Anesthesia E-ssential, March 30, 2012

Anesthesia E-ssential

March 30, 2012


Vital Signs

Journal Anesthesiology Confirms that Anesthesiologist Supervision Often Lapses 
Lapses in anesthesiologist supervision of CRNAs are common even when an anesthesiologist is medically directing as few as two CRNAs, according to an important new study in the March issue of the journal Anesthesiology. The study, titled "Influence of Supervision Ratios by Anesthesiologists on First-case Starts and Critical Portions of Anesthetics," looks at over 15,000 anesthesia records in one leading U.S. hospital and raises critical issues about propriety and compliance in the most common and costly model of anesthesia delivery at a time when quality and cost-effectiveness are white-hot healthcare issues at every level.
Medicare medical direction payment rules reimburse anesthesiologists 50 percent of a fee for performing all seven medical direction tasks in each of up to four CRNA cases concurrently. Anesthesiologist medical direction of CRNAs is not required by Medicare. Rather, medical direction is a billing modality in which physicians billing for medical direction personally attest to having performed specific tasks warranting reimbursement.
Yet, this new study states that "(e)ven at a ratio of 1:2, there would have been at least one such lapse in supervision for 35 percent of days. At a ratio of 1:3, there would be supervision lapses on 99% of days." The researchers define a "supervision lapse" as an instance when there is an "inability to supervise all critical portions" of a case. Without personally performing such supervision, the seven medical direction tasks that an anesthesiologist must complete for billing Medicare for medical direction are not fulfilled, and a medical direction claim is not permitted.
The findings now reported in Anesthesiology, published by the American Society of Anesthesiologists, are confirmed by AANA member survey data. According to our member data, where CRNA services are supervised by anesthesiologists, 74 percent are supervised at a rate of 1:2 or greater. Half of CRNAs report that 100 percent of their cases are considered medically directed by anesthesiologists. And of the seven medical direction tasks, CRNAs report anesthesiologists are involved in those activities only between 5 percent and 42 percent of the time. Anesthesiologists are simply not completing the requirements of medical direction, and may be billing Medicare for them.
Yet, is patient safety at issue here? No. The AANA has long held that medical direction ratios have nothing to do with quality of care, and everything to do with reimbursement systems inefficient, unsustainable systems that make healthcare cost too much and divert millions upon millions of scarce healthcare dollars from real patient needs. Recent landmark studies on anesthesia safety and cost-effectiveness published in the journals Health Affairs and Nursing Economic$ have confirmed the safety and cost-effectiveness of CRNAs, and the Institute of Medicine in The Future of Nursing emphasizes APRN safety in arguing for nurses to practice to their full scope. Now, this study in Anesthesiology confirms anesthesiologist supervision of CRNAs is more honored in the breach than in the observance.
Empowered by this additional peer-reviewed evidence in Anesthesiology on top of the evidence recently published in Health Affairs and Nursing Economic$, your AANA is continuing to work to make this message heard in the places it needs to be heard. Stay tuned.
What does this new study mean for CRNAs? Click here to access additional information on the AANA website to help you prepare for the potential impact of the study. Scroll down to the bullet points on that page.
After all these years, anesthesiologists themselves have now stated in their own journal what CRNAs have long known: Medical direction responsibilities are not fulfilled in every case where that service is billed. Such a striking conclusion confirms the evidence and our view that supervision ratios do not benefit patient outcomes, and that medical direction costs tremendous sums of money needlessly. Perhaps now the focus can be placed where it belongs and as we have long advocated: on the needs of patients.


Inside the Association

  • California Opt-Out Upheld
  • Choose How to Receive your 2012 AANA Election Ballot Materials
  • Coming Soon: Online Forum for Candidates for the AANA Board of Directors
  • AANA Journal Course #31 Available Only Online
  • Sharps Safety Consensus Statement and Call to Action Issued
  • Health Volunteers Overseas Needs Anesthesia Volunteer in Bhutan
  • AANALearn® Provides Prior-approved CE Courses for Recertification
  • Join the AANA's Social Network
  • AHRQ Offers HCUP Data Users' Workshop on April 25
  • Call for Applicants for The Hartford Institute 2012 Geriatric Nursing Research Scholars Program
  • Call for Comments for Practice Doctorate Standards
  • AANA President and President-elect Visit Key Federal Agencies
  • House OKs Medical Liability Reform and IPAB Repeal Bill March 22
  • Supreme Court Takes Up Health Law
  • House GOP Offers Budget with Medicare, Medicaid Changes; Enactment Outlook Dim
  • MedPAC Again Recommends Anesthesia and Specialty Cuts
  • Medicare Solicits Applications for Graduate Nursing Education Demonstration Project AANA Helped Enact
  • HHS Releases Final Rule Governing State-based Health Insurance Exchanges
  • AANA Participates in Health Plan Policy Conference
  • Medicare Recommends Coverage of TENS for Back Pain Only in Narrow Circumstances
  • How can CRNAs Use Social Media in Advocacy?
  • Book Your Mid-Year and Business of Anesthesia Meetings Now!
  • Join CRNA-PAC for “An Affair of State” April 15 at AANA Mid-Year Assembly
  • CRNAs Seen in Washington
  • Visit the CRNA Career Center.
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.
  • Voice, Throat Problems Common After Anesthesia
  • Drug Could Be Useful Treatment for Anesthesia-Related Memory Loss
  • Age-Old Anesthesia Question Awakened
  • Which Anesthesia Is Best for Cataract Surgery?
  • Pain Meds May Influence Cancer Growth
  • Peripheral Nerve Stimulation Helps Control Pain After Combat Injuries
  • Thin Patients at Greater Risk of Dying After Surgery
  • Little Evidence for Non-Drug Labor Pain Relief
  • Use of Anesthesia Providers During Gastroenterology Procedures Has Increased Rapidly, But May Be Unneeded

Inside the Association

Hot Topics

California Opt-Out Upheld
On March 15, 2012, the California Court of Appeals issued a ruling affirming the trial court’s ruling that California law does not require physician supervision of CRNAs, upholding the validity of the state’s opt-out. In this ruling the appeals court noted that California CRNAs administer anesthesia pursuant to a physician order, but that this is not a requirement to administer anesthesia under physician supervision.
The court also noted statutory language stating that CRNAs “shall be responsible for [their] own professional conduct and may be held liable for those professional acts” in determining that state law does not require supervision. The court concluded that, in order to side with the California Society of Anesthesiologists (CSA) and the California Medical Association (CMA), it “would have to ignore not just one, but multiple authoritative sources uniformly concluding that CRNA’s [sic] are allowed to administer anesthesia in California without physician supervision.” CSA and CMA could still attempt to petition the state supreme court to review the case, but there is no certainty that the court would agree to take the case.
In June 2009, California opted-out of the federal payment rule requiring CRNAs to be supervised in hospitals and ASCs that are reimbursed under Medicare Part A. For such an opt-out to be successful, a state’s governor must send a letter attesting to a number of things, including that the opt-out is consistent with state law, which has been interpreted to mean that the state cannot have a supervision requirement of its own. Following California’s opt-out, CSA and CMA sued the governor’s office, claiming, among other things, that the opt-out was inconsistent with state law since, in their opinion, state law requires physician supervision of CRNAs. CANA intervened as a party in the suit on behalf of the governor. In late 2010, the trial court granted summary judgment in favor of the governor, stating their opinion that California law does not require CRNAs to be supervised by a physician. In January 2011, CSA and CMA filed an appeal of the lower court ruling with the California Court of Appeal. This ruling is the result of that appeal.
Choose How to Receive your 2012 AANA Election Ballot Materials
Please respond by April 11, 2012.
All active members should have received a blast email from the AANA Election Coordinator asking them how they want to receive ballot materials for the upcoming elections (electronic or paper). Members who do not respond to the email will receive their ballot materials electronically. Members who request to receive ballot materials electronically will receive a personalized email from Survey and Ballot Systems (AANA’s Election Services Coordinator) containing a personalized E-signature and voting instructions. Those who ask to receive their ballot materials by mail will receive their E-signatures and voting instructions in their packets.
Coming Soon: Online Forum for Candidates for the AANA Board of Directors
The Online Forum for Candidates for the AANA Board of Directors will become available to members for question submission the day that the AANA candidates are introduced to the membership during the Mid-Year Assembly, Monday, April 16, 2012. The forum will be located in the members-only section of the AANA website along with the candidates’ speeches, photos, and position statements. Active AANA members will be able to submit questions to the Forum for approximately 45 days.
A moderator will review the questions before they are forwarded to the candidates for a response. The moderator will review the candidates’ responses before posting them for viewing by the membership. The forum will be available for members to view until the voting cut-off date at the end of June (June 19, 2012).
All members are invited to take advantage of this opportunity to become better acquainted with the candidates seeking election to the AANA Board of Directors. Further information and a schedule for submitting questions are available on the AANA website.
AANA Journal Course #31 Available Only Online
AANA members can take the AANA Journal course exam free of charge using the online format from April 2 through July 31 (ending at midnight central time). The exam will be available here (login required). In preparation for the exam, a study page with all six courses is available. The April Journal will feature the exam, but it can only be taken online. Exam answers will appear in the August Journal.
Sharps Safety Consensus Statement and Call to Action Issued
In the 10 years since the passage of the federal Needlestick Safety and Protection Act, much progress has been made to reduce the risk of healthcare worker exposure to bloodborne pathogens—yet significant challenges remain. The International Healthcare Worker Safety Center at the University of Virginia and the American Nurses Association, along with colleagues across the spectrum of healthcare (including the AANA), have agreed on a Consensus Statement and Call to Action to address these issues. Read the Statement here.
Health Volunteers Overseas Needs Anesthesia Volunteer in Bhutan
CRNA or MD is needed for a one-month assignment in August 2012. Volunteers provide continuing education and training to the local anesthesia providers. Other opportunities will be available in 2013. Please contact the Program Department for more information.
AANALearn® Provides Prior-approved CE Courses for Recertification 
If this is your year to recertify, now is the perfect time of year to review your continuing education (CE) transcript and verify that you have at least 40 CE credits available for your recertification application. AANALearn® can offer as many credits as you may need – we have more than 46 courses providing more than 50 CE credits.
As always, the online continuing education courses in AANALearn® are available for members 24 hours, 7 days a week, year round and the CE credits are automatically transferred into your transcript file the SAME DAY you complete the course. No other CE provider has this quick credit transfer capability. AANA members always receive a 30 percent discount off the regular price of courses. If you are seeking a few or many CE credits for 2012 recertification, AANALearn® can provide what you need. Members are encouraged to complete their recertification CE credits early – avoid the rush.
Check us out now at to browse the catalogs.
Join the AANA's Social Network 
AANA members can join the discussion on President Malina's Blog and in the Clinical Hot Topics Community at MyAANA. More discussion groups will be added soon. Check back often! (Login required)


AANA Foundation and Research

AANA Foundation Supports Research
AHRQ Offers HCUP Data Users' Workshop on April 25
Registration is now open for Agency for Healthcare Research and Quality’s (AHRQ's) one-day instructor-led workshop on the use of Healthcare Cost and Utilization Project (HCUP) databases and software tools for health services research. The curriculum includes instruction and hands-on experience conducting revisit analyses with HCUP State data.
The workshop is targeted at intermediate-level data users or people already familiar with HCUP. Prior experience with HCUP databases or prior attendance of a HCUP overview presentation, webinar or online course is encouraged. Computers will be provided and programming examples presented in SAS. HCUP is a family of health care databases, software tools, research publications, and support services created through a Federal-State-Industry partnership. HCUP is used for a broad range of health services research and policy issues at the national, State, and local market levels, including cost and quality of health services, medical practice patterns, access to health care, and outcomes of treatments. The workshop takes place Wednesday April 25 at the AHRQ Conference Center in Rockville, Md. There is no charge to attend, but registration is required. Early registration is encouraged because the workshop fills quickly. Click here to register.

Call for Applicants for the The Hartford Institute 2012 Geriatric Nursing Research Scholars Program
Application Deadline: May 15, 2012

Announcing an opportunity for researchers in academia or hospitals to participate in a week-long, intensive, summer seminar at New York University College of Nursing for an in-depth mentoring experience with nationally recognized gerontologic nursing researchers.
This summer program runs from July 30 – August 3, 2012 and will feature:
· Mathy Mezey, EdD, RN, FAAN – Associate Director, Hartford Institute for Geriatric Nursing, and Professor Emerita, Senior Research Scientist, and
Guest Faculty:
· Meredeth Rowe, PhD, RN – Lewis & Leona Hughes Endowed Chair in Nursing Science College of Nursing, University of South Florida
· Elaine J. Amella, PhD, RN, FAAN – Professor, College of Nursing, Medical University of South Carolina
Location: Hartford Institute for Geriatric Nursing – New York University College of Nursing
Fees & Housing (Breakfast & Lunch provided) – Seminar $1500 and hotel rates $169-$200 plus tax per night.
For more information please visit or contact NYU College of Nursing at
(212) 992-9416 or



News from COA

Call for Comments for Practice Doctorate Standards
Deadline: June 15, 2012
The Council on Accreditation of Nurse Anesthesia Educational Programs (COA) is soliciting comments from the communities of interest on the first draft of the “Practice Doctorate Standards for Accreditation of Nurse Anesthesia Educational Programs.” Written comments are being collected via an online tool located on the COA website at
Please note that an email containing the link for the call for comments has been sent to all program administrators, onsite reviewers, consultants, COA directors, AANA senior staff, AANA Board of Directors, AANA Education Committee, National Board of Certification and Recertification for Nurse Anesthetists Board of Directors, legal counsel, and the AANA archivist. The COA will be collecting comments on the first draft through Friday, June 15, 2012.


Federal Government Affairs and PAC

AANA President and President-elect Visit Key Federal Agencies 
During the week of March 12 AANA President Debra Malina, CRNA, DNSc, MBA, and President-elect Janice Izlar, CRNA, DNAP, met in Washington, D.C., with senior officials from three federal Health and Human Services agencies important to CRNA practice and reimbursement, including the Health Resources and Services Administration, the Centers for Medicare & Medicaid Services, and the Office of Health Reform. They also met with the top staff to the National Rural Health Association, a key AANA partner on rural patient access to quality care.
In these meetings, Malina and Izlar stressed the safety and cost-effectiveness of CRNAs’ anesthesia and pain care services provided by CRNAs, pointing to the established literature from Health Affairs and Nursing Economic$, and underscoring how CRNAs ensure patient access to care particularly in rural and medically underserved America. “Our hope is that maintaining, building and strengthening these relationships will translate into positive outcomes for our practice,” said AANA President Malina.

House OKs Medical Liability Reform and IPAB Repeal Bill March 22 
The U.S. House of Representatives adopted legislation on March 22 combining repeal of the Independent Payment Advisory Board (IPAB) provisions of the Affordable Care Act health reform law plus medical liability reforms that cap noneconomic damages.
On March 20, The House Rules Committee on March 20 packaged together the “Medicare Decisions Accountability Act of 2011” (H.R. 452) repealing the IPAB and the “Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act” (H.R. 5) into a new bill, the “Protecting Access to Healthcare Act” (also H.R. 5). If enacted, H.R. 5 would eliminate the yet-unnamed board charged with recommending specific reductions in the per-capita cost growth of the Medicare program beginning in 2014. By law, IPAB recommendations would be transmitted to Congress and the president, and would begin taking effect the following years unless Congress enacted and the president signed legislation disproving the recommendations and ordering alternative cost controls of the same scale. However, the 15-member IPAB has not yet got out of the starting blocks: President Obama has not nominated persons to serve on the panel, nor have Senate Republicans indicated any willingness to confirm such nominees for service. It would also adopt medical liability reforms that have passed the GOP-majority House in the past but have run aground in the Democratic-majority Senate.
During consideration of the Affordable Care Act, AANA expressed concerns about the IPAB provision. The AANA has supported medical liability reforms in the past. The administration has threatened to veto H.R. 5 if it comes to the president’s desk in its present form.

Supreme Court Takes Up Health Law  
The U.S. Supreme Court held six hours of oral arguments on the constitutionality of the Affordable Care Act health reform law March 26-28, two years after the law’s enactment, with a decision anticipated in the summer.
Justices are considering whether the law’s requirement that a person purchase health coverage or pay a penalty (known as the “individual mandate”) is constitutional; whether the law’s expansion of Medicaid programs operated by states is constitutional; and the important technical matter of whether a party can file suit about a law that has not taken effect.
Oral arguments before the Court are not televised or posted live; rather, the Court has agreed to make available audio recordings of oral arguments late in the day each of the three days that the arguments take place.
House GOP Offers Budget with Medicare, Medicaid Changes; Enactment Outlook Dim 
House majority Republicans have proposed a fiscal 2013 budget that recommends: A) substantial changes in the structure of the Medicare and B) Medicaid health programs critical to CRNAs, and lower overall spending levels than those provided by the 2011 Budget Control Act that would place downward pressure on nurse workforce development and research programs advocated by CRNAs. But its overall near-term outlook is dim, as an election-year divided government is unlikely to take up dramatic Medicare and Medicaid adjustments.
House Budget Committee action on the proposal introduced by committee Chairman Paul Ryan (R-WI) was slated to begin March 21. Under the proposal:
  • For persons age 54 and younger today, the Medicare program would be replaced by a premium support system in which beneficiaries could purchase coverage on an exchange, coverage that would include the current Medicare fee-for-service program, reducing projected Medicare spending.
  • The Affordable Care Act health reform law would be repealed.
  • Replacing the federal share of the Medicaid health program for the indigent with a block grant to states, reducing projected Medicaid spending.
The budget proposal met a harsh greeting from Democratic lawmakers and the administration, however, who condemned the GOP Medicare reform proposals. Ranking minority member Rep. Chris Van Hollen (D-MD) said, “The Republican budget doesn’t reform Medicare – it deforms it. It proposes to end the Medicare guarantee, shifting rising costs onto seniors and disabled individuals.”
Read an outline of the budget from Rep. Ryan’s Wall Street Journal op-ed, the budget recommendation itself, and the views of ranking Democratic member Rep. Van Hollen
MedPAC Again Recommends Anesthesia and Specialty Cuts
The Medicare Payment Advisory Commission (MedPAC) issued recommendations to Congress on March 16 for the future of the Medicare program, urging lawmakers to cut Medicare anesthesia and specialty care reimbursements 5.7 percent per year over three years-a total of 17 percent-reprising its October 2011 letter to Capitol Hill.
The MedPAC’s objective in cutting anesthesia and specialty care was to reduce the overall cost of repealing the flawed sustainable growth rate (SGR) Medicare funding formula that threatens a 32 percent cut to CRNA and physician payment, unless Congress acts to reverse it by Jan. 1, 2013. The effect of the cut would also be to reallocate a greater share of Medicare resources toward primary care, which MedPAC recommends to receive flat Medicare payment for the next 10 years. Following the anesthesia and specialty payment cuts, MedPAC recommends flat payment for those as well in the years thereafter.
The AANA had urged MedPAC in 2011 to reject such a proposal, and helped persuade over 90 members of the U.S. House of Representatives to write their bipartisan leaderships in opposition to it.
Read the MedPAC news release that links to its entire report to Congress and the AANA’s letter to MedPAC (requires AANA member login and password).
Medicare Solicits Applications for Graduate Nursing Education Demonstration Project AANA Helped Enact 
The Center for Medicare & Medicaid Services (CMS) on March 21 announced the application process for the Graduate Nursing Education (GNE) Demonstration which was a part of the Affordable Care Act health reform law, and which the AANA and a coalition of Advanced Practice Registered Nurse (APRN) groups alongside the AARP helped enact.
The project seeks to increase the number of APRNs to care for patients in an expanded healthcare system by working with hospitals and schools of nursing to offset the cost of clinical education of APRNs. Nurse anesthesia educational programs are eligible to participate regardless of whether they are housed in schools of nursing.
Proposals, which must be submitted by hospitals, are due to the Medicare agency by May 21, 2012. The Medicare GNE Demonstration solicitation is available online. The application instructions for this funding opportunity start at the bottom of page 8 via the pdf document available at this link. Educational opportunities to aid prospective applicants are under development.
HHS Releases Final Rule Governing State-based Health Insurance Exchanges
On March 12, the U.S. Department of Health and Human Services (HHS) issued its final rule governing state-based health insurance exchanges through which commercial coverage will be marketed, a critical aspect of health reform for CRNAs concerned about patient access to CRNA anesthesia and pain services.
AANA had submitted comments to the HHS last September, urging that CRNAs and other providers who bill for Medicare Part B and who are not physicians be included among the group of providers who consult with exchanges, and also have full voting representation on exchange governing boards. The AANA’s letter also requested that exchanges require CRNAs to be included in the qualified health plan provider networks participating in exchanges and that qualified health plans participating in Exchanges adhere to both state and federal provider nondiscrimination provisions.
According to the HHS, the final rule offers states flexibility as they work to design an exchange marketplace for operation by 2014. The rule offers guidance on how to structure exchanges in two key areas:
  • Setting standards for establishing exchanges, setting up a Small Business Health Options Program (SHOP), performing the basic functions of an exchange, and certifying health plans for participation in the exchange; and
  • Establishing a streamlined, Web-based system for consumers to apply for and enroll in qualified health plans and insurance affordability programs as beneficiaries.
The AANA Federal Government Affairs division is currently reviewing this 644-page final rule.
Read more about the final rule from an HHS news release and the final rule itself. See the AANA’s September 2011 comments (requires AANA member login and password).
AANA Participates in Health Plan Policy Conference 
To help AANA and CRNAs build productive, engaging professional relationships with health plans, on March 6 and 7 AANA staff attended America’s Health Insurance Plans’ (AHIP) 2012 National Policy Forum in Washington. The AHIP National Policy Forum focused on how health reform implementation is proceeding to the debate about the individual mandate to building exchanges in the states. The speakers included members of Congress, health plan executives and policy experts from think tanks and federal and state agencies.
Of particular note to CRNAs:
  • Steve Larsen, Deputy Administrator and Director for the Center for Consumer Information and Insurance Oversight (CCIIO) reported that 17 states now have legal authority to establish exchanges, and 14 states have appointed a governing body to help set up exchanges. He also reported that the federal government is working on setting up a federal exchange, addressing issues such as eligibility, information technology and financial functions.
  • Executives from two health plans spoke about implementing changes that have led to improvements and greater efficiencies in both the cost and delivery of health care – specifically a “health and wellness strategy” where they work with providers and consumers to reduce cost and improve quality of healthcare.
  • Two attorneys discussed the continuing debate over the individual mandate that requires most citizens to obtain health insurance or face a penalty, the subject of U.S. Supreme Court oral arguments late in March.
Medicare Recommends Coverage of TENS for Back Pain Only in Narrow Circumstances 
The Medicare agency proposed a National Coverage Determination (NCD) dated March 13 for transcutaneous electrical nerve stimulation (TENS) for chronic low back pain. The proposal would affect the circumstances for which TENS would be reimbursed, but would not limit the providers of the service.
Medicare proposes to reimburse beneficiaries for TENS services for lower back pain when all of the following conditions are met: an episode of low back pain persists for three months or longer; the low back pain is not the result of certain well-defined diseases, such as cancer, that may contribute to low back pain but is not the primary focus; and for particular clinical studies.
The proposed decision memo is available. The AANA continues to monitor this issue. CRNAs can comment on this proposal.
How can CRNAs Use Social Media in Advocacy? 
How can CRNAs use social media platforms like Facebook, Twitter and LinkedIn to stay in touch with members of Congress in one’s home state? After all, social media provide new and direct points of contact with elected officials who have authority over and interest in CRNA issues governing practice, reimbursement and educational funding. What they learn about the AANA and CRNAs may now come to them online – from you.
  • First, follow. Most lawmakers have Facebook, Twitter and LinkedIn accounts that CRNAs can use to follow their public pronouncements on issues of the day, votes, and statements and pictures about local appearances in the community. “Like” them on Facebook (regardless of whether you actually like them in real life!), “follow” them on Twitter, and “connect” on LinkedIn.
  • Second, share and comment. When an issue important to you arises on their Facebook pages, comment on it or share it with your friends. And when your lawmaker tweets a message on an issue important to you, consider retweeting the message or sending back a reply. Always be professional and gracious when communicating CRNA issues. If you tweet about your lawmaker, either locate or hashtag your lawmaker by name, such as @JohnBoehner or #NancyPelosi. Legislators follow closely the social media postings that mention them by name. And on LinkedIn, see if you and your lawmakers have any personal or professional connections in common.
  • Third, be prepared for a response. Lawmakers and their staffs follow closely comments on social media. When your response appears genuine and local, they may want to get to know your CRNA work more closely.
How are you using social media for federal advocacy? Let us know by emailing us at
Book Your Mid-Year and Business of Anesthesia Meetings Now! 
Now’s the time to book your seat at the AANA Business of Anesthesia conference on April 14, and the AANA Mid-Year Assembly on April 15-18, both in your Nation’s Capital!
Join CRNA-PAC for “An Affair of State” April 15 at AANA Mid-Year Assembly 
Enjoy a night with CRNA-PAC at an enclosed rooftop event offering a spectacular view of the White House from one of the most historic and prestigious hotels in Washington, the Hay Adams. Tickets are priced at $250 for CRNAs and $125 for student registered nurse anesthetists, tickets can be purchased on the Mid-Year Assembly registration form.

CRNAs Seen in Washington  
At a major political event in Washington the week of March 5 where AANA member attendance was supported by the nonpartisan CRNA-PAC, nurse anesthetists from the National Capital area visited with several U.S. Senators, including the chair of the Health, Education, Labor and Pensions Committee and a key Appropriations subcommittee on health, Sen. Tom Harkin (D-IA).
Pictured left to right below are Arvella Bing, CRNA, of Maryland; Louise Hershkowitz, CRNA, MSHA, of Virginia; Sen. Harkin, and John Bing, CRNA, of Maryland.
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 our 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. I am a US Citizen.

Healthcare Headlines

Voice, Throat Problems Common After Anesthesia
In a new study published in the Archives of Otolaryngology — Head & Neck Surgery, investigators from the Maastricht University Medical Centre in the Netherlands found that voice and throat problems are typical in patients who have had either an endotracheal tube or laryngeal mask in place during general anesthesia. Researchers looked at 13 studies that examined complications after the use of these two techniques, which are used to ease the breathing of sedated patients in the operating room. The complication rates varied greatly, and results were difficult to compare. The team found incidents of hoarseness and vocal cord injuries and also discovered that some patients recovered quickly. U.S. specialists not involved in the research indicated that the side effects are to be expected and are not alarming, with most symptoms clearing up on their own. "In general, it's a very safe thing to do—having general anesthesia with a breathing tube in place," according to Dr. Norman Hogikyan, an ear, nose, and throat physician at the University of Ann Arbor.
From "Voice, Throat Problems Common After Anesthesia" (03/22/12) Seaman, Andrew M.
Drug Could Be Useful Treatment for Anesthesia-Related Memory Loss
A drug targeting one specific receptor could become an effective treatment for the memory loss that sometimes occurs after anesthesia, according to a "proof-of-concept" study in the April issue of Anesthesia & Analgesia. Research shows that alpha-5 GABA type A receptors are involved in specific memory problems after anesthesia. These receptors could be targeted to restore memory even after the anesthetic has worn off, the researchers said. The study included an assessment of the mechanisms of memory loss after general anesthesia, focusing on the alpha-5 GABA type A receptors. The experiments included mice that were genetically engineered to lack the receptors. Exposure to isoflurane caused significant memory impairments in normal mice but not in mice without the alpha-5 GABA type A receptors. Memory deficits were specific to short-term memory rather than "working memory." The study also evaluated the effects of the experimental drug L-655,708, which blocks the alpha-5 GABA type A receptors. Treatment with this drug completely eliminated anesthesia-related memory deficits, even when treatment was not given until 24 hours after isoflurane exposure. Even without treatment, short-term memory impairment resolved within 72 hours after anesthesia.
From "Drug Could Be Useful Treatment for Anesthesia-Related Memory Loss"
Newswise (03/21/12)
Age-Old Anesthesia Question Awakened
Scientists have long wondered why inhaling anesthetics causes unconsciousness, but new insights may be available from research performed at the National Institute of Standards and Technology (NIST). Anesthesia may affect the organization of fat molecules in a cell's outer membrane, which may change the ability to send signals along nerve cell membranes. "A better fundamental understanding of inhaled anesthetics could allow us to design better ones with fewer side effects," says Hirsh Nanda, a scientist at the NIST Center for Neutron Research. Ion channels—large proteins embedded in the lipid molecules that form nerve cell membranes—conduct electrical impulses along nerve cells throughout the body. An ion channel's immediate surroundings often consist of a single type of lipid, which forms a sort of "raft" that is less fluid then the rest of the membrane. Disrupting these lipid rafts can affect a channel's function. The research team explored how a model cell membrane responded to two chemicals: inhaled anesthetic and another substance that has similar chemical properties as anesthetic but does not cause unconsciousness. The anesthetic disordered the rafts, freely mixing its lipids with the surrounding membrane, but the second chemical's effect was dramatically smaller. While this discovery does not answer the question definitively, it is a start for other experiments that could shed more light on the issue.
From "Age-Old Anesthesia Question Awakened"
Science Daily (03/21/2012)
Which Anesthesia Is Best for Cataract Surgery?
Regional anesthesia during cataract surgery provides better pain relief and fewer complications compared to topical anesthesia, but many patients choose topical, researchers write in the journal Ophthalmology. A team of Chinese researchers compared phacoemulsification under topical and retrobulbar or peribulbar anesthesia. Patients who received topical reported more pain during and after surgery; they also experienced more inadvertent eye movements and required additional anesthetic during the procedure. Patients who received regional blocks experienced more anesthesia-related complications, such as chemosis, periorbital hematoma, and subconjunctival hemorrhage. Overall, both topical and regional anesthesia had similar case outcomes, with no significant difference in complications or intraoperative difficulties. Topical anesthesia is less effective at pain relief and should not be used on patients with high blood pressure or greater pain perception. However, topical anesthesia does reduce injection-related complications and alleviates patients' fear of needles. A recent Outpatient Surgery survey of 216 facility managers showed that 75.6 percent use topical anesthesia on their cataract surgery patients, 65.7 percent use IV anesthesia, and 44.4 percent use retrobulbar blocks.
From "Which Anesthesia Is Best for Cataract Surgery?"
Outpatient Surgery (03/20/12) Cook, Daniel
Pain Meds May Influence Cancer Growth
Pain medicines such as opioids and anesthetics are critical for cancer patients, but new findings suggest that they deliver not only pain relief but a potentially negative side effect. A pair of laboratory studies published in the March 2012 issue of Anesthesiology show that opioid receptors in the brain effect the development, growth, metastasis, and outcome of breast and lung cancers. Researchers at the University of Chicago Medicine discovered that some lung cancers have 10 times the opioid receptors as normal cells. They also discovered that when human cancer cells engineered with more receptors were transplanted into mice, the cells grew twice as fast as those without the additional receptors and were 20 times as likely to metastasize. Opioid receptor-blocking medications caused the growth and spread of the cancer cells to slow, which may lead to the mu opioid receptor being a target for new therapeutics. The study from the University of North Carolina, meanwhile, retrospectively examined data for 2,000 breast cancer patients and found that women with genetic mutations that make them less sensitive to opioids lived longer. The more copies of the mutation, the more likely they were to be alive 10 years after treatment for invasive breast cancer. The researchers noted that morphine-like medication and the body's own opioids, like endorphins, impacted the spread of cancer cells and that mu opioid receptor-blocking agents could help discourage cancer growth and metastasis.
From "Pain Meds May Influence Cancer Growth"
DailyRx (03/22/12) Stoneham, Laurie
Peripheral Nerve Stimulation Helps Control Pain After Combat Injuries
An article in the March issue of Anesthesia & Analgesia concludes that a peripheral nerve stimulation technique shows promise as a way to help injured soldiers find relief from severe neuropathic (nerve-related) pain. Doctors in the anesthesiology department of Walter Reed Army Medical Center were working to treat severe neuropathic pain that two soldiers were experiencing in one or both legs from combat injuries. The team had wanted to use spinal cord stimulation that would send a mild electrical current through electrodes embedded near the spine, but were unable to do so due to patient conditions that made the surgery to implant the electrodes inadvisable. Instead, doctors tried applying electrical stimulation directly to the peripheral nerves in the leg; and once the stimulation was turned on, both patients experienced rapid relief, with pain scores dropping to 2 from 6 on the 10-point scale. The reduced level of pain enabled the patients to reduce or eliminate the use of strong pain medications; resume full participation in physical therapy; and experience improvements in mood, general activity, and sleep. The peripheral nerve stimulation originally had been intended as a temporary fix until the patients could undergo the spinal cord stimulation; but after a few weeks of treatment, both patients were able to control their pain without the need for permanent electrode impacts or electrical stimulation. The study suggests that this type of treatment is a viable option for acute management of severe neuropathic pain for soldiers with combat injuries. It is possible that short-term management with peripheral nerve stimulation can allow some patients to avoid the need for long-term spinal cord stimulation and can become a tool to use with those who do not respond to standard treatments.
From "Peripheral Nerve Stimulation Helps Control Pain After Combat Injuries"
Newswise (03/21/12)
Thin Patients at Greater Risk of Dying After Surgery
New research suggests that thinner patients may be at greater risk of death after a surgical procedure compared with overweight patients. In one study, published in the March issue of the Archives of Surgery, people with a body-mass index (BMI) of 23 or less were 40 percent more likely to die compared to patients with a BMI between 26 and 29. The difference persisted even when accounting for type of surgery. These findings agree with other recent studies, including one published in the Journal of Cardiothoracic and Vascular Anesthesia. In this study, 20 percent of underweight patients who had coronary artery bypass surgery died in the hospital, compared with 3 percent of obese patients. Study researcher George Stukenborg, of the University of Virginia’s School of Medicine, pointed out that healthcare providers should account for a patient's thinness when planning post-surgical care. Stukenborg's study analyzed data from 189,500 patients from 183 medical centers who underwent surgery between 2005 and 2006. Among patients with a BMI of 23.1 or less, 2.8 percent died within 30 days, compared to 1.5 percent of patients with a BMI between 26.3 and 29.7. Risk of death was similar among patients who were overweight, obese, or very obese. Another study found that underweight patients were also at higher risk of intestinal bleeding, pneumonia, prolonged stay in the intensive care unit, and need for a blood transfusion.
From "Thin Patients at Greater Risk of Dying After Surgery" (03/19/2012) Rettner, Rachael
Little Evidence for Non-Drug Labor Pain Relief
There are pros and cons to drug-based approaches for alleviating the pain of childbirth, according to a new overview of existing studies; but there is not yet enough research to show whether non-drug methods are an effective alternative. In the paper, published by the Cochrane Collaboration, investigators reported finding solid evidence that epidurals, which deliver pain-blocking medicine through an injection into the back, work. Combined spinal epidurals and inhaled analgesia were also deemed effective, based on the reviewed research. However, drug-based treatments are associated with a greater likelihood of assisted childbirth; a higher risk of developing of low blood pressure, which can slow a baby's heartbeat; immobility of legs for a period of time; and other side effects that take away some of their appeal. Non-drug strategies, including water birth, relaxation, local anesthetics, mild painkillers, massage, hypnosis, aromatherapy, and acupuncture appear to avoid these undesirable traits; but they have only been tested on a small sample of women and have not been proven effective for pain management. "I think there is a lot to be said for starting with simple methods and then working up if necessary," concluded lead researcher Dr. James Neilson of the United Kingdom's University of Liverpool. "Clearly there is a lot of variation in the amount of pain that women experience during labor."
From "Little Evidence for Non-Drug Labor Pain Relief"
Reuters (03/15/12) Joelving, Frederik
Use of Anesthesia Providers During Gastroenterology Procedures Has Increased Rapidly, But May Be Unneeded
A RAND Corporation study published in the March 21 edition of the Journal of the American Medical Association shows that the use of anesthesia providers to monitor sedation in outpatient gastroenterology procedures increased substantially from 2003-2009. The highest increase occurred among low-risk patients who, according to current guidelines, can safely receive intravenous sedation from the physician performing the procedure. These guidelines indicate that an anesthesia provider is needed only if the patient is at risk for complications because of illness such as advanced heart or lung disease. The increase in use of anesthesia providers in cases that do not meet these criteria is increasing costs unnecessarily. The study looked at care provided to 1.1 million Medicare fee-for-service beneficiaries and 5.5 million adults with commercial insurance and found that the use of these providers during outpatient GI procedures increased from 14 percent in 2003 to over 30 percent in 2009. The payments, nationally, for these anesthesia providers rose to $1.3 billion in 2009 from only $400 million in 2003, with $1.1 billion being spent on the two-thirds of services provided to those considered low-risk patients. The amount of the payments doubled for Medicare patients but quadrupled for those with commercial insurance.
From "Use of Anesthesia Providers During Gastroenterology Procedures Has Increased Rapidly, But May Be Unneeded" (03/20/12)