Anesthesia E-ssential, July 13, 2012

Anesthesia E-ssential

July 13, 2012 

Vital Signs

AANA Applauds Medicare Agency for Proposing to Resume Patient Access to CRNA Pain Care Services
CRNAs Asked to Take Action Soon
The AANA applauded the Medicare agency for proposing in the Federal Register on July 6 to resume patient access to pain care services provided by CRNAs. (Member login and password required to access link above.) The proposal is now subject to a 60-day public comment period through Sept. 4, 2012, during which thoughtful public comments submitted by CRNAs and their colleagues in favor of the proposal are critical to its becoming final and taking effect.
Direct reimbursement of CRNA pain care services was long the Medicare practice until early 2011 when one Medicare administrative contractor, Noridian, then another, Wisconsin Physician Services (WPS), issued policy denying direct reimbursement of CRNA pain care services, putting patient access to care at risk in 18 states in the West and upper Midwest. The Medicare agency proposal, following extensive AANA and CRNA advocacy work, would reverse the Medicare contractors’ rulings.
The agency’s narrative proposal concludes on page 232:

“After assessing the information available to us, we have concluded that chronic pain management is an evolving field, and we recognize that certain States have determined that the scope of practice for a CRNA should include chronic pain management in order to meet health care needs of their residents and ensure their health and safety. Therefore, we propose to revise our regulations at §410.69(b) to define the statutory description of CRNA services. Specifically, we propose to add the following language: “Anesthesia and related care includes medical and surgical services that are related to anesthesia and that a CRNA is legally authorized to perform by the State in which the services are furnished.” This proposed definition would set a Medicare standard for the services that can be furnished and billed by CRNAs while allowing appropriate flexibility to meet the unique needs of each State. The proposal also dovetails with the language in section 1861(bb)(1) of the Act requiring the State’s legal authorization to perform CRNA services as a key component of the CRNA benefit category. Finally, the proposed definition is also consistent with our policy to recognize State scope of practice as one parameter defining the services that can be furnished and billed by other NPPs.”


The Pulse

  • Register Online for AANA Annual Meeting
  • Annual Meeting Pre-Registration Ends at Noon on July 23
  • Here's Another Incentive to Attend the Business Meeting!
  • Wellness Tips for Running in this Heat!
  • Complete Your Continuing Education NOW with AANALearn®
  • New York: CRNA Title Protection Bill (A8392/S5356) Passed by the Assembly and Senate as of June 21
  • Missouri: SB 682/HB 1399 Signed into Law by the Governor
  • Tennessee Representative Thanks FTC 
  • Read About CRNA NewsMakers on the AANA Website
  • With Medicare Pain Rule Out, AANA Members' Pain Care TeleTownHall Set for July 17
  • Updates on Medicare Pain Care Issues for CRNAs
  • Medicare Proposes Cutting 2013 Part B Fees to Fund Primary Care Boost
  • Drug Shortage Relief Bill Signed into Law
  • Supreme Court Health Reform Ruling Affects Medicaid Expansion; How are CRNAs Affected?
  • HHS Identifies 89 More Accountable Care Organizations; Let AANA Know if You are Part of One
  • Applications for MSSP
  • HHS Identifies Top Three Small-Group Health Plans in Each State, to be Used as Benchmarks in Defining Essential Health Benefits
  • Sponsor of ASA-backed "Truth and Transparency" Bill Defeated in Primary Election
  • AANA Comments on Qualified Health Plans

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.

Inside the Association
Register Online for AANA Annual Meeting
Online Registration is now available and open for this summer’s AANA Annual Meeting. So, if you haven’t already registered…it couldn’t be easier! Go to AANA Annual Meeting 2012 and make your selections soon. Some sessions have already filled.
Annual Meeting Pre-Registration Ends at Noon on July 23
Registrations for the 2012 AANA Annual Meeting will be accepted online and by mail, fax, and email until noon CDT Monday, July 23. After noon on Monday, July 23, any new registrations or registration adjustments must be handled onsite in Exhibit Hall West Lobby at the Moscone Center West. Beginning this year, onsite registrants will be able to process their own registrations by visiting one of six kiosks in the convention center near the registration pick-up area. Staff will be available to assist anyone needing help, and a “Customer Concierge” will be circulating to provide direction and problem-solving.

Here's Another Incentive to Attend the Business Meeting!
Four significant prizes will be awarded to randomly selected voting members present at points throughout the AANA Annual Business Meeting on Saturday, Aug. 4, 1 p.m. to 4 p.m. at the Moscone Center in San Francisco. Come for the important business of the AANA and to be part of the necessary quorum.

Wellness Tips for Running in this Heat!
Whether you’re preparing for the 5K at Annual Meeting or another event, 2012 Walk/Run Chair Patti Bright, CRNA, MS, has some training tips for you to run safe in this hot weather

Complete Your Continuing Education Requirements Now with AANALearn®
The 2012 recertification deadline is almost here! The fastest way to have CE credits transferred into your transcript is with AANALearn online education courses. Just in time for July, one more clinical topic course has been added and will be on sale ONLY until July 31. There are now more than 50 courses available for members. Time is limited—check out the catalogs NOW. Login at with your member credentials to receive the member discount.


New York: CRNA Title Protection Bill (A8392/S5356) Passed by the Assembly and Senate as of June 21
This bill will allow CRNAs in New York to be formally recognized through certification by the New York State Education Department. This is a big step for CRNAs in New York and the result of tireless effort and hard work of New York State Association of Nurse Anesthetists (NYSANA) leadership. This bill will be submitted to the governor for signature before the end of the year.
Missouri: SB 682/HB 1399 Signed into Law by the Governor
This bill prohibits anyone, other than a physician licensed to practice medicine, from providing certain pain management services. This bill, as initially introduced, had very restrictive language for acute and chronic pain management. Missouri Association of Nurse Anesthetists (MoANA) lobbied hard on this bill and was able to preserve acute pain management as well as inter-laminar lumbar epidural injections. The bill also includes a four-year sunset provision, meaning that the provisions of this law that restrict CRNAs will automatically expire in four years unless reauthorized by an act of the Missouri General Assembly.
Tennessee Representative Thanks FTC
Representative Gary Odom of Tennessee sent a letter thanking the Federal Trade Commission (FTC) for submission of comments on Tennessee House Bill 1896. (See the FTC’s supportive comments on the pain management issue in Tennessee.) Rep. Odom stated in his letter that the "... agency’s comments were very useful in helping the Health committee better understand the impact of the proposed legislation from the aspect of its effect on competition and access to vital healthcare services."

Read About CRNA NewsMakers on the AANA Website
The AANA website has just introduced a NewsMakers section devoted to news about the accomplishments of AANA members. Get the scoop!

With Medicare Pain Rule Out, AANA Members' Pain Care TeleTownHall Set for July 17
With Medicare having issued a proposed rule July 6 regarding Medicare coverage of CRNA pain management services, the AANA invites AANA members to participate in a first-ever AANA TeleTownHall the evening of Tuesday, July 17, to support the Association’s advocacy efforts on the issue.
Additional email alerts will go out to AANA members alerting them to the TeleTownHall meeting. On the evening of July 17, AANA members from the Eastern and Central time zones will be called at 8 p.m. Eastern time. Members from Mountain, Pacific, Alaska and Hawaii Time will be called at 10 p.m. Eastern time. The TeleTownHall will provide an update about the Medicare proposed rule on CRNA pain management services and its importance to CRNA practice, and guidance on how to help support the strongest possible final rule for CRNAs through the AANA’s ProtectMyPainCare campaign.

Updates on Medicare Pain Care Issues for CRNAs
Since the Medicare agency published its proposed rule regarding CRNAs and pain management services July 6:
  • A website providing AANA members and the public with additional information about ensuring patient access to pain care services is being posted shortly at
  • At least two rural Kansas hospitals have stopped offering pain management services to patients because their Medicare administrative contractor, WPS, will not reimburse for those services when a CRNA is the provider. At least one Kansas hospital has been the subject of a recoupment notice from WPS.
The AANA is planning extensive advocacy activities at the Annual Meeting in San Francisco; stay tuned for more information!

Medicare Proposes Cutting 2013 Part B Fees to Fund Primary Care Boost
The Medicare agency says that the Medicare sustainable growth rate funding formula will cut CRNA and all Medicare Part B payments 27.2 percent starting January 2013, and proposes making additional across-the-board reductions in specialty payments including anesthesia services in order to fund a proposed 7 percent boost for primary care services.

The agency proposed these policy changes as part of its 2013 Physician Fee Schedule proposed rule, which is open for public comments through Sept. 4, 2012. According to the proposed rule, the preliminary Medicare allowed charges for CRNA services in calendar year (CY) 2013 are $1.142 billion, with the preliminary impacts of work and malpractice and practice expense relative value changes yielding reductions of minus 1 percent and minus 3 percent respectively, for a combined impact of minus 4 percent.

Of interest to CRNAs:
  • Under the Physician Quality Reporting System (PQRS), Centers for Medicare & Medicaid Services (CMS) is proposing to continue to use the following quality measures via claims reporting: Perioperative Temperature Management, Prevention of Catheter-Related Bloodstream infections (CRBSI: Central Venous Catheter (CVC) Insertion Protocol), and Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics.
  • CMS also is implementing a physician value-based modifier to be phased in over three years from CY 2015 to CY 2017, starting with CY 2015 for provider groups with 25 or more practitioners. This value-based modifier would adjust payment to practitioners and groups based on quality measures.
  • The pain management item mentioned above is also a part of this proposed rule.

The proposed rule is still under review by AANA, which will be developing a comment to the proposed rule.
Read the proposed rule. This 735-page link is temporary and will expire July 30 when the proposal is published in the Federal Register. See a summary at Kaiser Health News and from the Medicare agency.

Drug Shortage Relief Bill Signed into Law
President Obama signed into law July 9 AANA-backed legislation (S. 3187) requiring drug manufacturers to give greater advance notice of conditions that threaten shortages of anesthesia drugs.
The AANA had been working in support of the bill’s drug shortage advance notification provisions, and against language that would have listed products containing hydrocodone (Vicodin®) on Schedule II. According to the final bill, manufacturers of drugs “intended for use in the prevention or treatment of a debilitating disease or condition, including any drug used in emergency medical care or during surgery,” would be required to provide the Food and Drug Administration advance notice of conditions that might lead to shortages of such drugs. The purpose of the advance notification is to give the marketplace for such drugs time to act and keep shortages from taking place or reducing their incidence or severity. In addition, the final legislation did not change the controlled substances schedule on which products containing hydrocodone currently appear. Both outcomes met AANA’s advocacy objectives.
See the HHS Secretary’s statement on the signing of the bill.

Supreme Court Health Reform Ruling Affects Medicaid Expansion; How are CRNAs Affected?
The U.S. Supreme Court’s ruling upheld the constitutionality of most of the Affordable Care Act (ACA) – except a provision that would have eliminated a state’s Medicaid funding if it chose not to accept the ACA’s Medicaid expansion. With the expansion of Medicaid accounting for a sizeable fraction of the Act’s expansion of healthcare coverage, and state and federal funding combined for Medicaid already exceeding total Medicare outlays, how does this aspect of the ruling affect CRNAs?
The ruling means that states may choose not to expand patient eligibility for Medicaid, and to turn back its accompanying major increase in federal funding. According to National Association of Medicaid Directors chief Matt Salo, “The ruling, in effect, makes the ACA’s Medicaid expansion optional for the states.” Though some 26 states sued the federal government over the constitutionality of the ACA’s Medicaid provision, and others such as Virginia have expressed reservations about implementing it, which state will turn down the expansion of eligibility knowing that it comes with a great deal of federal funding?
For CRNAs, Medicaid programs operated by the states pay for some CRNA services more than others – pain care for laboring mothers can be a big Medicaid outlay, for example. And Medicaid programs reimburse CRNA services differently state by state – some directly, others only when the CRNA service is medically directed by an anesthesiologist, still others as part of the facility fee.

So, as the Medicaid aspects of the high court’s ruling settle out, keep an eye on how your state’s Medicaid agency considers how or whether to implement Medicaid benefits expansion and its effect on CRNA reimbursement. Already many states are converting their fee-for-service Medicaid systems into managed care programs which may affect CRNA reimbursement.
For more information see the National Association of Medicaid Directors, the federal government’s Medicaid site, your state’s Medicaid agency, and a list of current national Medicaid issues published by the Kaiser Family Foundation.

HHS Identifies 89 More Accountable Care Organizations; Let AANA Know if You are Part of One
An additional 89 healthcare provider organizations have been identified as Accountable Care Organizations (ACOs) by the U.S. Department of Health and Human Services, which means they are eligible for payment incentives associated with coordinating healthcare delivery, improving quality, and reducing costs. As a part of the Affordable Care Act implementation, the AANA has been working to ensure that CRNAs are eligible to participate in and lead ACOs and join in their shared savings programs. The AANA is also eager to learn about CRNA experiences in ACOs. If an organization with which you work is listed among these ACOs, please email and a member of the AANA Federal Government Affairs staff in Washington will respond to you with a few questions.

Applications for MSSP
Applications for the Medicare Shared Savings Program (MSSP) relating to ACOs for the period beginning January 2013 will open Aug. 1 through Sept. 6, 2012. See application requirements.

HHS Identifies Top Three Small-Group Health Plans in Each State, to be Used as Benchmarks in Defining Essential Health Benefits
On July 2, U.S. Department of Health and Human Services (HHS) Center for Consumer Information and Insurance Oversight released a list of the three largest small group plans in each state, which Centers for Medicare & Medicaid Services says states may evaluate in order to set an essential health benefits (EHB) threshold for health plans marketed through exchanges. The list is important to CRNAs because it influences what services plans marketed through exchanges must cover.
This list follows the December 2011 bulletin released by the HHS describing its intended approach to defining the essential health benefits under the Affordable Care Act, under which states would have the flexibility to select an existing health plan to set the “benchmark” for the items and services included in the EHB package. In its comments to HHS, the AANA asked the agency to require in the proposed EHB rule that anesthesia services be included among the ten categories of essential services in the Affordable Care Act; require that CRNAs and other providers who bill for Medicare Part B be included in health plans offering essential health benefits; and require health plans to comply with state and federal Non-Discrimination Provisions. The agency has now published its list of the three largest small group plans in each state, but has not yet published an EHB proposed rule.

Sponsor of ASA-backed "Truth and Transparency" Bill Defeated in Primary Election
The U.S. House representative who sponsored the American Society of Anesthesiologists- and American Medical Association-backed “Truth and Transparency in Healthcare Act” (H.R. 451) has been defeated for reelection. Rep. John Sullivan (R-OK) was defeated in his GOP primary election June 26 by Navy Reserves pilot and first-time candidate Jim Bridenstine.
Most media reports said that Bridenstine had backing from the Tea Party; campaign finance filings and a couple of select reports also found that he had backing from chiropractors and optometrists and a few CRNAs who’d had it with Sullivan’s repeated sponsorship of legislation that threatened their practice. Sullivan was also the beneficiary of some $44,000 in “independent expenditure” campaign assistance from the ASA-PAC.
Sullivan’s Tulsa-based district is deep red Republican turf; the GOP primary winner is fairly likely to win the general election to that seat in November. Read more.

AANA Comments on Qualified Health Plans
The HHS should require qualified health plan (QHP) networks to provide access to CRNAs to the fullest extent of their training and should require QHPs to adhere to state and federal provider nondiscrimination provisions, said the AANA in a comment letter sent to HHS on July 2 (login required).
In the letter signed by President Debbie Malina, CRNA, DNSc, MBA, the AANA stated, “Consistent with the goals and policies of the [Affordable Care Act] in establishing provider networks that ensure extensive access to care, we recommend that the agency require QHP networks to provide access to non-physician providers, such as CRNAs, and to reimburse these providers for all services that they are capable of providing, to the fullest extent of their training. To measure network adequacy and access to non-physician providers, we also recommend that the agency require QHP networks to measure, monitor, and report on the percentage of non-physician providers by type of provider that are being placed “in-network” versus “out of network” and to not accredit health plans that have a low percentage of “in-network” non-physician providers.”
The AANA also recommended that that the agency should avoid the use of the problematic Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surgical Care Survey and other survey instruments that strictly measure access to physicians.
Read the proposed rule (requires AANA login and password).
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FDA Approves Plan to Fight Growing Opioid Abuse
The U.S. Food and Drug Administration (FDA) on July 9 adopted a new Risk Evaluation and Mitigation Strategy (REMS) to combat the misuse and abuse of opioid prescription pain medications. The plan could impact more than 20 companies that manufacture opioid analgesics, which will be required to make educational programs available to prescribers based on an FDA blueprint. The firms also will have to provide educational materials for patients and perform periodic assessments of the mitigation program's implementation and success. The initiative is one part of a multiagency, national strategy to address opioid abuse—including addiction, overdoses, and deaths. FDA Commissioner Dr. Margaret A Hamburg said, "Misprescribing, misuse, and abuse of extended-release and long-acting opioids are a critical and growing public health challenge. The FDA's goal with this REMS approval is to ensure that healthcare professionals are educated on how to safely prescribe opioids and that patients know how to safely use these drugs."
From "FDA Approves Plan to Fight Growing Opioid Abuse"
Business Insurance (07/10/12) Ceniceros, Roberto

Texas Switches to 1-Drug Execution Due to Shortage
Faced with a shortage of pentobarbital, one of three ingredients in the fatal drug cocktail used for prisoner executions in Texas, state officials say they will move to a single-drug protocol. Correctional authorities had been using the sedative in combination with potassium chloride and pancuronium bromide, but the supply of the latter drug expired. Moreover, procuring pentobarbital—which Texas began using in 2011 after the anesthetic sodium thiopental became unavailable—also is becoming difficult since the Danish manufacturer vowed to prevent its use in lethal injections. Still, Texas has enough pentobarbital in reserve to put 23 inmates to death, and it plans to use the sedative alone in executions going forward. States including Arizona, Ohio, and Washington have preceded Texas in switching to a one-drug formula, although some plan to use propofol or another drug. The trend is raising concern among death penalty critics, who argue that single-drug injections may be less humane, citing a case in Arizona where an inmate shook for several seconds after receiving a fatal dose of pentobarbital. Three-drug cocktails work faster than a single anesthetic like pentobarbital, according to Death Penalty Information Center executive director Richard Dieter. "The person still goes to sleep and gradually loses mental capacity and dies, but it may take a slightly longer time," he explains. "I think the idea originally was to cause death quickly, but you needed the anesthetic to make those next two drugs painless." With Texas leading the nation in death row executions, Dieter believes all eyes will be on the state. Its experience will produce "more evidence that this or is not the way to go," he says.
From "Texas Switches to 1-Drug Execution Due to Shortage"
Tacoma News Tribune (WA) (07/10/12) Merchant, Nomaan

Post-Op Paralysis and NMBAs Still a Threat to Patient Safety
As many as 100,000 U.S. patients each year may suffer adverse events following a surgery—from airway obstruction to hypoxemic episodes—due to residual paralysis caused by neuromuscular blocking agents. Some 40 million surgeries are performed each year in the United States each year, nearly 60 percent of them involving general anesthesia. If residual paralysis occurs in up to 40 percent of patients who receive general anesthesia, that could mean 10 million patients affected, projects Dr. Sorin Brull, a professor of anesthesiology at Mayo Clinic in Jacksonville, Fla. Critical respiratory events occur in 0.8 percent of those patients, he cites; and another 0.1 percent will require emergent reintubation in the post-anesthesia care unit, meaning that there may be approximately 100,000 annual cases of potential harm “directly related” to residual paralysis. There are few clinical standards for monitoring post-surgery weakness, and clinical tests for residual paralysis—such as feeling for contraction in the affected muscles or judging how firmly a patient can squeeze a hand or bite down on a tongue depressor—are not wholly accurate. The currently available reversal agents also bear some responsibility—particularly neostigmine, which is less effective in achieving neuromuscular recovery. Residual paralysis could become an even more common occurrence with the rise of same-day surgeries and the increasing use of short-acting anesthetics like propofol and desflurane, warns Glenn Murphy, MD, director of cardiac anesthesia and clinical research at NorthShore University HealthSystem in Chicago. Researchers are attempting studies to address the lack of official guidelines and proper monitoring practice.
From "Post-Op Paralysis and NMBAs Still a Threat to Patient Safety"
Pharmacy Practice News (07/12) Vol. 39 Marcus, Adam

Researchers' Scoring System Predicts Unplanned Intubation
A study that ran in the July issue of Anesthesia & Analgesia affirms the accuracy of a clinical risk scoring system in evaluating a patient's odds of needing unplanned tracheal intubation after surgery. Data from the National Surgical Quality Improvement Program (NSQIP) was used to identify risk factors—including age, physical status, the presence of preoperative sepsis, and total operative time—which then were used to develop the Unplanned Intubation Risk Index. When compared to NSQIP data for over 176,000 patients from 2008, the scoring system—which ranges from 0 to 18—achieved 79 percent accuracy.
From "Researchers' Scoring System Predicts Unplanned Intubation"
Becker's ASC Review (07/12) Tawoda, Taryn
Japanese Anesthesiologist Fabricated Record Number of Scientific Papers
An investigative panel reviewed the work of Japanese anesthesiologist Yoshitaka Fuji as part of a public inquiry that began with a March 8 analysis in the journal Anaesthesia that challenged his data. Scrutiny of the work in question intensified when editors representing 23 other journals requested that officials at seven Japanese institutions review the anesthesiologist's published papers. The investigative committee's report found that of 212 papers reviewed from 249 total published works, 172 were not legitimate. Fuji, investigators discovered, invented patients, falsified evidence, and added co-authors that were not involved with his research. Furthermore, 126 of those 172 were found to be complete fabrications; 37 could not be substantiated; and just three were identified as legitimate. While the fictional research went largely unnoticed, the papers did provide Fuji with a prolific appearance that he leveraged to gain employment, win research funding, and collect speaking fees. Fuji might have to make 172 retractions from highly esteemed scientific research journals, topping the total of German anesthesiologist Joachim Boldt, who had 90 retractions after some of the same journal editors questioned his work.
From "Japanese Anesthesiologist Fabricated Record Number of Scientific Papers"
RedOrbit (07/05/12) Smith, Brett
Local Doc Who Treats Vets' PTSD Gets Big-Name Help
An Illinois doctor believes he has a treatment, and possibly even a cure, for post-traumatic stress disorder (PTSD). Mathew St. Patrick, best known for his role in HBO's "Six Feet Under," recently met up with Dr. Eugene Lipov to help promote the treatment, known as stellate ganglion block. The actor said he wanted to get involved because both his brother and his father served in the U.S. Armed Forces. When the two met, Lipov demonstrated his method, in which he injects bupivacaine into a group of nerves in the neck. St. Patrick said the difference was noticeable after meeting one of the veterans before and after his third ganglion block treatment. Lipov received an $80,000 grant from the Illinois Department of Veteran Affairs to treat 10 male veterans suffering from PTSD. The course of treatment involves three ganglion block treatments, at $1,000 each. "We are averaging 18 military suicides a day, 1,000 a month," said U.S. Marine Brigadier Gen. William Weir, noting that more soldiers are being killed due to PTSD than those killed in Afghanistan and Iraq. Lipov hopes to one day create a "center of excellence," where doctors who use the method can practice. "Doctors then can do it, under us," he says, "so they do it correctly."
From "Local Doc Who Treats Vets' PTSD Gets Big-Name Help"
Courier News (IL) (07/01/12) Walker, Janelle

IARS Announces Recipient of 2012 Frontiers in Anesthesia Research Award
The International Anesthesia Research Society (IARS) recently announced that Ansgar Brambrink, PhD, MD, of Oregon Health & Science University is the recipient of its 2012 Frontiers in Anesthesia Research Award. Brambrink will receive $750,000, the largest single grant ever awarded by IARS, to investigate the long-term ramifications of anesthesia exposure in infant non-human primates. Growing evidence shows that general anesthetics administered at clinically relevant doses can cause widespread cell death in the brains of baby animals, sometimes increasing the likelihood of learning, memory, and behavioral issues. But definitive evidence linking clinically relevant anesthesia practice and poor neurologic outcomes remains unavailable. "The proposed experiments will address a question that has potentially important public health implications—does exposure to the infant monkey brain to a clinically relevant anesthesia protocol on one occasion or on multiple occasions cause long-term neurobehavioral disturbances," Brambrink said. The study is expected to begin this month.
From "IARS Announces Recipient of 2012 Frontiers in Anesthesia Research Award"
News-Medical (06/29/12)

Post-Anesthesia Dementia, Like Alzheimer's, Looks Micro-'Tubular'
While anesthesia generally is considered safe, healthcare professionals increasingly have documented post-operative cognitive dysfunction in elderly patients. After being anesthetized for a surgery, some older individuals with Alzheimer's disease suffer worsening symptoms; while those without the diagnosis may find it unleashed by the medication, suggesting a correlation of some sort between the two. One type of brain lesion caused by Alzheimer's disease is a neurofibrillary tangle, which is made up of hyper-phosphorylated "tau"—a protein usually attached to microtubules (MTs) and also found in post-anesthesia dementia. Whether MTs play a primary or supportive role, their stability and function are critical to cognition and consciousness. Destabilized MTs appear to be the primary problem in both Alzheimer's disease and post-anesthesia dementia. A study by researchers from Canada, Portugal, and the United States reported molecular modeling that showed 32 anesthetic binding sites per tubulin, with at least 1 percent of the billion tubulins per brain neuron binding an anesthetic molecule at clinical concentration. The research reveals that two specific anesthetic binding regions may destabilize the MTs. The first is one that deactivates tubulin C-termini tails, while the other weakens side-to-side tubulin couplings. "The good news," according to lead study author Travis Craddock, PhD, "is that therapies aimed at microtubule stabilization may help in both Alzheimer's and post-anesthetic dementias."
From "Post-Anesthesia Dementia, Like Alzheimer's, Looks Micro-'Tubular'"
Science Daily (06/27/2012)

Analgesic Efficacy of Continuous Femoral Nerve Block Commenced Prior to Operative Fixation of Fractured Neck of Femur
Researchers compared the analgesic efficacy of continuous femoral nerve block (CFNB) as opposed to basic opiate-based analgesia in patients suffering from fractured neck of femur (FNF). In the study, patients awaiting FNF surgery were randomly assigned to receive either the standard opiate-based treatment—in this case, parenteral morphine as needed—or a femoral perineural catheter, a CFNB comprising a bolus of local anesthetic followed by a continuous infusion of bupivacaine. Both sets of patients had access to rescue analgesia in the form of intramuscular morphine, and all patients received paracetamol regularly. A visual analogue scale was used to gauge pain levels when patients were at rest and during passive movement (dynamic pain score) one half-hour after the first analgesic intervention and at six-hour intervals for a total of 72 hours. It was discovered that CFNB provided more effective perioperative analgesia for those undergoing fixation of FNF, as the patients who received CFNB reported lower pain scores at rest, lower dynamic pain scores up to 54 hours, and higher patient satisfaction scores as compared to the reports from the patients who received the opiate-based analgesia.
From "Analgesic Efficacy of Continuous Femoral Nerve Block Commenced Prior to Operative Fixation of Fractured Neck of Femur"
7thSpace (06/27/12) Szucs, Szilard; Iohom, Gabriella; O'Donnell, Brian; et al.

Pain, Agitation and Delirium Guidelines to Be Unveiled
Clinicians who helped update pain, agitation and delirium (PAD) guidelines for intensive care units offered a sneak peek at the new recommendations during the annual meeting of the Society of Critical Care Medicine. In terms of pain management, one of the biggest departures from the 2002 guidelines is the recommendation to begin analgesia prior to adding sedation for most patients. Other significant revisions include a recommendation to prioritize non-benzodiazepine agents like propofol or dexmedetomidine over benzodiazepines like midazolam and lorazepan as well as a recommendation to maintain light sedation in patients. The 2012 guidelines additionally favor routine pain monitoring in all adult ICU patients through self reporting or via one of two pain assessment scales: the Behavioral Pain Scale or the Critical-Care Pain Observation Tool. For evaluating sedation, objective measures of brain function—such as vital signs—are no longer considered acceptable as the primary method for determining depth of sedation in non-comatose, nonparalyzed patients. The Richmond Agitation-Sedation Scale and Sedation Agitation Scale are preferred instead. Intravenous opioids, meanwhile, are recommended for treating non-neuropathic pain; and preemptive treatment of pain before removing a chest tube or other painful procedure is suggested through both opioid and non-opioid recourse as well as through nonpharmacologic interventions such as music therapy and biofeedback.
From "Pain, Agitation and Delirium Guidelines to Be Unveiled"
Pain Medicine News (06/01/2012) Vol. 10, No. 6 O'Rourke, Kate

Anesthesia Recordkeeping: Accuracy of Recall With Computerized and Manual Entry Recordkeeping
Anesthesia information management systems (AIMS), which document all patient vital signs and parameters in both a legible hard copy and a permanent electronic record, have been trumpeted as an improvement over manual-entry recordkeeping systems (MERS). Researchers recently conducted a study to determine if an anesthesia provider's vigilance, as gauged by recall ability, is affected by the recordkeeping technique. The investigators examined differences in the accuracy of Certified Registered Nurse Anesthetists' memory of specific patient variables during the course a real anesthetic case. With four tertiary care facilities participating in the experiment, a total of 106 healthcare professionals using AIMS were compared against 108 using MERS. Researchers measured their accuracy in recalling highest and lowest values for heart rate, systolic blood pressure, inspiratory pressure, end-tidal carbon dioxide levels, lowest oxygen saturation, and total fluid volume. The results showed no significant statistical differences in recall accuracy between the two groups.
From "Anesthesia Recordkeeping: Accuracy of Recall With Computerized and Manual Entry Recordkeeping"
Journal of Clinical Monitoring and Computing (06/01/2012) Vol. 26, No. 3, P. 163 Davis, T.C.; Green, J.A.; Colquhoun, A.; et al.

Multi-Site Study Examines Role of IV Disinfection Cap in Catheter Bundle
Intravenous connectors, which hook tubing to catheters, can harbor potentially dangerous bacteria and transfer infection; but researchers out of Chicago believe a disinfection cap can enhance IV safety. Traditional disinfection entails manually scrubbing IV connectors with isopropyl alcohol for 15 seconds, a process that sometimes is not followed to the letter or is ignored altogether. As an alternative, the disinfection cap twists on, covering the top and sides of a needleless luer-lock IV connector; once attached, it washes the connector with a solution of isopropyl alcohol. The cap also remains in place between catheter accesses in order to ward off contamination. As part of the Chicago study, use of the disinfection cap produced a 51 percent decline in central line-associated bloodstream infections (CLABSIs) across the four sites participating in the research. Lead study author Marc-Oliver Wright, corporate director of infection control for NorthShore University HealthSystem, said, "As a result of our findings, our organization chose to adopt the disinfection cap as part of our standard operating procedure for the prevention of CLABSIs.” The study results were presented at the recent annual conference of the Association for Professionals in Infection Control and Epidemiology.
From "Multi-Site Study Examines Role of IV Disinfection Cap in Catheter Bundle"
Newswise (07/10/12) Dowling, Liz
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