Anesthesia E-ssential

AANA Anesthesia E-ssential, September 5, 2019

Vital Signs

CRNAdvocacy Alert: Tell CMS You Support its Proposal to Allow CRNAs to Perform the Pre-anesthetic Assessment in ASCs

The Centers for Medicare & Medicaid Services (CMS) recently published a preview of its 2020 Physician Fee Schedule proposed rules. We are pleased to report that, at the AANA's request, CMS included a proposal that would allow CRNAs to provide the pre-anesthetic evaluation in Ambulatory Surgery Centers (ASCs) as part of the Conditions for Coverage (CfC).

The Medicare ASC CfCs are federal regulations with which ASCs must comply in order to participate in Medicare. Currently, the ASC CfCs require a physician to examine the patient immediately before surgery to evaluate the risk of anesthesia and the procedure to be performed, precluding CRNAs from performing the pre-anesthetic evaluation.

This can be a major victory for CRNAs and our patients, but we need your help to get it across the finish line. The proposed rule is open for comments until Sept. 27, 2019. And you can guarantee that thousands of our colleagues at the American Society of Anesthesiologists (ASA) will be submitting comments opposing this important proposal which, in its words, "could compromise patient safety."

We urge every AANA member to submit a comment to CMS supporting its proposal to allow CRNAs to perform the pre-anesthetic evaluation in ASCs.

Please follow the instructions below to submit your comment TODAY!
1. Log into the CRNA-PAC website with your AANA username and password.

2. You will be directed to a sample comment letter. Please personalize this letter so that it is not seen by CMS as a "form" letter. We strongly suggest that you include the type of facility in which you practice.

3. Click "send letter" to have your letter posted to the comment site. Please note that all comments are public.

If you have any questions, please don't hesitate to contact AANA Federal Government Affairs at or 202-484-8400

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Hot Topics

AANA Urges Medicare Agency to Reduce Administrative Burden for CRNAs

In response to the Centers for Medicare & Medicaid Services' (CMS) Request for Information on reducing administrative burden, the AANA recommended regulatory reforms including removing costly and unnecessary supervision requirements, amending Medicare guidance to clarify that CRNAs can order and refer Medicare services, and including CRNAs among CMS's ordering and referring data file.

The letter, signed by FY2019 AANA President Garry Brydges, PhD, DNP, MBA, ACNP-BC, CRNA, FAAN, stated, "CRNAs are not expressly prohibited from ordering and referring Medicare services by legislation or by regulation. In fact, Medicare in November 2012 published a rule indicating Medicare coverage of all Medicare CRNA services within their state scope of practice. However, our membership has informed us that the services that CRNAs order and specialists they refer to are not being reimbursed because CRNAs are not included among the type or specialty to be on the CMS ordering and referring file. Furthermore, a Medicare Learning Network article revised in October 2015 does not list CRNAs among the specialists that can order and refer. These denials are affecting patient access to needed services, such as laboratory services and physical therapy related to chronic pain management services, especially in rural areas."

The AANA letter also recommended that CMS:

  • Amend the hospital Conditions of Participation so that anesthesia services can be under the direction of a CRNA;
  • Amend the anesthesia payment rules to allow 100 percent payment for one anesthesiologist teaching two SRNAs;
  • Update Medicare policy to include CRNAs among the list of providers who can provide evaluation and management services;
  • Re-evaluate its policy regarding qualified clinical data registries in the Merit-Based Incentive Payment System Program.

Read the AANA's comment letter.

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Deadline to Request Targeted Review for 2018 MIPS Data Approaching

CRNAs should review their 2018 MIPS Performance Feedback reports and request a Targeted Review by September 30, 2019 (8:00 p.m. EST) if potential errors in calculations of the MIPS scores are found. Clinicians must meet this deadline to ensure scores are correct and payment adjustments up to 5% are applied correctly in CY2020. A Targeted Review Fact Sheet and FAQs document are available from the Quality Payment Program Resource Library. To submit a review request, log in to your QPP account, using your HCQIS Access Roles and Profile System (HARP) credentials. Members also can contact the Quality Payment Program at 1-866-288-8292; TTY: 1-877-715-6222; or email:

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Call for Abstracts: Share Your Professional Knowledge by Presenting at AANA 2020 Annual Congress in San Diego

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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New: Five Things You Need to Know About CRNA Malpractice Insurance

Malpractice insurance can be complicated. Gain a basic understanding of CRNA Malpractice Insurance with AANA Insurance Service’s new Five Things You Need to Know resource. Learn more.

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Stave off Burnout with AANA Resources

Burnout is a hot topic right now. Did you know that the AANA has multiple types of resources for burnout? These include Wellness Milestones articles, podcasts, case studies from the National Academy of Medicine, and more resources from supporting organizations. Learn more.

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It Pays to Be Prepared - Save 25% on AANA 2020 CPC Core Modules

AANA Members can save 25% on all four required modules! For just $225, you’ll have peace of mind knowing you’re all set to meet CPC requirements. Plus, you’ll get access to our new video CE platform, CRNA Knowledge Network, through January 2020. Offer expires October 31, 2019. Learn more.

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Meetings and Workshops

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 Meetings: Refresh Your Knowledge and Make New Connections

Ultrasound-Guided Peripheral Nerve Blocks
When: September 21 - 22, 2019
Location: AANA National Headquarters, Park Ridge, Ill.
View Program

Spinal Epidural with Obstetric Essentials Workshop
When: October 24 - 26, 2019
Location: AANA National Headquarters, Park Ridge, Ill.
View Program

AANA Leadership Summit
When: November 8 - 10, 2019
Location: Naples Grande Beach Resort, Naples, Fla.


Assembly of Didactic and Clinical Educators (ADCE) 2020
When: February 19-22, 2020
Registration opens in October 2019.
Location: Chateau Élan Winery and Resort, Braselton, Ga.

Learn More

Planning ahead? Check out the Future Meetings and Workshops schedule.

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AANA Member Benefits

Respiratory Compromise: How Will You Know?

Learn how monitoring for respiratory compromise can help decrease complications for your patients. With this FREE course, you’ll gain a better understanding of the latest best practices to sharpen your skills and provide the best care for your patients.

As a member, you’ll earn 1 free Class A Credit plus 0.5 credit in Pharmacology/Therapeutics.

Learning objectives:

  1. Discuss the importance of monitoring ventilation using capnography to decrease the occurrence of respiratory compromise.
  2. Outline sedation and anesthesia techniques that may mitigate the risk of respiratory compromise.

Get Started Today! Visit

Supported by Medtronic.

This course has been prior approved by the AANA for 1.00 Class A CE credit; AANA Code Number: 1037860. AANA designates this program as meeting the criteria for up to 0.5 CE Credit in Pharmacology/Therapeutics. Course Expiration Date: June 30, 2022.

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CRNA Jobs: Locum Tenens and Permanent Placement Opportunities Across the Country

United Anesthesia – Various Locations. United Anesthesia has been a leading CRNA and Anesthesiologist Locum Tenens and Permanent Placement firm in the country for 40 years. By specializing in only anesthesia placement, we can partner with you to find the ideal situation to suit your strengths, your priorities, your dreams. Your dedicated personal coordinator is looking forward to your call! Learn more.

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CRNA: CHRISTUS St. Vincent Health System, Santa Fe, New Mexico

Our CRNAs work in a collaborative team environment with 18 CRNAs, 7 Anesthesiologists and 2 Anesthesia Techs. Primarily adult population, minimal pediatrics, and no hearts. Great case mix, a lot of autonomy, excellent support from care team.

  • Deliver anesthetics across 8 Main ORs, 6 Ambulatory surgery ORs, plus OB, GI, IR, and Cath Lab – all without major travel between facilities
  • Newest technology available with state of the art equipment and Epic health record
  • Hospital employed; competitive salary and benefits package
  • Reimbursement for continuing education with educational leave time
  • Paid malpractice and reimbursement for licensure and membership dues
  • Bonus of up to $40,000 for first three years of employment
  • Relocation assistance

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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Associate Director: TCU/School of Nurse Anesthesia, Fort Worth, Texas

Texas Christian University, Harris College of Nursing and Health Sciences, seeks an Associate Director of the School of Nurse Anesthesia (professional practice faculty, assistant/associate professor). The associate director assists the director of the school of nurse anesthesia with oversight of the daily operations of the school.

EXTRAORDINARY OPPORTUNITY – The associate director will collaborate with the director to:

  • Lead a team of expert and dynamic faculty into a new era at a fiscally strong university that is moving forward under a dynamic strategic plan
  • Lead a highly ranked program (top 30 by US News and World Report)
  • Lead a pain management program of national distinction (as awarded by AANA)
  • Engage with affiliations with major hospitals in the region and across the country
  • Actively engage with the newly accredited TCU and UNTHSC School of Medicine for innovative collaborations and learning experiences
  • Have a vast opportunity for growth and success as an academic leader

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.

Prevention of Postoperative Nausea and Vomiting by Use of Rapid Sequence Intubation

The results of a clinical case review support the use of rapid sequence intubation (RSI) to avoid postoperative nausea and vomiting (PONV), a common complication of anesthesia. The hypothesis underpinning the research is that the introduction of 100 percent oxygen or volatile anesthetics in the stomach may cause PONV during mask ventilation, which is performed after induction but before securing the airway. In theory, then, using RSI—which relies on adequate spontaneous ventilation rather than mask ventilation—should avoid PONV. To investigate, high-risk patients at four different surgical settings underwent RSI with succinylcholine or rocuronium. None received preventative anti-nausea medications. Evaluation for PONV was performed immediately after extubation in the post anesthesia care unit and before discharge, as well as during a follow-up phone call on postoperative day one. One study participant experienced nausea and another suffered both nausea and vomiting, but both responded well to rescue medication, with no delay in discharge time. With a PONV rate of just 1.5 percent among a population of high-risk patients, the results from this small quality improvement study are promising and warrant larger controlled studies, according to prime investigator John Arnett Mitchell, MD, of Chicago's Mount Sinai Hospital.

From "Prevention of Postoperative Nausea and Vomiting by Use of Rapid Sequence Intubation"
Anesthesiology News (08/30/19) Mitchell, John Arnett

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A Small Dose of Remifentanil Pretreatment Suppresses Sufentanil-Induced Cough During General Anesthesia Induction

A prospective study in China questioned whether pretreatment with a small dose of remifentanil might curtail patient cough triggered by intravenous sufentanil during anesthesia induction. The small trial included patients having elective surgery under general anesthesia, 42 of whom were randomized to an intravenous infusion of remifentanil one minute prior to sufentanil injection. A control cohort, with the same number of participants, received normal saline, also one minute before sufentanil injection. Researchers counted the number of coughs produced within one minute after the sufentanil injection. The incidence was 4.8 percent for the remifentanil recipients and 31 percent for the controls. Cough was also less severe in the remifentanil group. The investigators conclude that remifentanil effectively inhibits sufentanil-induced cough and does so safely, with no effect on mean arterial pressure or heart rate at the time of general anesthesia induction.

From "A Small Dose of Remifentanil Pretreatment Suppresses Sufentanil-Induced Cough During General Anesthesia Induction"
BMC Anesthesiology (08/28/19) Vol. 19, No. 164 Lin, Wendong; Sun, Jiehao; Fu, Shuying

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Perioperative Duloxetine for Pain Management After Laparoscopic Hysterectomy

Researchers in Istanbul report on outcomes in patients who received perioperative duloxetine to manage pain from laparoscopic hysterectomy. The randomized trial include two treatment arms, each with 40 participants, that received either perioperative duloxetine or placebo two hours before and 24 hours after their procedure. Median total scores on the post-discharge Quality of Recovery-40 questionnaire came in a 111/200 and 112/200, respectively, for active treatment patients and controls. The difference was not considered to be statistically significant—nor were any of the subcomponents, including postoperative opioid consumption and duration of hospital stay.

From "Perioperative Duloxetine for Pain Management After Laparoscopic Hysterectomy"
Journal of Minimally Invasive Gynecology (08/30/19) Takmaz, Ozguk; Bastu, Ercan; Ozbasli, Esra; et al.

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Infrared Thermography to Assess Dermatomal Levels of Labor Epidural Analgesia

A team of researchers in France explored the concept of using infrared thermography to gauge the efficacy of epidural analgesia for childbirth. The prospective cohort study involved 53 women who were in spontaneous labor and requested epidural analgesia, which was induced with ropivacaine and sufentanil followed by continuous epidural infusion. Thermography was used to measure skin temperature at various dermatomes before the initial epidural bolus and then again 20 minutes later. In all but one of the dermatomes targeted, researchers observed a change in skin temperature in response to the epidural. The reaction represented sympathetic block activity of the cutaneous area. There also was a significant difference in the temperature change at the T10 dermatone in the 50 successful versus the three failed epidural procedures. Based on the work, the investigators believe infrared thermography could be a viable tool for objectively assessing the success of obstetric epidural analgesia.

From "Infrared Thermography to Assess Dermatomal Levels of Labor Epidural Analgesia"
International Journal of Obstetric Anesthesia (Summer 2019) Bouvet, L.; Roukhomovsky, M.; Desgranges, F.-P.; et al.

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IV APAP of Little Benefit for Cardiothoracic Post-op Pain

New evidence indicates that intravenous acetaminophen has little impact on pain when included in multimodal analgesia regimens after cardiothoracic surgery. To get a real-world view, researchers at Ferris State University in Michigan examined the medical records of 92 patients who received I.V. acetaminophen immediately after their procedure and 166 matched patients who did not. The main outcome was opioid analgesic consumption in the first 24 hours postoperatively. Patients in the acetaminophen group required 14.7 mg of morphine milligram equivalents (MMEs) during that time frame, while the controls used only 11.8 mg. While I.V. acetaminophen did not reduce MME after cardiothoracic surgery, the researchers did observe an association with hypotension. Among patients receiving I.V. acetaminophen, 28 percent experienced an infusion-related episode of hypotension, which study lead Paul Thill, PharmD, says suggests "a potential adverse effect of particular significance to this fragile population coming off bypass." In light of the finding, he adds that "assumptions about the efficacy and lack of toxicity of IV acetaminophen may need to be reexamined."

From "IV APAP of Little Benefit for Cardiothoracic Post-op Pain"
Pain Medicine News (08/13/19) Bender, Kenneth

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Study Confirms Cannabis Is Effective, Safe as Pain Killer

Evidence is growing that cannabis is a safe and effective agent for pain relief. A study out of the University of New Mexico finds that cannabis acts rapidly to curb pain, with little to no adverse effects, in people with a range of health conditions. The researchers analyzed data from Releaf App, where users report on the effects of cannabis-based products. The results indicate that products containing high levels of tetrahydrocannabinol (THC) effectively reduce pain, with the greatest relief coming from whole dried cannabis flower—or buds. "Cannabis likely has numerous constituents that possess analgesic properties beyond THC, including terpenes and flavonoids, which likely act synergistically for people that use whole dried cannabis flower," says lead investigator Jacob Miguel Vigil. Nonetheless, he and his team warn that moderate use is best because cannabis is potentially addictive and is associated with short-term cognitive and behavioral changes. The study appears in Complementary Therapies in Medicine.

From "Study Confirms Cannabis Is Effective, Safe as Pain Killer"
Medical Daily (08/23/19) Malicdem, Darwin

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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 5, 2019
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