December 16, 2013
AANA-Backed Legislation Repealing Medicare Sustainable Growth Rate Passed by House, Senate Committees
Legislation permanently repealing the Medicare sustainable growth rate (SGR) – a formula that threatens each CRNA with an average $16,400 hit in 2014 – was passed Dec. 12 by the House Ways & Means Committee on a 39-0 vote, and by the Senate Finance Committee by voice vote, with the support and involvement of the AANA
and a broad coalition of APRN organizations
. The next step is for Congress to determine how to offset the bill’s estimated $130-150 billion cost. With the Jan. 1 cuts looming, lawmakers are buying time for that work by including a three-month SGR relief provision in a separate budget measure moving through Congress this month.
- NEW! Featured Career Opportunities in Updated E-ssential Jobs Section
- AANA Journal Celebrates 80 Years
- Save the Date: 2014 Nurse Anesthesia Annual Congress Coming in September
- Don't Forget—Ordering Deadline for National Nurse Anesthetists Week Coming Soon!
- Register Now for the Assembly of School Faculty
- Attention Employed CRNAs: Supplemental Liability Insurance Available for You!
- Experience Making a Difference at AANA Mid-Year Assembly 2014
- Save the Date for the Upper and Lower Extremity Nerve Block Workshop
- Support Nurse Anesthesia Research and Education: Make Your Year-End Donation to the AANA Foundation Today
- CRNAs are Fantastic: Nominate Someone Today for a 2014 Award
- Sponsor a Student for 2014
- Happy Holidays—And See You Next Year!
- Medicare Projects 24.1% Anesthesia Cut in 2014 Physician Fee Schedule Unless Congress Acts to Reverse It
- Medicare to End Moratorium on Enforcing Supervision for Outpatient Therapeutic Services in CAHs and Rural Hospitals Starting Jan. 1, 2014
- AANA Comments on Medicare Coverage of CRNA Pain Management Services in Two MAC Regions
- FDA Proposes Up-scheduling Pharmaceuticals Containing Hydrocodone; AANA Joins Healthcare Professional Groups Supporting Patient Safety and Expressing Concerns Over Access
- HHS Inspector General Issues New Memo on Anesthesia Payment Arrangements
- Following AANA Request, Medicare’s 2014 Coding Manual More Accurately Reflects CRNA Practice
- AANA Requests CRNA Services be Included in Health Plans Participating in the Basic Health Program
- Congress Enacts Compounding Reform Legislation
- Medicare Offers National Provider Call on Physician Quality Reporting System for Providers and Their Billers
- AANA Issues Second Edition of Reimbursement Primer for CRNAs
- Thanks to AANA Members at Fall Leadership Academy, CRNA-PAC Raised Over $40,000 at “Havana Nights”
- CRNA-PAC Now Accepting Applications
- Pardon the Interruption
- FEC REQUIRED LEGAL DISCLAIMER FOR CRNA-PAC
Healthcare HeadlinesHealthcare 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.
Inside the Association
NEW! Featured Career Opportunities in Updated E-ssential Jobs Section
Scroll down to the revamped Jobs section (directly above the Healthcare Headlines) to check out this issue's Featured Career Opportunities.
Save the Date: 2014 Nurse Anesthesia Annual Congress Coming in September
The 2014 Nurse Anesthesia Annual Congress will be held Sept. 13-16 in Orlando, Fla. This annual meeting is the premier educational event for CRNAs. The Congress provides members with the latest techniques and didactic education in the specialized field of anesthesia. Registration opens March 3. Check your March NewsBulletin for your preliminary program listing.
AANA Journal Celebrates 80 Years
After 80 years of publishing, the AANA Journal has gone through as many changes as the AANA itself. The two have been intertwined since the organization’s beginnings in 1931, with the “Report of the First Annual Meeting of the National Association of Nurse Anesthetists” published in 1933, a publication that would eventually become the AANA Journal we know today. Gertrude Fife, CRNA, the NANA’s second president, served as the publication’s first editor from 1933 to 1945.
The Journal’s first decade, like the Association’s, was about establishing an identity and a foundation. The Journal underwent a series of name changes—to the “Bulletin of the National Association of Nurse Anesthetists” in 1935 and “Bulletin of the American Association of Nurse Anesthetists” in 1940 when the organization reincorporated—as well as color and design modifications (the publication received a blue-and-silver cover makeover in 1938). The name “AANA Journal” would not be adopted until 1974.
The first decades found the Journal cementing its scholarly appeal, but not all topics were academic in nature. A 1942 column rallied nurse anesthetists (the certified registered nurse anesthetist credential would not be used until 1956) for civilian and military service during World War II.
The first book reviews made their way into the Journal in 1947, and 1955 was the last time it published a list of the entire membership of the Association. In 1960, the Journal and the AANA NewsBulletin, which had been publishing since 1947, began a bimonthly schedule.
The 1970s and 80s saw a slight expansion of the scope of the AANA Journal, moving it toward the worldwide educational resource it is today. The Editorial Advisory Board was created in 1977, and the first Journal course was published in 1981. Today’s Editorial Committee is composed of anesthesia professionals who work hands-on daily in the field. Current longtime editor-in-chief Chuck Biddle, CRNA, PhD, continues to oversee and expand the Journal’s oft-cited and highly visible reputation. Five associate editors and thirty five reviewers ensure the quality of content published.
The Internet allowed the AANA Journal to be easily accessed around the globe. A wider readership resulted in an increase in international submissions. A recent guest editorial was written by nurse anesthetists who practice in China. The Journal is indexed on several major databases including MEDLINE, CINAHL, and Mosby’s Nursing Consult. An AANA Journal app, allowing free access to current and back issues on smartphones and tablets, launched in 2011.
After 80 years, the AANA Journal
continues to thrive as a publication that’s earned worldwide respect. The official scholarly journal of the AANA is delivered to more than 47,000 CRNAs and attracts readers in every area of anesthesia, including delivery, research, and education. View the December issue here
Don't Forget—Ordering Deadline for National Nurse Anesthetists Week Coming Soon!
Register Now for the Assembly of School Faculty
The 2014 Assembly of School Faculty, to be held Feb. 18-20 in San Diego, Calif., will be the premier meeting of the year for nurse anesthesia program administrators and program faculty. While the 2014 meeting will run midweek (Tuesday – Thursday this year only), the agenda will continue to tackle the issues faced by nurse anesthesia educators, educational programs and student registered nurse anesthetists, including:
- How will changes in healthcare policy affect education?
- What are the barriers to evaluating clinical performance?
- What effect do recent regulatory changes have on accreditation and certification?
- And more!
Register Now, and receive $50 off your registration! Read more
Attention Employed CRNAs: Supplemental Liability Insurance Available for You!
Employed CRNAs now can take control of their insurance protection like never before. Seeing an unfilled need and using input from employed CRNAs, AANA Insurance Services has developed a new, first-of-its-kind product: an occurrence policy that works in conjunction with an employed CRNA's existing policy. This policy will provide employed CRNAs with security and peace of mind knowing that their interests and professional reputation will not be compromised in order to settle a claim. To apply for coverage or to get more information, go to the Insurance section on the AANA website
(AANA member login and password required) or call AANA Insurance Services at (800) 343-1368.
Experience Making a Difference at AANA Mid-Year Assembly 2014
The AANA Mid-Year Assembly, April 5-9, will expose AANA members to the inner workings of the lobbying scene in the nation's capital and follow up that knowledge with hands-on experience, bringing the issues of CRNA practice directly to members of Congress. An intensive seminar and workshop starts the afternoon of April 5, with educational presentations from leaders in healthcare policy, including top officials from the executive branch and Capitol Hill. On April 8 and 9, assembly attendees will put what they've learned into practice and educate members of Congress and their staffs in person alongside CRNA and nurse anesthesia student colleagues. Find out more and register here
Save the Date for the Upper and Lower Extremity Nerve Block Workshop
The Upper and Lower Extremity Nerve Block Workshop is March 8-9, 2014, in Park Ridge, Ill. This workshop is being held at the AANA National Headquarters and is designed for CRNAs interested in developing their skills and knowledge of peripheral nerve blocks. The program includes anatomy, pharmacology, and ultrasound techniques, and also includes case studies and hands-on demonstrations, return demonstration, and skill validation. Register today
Support Nurse Anesthesia Research and Education: Make Your Year-End Donation to the AANA Foundation Today
The AANA Foundation funds critical research that benefits all nurse anesthetists and their patients. Evidence provides proof and proof is power! Take a moment today to make your year-end, tax-deductible gift to AANA Foundation’s Proof is Power
campaign – click here
to access the Foundation’s secure donation page. To maximize your opportunity for 2013 tax benefits, please submit your gift before 11:59 p.m. on Tuesday, Dec. 31, 2013. Thank you for your support!
CRNAs are Fantastic: Nominate Someone Today for a 2014 Award
Deadline: Feb. 1, 2014
The AANA Foundation presents annual awards to individuals who have made a difference in the nurse anesthetist community. The following awards will be presented at the Nurse Anesthesia Annual Congress in Orlando, Fla., in September 2014:
- Advocate of the Year
- John F. Garde Researcher of the Year
- Rita L. LeBlanc Philanthropist of the Year
- Janice Drake CRNA Humanitarian
Please take the time to nominate someone you know and recognize them for the work they do on behalf of nurse anesthesia. It is truly an honor to be considered for one of these prestigious awards. Click here
for more information and to access the nomination forms. If you have any questions, contact the AANA Foundation at firstname.lastname@example.org
or (847) 655-1170.
Sponsor a Student for 2014
Deadline: Jan. 1, 2014
You can make a difference by supporting a nurse anesthesia student. We are once again seeking sponsors to support nurse anesthesia students through their nurse anesthesia program. If you wish to be part of this important program, click here
to visit our website and access the Fellowship and Scholarship Sponsorship Application. Please note that the minimum donation to sponsor a student is $3,000 per scholarship. In 2013, the AANA Foundation’s Student Scholarship Program awarded 54 scholarships totaling $112,000.
Happy Holidays—And See You Next Year!
Due to the holidays, Anesthesia E-ssential will not come out on Dec. 30, 2013, and will resume publication with the Jan. 15, 2014, issue. The E-ssential staff wishes all of our readers a joyous holiday season, and we look forward to serving you in 2014.
Medicare Projects 24.1% Anesthesia Cut in 2014 Physician Fee Schedule Unless Congress Acts to Reverse It
Medicare Part B anesthesia payment will be reduced 24.1 percent Jan. 1, 2014, unless Congress acts to reverse the “sustainable growth rate” formula funding cuts, the Medicare agency announced Nov. 27 in its 2013 physician fee schedule (PFS) final rule. If these cuts take hold in January and last the whole year, the average CRNA would see a $16,483 cut from his or her Medicare reimbursements alone, just in one year. AANA has been at work on Capitol Hill to reverse these cuts not just temporarily, but permanently (see story above).
If Congress fails to reverse the cuts, the mean Medicare anesthesia conversion factor will drop to $17.2283 per unit for services beginning Jan. 1, 2014. The regular physician conversion factor, applicable to CRNA services such as chronic pain management and line insertions that are not anesthesia services, would fall to $21.2006 per unit for services beginning Jan. 1, 2014.
Other provisions of the final rule that the AANA is reviewing closely include:
- The agency estimates CRNA-allowed charges of $1.061 billion for 2014, an increase of 3 percent allowing for the impacts of adjusting relative value units (RVUs) to match the revised Medicare economic index weights.
- The agency intends to review CPT code 79642, ultrasound guidance for needle placement, as a potentially misvalued code (p. 109).
- The agency indicated that it will evaluate in the future the feasibility of including the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surgical Care Survey on the Physician Compare website (p.722). AANA continues to press the agency that such survey tools fail to recognize the contributions of CRNAs and other nurses and should not be used to inform public policy decision making.
- Medicare will continue to allow claims-based reporting for reporting individual quality measures for the 2014 Physician Quality Reporting Program (PQRS), but it will phase out its claims-based reporting option for reporting of PQRS quality measures groups (p. 749).
Medicare to End Moratorium on Enforcing Supervision for Outpatient Therapeutic Services in CAHs and Rural Hospitals Starting Jan. 1, 2014
According to a Nov. 27 final rule issued for 2014 hospital and outpatient prospective payment systems (OPPS), Medicare is allowing its enforcement moratorium to expire Dec. 31, 2013, “such that all outpatient therapeutic services furnished in hospitals and CAHs would require a minimum of direct supervision unless the service is on the list of services that may be furnished under general supervision or is designated as a nonsurgical extended duration therapeutic service.” Even though most services affected by this provision are not CRNA services, the AANA had joined rural health and hospital organizations in requesting that the agency keep the moratorium.
In other matters in the OPPS rule, CMS acknowledged it seeks “to develop a comprehensive set of quality measures to be available for widespread use for informed decision making and quality improvement in the ASC setting. Through future rulemaking, we intend to propose new measures that address clinical quality of care, patient safety, care coordination, patient experience of care, surgical outcomes, surgical complications, complications of anesthesia, and patient reported outcomes of care.” The agency also will develop a comprehensive set of quality measures in the Hospital Outpatient Quality Reporting Program (OQR) that, through future rulemaking, will help further the goal of achieving better healthcare and improved health for Medicare beneficiaries who receive healthcare in hospital outpatient settings.
AANA Comments on Medicare Coverage of CRNA Pain Management Services in Two MAC Regions
AANA has urged two Medicare administrative contractors, Noridian Medicare, serving western states, and Palmetto GBA, serving four southeastern states, to recognize the full scope of CRNA practice when considering Medicare coverage of pain management services such as epidural steroid injections and facet joint injections. The recommendations were provided to Noridian and Palmetto in comment letters during November.
Noridian Medicare recently released two draft local coverage determinations (LCDs) stating, “Patient safety and quality of care mandate that healthcare professionals who perform epidural steroid injections (and facet joint injections, medial branch blocks, and facet joint radiofrequency neurotomy) are appropriately trained and/or credentialed by a formal residency/fellowship program and/or are certified by either an accredited and nationally recognized organization or by a post-graduate training course accredited by an established national accrediting body or accredited professional training program.” AANA responded in a letter signed by President Dennis Bless, CRNA, MS, stating that, “We read this section to clearly state that Noridian Medicare covers all Medicare CRNA services within their state scope of practice, including the services described in these LCDs. CRNAs have long had the education and training to safely perform high quality pain management services and furthermore, the Medicare agency in its 2013 final rule covering all Medicare services provided by CRNAs within their state scope of practice clearly defers to states on the issue of what services are within that scope.” The association provided similar language to Palmetto GBA in response to its LCD, stating that CRNAs are appropriately trained and certified to deliver epidural steroid injections.
FDA Proposes Up-scheduling Pharmaceuticals Containing Hydrocodone; AANA Joins Healthcare Professional Groups Supporting Patient Safety and Expressing Concerns Over Access
AANA has urged Secretary of Health and Human Services Kathleen Sebelius to reconsider the agency’s plan to up-schedule hydrocodone-combination substances because of the negative impact that such a move would have on millions of Americans with a legitimate clinical pain treatment need.
Together with members of the Patient Access to Responsible Care Alliance (PARCA), a national coalition representing the interests of millions of patients and non-MD/DO healthcare professionals, AANA wrote the HHS Secretary Nov. 15 in response to the U.S. Food and Drug Administration Center for Drug Evaluation and Research (FDA CDER) statement recommending the reclassification of hydrocodone-combination products from Schedule III to Schedule II controlled substances. “While diversion, misuse, and abuse of opioids have reached unacceptable levels in certain parts of the United States, reclassifying hydrocodone-combination drugs as Schedule II controlled substances will irrefutably have serious health consequences for patients,” the PARCA letter stated. “Overall, reclassification would severely limit patient access to effective pain treatment and would, in some cases, completely eliminate the ability of some types of providers to deliver treatment to their patients when they need care and during a critical time in the healing process.”
In previous comments to Congress and federal agencies, the AANA has urged the government to promote evidence-based guidelines and rules governing products under its jurisdiction.
HHS Inspector General Issues New Memo on Anesthesia Payment Arrangements
Anesthesia payment arrangements where the facility or physicians bill for anesthesia services and then pay anesthesia professionals a per-diem rate below fair market value may run afoul of federal laws prohibiting kickbacks and may be subject to penalties, a Nov. 15 Health and Human Services Office of the Inspector General (HHS OIG) opinion states.
The opinion involved a situation where a “Psychiatry Group would bill and collect for those (anesthesia) services and, in turn, would pay Requestor (the anesthesiologist) a fixed, per-diem rate of [amount redacted] for the anesthesiologists’ services, which Requestor asserts is below fair market value and below what it would receive if it billed for the services directly. The Psychiatry Group would retain the difference between the amount collected and the per-diem rate.” (Parentheses are added, brackets are in the original.) Outlining the federal anti-kickback statutes and their penalties, HHS OIG observed that the “Proposed Arrangement appears to be designed to permit the Psychiatry Group to do indirectly what it cannot do directly; that is, to receive compensation, in the form of a portion of Requestor’s anesthesia services revenues, in return for the Psychiatry Group’s referrals of ECT patients to Requestor for anesthesia services.”
While the OIG Advisory Opinion 13-15 states it applies solely to this case and does not express an opinion about any other case, it does give CRNAs and other anesthesia professionals an indication of what arrangements the OIG would find problematic. AANA has materials available for CRNAs interested in this topic, but CRNAs interested in developing or evaluating business arrangements for compliance with the law should consult competent legal counsel.
Following AANA Request, Medicare’s 2014 Coding Manual More Accurately Reflects CRNA Practice
Medicare’s new National Correct Coding Initiative (NCCI) policy manual for 2014 incorporates important changes recommended by AANA that more accurately reflect CRNA practice for submitting claims for reimbursement. The new manual, developed by Medicare to educate billers and coders about making accurate claims, eliminates old language that said evaluation and management services, and certain nerve block services, can only be performed by “anesthesiologists,” and now states that these can also be CRNA services. The AANA’s action to secure these NCCI manual changes helps to promote among anesthesia billers and coders the value and flexibility of CRNA services.
AANA Requests CRNA Services be Included in Health Plans Participating in the Basic Health Program
The AANA has requested that the Medicare agency require standard health plans to include the services of CRNAs and other non-physician providers who bill for Medicare Part B. The AANA’s Nov. 15 comment responds to a Medicare proposed rule establishing the Basic Health Program (BHP), part of the Affordable Care Act. In the letter signed by President Dennis Bless, CRNA, MS, the AANA requested the agency require anesthesia services be included in the 10 categories of benefits provided by standard health plans participating in a BHP and that these plans assign their payment systems to comply with state and federal nondiscrimination provisions. The AANA letter also asked that CRNAs be included in provider lists supplied by standard health plans participating in a BHP and that these plans also dedicate an email address to review inaccurate provider information.
Congress Enacts Compounding Reform Legislation
One year after pain injection patients became victims of unsanitary production practices at the NECC pharmaceutical compounder, Congress has enacted bipartisan legislation reforming the Food and Drug Administration regulation of large compounders, establishing a path toward tracking and tracing pharmaceuticals by unit within a decade, and otherwise leaving alone smaller compounding practices in hospitals, healthcare facilities, and community pharmacies. The legislation was of interest to CRNAs who share the public’s concern about ensuring a safe supply of pharmaceutical products and avoiding unintended legislative consequences.
The “Drug Quality and Security Act” (HR 3204) was supported by organizations representing hospitals and community and health system pharmacists, and by both House and Senate committee negotiators. Approved by the House Sept. 28, the Senate adopted it by voice vote Nov. 18, and it awaits the president’s signature into law.
Medicare Offers National Provider Call on Physician Quality Reporting System for Providers and Their Billers
The Centers for Medicare & Medicaid Services (CMS) is hosting a National Provider Call on quality reporting on Dec. 17 from 1:30 to 3 p.m. ET. This National Provider Call will focus on changes to such quality reporting programs as the Physician Quality Reporting System (PQRS) in the Physician Fee Schedule final rule for CY 2014 (a rule that has yet to be issued).
AANA Issues Second Edition of Reimbursement Primer for CRNAs
The second edition of the AANA’s “Issue Briefs on Reimbursement and Nurse Anesthesia” is now available online for AANA members. Of interest to all CRNAs, especially those who are self-employed or serve in an AANA state leadership position (including State Reimbursement Specialists), this 40-page primer provides basic information about policies and issues shaping CRNA reimbursement. The primer reviews essentials about Medicare, other benefit plans and commercial health plans, and health reform implementation.
Thanks to AANA Members at Fall Leadership Academy, CRNA-PAC Raised Over $40,000 at “Havana Nights”
CRNAs at the AANA Fall Leadership Academy in Miami Beach raised some $42,000 for the CRNA-PAC at its “Havana Nights” reception Nov. 9, and the CRNA-PAC Committee says “thank you!”
Latin music like this
, a cigar roller, and your AANA member colleague friends were all on hand to make it a special night for the cause of keeping your CRNA voice strong in Washington. And for this night only, Havana Nights attendees enjoyed salsa dancing lessons by leading AANA members.
CRNA-PAC Now Accepting Applications
Interested in making a difference for the profession? The AANA will be accepting applications to serve as a member of the CRNA-PAC Committee until Jan. 31, 2014. From a slate of member nominees provided by the AANA Board of Directors in February, the CRNA-PAC Committee elects two CRNAs each year for three-year terms and one student nurse anesthetist for a one-year term. Member responsibilities include setting and overseeing CRNA-PAC expenditure and income policy, determining funding of open-seat and challenger candidates, fulfilling duties at CRNA-PAC events and AANA national meetings, participating in fundraising duties, and attending CRNA-PAC Committee meetings. Candidates should have a strong interest in furthering the profession through federal advocacy. If you are interested in serving on the CRNA-PAC Committee, see http://www.aana.com/myaana/Advocacy/fedgovtaffairs/Pages/Join_CRNA_PAC.aspx
Pardon the Interruption
The following is an FEC required legal notification for CRNA-PAC: 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 without reprisal. The guidelines are merely suggestions. You are free 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 its 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. Each contributor must be a US Citizen.
NEW! Featured Career Opportunities
Certified Registered Nurse Anesthetist - Somnia Anesthesia
Somnia seeks an experienced CRNA to join its team at Hazleton General Hospital, a community hospital close to the Pocono Mountains & within driving distance of Philadelphia and NYC. Read more about this position.
CRNA - Somnia Anesthesia
Somnia is actively seeking to hire a CRNA for Fayette Regional Health System, a community hospital in eastern central Indiana. Read more about this position
CRNA Opportunities – EmCare Anesthesia Services
Multiple Opportunities Exist Nationwide
Locum Tenens & Permanent Placement Across the Country – United Anesthesia
United Anesthesia has had a reputation of excellence in CRNA Locum Tenens and Permanent Placement since 1979. Specializing in CRNA placement across the country with personalized service. Read more about this position
Researchers Design Sedative for Rapid Action
In a study published in the November issue of Anesthesia & Analgesia
, researchers at Johns Hopkins Hospital discussed a newly developed sedative that was specifically designed to deliver rapid onset, predictable effects, and a shorter recovery time. The team has been testing remimazolam on human patients as an alternative to the use of propofol as a sedative for colonoscopies and other short procedures. Although most patients in the study were found to be sufficiently sedated less than one minute after being injected with the drug and needed less than 10 minutes to regain full alertness, the researchers believe that further research is needed to determine the optimal dose of remimazolam. The researchers note that an injection of flumazenil works as a reversal agent, returning patients to full alertness within a minute of administration.
From "Researchers Design Sedative for Rapid Action"
Outpatient Surgery (11/26/13) Bernard, David
Laparascopic Hysterectomy Appears Less Painful Than Robotic Surgery
The need for postoperative analgesia is much greater in women who undergo robotically assisted laparoscopic hysterectomy compared to patients who elect for a conventional laparoscopic procedure, according to a new study. Dr. Megan Wasson of Christiana Care Health System in Wilmington, Del., analyzed the postoperative analgesic requirements for 353 patients who had hysterectomies at the facility from 2009 to 2012. Of the study group, 237 were operated on with robotic assistance; and 116 received the conventional approach to laparoscopic hysterectomy. The women who had the traditional surgery required 10 mg less of postoperative analgesia—converted into oxycodone equivalents—than did the women who underwent robotically assisted operations. Wasson said the results may prove helpful in deciding which procedure is best, in cases where postoperative pain is a major recovery factor.
From "Laparascopic Hysterectomy Appears Less Painful Than Robotic Surgery"
Ob.Gyn. News (12/13) Sullivan, Michele G.
Older Patients Likely Overdosed With Inhaled Anesthetics
Two new studies, one on animals and one on humans, suggest that anesthesia providers may be administering too much volatile anesthetics to older patients. In the human study, increasing patient age was linked to higher levels of delivered anesthetics than the adjustment expected for age based on minimum alveolar concentration (MAC). Lead researcher Alec Rooke, MD, PhD, commented that clinicians are only partly correcting MAC for age, because they feel reassured that they are not underdosing. However, "if, as some studies suggest, deeper levels of volatile anesthetics are found to increase the risk for postoperative cognitive dysfunction, then we need to be concerned that we may be administering unnecessarily deep levels of anesthesia to our elderly patients," said Rooke, professor of anesthesiology and pain medicine at the University of Washington Medical Center in Seattle. The results of the animal study, conducted by researchers at Harvard University and Massachusetts General Hospital, found that older rats experienced prolonged emergence from anesthesia and required lower doses to become anesthesized. Ken Solt, MD, assistant professor of anesthesia at Harvard Medical School, said the results suggested that "there's a fundamental difference in anesthetic sensitivity" between young brains and older brains, with the aged brain being more sensitive.
From "Older Patients Likely Overdosed With Inhaled Anesthetics"
Anesthesiology News (12/01/13) Vol. 39, No. 12 Armitage, Mandy
Will Opioid Scrutiny Spur NSAID Overuse?
Scrutiny from the Food and Drug Administration has led to changes in labels for extended-release/long-acting opioid pain relievers, driving clinicians and patients to seek alternatives that can manage moderate pain. A potential alternative is found in non-steroidal anti-inflammatory drugs (NSAIDs), although some argue that increasing the use of NSAIDs raises its own set of concerns. Daniel Brzusek, DO, vice chair of the Alliance for Rational Use of NSAIDs, said his group anticipates that the public and physicians will increase their reliance on NSAIDs. On the other hand, Michael Carome, MD, director of Public Citizen's Health Research Group, noted that there are a variety of pain relief options—including Tylenol—that could be used in lieu of opioids or NSAIDs. Both men cited non-pharmaceutical ways to relieve pain, including exercise and physical therapy, while Brzusek also cited acupuncture as "a safer, zero-risk alternative." Brzusek noted that patients who use NSAIDs should take the "least dose possible for the shortest period of time." When used properly, NSAIDs are considered safe but still may cause adverse effects, such as cardiovascular events and gastrointestinal (GI) bleeding. How much of a problem they pose, especially in comparison to opioids, remains up for debate.
From "Will Opioid Scrutiny Spur NSAID Overuse?"
Pain Medicine News (11/01/2013) Vol. 11 Guarino, Ben
High Incidence of Residual Paralysis Found in Canadian Study
During the RECITE (Residual Curarization and its Incidence at Tracheal Extubation) study, Canadian researchers discovered that more than half of patients who undergo laparoscopic or open abdominal surgery experience residual paralysis at extubation. As part of the research, which examined the incidence and severity of residual neuromuscular blockade (NMB) immediately before extubation and on arrival in the postanesthesia care unit (PACU), patients were given at least one dose of a nondepolarizing neuromuscular blocking agent for endotracheal intubation or maintenance of blockade, while 74 percent of the patients were given neostigmine for NMB reversal. The incidence of residual paralysis was found to be 56 percent at tracheal extubation and 44 percent on arrival in the PACU; and although both numbers were higher in patients who received neostigmine, the differences were statistically negligible. The researchers found no statistically significant difference associated with patient age, body mass index, comorbidities, patient physical status, sex, or type of surgery; or between the eight study sites. The research group said the findings highlight the need to have more effective detection and management of residual paralysis. Lead researcher Louis-Philippe Fortier, MD, chief of staff at Maisonneuve-Rosemont Hospital in Montreal, said "We are very concerned about the result that we got," adding, "we want to find new ways to make managing neuromuscular blockade during surgery more efficient."
From "High Incidence of Residual Paralysis Found in Canadian Study"
Anesthesiology News (11/01/13) Vol. 39, No. 11 Armitage, Mandy
Guidelines Released by Joint Commission Highlight Importance of Nurses in Preventing Deadly Bloodstream Infections
New standards from The Joint Commission, the accreditation body for U.S. healthcare facilities, emphasizes the role of nurses in preventing bloodstream infections. Central line-associated bloodstream infections (CLABSI) caused by improper placement of catheters prolong hospital stays, increase hospital readmission rates, and inflate the cost of care for thousands of patients every year; but The Joint Commission's best practices insist that this complication is avoidable, with nurses' help. "Nurses are on the front lines and can take advantage of their constant contact with patients and other caregivers to explain infection-control techniques and help health facilities develop and enforce standards of care that have been proven protective against CLABSI," according to Patricia Stone, PhD, MPH, RN, FAAN, a professor at Columbia University School of Nursing who contributed to the new guidelines. She points out that nurses are integral in the fight against infection prevention, often helping to organize and adopt catheter insertion checklists, proper hand-washing techniques, and other preventative efforts.
From "Guidelines Released by Joint Commission Highlight Importance of Nurses in Preventing Deadly Bloodstream Infections"
Reducing the Burn: Choosing the Optimal Local Anesthetic for Peripheral IV Catheter Placements
The placement of a peripheral intravenous (PIV) catheter to deliver medication can create physical discomfort as well as anxiety in hospitalized patients. Administering a local anesthetic as a premedication is helpful; but selecting the best agent for the job can be problematic, since industry consensus is lacking. While lidocaine is the current standard, patients may feel a burning sensation during infiltration. "Buffering" the lidocaine with sodium bicarbonate to neutralize its acidity has shown to address that and reduce pain; however, its downsides include conflicting results. To prove its efficacy, Abbott Northwestern Hospital staff pharmacist David Gurda, PharmD, carried out a study comparing pain reduction achieved by 1% lidocaine, 1% buffered lidocaine, and 0.9% bacteriostatic normal saline. The findings suggested that 1% buffered lidocaine most effectively curtails pain with PIV placement, but its viability is compromised by an onerous compounding process, drug shortages, an abbreviated shelf life, and the potential for waste due to unused preparations. Until these issues are resolved, Gurda concluded, 1% percent, "unbuffered" lidocaine is practical and effective and should remain the recommended practice.
From "Reducing the Burn: Choosing the Optimal Local Anesthetic for Peripheral IV Catheter Placements"
Pharmacy Practice News (12/13) Vol. 40 Gurda, David
General Anesthesia Linked to Language Problems in Children
Use of general anesthesia in young children undergoing surgery could diminish their language abilities and cognition and cause long-term regional volumetric alterations in brain structure, according to a new study by researchers from Cincinnati Children's Hospital Medical Center. The investigators compared 52 children who had been exposed to anesthesia before their fourth birthday with 52 children who had not been exposed. Neurocognitive assessments included language skills and intelligence; and T1-weighted MRI scans were used to perform structural brain evaluations. Most of the procedures involving anesthesia used either halothane or sevoflurane. At the annual meeting of the International Anesthesia Research Society, the researchers noted that although average test scores for both groups were within population norms, children who had been previously exposed to anesthesia scored lower in all tests. The exposed children scored lower in listening comprehension, expressive language, and measures of IQ. MRIs showed that the volume of gray matter was sporadically reduced in posterior brain regions of previously exposed children. The findings, however, may be due to other factors, such as postoperative pain or an inflammatory response to surgery.
From "General Anesthesia Linked to Language Problems in Children"
Anesthesiology News (12/01/13) Vol. 39, No. 12 Vlessides, Michael
Comparison of Intraoperative Blood Loss During Spinal Surgery Using Either Remifentanil or Fentanyl as an Adjuvant to General Anesthesia
Because remifentanil improves hemodynamic stability during surgery, researchers in Japan suspected that the analgesic might reduce intraoperative blood loss when used as an adjuvant to general anesthesia. To test the theory, they looked at data from 64 consecutive spinal surgery patients treated between April 2010 and March 2011. The two study groups included 35 patients who were administered remifentanil as an opioid analgesic during general anesthesia and 29 who received fentanyl instead. The researchers tracked not only intraoperative blood loss but also blood pressure, heart rate, and other indicators of hemodynamic stability. Patients in the remifentanil group presented markedly lower intraoperative blood loss than the fentanyl group—possibly due to the lower intraoperative blood pressure that those patients also experienced. While the results of the small, retrospective, single-site study are encouraging, the investigators agree that a larger-scale, prospective randomized trial is needed to verify the initial findings and to determine whether remifentanil has the same effect for other types of operations.
From "Comparison of Intraoperative Blood Loss During Spinal Surgery Using Either Remifentanil or Fentanyl as an Adjuvant to General Anesthesia"
7thSpace (12/05/13) Kawano, Hiroaki; Manabe, Sawa; Matsumoto, Tomomi; et al.
Cycloplegic Eye Drops Needed When Measuring Refraction in Children Under General Anesthesia
A small-scale study has found that clinicians should use cycloplegic eye drops when measuring refraction in children who have been administered general anesthesia. Researchers analyzed myopic measurements from 41 pediatric patients who underwent cycloplegic retinoscopy, followed six months later by streak retinoscopy under general anesthesia without cycloplegia. The investigation revealed significantly higher myopic measurements with retinoscopy under general anesthesia compared to cycloplegic retinoscopy. "The main study question, from a practical perspective, was whether cycloplegic eye drops are needed when measuring the refractive error in children under general anesthesia, and the short answer is yes," the study authors concluded in their report in the American Journal of Ophthalmology
From "Cycloplegic Eye Drops Needed When Measuring Refraction in Children Under General Anesthesia"
Intravenous Haloperidol Does Not Prevent ICU Delirium
English researchers set out to answer the clinical question of whether the anti-psychotic drug haloperidol can reduce delirium in critically ill patients if initiated early on during their stay in the ICU. The 142 study participants were randomly assigned to receive either a placebo or 2.5 mg of intravenous haloperidol every eight hours for up to 14 days. The results revealed no significant difference in the time spent free of delirium or coma between the groups and indicated that the use of haloperidol lead to more sedation and less agitation. While no severe adverse effects were observed, the researchers conclude that scheduled anti-psychotics should not be used to reduce instances of ICU delirium. Instead, they recommend that the first-line strategies for reducing delirium rates should continue to be addressing modifiable risk factors and using dexmedetomidine, instead of lorazepam, to induce sedation.
From "Intravenous Haloperidol Does Not Prevent ICU Delirium"
The Hospitalist (12/04/13) Cumbler, Ethan; Simpson, Jennifer; Virapongse, Anunta; et al.
Study Links Low Melatonin With Postoperative Delirium
The results of a small Japanese study suggest that intensive care unit patients suffering from postoperative delirium have lower melatonin levels in the hours after an operation than do those who do not experience delirium. A negative correlation was also discovered between melatonin levels and exposure to sevoflurane, while a positive correlation was documented between fentanyl concentrations and melatonin levels. Based on previous studies involving non-ICU patients who developed postoperative delirium, which also observed alterations in melatonin levels, Moritoki Egi, MD, from the Okayama University Hospital and fellow researchers decided to examine this correlation in ICU patients. They analyzed data from 10 ICU surgical patients who met the Confusion Assessment Method for the ICU (CAM-ICU) delirium criteria and 23 similar patients without postoperative delirium. Egi speculated that the risk for delirium may increase postoperatively when decreases in melatonin levels trigger sleep disturbances, which are known to contribute to the risk for delirium. In an interview, he commented that, "If this is the case, it would be worth conducting a randomized trial to see how exogenous melatonin affects melatonin levels and whether this will have an impact on delirium." The study was too small, he said, to draw any real conclusions about the reported associations between melatonin levels and choice of sedation agent.
From "Study Links Low Melatonin With Postoperative Delirium"
Pharmacy Practice News (11/13) Vol. 40