Anesthesia E-ssential

AANA Anesthesia E-ssential
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FDA Warns about Withholding Opioid Addiction Medications

The U.S. Food and Drug Administration (FDA) is advising that the opioid addiction medications buprenorphine and methadone should not be withheld from patients taking benzodiazepines or other drugs that depress the central nervous system (CNS). The combined use of these drugs increases the risk of serious side effects; however, the harm caused by untreated opioid addiction can outweigh these risks. Careful medication management by healthcare professionals can reduce these risks. The FDA is requiring that this information be added to the buprenorphine and methadone drug labels along with detailed recommendations for minimizing the use of medication-assisted treatment (MAT) drugs and benzodiazepines together.  Read the entire Drug Safety Communication.
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New Video: “The Art of Reviewing and Revising State Legislative and Regulatory Proposals” and other Resources

“The Art of Reviewing and Revising State Legislative and Regulatory Proposals” a new video for AANA members from the AANA Government Relations Committee and State Government Affairs Division staff is now available.  In this video, experienced CRNAs provide helpful instructions for advancing your state’s legislative and regulatory goals. Watch video.
For more tips on effective State Government Affairs Advocacy, check out the following tip sheets:
  • Top Ten Tips for Testifying Effectively
  • Top Ten Suggestions On Establishing a Proactive Government Relations Committee
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The Joint Commission Issues Safety Alert: Minimizing Noise and Distractions in the OR and Procedural Units

The Joint Commission Quick Safety Issue lists common areas of noise and distraction in the OR (such as phones, computers, music) and describes studies measuring OR noise. The Quick Safety Issue notes that studies relevant to anesthesia concluded that the noisiest periods during surgery are associated with induction and emergence of anesthesia. Noise weakens concentration and lowers the ability to detect equipment signals. Given that noise can lead to distraction, impaired communication, and risk of adverse events, The Joint Commission recommends a systems approach to minimizing unnecessary distraction and noise, including: creating a no-interruption zone during critical phases of a procedure, measuring noise levels to provide evidence for noise-reduction strategies and real-time information to the team regarding noise levels that are exceeding recommended levels, staff education and simulation training, and equipment alternatives.  The Joint Commission also recommends actions to support noise reduction activities, such as maintaining a safety culture in which staff feel comfortable asking for silence and developing a code of conduct that addresses noise reduction and distraction.
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CMS Granting Quality Reporting Exemptions to Those Affected by Hurricane Harvey ​

On August 31, the Centers for Medicare & Medicaid Services (CMS) released an email that states it is "granting exceptions under certain Medicare quality reporting and value-based purchasing programs to acute care hospitals, PPS-exempt cancer hospitals, inpatient psychiatric facilities, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, outpatient dialysis facilities, long-term care hospitals, and ambulatory surgical centers located in areas affected by Hurricane Harvey due to the devastating impact of the storm.
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AANA Posts Hurricane Resources Online

Our thoughts are with everyone suffering hardships in the wake of hurricanes Harvey, Irma, and Maria. The AANA will continue to monitor the situations and keep you updated. Please visit the AANA's Hurricane Harvey, Hurricane Irma, and Hurricane Maria webpages for further information and links to charities, relief organizations, and other resources.The AANA will continue to update these pages as more resources become available.
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Register Now for the Fall Leadership Academy
November 3-5, Rosemont, Ill.

The AANA Fall Leadership Academy features expert speakers in six educational tracks including AANA Foundation Advocate Workforce, Business and Facility Leadership, Federal Political Director, State Grassroots Advocacy, State President-elect, and State Reimbursement Specialist. Hone and develop leadership skills for your practice, state, and business. Plus, you'll expand your network of colleagues around the country.
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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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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.

Poorly Controlled Postoperative Pain: Prevalence, Consequences, and Prevention

Despite the many benefits of surgery and anesthesia, more than 80 percent of Americans suffer from suboptimal control of acute postoperative pain. A review of the evidence suggests they subsequently are vulnerable to elevated risk of death, impaired physiological and psychological function, poorer quality of life, and higher healthcare costs, among other consequences. To prevent persistent postoperative pain from becoming a chronic condition—as has been demonstrated to occur—the author writes that more needs to be done to minimize the incidence and intensity of pain during the perioperative period as well as immediately after a procedure. Researchers suspect that local and regional anesthesia and nonopioid analgesics, as well as antiepileptic and antidepressant agents, could play a role; but additional study is needed. In the meantime, providers must continue to weigh the efficacy of opioid pain relief—the standard of care, for now—against the potential adverse effects, including nausea and vomiting, bowel dysfunction, and respiratory depression. A promising development on this front comes in the form of three new mu-opioid agonists that work differently from traditional opioids, with a better safety and tolerability profile. Preliminary data on oliceridine, for example, indicates that its selective nature expands the therapeutic window compared with unselective opioids, allowing it to produce fast postoperative analgesia with fewer complications compared with morphine. The author of the review concludes that large-scale, well-controlled studies are warranted to determine if novel therapies like oliceridine and already available interventions, such as multimodal anesthesia, mitigate the negative effect of inadequate pain management following surgery.

From "Poorly Controlled Postoperative Pain: Prevalence, Consequences, and Prevention"
Journal of Pain Research (09/17) Vol. 2017, No. 10, P. 2287 Gan, Tong J.

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Hypotensive Epidural Anesthesia Well Tolerated in Total Hip Patients

Hypotensive epidural anesthesia promises to safely and effectively reduce intraoperative blood loss during total hip replacement, a new study suggests. The single-site investigation took place at the Hospital for Special Surgery, where a team led by Sean Garvin, MD, examined the relationship between cerebral desaturation events and hypotensive epidural anesthesia in 100 patients. Hypotension was induced through combined spinal epidural with bupivacaine, with eprinephrine infusions used to maintain arterial pressure. No patients suffered stroke or delirium, and just four experienced a cerebral desaturation event—only one of which lasted longer than 15 seconds. Garvin and colleagues report that their results dovetail with previous research demonstrating preserved cerebral blood flow velocity and low rate of cognitive dysfunction and delirium with hypotensive epidural anesthesia. However, he emphasized the study's focus on healthy patients. "It's definitely worthwhile to consider this technique [for them], but more data—particularly in higher-risk patients—would be useful," Garvin remarked. He presented the findings at the 2017 annual spring meeting of the American Society of Regional Anesthesia and Pain Medicine.

From "Hypotensive Epidural Anesthesia Well Tolerated in Total Hip Patients"
Anesthesiology News (09/15/17) Doyle, Chase

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Accuracy of Capillary and Arterial Whole Blood Glucose Measurements Using a Glucose Meter in Patients Under General Anesthesia in the Operating Room

With more than 9% of all Americans battling diabetes, maintaining glycemic control in critically ill patients under general anesthesia is increasingly important. Surgical teams are advised to monitor glycemic levels in all insulin-dependent patients, those that present any risk of severe spikes or drops in blood glucose, and for any procedure lasting more than one to two hours. As a less cost- and time-intensive alternative to laboratory testing and blood gas analysis, Mayo Clinic researchers investigated the use of glucose meters in the operating room to capture not only arterial but also capillary—or fingerstick—whole blood glucose measurements. The feasibility of the approach was in question, as factors like hematocrit, blood pressure, pH, and carbon dioxide pressure can change quickly under anesthesia and throw off meter accuracy. Newer devices, however, have been improved to correct for these interferences. The study involved 196 patients, whose glucose levels were taken intraoperatively with a glucose meter and compared with reference measurements obtained with a blood gas analyzer. Based on 368 paired capillary and arterial samples and 368 reference arterial samples, the analysis indicated that both capillary and arterial whole blood glucose—as measured by glucose meter—can be used safely and effectively for intraoperative subcutaneous dosing of insulin. Neither, however, proved accurate enough to satisfy criteria for intravenous insulin or more intensive glycemic control protocols.

From "Accuracy of Capillary and Arterial Whole Blood Glucose Measurements Using a Glucose Meter in Patients Under General Anesthesia in the Operating Room"
Anesthesiology (09/17) Vol. 127, No. 3, P. 466 Karon, Brad S.; Donato, Leslie J.; Larsen, Chelsie M.; et al.

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The 2 Most Effective Operating Room Practices to Reduce SSIs

Results from a new survey identify which operating room practices most effectively curb surgical site infections (SSIs). The questionnaire asked surgeons at 20 Texas hospitals to rank surgery, anesthesia, and nursing adherence rates for dozens of infection control practices related to preoperative prep, intraoperative protocol, and postoperative care as well as to antibiotics administration, outcomes reporting, and operating room attire. "The best performing hospitals were vigilant about skin prep, using a clean closure and giving antibiotics appropriately—all those things that happened right at the level of the wound," reported lead author Thomas Aloia, MD, a surgeon at the University of Texas MD Anderson Cancer Center. "In addition, the hospitals that reported out their data on a formal basis—monthly or quarterly—to their surgeons, departments, and institutions also had the highest performance."

From "The 2 Most Effective Operating Room Practices to Reduce SSIs"
Becker's Hospital Review (09/18/17) Bean, Mackenzie

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Study Adds More Evidence That Racial, Socioeconomic Disparities May Occur During Surgical Pain Management

A retrospective review performed at The Johns Hopkins Hospital reflects a pattern of differential healthcare, especially in the area of pain management, based on racial and socioeconomic background. The "look back" analysis focused on more than 600 major colorectal operations done there from January 2013 through June 2016. Nearly 200 of the procedures took place before the institution adopted enhanced recovery after surgery (ERAS)—healthcare pathways designed to curb complications, shorten hospitalization time, and improve patient satisfaction—and about 440 occurred after implementation. The investigators, led by research fellow Ira Leeds, MD, determined that white patients and those with higher socioeconomic status were more likely to undergo transverse abdominal plane blocks and also more likely to have epidurals initiated and maintained than were nonwhite patients or those with lower socioeconomic standing. According to Leeds, the findings suggest either that nonwhite patients refused epidural blocks more often because of inadequate counseling on the advantages or that these options were offered less often to minorities and low-income patients because of internal physician bias. "This study demonstrates that process measures, which guide and document each step of care, may be critical factors in preventing differences in care, particularly those due to race and socioeconomic status," he said. "We can't fix what we don't measure."

From "Study Adds More Evidence That Racial, Socioeconomic Disparities May Occur During Surgical Pain Management"
News-Medical (09/13/17)

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Conscious Sedation in TAVR Linked to Lower Mortality, Shorter Hospital Stays

Colleagues at the Hospital of the University of Pennsylvania tackled a large-scale analysis of the use of conscious sedation for transcatheter aortic valve replacement (TAVR). The data set for the study covered 10,997 patients nationwide who underwent transfemoral TAVR from April 2014 to June 2015—roughly 90 percent of all such procedures during that time frame, according to senior author Jay Giri, MD, MPH. Just under 16 percent overall had the surgery under conscious sedation; but there was a pattern of increased use of the technique over the years, to more than 40 institutions as of 2015. The researchers also confirmed that TAVR patients who received conscious sedation experienced lower rates of stroke and/or mortality in hospital and at 30 days, were less likely to require intraoperative inotropes, and spent less time in the intensive care unit and for their overall hospital stay. However, Giri stressed, the differences between the two groups were not earth-shattering but, rather, suggest that conscious sedation is at least as safe as general anesthesia. "There are a series of steps required in the use of general anesthesia that have the potential to raise risk in patients who are otherwise potentially candidates for both approaches," he explains. "I would never say don't ever put a patient under general anesthesia for TAVR. . But it's a call to action to groups that have been resistant to get together with their heart team to come up with protocols that enable us to select patients initially that we find we're comfortable attempting without general anesthesia."

From "Conscious Sedation in TAVR Linked to Lower Mortality, Shorter Hospital Stays" (09/07/17) McKeown, L. A.

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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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