Anesthesia E-ssential

AANA Anesthesia E-ssential, September 12, 2019

Vital Signs

AANA Sends Letter to AARP The Magazine Regarding VA Issue

In June, former AANA President Garry Brydges, DNP, PhD, MBA, CRNA, ACNP-BC, FAAN, sent a letter to the editor of AARP The Magazine titled “Underutilization of CRNAs Prevents Veterans From Receiving Care They Deserve.” AARP doesn’t typically publish letters to the editor, but the outreach nonetheless served its purpose by further educating an important AANA ally about the ongoing issue of veterans’ access to care and promoting CRNAs as a viable solution to reducing veterans’ wait times. The AANA advocacy team and Board of Directors continue to make this a high priority of the association heading into the new fiscal year. Learn more (Log in required).
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The Joint Commission Tackles Perinatal Safety Issues with the Help of Two CRNAs

Effective July 1, 2020, two new maternal safety accreditation standards requiring Joint Commission- accredited hospitals to examine their processes and procedures surrounding the care of women experiencing hemorrhage and severe hypertension/preeclampsia take effect. According to the Joint Commission, the U.S. is 65th among industrialized nations in terms of maternal mortality. National trends reflect worsening maternal morbidity and mortality. A Technical Advisory Panel and a Standards Review Panel (SRP) provided expert guidance on the new standards, including SRP participation by Beth Ann Clayton, DNP, MS, CRNA, and Joseph Pellegrini, PhD, CRNA, FAAN.

The new Joint Commission standards contain 13 elements of performance (EPs) and include many steps. The EPs deal with prevention, early recognition, and timely treatment of maternal hemorrhage and severe hypertension/preeclampsia. The maternal hemorrhage EPs require:
  • Assessments;
  • Written evidence-based procedures for stage-based management of patients with maternal hemorrhage;
  • Standardized, dedicated hemorrhage supply kits;
  • Role-specific education about the hospital’s hemorrhage procedures;
  • Drills, including a team debrief, at least annually;
  • Case evaluations; and
  • Patient and family education.
The severe hypertension/preeclampsia standard requires written evidence-based procedures for measuring blood pressure, including: 
  • Criteria identifying patients with severely elevated blood pressure;
  • Written evidence-based procedures for managing pregnant and postpartum patients with severe hypertension/preeclampsia;
  • Role-specific education about the hospital’s severe hypertension/preeclampsia procedures;
  • Drills, including a team debrief, at least annually;
  • Case evaluations; and
  • Patient and family education.
Many of these standards require anesthesiology representatives on the multidisciplinary implementation team. Read the detailed prepublication standards and The Joint Commission R3 Report Requirement, Rationale, Reference here.
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Suicide Prevention Week: Sept. 9-14, 2019

This week through September 14th, the nation recognizes National Suicide Prevention week; World Suicide Prevention Day was on September 10th. Women in healthcare have the 6th highest suicide rate and men the 8th among professions. The AANA cares about you and offers a collection of resources at for prevention, management for ideations, recognizing warning signs, and dealing with loss to suicide. Concerns – call the National Suicide Prevention Lifeline 800-273-8255. Safe reporting saves lives!
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Hot Topics

Resource for 2018 MIPS Performance Feedback Report and 2020 Payment Adjustment

The Centers for Medicare & Medicaid Services (CMS) published Frequently Asked Questions about the 2018 Performance Feedback Report, which is available through the Quality Payment Program (QPP) Resource Library. The file includes fact sheets that provide guidance on navigating the report, and how the 2018 merit-incentive payment system (MIPS) Final Score and Payment Adjustments for CY2020 were calculated. CRNAs can view their 2018 Performance Feedback Reports by logging in to their QPP account, using HCQIS Access Roles and Profile System (HARP) credentials. Members can request a targeted review of their MIPS Final Score/Payment adjustment until September 30, 2019 if they believe there is an error in their Performance Feedback, MIPS Final Score or Payment Adjustment.
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The Joint Commission Focuses on Combating Nurse Burnout

The Joint Commission (TJC) has released strategies to combat nurse burnout. The strategies involve developing resilience in both healthcare environments and healthcare professionals. Resilience is defined as “the ability to adapt successfully in the face of adversity or significant threat.” Resilience-building strategies include, but are not limited to:
  • Creating stress-defeating support systems and a culture of mutual openness, enhancing the meaningfulness of work, and providing opportunities to participate in decision-making.
  • Healthcare organizations can foster resilience by implementing burnout interventions, such as mindfulness and resilience training.
  • Healthcare leaders also can support resilience by reducing and eliminating barriers and impediments to work flow, such as staffing and workplace environment concerns. They can promote workplace empowerment by providing employees access to resources, information, and support needed for their jobs and opportunities to develop.

Learn more about strategies to support healthcare environment and professional resilience.

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Much More than Malpractice Protection

Did you know the malpractice insurance coverage offered by AANA Insurance Services includes additional coverages such as deposition representation and substitute coverages? Visit the new Additional Coverage Benefits page to learn more about the benefits of securing coverage through AANA Insurance Services. Learn more.
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AANA Journal Gets Greener

The U.S. Postal Service has now approved a degradable poly wrapper. This means that AANA Journal will soon mail in a wrapper that degrades. Rather than mailing AANA Journal to members in a plastic wrapper that is not environmentally friendly, this new wrapper will degrade entirely if left in the open air. This new poly wrapper is not recyclable – the U.S. Postal Service has not approved a recyclable wrapper yet. The “greenest” option available as of now is the new degradable poly wrapper. 

Spread the good news! The mailing of AANA Journal will no longer litter the earth with 53,000 pieces of non-biodegradable plastic.
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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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NewsMaker: CRNA Kellon Smith Part of Concerted Effort to Battle Opioid Crisis

The Garrett County Republican reports that Garrett Regional Medical Center and Potomac Valley Hospital will both be sites of Integrative Pain Centers that will help patients struggling with chronic pain find relief through alternative treatment methods. Kellon Smith, MHS, CRNA, NSPM-C, is a board-certified non-surgical pain management specialist, the first CRNA in West Virginia to be board certified in this field, of which there are only 60 in total across the country. Because of the additional training he received through Harvard Medical, Smith will be one of the only providers in the region offering unique procedures like craniofacial injections, along with spinal injections to relieve back pain. Learn more.
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NewsMaker: CRNA Maria Ross Named CRNA of the Year by R.I. State Nurses Association, Rhode Island Monthly

The 2019 Excellence in Nursing Awards, by the Rhode Island State Nurses Association in collaboration with Rhode Island Monthly, honors 13 nurses this year. Among them is Maria Ross, MSNA, CRNA, APRN, as the Certified Registered Nurse Anesthetist of the Year. Learn more.
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NewsMaker: CRNA Debbie Fajans Opens an IV Hydration Lounge

As reported on KTVN in Reno, Nev., Debbie Fajans, CRNA, "got the idea to open a hydration lounge after an out of the country adventure with friends." One of her friends got so dehydrated that "every body part started cramping." When a bag of saline solved the problem, Fajans knew she was on to something. She has since created custom blends, like a yellow-hued mix called Fatigue Fighter. Learn more
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Meetings and Workshops

Brain Health Initiatives: What Is It, Why Now, and How Can I Make a Difference?

A new course, Brain Health Initiatives: What Is It, Why Now, and How Can I Make a Difference? - is now live on AANA Learn. You can find this course in the New!, Member Exclusives, and All Courses categories, and you can earn 1.00 Class A credit.

The course fees are:
  • Members: Free
  • Associate Members (students): Free
  • Non-Members: $50.00
Learn more.

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New! A Unique, Hands-on Obstetrics/Maternal Care Learning Opportunity Coming to Your Area in September

Corporate partner Pacira Biosciences will be hosting hands-on educational workshops in New Jersey, Florida, and Colorado this month. As leaders in anesthesia care, join other clinicians dedicated to advancing patient safety with this live, in-person workshop to learn how to build an evidenced-based, enhanced recovery protocol focused on obstetrics and maternal care. Details for the regional workshops follow.

Register today for any of the following sessions! 

New Brunswick, N.J.
Friday, September 20, 2019 from 12:30 p.m. – 5:30 p.m.

Aurora, Colo.
Saturday, September 28, 2019 from 7:30 a.m. – 12:30 p.m.

Celebration, Fla.
Sunday, September 29, 2019 from 7:30 a.m. – 12:30 p.m.

Course overview:
This course includes lectures, hands‐on workshops on fresh frozen human cadavers, and live model scanning. Techniques are taught by expert instructors, offering up-to-date evidence applicable to your surgical practice.

Learning objectives:
  • Describe the opioid epidemic as it specifically relates to the women’s health arena.
  • Review legislative movement toward opioid minimization.
  • Outline society guidelines addressing a multimodal approach for postsurgical care in obstetrics and gynecological procedures.
  • Analyze the scientific literature that supports opioid avoidance.
  • Build out an interactive multimodal and enhanced recovery pathway.
  • Utilize a cadaveric model focused on surgical techniques applicable to addressing pain management in C‐section as well as vaginal, open, and minimally invasive hysterectomy.
  • Demonstrate skill in ultrasound-guided transversus abdominis plane blocks, including live model scanning and cadaveric real-time application.
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AANA Member Benefits

24/7 Resources Provided by AbbVie

Check out the recently updated Anesthesiology Hub! Developed by AbbVie as the comprehensive source of AbbVie anesthesia product information. Available 24/7, the Anesthesiology Hub offers anesthesia providers:
  • Real-time product availability status
  • Online ordering for Ultane and NiMBex (current customer only)
  • Direct links to anesthesia clinical studies via PubMed
  • Plus dozens of other resources dedicated to anesthesia providers – All in one place!
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Nurse Anesthetist: Prisma Health, Greenville, South Carolina

Prisma Health, the largest healthcare provider in South Carolina, seeks Nurse Anesthetists to staff our academic Level 1 Trauma Center, community hospitals, or outpatient surgery centers throughout upstate South Carolina. Our group provides anesthesia coverage for all specialties within a collaborative team care work environment.

We have openings at the following locations:
  • Prisma Health Greenville Memorial Hospital (downtown Greenville): 710-bed academic Level 1 trauma center.
  • Prisma Health Patewood Memorial Hospital: A free standing inpatient hospital offering full time 24/7/365 care for both surgical and obstetric patients.
  • Prisma Health Baptist Easley Hospital (Easley, S.C., right outside downtown Greenville): primary healthcare service provider in Pickens County; 109-bed general acute care facility.
  • Prisma Health Oconee Memorial Hospital (mountain lakes community near Clemson University): 169-bed hospital.
  • Prisma Health Patewood Outpatient Surgery Center (east side of Greenville): pediatric and adult outpatient surgery procedures in 6 operating rooms and 2 GI rooms.
Prisma Health-Upstate employs 16,000 people, including 1,200+ physicians on staff. Our system includes clinically excellent facilities with 1,627 beds across 8 campuses. Additionally, we host 14 residency and fellowship programs and a 4-year medical education program: University of South Carolina School of Medicine–Greenville, located on Prisma Health-Upstate Greenville Memorial Medical Campus. We are a designated Level I Emergency Trauma Center and also have a separate research facility. Learn more.
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CRNA: Claxton-Hepburn Medical Center, Ogdensburg, New York

A CRNA, under the general supervision of an anesthesiologist, will provide professional anesthesia services in all hospital areas to all patient populations. Primarily bread and butter cases (NO Cardiopulmonary, Neuro, or high risk OB), and will assist with anesthesia-related medical situations such as airway management. Must be able to do Spinals & Epidurals and function independently. Call required with NO second call. A complete employee benefit package for full-time employees.

  1. Certification by the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) as a CRNA.
  2. Licensure as a registered nurse in the state of New York.
  3. Credentialing as Allied Health Professional by CHMC.
  4. Must maintain current CPR, ACLS and PALS certification.
  5. Must maintain appropriate Board certification.
Learn more.
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CRNA: University of Wisconsin/UW Health, Madison, Wisconsin

At the University of Wisconsin Department of Anesthesiology, the practice of anesthesiology encompasses a medically directed team approach involving faculty anesthesiologists, anesthesiology fellows, residents and clinical anesthetists. In this department the ability to provide high quality anesthesia care to a complex patient population and simultaneously provide a quality teaching experience, while working within the team anesthesia concept, is the basic requirement of Clinical Anesthetists at all levels. Clinical Anesthetists will perform their duties under the medical direction provided by the UW Department of Anesthesiology faculty anesthesiologists.

Base Salary Pay Range: $170,000 - $185,000 (determined by experience level). Pager and weekend overtime pay are in addition to base salary pay. Learn more.
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CRNA: Banner Health, Ogallala, Nebraska

Nebraska isn't for everyone, but if you enjoy unique adventures, beautiful scenery, calm pace of life, and a solid compensation package, this opportunity is just right for YOU!

Banner Health is one of the largest non-profit healthcare systems in the country with 28 hospitals, six long-term care centers and an array of other services, including family clinics, home care services and home medical equipment, in six Western states.

We have an excellent opportunity for a dynamic CRNA to join our highly trained team!
  • CRNA-only practice model.
  • Responsible for performing general, regional, and monitored anesthesia services including Ultra Sound guided block, and OB.
  • Experience preferred.
  • One week on, one week off, one week call.
Ogallala Community Hospital (OCH) is an 18-bed critical access hospital committed to meeting the health care needs of western Nebraska and was one of four Banner Health facilities named HealthStrong™ Top 100 Critical Access Hospitals scoring best among critical access hospitals on the iVantage Health Analytics’ Hospital Strength Index™. The Hospital Strength Index is a comprehensive rating of critical access hospitals, and results recognize the Top 100 Critical Access Hospitals that provide a safety net to communities across rural America. Service area 15,653. 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.

Pain Relief Without Opioids

Enhanced recovery after surgery (ERAS) has caught on as a way to manage pain and accelerate return to normal function by using opioids sparingly and pairing them with other types of analgesia. Now, the Rush University Medical Center researchers who pioneered the technique have tweaked the model to remove the opioid component altogether. They tested the intervention in a study with 65 participants, 28 of whom received multimodal analgesia (MMA) that included intraoperative intravenous acetaminophen followed by oral acetaminophen and gabapentin. The other 37 patients received traditional anesthetic care with prescription acetaminophen, hydrocodone-acetaminophen, and I.V. morphine, as needed. "The patients receiving the MMA protocol received less opioids and reported improved pain management compared to the traditional group," said researcher Peter Revenaugh, MD. "Importantly, there was also a statistically significant reduction in the number of patients being discharged on opioid medications." The findings appear in the Journal of the American Medical Association.

From "Pain Relief Without Opioids"
Newswise (09/09/19)

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False Teeth Should Be Removed Before General Anesthetic Procedure: BMJ Case Report

A medical encounter described in BMJ Case Reports demonstrates the importance of taking out dentures before procedures requiring general anesthesia. The danger, the authors explain, comes from the possibility that the patient could inhale the false teeth during anesthesia infusion. "There are no set national guidelines on how dentures should be managed during anesthesia, but it is known that leaving dentures in during bag-mask ventilation allows for a better seal during induction, and therefore many hospitals allow dentures to be removed immediately before intubation," they note. In the incident in question, an elderly male presented for emergency care six days after minor abdominal surgery. On postoperative day eight, doctors discovered that the man's false teeth were lodged in his larynx, where they caused tissue damage, bleeding, and other complications. While the patient eventually recovered, that was only after suffering significant pain, experiencing difficulty in swallowing that made it impossible to eat solid food, undergoing several rounds of invasive tests, and undergoing additional surgery. "This case raises questions about perioperative care in patients with dentures, diagnostic decision-making in the emergency care setting and postoperative care after delayed removal of foreign bodies from the upper aerodigestive tract," the authors conclude. They also recommend that the surgical team document the presence of any false teeth or dental plates before and after an operation, with all team members notified of what is to be done with them.

From "False Teeth Should Be Removed Before General Anesthetic Procedure: BMJ Case Report"
Specialty Medical Dialogues (09/04/19) Baranwal, Medha

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Effectiveness of Magnesium in Preventing Shivering in Surgical Patients

Magnesium has shown promise as an anti-shivering agent during the perioperative period, prompting a systematic review and meta-analysis of the literature. Investigators in Yokohama, Japan, identified 64 randomized clinical trials that compared outcomes in surgical patients who received magnesium versus placebo or no treatment. They measured the incidence of shivering—the primary outcome—at 9.9 percent for the 2,300 participants in the magnesium group and at 23 percent for the 2,003 controls, with no adverse events reported for either cohort. Subgroup analysis, meanwhile, revealed that shivering was least likely to occur with intravenous delivery of the magnesium. The findings confirm that perioperative I.V. administration of magnesium effectively curtails patient shivering and, based on Trial Sequential Analysis, the review authors declare that further trials are not necessary to demonstrate this effect.

From "Effectiveness of Magnesium in Preventing Shivering in Surgical Patients"
Anesthesia & Analgesia (09/19) Vol. 129, No. 3, P. 689 Kawakami, Hiromasa; Nakajima, Daisuke; Mihara, Takahiro; et al.

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Study Maps I.V. Morphine Equivalence of Sublingual Sufentanil

A single 15-mcg dose of oral sufentanil delivers as much pain relief as 2.5 mg of intravenous morphine, report researchers at Houston's Memorial Hermann Memorial City Medical Center. That—along with its lower maximum plasma concentration, longer duration of action, and avoidance of I.V. access—makes sublingual sufentanil tablet (ssT) a suitable option for patients with moderate to severe postoperative pain, they conclude. Led by Harold Minkowitz, MD, the team documented pain outcomes in 357 adults scheduled for open abdominal or major orthopedic surgery. Among those randomized to receive ssT, 78.5 percent achieved successful pain management versus 65.6 percent of those randomly assigned to I.V. patient-controlled morphine sulfate. The results not only demonstrated the noninferiority of ssT but established its statistical superiority to I.V. patient-controlled analgesia. Researchers also determined that 30 mcg of ssT, the dosage now approved in the United States, would be on par with 5 mg of I.V. morphine. While the results are promising, there is still some apprehension in the medical community—largely surrounding the potential for abuse. In addition, sufentanil citrate injection is highly familiar while significantly fewer anesthesia providers have administered sublingual sufentanil.

From "Study Maps I.V. Morphine Equivalence of Sublingual Sufentanil"
Anesthesiology News (09/07/19) Covey, Ethan

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Cognitive Function After Surgery with Regional or General Anesthesia

A study out of the Mayo Clinic investigated whether surgery under regional anesthesia affects long-term cognitive decline in the same way that general anesthesia does. Researchers analyzed longitudinal cognitive function in 1,819 older adults. They found that exposure to anesthesia—whether general or regional—was associated with a higher postoperative rate of change in cognitive global z-score. In addition, the investigators discovered that accelerated decline in memory typically occurred in patients who underwent general anesthesia but not in those who received regional anesthesia.

From "Cognitive Function After Surgery with Regional or General Anesthesia"
Alzheimer's & Dementia (09/19) Sprung, Juraj; Schulte, Phillip J.; Knopman, David S.; et al.

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Low-Dose Ketamine in Painful Orthopedic Surgery

Given the growing popularity of low-dose ketamine, Oxford and Dartmouth researchers surveyed the literature for studies that assessed its use in major, painful orthopedic surgeries. Their meta-analysis included 20 randomized controlled trials that compared intravenous, low-dose ketamine with placebo in this setting. Based on moderate-quality evidence, the team found that time to first opioid dose was delayed with low-dose ketamine, which also significantly curtailed opioid use overall. Additionally, pain scores at 24 and 48 hours after surgery were much lower among study participants who received low-dose ketamine. The benefits were most pronounced in patients who underwent total joint replacements. The review authors conclude that low-dose ketamine is a viable adjuvant for reducing pain and opioid demand in the orthopedic surgical setting—particularly in the first postoperative day.

From "Low-Dose Ketamine in Painful Orthopedic Surgery"
British Journal of Anaesthesia (09/19) Vol. 123, No. 3, P. 325 Riddell, J. Mark; Trummel, John M.; Onakpoya, Igho J.

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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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Phone: (855) 526-2262 (toll-free)/(847) 692-7050
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Attn: Cathy Hodson
E–ssential Editor
September 12, 2019