Anesthesia E-ssential, June 28, 2013

Anesthesia E-ssential

June 28, 2013


Vital Signs

Rhode Island Removes Supervision Requirement for CRNAs from State Law
On Monday, June 17, Rhode Island Governor Lincoln Chafee signed a bill (S.B. 614/H.B. 5656) into law that has removed a significant barrier to the practice of nurse anesthesia for Certified Registered Nurse Anesthetists (CRNAs) across the state. This law removes “under the supervision of” in the state’s Nurse Practice Act and now provides that CRNAs practice “in collaboration with,” anesthesiologists, licensed physicians, or licensed dentists.
Rhode Island is the first state to remove the CRNA supervision requirement language from a state nursing law or rule since 1999.  The bills passed unanimously in both houses, with the House passing H.B. 5656 by a vote of 72 to zero and the Senate passing S.B. 614 by a vote of 37 to zero.
The new law is consistent with the latest recommendations from the Institute of Medicine (IOM) report titled “The Future of Nursing: Leading Change, Advancing Health,” released in October 2010, which urges policymakers to remove policy barriers that hinder nurses—particularly advanced practice registered nurses such as CRNAs—from practicing to the full extent of their education and training. The report offers further evidence that advanced practice registered nurses should be a major part of the solution to the nation’s healthcare issues, especially ensuring access to care in medically underserved areas.
Rhode Island became the 40th state to have no supervision requirement for CRNAs in the nurse practice acts, board of nursing rules and regulations, and medical practice acts or board of medicine rules and regulations


The Pulse

  • Oregon CRNAs Granted Prescriptive Authority
  • Nevada CRNAs Invite You to "Their Vegas" in New Video
  • Earn Credits at Annual Meeting
  • Critical Incidents and Adverse Events Open Forum to Be Held During Annual Meeting
  • Business of Anesthesia Conference Coming in October
  • Register Today for the Jack Neary Pain Workshop
  • HVO Launches Nurse Anesthesia Program in Belize City, Belize
  • AANALearn® - Continuing Education Credits Always Available!
Professional Practice
  • View Award-Winning Video From the One & Only Campaign
  • Refresh Your Practice Knowledge: Reducing Pain for Children and Adolescents Receiving Injections
  • The Joint Commission Publishes Implementation Guide for NPSG.07.05.01 on Surgical Site Infections
  • Member Spotlight added to AANA Website
  • Call for Entries: AANA Public Relations Recognition Awards
  • Hearing and Call for Comments on Second Drafts of Practice Doctorate Standards and Post-Graduate Fellowship Standards
  • AANA Urges Noridian Medicare to Remove Post-Op Pain Block Restrictions from Draft Local Coverage Determination
  • AANA Urges Medicare to Consider Hospital Anesthesiology Efficiency Measures
  • House Panel Extends Incentive Special Pay Program for Military CRNAs
  • New Website Unveiled for Health Insurance Marketplaces under Health Reform
  • CMS Issues Proposal on the Program Integrity of Health Insurance Marketplaces
  • Most Health Reform is on Schedule, but Some May be Delayed, Government Accountability Office Says
  • Plan to Join the CRNA-PAC’s Retro Rat Pack in Las Vegas at the AANA Annual Meeting

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
Oregon CRNAs Granted Prescriptive Authority
Oregon Senate Bill 136 was signed into law, granting CRNAs prescriptive authority. The authority is independent and includes controlled substance schedules II-V. The new law makes Oregon the 30th state where CRNAs have prescriptive authority.
Nevada CRNAs Invite You to "Their Vegas" in New Video
The AANA Annual Meeting in Las Vegas is the "Don't Miss Event of the Year"--and Nevada CRNAs tell you why in "This is My Vegas," a new video available on the AANA website. In addition to the excitement and storied nightlife of Las Vegas, Nevada offers visitors a wealth of attractions, activities, and scenic wonders. If you haven't already, don't forget to register for the AANA Annual Meeting, to be held Aug. 10-13, at The Mirage in Las Vegas.
Earn Credits at Annual Meeting
Earn valuable CE credits and network with your fellow CRNAs during the 2013 AANA Annual Meeting at The Mirage in Las Vegas, Nev., Aug. 10-13. Register for Annual Meeting plus one of the exciting Preconvention Workshops to receive additional CE credit and a $50 discount on the combined registration. Don’t miss this opportunity to earn up to half of your recertification CE credits all in one place. Register today!
Critical Incidents and Adverse Events Open Forum to Be Held During Annual Meeting
All Annual Meeting attendees are invited to the open forum discussion Sunday, Aug. 11, to share personal experiences of emotions following a surgical and anesthesia critical incident. It’s an opportunity to share, or just listen, to offer a supportive ear. AANA Professional Practice and AANA Health and Wellness are partnering to address the supportive and respectful management of serious clinical adverse events, which you or colleagues may experience during your anesthesia career. Forum facilitators are Maria van Pelt, CRNA, MS, MSN, and Lynn Reede, DNP, MBA, CRNA, AANA Senior Director of Professional Practice. Van Pelt is also this year’s Jan Stewart Memorial Wellness Lecture Series, who, on Monday, Aug. 12, will lecture on her doctoral research—“The Aftermath of Perioperative Catastrophes: Our Voices are Finally Heard!"
Business of Anesthesia Conference Coming in October
The AANA Business of Anesthesia Conference is coming in October, and you don’t want to miss it! Boost your business savvy by attending this highly successful conference Oct. 19 at the Renaissance Pittsburgh Hotel in Pittsburgh, Pa. Designed by CRNAs for CRNAs, this program will cover anesthesia business from your colleagues who know it best. Here is what past participants have to say about the conference:
  • “This was one of the best educational meetings of my career… from ANY source!”
  • “It’s the best AANA meeting that I have attended in my 38-plus years as a CRNA.”
  • “I got information there that you just don't find anywhere else.”
Register before Friday, Sept. 22, and save $75 on the registration fee.
Register for Jack Neary Pain Workshop
Register today for the AANA Jack Neary Advanced Pain Management Workshop series. We are offering a series of workshops all focusing on various aspects of importance to the pain practitioner. Each workshop below can be registered for separately, but the biggest impact comes from taking them all together as a training plan:
  • AANA Jack Neary Advanced Pain Management I Workshop – Oct. 12-13, 2013
  • AANA Jack Neary Advanced Pain Management II Workshop – Oct. 14-15, 2013
  • Neuroanatomy Prosection Lab – Oct. 16, 2013
These workshops will incorporate both lecture and hands-on instruction facilitated by expert faculty. The lecture portion will include scientific and theoretical bases of pain, pharmacology, and pain management practice considerations. Attendees will have an opportunity to learn and practice pain management techniques on human cadavers and state-of-the-art pain procedure simulators.
Don’t miss this outstanding workshop!
HVO Launches Nurse Anesthesia Program in Belize City, Belize
Health Volunteers Overseas (HVO) is launching a new nurse anesthesia program in Belize. In partnership with the University of Belize and the Karl Heusner Memorial Hospital (KHMH) in Belize City, HVO volunteers will work to increase the number of highly-skilled, safe, and effective nurse anesthetists in the country by January 2015 through development and implementation of a formal two-year, full-time bachelor's of nurse anesthesia program.
Students will attend classes at the University of Belize (UB) campus in Belize City and complete clinical rotations at KHMH, the country's largest and only referral hospital. Other regional hospitals will serve as advanced clinical sites.
HVO volunteers will provide the majority of the faculty for the technical courses related to anesthesia while nursing and allied health faculty from UB will teach university core courses, including a master's-level pharmacology course. HVO will recruit highly-qualified CRNA volunteers—active or retired—in all areas of nurse anesthesia expertise to provide both clinical and didactic training. Clinical faculty volunteers must hold a current license to provide anesthesia in the United States, but HVO will consider volunteers without an active license to provide didactic instruction. Assignments range from two to four weeks, though four weeks is preferred.
Health Volunteers Overseas is a private, nonprofit organization founded in 1986 to improve global health through the education of local healthcare providers. In 26 years of service, HVO's training has transformed lives through the design and implementation of clinical and didactic education programs in child health, primary care, trauma and rehabilitation, essential surgical care, oral health, blood disorders and cancer, infectious disease, nursing education, and wound management. In more than 25 resource-poor countries, HVO volunteers train, mentor, and provide critical professional support to healthcare providers who care for the neediest populations in the most difficult circumstances. For more information, visit the Health Volunteers Overseas website.
AANALearn® - Continuing Education Credits Always Available!
Do you need a few more CE credits for recertification this year? The deadline is quickly approaching. There’s no better time than now to review your transcript and make sure you have adequate CE credits, especially if you plan to recertify by July 31.
All courses are prior approved by the AANA, and the credits will automatically transfer to the AANA transcript*. AANA members have an existing account with AANALearn® which is easily accessed from the AANA website using their AANA login username and password. Browse the AANALearn® catalogs now at
* CE credit transfer is only for AANA members or nonmembers with record keeping contracts.

View Award-Winning Video From the One & Only Campaign
The One & Only Campaign’s "Safe Injection Practices—How to Do It Right” video was the grand-prize winner of the third annual film festival at the 40th Annual Conference of the Association for Professionals in Infection Control and Epidemiology. The video was created to raise awareness among patients and healthcare providers about safe injection practices. View this and other informational resource videos from the One & Only Campaign at
Refresh Your Practice Knowledge: Reducing Pain for Children and Adolescents Receiving Injections
Cincinnati Children's Hospital Medical Center has put together a best-evidence statement and recommendations, resulting from a review of literature and current practices, regarding reducing pain for children and adolescents receiving injections. Recommendations include age-appropriate use of sucrose solution, breastfeeding, holding the infant, distraction, topical agent containing lidocaine/prilocaine, sequential injection, rapid combined injection, preparation, positioning, breathing exercises, and hypnosis. Access intervention recommendations, presented by developmental level from infant to adolescent, and supporting evidence through AHRQ’s National Guideline Clearinghouse.
The Joint Commission Publishes Implementation Guide for NPSG.07.05.01 on Surgical Site Infections
Surgical site infections (SSIs) are a serious healthcare concern. The Joint Commission has published a guide to assist healthcare organizations with the implementation of the National Patient Safety Goal (NPSG) on SSIs. This guide is based on the work of the SSI Change Project, which focused on identifying effective practices for implementing NPSG.07.05.01 and reducing SSIs. The implementation guide defines 23 effective practices and includes supporting statements from the 17 hospitals that participated in the SSI Change Project, a section focused on pediatrics, and a recommended method for using the guide. Download the guide and listen to the supplemental podcast here.

​Member Spotlight added to AANA Website
A section has been added to the AANA website that aims to shine a light on CRNAs taking part in noteworthy endeavors. The Member Spotlight page is filled with features stories, pictures, and information about the hobbies, charities, and second lives of anesthetists. The latest story is about Sylvia Bernassoli, a 79-year-old CRNA who has been working for 56 years and donated nearly a half-million dollars to the in vitro clinic where she works. It can be accessed by clicking on the News & Journal tab on the homepage or by clicking here. If you know someone you think should be profiled, contact Leland Humbertson at
Call for Entries: AANA Public Relations Recognition Awards
Deadline: July 15, 2013
The AANA Public Relations Committee is seeking entries for the 2013 Public Relations Recognition Awards. Visit the AANA website for more information about the awards criteria and guidelines and an electronic entry form.

Hearing and Call for Comments on Second Drafts of Practice Doctorate Standards and Post-Graduate Fellowship Standards
The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) approved the second drafts of the Practice Doctorate Standards for Nurse Anesthesia Programs and the Standards for Post-Graduate Fellowships at its May 2013 meeting.
The AANA Education Committee will conduct a Hearing and a Focus Session to obtain comments from the community of interest on the Standards at the 2013 AANA Annual Meeting in Las Vegas, Nev. The Hearing will take place on Saturday, Aug. 10, from 3:30-4:30 p.m. The Focus Session will be held on Sunday, Aug. 11, from 6 to 7 p.m.
A Call for Comments will be distributed early in July to the community of interest including CRNA program administrators, faculty, CRNA practitioners, student registered nurse anesthetists, state boards of nursing, deans, the higher education community, and the public.
Following the Annual Meeting, the comments from the Hearing, Focus session, and Call for Comments will be compiled and forwarded to the COA’s Standards Revision Task Force for consideration as it prepares Draft Three of both sets of Standards. Contact the COA at or (847) 655-1160 with any questions.

AANA Urges Noridian Medicare to Remove Post-Op Pain Block Restrictions from Draft Local Coverage Determination
The AANA requested that Noridian Medicare reverse its proposed local coverage determination (LCD) that would deny coverage of post-operative pain blocks, noting the benefits of placing such blocks earlier.
The June 17 letter, signed by President Janice Izlar, CRNA, DNAP, stated, “The draft LCD is inconsistent with the principles of correct coding as outlined in the National Correct Coding Initiative Policy Manual for Medicare Services (“NCCI manual”), Chapter 2 Anesthesia Services, revision date Jan. 1, 2013… The draft LCD should be changed to allow anesthesia professionals, including CRNAs, to be paid for placing post-operative pain blocks as outlined in the NCCI policy manual.” The letter also states that the policy is inconsistent with the peer-reviewed literature, which demonstrates the value of post-operative pain blocks prior to the emergence from anesthesia.
AANA Urges Medicare to Consider Hospital Anesthesiology Efficiency Measures
The AANA has recommended that Medicare consider the costs of various anesthesia delivery models and of hospital anesthesia subsidies per anesthetizing location as part of quality measures intended to capture the efficiency of hospital anesthesia services.
The June 21 letter, signed by President Janice Izlar, CRNA, DNAP, stated, “The Agency may want to consider the costs of meeting the seven medical direction steps as part of the anesthesiology spending and cost-efficiency measure. Under the medical direction practice model, the medical directing anesthesiologist must complete seven steps in order to bill for this modality. The Agency has clearly stated that medical direction is a condition for payment for anesthesiologist services and not a quality standard.”
The AANA discussed the ways that the requirements associated with anesthesiologist medical direction claims contribute to healthcare cost growth, noting specifically the requirement that the anesthesiologist be “present at induction.” “For every minute spent waiting for an anesthesiologist to arrive and be present at induction, some of the costliest resources in the hospital are wasted. The clock is running on the surgeon, circulating nurse, scrub tech, and nurse anesthetist waiting in the operating room. Waiting costs cascade throughout the day, postponing the surgery schedule to require overtime and on-call staff, delaying the surgeon’s rounds to affect patient care and discharge of the patient from the healthcare facility. Waiting costs also add opportunity costs, diverting needed resources from other patient care,” continued the letter.
The letter also recommends including the cost per anesthetizing location as part of the proposed anesthesiology measure since hospitals pay an average of $160,096 per anesthetizing location to anesthesiology groups, and increasing the weight placed on clinical process of care measures, such as the Surgical Care Improvement Project (SCIP) measures, under the hospital value based purchasing program.
House Panel Extends Incentive Special Pay Program for Military CRNAs
Incentive Special Pay (ISP) programs that the U.S. Armed Forces use to recruit and retain CRNAs into active duty and reserve military service are extended one more year, to Dec. 31, 2014, according to provisions of the 2014 national defense authorization cleared by a key House committee.
The bill, including the ISP language, the National Defense Authorization Act for Fiscal Year 2014 (HR 1960), was reported by the House Armed Services Committee June 6 on a 59-2 vote and awaits consideration by the full House of Representatives. A similar defense authorization bill is anticipated to be taken up by the panel’s Senate counterpart later in the summer. The AANA annually advocates for extension of the services’ ISP program.
Read the bill here and see the CRNA provision on p. 271.
New Website Unveiled for Health Insurance Marketplaces under Health Reform
The federal government unveiled a new website June 24 and a 24-hour consumer hotline to help people learn about and enroll in health coverage under the Affordable Care Act this fall. Enrollment begins Oct. 1, 2013, for plans that take effect Jan. 1, 2014.
“The re-launched and new call center will help consumers prepare for the new coverage opportunities coming later this year,” said Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner, RN, MHA, FACHE. “In October, will be the online destination for consumers to compare and enroll in affordable, qualified health plans.”
The new site is designed for consumers and employers, more so than for healthcare providers such as CRNAs. However, CRNAs involved in community education efforts targeted toward enrolling people in health coverage can use the site and the 24-hour hotline to provide authoritative information and answer questions. As the Oct. 1 enrollment start date approaches, more functionality will be added to the site so that consumers can create accounts, complete an online application, and shop for qualified health plans.
See the site at, and in Spanish at The 24-hour hotline is 1-800-318-2596. Hearing-impaired callers can use TTY/TDD technology at 1-855-889-4325.
CMS Issues Proposal on the Program Integrity of Health Insurance Marketplaces
The Department of Health and Human Services (HHS) released a notice of proposed rulemaking (NPRM) June 14 focusing on program integrity regarding State Marketplaces and oversight of issuers offering coverage in the Federally-Facilitated Marketplace, offering an opportunity for the AANA and CRNAs to promote the importance of provider nondiscrimination.
The AANA supports provider nondiscrimination because it protects health plans from discriminating against qualified licensed health professionals, such as CRNAs, solely on the basis of licensure. Under the proposal, HHS states that the Federally-Facilitated Marketplace must comply with current federal nondiscrimination requirements. Furthermore, in order to assure that consumers are properly given a choice of available coverage and providers, this proposal also suggests standards for the oversight of State Marketplaces through monitoring, reporting, and oversight of financial activities and Marketplace activities. The rule proposed that State Marketplaces must provide eligibility and enrollment reports to HHS annually that include information on nondiscrimination safeguards.
For further information, see the fact sheet on the proposed rule.
Most Health Reform is on Schedule, but Some May be Delayed, Government Accountability Office Says
The federal government’s fiscal watchdog says implementation of the Affordable Care Act health reform law is mostly proceeding as scheduled, but is a complex process that is facing some delays less than four months before enrollment in new health plans opens Oct. 1. For CRNAs, the issue is important to follow because the act intends to expand the number of people with health coverage.
According to two Government Accountability Office (GAO) reports issued June 19, funding awards for “navigators” intended to educate consumers about healthcare coverage enrollment have been delayed by two months, delaying other training and implementation requirements. “Much progress has been made, but much remains to be accomplished in a short period of time,” the report said. Implementation of the state-based Small Business Health Options Programs (SHOPs) hinges on whether a state is one of 18 operating a SHOP exchange, or one of 33 where the federal government is facilitating the exchange.
Read the GAO report on establishing federally facilitated exchanges for health coverage here, and the report for small business exchanges here.
Plan to Join the CRNA-PAC’s Retro Rat Pack in Las Vegas at the AANA Annual Meeting
While you’re at the AANA Annual Meeting in Las Vegas, embark on a one-of-a-kind experience with the CRNA-PAC at the Cleveland Clinic Lou Ruvo Center for Brain Health on Saturday, Aug. 10, from 6:30 to 8:30 p.m. Starting from our convention hotel, guests will be transported a short drive off the Vegas strip and back to a different decade as the CRNA-PAC celebrates with a “RETRO RAT PACK” reception and silent auction. Designed by world-renowned architect Frank Gehry, the Lou Ruvo Center is an iconic architectural landmark that includes a Wolfgang Puck-inspired kitchen, 199 unique windows, and a surrounding stainless steel trellis canopy, creating a truly magical experience.
With a venue mantra of “Keep Memory Alive,” the evening surely will be one to remember for years to come. Get your tickets today when you register for the AANA Annual Meeting. Tickets also can be purchased and/or picked up on site at the PAC booth located near meeting registration. Please visit for additional information. Proceeds to benefit the AANA’s CRNA-PAC, the only PAC in the United States devoted 100 percent to keeping the voice of nurse anesthesia strong in Washington, D.C.
About This Document
The AANA Federal Government Affairs Hotline is published for the nurse anesthetist members of AANA Mondays when Congress is in session by the AANA Office of Federal Government Affairs, Washington DC, (202) 484-8400,, Frank Purcell, Senior Director. © 2013 American Association of Nurse Anesthetists. 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.


Etomidate Linked to Worse Post-Op Outcomes vs. Propofol
Cleveland Clinic researchers have found that critically ill patients who receive etomidate during anesthesia induction are at greater risk of dying within 30 days compared to patients who are administered propofol for the same purpose. Led by Ryu Komatsu, MD, the team reviewed electronic records for 31,148 patients who had noncardiac surgery under general anesthesia between 2005 and 2009. Propofol was used to induce anesthesia in 28,532 patients, while etomidate was used for 2,616 patients. The results of the retrospective analysis indicated that the etomidate group had more deaths within 30 days of surgery (139, compared to 134 among the propofol patients), longer hospital stays (seven days compared to six), and lower systolic blood pressure during surgery. Additionally, patients receiving etomidate were 18 percent less likely to be discharged from the hospital at any time following surgery. "We could only show an association between worse outcomes and etomidate use," said Komatsu. "Randomized controlled trials are necessary to determine if there is another relationship between etomidate use and outcomes, as well as to define precisely the effect of etomidate." In the meantime, Komatsu recommended that clinicians use etomidate "judiciously."
From "Etomidate Linked to Worse Post-Op Outcomes vs. Propofol"
Anesthesiology News (06/01/13) Vol. 38, No. 6 Vlessides, Michael

'Laugh' Your Way Through Surgery
Although some research has drawn a correlation between nitrous oxide—better known as laughing gas—and an increased risk of heart attack, a new study from the Washington University School of Medicine suggests that it would be premature to discount the use of this anesthetic. It had been thought that rising levels of the amino acid homocysteine in the blood that occur when laughing gas inactivates vitamin B12 would elevate the risk of both peri-operative and post-operative heart attack. To investigate, the team considered 500 patients who received laughing gas during non-heart surgery, although all had been diagnosed with health problems tied to the risk of heart attack. They found no significant differences in the rate of heart attack between patients who received vitamin B injections to prevent a rise in homocysteine levels and those who did not, suggesting that risk was not influenced by homocysteine levels. An enzyme called troponin I, which is found in the blood and has been linked to heart muscle damage, was also monitored for a link to homocysteine levels. No such link was found, indicating that nitrous oxide's influence on homocysteine levels is not directly associated with heart damage. Gene variations linked to higher homocysteine levels also were examined; carriers of the risky gene variation experience spiked homocysteine levels when exposed to laughing gas anesthesia. Since only 3.1 percent of patients who had the gene variation suffered heart attacks during or after surgery, the researchers concluded that neither the gene variation nor homocysteine levels raise the risk of heart attack. In the July issue of Anesthesiology, the researchers noted that a larger study with more participants is needed to better address the issue.
From "'Laugh' Your Way Through Surgery"
DailyRx (06/21/13) Viswanathan, Nishi

Use of Longer-Acting Anesthetic Shows No Difference in Duration of Hospitalization
Refuting the results of their own previous research, investigators at the Cleveland Clinic report in the July issue of Anesthesiology that using a cheaper but longer-acting anesthetic in place of a more expensive but shorter-acting agent actually does not influence length of hospital stay. Initial results, derived from a retrospective review of nearly 8,700 existing electronic medical records, suggested that the longer-acting drug, isoflurane, prolonged hospitalization. The Cleveland Clinic team followed up that research, however, with a prospective study that contradicted the earlier finding. That trial, involving 1,501 patients, indicated a mean 4.1 days in the hospital for patients given isoflurane and a mean 4.2 days for those given the shorter-acting sevoflurane—a difference that was not considered statistically significant. The researchers agree that the different results underscore the importance of following up a retrospective study with a prospective one in order to achieve the most accurate findings.
From "Use of Longer-Acting Anesthetic Shows No Difference in Duration of Hospitalization"
News-Medical (06/20/13)

Reports of Retained Guidewires to Place CVCs Draw Attention to 'Never Events' in Anesthesia
Guidewires are commonly used when placing central venous catheters (CVCs) for the purpose of administering drugs or fluids, monitoring patients, or performing other functions. Although considered a "never event," meaning there is no reason this scenario should ever unfold when routine precautions are taken, clinicians on rare occasion do fail to remove guidewires following a procedure. In the July issue of Anesthesia & Analgesia, Dr. Andrea Vannucci and colleagues share the details of four cases of retained guidewires following CVC replacement at their hospital. Factors that may have contributed to the incidents, they suggest, include the urgent nature of the surgeries and patients' unstable condition during the procedures, which may have distracted operating room personnel from following protocol, as well as confusion over the use of more than one guidewire. The incidents have led to new preventative measures at the hospital, including a mandatory training program for residents, a reminder on guidewire removal incorporated into the electronic medical record, and a checklist to guide every CVC placement. In an editorial accompanying the report, Drs. Jeffrey Green and John Butterworth of Virginia Commonwealth University stress that the process of CVC placement needs to be re-engineered. "Only after we adopt systems approaches to counter the failure modes present in many of the high-risk activities in anesthesiology will we begin to move these sentinel events into the 'never' category," they declare.
From "Reports of Retained Guidewires to Place CVCs Draw Attention to 'Never Events' in Anesthesia"
Infection Control Today (06/20/13)
Rediscovered Local Holds Promise for Spinal Anesthesia
A literature review by New York University associate anesthesiology professor Arthur Atchabahian, MD, and anesthesiology resident Elyse Goldblum, MD, suggests that 2-chloroprocaine provides clinical advantages for brief lower-body surgical procedures. The local anesthetic, recently approved in Europe for intrathecal use, appears to have a substantially lower risk for transient adverse neurological effects than lidocaine. While a paucity of data prevented a full systematic review, Atchabahian and Goldblum discovered some promising findings, which they reported in a paper published in the May issue of Acta Anesthesiologica Scandinavica. The results included a double-blind trial by Montreal researchers that found a less than 2 percent rate of transient neurologic symptoms in patients given 2-chloroprocaine, compared to as high as 40 percent for lidocaine administered during spinal anesthesia. Additionally, a retrospective review at Virginia Mason Medical Center revealed that none of 503 outpatients who received 2-chloroprocaine experienced this type of adverse outcome. University of Pittsburgh anesthesiology professor Jacques Chelly, MD, PhD, MBA, commented that the drug could be "of great value" as a spinal anesthetic, adding that he "would not be surprised if an application would be submitted to the FDA to get approval [for that indication within the United States]." According to the review, 2-chloroprocaine also offered other benefits, including earlier discharge and shorter recovery time.
From "Rediscovered Local Holds Promise for Spinal Anesthesia"
Anesthesiology News (06/01/13) Vol. 38, No. 6 McNamara, Damian
Better Guidance Urgently Needed for 'Epidemic' of Sleep Apnea in Surgical Patients
In an editorial published in the New England Journal of Medicine, Stavros Memtsoudis, MD, PhD, of New York City's Hospital for Special Surgery puts out the call for a new research initiative to pinpoint the safest and most effective ways to manage surgical patients suffering from sleep apnea. While the disorder is more common than diabetes and presents a high risk of complications during surgery—including airway blockage and intubation difficulties—little research has been done, and few hospitals have management policies in place. While the American Society of Anesthesiologists issued guidelines in 2006, Memtsoudis says there is little research to support the protocol. Those guidelines dictate that clinicians conduct a pre-operative evaluation; favor local or regional anesthesia or perioperative nerve blocks over general anesthesia; recommend that continuous positive airway pressure (CPAP) be used perioperatively; and call for extended periods of observation post-surgery. However, as Memtsoudis notes, "there is insufficient evidence to tell us whether these actions actually have any effect," and since "these approaches require extensive resources [they] may be hard to justify given the high cost and lack of evidence that they truly change outcomes." After publishing in May the first study to date that provides evidence supporting specific techniques for the safe management of surgical patients with sleep apnea, Memtsoudis and his colleagues from the Department of Public Health at Cornell University have been working with members of the new Society for Anesthesia and Sleep Medicine to design a multicenter "practice based evidence" study that will allow them to better "assess what works and what doesn’t work and who among sleep apnea patients is actually at risk."
From "Better Guidance Urgently Needed for 'Epidemic' of Sleep Apnea in Surgical Patients"
RedOrbit (06/20/13)

Guided Method May Make Children Less Agitated After Sedation
Children who receive general anesthesia for dental surgery, usually through an inhaler, often experience delirium and agitation when they regain consciousness, which can increase their risk of injury and lower their parents' satisfaction with the dental care. A report in the journal Anesthesia Progress looks at a new technique that could reduce the occurrence of this delirium and agitation. Most dentists choose sevoflurane as an inhalant for young patients, because the I.V. does not have to be started while the child is awake and it is easy to regulate. However, patients receiving it are more likely to be anxious and disoriented, especially preschool-age children. One solution is a technique called Bispectral Index System-guided anesthesia. The child still receives sevoflurane to induce anesthesia; however, 30 minutes before the end of the procedure, the anesthesiologist changes from sevoflurane to propofol, which shortens recovery time and reduces the concentration of the drug used. With this technique, the effects of the second drug are gone in about 15 to 20 minutes. In over 300 procedures that have used this technique, the children experienced less agitation and delirium after their surgery more than 90 percent of the time.
From "Guided Method May Make Children Less Agitated After Sedation"
Digital Journal (06/18/13)

Penn Researchers Design Variant of Main Painkiller Receptor
It is known that when the mu opioid receptor bonds to opioid molecules, it greatly alleviates pain—but it also causes a variety of unpleasant and potentially lethal side effects, which drug designers are anxious to address. Previously experimenting with this receptor has been a challenge because it is scarce in humans, cannot be grown recombinantly, and is coated with a layer of hydrophobic amino acids groups that make it insoluble in water. Now, however, University of Pennsylvania researchers have developed a variant of the mu opioid receptor that can be grown in large quantities in bacteria and is water-soluble. "This is a great product that can do a lot of things," according to Renyu Liu of Penn's anesthesia and critical care department. "You can use this variant to look at the structure-function relationship for the receptor, or even potentially use it as a screening tool. The computer modeling approach used means that the team can more easily design further iterations of the variant by tweaking it alongside experimental conditions.
From "Penn Researchers Design Variant of Main Painkiller Receptor" (06/15/13) Lerner, Evan
Common Cold Adds Complications, Costs to Peds Heart Surgery
Infants who undergo heart surgery with a human rhinovirus (HRV) infection are more likely to experience a longer hospitalization and more respiratory complications than uninfected children, according to a study by researchers at Nationwide Children's Hospital and the Ohio State University Wexner Medical Center. Respiratory complications during and after surgery can lengthen the time that patients need mechanical ventilation. The study reviewed data for all infants admitted for surgery to repair congenital cardiac anomalies at the two hospitals. Among nine children who tested positive for HRV undergoing a variety of cardiac surgeries, the median hospital stay was 97 days, while for 24 HRV-negative children undergoing comprehensive stage II surgeries, the median hospital stay was 14 days. Twenty-eight uninfected infants undergoing complete atrioventricular canal repair had a median hospital stay of six days. For an HRV-positive patient who underwent stage II palliation, the treatment cost was $788,462, compared with $273,834 for a typical patient not infected with the virus. The researchers presented the results at the 2013 annual meeting of the Society for Pediatric Anesthesia. These findings emphasize the need for a standard of care and preoperative protocol for pediatric surgical patients.
From "Common Cold Adds Complications, Costs to Peds Heart Surgery"
Anesthesiology News (06/01/13) Vol. 38, No. 6 Savoie, Keely

CDC Grand Rounds: Preventing Unsafe Injection Practices in the U.S. Health-Care System
Outbreaks attributed to unsafe injection practices have risen substantially in the United States in recent years. The Centers for Disease Control and Prevention (CDC) and state and local health departments have investigated the outbreaks and the results reveal that the healthcare system in susceptible to the dangers of unsafe injections. State and federal governments have pursued policy and educational initiatives to address the problem, but injection safety interventions will need to be implemented in all settings where injections are delivered. Many outpatient facilities typically do not fall within the purview of federal and state regulatory oversight of healthcare facilities, making it difficult to monitor injection safety and other infection control practices. The risks of unsafe injections practices are unacceptable, and the harm is "entirely preventable," the CDC said.
From "CDC Grand Rounds: Preventing Unsafe Injection Practices in the U.S. Health-Care System"
Morbidity and Mortality Weekly Report (05/31/13) Vol. 62, No. 21, P. 423

ICU Checklist Avoids Unplanned Readmissions
Mayo Clinic researchers have developed a checklist for the transfer of patients from the operating room to the ICU that they say can help eliminate unplanned readmissions. The guidance features seven items addressing antibiotics, anticoagulation, antihypertensive management, arrhythmias, blood products, delirium, diuretics, respiratory support, pain, and any nursing concerns. The team incorporated the checklist into rounds, then monitored its use over five weeks last year. The tool was used for 42 of the 141 dismissals during that period, and researchers documented 17 unplanned readmissions that occurred for patients at whose original dismissal the checklist was not used. Nathan Smischney, MD, a Mayo Clinic Scholar who presented the findings at the 2013 annual congress of the Society of Critical Care Medicine, attributed the low compliance rate to the fact that many residents considered the checklist too long. He said a group of fellows is abbreviating it to include only the most essential components for ICU staff and receiving surgical teams. The checklist was described as a "helpful communication tool" despite its inconsistent use by Eugenie Heitmiller, MD, associate professor of anesthesiology and pediatrics at Johns Hopkins School of Medicine. She suggested that a study of the checklist on a larger scale might reveal higher efficacy and stressed that in order to be fully implemented, a checklist must be embraced by those who will use it—which requires that is easily available, user-friendly, and widely disseminated.
From "ICU Checklist Avoids Unplanned Readmissions"
Anesthesiology News (05/01/13) Vol. 39, No. 5 Blum, Karen
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