Titrating Your Anesthetic

The “Bookends” of SafetyDean Mazurek, CRNA

All about meAll about me

••Independent Contractor since 2004Independent Contractor since 2004

••Chairman, AANA Nominating Chairman, AANA Nominating committee, 2008committee, 2008

••Member, 2006Member, 2006

••Member, AANA Programs Committee Member, AANA Programs Committee 20082008

••Member OSHA committee 2004Member OSHA committee 2004--20052005

••Member SODCMember SODC\\SRF committee 2003SRF committee 2003

••Member PR committee 2001Member PR committee 2001--20022002

••SecretarySecretary--treasurer for NJANA 1998treasurer for NJANA 1998--20042004

t t t

““Mr. June 2008Mr. June 2008””

My patientMy patient

AgendaAgendaExamine incidence of awareness under Examine incidence of awareness under anesthesia anesthesia Discuss causes and long term Discuss causes and long term consequences consequences Review literature surrounding Review literature surrounding ““too much too much anesthesiaanesthesia””Other longer term effectsOther longer term effects

Anesthetic Depth and RecallAnesthetic Depth and Recall

Awake

Explicit Memory

Responsiveness to Commands

Implicit Memory

Movement

Fully “Anesthetized”

Increasing Anesthetic D

epthIncreasing A

nesthetic Depth

“I’ve never had an awareness case in all my years of giving anesthesia.”

- a frequent comment by anesthesia providers

““II’’ve never had an awareness case in all ve never had an awareness case in all my years of giving anesthesia.my years of giving anesthesia.””

-- a frequent comment by anesthesia providersa frequent comment by anesthesia providers

When are you asking the question?When are you asking the question?When are you asking the question?

Incidence of Awareness With RecallIncidence of Awareness With Recall11,785 patients11,785 patients

Interviews at PACU discharge, 1Interviews at PACU discharge, 1--3d, 73d, 7--14d14dOnly 33% of awareness cases (6/18) were detected in Only 33% of awareness cases (6/18) were detected in PACU, PACU, others detected laterothers detected laterAwareness: 0.18% with NMB Awareness: 0.18% with NMB –– more severemore severeAwareness: 0.10 % Awareness: 0.10 % withoutwithout NMB NMB –– less severeless severe

Implications:Implications:Avoiding NMB does not prevent awarenessAvoiding NMB does not prevent awarenessAwareness with paralysis increases severityAwareness with paralysis increases severityPACU screening misses most awareness episodes PACU screening misses most awareness episodes 39% had benzodiazepines39% had benzodiazepines (little insurance)(little insurance)

Sandin et al, Awareness During Anaesthesia: a prospective case study Lancet 355: 707, 2000

How are you asking the question?How are you asking the question?How are you asking the question?

Suggested PostSuggested Post--op Questionsop Questions1. Last thing you remember before you went

to sleep?2. First thing you remembered when you

woke up?3. Remember anything between these two

periods?4. Dreams during operation?5. Worst thing about the operation?

1.1. Last thing you remember before you went Last thing you remember before you went to sleep?to sleep?

2.2. First thing you remembered when you First thing you remembered when you woke up?woke up?

3.3. Remember anything between these two Remember anything between these two periods?periods?

4.4. Dreams during operation?Dreams during operation?5.5. Worst thing about the operation?Worst thing about the operation?

Liu, et al. Liu, et al. AnaesthesiaAnaesthesia.. 19911991

Incidence of AwarenessIncidence of AwarenessGeneral Incidence 0.1General Incidence 0.1--0.2% 0.2% (>40,000 in (>40,000 in US?)US?)

GhoneimGhoneim AnesthesiologyAnesthesiology 92 :597 , Feb 2000 (review)92 :597 , Feb 2000 (review)SandinSandin RH, RH, EnlundEnlund, G Samuelson P, , G Samuelson P, LennmarkenLennmarken C. C. LancetLancet. 2000 Feb 26;355(9205):707. 2000 Feb 26;355(9205):707--1111

ObstetricsObstetrics0.9% recall and 6.9% dreams (Lyons 1991) 0.9% recall and 6.9% dreams (Lyons 1991)

CardiacCardiac1.1% recall (Phillips 1993)1.1% recall (Phillips 1993)0.3% recall (Dowd 1998)0.3% recall (Dowd 1998)

Awareness in the USAwareness in the US

Goal: determine incidence of awareness in US Goal: determine incidence of awareness in US Large, prospective, multicenter study Large, prospective, multicenter study 19,576 Patients interviewed 19,576 Patients interviewed

Postoperatively Postoperatively After one week After one week

Convenience sampling of all patients typesConvenience sampling of all patients types

Sebel et al., “The Incidence of Awareness During Anesthesia: A Multicenter United States Study,” Anesth Analg 2004; 99:833-9

Incidence of Awareness Incidence of Awareness -- USUS

The findings from this US multi-center study are similar to previously reported awareness incidence reports from Australia and Sweden. Awareness during anesthesia is a ubiquitous phenomenon occurring at an incidence between 1-2 cases per 1000. Sebel et al, Anesth Analg. 2004; 99: 833-9

0

0.05

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0.15

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0.25

Aw

are

ness

Inci

dence

(%

)

1 2 3 4 5 6 7 TotalSite Number

1 case per 1000

1 case per 500

Experiences During AwarenessExperiences During Awareness

Sounds, conversationIntubation/ endotracheal tubeSensation of surgerySensation of paralysisAnxiety and panicHelplessness and powerlessnessPain

Sounds, conversationSounds, conversationIntubation/ endotracheal Intubation/ endotracheal tubetubeSensation of surgerySensation of surgerySensation of paralysisSensation of paralysisAnxiety and panicAnxiety and panicHelplessness and Helplessness and powerlessnesspowerlessnessPainPain

““AwarenessAwareness”” –– A Self ReportA Self Report““I share my experience as a general practioner, I share my experience as a general practioner,

awake but paralyzed whilst undergoing a awake but paralyzed whilst undergoing a laparoscopic cholecystectomy . . .laparoscopic cholecystectomy . . .””

““I could feel the cool iodine being sponged onto my I could feel the cool iodine being sponged onto my abdomen. I was terrified as I realized I had abdomen. I was terrified as I realized I had sensation and was going to feel the surgerysensation and was going to feel the surgery……. . The first umbilical incision, although only a few The first umbilical incision, although only a few centimeters long felt like a huge incision across centimeters long felt like a huge incision across my abdomenmy abdomen””

Rowan, Anaesth Intensive Care 2002; 30:505-6

Jeanette M. Liska, PhD.

Silenced Screams

Surviving Anesthetic Awareness During Surgery: A True Life Story

AANA Publishing Inc, Park Ridge IL. 2002

What Causes Awareness?What Causes Awareness?

Awareness: A DOSING ProblemAwareness: A DOSING Problem

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12:44 12:54 13:04 13:14 13:24 13:34 13:44 13:54 14:04 14:14 14:24 14:34 14:44 14:54

BIS

Sevo 3 - 2%

Sevo 0.8% Sevo

1.3%Sevo 1.7%

On CPBIso 2%

Incision &Incision &SternotomySternotomy

Anesth Analg 2001; 93:798-799

Awareness: A DELIVERY ProblemAwareness: A DELIVERY Problem

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7:41 7:58 8:16 8:33 8:50 9:08 9:25 9:42 10:00 10:17 10:34 10:52

Time

BIS

Luginbühl, M and Schnider T. Detection of Awareness with the Bispectral Index: Two Case Reports. Anesthesiology 2002;96:241-243

Noted that the anesthetics were "backed up" in the IV line. Patient was unparalyzed but did not move during this time.

~40 yo female, 53 kg

PSH: Anterior lumbar fusion as well as 2 prior lumbar lamis

60 mg Oxycontin BID with adjuncts

Now presenting for ACDF with SSEP monitoring

Received in OR

•5500 mg propofol for 2.5 h procedure

•691 µg/kg/min!

•1250 µg fentanyl (25 ml)

•17 mg midazolam

Awareness: A Resistance ProblemAwareness: A Resistance Problem

Resistance to AnestheticsResistance to Anesthetics

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Resistance to AnestheticsResistance to Anesthetics

Extubated in OR

C/o pain in Recovery Room

Treated with Morphine 20 mg

What are the Consequences of What are the Consequences of Awareness?Awareness?

Consequences: PATIENTConsequences: PATIENT18 cases of Awareness 18 cases of Awareness ––

Initial Treatment (up to 3 weeks): Discussion/supportInitial Treatment (up to 3 weeks): Discussion/supportPatient satisfied: Patient satisfied: ““All symptoms had disappearedAll symptoms had disappeared””Patient considered further contact unnecessaryPatient considered further contact unnecessaryAll declined referral to psychiatristAll declined referral to psychiatrist

2 yr Follow2 yr Follow--up:up:6/18 6/18 –– Refused interviewRefused interview

Avoidance as part of PTSD?Avoidance as part of PTSD?9/18 patients 9/18 patients –– Located and agreed to interviewLocated and agreed to interview

4/9 4/9 –– psychiatric psychiatric sequelaesequelae with severe disabilitywith severe disabilityAll with ANXIETY, One with PAIN during Awareness EpisodeAll with ANXIETY, One with PAIN during Awareness Episode

3/9 3/9 –– Less severe, transient disabilityLess severe, transient disability2/9 2/9 –– Denied any sequelaeDenied any sequelae

Lennmarken et al, Victims of awarenessActa Anaesthesiol Scan 2002; 46:229-231

AANA and ASA Joint BrochureAANA and ASA Joint Brochure

Does Brain Function Does Brain Function Monitoring (BFM) make a Monitoring (BFM) make a difference in awareness?difference in awareness?

Intraoperative Awareness: Intraoperative Awareness: How Effective are How Effective are

HemodynamicHemodynamic Markers?Markers?ASA Closed Claims ReviewASA Closed Claims Review

15% 15% -- hypertensionhypertension7% 7% -- tachycardiatachycardia

Domino, et al. Domino, et al. AnesthesiologyAnesthesiology, April 1997, April 1997

Recent Awareness StudiesRecent Awareness StudiesImpact of BFM MonitoringImpact of BFM Monitoring

SAFESAFE--2 Study2 Study ((EkmanEkman et al. et al. ActaActaAnesthAnesth Scand. 2004; 48:20Scand. 2004; 48:20--26)26)

BB--Aware StudyAware Study (Myles et al. Lancet. (Myles et al. Lancet. 2004; 363:17572004; 363:1757--63)63)

SAFESAFE--II: Study Design / ResultsII: Study Design / Results5057 consecutive patients > age 165057 consecutive patients > age 16GAsGAs w/ relaxant technique w/ relaxant technique All BISAll BIS--monitoredmonitoredPostPost--op interviews conducted for potential op interviews conducted for potential awareness (3 over 14 days)awareness (3 over 14 days)Results compared with historical dataResults compared with historical data

EkmanEkman et al. et al. ActaActa AnesthAnesth Scand. 2004; 48:20Scand. 2004; 48:20--2626

BFM Use Reduces AwarenessBFM Use Reduces Awareness

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NO BIS n=7811 BIS n=5057

AW

AR

EN

ESS I

NCID

EN

CE 78% reduction78% reduction

““The incidence found is the lowest ever reported in a The incidence found is the lowest ever reported in a reasonably large studyreasonably large study””

14

2

EkmanEkman et al. et al. ActaActa AnesthAnesth Scand. 2004; 48:20Scand. 2004; 48:20--2626

SAFESAFE--2 Awareness Cases: 2 Awareness Cases: High BIS ValuesHigh BIS Values

Awareness during intubation

Case 1: KLR 71

Time

10:2

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Awareness during intubation

Lennmarken et al. Anesth Analg 2003; 96:S133; Acta Anesth Scand (In Press)

BB--Aware Trial: Study Design Aware Trial: Study Design Prospective, randomized, doubleProspective, randomized, double--blind, multiblind, multi--center center 2,500 high2,500 high--risk adult patients risk adult patients (c(c--section, highsection, high--risk cardiac, trauma, rigid risk cardiac, trauma, rigid bronchoscopybronchoscopy, prior awareness experience), prior awareness experience)

randomized into 2 groups: BISrandomized into 2 groups: BIS--guided and routine guided and routine carecare

Blinded observer assessment for recall at 3 Blinded observer assessment for recall at 3 regular intervals after surgeryregular intervals after surgeryBlinded adjudication committee determined Blinded adjudication committee determined status:status:

awareness/possible awareness/no awareness awareness/possible awareness/no awareness

Myles et al. Lancet 2004

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0.25

0.5

0.75

1

NO BIS n=1238 BIS n=1227

AW

AR

EN

ES

S I

NC

IDEN

CE

Total Patients Enrolled: 2503Total Patients Enrolled: 2503

BFM Reduces AwarenessBFM Reduces AwarenessProspective, Randomized, DoubleProspective, Randomized, Double--blinded, blinded,

MulticenterMulticenter StudyStudyAdult Patients at High Risk for AwarenessAdult Patients at High Risk for Awareness

82% reduction82% reduction

P=0.022; 95% CI 17P=0.022; 95% CI 17--98%98%

1111

22

Myles et al. Lancet 2004

BB--Aware: BIS Monitored CasesAware: BIS Monitored Cases

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EMG

Brief recollection ofBrief recollection of rigid rigid bronchoscopybronchoscopy with slight with slight pain. BIS recorded at 79pain. BIS recorded at 79--82. 82. BIS > 60 for 5 minutesBIS > 60 for 5 minutes

Heard voices and Heard voices and sternalsternalsaw, with some pain. BIS saw, with some pain. BIS recorded as 55recorded as 55--59, > 60 for 59, > 60 for 9 minutes9 minutes

Two awareness cases in the BIS guided treatment groupTwo awareness cases in the BIS guided treatment group

“Monitors by themselves are not therapeutic – they require

understanding and interpretation, after which a rational action must be

undertaken.”

““Monitors by themselves are not Monitors by themselves are not therapeutic therapeutic –– they require they require

understanding and interpretation, understanding and interpretation, after which a rational action must be after which a rational action must be

undertaken.undertaken.””

Brodsky JB. What Intraoperative Monitoring Brodsky JB. What Intraoperative Monitoring Makes Sense? Makes Sense? ChestChest. 1999;115: 101S. 1999;115: 101S--104S104S

What are the long term effects What are the long term effects of general anesthesia, of general anesthesia, especially especially ““too much too much

anesthesiaanesthesia””??

Apoptosis: (deft.) cell selfApoptosis: (deft.) cell self--destruction, a physiologic process destruction, a physiologic process eliminating DNAeliminating DNA--damaged, superfluous or unwanted cells. Also damaged, superfluous or unwanted cells. Also called programmed cell deathcalled programmed cell death

Widespread Widespread nonphysiologicnonphysiologic apoptosis and apoptosis and neurodegenerationneurodegenerationhave been observed in laboratory rodent fetal brains after shorthave been observed in laboratory rodent fetal brains after short--term anesthetic exposure term anesthetic exposure

Even in mature brain, the transition of immature cells into moreEven in mature brain, the transition of immature cells into morehighly differentiated neurons with the complex synaptic highly differentiated neurons with the complex synaptic structure needed for learning could be compromised by routine structure needed for learning could be compromised by routine anesthetic exposure. anesthetic exposure.

Some preliminary clinical data could also be interpreted to suppSome preliminary clinical data could also be interpreted to support ort the hypothesis that anesthetics have intrinsic potential the hypothesis that anesthetics have intrinsic potential neurotoxicityneurotoxicity. In elderly surgical patients, for example, deeper . In elderly surgical patients, for example, deeper levels of inhalational anesthesia are associated with more severlevels of inhalational anesthesia are associated with more severe e early postoperative cognitive impairmentearly postoperative cognitive impairment

This suggests that in individuals with limited nervous system This suggests that in individuals with limited nervous system reserve or impaired tolerance for oxidative stress, prolonged reserve or impaired tolerance for oxidative stress, prolonged exposure, or higher anesthetic concentrations could be, in effecexposure, or higher anesthetic concentrations could be, in effect, t, neurotoxic.neurotoxic.106106

FDA ConferenceFDA Conference

Rodent: First three weeks after birth.

Human: From mid-gestation to several years after birth.

Brain Growth Spurt (BGS) period a time of synaptogenesis (neural synapse formation)

The BGS period occurs in different species at different times relative to birth.

“Window of Vulnerability”

Dobbing & Sands, Early Human Dev., 3, 79, 1979

All general anesthetics used in obstetric and pediatric medicine incorporate mechanisms which lead to neuroapoptosis• We have demonstrated that exposure for 6 hrs to an

anesthetic cocktail used commonly in pediatric anesthesia (midazolam, nitrous oxide, isoflurane), triggers extensive neuroapoptosis in the developing rat brain, followed by learning/memory deficits at 30 days of age which persist into adulthood

Jevtovic-Todorovic et al. J. Neuroscience, 2003

Your typical anestheticYour typical anesthetic

Alternative Therapies For Children

Neuraxial/regional/local anesthesia Opioid anesthesiaNo anesthesiaDelay surgery

Will we be seeing “black box” warnings on volatile anesthetics?

Anesthetic Exposure & Anesthetic Exposure & AlzhemierAlzhemier’’ss DiseaseDiseaseNo Clinical Association?No Clinical Association?

(*80% power, alpha = 0.05)

EXPOSUREEXPOSURE YESYES NONO Odds RatioOdds Ratio[95% CI][95% CI]

Any prior exposure of general anesthesiaAny prior exposure of general anesthesiaCaseCase 208208 4444

ControlControl 199199 5353Six or more prior events of general anesthesiaSix or more prior events of general anesthesia

CaseCase 2525 227227ControlControl 1818 234234

>Ten cumulative hours of general anesthesia>Ten cumulative hours of general anesthesiaCaseCase 88 244244

ControlControl 55 2472471.631.63

[0.53[0.53--5.04]5.04]

1.441.44[0.77[0.77--2.71]2.71]

1.281.28[0.82[0.82--2.00]2.00]

General Anesthesia and Breast General Anesthesia and Breast MetastasesMetastases

Retrospective Clinical AnalysisRetrospective Clinical Analysis129 consecutive breast cancer patients 129 consecutive breast cancer patients Mastectomy + Mastectomy + AxillaryAxillary Node DissectionNode DissectionSame anesthesia provider, same surgeon, same oncologist caring for all the patients within the studyNonNon--randomized:randomized:

79 pts: GA only79 pts: GA only50 pts: 50 pts: ParavertebralParavertebral + GA+ GA

FollowFollow--up: 32 up: 32 ±± 5 months5 months

Breast CancerBreast Cancer

Exadaktylos, Anesthesiology. 2006;105:660-4

Metastasis-free survival (%)

24 mo 36 mo

Paravetebral 94 94

GA 82 77*

*p= 0.012

This retrospective analysis suggests that paravertebralanesthesia and analgesia for breast cancer surgery reduces the risk of recurrence or metastasis during the initial years of follow-up

Breast CancerBreast Cancer

Exadaktylos, Anesthesiology. 2006;105:660-4

•The stress response impairs numerous immune functions including a marked attenuation of natural killer cells

•Natural killer cells are thought to play a central role in preventing tumor dissemination and establishment

•Experimental studies show that surgical stress is attenuated better by regional anesthesia than by GA and that consequently, natural killer cell function is better preserved and metastatic load is reduced.

A little insightA little insight““The original study was designed to have cognitive The original study was designed to have cognitive decline at 3 months and a secondary endpoint of survival decline at 3 months and a secondary endpoint of survival at one yearat one year……There have been several longitudinal studies of aging There have been several longitudinal studies of aging --the Berlin Aging study and the Seattle Aging Study that the Berlin Aging study and the Seattle Aging Study that have shown that abrupt cognitive declines for any reason have shown that abrupt cognitive declines for any reason are associated with an early death are associated with an early death -- thus, I thus, I put the put the survival end point in to see if the patients who had survival end point in to see if the patients who had cognitive decline after surgery were more likely to cognitive decline after surgery were more likely to die. die. There was a significant association between There was a significant association between cognitive decline at 3 months after surgery and death in cognitive decline at 3 months after surgery and death in the first year after surgery.the first year after surgery.””

Personal communication with Dr. TG Monk, 2/14/2006Personal communication with Dr. TG Monk, 2/14/2006

Anesthetic Management and One Year Anesthetic Management and One Year Mortality after NonMortality after Non--Cardiac SurgeryCardiac Surgery

1064 Patients1064 PatientsProspective DesignProspective DesignOverall Mortality 5.5%Overall Mortality 5.5%Mortality 10.3% if age>65Mortality 10.3% if age>653 independent variables were predictive of 3 independent variables were predictive of mortality:mortality:

CoCo--morbiditymorbidityCumulative intraoperative hypotensionCumulative intraoperative hypotensionCumulative deep hypnotic time (BIS<45)Cumulative deep hypnotic time (BIS<45)

Monk TG, Monk TG, et.alet.al. . AnesthAnesth Analg;100:4Analg;100:4--1010

Independent Multivariate PredictorsIndependent Multivariate Predictorsof Oneof One--Year MortalityYear Mortality

0.01210.01211.2441.244[1.062[1.062--1.441]1.441]

Cumulative Deep Cumulative Deep Hypnotic Time (BIS < Hypnotic Time (BIS < 45)45) (per hour)(per hour)

0.01250.01251.0361.036[1.006[1.006--1.066]1.066]

Hypotension Hypotension SBP < 80 mm Hg SBP < 80 mm Hg (per (per minute)minute)

<0.0001<0.000116.116 16.116 [10.110 [10.110 –– 33.717]33.717]

CharlsonCharlson Comorbidity Comorbidity Score Score (3+ (3+ vsvs 00--2)2)

P P ValueValue

Relative Risk Relative Risk [Bootstrapped 95% [Bootstrapped 95%

CI]CI]PredictorPredictor

Monk et al. Anesth Analg 2005; 100:4-10

c-statistic: 0.847 [95%CI: 0.788-0.906, p < 0.001]

Independent Multivariate PredictorsIndependent Multivariate Predictorsof Oneof One--Year MortalityYear Mortality

0.01210.01211.2441.244[1.062[1.062--1.441]1.441]

Cumulative Deep Cumulative Deep Hypnotic Time (BIS < Hypnotic Time (BIS < 45)45) (per hour)(per hour)

0.01250.01251.0361.036[1.006[1.006--1.066]1.066]

Hypotension Hypotension SBP < 80 mm Hg SBP < 80 mm Hg (per (per minute)minute)

<0.0001<0.000116.116 16.116 [10.110 [10.110 –– 33.717]33.717]

CharlsonCharlson Comorbidity Comorbidity Score Score (3+ (3+ vsvs 00--2)2)

P P ValueValue

Relative Risk Relative Risk [Bootstrapped 95% [Bootstrapped 95%

CI]CI]PredictorPredictor

Monk et al. Anesth Analg 2005; 100:4-10

c-statistic: 0.847 [95%CI: 0.788-0.906, p < 0.001]

Is Is ““Depth of AnesthesiaDepth of Anesthesia”” Associated Associated with Onewith One--Year Mortality?Year Mortality?

MultiMulti--center Prospective Trial (Sweden)center Prospective Trial (Sweden)5,057 General Anesthetics, Non5,057 General Anesthetics, Non--cardiac cardiac SurgerySurgery

1 Year Mortality Rate = 5.6%1 Year Mortality Rate = 5.6%vs. 5.5% in Monk Studyvs. 5.5% in Monk Study

Deep Anesthesia Time: Deep Anesthesia Time: Significant Independent Predictor Of MortalitySignificant Independent Predictor Of MortalityIncreased Relative Risk: 19.7% / HrIncreased Relative Risk: 19.7% / Hr

vs. 24.4% in Monk Studyvs. 24.4% in Monk Study

Lennmarken et al, Anesthesiology 2003; 99:A-303

This collaborative conference provided the This collaborative conference provided the opportunity to examine a variety of issues.opportunity to examine a variety of issues. One had One had

to do with surprising to do with surprising -- but very preliminary but very preliminary -- data data regarding postregarding post--surgical survival that might affect the surgical survival that might affect the

lives of tens of thousands of patients each lives of tens of thousands of patients each year.year. These new data showed an unexpected These new data showed an unexpected

correlation between the time a person spent at more correlation between the time a person spent at more profound levels of 'brain wave" changes during profound levels of 'brain wave" changes during

anesthesia and the likelihood of their dying within anesthesia and the likelihood of their dying within the first year after their surgery from causes totally the first year after their surgery from causes totally

unrelated to the surgery.unrelated to the surgery.http://www.apsf.org/initiatives/outcomes.mspx

Inflammation has been implicated in many Inflammation has been implicated in many disease processes and it is definitely possible disease processes and it is definitely possible that there exists a relationship between that there exists a relationship between inflammation and the longinflammation and the long--term outcomes term outcomes associated with surgery and anesthesia.associated with surgery and anesthesia. But But much remains to be determined to see if this much remains to be determined to see if this linkage is present, and if so its strength and linkage is present, and if so its strength and what can be done about it.what can be done about it. Studies are needed Studies are needed both on the basic biology of inflammation, and both on the basic biology of inflammation, and on the specifics of this biology in the setting of on the specifics of this biology in the setting of anesthesia and surgery. anesthesia and surgery.

http://www.apsf.org/initiatives/outcomes.mspx

Points to PonderPoints to Ponder

CanCan’’t we just stop giving anesthesia?t we just stop giving anesthesia?Can we delay when it is given?Can we delay when it is given?

Can we give less anesthesia?Can we give less anesthesia?What is the best choice of anesthesia for What is the best choice of anesthesia for any particular patient?any particular patient?

ConclusionConclusion

All Truth Goes Through Three StagesAll Truth Goes Through Three StagesFirst it is ridiculedFirst it is ridiculedThen it is violently opposedThen it is violently opposedFinally, it is accepted as selfFinally, it is accepted as self--evidentevident

Arthur Schopenhauer (1788 Arthur Schopenhauer (1788 -- 1860) 1860) German philosopherGerman philosopher

Thank YouThank You

ReferencesReferencesAnesthesiology News, Issue 12/2005, Vol 31:12Anesth analg. 2006 Aug;103(2):403-409Circulation. 2006 Jun 20;113(24):2790-5. Epub 2006 Jun 12. Neubauer, Journ Amer Phys Surg, Vol 10, No 1, Spring 2001 22http://www.apsf.org/initiatives/outcomes.mspxTaggart DP Heart. 2003 Aug;89(8):897-900 http://Seattletimes.rwsource.com/html.healthscience/134569552_brainfog05.htmlMonk TG et al. Anesth Analg. 2005 Jan;100(1):4-10.Arch Gen Psychiatry 1976 Feb;33(2) 255-9Monk TG et al. ASA abstracts, 2002 A-40Chan Anesth Analg 2004; 98:S126Schubert, et al. Anesthesiology 2001;95:A52Monk TG et al. Anesth Analg. 2005 Jan;100(1):4-10. Anesthetic management and one-year mortality after noncardiac surgeryLennmarken et al, Anesthesiology 2003; 99:A-303Larijani GE, et al Anesth Analg. 2004 Dec;99(6):1876; Modafinil improves recovery after

general anesthesia.

AANA CommitteesAANA Committees

WeWe’’re looking for re looking for ““a few good CRNAa few good CRNA’’ss””Nominating CommitteeNominating CommitteeResolutions Resolutions committecommitte

Regional DirectorRegional Director

Nominating CommitteeNominating Committee

Nominating Committee is responsible for Nominating Committee is responsible for preparing the official ballot and reviewing preparing the official ballot and reviewing candidate submissions. Includes candidate submissions. Includes eliminating candidates and recruiting eliminating candidates and recruiting candidates as necessarycandidates as necessary

Nominating CommitteeNominating Committee

The Nominating Committee meets 1 day The Nominating Committee meets 1 day twice a yeartwice a year

Annual Meeting and typically the first Annual Meeting and typically the first Saturday in March in ChicagoSaturday in March in Chicago

The Nominating Committee usually holds The Nominating Committee usually holds 33--5 one hour conference calls during the 5 one hour conference calls during the fiscal year. The dates of the calls are fiscal year. The dates of the calls are predeterminedpredeterminedAll expenses are paid for March meetingAll expenses are paid for March meeting

Resolutions CommitteeResolutions Committee

The Resolutions Committee is responsible The Resolutions Committee is responsible for reviewing proposed resolutions for for reviewing proposed resolutions for proper format and studying the proposed proper format and studying the proposed resolution for the purpose of making a resolution for the purpose of making a recommendation to the membership at the recommendation to the membership at the annual Business Meeting annual Business Meeting

Resolutions CommitteeResolutions Committee

The Resolutions Committee may meet The Resolutions Committee may meet twice during the year, typically on a twice during the year, typically on a conference call and at the Annual Meeting conference call and at the Annual Meeting in August, if there are resolutions to in August, if there are resolutions to considerconsider

Recommended TalentsRecommended TalentsResolutions and Nominating Resolutions and Nominating

CommitteeCommitteeTalents include, but are not limited to: Talents include, but are not limited to:

Problem evaluationProblem evaluationProblem solvingProblem solvingDecisionDecision--making abilitymaking abilityAbility to work with othersAbility to work with othersRespect among peers Respect among peers The ability to present a position to the membershipThe ability to present a position to the membership

Cleveland Clinic StudyCleveland Clinic Study

General AnesthesiaGeneral Anesthesia900 patients900 patientsBIS monitoringBIS monitoring““AggressiveAggressive”” glucose control glucose control DexamethasoneDexamethasoneNeurocognitiveNeurocognitive testingtestingOne year survivalOne year survival

Questions?Questions?