Anesthesia E-ssential

AANA Anesthesia E-ssential, May 24, 2018
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20 Percent Off Class A Pharm Credits for Virtual Simulations Course Through May 31

A new online course is now available on AANALearn® featuring three virtual simulations of opioid prescribing scenarios. Based on CDC Guidelines for safe opioid prescribing, the content in this new course is immediately applicable to the work CRNAs do every day. Register today for the course before the price increases on June 1. Watch the video tutorial to learn more.

Learning Objectives:
  1. Understand and calculate Morphine equivalent.
  2. Use CDC Opioid Guidelines for safe prescribing strategies of opioids in the acute and chronic pain setting.
  3. Use CDC Opioid Guidelines to offer alternative and complementary non-opioid pain control measures.
Educational benefits of virtual simulation:
  • Gain experience in three realistic scenarios in a no-risk patient interaction.
  • Unlimited attempts to practice the clinical scenario until you succeed.
  • No test at the end. Assessment is built into the serious gaming experience.
  • Multi-sensory, interactive learning increases retention.
  • Accessible from your own computer, 24x7.
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NewsMaker: Lynn Reede to Serve on ANA #EndNurseAbuse Steering Committee

Lynn Reede, DNP, MBA, CRNA, FNAP, AANA Chief Clinical Officer, has been invited to serve on the American Nurses Association #EndNurseAbuse Steering Committee Panel to increase awareness of the serious problem of physical and verbal abuse against nurses. The initiative will focus on strengthening zero tolerance policies for violence against nurses and reporting of nurse abuse. To learn more about the initiative and workplace wellness resources, visit AANA Wellness in the Workplace.
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NewsMaker: CRNA Freddy Box is a Healthcare Heroes Finalist

Freddy Box, CRNA, recently had the honor of being a finalist in the Healthcare Hero Awards, CRNA Category, and received recognition at the Healthcare Heroes banquet last month.

One of three finalists from Morehouse General Hospital in Bastrop, Louisiana, Box is a CRNA with more than 14 years of experience in his field. He has worked as a nurse for 22 years. It was while working as a nurse that he took an interest in anesthesia.

Read more in Beauregard Daily News
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Professional Practice

2018 APSF Trainee Quality Improvement (TQI) Recognition Program

Student registered nurse anesthetists are encouraged to submit a video to demonstrate their program’s work in patient safety and QI initiatives to the Anesthesia Patient Safety Foundation’s Trainee Quality Improvement Program. The top two projects will receive APSF recognition and financial rewards. Learn more on the APSF website. Deadline extended until August 31, 2018.
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Ketamine Infusion Therapy Survey Report Available

The AANA recently conducted a survey of CRNA practice related to ketamine infusion therapy for psychiatric care or chronic pain management. View the survey report, under AANA Resources, and other resources at Ketamine Infusion Therapy.
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FDA Approves the First Non-Opioid Treatment for Management of Opioid Withdrawal Symptoms

The U.S. Food and Drug Administration (FDA) has approved Lucemyra (lofexidine hydrochloride) for the mitigation of withdrawal symptoms to facilitate abrupt discontinuation of opioids in adults. While Lucemyra may lessen the severity of withdrawal symptoms, it may not completely prevent them and is only approved for treatment for up to 14 days. Lucemyra is not a treatment for opioid use disorder (OUD), but can be used as part of a broader, long-term treatment plan for managing OUD. Learn more in the FDA news release.
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NIOSH and FDA Collaboration Streamlines Regulatory Oversight for N95 Filtering Facepiece Respirators

In a collaborative effort to harmonize regulatory oversight of N95 filtering facepiece respirators, or N95s, the National Institute for Occupational Safety and Health (NIOSH) and the Food and Drug Administration (FDA) have joined forces to help reduce duplicative premarket processes for N95s used in healthcare settings. On May 17, 2018, FDA published a final order to exempt a subset of N95s intended for use in healthcare from premarket notification requirements subject to conditions and limitations. NIOSH and FDA entered into a Memorandum of Understanding that provides a framework for efficient and coordinated regulatory oversight between FDA and NIOSH, and outlines the agencies’ mutually agreed upon review process. Learn more in the NIOSH Science Blog.
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Featured Career Opportunities

FT CRNA Faculty Position (DNAP Research Director)
Georgetown University
Washington, DC

Georgetown University Doctor of Nurse Anesthesia program (DNAP) seeks a full-time doctoral prepared CRNA faculty as the Director of Research. If interested, kindly contact Ladan Eshkevari, PhD, CRNA at!

CRNA – Steward Medical Group
Fall River, MA

Prep patients and post-operative care for adults and children in Orthopedics, General and Vascular, ENT, Thoracic, Obstetrics, Neurosurgery & Same-day Pediatrics.


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Visit 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.

Patient-Controlled Analgesia Pumps Have Low Device-Related Error Rates

Anesthesia & Analgesia reports on a retrospective analysis of device-related errors associated with intravenous, epidural, and nerve block patient-controlled analgesia (PCA). The researchers examined records for nearly 83,000 patients who had surgery over a four-year time span at a single institution. They attributed 610 PCA errors to human mistakes, and only 155 to device-related malfunctions. About half of the device-related problems were due to underflow, the No. 1 reason for pump error, although overflow actually presented more risks inherent with opioid analgesics. That suggests, the investigators concluded, that "effective postoperative pain management requires a balance between safety issues, mainly from overflow, and satisfaction issues, mainly from underflow." Other, less-frequent culprits included display error or broken device. Problems were most likely to affect electronic programmable pumps, followed by semi-electronic pumps, carbon dioxide-driven infusers, and balloon infusers. The researchers noted that about 63 percent of patients whose device failed suffered an adverse event, including inadequate analgesia and opioid overdose symptoms. Overall, however, the rate of device-related error was low, indicating that they can safely be used to control pain after a surgical procedure.

From "Patient-Controlled Analgesia Pumps Have Low Device-Related Error Rates"
Clinical Pain Advisor (05/22/18) Rothbard, Gary

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IV Tramadol Significantly Reduces Post-Op Pain in Phase 3 Study

New findings indicate that intravenous tramadol effectively relieves moderate to moderately severe pain after bunionectomy. The evidence comes from a randomized trial involving 409 patients—a third of whom were assigned to 25 mg of IV tramadol, a third of whom received 50 mg of the synthetic opioid, and a third of whom were given placebo postoperatively. Treatment was administered over 15 minutes at zero, two, and four hours after surgery and every four hours thereafter for up to 13 doses. The researchers found that 50 mg of tramadol significantly improved Sum of Pain Intensity Difference (SPID) scores over 48 hours postoperatively compared to placebo, which was the primary outcome. It additionally was superior to placebo on the secondary endpoints: SPID over 24 hours, total usage of rescue medication, and Patient Global Assessment. Pain in these patients was curtailed markedly at the first evaluation, 30 minutes post-dose. Although IV tramadol was associated with greater risk for nausea, vomiting, and somnolence, these side effects typically were mild or moderate in nature, and the treatment was generally well tolerated.

From "IV Tramadol Significantly Reduces Post-Op Pain in Phase 3 Study"
Monthly Prescribing Reference (05/21/18) Ernst, Diana

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Surgery Can Cause Cognitive Losses in Some Seniors

The medical community is looking forward to the June release of new research plus a two-day summit on postoperative cognitive dysfunction (POCD), which they hope will clear up some of the mystery behind the phenomenon. Though subtle, the symptoms—which include memory problems, learning difficulties, and more—can last as long as a year and tend to affect older populations following surgery. Estimates on the share of patients who experience POCD vary from study to study, but the percentages are considerable. Some other questions include how best to measure the complication and whether it can be prevented or treated. There is also the matter of anesthesia and its possible role in POCD. Research has looked at whether choice of intraoperative anesthetic or depth of anesthesia have any relevance when it comes to POCD, but findings to date have been inconclusive. Other studies point to the stress of surgery itself, rather than the anesthesia, as a trigger for POCD. For example, Stacie Deiner of the Icahn School of Medicine at Mount Sinai in New York City has been performing general anesthesia on healthy seniors who undergo cognitive testing and brain scans both before and after. Preliminary results indicate "very good and rapid cognitive recovery in older adults after anesthesia," according to Deiner, who says that suggests "the surgery or the medical conditions surrounding surgery" are to blame for subsequent cognitive dysfunction.

From "Surgery Can Cause Cognitive Losses in Some Seniors"
Washington Post (05/19/18) Graham, Judith

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Intra-op IV Methadone Lowers Post-op Opioid Use

Based on the proven efficacy of intraoperative long-acting opioids for inpatient surgeries, researchers at Washington University wondered whether the drugs would also be effective for outpatient procedures. The team recruited 60 ambulatory surgery patients, most of whom were undergoing laparoscopic cholecystectomy, tubal ligation, or inguinal hernia repair. Participants were randomized to receive either a single dose of intravenous methadone or a short-acting opioid (the provider's choice of fentanyl or hydromorphone) at anesthesia induction. At a dose as low as 0.1 mg/kg of IV methadone, patients required substantially fewer intraoperative opioids than did the controls. At a dose of 0.15 mg/kg, methadone recipients also consumed fewer opioids in the post-anesthesia care unit and for the entire duration of their postoperative stay. They additionally used fewer total take-home opioids and discontinued usage earlier than the patients who received short-acting opioids for their procedures. During the 30 days following surgery, meanwhile, pain scores at rest were better for the higher-dose methadone patients than for the controls. Helga Komen, MD, an instructor in anesthesiology at Washington University, presented the findings at the 2017 annual meeting of the American Society of Anesthesiologists.

From "Intra-op IV Methadone Lowers Post-op Opioid Use"
Anesthesiology News (05/18/18) Vlessides, Michael

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Ketamine, Other Adjuvant Analgesics Could Be Answer to Improving Outcomes for Burn Patients

Nonopioid adjuvant pain medications can reduce the amount of narcotic painkillers that burn victims need, a new study suggests, but the strategy is greatly underused. A team from the University of Kansas performed a retrospective analysis of 664 burn patients of a period of two years. During that time, just 30 percent of the study population received ketamine or other adjuvant analgesics. "Traditionally, the gold standard has been to treat these patients with opioids, which we all know is not ideal for a number of reasons," lead author Joshua Cleveland, MD, told the 2017 annual pain medicine meeting of the American Society of Regional Anesthesia and Pain Medicine. "You have the hyperalgesia, the respiratory depression, and addiction." However, patients included in the analysis who received an infusion of ketamine cut their opioid use by 40 percent from day of admission to discharge. Those who received other adjuvant medications saw their consumption of oral morphine equivalents as an inpatient drop by 15 percent.

From "Ketamine, Other Adjuvant Analgesics Could Be Answer to Improving Outcomes for Burn Patients"
Pain Medicine News (05/18/18) Holzman, David C.

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Protocol Changes Reduce Likelihood of Oversedation During Radiology Procedures

New research suggests that refreshing hospital protocols can curtail oversedation events during invasive radiology procedures. "Despite the general acceptance of the safety of opioids and benzodiazepines (BZDs) for sedation, there is still a potential for oversedation and related serious adverse drug events," the researchers write in the Journal of the American College of Radiology. "When oversedation occurs with opioids or BZDs, it may require the administration of reversal agents such as naloxone or flumazenil, which carry their own risks and side effects." The team from Emory University analyzed data from March 2012 to January 2016 from procedures in which naloxone or flumazenil was used to reverse sedation, identifying 70 cases. The group then updated the hospital protocol, making changes such as adding a "two-step timeout process" before administering sedation and providing "dedicated moderate sedation in-servicing" to all staff involved with interventional radiology. With these changes fully implemented, only three sedation reversal events were documented from February 2016 to January 2017, lowering the incidence rate from 5.37 oversedation events per 1,000 cases to 1.03 per 1,000 cases. Moreover, the study authors report, "The cost of our intervention and educational campaign was negligible, with only a minimal increase in time and charting demands throughout the day."

From "Protocol Changes Reduce Likelihood of Oversedation During Radiology Procedures"
Radiology Business (05/18/18) Walter, Michael

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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.

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May 24, 2018