Clinical Topic: Propofol Related Infusion Syndrome (PRIS)

Propofol Related Infusion Syndrome (PRIS) is typically associated with metabolic acidosis followed by cardiovascular failure. The condition is most commonly reported in ICU patients who require long term sedation. As the incidence of PRIS increase, so do the number of case reports and studies published in the literature.

An excellent review by Fudickar and Bein published in Minerva Anesthesiol offers a historical perspective and details pathophysiologic changes that occur when propofol in infused over a prolonged period of time. The authors describe cytolysis of cardiac and skeletal muscle as being central to the problem. Mitochondrial fatty acid metabolism impairment was implicated. Patients with a low carbohydrate supply, such as children, are at increased risk for developing PRIS. The authors state that their protocol limits propofol to no more than 4mg/kg/hour for long term sedation.

The question arises as to whether or not we place our patients at risk by using TIVA for general anesthesia. Children receive up to 9 mg/kg/hour for up to 4 hour procedures and infusion rates of up to 30mg/kg/hr have been reported when TIVA is used in adults. Are we placing our patients at risk?

An article by Guitton et al published in Neurocritical Care describes the development of PRIS in an adolescent with status epilepticus who received propofol sedation for seizure control. The patient developed a metabolic syndrome with rhabdomylitis after 58 horus of propofol at 8.8mg/kg/hr. Cardiac arrest followed and extracorporal membrane oxygenation was required.

Various articles agree that PRIS is related to dose and length of time that propofol is administered. In the ICU, long term dosage should be kept below 4-5 mg/kg/hour. In the operating room when higher doses are required, the anesthetist should consider stopping the TIVA as soon as it is no longer absolutely required for the procedure. During the procedure, be aware of the dosage you are giving and try to limit it to the lowest effective dose.

Review the articles that this posting links to and then come back and tell us about your experience and recommendations for TIVA

Meeting Review: NWAS, Las Vegas

The following review was submitted by a CRNA attending the recent January 2012 Northwest Anesthesia Seminar in Las Vegas. Procrna.com thanks you for the posting and encourages others to send reviews when they attend meetings.

Date: 1/23/12

Meeting strengths: Interesting topics & speakers. NWAS does a great job recruiting their speakers & provides great information on updates regarding anesthesia practice. The Las Vegas meeting is one of the most popular & it’s a great location! The speakers in January focused on ASC guidelines & updates for discharge. Current recommendation is that the patient does not need to void or drink before being discharged. The L&D and positioning portion of the lectures were week. They also shared good information on pediatric anesthesia & new information on robotic anesthesia. Dr. DeSoto was a great speaker!

Suggested improvement: I would like to see more information on what we as providers can do during our current drug shortages. Also, there was very limited information on difficult airway management which is always a great topic to revisit during CME conferences.

Overall value for the money: Great value for your money if you like Las Vegas. I would not suggest it to anyone who was not interested in visiting Las Vegas. Lots of food, great shows, shopping, gambling, and people watching!

NWAS did a great job scheduling the meeting with two days starting & ending in the morning and the other 2 days starting in the afternoon & ending in early evening.
Paris hotel is in a good location to other things on the strip. The conference rooms were comfortable & the food they provided was great.

CRNA Fitness: Make the Most of Your Meeting

Boston, Seattle, San Francisco, Honolulu, Jackson Hole, San Antonio…there are some amazing destinations for anesthesia meetings right here in the USA. Most of the venues are places where there is a long list of thing s to see and do. And all of the destinations provide plenty of opportunities for you to stay active.

Run For Fun

AANA’s annual meeting has been offering a 5-K fun run for just under a decade. It’s an easy 3.1 mile course along the city’s most scenic route with shuttle service provided start and finish. Runners, walkers, strollers (those are the people who stayed up late the night before) are all welcome and you’re the celebrity. Beautiful surroundings, beautiful celebs, and a free t-shirt as beautiful as t-shirts get, make all that exercise a beautiful bonus. Sometimes the local ANA offers early morning fitness classes at the host hotel with leadership provided by CRNA’s who apparently enjoy waking people up as much as putting them to sleep. Click here for the AANA wellness run in San Francisco

Take Your Bands

Exercise bands are almost as easy to use as they are to pack. You can do a complete work-out in your hotel room, in the hotel gym, in a park, at the beach or looking out over the harbor in Seattle or Boston. All you need is two or three bands, a doorjamb, railing or a pole to anchor them, a little backpack to carry them, or a waist small enough to tie them around your middle. With access to cool water and a hotel-sized washcloth, aka sweat rag, you’re good to go. Bands weigh less than an I-pad and they pack flatter than a ten-dollar bill.

Rent A Bike

One of the best ways to see your city and get some great exercise at the same time is to rent a bike. Google “bicycle tours in Vancouver” or “rent a bicycle in Austin” and refine the search from there. Be sure to use the word bicycle because otherwise you’ll end up with Harley Suzuki as your travel companion, which might be a blast, but you won’t get much exercise unless you fall off and have to walk back. You may be able to get a private, guided bicycle tour – more money, of course, but if you like to be at the head of the class asking questions, money talks and the expense will pay off. Click here to learn about bike rental in San Francisco.

Many cities have initiated bike-share programs. This service goes by a variety of names – like Q-bikes in Portland, B-cycle in San Antonio, or simply Bike-share in Boston – and features a fleet of bicycles that anyone can use. Just swipe your credit card at the vertical terminal, release one of many bikes from its locked stall, then ride it on marked cycling routes throughout the city, or directly to a destination. Parking stalls and routes are indicated on maps at each bike installation so you won’t get lost. Each time you stop to sight-see near a bike-share stall, just slide the bike into a rack, it locks automatically, and very shortly it will become someone else’s exercise partner. The beauty of the service is that it generally doesn’t require a helmet. One of the drawbacks of the service is that it generally doesn’t require a helmet… AND if you have to wait for a bike to become available when you’re in Brooklyn, you could be late for cocktails in the Bronx. Click here to learn about community bike share in San Francisco.

Walk

If you didn’t download a city map and a printable walking tour before leaving town for your meeting, you can ask your hotel concierge to highlight the best walking destinations on a brochure and outline some routes for you. Check things off on your brochure as you go so you don’t miss the major attractions, and don’t be afraid to get off the beaten path. Make note of noteworthy and eccentric establishments as your cabbie whisks you through the city from the airport, then go back and find them on your feet. You’ll run into the best coffee art cafes, the most interesting old houses, and charming little corner stores that you won’t find on Tourist Avenue. You may burn enough calories to almost justify the mouth-watering apple fritter you found at Dave’s Sugar Shack not to mention the energy you’ll have the rest of the day just from staying on your toes. If Rick Steves or Lonely Planet has published a travel guide for the city you’re visiting, it’ll be a quality purchase, and when it rains, you can walk the halls, climb stairs between 2^nd and 12^th, or go to the hotel fitness club. Remember to pack your Nike’s and your fitness duds so you can avoid blisters and excuses. Click here to learn about walking tours in San Francisco.

Go to The Fitness Club

One of the criteria for selecting a hotel is the quality of the fitness club. Every large hotel in a large city has a fitness center and some of them have glitz galore. The Omni in San Diego, the Sheraton in Seattle, the Sheraton in Boston, even the Holiday Inn in Columbia, MO all have exceptional facilities for working out. Check online or talk to the actual hotel desk staff before you reserve your room and ask about these items: Cardio equipment(treadmills, elliptical trainers, lifecycles, walking tracks); strength-training equipment(training circuit, free weights, vertical bands stations); abs room or abs corner (mats, fitballs, body bars, medicine balls); and towel service as well as a decent-sized pool. Gym-rats are going to get to the facility early, so go really early or go a bit late, but get going.

Your anesthesia meeting is a place to learn more about your ever-changing industry but it’s also a place to have fun with old friends and to make news ones, a place to experience a new city in a new way. Hike Aspen Mountain, jog the stairs next to the San Diego Convention Center, power walk the promenade while cruising between glaciers in Alaska, cycle from Fenway Park to The Old South Church. You won’t be putting anyone to sleep or trying to stay awake for one whole week. Go make the most of it!

You can visit Liz at www.bdyfrm.com and learn more about her Traveling Bands comprehensive work-out indoors or out, and how to gain access to the Bands In the Park mobile browser. Read motivational, entertaining Lizlines every weekday including the weekly original Lizlimerick.

Meeting Review: Emory University New Horizons

Emory University is proud to announce two upcoming meetings

The first meeting is New Horizons in Anesthesiology in Big Sky, Montana, March 11-16, 2012. We have been running a ski meeting for 24 years. This particular meeting will include topics such as the effects of anesthesia on sleep, patients’ memory as well as patient awareness. Issues pertaining to clinician efficiency and productivity as well as topics relating to staff motivation and practitioner fraud and abuse will be discussed. This course will offer 22 CE credits for CRNA’s.

Big Sky Resort is located in southwestern Montana, just north of Yellowstone and Grand Teton National Parks. Big Sky offers instant access to some of the most diverse skiing and snowboarding amongst breathtaking vistas in the lower 48. Beautiful scenery, abundant wildlife, and gracious hospitality make Big Sky Resort Montana’s premier ski destination.

Our 2nd meeting New Horizons in Anesthesiology – Cozumel, Mexico April 15-20, 2012 in its 13th year will cover topics such as the role of clinical pharmacology in legal cases and allergic and anaphyllactoid reactions. Comparative opioid pharmacology and pharmacologic approaches to managing perioperative hypertension, including information on new clinical trials and discussions on the identification and treatment of the patient at risk for severe postoperative pain will be presented. This course will offer 22 CE credits for CRNA’s.

The meeting will be held at the Presidente Intercontinental Cozumel Resort & Spa. This beachfront hotel offers the perfect blend of accommodations, service, meeting and recreational facilities. Jacques Cousteau declared Cozumel “one of the most beautiful scuba diving areas of the world”. You can leave from the dock of the hotel for daily scuba diving.

Click here for information about the meeting agenda and registration

After you attend the meeting, return to www.procrna.com and leave a comment. Let your colleagues know about your experience

Meeting Review: MUSC, Charleston, S.C.

2012 marks the 25th anniversary of this conference. Enjoy a variety of topics (20 hourse of CE) with a fantastic speaker panel including Debbie Mailina, AANA President, Christine Zambricki AANA Deputy Executive Director, Jackie Rowles Past President talking about Pain and many more.

If you like history and good food, visiting Charleston, SC is always a treat. We have plenty of both and the first week of May is a great time to visit and explore.

Join us in Charleston South Carolina May 4-6 for a great meeting and a memorable experience.

Click here for more information or to register on line. After the meeting, make a comment on procrna.com and share your experience with your colleagues.

Clinical Forum: Evidence Based Management

“Show me the money” “Where’s the beef?” Health care delivery has evolved over the past few decades to evidence based practice. With the emergence of new drugs, techniques, and regulations health care providers are demanding “where’s the evidence”. In our quest for evidence to guide our medical resource management, we often overlook the fact that our personnel are the most important resource that we manage.

An excellent article by Vicki Hess, RN published in Hospital and Health News (Jan 19, 2012) encourages evidence based management as a tool for increasing employee satisfaction and productivity.

In the article, Vicki states that in recent years, scholars have studied and written about evidence-based leadership and evidence-based management. A logical progression in this thinking is evidence-based employee engagement. Employees are engaged when they are satisfied (they like what they do), energized (they put effort behind it) and productive (their work contributes to organizational goals). Leaders who are effective in engaging others are facilitators of the engagement process. Because no one external source can motivate an employee, providing an environment that encourages intrinsic motivators is critical.

The article continues with the concept that employee preferences are an important but often overlooked factor in department management. Engaged managers are in touch with employee preferences and make personal contact with employees on a daily basis.

She concludes that by adopting an evidence-based employee engagement approach that combines current engagement research, leadership insights and employee preferences, leaders can positively impact important business results without subtracting from the bottom line.

Click here to read the excellent article by Vicki Hess, RN

Clinical Forum: Propofol dose in the Obese Patient

As the American population grows both in number and size, anesthetists are challenged with selecting the proper dose of drugs. Some believe that doses should be based on actual body weight while others believe that calculating a dose based on lean weight or ideal weight are better options. In this study published in Anesth Analg. 2011 Jul;113(1):57-62. Epub 2010 Sep 22, Ingrande J, et al compared the induction dose of propofol in obese patients using actual weight and lean body weight.

The authors found that patients receiving propofol based on actual body weight received a larger total dose and shorter time to loss of consciousness. When given based on lean body weight, patients had similar time to loss of consciousness. The authors concluded that lean body weight appears to be the most appropriate plan for dosing propofol in the obese patient.

Click here to read the original abstract of the work described in this post. Return to www.procrna.com and leave a comment.

Clinical Topic: National Nurse Anesthetist Week

Every year the last full week in January is designated as National Nurse Anesthetist week. This is our opportunity to capture media coverage and let the world know who we are and what we do. PROCRNA.com encourages you to offer “CRNA for a day” to your local nursing school. Welcome students at the head of the table as they rotate through the operating room.

The picture on this posting and the suggestions below come directly from the AANA web site. Click here to view the original posting from the AANA.

National Nurse Anesthetists Week Ideas

There are countless possibilities for promoting your profession during National Nurse Anesthetists Week, January 22-28, 2012. Have you considered the following?

1. Legislative Day. Invite your state legislators to a breakfast or coffee at a gathering place near the state capitol, or recruit state association members to pay a visit to your legislators’ offices.

Many state associations have had success with legislative days in years past. If you are interested in organizing a legislative day for your own state association, be sure to contact your state lobbyist for input on state rules and regulations concerning giving gifts to, entertaining, and lobbying legislators.

Community Calendars. Contact your local newspapers and radio/television stations and ask to have your National Nurse Anesthetists Week activities included in their Community Calendars.

Proclamations. Some states are already contacting their legislators, governors, and community leaders to have the week of January 22-28, 2012, publicly proclaimed as National Nurse Anesthetists Week. Try contacting the appointment secretary at the state capitol or governor’s office for information on how to proceed. (See the sample proclamation included in this section of the website.)

Career Days. Contact local junior high schools and high schools, junior colleges, and colleges/universities regarding speaking and exhibiting opportunities to promote careers in nurse anesthesia.

Public Speaking. Opportunities for public speaking are limitless. Contact your chamber of commerce, community center, high school, park district, local chapters of professional associations, or clubs, to name a few possibilities. Or stay closer to home and arrange to give a presentation at the hospital or healthcare facility where you work. Target the general public or specific market segments like senior citizens, other healthcare professionals, expectant mothers, etc.

Billboards. For previous Nurse Anesthetists Weeks, a few states purchased billboard advertising space and reported great results. The Delaware Association of Nurse Anesthetists borrowed from the 2005 Nurse Anesthetists Week materials (“How Do You Say Quality Anesthesia Care?”) to create a billboard that appeared along a busy highway during Nurse Anesthetists Week 2006. AANA has some information concerning billboards that is available upon request. For more comprehensive information, however, search “billboards” on the Internet. Also, if you would like to find out more about DANA’s billboard project, contact Del Price, Jr., CRNA, MSN, via email at delsleeper@aol.com.

Table-top Displays. Obtain permission from your hospital, ambulatory surgical center, or physician’s office to set up a table-top display during National Nurse Anesthetists Week. Put out brochures, giveaways, and a bowl of candy, tack up a poster or two, or get more elaborate and run the videotape The Best Kept Secret in Healthcare: Certified Registered Nurse Anesthetists, which is available through the AANA Bookstore.

Educate Acquaintances about CRNAs. Make it a point during Nurse Anesthetists Week to explain to as many family members, friends, patients, and others as possible, exactly who you are and what you do. The world needs to know, and you are the best ambassador to deliver this message on a one-to-one basis. In fact, make delivering the message part of your daily routine.

Phone-System Message. Obtain permission to record a message about CRNAs and Nurse Anesthetists Week on your hospital’s phone system. When callers to the hospital are put on hold, they will hear the educational/promotional message.

Cinema Ads.
The following information consists of generalized pricing that may vary depending on the number of movie screens at your local cinema complex. For instance, if the cost to show a 30-second public service announcement during the 20 minute preview portion of the movie were $40 per screen, and the theatre has 20 screens, it would cost a total of $800 per week to advertise in that theatre. However, if the theatre complex has four screens, the cost would be $160 per week. In addition, most theaters show an ad for an average of four times per day (at no additional cost), and there may be a one-time cost to digitize the ad. Most theatres contract with a third part company who handles all of their advertising. National CineMedia places advertising in the following movie theatres: AMC, Regal, Century, United Artist, Edwards, and Cinemark. The contact number is 1-800-828-2828. Please call for current figures.

11. Magazine Covers. Northeast Medical Center in Concord, N.C., won an honorable mention in the 2003 PR Recognition Award contest for creatively educating patients and their families about nurse anesthetists. The CRNAs there purchased magazine subscriptions for the hospital’s waiting rooms, and placed each issue of the magazines in clear, protective plastic covers. On each cover they then placed a large sticker that stated the magazines were compliments of the anesthesia department and provided information about nurse anesthetists. The information was read by countless people throughout the year.

Special thanks to those CRNAs who offered ideas and suggestions for Nurse Anesthetists Week. Additional ideas and suggestions are always welcome! Please send to Christopher Bettin, AANA Senior Director of Communications, at cbettin@aana.com.

Clinical Topic: Ethanol intoxication, Brain injury and outcome

All CRNAs who take call in a medical center have had the challenge of caring for the intoxicated driver who arrives at the Hospital with a head injury. Imagine that both drivers sustained a traumatic head injury. One driver was intoxicated and the other was completely sober. Which driver is more likely to have a better outcome?

A study by Lustenberger, T, et al published in the Journal of Neurotrauma looked at outcomes of patients with traumatic brain injury. The aim of this study was to determine the impact of ethanol (ETOH) on the incidence of severe traumatic brain injury associated coagulopathy and to examine the effect of ETOH on in-hospital outcomes in patients sustaining sTBI. The incidence of admission coagulopathy, in-hospital complications, and mortality were compared between patients who were ETOH positive and ETOH negative.

The authors found that coagulopathy was significantly less frequent in the ETOH (+) patients compared to their ETOH (-) counterparts

For brain-injured patients arriving alive to the hospital, ETOH intoxication is associated with a significantly lower incidence of early coagulopathy and in-hospital mortality.

Click here to read an abstract and link to the original article by Thomas Lustenberger.

CRNA Fitness: Cardiovascular Exercise

Cardio is probably the most common form of structured exercise in America.

In the 1960’s Dr Kenneth Cooper, the founder of The Cooper Institute in Dallas, TX, introduced aerobic exercise to the fitness world and made cardio a common household word. Cooper soon after became crowned the “king of hearts.”

Cardiovascular or aerobic exercise is any structured exercise that elevates the heart rate for a sustained period of time such as jogging, power walking, elliptical training, treadmill walking, and lifecycle pedaling and is essential to any quality fitness program. Not only does aerobic exercise strengthen the heart, it raises the metabolism, which burns calories, which helps you lose or maintain weight, not to mention releasing feel-good endorphins which makes you feel good to be around. And you’ll notice that someone who has just completed a cardio work-out doesn’t usually slouch out the gym door..they hustle out. Cardio is better than Boost for raising your level of energy and it’s lower in calories, too.

To get the most out of your cardio, allot a specific amount of time, start out a tad slowly, then pick up the pace, sustaining a challenging speed for the majority of the work-out. Turn on your i-pod or watch a video flick, but take mental time to focus on form and breathe smoothly, with rhythm. Did I mention water? Drink before, drink during, drink after. You do not need any beverage other than cool water for normal work-outs. Remember, you’re trying to burn calories, not drink them. Allow a two to five-minute gradual cool down, wipe up the sweat and stretch. It’s okay to stretch before the session begins, but you won’t be warm enough to do a great job of it. Better to simply be fully awake, get a few calories from an orange or tiny bowl of oatmeal, get partially hydrated and “hit the road.” If you’re really slow at getting warmed up, you can stop after five minutes to stretch before continuing, especially if you’re on pavement, otherwise, five to ten minutes of long leisurely stretching following your cardio is ideal.

Stay off the pavement if you have bad knees, wear padded pants if you cycle, don’t carry anything heavy when you power walk, make like a camel for all cardio, and burn, Baby, burn. You, too, can be crowned the King and Queen of Hearts.

You can visit Liz at www.bdyfrm.com where the unique, informative and entertaining Lizlines are posted Monday through Friday. Don’t miss the weekly Lizlimerick, always a Liz original!

Clinical Topic: Controlled Substances and State Law

CRNAs are certified as qualified to practice by the Council on Certification and Recertification of Nurse Anesthetists. In addition, they must be licensed to practice nursing by the state in which they practice. Questions often arise regarding prescriptive authority and the legal ability to use controlled substances in our daily practice. Laws vary from state to state. Below is an excellent review of the Law of the State of Texas prepared by Pamela Chambers, CRNA. Contact Ms Chambers at Lex Terrae consulting if you have questions about the laws in your state.

Submitted by Pamela Chambers, MSN, CRNA, EJD

Every year new laws become effective that affect all of us. Some are so obscure that we never become aware of them – unless we violate them. As mentioned in earlier articles, ignorance of the law is rarely a defense to violating it. Two recent legislative changes (i.e. new laws) that affect nurse anesthesia practice are the new consent requirements and the controlled substance program requirements.

Title 25 of the Texas Administrative Code (Health Services) Part 7 (Texas Medical Disclosure Panel) Chapter 601 (Informed Consent) codifies the requirements of the Texas Civil Practice and Remedies Code, Chapter 74, Medical Liability, Subchapter C, section 74.102. In English: the new consent rules are laws that further explain the law regarding medical liability in Texas. The importance of this cannot be overstated. The new consent procedure, requiring a specific form to be completed and signed by the anesthesia practitioner, is a law. This is not “just another rule” designed to test our memory of rules. This new law was likely the result of changing health care realities (i.e. such as the patient who awakens from surgery having had procedures that were necessary but not specifically discussed prior to induction). When society changes we have the ability to change our laws to reflect the will of the electorate, and the good of society.

In an effort to protect society by controlling dissemination of federally controlled substances, the Texas Department of Public Safety (DPS) requires registration of all individuals who possess a DEA# for the purpose of prescribing, or dispensing controlled substances in the state of Texas. As with many of our laws in every state of the union, this instance derives from federal law.

In the State of Texas, relevant guidance pertaining to controlled substances is found in the Controlled Substance Act; Title 21 United States Code (USC) sections 801-971 (specifically sections 821-829); Department of Justice Drug Enforcement Agency (DEA) Clarification of Registration Requirements for Individual Practitioners 21 Code of Federal Regulations (CFR) Part 1301; and Texas Occupations Code Title 3 Health Professions Subtitle B Physicians (“medical practice acts”) Chapter 157 Authority of Physician to Delegate Certain Medical Acts.

Additionally, registered nurses are governed by the Texas Occupations Code Title 3 Subchapter E Regulation of Nursing (“nurse practice acts”) Chapter 301 Nurses. Section 301.154 section (a) states the following: Rules regarding delegation of certain medical acts. (a) The board may recommend to the Texas State Board of Medical Examiners the adoption of rules relating to the delegation by physicians of medical acts to registered nurses and vocational nurses licensed by the board. In making a recommendation, the board may distinguish between nurses on the basis of special training and education. Further, chapter 222 of the Texas Board of Nursing Rules and Regulations relating to Nurse Education, Licensure, and Practice states that for approval of prescriptive authority, an RN shall “have full licensure from the Board to practice as an advanced practice registered nurse” and submit an application with evidence of successful completion of specific graduate level courses.
Subsection 157.0511 of the medical practice acts indicates the following: Prescription Drug Orders (a) A physician’s authority to delegate the carrying out or signing of a prescription drug order under this subchapter is limited to: (1) dangerous drugs; and (2) controlled substances to the extent provided by Subsection (b). Subsection (b): A physician may delegate the carrying out or signing of a prescription drug order for a controlled substance only if: (1) the prescription is for a controlled substance listed in Schedule III, IV, or V as established by the commissioner of public health under Chapter 481, Health and Safety Code… (4) (b-1) The board shall adopt rules that require a physician who delegates the carrying out or signing of a prescription drug order under this subchapter to register with the board the name and license number of the physician assistant or advanced practice nurse to whom a delegation is made. The board may develop and use an electronic online delegation registration process for registration under this subsection.
(c) This subchapter does not modify the authority granted by law for a licensed registered nurse or physician assistant to administer or provide a medication, including a controlled substance listed in Schedule II as established by the commissioner of public health under Chapter 481, Health and Safety Code, that is authorized by a physician under a physician’s order, standing medical order, standing delegation order, or protocol.

The Texas Department of Public Safety governs the Texas Prescription Program which regulates the dissemination of controlled substances to consumers in Texas. According to the DPS website, http://www.txdps.state.tx.us/RegulatoryServices/prescription_program/prescriptionforms.htm accessed January 12, 2012, “Every Official Prescription form, produced from January 1982 through the present, contains the practitioner’s DPS and DEA registration numbers, a unique control number and the DPS seal (as a watermark) on the face of the prescription. The modifications to the Official Prescription forms do not invalidate previously issued prescription forms. An Official Prescription form is considered valid if it contains the security features associated with that particular format/layout and the practitioner’s DPS Controlled Substance Registration number is current and valid.” Further, the DPS drug rules, subchapter D section 13.81 indicates specific actions to be taken if a prescription for a controlled substance is questionable, to wit: If a dispensing pharmacist receives an official prescription form that creates a substantial question or doubt in the mind of the dispensing pharmacist, the pharmacist must, before filling the prescription, communicate with the prescribing practitioner in order to resolve the question or doubt. Additionally, Section 481.061 Subsection 2 (h), of the Texas Health and Safety Code was amended to include the following rule “ A pharmacist may dispense a controlled substance listed in Schedule III, IV, or V under a written, electronic, oral, or telephonically communicated prescription issued by a practitioner defined by section 481.002 (39) (C) and only if the pharmacist determines that the prescription was issued for a valid medical purpose and in the course of professional practice…“

The available resources repeatedly indicate the requirement of the DEA# and registration in the DPS controlled substance registration program. Registrants in the Texas DPS controlled substance program may use the specified form which has the DEA# and DPS# preprinted on the prescription form. An advanced practice nurse who has satisfied all of the applicable state and federal requirements, may indeed prescribe controlled substances in Texas. However, an advanced practice nurse may also facilitate a prescription for controlled substances as a delegated duty from a supervising physician. In this capacity, the signature on the prescription form of an advance practice nurse acting on behalf of the supervising physician is the same as a valid signature from the prescribing physician. If, hypothetically, an error or omission is noted on a prescription form – the pharmacist has a duty as indicated in the above referenced statute to contact the prescribing provider to clarify the suspected error or omission.

Let’s use an example that may illustrate the importance of being aware of this law: Let’s say a CRNA has a DEA# because they have at one time practiced as a locums provider in an arrangement that required the individual CRNA have their own DEA# (i.e. without a supervising physician or “medical direction”); then the CRNA changes practice arrangements (i.e. relocates or takes another locums assignment) to a facility, which has its own DEA#, and permits advanced practice nurses practicing within the facility, (with or without “medical direction”), use of the facility DEA#……..Hmmm Such a set of facts might prompt a call from the DEA to inquire about your DPS number. Why? DEA #’s are specific not only to the provider to whom they are issued, but they are also specific to one facility or one state.

Keep in mind, our legislated laws are written for the masses. Thus laws that are designed to cast a very wide net, may inadvertently harm some of the small fish. Forewarned is forearmed.

Additional resource:
http://codes.lp.findlaw.com/uscode/21/13/I/C

About the author: Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted. Click here to learn more about Lex Terrae Legal consulting services.

Clinical Topic: Post-op Fluids for Children

The literature is full of studies related to postoperative nausea and vomiting. I once heard an Anesthesia instructor say “if I have one more student do a vomiting study, I’m going to puke”. Even so, PONV continues to be a problem and creative investigators continue to find new aspects to study.

A recent study by Mercan et al published in Paediatric Anaesthesia looked at the timing and temperature of the first liquid given after recovery from anesthesia. Different groups of Children were given a first liquid at different time intervals and different temperatures following recovery. Liquids were either at room temperature or at body temperature. The researchers found that children receiving liquids at body temperature had significantly less post-operative vomiting than children receiving liquids at room temperature.

Click here to read more about this study and their findings.

Meeting Review: Utah Association of Nurse Anesthetists

The Utah Association of Nurse Anesthetists (UANA) will hold an annual meeting on January 28, 2012. We will have national representation from the AANA (Debbie Malina, President) and the NBCRNA (Robyn Ward, Secretary/Treasurer). We will cover a variety of clinical topics including: New Drugs on the Horizon, Regional Anesthesia, Pediatrics, Surgical Stress, etc. In addition, we will hear from professionals whose lectures will focus on business and retirement practices. We are offering two breakout sessions which will allow you to select topics that interest you. Attendees who sign in at vendor tables will be entered into a drawing for two iPads.

Register online at uana.org or by mail. Contact April Blair if you have any questions at aprilblair@gmail.com. We hope to see you there.

CRNA Fitness: Procrna Fit-tips

Integrating healthy concepts into your life is like riding a tandem bike. It takes two participants and a bicycle that works. To meet the challenge of getting in shape this month, be sure to integrate both sound nutrition (see January posting) and efficient exercise into a quality plan. Once you have tweaked or completely revamped your daily diet and selected a venue for structured exercise, start supplementing your coffee break with some gentle stretches like slow, easy toe-touches to loosen hamstrings and relieve stress on the lower back. When the lunch-break-boy finally makes it into your room, take a few minutes in the lounge to do seated leg raises and neck rotations. And if some kind soul mercifully shows up to give you a potty break, take an extra minute to carefully lunge back down the hall on your way to relieve the reliever. As your 8-hour day stretches into 12, remember, careful stretching provides relief, while too much coffee requires it.

To read Lizlines and to view seated leg raises, click on www.bdyfrm.com.

Liz Sanner Davis is the owner of Body Firm Integrated Fitness Solutions. She is the author of Lizlines, posted each weekday on her web site.

CRNA Fitness: Nutrition

The Gas Range
By Liz Sanner Davis

Think of the food on your plate as Fuel. Think of the container it comes in as the Gas-can. And label the inside of your body as The Tank. At every meal you must carry the fuel in a gas can and deliver it unpolluted to the tank if you want to have enough gas to live life and to give life in the OR. When the patient is short on gas, he crumps. When you are short on gas, you crump. And when low-grade gas is delivered to the tank ( think paper bags with famous logos, cardboard boxes with grease-covered bottoms, and paper cups with sippy devices), you and your patient may both wind up driving on empty. During the month of January, try making this change in your nutrition habits at work. Bring fresh lunch foods to work prepared in your own kitchen – last night’s leftover salmon is a worthy protein, light yogurt and low-sugar granola, a crisp apple, a ripe avocado big enough to share are all perfect pick-me-ups. Or stack your own turkey sandwich made with whole grain bread, lettuce and tomato. Avoid saltyfoods from the cafeteria and resist the urge to send out Smiling Samantha for pepperoni pizza with stuffed cheese crust, “double-the-olives.” Fill your tank with superior grade fuel delivered in a pollutant-free gas-can. You’ll sustain two lives – yours and the patient’s.

Liz Sanner Davis is owner and trainer at Body Firm Integrated Fitness Solutions, Temple, TX. Visit Liz online at www.bdyfrm.com and read her humorous and motivational Lizlines or Lizlimericks published daily.

CRNA Today; Online CME for CRNAs

To enhance your CME experience, PROCRNA.com offers reviews of meeting attended by our readers. Several readers have requested a review of online CME. CRNA Today is an online CME offering for CRNAs. Read the review, visit their site, and return and offer your comments to your colleagues.

As described by the owners, CRNA Today is a CRNA owned, web based CME offering committed to delivering complete online education for CRNAs in a fresh and engaging way. The platform was created to deliver CE courses online and is centered around making continuing education easy and exciting. Instructors and editors have decades of practical experience as seasoned CRNAs. You can choose from multiple ways to access your course content. We’re committed to constantly updating and adding to our course selections based upon feedback from the CRNAs we serve.

Below is a testimonial from a CRNA who has used CRNAtoday.com to obtain CME credit:

“Your course had very good speakers and informative sessions in the comfort of my home computer. It was a godsend. Not only was it cost effective, but the time involved without leaving my home was wonderful. I would like to thank you for your help in guiding me through the process of taking the quiz at the end of the course. CRNAtoday is one of the best ways for crna’s with limited spare time from their families to get the credits needed every 2 years. Thank you and your staff who got this course off the ground for people like me.”

PROCRNA.com would like to hear from CRNAs who have used the CRNA Today CME program. Write a comment and let us know how it worked for you.

Click here to view CRNAtoday.com How does online CME work for you?

Obesity, The Airway & Good Positioning

Troop Elevation Pillow

Every anesthesia provider across the country cares for obese and morbidly obese patients. Numerous studies now support that the head elevated laryngoscopy position (HELP) facilitates intubation and in general improves airway management of the obese patient. The Troop Elevation Pillow (TEP) was designed by a practicing anesthesiologist to achieve HELP quickly and consistently yields a predictable and stable result. The TEP is meant to replace a pile of unstable blankets; click here to go to Dr. Troop’s teaching web site.

If you have experience with this device, please return after you view Dr. Troop’s web site and write a review for your colleagues.

CRNA Fitness: Selecting a Gym

Losing weight used to be numero uno on the News Year’s Resolution list but lately it’s given way to touchy, feely hopefulness charged with sentiment and inertia. In spite of the second-place status, ‘lose weight’ is a list-maker that will open gym doors and sell overpriced clearance tights…for about three months. Over 30% of the people who join a gym in January, will stop going by March, and may never return. If you are one of those who does follow through on your resolution commitment of losing weight, here are some tips for joining a gym and/or hiring a personal trainer.

The Goals

Establish your basic goals.

That means you may need to sit down at your computer and write down two or three well-defined things you intend to accomplish by joining, then select a gym that has what you need in order to achieve your written goals.

The Proximity

Locate a gym or trainer that is close to home or close to work or right on the precise route that you take to one or the other. If you have to go the least bit out of your way or have to stop at one light a little too long, you’ll be back under the covers in less than a month.

The Money

Gyms and fitness facilities are muy espensivo to operate so they want, they need your money. Still, wangle the best deal you can get. Three-month specials abound (‘cause they know you’re gonna quit in March!) and perks like a free trial visit, personal training packages, free classes, and guest passes are often an option. Accept an automatic withdrawal from your account ONLY if you fully understand the fine print in the contract. Yep! There will be a contract and you won’t get out of it easily in March…or June, either. Read, comprehend, then pay up and USE the place faithfully. Tip: Go as the guest of your buff and beautiful friend so you don’t have to listen to marketing hype first-time in the door.

The Machines and the Maintenance

Machines should be up to date and in good repair– you can tell by getting on one and using it or by counting the number of signs on equipment that say Out Of Order. It doesn’t hurt to take note of the rips and tears in vinyl machine pads, the cracked or missing water holders on cardio machines, or single dumbbells now divorced from their partners. Check out the bathroom, the showers, the toilets – um-hmmm – and ask straight out how often the cleaning service marches their bucket brigade from ellipticals to lockers and beyond. There is no better place to get colds, flus and infected scratches and wounds than at a work-out facility. If you have to step over the spit on the floor next to the squats cage, move on dot com.

The Environment

How’s the music? Can you hear yourself think? Is this a meat market or a family fitness center? Do you recognize some people from work or bridge club? Do people behave respectfully and share equipment and clean up after themselves on the gym floor? Does Jocko Madzilla remove the 800 pounds of weight plates from the leg press when he’s finished and does Little Lucy Latte get off the elliptical promptly when her time is up without re-setting the timer when no-one’s looking? These observations take time so take that time to avoid being sorry.

The Members

Then, ask the members who are there if they are happy with the variety and supply of equipment, with the quality of classes and with the level of maintenance and overall professionalism. Discuss their payment satisfaction and what they like best and least about the facility. Find out if theft is a problem and how issues have been resolved. Observe the members as they arrive and leave, as they work out and socialize, as they interact with personnel and how they treat the place, ‘cause that’s how they’re going to treat you.

The Trainers

This is my area, Kids. I’m an integrated fitness trainer and I take this seriously. If you want a trainer whether short-term or long-term, do your due diligence as real estate people like to say. Look at other client’s results, interview more than one client to get their comments and interview more than one trainer to feel the fit. Inquire about credentials and certifications and if you’re at a gym, ask the gym leadership to tell you what the requirements are for trainers – eg, insurance, certifications, age and experience. Then observe at least one session and don’t look at the trainer’s biceps and glutes; look at the attention he/she gives the client, the focus, the total professionalism. If the client is grunting, pouring sweat and hobbles for three days after the session, run the other way while you have two good feet. Efficiency, form, and safety are tantamount and pushing clients too hard is a deal breaker. Make sure the trainer keeps good records of client progress and has some level of education in nutrition. Supplements of any kind are not necessary for achieving normal, healthy results, but trainers often earn mega extra income by selling them. If you find a high-quality trainer whom you trust and who guides you to your mutual goals, that’s the deal maker. Just offer her/him a good tip and consider yourself pumped!

A well-run fitness facility is a social mecca for exercise where you can pay for the opportunity to get in touch with your wellness and, therefore, your well-being. With precious little time and money to spare during this extended employment drought, do your homework before you slide your card then stick with your plan beyond the Ides of March.

Liz Sanner Davis is owner and trainer at Body Firm Integrated Fitness Solutions, Temple, TX. Visit Liz online at www.bdyfrm.com and read her humorous and motivational Lizlines or Lizlimericks published daily.

Distracted Health Care Providers

Hospitals across the nation have encouraged the use of computers, ipads, smart phones and other devices to improve the access of health care workers to information essential for safe patient care. Information about lab interpretation, drugs, and diagnosis are all readily available on line. In some institutions, the Anesthetist is encouraged to call or text the Recovery area prior to delivering a fresh post-op patient. It now appears that the use of technology can be a two edged sword.

In addition to the intended use of electronic devices to enhance patient care, there is increasing evidence that health care providers are becoming distracted from patient care. A front page article by Matt Richtel in the New York times titled “As Doctors Use More Devices, Potential for Distraction Grows?” tells of a Neurosurgeon taking 10 personal calls during a case in which the patient was harmed. An article in Perfusion magazine reported that nearly half of the perfusionists in a survey admitted to texting or making a personal call while the patient was on cardiopulmonary bypass. Other stories include Circulating nurses making airline reservations during a case as well as texting facebook friends.

Patient advocate Suzanne Gordon writes of the problem of distracted drivers using cell phones and notes that 15 states still do not have laws against texting while driving. When discussing the case of the Neurosurgeon making numerous calls during surgery, she asks “where were the other OR staff when this was going on?” She notes that the same people who are texting in their cars are now texting while doing patient care. Suzanne recommends that one person in the operating room be designated as the only person to have access to cell phones during the case.

The challenge for health care workers is to fix the problem themselves before congress or Joint Commission imposes new rules. We must remember that the welfare of the patient comes first and resist the urge to text, call, or surf the net while providing patient care.

Standards, the Expert Witness

Submitted by Pamela Chambers, MSN, CRNA, EJD

Click here for Lex Terrae consulting

As we all know, legislative bodies enact the laws that we must all abide by – whether we are aware of them or not. Ignorance of the law is rarely a defense to violating it, whereas professions set their own standards of care. Ignorance of the standard of care while not illegal, may be described as poor practice. But how does the public – or the courts, know what constitutes poor practices? How would a court determine the standard of care for nurse anesthesia practice in Temple, TX; or in Dallas, TX; or in Bay City, TX?

The United States Supreme Court held that expert opinion is only admissible when it is generally accepted as reliable the relevant scientific community Frye v. United States, 54 App.D.C. 46, 293 Fed.1013 (1923). The decision handed down in Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113 S.Ct. 2786, 125 L.Ed.2d 469 (1993) went a step further in clarifying that expert testimony must have a valid scientific connection to the issues of a particular case. So why is this important to know?

Upon review of Carolan v. Hill, 553 N.W. 2d 882, Iowa 996, the issue on appeal was the admissibility of expert testimony. The harm suffered by the plaintiff (Carolan) was ulnar nerve damage sustained during the administration of anesthesia for a surgical procedure unrelated to plaintiff’s arm. The trial court refused to allow the plaintiff’s expert witness testimony. The trial court relied upon its interpretation of the Iowa Code regarding who could establish standard of care. On appeal, the Iowa Supreme Court clarified the interpretation of the law in Iowa. The relevant code noted that a “person” qualified to provide expert testimony shall be so qualified based on medical or dental qualifications that relate directly to the issues in the case at bar. Furthermore, if the legislature had intended qualified individuals be restricted to physicians and dentists, it would have done so explicitly. In this instance, this issue was reversed (overturned the jury verdict for the defendant anesthesiologist) and remanded to the lower court. Plaintiff’s expert witness was a Nurse Anesthetist.

The Federal Rules of Evidence, rule 702, state the following with regard to expert witnesses: A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if: the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue; the testimony is based on sufficient facts or data; the testimony is the product of reliable principles and methods; and the expert has reliably applied the principles and methods to the facts of the case. This rule is based largely on Daubert, but has been amended and modified as other landmark decisions (such as Kumho Tire Co. v. Carmichael, 119 S.Ct. 1167 (1999) have been decided regarding expert testimony.

Daubert set forth a non-exclusive checklist for trial courts to use in assessing the reliability of scientific expert testimony. The specific factors delineated by the Daubert Court are (1) whether the expert’s technique or theory can be or has been tested—that is, whether the expert’s theory can be challenged in some objective sense, or whether it is instead simply a subjective, conclusory approach that cannot reasonably be assessed for reliability (i.e. an opinion); (2) whether the technique or theory has been subject to peer review and publication; (3) the known or potential rate of error of the technique or theory when applied; (4) the existence and maintenance of standards and controls; and (5) whether the technique or theory has been generally accepted in the scientific community. The Court in Kumho held that these factors might also be applicable in assessing the reliability of nonscientific expert testimony, depending upon “the particular circumstances of the particular case at issue.” 119 S.Ct. at 1175.

So what does all of this mean? How does affect your practice if it affects it at all? Consider this, when you make a decision as to which nondepolarizing muscle relaxant you will use (when you have a choice) ask yourself if the decision you’ve made is accepted practice. When you decide to conduct your anesthetic in a manner that you deem best for your patient, ask yourself if the methods that you use are (still) relevant and valid? If any of us are practicing the “way we’ve always done it”, ask yourself this question – Is this defensible in a court of law?

About the author: Pamela Chambers is a staff CRNA a Central Texas regional trauma center and the affiliated Children’s hospital. Ms Chambers received her MSN in 2000 while on active duty in the U.S. Army; then received her Executive Juris Doctor (EJD) in Health Law in 2008 from Concord Law School. Ms. Chambers owns Lex Terrae Consulting a health law research and consulting firm and also teaches Legal Nurse Consulting for Kaplan University. Ms. Chambers is not an attorney. The information provided is legal research and should not replace consultation with an attorney or physician when warranted. Click here to learn more about Lex Terrae Legal consulting services.

Radiation Exposure to Anesthetists

Radiation exposure has long been a concern to Radiologists and their assistants. Lead aprons, thyroid shields and more recently leaded eyeware have reduced their exposure to radiation. Anesthetists are frequently assigned to sedate / anesthetize patients in the interventional radiology suite. Like the Radiologist, the anesthetist is exposed to radiation danger.

In a study by Anastasian, ZH, et al published in Anesthesiology, the facial exposure to radiation was compared between the Radiologist and the Anesthetist. Both providers wore lead aprons. The Radiologist wore leaded eyeglasses and stayed behind a leaded acrylic shield to the extent possible. The Anesthesiologist also was instructed to stay behind a leaded shield to the extent possible and to keep maximum distance from the source of radiation.

The authors of the study demonstrated that the Anesthesiologist had a 3 fold increase in facial exposure to radiation than did the Radiologist, thus increasing the risk of developing cataracts. Exposure of the Anesthesiologist was correlated to the number of pharmacologic interventions performed during the case.

The best ways to reduce exposure to radiation are distance and shielding. Lightweight leaded eyeglasses reduce exposure of the cornea by 98% and are recommended for those spending significant time administering anesthesia for interventional radiology

Click here to review the work by Anastasian, ZH et al.

Please return to this site and leave a comment

Anesthesia Awareness and the Bispectral Index

To BIS or not to BIS. That is a common topic for discussion in the anesthesia community. Unanticipated intraoperative awareness is a traumatic event for the patient with many developing post traumatic stress disorder. Anesthetists are challenged with providing safe anesthesia which includes the absence of recall by the patient.

The Bispectral Index was developed from technology related to the processed electroencephalogram. Claims are made that when the BIS value remains below 60 the risk of awareness under anesthesia is greatly reduced.

A study by Avidan et al published in the New Engl J Med studied the effectiveness of the BIS monitor compared to strict monitoring of the end tidal anesthetic gas concentration. Target values of 40-60 were used for the BIS group and 0.7-1.3 MAC for the end tidal anesthetic group. Alarms were set to warn the anesthetist when patient values were outside the prescribed limits.

The authors concluded that use of the BIS monitor did not reduce awareness as compared to strict monitoring of the end tidal anesthetic gas concentration. The study suggests that using the end tidal gas concentration protocol in patients at high risk for awareness could be of benefit. Setting alarms for monitoring end tidal gas concentration is essential.

Click here to read the full article. Please use the “comments” prompt at the top of this page to share your thoughts and experiences.

Dannemiller Nurse Anesthetist Review and Update

November 29 – December 4, 2011, San Antonio, TX

I’ve been attending this Dannemiller offering for years and it consistently meets my continuing education needs. It’s very convenient to visit a beautiful place like San Antonio, TX for a few days and earn enough CE credits for the two year re-certification. This time they provided 32 hours of lecture (including pharmacology credit) and an optional 8 hour hands-on ultrasound guided nerve block workshop. I especially enjoyed the lectures onreactive airway management, pediatric congenital heart disease, geriatric poly-pharmacology, perioperative diabetic management, one lung ventilation, and preoperative pulmonary assessment. Our AANA President Debra Malina provided insightful information regarding current and future nurseanesthesia trends and issues including NBCRNA mandatory recertification. I highly recommend all Dannemiller education products. Check out their website.

Click here to check out their website.

Reviewed by Bill Shopp, CRNA

The Influence of Perioperative Care and Treatment on the 4-Month Outcome in Elderly Patients With Hip Fracture

With the baby boomers coming of age, the demographics of those seeking health care is changing. The percentage of those considered “elderly” in the surgical population has had a steady increase over the past few decades. In a study published in the February 2011 edition of the AANA Journal, Bjorkelund et al discuss risk factors of anesthesia related to the elderly population.

In this study of elderly patients with hip fracture, premedication, prolonged fasting and fracture type were related to postoperative confusion and mortality at 4 month. The authors found that decreased SpO2, prolonged fasting and increased number of units transfused all impaired recovery and were correlated to a higher mortality rate. Patients with the longest fasting times tended to receive a larger volume of fluid which may have stressed physiologic reserve.

The effects of preoperative medication on outcome produced an unexpected finding. In this study, those who received no premedication had a higher rate of confusion and mortality at 4 months. The authors speculate that either the premedication reduced the stress of surgery and improved outcome or that those who were not premedicated were in a higher risk group and possibly not a candidate for sedation.

Click here to view the study published in the AANA Journal.

Promote your Profession

Nurse Anesthesia has a long and proud history dating back to the late 1800’s. Watchful Care by Marianne Bankert documents our history and the contributions made by the early pioneers of the profession. Nurses were selected as the ideal anesthetists because of our attention to detail, vigilance, and commitment to patient safety. Day in and day out, Nurse Anesthetists delivered quality care to patients and service to surgeons.

In the century that followed, many changes in Health care have taken place but one factor remains constant; the safety and quality of patient care delivered by Nurse Anesthetists. To support the quality of care we deliver, we must actively promote our profession and contribute to the body of knowledge If we are to remain trusted and respected in the of delivery of anesthesia services. We must all contribute to promoting our profession. Some will participate in research or Public Relations projects. Others who can not actively work to promote the profession must help by supporting the work of others.

The AANA foundation has the mission of advancing the science of anesthesia through education and research. The Foundation provides an excellent opportunity for each individual CRNA to support our profession by supporting the research done by our colleagues. Original studies to promote safe practice and to validate the safety and cost effectiveness of Nurse Anesthesia have been funded and published by the AANA Foundation.

Did you know that last year the AANA Foundation:

Funded $73,045 in research initiatives

Awarded $129,000 in student scholarships

Awarded $250,000 in Post-Doctoral and Doctoral fellowships

Presented 95 research posters

Please take the opportunity to support your profession through support of the AANA Foundation. Regardless of the size of your contribution, add your name to the list of those who support CRNA research and education through the AANA Foundation. Click here to go to the Foundation web site. After reviewing the site, please contribute.