AANA Anesthesia E-ssential

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AANA Files Suit in Federal Court over MAC Limiting CRNA Payment for Pain Management

As part of its mission, the AANA strives to protect CRNA scope of practice and reimbursement. The AANA’s federal advocacy efforts include monitoring and influencing CRNA reimbursement by the Centers for Medicare & Medicaid Services (CMS) through its Medicare Administrative Contractors (MACs). In fall 2016, the MAC Novitas Solutions, Inc., which operates in certain Mid-Atlantic, Southern, and Southwestern states including Arkansas, Colorado, New Mexico, Oklahoma, Texas, Louisiana, Mississippi, Delaware, Maryland, New Jersey, Pennsylvania, and the District of Columbia (including some counties in Virginia), issued a local coverage determination (LCD) that would limit payment to CRNAs for epidural injections for pain management. This LCD is scheduled to take effect on May 4, 2017. AANA representatives met with CMS officials on April 10 to ask for immediate relief from this detrimental LCD, during which AANA was informed that the agency cannot require Novitas to reverse its course. Thus, on April 11 the AANA filed a lawsuit in federal court to prevent the LCD from taking effect. Download a a copy of the AANA complaint.

Read on for answers to frequently asked questions about the Novitas lawsuit. Member login and password required.

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Hot Topics

AANA Delivers Strong Response to Naval Association's Offensive, Inaccurate Article on VA Rule

On page 8 of its Winter 2017 issue, the Association of the U.S. Navy (AUSN) published an article in Navy magazine boasting how it had influenced the VA “to reverse its proposal to replace physician anesthesiologists with nurses in VA health care facilities," and calling the December 13 publication of the final rule “an early Christmas gift” for the AUSN Legislative Department. AANA members, especially Navy veterans who are also members of AUSN, are encouraged to read the letter to the editor from AANA President Cheryl Nimmo, DNP, MSHSA, CRNA, and consider writing their own letter to the editor to professionally express displeasure with the article’s misinformation and unsupportable conclusions.

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April 2017 AANA Journal Overview

Read on for highlights of the April 2017 issue of AANA Journal.

Propofol: Review of Potential Risks During Administration
In his provocative review, the author reminds us of potential safety issues, including infection, use in pediatrics for sedation and propofol infusion syndrome, associated with the most widely used hypnotic agent in use today.

An Initiative to Optimize Waste Streams in the OR: RECycling in the Operating Room (RECOR) Project
The authors describe a systematic program of medical waste management, something we all observe and contribute to in our daily clinical duties, yet the downstream consequences of which are rarely given due attention.

Development, Implementation, and Evaluation of a Nurse Anesthesia Program in Belize
The authors detail the development and implementation of a new nurse anesthesia education program in this underserved Central American country. The rigors are frankly presented from the planning stage through the graduation of its first class of ten.

Effectiveness of Interventions to Increase Provider Monitoring of Endotracheal Tube and Laryngeal Mask Airway Cuff Pressures
The authors present a program of education, strategic reminders, and a formal documentation site on the electronic medical record targeting the monitoring of endotracheal and laryngeal mask airway cuff pressures. They report compliance metrics with the program, designed to decrease the risk of pharyngolaryngeal complications.

Effects of Ondansetron on Attenuating Spinal Anesthesia-Induced Hypotension and Bradycardia in Obstetric and Nonobstetric Subjects: a Systematic Review and Meta-Analysis
The authors included 13 randomized trials in their meta-analysis examining the role of the commonly used anti-emetic agent, ondansetron, in preventing both hypotension and bradycardia often seen with subarachnoid, neuraxial anesthesia, finding a clinically relevant benefit of the drug in both obstetric and nonobstetric settings.

Pain Management Efficacy Study Between Continuous and Single-Administration Bupivacaine Following Lumbar Spinal Fusion
In a retrospective analysis, the authors found no difference between single shot liposomal and continuously infused plain bupivacaine in providing postop analgesia after lumbar spine surgery. They noted advantages of the former as it avoids a number of hazards associated with the continuous infusion approach.

Laryngeal Mask Airway Use in Morbidly Obese Patients Undergoing General Anesthesia
The authors examined the commonly posed question, “to LMA or not to LMA” in the patient who is morbidly obese. Issues are examined using a review of the relevant literature, finding a good deal of variance, and an absence of high-quality studies that can provide definitive recommendations.

Considerations of Epidural Analgesia in a Patient with Suspected Uterine Rupture
The author reported on a case of uterine rupture occurring in a 35-year-old woman with an epidural in place. The successful management of the case is described and serves as a testimonial to the importance of early diagnosed and systematic clinical intervention in this event whose outcome can otherwise be very poor.

AANA Journal Course: Update for Nurse Anesthetists—Part 1—A Tour of Autonomic Reflex Activity Relevant to Clinical Practice
The authors, in this CEU offering, review the mechanisms and importance of common autonomic reflexes that may be provoked during the anesthetic care of the patient and discuss their relevance, associated concerns, and where appropriate, their treatment.

ONLINE CONTENT at aana.com:

Infection Control and Patient Safety: What Is Desirable and What Is Possible During Anesthesia?
The authors provide a cogent review of the anesthesia provider's role in infection-related iatrogenesis, providing us with both challenges and the opportunities that highlight the issues that are generally “off our radar” in that they manifest well after our care responsibilities have been completed.

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Update on CEO Search

On Feb. 28, AANA President Cheryl Nimmo, DNP, MSHSA, CRNA, announced the planned retirement of AANA CEO Wanda Wilson, PhD, MSN, CRNA. An update on the search for her replacement is posted on the AANA website. See http://www.aana.com/aboutus/Pages/CEO-Search.aspx for further information, and watch the AANA website and publications for updates as they become available.

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Want to Serve on an AANA Committee?

Positions are available on AANA committees for CRNAs and student registered nurse anesthetists. Check out the committee page on the AANA website to read about the various opportunities. Deadline for submission of a committee request is May 15, 2017. Please note: If you currently serve on a fiscal year 2017 committee, you must reapply for fiscal year 2018.

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Professional Practice

Joint Commission Issues New Sentinel Alert on Safety Culture

On March 1, The Joint Commission issued Sentinel Event Alert #57, titled “The Essential Role of Leadership in Developing a Safety Culture.” The alert includes tools and techniques to improve safety culture, including an “Incident Decision Tree.” The decision tree analyzes systems failures, ranging from blame-free to willful and purposeful noncompliance, and provides related policies and procedures to facilitate patient safety. The alert includes eleven specific recommendations to achieve a safety culture.

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CRNA Volunteers Needed

Join Community Cares for Kids in Ecuador on July 22-29 to help change the lives of underserved children. The cost of hotel, airfare, and most meals is covered. For more information, contact Francis Collini, MD, FACS, PC, at fcollini@collini.com.

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Recall of Sterile Compounded Products

Isomeric Pharmacy Solutions is voluntarily recalling all lots of sterile products compounded and packaged by Isomeric and that remain within expiry to the hospital/user level because of the US Food and Drug Administration’s concerns of a lack of sterility assurance. More information and affected drugs can be found at FDA.gov.

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Foundation and Research

CRNA and Student Positions Available on AANA Foundation Board
Application Deadline Extended to June 1

The mission of the AANA Foundation is to advance the science of anesthesia through education and research. As the philanthropic arm of the AANA, the Foundation raises funds and invests in projects that directly support the nurse anesthesia profession. The Foundation is currently looking for candidates interested in playing an active role in supporting these important aspects of the CRNA profession by participating on the AANA Foundation Board of Trustees. Review the criteria and access the application and nominee profile form at
dNominationApplication.aspx. If you have any questions, contact the Foundation at (847) 655-1170 or foundation@aana.com.

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Application Deadline for Post-Doctoral and Doctoral Fellowships “State of the Science” General Poster Presentations and Research Grants is May 1

Attention researchers: Applications are available for Post-Doctoral and Doctoral Fellowships, “State of the Science” General Poster Presentations, and Research Grants. The deadline for submission is May 1, 2017. Visit the applications and program information page on the AANA Foundation website and contact the AANA Foundation at (847) 655-1170 or foundation@aana.com if you have questions. Thank you!

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Support Important Research: Donate to the AANA Foundation Annual Campaign Today!

The AANA Foundation supports important research with the help of individuals, state associations, and corporations. Evidence provides proof, and proof is power! Take a moment today to make your tax-deductible gift to AANA Foundation’s Proof is Power campaign—access the Foundation’s secure donation page.

Donations of $100 or more made by July 1, 2017, will be included in the AANA Foundation Fiscal Year 2017 Annual Report and Recognition booklet.

Thank you in advance for your contribution and support of nurse anesthesia through the AANA Foundation!

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

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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.

Conscious Sedation Is a Safe Alternative to General Anesthesia for Heart Valve Procedure

Transcatheter aortic valve replacement (TAVR) can be safely and successfully performed under conscious sedation, report UCLA researchers. Using medical records for 196 patients who underwent the minimally invasive heart procedure at the same facility between August 2012 and June 2016, the team studied outcomes as well as the cost of care in the study population. Compared with general anesthesia, which is normally used for the procedure, TAVR patients who remained awake but free of pain stayed in the intensive care unit for only 30 hours versus 96 hours. They were discharged sooner, too—in 4.9 days compared with 10.4 days for general anesthesia patients—and their direct cost of care was 28 percent lower. Meanwhile, adverse events—including death—occurred at a similar rate between the two cohorts. Based on their findings, the UCLA investigators believe a large, randomized controlled trial is warranted to confirm the evidence.

From "Conscious Sedation Is a Safe Alternative to General Anesthesia for Heart Valve Procedure"
Medical Xpress (04/11/17)

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What Are Surgical Mortality Risks in Relatively Healthy ASA I and II Patients?

An analysis done by the University of California, San Diego indicates that fewer deaths are occurring during or after surgery among the relatively healthy set. Based on a sample of more than 1.5 million patients in the National Surgical Quality Improvement Program database who were designated as ASA I or II, 0.11 percent died within 30 days of an operation. The rate, as researchers suspected it would, declined annually between 2006 and 2013; but surgery is not without its risks for these patients. The UCSD team also developed a risk calculator to flesh out clinical predictors for perioperative mortality in the ASA I or II population. Among others, the investigators cited general anesthesia, preoperative pneumonia or sepsis, history of alcohol abuse, emergency status of surgery, elevated or depressed white blood cell count, longer duration of surgery, and age older than 65 years as risk factors. "We always think about ASA I and ASA II patients as being healthy and that they'll do fine if we take them for surgery," noted researcher Diana J. Hylton, MD. "But I think it's helpful to know that these patients—particularly those with certain risk factors—actually have fairly high mortality rates." Taking these factors into account, she and her team conclude, could enhance preoperative optimization of patients.

From "What Are Surgical Mortality Risks in Relatively Healthy ASA I and II Patients?"
Anesthesiology News (04/11/17) Vlessides, Michael

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New Anaesthesia Technique Saves Patient With Obstructed Airway

An innovative anesthesia technique, reported by the British Journal of Anaesthesia, has proven to be a life-saver under real-world circumstances. STRIVE Hi, which couples two relatively new approaches, is designed to protect surgical patients who are handicapped by an obstructive airway. Doctors in Australia say it was used to safely keep rapid swelling from blocking the airway of a man with an infected epiglottis. A study at Princess Alexandra Hospital there demonstrated the viability of the new technique, which takes the place of intubation. Instead, patients are oxygenated through spontaneous breathing during anesthesia plus high-flow nasal oxygen supply. "Through this combination we have been able to manage anaesthesia for patients with very challenging airway narrowing," confirmed Anton Booth, senior lecturer at the University of Queensland in Brisbane. "We have been able to achieve quite spectacular improvements in oxygen levels while patients are in deep anesthesia. This is a modern alternative to traditional techniques and has great potential to be used in many other scenarios." He added that STRIVE Hi is improving quality of life for patients who until now have not been good candidates for surgery.

From "New Anaesthesia Technique Saves Patient With Obstructed Airway"
Ians News Service (04/10/17)

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Conscious Sedation OK for Posterior Stroke Thrombectomy

Based on findings from the SIESTA trial, investigators at Emory University believe some vertebrobasilar occlusion stroke patients are viable candidates for conscious sedation instead of general anesthesia during endovascular therapy. Clinicians tend to avoid monitored anesthesia care in this population because of concerns about periprocedural complications—including hemorrhage—due to patient movement and airway protection problems caused by a depressed level of consciousness. However, the Atlanta researchers write in JAMA Neurology, "the routine application of general anesthesia may be harmful in a subset of patients because it may lead to decreased blood pressure and delays in achieving reperfusion." For the primary analysis, the retrospective study examined clinical outcomes in 122 propensity-matched patients. At 90-day followup, there was no meaningful disparity between vertebrobasilar occlusion stroke patients who received conscious sedation and those who were intubated in terms of mortality rate or distribution of Rankin scale scores. Recanalization rates and procedure times also were similar. "This study represents, to our knowledge, the first systematic matched case-control analysis and the largest report addressing this critical issue," the Emory team summarized. "This becomes particularly important in the face of the decline in the use of general anesthesia for stroke thrombectomy. Given this trend and in the face of our data, the routine use of general anesthesia for posterior circulation thrombectomy should be reconsidered and warrants further investigation."

From "Conscious Sedation OK for Posterior Stroke Thrombectomy"
MedPage Today (04/10/17) Lou, Nicole

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UCSF Study: Temporary Memory Loss After Surgery May Be Tied to Brain's Immune Cells

Deep anesthesia has long shouldered the blame for post-surgical cognitive loss in the elderly, but there is growing proof that the actual cause may be brain inflammation. The evidence suggests that the reaction occurs in response to tissue trauma anywhere in the body; however, excessive or overly persistent inflammation may become harmful to cognition rather than protective of it. The latest study to suspect this correlation comes out of UC San Francisco, where researchers investigated specialized immune cells in the brain—known as microglia—in mice. The laboratory animals were given an experimental drug that temporarily wipes out microglia before an operation. Several days post-op, the rodents were much less likely to fail memory tests. "There is an impact on memory in the mouse model that mirrors what has been observed in studies of post-surgical cognitive impairment in humans," remarked Suneil Koliwad, MD, an assistant professor of medicine at UCSF, "and we can mitigate it with treatment that we think is not harmful to the animal." The research is published in JCI Insight.

From "UCSF Study: Temporary Memory Loss After Surgery May Be Tied to Brain's Immune Cells"
San Jose Mercury News (04/06/17) Seipel, Tracy

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UMD Researchers' Augmented Reality Technology Could Help Doctors in the Operating Room

The University of Maryland's Augmentarium and its shock trauma center teamed up to develop augmented reality technology that ultimately could find a home in operating rooms. In a recent demonstration of the innovation, which is still being fine-tuned, researchers and doctors showed how it can help with intubation as well as ultrasound. Developers also believe it may be useful for training purposes in medical settings. Augmented reality technology adds real-time data to the field of view of a user wearing a headset, so that he or she does not have to repeatedly look away to see the information in a separate environment. "Some surgeries are very complex," notes Brian Servia, president of the augmented reality club at UMD. "Maybe we can standardize the entire surgery throughout the United States with this lightweight device that can augment the steps of the surgery that are non-invasive." For now, though, developers must conduct practitioner studies to determine if the technology is beneficial for clinical use. If it is deemed so, the next steps will entail researching how information can best be presented on the headsets, obtaining necessary regulatory approvals, and introducing the devices to the medical community.

From "UMD Researchers' Augmented Reality Technology Could Help Doctors in the Operating Room"
Diamondback (MD) (04/06/17) Roscoe, Jack

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Efficacy of TAP Block Unreliable in Morbidly Obese Parturients

Transversus abdominis plane (TAP) block is sometimes included in multimodal analgesia following cesarean section, but the optimal approach for administering it has not been established. To investigate, researchers studied 120 morbidly obese patients at Northwestern University's Feinberg School of Medicine. Due to the risk of respiratory depression, the Chicago institution avoids neuraxial morphine for post-cesarean pain relief in heavy patients. Instead, the women were randomized to receive postoperative TAP block with either saline or one of three doses of ropivacaine. Morphine-equivalent consumption at 24 hours, the primary outcome, was lower for mothers who received 0.2 percent or 0.5 percent ropivacaine in their TAP block compared with the saline patients. Oddly, however, there was no meaningful difference between the control patients and those who received the highest dose of ropivacaine: 0.75 percent concentration. Based on the wide confidence intervals—with no obvious difference in patient traits to explain them—Feinberg assistant anesthesiology professor Joseph Bavaro, MD, said his team determined that TAP analgesia is inconsistent and unreliable for morbidly obese women following cesarean delivery.

From "Efficacy of TAP Block Unreliable in Morbidly Obese Parturients"
Anesthesiology News (04/05/17) Vlessides, Michael

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Ketamine for Chronic Pain on the Rise

Ketamine, introduced in 1966 as an anesthetic, is increasingly showing up in private clinics nationwide as a treatment for chronic pain. While the drug is indeed a potent pain reliever, its effect is short-lived; and use may be accompanied by headache, nausea, and fatigue, among other adverse outcomes. There also is a risk of abuse given ketamine's euphoric properties, which have earned it a reputation as a club drug. For these and other reasons, clinicians are apprehensive about pain centers administering off-label ketamine infusions for conditions ranging from fibromyalgia to migraines. The jury is still out, they say, on whether ketamine is a viable option for pain management. While some studies have reported a benefit, the quality of the evidence is low due to the small scale, limited generalization, and lack of effective blinding in these investigations. Moreover, research evaluating ketamine for chronic pain has focused on intravenous infusion, which inflates the cost of treatment and limits its use over the long term. The American Society of Regional Anesthesia and Pain Medicine is expected to issue guidelines on ketamine use for pain management within six months, but University of Pittsburgh anesthesia and psychiatry professor Ajay Wasan, MD, says clinicians will not get much real direction until more is known. "It's not clear at all at this point exactly how to administer it," he points out. "We don't really know how beneficial it is or which patients would be the best ones to put on it. We also don't know exactly how much ketamine to infuse and for how long and how frequently to give the infusions." AANA has ketamine resources available to members at www.aana.com/KetamineInfusion.

From "Ketamine for Chronic Pain on the Rise"
Medscape (04/04/17) Anderson, Pauline

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Brain Differences Between Men, Women Affect Response to Pain Relief

Researchers at Georgia State believe they have unlocked the mystery of why more morphine, sometimes twice as much, is needed in women than in men to reach similar levels of pain relief. They attribute the difference in analgesic requirement to the behavior of microglia, immune cells that activate at any sign of injury to protect the central nervous system against pathogens. According to the investigators, microglia exist at the same density in the brains of men and women but are more active in the pain-processing areas of the female brain. The extent of activation, meanwhile, is an indicator of how much morphine it takes to achieve a specific analgesic effect. The immune receptor TLR4, which produces a neuroinflammatory response when binded by morphine that works against the drug's pain-killing properties, also plays a role. In laboratory testing, the gender disparity in morphine responsiveness was eliminated when male and female rats were given a TLR4-blocking agent. Associate professor and senior author Anne Murphy notes, "The results of the study have important implications for the treatment of pain, and suggest that microglia may be an important drug target to improve opioid pain relief in women."

From "Brain Differences Between Men, Women Affect Response to Pain Relief"
Daily Times (04/03/17)

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Music Therapy Reduces Pain in People Recovering From Spine Surgery

New research published in The American Journal of Orthopedics suggests that music therapy can offer relief following spine surgery. The study compared pain scores between patients who received routine postoperative care and patients who additionally underwent music therapy within 72 hours of spinal fusion. The Louis Armstrong Center for Music and Medicine provided the 30-minute sessions, which included live music or combination singing and rhythmic drumming as well as breathwork and visualization techniques. Pain scores—measured using the visual analog scale—improved in the 30 music therapy patients but worsened in the 30 patients who received usual care. "The degree of change in the music group is notable for having been achieved by non-pharmacologic means with little chance of adverse effects," said study co-author Joanne Loewy, who runs the Louis Armstrong Center. The research was conducted in collaboration with the Mount Sinai Department of Orthopaedics.

From "Music Therapy Reduces Pain in People Recovering From Spine Surgery"
National Pain Report (04/02/17)

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Scheduled Oral Analgesia for Superior Pain Control in Postcesarean Women

An Israeli study demonstrates that prescheduled pain management, as opposed to waiting for the patient to ask for medication, delivers greater relief following cesarean section. The 214 women who participated were all given the same pain control agents in the 48 hours after delivery, with 108 randomized to receive them at pre-planned fixed intervals and 106 assigned to get them on demand. Upon arrival to the maternity ward after the procedure, patients were administered intravenous tramadol hydrochloride, oral paracetamol, and diclofenac. Women on the predetermined medication schedule also took a combination of paracetamol and tramadol every six hours thereafter and diclofenac again at 12, 24, and 48 hours. Those in the other cohort only received additional medication when they requested it—as long as it was within the same time parameters as the scheduled group. Pain scores, evaluated every six hours on the visual analog scale, revealed reduced pain and higher satisfaction with the pain management approach in women on the fixed schedule at all intervals. "In my opinion, early treatment when the pain is not very intense, as well as anticipation of pain relief, contribute to the superiority of fixed-time interval protocol over analgesia administration following demand," said lead study author Enav Yefet, MD. "Those findings stress the fact that pain should be prevented, rather than treated." The study is reported in the British Journal of Obstetrics and Gynaecology.

From "Scheduled Oral Analgesia for Superior Pain Control in Postcesarean Women"
Clinical Pain Advisor (03/30/17) Peckel, Linda

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UAMS Study Says 3 Day Supply of Opioids Could Reduce Chronic Opioid Usage

Having opioid analgesic supplies of three days or fewer will reduce the likelihood of chronic opioid use, according to a new study from the University of Arkansas for Medical Science (UAMS). Researchers looked at individuals aged 18 years and older who were prescribed opioid analgesics from 2006 until 2015. They documented such information as whether people used opioids within the last six months, the number of days on a prescription, and whether patients continued to use opioids years later. The findings showed that the likelihood of chronic opioid use increased with each additional day of medication after the third day. Moreover, addiction to opioid analgesics increased the sharpest after the sixth and 31st days of opioid use or when a second prescription was authorized or refilled. The UAMS study noted that approximately 10% of patients were prescribed tramadol, which the study lists as a Schedule III-IV opioid. The investigators suggested that those on tramadol might show an "intentional chronic opioid prescribing."

From "UAMS Study Says 3 Day Supply of Opioids Could Reduce Chronic Opioid Usage"
KTHV-TV (Little Rock) (03/27/17)

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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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April 14, 2017
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