BURRRRRRR!!! Winter has arrived, the Holiday’s are behind us, and our resolutions have been made. I hope working with National was one of your resolutions this year. If you haven’t worked for National, make 2007 the year to experience the “National Difference.”
This issue of the National News contains several articles that may be of interest to you. You will read with interest how “Smoking Influences Propofol’s Anesthetic Effect,” and then how the “Duration of Anesthesia Induction is Sometimes Hard to Predict.” We also include an inspirational story we hope you will enjoy entitled “Get Rid of The Splinter.”
On the “Connect with National” side you will have the opportunity to meet one of “National’s Best,” whom many of you may already know, Account Manager Denise Fraser.
The most effective way to uphold your resolution to work with National is by simply signing up for National’s “Job Alerts!” at

http://www.nationalanesthesia.com/about_conta ct2.asp

where the jobs come to you! Our apologies to those CRNA’s and MD’s already signed up; due to a computer glitch this feature of our website has been out of use for the past few weeks. It is now fully operational!
Once again, thank you for allowing us to “Connect” with you through our newsletter and I hope you enjoy this issue.

Let’s Stay Connected!

Stephen Read, President
National Anesthesia Services, Inc.

Many of life's failures are people who did not realize how close they were to success when they gave up.
--Thomas Alva Edison

Smoking may effect the hypnotic efficacy of propofol, say researchers who highlight that this may have an impact on the use of target controlled infusion systems in smokers.
"Chronic exposure to nicotine induces up- reulation and desensitization of nicotinic acetylcholine receptors as well as enhancement of gamma-aminobutyric acid (GABA)-ergic transmission in the brain," note Christopher Lysakowski (Geneva University Hospitals, Geneva, Switzerland) and colleagues.
"This could change the potency of anesthetic drugs which act on the GABAA receptors."
One such drug is propofol, which is often administered using target controlled infusion systems. While age, gender, and body weight are used to adjust the dose of propofol administered by these systems, the effect of smoking is not currently considered.
The researchers examined if smoking influences the anesthetic effects of propofol in 25 people who had smoked an average of 20 cigarettes a day for years. For comparison, 2 non-smokers of similar age, gender, and body weight were also assessed.
In both groups, the bispectral index (BIS) values, a measure of propofol hypnotic efficacy, consistently decreased with increasing target effect- site concentrations of propofol.
However, at baseline, BIS values were slightly higher in smokers compared with non-smokers, at 98 and 97, respectively. The values remained higher in smokers compared with non-smokers as target effect- site concentrations of propofol wee increased, at 97 versus 95 for 0.7 ml and 94 versus 89 for 1.1 ml, respectively.
At propofol effect-site concentrations of 2.0 ml and 4.0 ml, there was no significant difference in BIS values between the two groups.
Finally, loss of consciousness occurred at significantly higher propofol effect-site concentrations in smokers than in non-smokers, at 2.4 ml versus 2.0 ml, but BIS values were significantly lower, at 60 and 66, respectively.
"Therefore to anesthetize smokers requires greater concentrations of propofol," the researchers report in the journal Anesthesia.
They add that they reduced hypnotic efficacy of propofol at low effect-site concentrations and the need for higher concentrations of propofol to induce loss of consciousness will impact the way the anesthetic agent is used for intravenous sedation in smokers.
The team suggests that nicotine may inhibit GABA-ergic activity and facilitate glutamatergic transmission; both of which result in an enhanced excitatory state of the brain.
"Although the observed differences were small, they may have some clinical relevance, as they became apparent in the range of propofol effect-site concentrations commonly used for sedation." Lysakowski et al conclude.

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Anaesthesia 2006

Hi! I can’t believe it has been 3 years already since I’ve joined the National family! I came to National Anesthesia Services on December 1, 2003 after spending 5 years in the Human Resources department of a manufacturing company where I was responsible for hiring all the manufacturing employees. Before that position I spent 6 years staffing for clerical positions. Stepping into the anesthesia staffing business was a whole new world, but with the help of a great group of Account Managers and management that we have here, I was quickly up to speed and began building my client base! I genuinely enjoy my position here at National Anesthesia Services; I love working with all my clients and all the great providers I’ve gotten to know over the years. You are all truly the best! When I’m not working, I am enjoying my second passion, which is dancing! I have been dancing for 11 years and have been a Beginning Line Dance instructor for 6 years. In addition to the dancing, I also enjoy spending time with my 3 grown sons and 3 grandchildren (I know, it’s hard to believe I have grandkids! It's hard to believe it myself)! I intend to carry on with my success at National Anesthesia for many years to come and to continue wearing my crown of Top Producer proudly!

Researchers have identified key factors that influence the prediction of time required for the induction of anesthesia, the knowledge of which could enhance the accuracy of the operating room schedule.
Jan Ehrenwerth, from Yale University School of Medicine in New Haven, Connecticut, and colleagues note that, with an increasing emphasis on efficiency, there is a need for anesthesiologists to better predict the time it takes for anesthesia to take effect before starting surgery.
"No investigation has rigorously addressed the ability of the anesthesiologist to predict the actual time required for induction of anesthesia," they add.
The researchers therefore carried out a prospective, observational study of 1265 anesthesiologists to determine their ability to accurately predict anesthesia release time (ART).
On the whole, anesthesiologists accurately predicted ART most of the time, with predicted ART highly correlated with actual ART. However, taking into account degrees of under- and over-predicting, which occurred in 24% of cases each, reduced the accuracy of prediction to just 53% per individual case.
Under-prediction seemed to be more common in cardiothoracic and transplantation procedures, while over-prediction was significant for gynecologic operations and plastic surgery.
Under-prediction of ART was associated with cases involving patients with an American Society of Anesthesiologists physical status of IV, a regional anesthetic technique, patients older than 65 years, and the need for invasive hemodynamic monitoring.
Ehrenwerth and colleagues note in the journal Anesthesia and Analgesia that among anesthesiologists who under-predicted ART by less than 10 minutes, only 2.0% rated the induction as very difficult.
For those who under-predicted by more than 10 minutes, 12.4% of anesthesiologists rated the inductions as very difficult.
"Thus, anesthesiologists were more likely to under-predict with difficult inductions," the researchers say.
"We have clearly shown that induction times in elderly, high-risk patients who require invasive monitoring are difficult to estimate and almost always take longer than expected."
The team concludes that, by considering the factors outlined in their study, the ability to predict ART for individual cases may be significantly improved.
"This can lead to more accurate scheduling and more efficient operating time management," they highlight.

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Anesth Analg 2006; 103: 938–940

At the start of a new year, everyone is focused on improving things. New Year's resolutions abound, everything from vowing to wear more skirts to the office to committing to advance education or maybe even trying for another baby! Everybody seems to enter the New Year with refreshed hope that all those wonderful things that we dream could happen will really come true this time.

But, is there something that you already HAVE in your life that is holding you back? The other day, I saw my four year old was limping noticeably. I asked him if something was wrong with his foot, but he replied "no". This happened three or four times before he finally admitted that he had stepped on something and it had gotten into the bottom of his foot. If there is one thing Douglas does not like, it's mommy or daddy having to remove splinters. He was willing to put up with the pain of the splinter rather than admit that he had a problem. It was hard for me to understand why he preferred the pain of the splinter to the solution. But, he was in denial. He had talked himself into believing that the splinter wasn't that bad, that it would go away, and that the pain would get better.

We laugh when we see a child behave this way. But do you have a splinter in your life that you are ignoring?
Maybe your health isn’t so great, or you owe too much money. Maybe you are having family problems or are afraid to fly in a plane. I’ll bet almost everybody has something that they are choosing to ignore.

I have a splinter. But I’m not going to tell you what it is. And I won’t ask you about your’s. Because I think the thorns in our life are too personal. It is easy to talk about our goals, our dreams and our schemes. It’s fun to share with people our hopes for the future, especially when we have set solid resolutions to see them to fruition. But, the splinters in our life are different.

For one thing, for a long time, we just choose to ignore our splinters. We behave like Douglas did with the real splinter. We tell ourselves that it’s not so bad, that it will go away. We can handle it. So, although it's there, we don’t even recognize it.

But then, there is a point in our life when we face the splinter. We realize it won’t get better unless we leave our denial behind, stop ignoring it, and act. Maybe we discuss it with people close to us. Maybe we seek guidance from a doctor or a support group. In fact, sharing the splinter with loved ones or professionals can be very helpful in dealing with the sorrow we are feeling. But, ultimately, when it comes down to the final solution, it is all up to us. With splinters, we can’t expect anyone else to solve it for us. We have to admit it is there, that it needs to change, and that we need to change it.

Brian Tracy said in his book “Focal Point” that one of the great life lessons we all have to learn is that “your life only gets better when you get better”. It seems such a simple statement, but has a tremendous impact to our lives when we accept it.

It’s the time for making resolutions, and we should all do that, looking forward to achieving our dreams. I have made several this year. But, I have decided that this is the time to finally deal with my splinter, as well. I’m not looking forward to it. It will be much more difficult, and much more painful than going for my goals. But, I think that unless I do face it, I’ll never be truly happy even if I do achieve my goals. Maybe, in order to achieve our destiny, we have to find the courage to first eliminate the splinters in our lives. Once they are removed, we are free to fly!

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By Sue Dickinson

General Disclaimer: The materials have been compiled by National Anesthesia Services. Inc. from internal and external sources. However, while we have attempted to provide accurate information in this publication, no representation is made or warranty given as to the completeness or accuracy of the Materials. In particular, you should be aware that the Materials may be incomplete, may contain errors, or may have become out of date. You should therefore verify information obtained from this publication before you take any action upon it.