• SDN Site Updates

    Hey everyone! The site will be down for approximately 2 hours on Thursday, August 5th for site updates.

  • How To ACE Your Medical School Interview

    In this webinar hosted by SDN with experts from BeMo Academic Consulting, you will learn a simple five-step process to help you translate your interview invitation into an acceptance.

Darwin

Full Member
10+ Year Member
15+ Year Member
Aug 19, 2001
315
1
HMS Beagle
Status (Visible)
The AANA publishes and has been on record stating to congress that there are no studies showing outcome differences in regards to anesthesiologist directed CRNA supervision.

But there is.

Silber JH, Kennedy SK, Even-Shoshan O, Chen W, Koziol LF, Showan AM, Longnecker ED. Anesthesiologist direction and patient outcomes. Anesthesiology 2000; Jul 93(1): 152-163


Why is this study not talked about? The ASA has mentioned it a couple of times on their website (you have to dig to find it), and even then only in passing.
 

The_Sensei

Membership Revoked
Removed
10+ Year Member
Dec 28, 2005
526
0
Status (Visible)
  1. Attending Physician
The AANA publishes and has been on record stating to congress that there are no studies showing outcome differences in regards to anesthesiologist directed CRNA supervision.

But there is.

Silber JH, Kennedy SK, Even-Shoshan O, Chen W, Koziol LF, Showan AM, Longnecker ED. Anesthesiologist direction and patient outcomes. Anesthesiology 2000; Jul 93(1): 152-163


Why is this study not talked about? The ASA has mentioned it a couple of times on their website (you have to dig to find it), and even then only in passing.


Poor study........widely criticized.
 

VolatileAgent

Livin' the dream
15+ Year Member
Jul 6, 2005
1,049
13
Status (Visible)
there are two studies, silber and pine, that both come to opposite conclusions. both are retrospective and the methodologies are bad.

you can't judge quality differences in anesthesia based on morbidity/mortality, especially in the team approach and when the numbers already are so small.

each of these two studies ultimately prove nothing except, what should already be intuitive, that the anesthesia care team is a better delivery paradigm.

http://www.asahq.org/Newsletters/2003/07_03/warner.html

and, there is even proof that state governments don't put much creedence into such studies when determining policy:

http://www.asahq.org/Newsletters/2005/08-05/stateBeat08_05.html
 
About the Ads

opa beleza?

Junior Member
10+ Year Member
5+ Year Member
Dec 21, 2005
36
0
Status (Visible)
  1. Medical Student
a Q:

is there data showing that CRNA unsupervised are just as safe as the ACT, or is there merely an absence of good data showing harm with CRNA out of teh ACT.

I think an important difference.:thumbup:
 

VolatileAgent

Livin' the dream
15+ Year Member
Jul 6, 2005
1,049
13
Status (Visible)
a Q:

is there data showing that CRNA unsupervised are just as safe as the ACT, or is there merely an absence of good data showing harm with CRNA out of teh ACT.

I think an important difference.:thumbup:

there's neither, really. just post hoc comparison based on limited available outcomes data. and, a lot of convention and assumption was used in both studies to make the comparison.

what such studies do not show, but what would be important in my opinion, prospectively are:

1) rate/incidence of prolonged post-op hospitalization and/or increased level of care (ie. SICU vs. intermediate vs. floor) when an anesthesiologist is not directing care

2) peri-operative morbidity (not mortality), to include (among others) softer endpoints such as poorly controlled pain, uncontrolled hyper-/hypotension, acute renal failure - and this should be stratified to a equal case-to-case comparison (ie. unfair to compare the outcome of a healthy 25-y.o. female undergoing Essure placement to a 82-y.o. poly-morbid patient undergoing a Whipple) that do not end-up (necessarily) in permanent morbidity/mortality

3) total peri-operative cost, again stratified to maintain parity among case mix, of anesthesiologist vs. non-anesthesiologist directed care

4) time spent in PACU when anesthesiologist vs. non-anesthesiologist directs care

these are just a few ideas. the problem is, you have to do this prospectively and intra-institutionally if you want to get the best results. likewise, you have to inform people that they are being studied, which may result in people bringing their "a-game" (which would be okay... you should always bring your a-game) even to the chip shot cases.

the reality is that it would be incredibly difficult to find 1) willing participants (from either camp) and 2) a practice milieu that would allow such a study to be run prospectively.

what will likely happen is that there will be long-term outcomes, again post-hoc, measurement in those systems where there is parity. for example, in an "opt-out" state where a crna-only group operates a similar case mix to a anesthesiologist group. then, you could do a similar side-by-side comparison.

generally, i agree with others that it is an unfair comparison, though, to make between the advanced and extensive training we get in comparison to those a nurse gets. i just understand what's going on inside a patient much better than my crna colleagues, and most of them know this and admit this. where their hubris shows is the belief that this ultimately doesn't matter. of course, we know better intuitively. and, no study will ever be able to prove that.
 

VolatileAgent

Livin' the dream
15+ Year Member
Jul 6, 2005
1,049
13
Status (Visible)
i'll give you a prime example of what i'm talking about...

conversation with a 20+ year crna just the other day for a patient that was going into surgery for removal of a gastric carcinoid tumor. it was before lecture and my other case had taken a little longer than expected (difficult matted abdominal tumor extraction). so, we were between cases, i set up the room and am getting relieved for lecture by one of our fine crna's. i explained the case to him, told him what my plan was, and then mentioned that my goal was to put in an a-line post-induction and... he stopped me right there and said in these exact words (i kid you not), "why the hell do you need an a-line? i'm not going to put an a-line in this patient. 47-y.o. female, no significant pmh."

i said, "um, okay. aren't you concerned about potential for carcinoid crises when they manipulate the tumor?"

he said, "i'll just cycle the cuff more frequently."

i said, "um, okay. your case, but why don't you discuss that with dr. (attending) as we'd already planned a few things. do you want me to go pick-up the octreotide from the pharmacy before i leave and put it in the room for you?"

he replied, "nah, we don't need that."

100% true story (with some minor paraphrasing).

so, maybe this is not the type of case that is usually dealt with by crna's at our institution, granted. and, he did have an attending that was supervising him and knew the patient. but, makes you wonder what really goes on out there. and, like certain other posters i've noticed here (but won't name names), their general modus operandi is that it's better to be lucky than good.

a well-designed prospective study would be able to tease out the lucky ones from the good ones, because luck actually fails people more often than they realize or are willing to admit to themselves. and, the honest truth is that most of us wouldn't want some cavalier joker playing quite so fast-and-loose with one of our loved ones. that's the bottom line.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
That is a poor example......Do you know how many cases like that are done outside the academic world without a-lines?

Choice of monitors is not what differentiates a physician from a physician extender.

Monitors do not improve outcome.....per Connors et al 1997.....in regards to the pulmonary artery catheter...and many studies after that.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
Just remember how LITTLE actual experience in taking care of really SICK patients you have....

You are after all....just a resident.....with NO years of ACTUAL practice experience under your belt....ZERO cases where YOU ARE IT...where YOU ARE the BOTTOM LINE.

You can argue this all you want...but the truth is the truth.
 
C

CremeSickle

Well said MilMD

The fact is anesthesia is like a cat, there are 100 ways to skin it. Thats the "Art" part of anesthesia. What you wanted wasent needed even if to you it was.

I was "schooled" on this the other day when i wanted to do some things i thought were necessary and the attending stopped me and he said "Son, thats the difference between academia and experience".

I bet you wouldnt have bothered to post this had it been yer attending anesthesiologist who said that to you.
 

VolatileAgent

Livin' the dream
15+ Year Member
Jul 6, 2005
1,049
13
Status (Visible)
well, you missed the point (not surprised).

the point was that this crna had no idea about what the potential risks were for doing a carcinoid resection. we had planned to start octreotide before the case started.

again, in my estimation you are one of the lucky ones... i hope i never need surgery when you're at the anesthesia helm.
 

zippy2u

Senior Member
10+ Year Member
5+ Year Member
Feb 19, 2005
501
5
Status (Visible)
Volatile, don't leave us in a lurch like that. So the CRNA didn't put in an a-line and never gave the pt. the octreotide( the CRNA didn't even know what the hell that is to be truthful--prolly some caterpillar with 8 legs). The pt. did well and everybody lived to spend another day in the trenches. That's how it played out, right? Regards, ---Zip
 

VolatileAgent

Livin' the dream
15+ Year Member
Jul 6, 2005
1,049
13
Status (Visible)
Volatile, don't leave us in a lurch like that. So the CRNA didn't put in an a-line and never gave the pt. the octreotide( the CRNA didn't even know what the hell that is to be truthful--prolly some caterpillar with 8 legs). The pt. did well and everybody lived to spend another day in the trenches. That's how it played out, right? Regards, ---Zip

i don't know what happened intra-op because i went to lecture and didn't get the case back when i went back to the OR to sign out. the patient did live and made it to the sicu (this particular surgeon is notorious for putting almost all of his patients in the sicu for 24 hrs post-op, whether they need to be there or not), so i don't know if that was an indication of negative outcome. as far as i could tell, they did a good job of ligating the stalk of the tumor and there wasn't a carcinoid syndrome that i heard of. i did talk to my co-resident in the sicu on thursday (POD#1) just to get the curbside update, but didn't formally evaluate the patient myself as i'd turned the case over.
 

opa beleza?

Junior Member
10+ Year Member
5+ Year Member
Dec 21, 2005
36
0
Status (Visible)
  1. Medical Student
there's neither, really. just post hoc comparison based on limited available outcomes data. and, a lot of convention and assumption was used in both studies to make the comparison.

what such studies do not show, but what would be important in my opinion, prospectively are:

1) rate/incidence of prolonged post-op hospitalization and/or increased level of care (ie. SICU vs. intermediate vs. floor) when an anesthesiologist is not directing care

2) peri-operative morbidity (not mortality), to include (among others) softer endpoints such as poorly controlled pain, uncontrolled hyper-/hypotension, acute renal failure - and this should be stratified to a equal case-to-case comparison (ie. unfair to compare the outcome of a healthy 25-y.o. female undergoing Essure placement to a 82-y.o. poly-morbid patient undergoing a Whipple) that do not end-up (necessarily) in permanent morbidity/mortality

3) total peri-operative cost, again stratified to maintain parity among case mix, of anesthesiologist vs. non-anesthesiologist directed care

4) time spent in PACU when anesthesiologist vs. non-anesthesiologist directs care

these are just a few ideas. the problem is, you have to do this prospectively and intra-institutionally if you want to get the best results. likewise, you have to inform people that they are being studied, which may result in people bringing their "a-game" (which would be okay... you should always bring your a-game) even to the chip shot cases.

the reality is that it would be incredibly difficult to find 1) willing participants (from either camp) and 2) a practice milieu that would allow such a study to be run prospectively.

what will likely happen is that there will be long-term outcomes, again post-hoc, measurement in those systems where there is parity. for example, in an "opt-out" state where a crna-only group operates a similar case mix to a anesthesiologist group. then, you could do a similar side-by-side comparison.

generally, i agree with others that it is an unfair comparison, though, to make between the advanced and extensive training we get in comparison to those a nurse gets. i just understand what's going on inside a patient much better than my crna colleagues, and most of them know this and admit this. where their hubris shows is the belief that this ultimately doesn't matter. of course, we know better intuitively. and, no study will ever be able to prove that.



Should'nt studies be done prior to the authorization and institution of a nontraditional intervention -- like CRNA independant anesthesia? After all --as New Jersey stated anesthesia is the practice of medicine -- which traditionally requires at least the involvement of a doc.

How can the AANA have current CRNA independance and forcefully push for more CRNA independance and then try to scrape sketchy retrospective data to support the non-traditional practice of medicine after the fact. The order in which this has all unfolded is SO BACKWARD.

If they really want independance prove, I mean really prove, that it is as safe and as effective, efficient etc... as with the supervision of a physician. Then after they have made their case a decision can be made by the health care community.

But the reverse has happened already. Thay went out got independance and are trying to show in a junky way that it is safe retrospectively. This is not the way it is supposed to work. hmmm... yet it is real?!
 
C

CremeSickle

If we are define independance by not working in an anesthesia care team with an Anesthesiologist running it then they were doing it before we were. You have it backwards.
 

militarymd

SDN Angel
10+ Year Member
15+ Year Member
Dec 17, 2003
5,889
20
Status (Visible)
  1. Attending Physician
well, you missed the point (not surprised).

the point was that this crna had no idea about what the potential risks were for doing a carcinoid resection. we had planned to start octreotide before the case started.

again, in my estimation you are one of the lucky ones... i hope i never need surgery when you're at the anesthesia helm.

No...I didn't miss the point....

YOU...missed my point...

To people who have been in the business for years...this is what we see:

A trainee beating his chest about how great he is....compared to someone who has been doing the job for 20 years.......over a case where the chest beating trainee's opinion meant very little in the overall care of the patient.
 
About the Ads
This thread is more than 14 years old.

Your message may be considered spam for the following reasons:

  1. Your new thread title is very short, and likely is unhelpful.
  2. Your reply is very short and likely does not add anything to the thread.
  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.