biopsy. In all, 26 published reports on 32 randomized controlled trials (RCTs) were included in the meta-analysis. The various studies compared intrarectal local anesthesia (IRLA) with no anesthesia or placebo gel; periprostatic nerve block (PPNB) against no injection, periprostatic placebo injection, or IRLA; combined PPNB and IRLA against PPNB by itself; and combined PPNB and intraprostatic nerve block (IPNB) against PPNB alone. Based on outcomes including biopsy pain score, probe manipulation pain score, and anesthetic infiltration pain score, a combination of PPNB with IRLA or IPNB effectively and safely eases pain during TRUS-guided prostate biopsy. However, the researchers acknowledge, additional RCT data is needed to validate the finding.

From "Local Anesthesia for Pain Control During Transrectal Ultrasound-Guided Prostate Biopsy"
Journal of Pain Research (10/16) Yan, Pu; Wang, Xiao-yan; Huang, Wei; et al.

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Anesthesia E-ssential is an executive summary of noteworthy articles of interest to nurse anesthetists. It is distributed bimonthly to AANA members.

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 28, 2016
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