Anesthesia E-ssential

AANA Anesthesia E-ssential
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Vital Signs

From the AANA Board of Directors:
Hurricane Harvey Resources

Our thoughts and prayers are with everyone in Texas affected by Hurricane Harvey as they struggle with the loss and damage caused by this devastating storm. We've heard from the nurse anesthesia programs located in this area, and they have indicated most of their students and faculty have checked in and are safe. 
The AANA has resources to help. Please visit to find an open shelter, list yourself as safe and well, and find links to additional Hurricane Harvey resources. We have also provided a link on that page to how you can get and offer help.
We will continue to monitor the situation and keep you updated.
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Hot Topics

President Nimmo's Editorial Tackles Opioid Crisis

An opinion-editorial by AANA President Cheryl Nimmo, DNP, MSHSA, CRNA, titled, "The healthcare industry has been part of the opioid problem—it's time we're part of the solution," was published in the Aug. 25 issue of the Washington, D.C., newspaper The Hill. In it, Nimmo discusses the roots of America's burgeoning opioid addiction crisis and offers recommendations on how CRNAs can be part of the solution. 
Nimmo states,"...while vital efforts and resources have been focused on helping millions of Americans recover from addiction, not nearly enough attention has been paid to correcting the problem at its source. It is time that the healthcare community comes together, recognizes its faults, modernizes opioid-prescribing criteria and develops more effective, evidence-based solutions to pain management practices, to help prevent rather than treat opioid addiction."
Nimmo points to current patterns of prescribing opioids for acute and chronic pain as one of the causes of the crisis. "As long as we continue to view opioids as the indiscriminate first rather than the last possible solution to manage pain, we cannot expect to see any change in addiction and overdose statistics," Nimmo writes. "Acute and chronic pain are best treated and managed by a team of healthcare professionals that actively engages patients in the diagnosis and management of their pain for improved well-being, functionality, and quality of life." 
With their holistic approach to patient care, CRNAs are positioned to be at the forefront of that team, Nimmo states. "Certified Registered Nurse Anesthetists, who are on the front lines of pain management, are implementing a proven, multimodal pain management strategy which begins before the procedure and continues through discharge using opioid-sparing techniques such as regional anesthesia, peripheral nerve blocks, non-pharmacologic approaches and non-opioid medications. This thorough assessment and treatment of pain, which may include judicious opioid prescribing, can decrease the risk of acute pain transitioning to chronic pain and the development of opioid dependency and abuse."
Read the full editorial.
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CRNAs to be Featured in USA Today Insert on “Future of Anesthesiology”

A special insert on the “Future of Anesthesiology” to appear in the Sept. 8 weekend edition of USA Today will include a two-page spread featuring an interview article with CRNAs discussing Enhanced Recovery after Surgery (ERAS) and a full-page ad promoting the role and value of CRNAs in today’s healthcare system.
The interviewees for the full-page article were 2018 AANA President Bruce Weiner, DNP, MSNA, CRNA, President-elect Garry Brydges, DNP, MBA, MSN, CRNA, ANCP-BC, and Senior Director of Professional Practice Lynn Reede, DNP, MBA, CRNA, FNAP. The print ad and four complementary digital ads promote the 2018 CRNA Week theme “Every Breath, Every Beat, Every Second—We are There.”
Produced by MediaPlanet, 250,000 print copies of the insert will be distributed through USA Today in the following markets: Boston, Chicago, Los Angeles, and New York. Total potential readership is estimated at 750,000, not including online.
The insert will also be distributed to attendees of the AANA Nurse Anesthesia Annual Congress in Seattle Sept. 8-12. A link to the insert will be available upon publication.
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Now Available: 2017 CRNA Compensation and Benefits Report

The AANA Compensation and Benefits Report provides a valuable resource on everything you need to know about CRNA employment trends. Whether you're negotiating your own salary, benchmarking salaries for your staff, or conducting research, the AANA provides a comprehensive and reliable source of CRNA-specific compensation and benefits data in an easily digestible report. AANA Members receive a free 13-page Executive Summary and 50 percent off the full 170+ page report. Order your copy today from the AANA Store.
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2016-17 AANA Annual Report Posted

The 2016-2017 AANA Annual Report is now available on the member side of the AANA website. Included are reports from AANA standing, elected and other committees; the AANA Journal Editorial Committee; AANA liaisons with other organizations; the AANA Foundation; the Council on Accreditation (COA) of Nurse Anesthesia Educational Programs and the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA); the International Federation of Nurse Anesthetists (IFNA); and AANA CEO Wanda Wilson, PhD, CRNA. Included in the CEO report is data from AANA practice profile and member demographics surveys.      
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New Billing Resource Available for Members

Review AANA's new Anesthesia Billing Basics Considerations Checklist (login required), which describes anesthesia billing, reimbursement, and documentation.  See Anesthesia Billing Basics. The document also provides suggestions for steps to take in the case of reimbursement denials. For additional practice management resources, visit PracticeManagement.
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Upcoming Webinar: Obstetric Care for Women with Opioid Use Disorder

Join the Council on Patient Safety in Women’s Health Care for a complimentary webinar on Wednesday, September 6, at 1:30 pm ET, providing an in-depth discussion of the Obstetric Care for Women with Opioid Use Disorder Patient Safety Bundle. Learn how to effectively implement and utilize the bundle within your organization. 
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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.

Fentanyl Not Recommended for Routine Use During Coronary Angiographies

There is new evidence to suggest that fentanyl is not an ideal choice for sedation during coronary angiography. The PACIFY study at Johns Hopkins University included 107 patients who were administered fentanyl in addition to local anesthetic and intravenous midazolam to prepare them for the procedure. An additional 105 angiography patients received the local anesthetic and midazolam only. Seventy participants who required a heart stent to open a blockage also were given ticagrelor, a fast-acting platelet blocker. Investigators not only determined from postoperative surveys that pain relief from the drug was no better than that offered by local anesthesia, but they also found that fentanyl can actually be harmful in this setting. According to their research, the anesthetic dilutes the efficacy of ticagrelor—which belongs to a class of drugs that work to keep platelets from sticking together to form blood clots on stents. Based on the findings, the researchers believe the time has come to reconsider the routine use of fentanyl for angiography and stenting.

From "Fentanyl Not Recommended for Routine Use During Coronary Angiographies"
Medicalxpress (08/29/2017)

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Routine Pressure Checks Reduce Incidence of Laryngeal Mask Cuff Overinflation

Researchers have offered a solution to the problem of laryngeal mask (LM) cuff overinflation during general anesthesia, which can contribute to postoperative sore throat and other adverse events. The first phase of their study compared cuff pressures in 61 patients undergoing general anesthesia with endotracheal tubes (ETTs) and 51 with LMs. While ETT cuff pressures were measured at a mean 20 cm H2O, an acceptable level, LM cuff pressures trended at more than 60 cm H2O. The second phase of the study, involving 50 patients, introduced a pressure-regulated syringe for monitoring. The investigators also used a manometer to gauge pressures separately. Cuff pressures were lowered substantially, to a mean level of 25 cm H2O. Because the “green zone” indicators for suitable pressures ranged from 40 to 60 cm H2O on the LM syringes, colleagues Christian Taylor, MD, and Robert Friesen, MD, prefer the manometry method. “Using a manometer is a relatively easy process to do; it only takes about two or three seconds,” explained Taylor, a pediatric anesthesia provider at Children's Hospital Colorado, where the study was conducted. “We think that if providers made it a part of their routine practice, the risk of causing airway adverse events could be significantly decreased.” He and Friesen's findings were first presented at the 2017 meeting of the Society for Pediatric Anesthesia/American Academy of Pediatrics Section on Anesthesiology and Pain Medicine.

From "Routine Pressure Checks Reduce Incidence of Laryngeal Mask Cuff Overinflation"
Anesthesiology News (08/23/17) Raj, Ajai

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Caffeine May Reduce Surgical Pain Caused by Poor Sleep

The link between lack of sleep before an operation and pain after it has been well-documented, but researchers at the University of Michigan sought to deepen that understanding. Led by Giancarlo Vanini of the school's anesthesiology department, they used lab animals to explore whether a short period of sleep deprivation ahead of surgery would affect postoperative pain and recovery. Some of the rats were deprived of sleep before surgical cuts were made in their paws, while others were well-rested before the procedure. The sleep-deprived rodents were much more sensitive to pain after the incisions and required more recovery time than the control animals. The effect was mitigated, however, by inhibiting receptors for adenosine—a neurotransmitter implicated in sleep regulation—in the hypothalamus region of the brain. With that knowledge, the investigators also observed the effect of caffeine—which is known to block adenosine receptors—on the rats. The stimulant did curtail postoperative pain, but only in rats that were deprived of sleep before surgery. "We think that caffeine might prevent the increase in pain sensitivity by blocking part of the neurochemical changes induced by sleep deprivation in specific brain areas that control sleep and wakefulness, and project to pain-related sites," explained Vanini. "This study suggests a novel intervention with potential to significantly improve postoperative pain management in clinical settings. We now look forward to testing whether caffeine is effective to reduce pain in surgical patients."

From "Caffeine May Reduce Surgical Pain Caused by Poor Sleep"
Medical News Today (08/22/17) Whiteman, Honor

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Opioid Reduction Strategy Lowers Unanticipated Admissions and 30-Day Emergency Visits

In Missouri, anesthesia providers at Phelps County Regional Medical Center in Rolla say their experience demonstrates how taking an opioid-sparing approach in the perioperative stage yields favorable short- and long-term outcomes. The retrospective study included patients who had arthroscopic shoulder surgery under an enhanced recovery after surgery (ERAS) pathway, a multimodal pain management strategy. A total of 88 patients underwent standard ERAS protocol. For another 88, the beta blocker esmolol was used in place of the opioid fentanyl for sympathetic blockade. Unexpected admissions and 30-day emergency department visits dropped sharply—to 2.27 percent from 11.4 percent and to 3.41 percent from 12.5 percent, respectively—among the patients who received esmolol. While reviewing patient charts for possible factors to explain the disparity, Emily Buckley and Michael Burns flagged between-group differences in intraoperative and total opioids consumed. "Patients receiving a large dose of opioids intraoperatively were at higher risk of failing the OSA [obstructive sleep apnea] protocol, which kept you in-house longer," Buckley noted. Burns added, "Many of our patients were leaving the medical center and quickly re-entering the health care system. With the initiation of this protocol, however, we had a risk change from one out of four patients being readmitted within 30 days or unanticipated admission the day of surgery to one out of 16."

From "Opioid Reduction Strategy Lowers Unanticipated Admissions and 30-Day Emergency Visits"
Pharmacy Practice News (08/21/17) Doyle, Chase

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Electrotherapy and Acupuncture Linked With Decreased, Delayed Opioid Use After TKA

A systematic review published in JAMA Surgery suggests that the need for opioid relief following total knee arthroscopy (TKA) can be lessened by nonpharmacological interventions. The meta-analysis included 39 randomized controlled trials that evaluated cryotherapy, preoperative exercise, electrotherapy, continuous passive motion, acupuncture, or other alternatives after TKA. The findings suggested a pain relief benefit with acupuncture; however, the quality of that evidence was low. Curtailed opioid use and greater pain relief were tied to cryotherapy, but that data also was low in certainty. The results additionally indicated that opioid use and pain scores were not lowered with continuous passive motion nor with preoperative exercise. Moderate-certainty evidence, meanwhile, correlated reduced opioid use with acupuncture and lower opioid consumption with electrotherapy.

From "Electrotherapy and Acupuncture Linked With Decreased, Delayed Opioid Use After TKA"
Healio (08/16/2017) Jaramillo, Monica

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Are OTC Lidocaine Patches as Effective as Rx for Localized Pain?

Lidocaine patches sold over the counter (OTC) relieve localized pain just as well as prescription versions, according to a new study. A total of 87 patients were randomly assigned to treatment with OTC transdermal patches consisting of 3.6 percent lidocaine and 1.25 percent menthol, to prescription patches with 5 percent lidocaine, or to placebo. The results indicated that the OTC patches were on par with prescription lidocaine in terms of efficacy, safety, and quality of life and were superior in those respects to placebo. The study authors—who reported their data in Pain Management—surmise that the menthol in OTC transdermal patches increases skin permeability, facilitating more efficient drug delivery to the target area.

From "Are OTC Lidocaine Patches as Effective as Rx for Localized Pain?"
Monthly Prescribing Reference (08/17) Han, Da Hee

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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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