iPhone App Review: Anesthesia 101

Contributing Author Tech Nick Lee:

Twice a year participants for the Oral exams fret, paying big money and taking time off to study for the event. There are several written board review apps in circulation, but a new one, Anesthesia 101 by Blue Sky Innovations, seems to be creating quite a buzz among the residents as a tool for preparing for the Oral Board exam.

Review:

Anesthesia 101 is advertised as a point-of-care reference app for the iPhone, iTouch and iPad. It has 62 topics covering basics like the management of hypertension to complex scenarios like fetal resuscitation and Guillian-Barre syndrome.

 

 

 

 

 

 

 

 

 

 

 

A typical reference app would present the information as a page of information. A written review app would probably give you multiple-choice questions. This one, however, walks you through 6 to 14 pertinent questions and answers you will likely have for dealing with the management of the case.

The title bar on top tells you how many pages are associated with the topic. This unique presentation is what makes it excellent as an oral board review app. I still remember when first started reading through the topics. I felt like I was having a quiz by an examiner. Once I answered the first question, the next one probed deeper. Some of the questions were easy; others were difficult, depending on your familiarity with the topic.

I have to say that this has to be one of the best oral board simulated exams I have seen. I found it even more effective when used with a partner, who could play the role of the examiner by using the app as a guide. That being said, it is also a great app for prepping for a case, which is its true purpose. I had to take care of a patient with a pheochromocytoma. I found this within the topics list. After selecting it, the first page gave a typical presentation for the condition. Each question covered a facet of the case management, including the diagnosis, signs and symptoms, pre-op management, induction, and intra-op management.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Just like a book, you get to flip through the pages.

 

 

 

 

 

 

 

 

 

 

 

If you hold your finger down on the topic a post-chapter quiz appears. The quiz has either has two TRUE or FALSE questions, or you have to diagnosis an image relevant for the case topic. Below is the quiz from the Anterior Mediastinal Mass topic.

 

 

 

 

 

 

 

 

 

 

 

Highlights:

1. Highly detailed, point-of-reference app for case management

2. Unique dialogue-style accurately simulates Oral Board questions and answers

3. Book-style presentation allows you to flip through pages for each topic

4. Post-chapter quiz given for each topic

Area for improvement:

1. An android version is lacking

Conclusion:

This is a well-designed app for the anesthesia field. Its unique question-and-answer dialogue presentation allows it to serve two purposes. One, it is an excellent point-of-care reference, covering 62 topics from the common to the uncommon. Second, this presentation makes it perfect, inexpensive tool for studying for the Oral Board exams. I think many will find it a welcome addition for their study ritual.

Elucidating the Mechanisms of Anesthesia

The Anesthesia Blog has tended to attract a certain tech-geek type of anesthesia provider.  We have attempted to cater to our audience by highlighting anesthesia tech products, smartphone apps and advances in our field.  Like many who sit and ponder about all things anesthesia, we’ve often wondered how anesthesia actually produces its desired effect?  Meyer-Overton was a nice thought but proven too simplistic.   Last we heard it had something to do with meddling with the lipid bilayer sandwich…but nobody seems to know for sure.

In a provocatively titled article in Scientific American called “What Doctors Don’t Understand About Anesthesia” we dive deeper into an interesting revelation into the effects of anesthesia on the brain:

Highlighting these fundamental gaps in knowledge, a group of researchers recently made a surprising discovery about how we transition out of consciousness and back. The common view holds that going under (induction) and coming back up (emergence) are the same process, albeit in different directions. However, a recent study published in the journal PLoS ONE suggests that going under is not the same as coming back up.

The researchers, led by Dr. Max Kelz at the University of Pennsylvania School of Medicine, observed that less anesthetic is required to keep the brain anesthetized than to induce unconsciousness. To explain these observations, the researchers have introduced a concept they call “neural inertia,” referring to the brain’s resistance to transitions between consciousness and unconsciousness. Elucidating the mechanisms of neural inertia could be critical to the task anesthesiologists perform every day, namely preventing patients from experiencing pain or awareness during surgery and in helping those patients who exhibit delays returning to the conscious state. This line of research could also provide insights into disrupted states of consciousness like coma.

Excellent work by Dr Kelz.  Thanks for adding to our understanding.

Anesthesia Drug Shortages Continue.

Since the great propofol shortage of 2010-11 there have been intermittent shortages of many drugs in many classes.  Chemotherapeutics, antihypertensives, you name it, its been short.  This is a blog about all things anesthesia so naturally we have taken that angle.  With that in mind I will again post the generic form you can cut and paste and send to your favorite generic drug maker:

Dear Generic Drug Maker,

It is both annoying and possibly life-threatening that we no longer have adequate supplies of _______.  Please make more, thanks.

Signed,

“Anesthesia”

 

Not really sure how to deal with this problem (besides poking fun at it) we, at The Anesthesia Blog, have compiled a list of useful links.  The ASA is also taking a stand and getting behind the “Preserving Access to Life-Saving Medications Act” which would at least let give the FDA some lead time in dealing with an impending shortage.

Useful resources:

Image: vongvanvi / FreeDigitalPhotos.net

 

Update on the Company Model of Anesthesia Services

Guest post by Mark F. Weiss, J.D., Advisory Law Group

Background: The “company model” is the name given to a type of suspect anesthesia joint venture likely violative of the federal antikickback law. In its simplest form, it involves the creation of a business structure by the surgeons controlling the flow of referrals to an ASC in order to profit from the provision of anesthesia services at the facility. Read my article The Company Model: Is Making Less Money To Work at a Surgicenter Worth Jail Time? appearing in the January 2011 issue of Anesthesiology News and available on the articles page at advisorylawgroup.com.

***

It’s one thing to make a profit from medical practice – in fact, I’m more than all for it.

It’s quite another to extort a kickback for the referral of patients. That’s a crime. In connection with Medicare and Medicaid patients it’s a violation of the federal antikickback statute (the “AKS”). In fact, simply offering or soliciting remuneration for referrals is a crime under that statute.

Over the past several years, the so-called “company model” of anesthesia services has taken form, through which ASC owner surgeons have extracted a share of fees from the anesthesiologists working at the facility.

Although this post is appearing on an anesthesia blog, you may want to remind your colleagues in other specialties that the company model is not simply an anesthesiologist’s issue. In a very real sense, anesthesiologists are the “canaries in the coal mine.” Little suspension of disbelief is required to see anesthesia company model thinking permeating into other areas, say, internists setting up entities to capture the profit of referrals to gastroenterologists.

Of course, all company model situations are rife with compliance concerns.

The AKS

The AKS prohibits remuneration, that is, the transfer of anything of value, for referrals. It also prohibits offering or soliciting that remuneration.

Certain exceptions, known as safe harbors, define permissible practices not subject to the antikickback statute because they are unlikely to result in fraud or abuse. The failure to fit within a safe harbor does not mean that an arrangement violates the law; there’s just no free pass.

Joint Ventures

HHS’s Office of Inspector General (the “OIG”) coordinates enforcement of the AKS.

The OIG uses the term “joint venture” to mean any arrangement, whether contractual or involving a new legal entity, between parties in a position to refer business and those providing items or services for which Medicare or Medicaid pays. Some joint ventures are legal – others are simply disguised violations of the AKS.

The OIG issued two important alerts on joint ventures, its 1989 Special Fraud Alert on Joint Venture Arrangements, republished in 1994, and a 2003 Special Advisory Bulletin on Contractual Joint Ventures, describing the features of suspect arrangements.

In essence, suspect ventures involve an owner in one line of health care business which expands into another related health care business line to serve the owner’s federal health care program patients. The expansion is accomplished by contracting with an existing provider of the second business line – that is, a potential competitor as to the second business line. The owner essentially arranges for the existing provider to run the new business line for the new venture, with the owner participating in the profits from what are essentially its own referrals.

Safe Harbors Are Not So Safe

Both the AKS and the OIG’s regulations set forth “safe harbors,” i.e., requirements, which if complied with, provide assurance that the payment practice will not be considered a violation of the AKS.

The OIG’s position is that good faith is required for protection within a safe harbor. Additionally, as the OIG made clear in the 2003 Special Advisory Bulletin, although a safe harbor may protect the payments in one direction, the discount given in the other direction may not be protected and therefore may trigger prosecution.

The Tighter the Economy the Stickier the Fingers

As the general, and the healthcare, economies become tighter, more individuals and entities in a position to generate referrals will consider the profitability of joint ventures. A subset will disregard the issue of legality.

For years, the American Society of Anesthesiologists has been urging the OIG to adopt a Special Fraud Alert on the company model situation. The ASA’s most recent letter to the OIG on this topic, dated February 2011, sites a survey in which 41% of the responding anesthesia practices indicated that they had been approached by ASCs to do company model deals, and that out of the total 332 requests to participate in a company model entity, the practices lost their contract to provide services at the requesting ASC in at least 159 instances. The OIG has yet to act.

However, in April 2011, the OIG issued an advisory opinion (Advisory Opinion 11-03) involving a proposed pharmacy company set up very similar to the average company model deal.

In the proposed facts disclosed to the OIG, a pharmacy providing products and services to long-term care facilities would form a new long-term care pharmacy to be owned in common with one or more long-term care facilities. The long term care facilities would, of course, now share in the profits of pharmacy services generated from their own facilities.

The OIG found the proposed arrangement likely violative, focusing on similarity between the proposed deal and the problematic arrangement outlined in the 2003 Special Advisory Bulletin, with the long-term care facility owners doing nothing to operate the new venture but receiving a share of the profits. Those facility owners would have little or no business risk and the payment to the new joint venture would vary with the volume or value of referrals from the facilities to the new business.

Even though, legally, the advisory opinion does not extend beyond that particular deal, it certainly does not bode well for potential requestors of opinions in respect of anesthesia company entities. Note, though, that a deal which is planned around the problematic elements of the Fraud Alert and the Special Advisory Bulletin may well receive the approval of the OIG.

Unfortunately, there’s no bright line test and the facts and circumstances of each situation must be fully analyzed to achieve an understanding of the potential risk. But in terms of potential penalties, fines, exclusion from Medicare and Medicaid, and even jail time, understanding the risk is worth substantially more than just a good night’s sleep.

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© 2012 Mark F. Weiss

Mark F. Weiss is an attorney who specializes in the business and legal issues affecting anesthesiology and other physician groups. He holds an appointment as a clinical assistant professor of anesthesiology at USC’s Keck School of Medicine and practices with Advisory Law Group, a firm with offices in Los Angeles and Santa Barbara, Calif. He can be reached by email at markweiss@advisorylawgroup.com and by phone at 800-488-8014. His website, www.advisorylawgroup.com, features a plethora of complimentary resources. He’s happy to discuss this blog post with any reader.

Image: smokedsalmon / FreeDigitalPhotos.net

Political lobbyists, anesthesiology and you.

2011 was quite the year in Washington politics.  This type of bickering amongst the political parties has likely existed since the beginning of politics.  Last year this was made particularly poignant when a lack of agreement on budget issues led to a downgrade of the the U.S. credit rating from great to…not so much.  The Anesthesia Blog has tried, unsuccessfully for the most part, to stay above the fray and just blog about what we see.  Everyone wants their voice heard in a democracy and unfortunately (or fortunately depending who you are) those holding the largest money bags get heard the most.  This came across our collective inbox the other day:

ASAPAC Remains America’s #1 Physician PAC
On January 31, the Federal Election Commission (FEC) released the filing results for calendar year 2011. According to these filings, the ASAPAC out-raised all other physician PACs, solidifying ASAPAC’s position as America’s largest physician PAC for the third year in a row. ASAPAC raised a total of $1.67 million in calendar year 2011, a new calendar year record for anesthesiologists’ political fund.

Jeff Mueller, M.D., Chair, ASAPAC Executive Board said Wednesday, “2011 continues to be a banner year for ASAPAC. The continued effective leadership of ASAPAC Representatives and members led ASAPAC to once again be the top physician health care PAC in America. As we start our 2012 effort; let’s make it another record year for America’s largest physician PAC and continue to raise anesthesiology’s voice during this formative election.”

Just to put this in perspective we scoured the Federal Election Committee website to find a frame of reference for our readers:

  • American Association of Nurse Anesthetist’s CRNA-PAC raised $776,256
  • American Medical Association’s AMA-PAC raised $943,715
  • American Society of Plastic Surgeon’s PLASTY-PAC raised $144,658
  • American Academy of Opthamology’s OPHTC-PAC raised $594,123
  • National Association of Realtor’s PAC raised $4,001,698

Take from the above what you may.  Comments are open for this post.

Image: scottchan / FreeDigitalPhotos.net

 

iPhone App Review: Anesthesia Drugs Fast

Review by contributing author Tech Nick Lee:

Anesthesia Drugs Fast is an app for the iPhone, iTouch and iPad. It is designed as a point-of-care utility for calculating dosages for the most common anesthesia drugs. There is no Android version at this time.

Review:

One of the tenets of a well-designed app is simplicity and elegance. This is a single view app with only one control: the weight selection. Unlike other apps where you have to navigate through different screens to get information, everything is presented on one page.  Choose the patient’s weight from 1 to 200 kilograms, and this app will immediately give you a dosage range.

 

The drug categories are induction agents, muscle relaxants, sedatives, antiemetics and basic resuscitation medications. It gives you intravenous and intramuscular dosages for some of the medications. By touching the information button you can see the formulas used for the range calculation. With just one selection control and one page view, I found I could determine the proper dose while running down a hallway. It was that easy.

 Pros:

  1. Probably the easiest to-use app I’ve seen.
  2. Simple presentation, packed with the most common drugs on a single page.
  3. Only one selection needed to get drug dosages

 Cons:

  1. An Android version is lacking

Conclusion:

This is a well-designed app for the anesthesia provider. While those new to anesthesia will find it invaluable, seasoned clinicians will find it useful for pediatrics and bariatrics. It is so easy to use you can determine the correct dosage range while running down the hallway to a code.

TED Talks: The Universal Anesthesia Machine

Fascinating talk by Erica Frenkel, Program Officer at UAM Global:

Better Quality Link:
The Universal Anesthesia Machine

Thanks to LK Louis for the info.

Multiple Anesthetics Linked to ADHD

The Mayo clinic today published another chapter in the pediatric anesthesia story.  I have blogged about some of the initial studies that pointed to neurotoxcity here.  Dr Sprung et al published a paper entitled : ”Attention-Deficit/Hyperactivity Disorder After Early Exposure to Procedures Requiring General Anesthesia”

Abstract:

Objective
To study the association between exposure to procedures performed under general anesthesia before age 2 years and development of attention-deficit/hyperactivity disorder (ADHD).

Patients and Methods
Study patients included all children born between January 1, 1976, and December 31, 1982, in Rochester, MN, who remained in Rochester after age 5. Cases of ADHD diagnosed before age 19 years were identified by applying stringent research criteria. Cox proportional hazards regression assessed exposure to procedures requiring general anesthesia (none, 1, 2 or more) as a predictor of ADHD using a stratified analysis with strata based on a propensity score including comorbid health conditions.

Results
Among the 5357 children analyzed, 341 ADHD cases were identified (estimated cumulative incidence, 7.6%; 95% confidence interval [CI], 6.8%-8.4%). For children with no postnatal exposure to procedures requiring anesthesia before the age of 2 years, the cumulative incidence of ADHD at age 19 years was 7.3% (95% CI, 6.5%-8.1%). For single and 2 or more exposures, the estimates were 10.7% ( 95% CI, 6.8%-14.4%) and 17.9% ( 95% CI, 7.2%-27.4%), respectively. After adjusting for gestational age, sex, birth weight, and comorbid health conditions, exposure to multiple (hazard ratio, 1.95; 95% CI, 1.03-3.71), but not single (hazard ratio,1.18; 95% CI, 0.79-1.77), procedures requiring general anesthesia was associated with an increased risk for ADHD.

Conclusion
Children repeatedly exposed to procedures requiring general anesthesia before age 2 years are at increased risk for the later development of ADHD even after adjusting for comorbidities.

While time and smarter people than us will point out the flaws and confounding variables, it does seem like there is an emerging picture of neurotoxicity in repeat exposures to GA.

The popular press has a way of running with negative headlines when it comes to anesthesia.  Whether it is awareness under anesthesia, anesthesia providers gone bad, or weird side effects, the media is always ready to pounce.  This phenomena is most likely related to an underlying fear that the majority of their readers harbor and therefore buy more newspapers.  Our response, since the start of this blog, has been to cut through the BS and tell it like it is.  This mostly just succeeds in making ourselves feel better and not much else.  Some of the headlines related to this study:

 

Anesthesia before age 3 raises child’s ADHD risk
Children exposed to anesthesia multiple times are more likely to have disorder

-MSNBC

Could anesthesia cause ADHD in your child?

-FoxNews

General anesthesia in infancy linked to higher risk of ADHD

-CNN

Stay tuned for further developments.

Image: Salvatore Vuono / FreeDigitalPhotos.net

 

Journal Watch: Local Anesthestic Toxicity and Lipid Rescue

The toxicity of local anesthetics makes many a sphincter clench, especially for those of us who routinely practice regional anesthesia.  The advent of lipid rescue by Dr Weinberg and colleagues, has been a tremendous advance in the safety of regional anesthesia.  Dr Weinberg has established the excellent registry of cases over at Lipid Rescue.org

The advances keep a-happenin as they say.  It is a relatively new area of study one not amenable to randomized controlled trials in humans…hard to tell the IRB that the control group gets sugar water after a mega-dose of bupivicaine.   Therefore, most new data comes from our friends at the bench.  This months Anesthesiology further adds to our knowledge base on this topic.  Researchers in the U.K. analyzed the difference between mixed (medium- and long-chain) and long-chain lipid emulsions, for their ability to extract local anesthetic from serum.  They concluded that the type of emulsion may make the reversal more effective:

Lipofundin®, a lipid emulsion containing 50% each of medium-and long-chain triglycerides, sequestered all three drugs to a significantly greater extent than Intralipid® (long-chain triglycerides only) from human serum, which is in contrast with previous studies describing extraction from a buffer solution. These findings call into question the current advanced cardiac life support guidelines specifying use of a long-chain triglyceride emulsion for lipid rescue,23 although further in vivo studies that confirm a significant improvement in resuscitation from local anesthetic toxicity with Lipofundin® are obviously required before drawing any confident conclusions.

In case you ended up here at this post in an emergency, or just want a refresher the protocol is as follows (from lipidrescue.org):

20% Intralipid:

  1. Administer 1.5 mL/kg as an initial bolus; the bolus can be repeated 1- 2 times for persistent asystole.
  2. Start an infusion at 0.25 mL/kg/min for 30-60 minutes; increase infusion rate up to 0.50 mL/kg/min for refractory hypotension.

or you can print it out here.  ASRA pdf version of protocol here.

Update 1/31/12.

Thanks to Dr Patel for bringing the “Lipid ALS” app to my attention.  We may get around to a full review but from the screenshots its seems worth the price:


Image: digitalart / FreeDigitalPhotos.net

 

 

Anesthesia Humor

This video was sent over anonymously.  Funny stuff: