Do you feel well-prepared for the National Certification Examination (NCE)? Are you looking for an additional resource to help prepare you for the Self-Evaluation Examination (SEE)? While studying for these exams (or any exam for that matter) may invoke anxiety, adequate exam prep will help you build confidence and achieve success.

That’s where we want to help! APEX Anesthesia Review was founded by CRNAs. We have the tools you need to prepare for the NCE and embark on your professional career as a Certified Registered Nurse Anesthetist (CRNA).

The challenge behind CRNA boards

The CRNA boards are complex, meaning you shouldn’t rely on rote memorization to pass. Administered by the National Board of Certification & Recertification for Nurse Anesthetists (NBCRNA), the NCE assesses one’s capability to deliver safe patient care, evaluating one’s knowledge after years of education, clinical experiences, and extensive study.

Fear of failure is understandable; however, 89.3% of first-time NCE candidates passed in 2024. With the appropriate CRNA board prep, you can also be successful on your initial attempt!

APEX Anesthesia’s Boards Bootcamp for CRNA board prep

Our two-day CRNA board review course will help you develop the confidence you need to sit for this stressful exam. Join us at one of our regional events near you to gain a fresh perspective on high-yield NCE content.

During this in-person learning experience, you will:

• Learn from world-class instructors via Zoom
• Grasp high-yield concepts and encounter board-type questions
• Receive new practice questions and printed handouts
• Network with fellow SRNA peers
• Take a pre- and post-exam exclusively for Bootcamp students

Review lectures are impactful and integrate all four NCE content domains. Throughout the live event, you will receive expert advice on test-taking strategies and have the opportunity to ask questions, ensuring you walk away feeling knowledgeable and confident.

Hear what your peers have to say about it!

How to lay the groundwork before Bootcamp

Although not required, we recommend completing our online course at least once before the live event. The Boards Bootcamp is designed to supplement APEX’s online SRNA review course, helping students avoid the confusion caused by inconsistent NCE information between vendors. 

With the APEX Student Review Course, you’ll learn efficiently and enhance your critical thinking skills. It features:

• Rapid and in-depth reviews in every lesson
• More than 3,000 board-type questions
• Thousands of flashcards and interactive elements
• Illustrations, tables, and videos to engage all learning styles

And we recommend that you employ smart study strategies throughout your journey.

Solidify your knowledge after bootcamp

After attending the bootcamp, you should reinforce your understanding with an NCE question bank. We provide an add-on SmartBank with 1,250+ board-style NCE/SEE practice questions exclusively for APEX Student Course users. This will expose you to item types you’ll see on exam day, further refining your test-taking skills.

The SmartBank surfaces content weaknesses and strengths through the performance dashboard, provides content references from the Student Review Course for quick review, and has an app for you to learn from your Apple or Android device.

Plus, you can gain 1 year of access when you add on today. Just activate the SmartBank when you’re ready to start testing!

Get the best value and the most benefits for CRNA prep—reserve your bootcamp spot today.

Most CRNAs prepare for job interviews by updating their resume, thinking through their clinical experience, and rehearsing how they’ll answer common questions. These are important, but they’re only half the equation.

The truth is, you’re interviewing them too.

Asking smart questions during your interview positions you as a professional who values alignment, not just a paycheck. It gives you a clearer picture of what the job will feel like if you choose to accept it. It also helps you spot hidden expectations, understand the team dynamics, and avoid surprises down the road. We’ve given you a lot of interview questions, so only ask the ones that are relevant to you (you don’t have to ask all of them).

We won’t cover compensation and benefits in this guide. For a deep dive into how to evaluate salary structures, contract terms, retirement plans, CME allowances, and other financial considerations, check out our companion article: Understanding CRNA Compensation and Benefits: It’s More Than Your Salary.

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Table of Contents

• Clinical Practice and Autonomy
• Culture and Team Dynamics
• Leadership and Management
• Schedule and Lifestyle
• Don’t Ask These Questions Too Early
• Follow-Up Questions

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Clinical Practice and Autonomy Questions

1. What level of autonomy do CRNAs have in their daily practice? This gives you a direct sense of how independently you’ll be allowed to function.
2. What clinical decisions are CRNAs expected to make independently without MD input? This reveals the true scope of your autonomy and how much critical thinking is expected or supported.
3. Are there certain cases or procedures that CRNAs can’t do (i.e., are only done by the anesthesiologists)? This helps you determine whether you’ll be able to work at (or near) the top of your license or be restricted to a narrower scope.
4. Who decides how cases are assigned (CRNA leadership, anesthesiologists, or schedulers)? How are case types distributed? Knowing how cases are distributed reveals whether the system is fair and transparent.
5. Do CRNAs typically manage their own pre-op assessments, anesthetic plan, and PACU handoffs? This gives you insight into the workflow and how much clinical ownership you’ll have.
6. Are CRNAs allowed and expected to place regional blocks and invasive lines? This indicates both the scope of your clinical practice and whether you’ll keep or build advanced skills.
7. What role do CRNAs play in OB, trauma, or other high-acuity situations? The answer shows whether CRNAs are fully integrated into critical care scenarios or sidelined.
8. In a care team model, how involved are anesthesiologists during routine cases? This helps you gauge whether autonomy is supported or undermined by micromanagement.
9. What percentage of the time are anesthesiologists present to meet TEFRA requirements? This helps you assess whether the practice is truly compliant or cutting corners, which can affect both your autonomy and legal risk.
10. How is CRNA competence assessed when it comes to complex or advanced cases? This reveals whether you’ll have the opportunity to grow into tougher assignments or be held back.
11. Is there a process for CRNAs to pursue training in new techniques, such as advanced regional anesthesia? This shows whether the culture supports clinical development and staying current.
12. What happens when a CRNA needs help during a case? Who responds and how quickly? How is this different during normal hours and call? The answer reveals team responsiveness, safety culture, and how supported you’ll feel clinically.
13. How are CRNAs onboarded for specific case types they haven’t done recently or often? A thoughtful onboarding plan is a sign that clinical autonomy is built on preparation, not pressure.
14. How does the group handle disagreements between CRNAs and anesthesiologists about anesthetic plans? This helps you assess whether autonomy is respected or if you’re expected to stay silent.
15. Do you employ AAs? If so, how is their practice different from CRNA practice? Are you valued as a CRNA or are you easily interchangeable with an AA?

Culture and Team Dynamics

1. What makes someone successful here beyond purely clinical skills? This helps you understand the “unwritten rules” that define cultural fit.
2. How long does the average CRNA stay at this job? Long tenure usually signals a supportive work environment and strong team cohesion.
3. Can I speak with one or two CRNAs currently on staff (not locums) who have been here at least a few years? Talking directly with peers gives you a clearer, unfiltered sense of the day-to-day culture. Ask them if they had to make the decision again, whether they would choose to work here and why.
4. What’s the team dynamic like between CRNAs, anesthesiologists, and AAs (if present)? This reveals how collaborative or hierarchical the group truly is in practice.
5. What’s the team dynamic like between CRNAs and the surgeons and OR staff? This reveals how collaborative and respectful the overall working environment is, which directly impacts your daily stress level and job satisfaction.
6. What does the group do, if anything, to build camaraderie outside the OR? Social dynamics outside of work often reflect how connected and supported staff feel. Some CRNAs thrive on this, while others don’t want to think about work after they leave the OR.
7. Are there opportunities for CRNAs to take on leadership, education, or mentorship roles? This tells you whether the group values professional growth or sees CRNAs as disposable labor.
8. How are mistakes handled here when something doesn’t go as planned? This reveals whether the environment is punitive or focused on learning and accountability.
9. What’s one thing current CRNAs would like to see improved about the team or workplace? You’ll learn what frustrations exist and how transparent the group is about challenges.
10. How does the anesthesia department or hospital deal with bullying or disruptive behavior from surgeons, anesthesiologists, or other staff? This can uncover toxic personalities or cultures that leadership may or may not tolerate.
11. How does the team support each other during busy or understaffed days? You’ll get a sense of whether the group pulls together or whether you’re on your own.
12. What happens if someone is struggling clinically or personally? How is that handled? Support during difficult times is a strong indicator of a healthy team culture.
13. Are CRNAs encouraged to mentor new hires or SRNAs? A mentoring culture often reflects a collaborative and generous team dynamic.

Leadership and Management

1. What is the leadership structure in the anesthesia department? Are any CRNAs included in the leadership structure? This helps you understand how decisions are made and whether CRNA voices are represented at the leadership level.
2. How politically active are the anesthesiologists and CRNAs? How does this impact their day-to-day working relationship?
   This can reveal whether leadership dynamics are driven more by clinical collaboration or behind-the-scenes power structures that could lead to animosity.
3. How does leadership gather feedback from CRNAs, and what do they do with it? This shows whether leaders are actually listening or just going through the motions.
4. What’s an example of a recent change that was made based on CRNA input? A real example gives you proof that leadership is responsive, not just reactive.
5. How are performance issues or clinical concerns typically addressed? The response reveals whether leadership is fair and constructive or punitive and distant.
6. How transparent is leadership when challenges come up, such as staffing shortages or budget issues? You want to know whether you’ll be kept informed or blindsided by sudden changes.
7. Who runs the OR board, and how are case assignments prioritized? This reveals how much influence CRNAs have in daily operations and whether assignments are made fairly or influenced by internal politics.
8. Where do CRNAs hang out when not in a case? Where do they eat? Where do they park? This is a softer way of understanding how CRNAs are valued in the organization.
9. Are there professional perks such as free meals and free parking? This helps you understand how CRNAs are valued by the organization.

Schedule and Lifestyle

1. What is the typical weekly schedule for CRNAs? This helps you understand the baseline workload and whether it aligns with your lifestyle goals.
2. How are shifts structured (8s, 10s, 12s, 24s, or pecking order)? The shift structure can dramatically affect your work–life balance and predictability.
3. What’s the typical OR start time, and when are CRNAs expected to arrive at the start of the day? This reveals whether there’s pre-start work that isn’t clearly documented.
4. How often will I be scheduled for overnight or weekend call? Call type and frequency give you insight into the actual demands of the job beyond regular hours.
5. What is the frequency and duration of in-house call? Knowing how often you’ll need to sleep on-site helps you prepare for the physical and mental toll.
6. Are post-call days guaranteed off? This helps you assess recovery time and how the facility supports rest after demanding shifts.
7. What happens if a case runs late and overlaps with shift change? This highlights staffing depth and fairness of handoffs.
8. How often do CRNAs stay late past their scheduled end time? This will uncover how predictable the schedule really is.
9. Is there any mandatory overtime, and how often are CRNAs expected to stay late when they’re not assigned to stay late? This reveals whether the practice runs efficiently.
10. Are there opportunities for overtime if I want extra shifts? This gives you insight into staffing needs and the potential to boost your income if desired.
11. How far in advance is the schedule published, and how often does it change? Predictability can reduce stress and allow for better planning.
12. How is the call schedule created, and how far in advance is it posted? Timely and transparent scheduling reflects good management and respect for your planning needs.
13. How is vacation time approved, and how far in advance do you need to make the request? You’ll want to know if you can get vacation when you want it and to understand how likely you are to get it. Is it based on seniority or some other method? Some groups require PTO requests before the next calendar year, while others are more flexible.
14. Do CRNAs have input into their own schedule or shift preferences? This shows how much control you’ll have over your work–life balance.
15. Are there pre-assigned lunch or break periods? Break coverage can affect morale and energy over a long shift.
16. How is sick coverage handled? This reveals whether you’ll be pressured to cover when others are out.
17. How often are CRNAs floated between sites or assignments? Frequent floating can disrupt routines and impact job satisfaction.
18. Is there a dedicated CRNA educator or point person for orientation and support? Support systems speak volumes about how much they invest in your success.

Don’t Ask These Questions Too Early

1. Can I have all the job details emailed to me before I decide whether to interview? This signals low interest or high entitlement, which can turn off a potential employer.
2. How soon can I take vacation? Asking this early can signal you’re already planning time off before you’ve even started. If you have a trip already planned, you’ll want to discuss this a bit later in the hiring process (during negotiation).
3. Can I leave early if my cases are done? This can give the impression that you’re focused on minimizing work rather than contributing to the team.
4. What happens if I’m late or miss a shift? This leads employers to question your reliability and professionalism.
5. Can I avoid OB, call, or certain types of cases? This suggests inflexibility before they’ve had a chance to see your full range of strengths.
6. What’s the policy on taking locum work on the side? Asking this can raise red flags about commitment or split priorities.
7. How often do I get lunch or breaks? While important, this may seem petty if asked too early, especially if culture and patient care haven’t been addressed yet.
8. Do I have to take call if I don’t want to? Framing it this way implies you’re negotiating out of core responsibilities before establishing your value. A better approach is to ask how call is structured and how often CRNAs are typically scheduled, which shows interest without sounding inflexible.
9. Will you pay off my student loans or cover moving expenses? Some employers offer these benefits, but asking too early can make the conversation feel transactional.
10. Can I work part-time eventually? Even if that’s your long-term goal, it’s better to discuss after establishing your value.

How to Follow Up with Additional Questions After the Interview

If you walk away from the interview with lingering questions (or think of something important you forgot to ask) it’s completely appropriate to follow up. Send a short, polite email to your primary contact. Thank them for their time, express your continued interest, and ask your remaining questions clearly and concisely. Try to keep your questions in your initial email so you don’t overwhelm their inbox.

Example: “Thank you again for taking the time to speak with me. I enjoyed learning more about your team. After reflecting on our conversation, I had a couple of follow-up questions and would appreciate any additional information you can share.”

Keep it focused, respectful, and professional. Most organizations appreciate that you’re being thorough, and it shows you’re serious about making the right decision.

Final Thoughts

A job interview isn’t just about proving you’re qualified. It’s also your opportunity to make sure the role fits your goals, values, and lifestyle. The best CRNA positions are built on mutual respect, clear expectations, and strong communication.

By asking thoughtful questions, you not only leave a strong impression, but also gather the insight you need to make a confident decision. You’re not just trying to get the job. You’re deciding where to invest your time, energy, and expertise. Make sure it’s a place where you’ll thrive.

There’s more to landing the right CRNA position than chasing the highest salary. Even if you prioritize pay above lifestyle, location, or scope of practice, focusing on base salary alone can lead you down the wrong path. Instead, think about total compensation, where you can view it as a pie with salary being only a part of the whole.

When you understand how each factor affects your total compensation, you can confidently negotiate and avoid costly mistakes. This article breaks down every major component of a CRNA salary, translates industry jargon into plain numbers, and gives you the tactical guidance you need to compare job offers, apples to apples.

DISCLAIMER: This information is for educational purposes only and is not financial, tax, or legal advice. We’re not CPAs, financial advisors, or attorneys. You should consult with a qualified professional before making any financial, tax, or business decisions. Additionally, we’ll speak in generalities throughout this article, so recognize that there are always exceptions.

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Table of Contents

• Base Salary
• W-2 vs. 1099
• Retirement Plans
• Health Insurance
• Disability Insurance
• Malpractice Insurance
• Paid Time Off
• Sign-on Bonus
• Retention Bonus
• Professional Development Benefits

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Base Salary

An employer doesn’t set a CRNA’s salary arbitrarily. Instead, it’s a reflection of underlying market dynamics.

Geographic Factors: The most significant driver is the CRNA supply-and-demand balance in a given region. Rural areas or regions with fewer anesthesia providers may need to offer more attractive compensation packages to attract top talent. Conversely, desirable markets (often urban or tourism destinations) typically offer a comparatively lower base compensation (all other things being equal) because employers face less difficulty filling positions.

Beyond Geographic Factors: Compensation reflects the practice setting, payer mix, and job requirements. Positions involving higher clinical complexity (e.g., cardiac, trauma, and OB) or extensive call requirements generally pay more due to the specialized skill sets required and the added burden of unpredictable schedules.

Staff turnover rate may impact the need to offer higher pay to attract talent. For context, the few studies that examine CRNAs suggest 9–12% average annual turnover. Payer mix (the ratio of private health insurance, Medicare, Medicaid, and self-pay) impacts a facility’s bottom line and can influence CRNA salaries, where a higher balance of private health insurance and self-pay often increases revenue. Finally, critical access hospitals get higher reimbursement rates because they receive reasonable costs instead of the fixed rate set by Medicare’s payment system, which explains why they typically pay well.

Practice Model: How you’re deployed in the OR directly shapes your paycheck (our example assumes all other things are equal).

• Physician‑led ACT model (1 MD: < 4 CRNAs): One anesthesiologist may supervise multiple CRNAs, so the revenue is split across providers.
• Mixed model (1 MD: > 4 CRNAs): CRNAs run solo rooms, but an MD is available for consultation. Salaries are likely to increase because the pie is split between fewer providers.
• CRNA‑only or independent practice: Every anesthesia dollar flows through the CRNA team. You’re also carrying the full clinical responsibility (e.g., blocks, lines, call, and decision‑making), which justifies a premium for the added autonomy and liability.

🔍 APEX Insights

• Always translate an offer into total compensation (base pay, bonuses, benefits, and call differentials), not just the headline salary. Remember this when you use the salary filter when using a job board. Check out the APEX CRNA Job Board to find top jobs in your location.
• Balance money against lifestyle. High pay often comes with strings attached, such as heavy call, remote geography, high‑acuity cases, or a toxic work environment. Make sure the trade‑off works for you and your family.
• If a position offers notably higher compensation compared with similar jobs, carefully assess organizational stability, provider turnover rates, and regional healthcare market conditions to ensure you’re making a sustainable career decision.
• Regularly revisit industry CRNA salary benchmarks (e.g., AANA salary surveys) to strategically negotiate higher compensation in line with your skills and the complexity of your role.
• Critical access hospitals can out‑pay urban centers because of cost‑based Medicare reimbursement (i.e., Medicare reimburses higher for these facilities to help keep them in business). Verify that status before you sign.

W-2 vs. 1099 Independent Contractor

Choosing between a W-2 employee and a 1099 independent contractor role significantly impacts your financial planning, benefits structure, and career flexibility. One is not inherently better than the other (despite what you see on social media), so take the time to determine what’s best for you. We dive deep into 1099 here but, for now, you should understand both in terms of your total compensation package.

W-2: As a W-2 CRNA, your employer handles employment taxes (e.g., social security and Medicare taxes) and provides comprehensive benefits such as health insurance, retirement plans, malpractice insurance, PTO, CE funds, and other benefits, thus simplifying your financial management. Because your employer picks up the tab for these things, your salary will represent a lower percentage of your total compensation.

1099 Independent Contractor: Conversely, 1099 positions offer higher base compensation rates but shift responsibility for taxes, benefits, and retirement planning entirely onto you. This increases your financial responsibility and administrative workload.

Key responsibilities of 1099 CRNAs include setting up and maintaining your business entity, paying quarterly taxes, maintaining a separate business bank account for your business expenses (never mix business and personal expenses), obtaining health insurance on the private market, and setting up your retirement plan (e.g., solo 401(k) or SEP IRA). You may also benefit from tax deductions related to your business, and you might qualify for the qualified business income (QBI) deduction if you meet certain thresholds. Many CRNAs elect to work with a CPA, financial planner, and/or attorney to ensure they’re doing things correctly, which adds to your expenses as a 1099.

🔍 APEX Insights

• Evaluate each employment type by calculating your effective net income after taxes, retirement contributions, healthcare premiums, malpractice insurance, and other benefits we discuss.
• Consider your risk tolerance, financial discipline, and administrative capacity when evaluating 1099 roles, as they require meticulous financial planning and management.
• Consult a CPA and/or financial planner experienced in CRNA compensation to accurately estimate your total financial responsibility and potential tax deductions in a 1099 role.

Retirement Plans: 401(k), 403(b), Pension, Profit Sharing

Employer Matching Contributions: Many employers offer to match a percentage of your salary that you contribute to your 401(k). For example, if your employer offers a 100% match on up to 5% of your salary, and you contribute 5%, your employer will add an additional 5%, effectively doubling your contribution. Think of this as free money. Also, some companies require you to opt in to their retirement plan, while others enroll you by default and allow you to opt out.

Profit Sharing: Some organizations (typically private practices) may distribute some of the company’s profits. This follows a predefined formula set by the company’s plan.

Vesting Schedule: Vesting refers to the period of time you must remain employed before you fully own your employer’s contributions to your retirement plan. Leaving before you are fully vested means you forfeit a portion (or all) of the employer’s contributions.

• Immediate vesting schedule = You own the funds as you receive them.
• Graded vesting schedule = You gain ownership gradually over time (e.g., 20% per year over 5 years).
• Cliff vesting schedule = You must stay a set number of years before you own any of the employer’s contributions (e.g., 100% vested after 5 years).

Pension: A pension is a retirement plan in which an employer contributes funds on behalf of an employee, often based on salary and years of service, with the promise of providing a fixed, regular income after retirement. Unlike 401(k) plans, which depend on individual contributions and investment performance, pensions typically offer guaranteed lifetime payments, making them highly valuable but increasingly rare.

🔍 APEX Insights

• A strong employer match can be worth thousands of dollars annually, which compounds over the duration of your career.
• Job hopping (e.g., consistently leaving positions before reaching full vesting) can cost you tens of thousands of dollars (or more) by significantly reducing your long-term retirement savings.

Health Insurance

Health insurance is the sleeper variable that can swing your real take‑home pay by thousands, yet many CRNAs skim past it. A W‑2 offer might offer a lower salary but cover 75% of family premiums, throw in dental and vision, and seed an HSA each January. Before considering a 1099 role, price out the cost of obtaining your own health insurance. Many 1099s choose the least-expensive, high-deductible plans to keep monthly premiums manageable. Make sure you understand the risks of the coverage level you choose.

Dig deeper than the brochure when evaluating an employer’s health insurance options. Ask for the full Summary of Benefits and Coverage and run the math on annual premium share plus worst‑case out‑of‑pocket costs. Let’s take a minute to consider these things.

• Annual premium: This is what you pay for your health insurance policy. If you’re a W-2, your employer may pay for all or part of your (and your family’s) premium.
• Deductible: This is the amount you will pay before insurance kicks in. This amount resets to zero each year.
• Co-insurance: After you meet your deductible, co-insurance kicks in. Your policy will pay a certain percentage of in-network costs until you hit your out-of-pocket maximum.
• Out-of-pocket (OOP) maximums:
  • Individual OOP max = The ceiling for any one covered person.
  • Family OOP max = The combined ceiling for all members on the plan.
• Employer-funded HSA contribution: If you have an HSA, an employer may deposit money into your account as a benefit of employment.

Here’s how to calculate your worst-case OOP. This example uses an HSA with an employer contribution; however, if you didn’t have this benefit, then you’d remove it from the equation.

How a family OOP maximum works

Plan design

• Individual OOP max = $7,500
• Family OOP max = $15,000

Family expenses

• Early in the year, your spouse needs surgery and quickly hits the $7,500 individual cap. From that moment on, the plan pays 100% of your spouse’s covered, in‑network costs for the rest of the year.
• Mid‑year, your child breaks a leg. After deductibles and co-insurance, the child’s bills add another $5,000 to the family total.
• Later, you have an unexpected ER visit that costs $2,500 out of pocket.

Running total

• Spouse = $7,500
• Child =  $5,000
• You = $2,500
• Family OOP spend: $15,000

Because the combined expenses now equal the $15,000 family cap, the plan begins paying 100% of covered, in‑network costs for everyone in your household for the remainder of the year. If only one family member had expenses, your exposure would have stopped at $7,500 (at the individual OOP max), but with multiple members needing care, you had to be prepared for the higher $15,000 worst‑case spend.

Know what counts towards your out-of-pocket maximum. Most in‑network deductibles, co-insurance, and copays apply, but out‑of‑network charges often do not. If you live near only one hospital, make sure it’s in‑network. Otherwise, the “max” isn’t really a ceiling.

Finally, look at soft benefits, such as employer‑funded HSAs, mental health coverage, fertility services, or tiered pharmacy programs. Those can save (or cost) thousands over the life of a contract.

🔍 APEX Insights

• Price the “all‑in” number, not just the premium. Add your annual payroll deduction to the plan’s out‑of‑pocket maximum; that total is the true worst‑case cost you must be ready to cover.
• If you’re selecting a plan as a 1099, match the network to your life, not your ZIP code. Confirm that the plan’s in‑network hospitals include the regional trauma center, children’s hospital, and any specialists you’d actually use. If the right facility is out-of-network, saving a few dollars on premiums is pointless.

Disability Insurance (Short- and Long-Term)

Disability insurance provides income protection if you’re unable to work due to illness or injury.

Short-Term Disability (STD): Short-term disability is designed for common, high-probability events such as surgery, injury, or pregnancy complications. STD typically lasts from a few weeks to 6 months, with a short waiting period (often just a few days) before benefits begin. Short-term disability policies often replace 50–70% of your salary, helping cover expenses while you recover. STD policies are more expensive because they pay almost immediately after a claim is filed, which increases the insurer’s financial risk.

Long-Term Disability (LTD): Long-term disability is intended for serious or long-term medical conditions that prevent you from working for an extended period (often years or even until retirement). LTD benefits typically begin after a waiting period of 90–180 days and replace 50–60% of income. While many employers provide short-term disability as part of their benefits package, long-term disability coverage is often optional or self-funded, making it crucial for CRNAs to consider private LTD insurance to ensure financial security if they develop a condition that prevents them from working long term.

Tax Implications of Disability Insurance: Understand the tax implications of your policy. If the premiums are paid by your employer with pre-tax dollars, these benefits are typically taxed as regular income. Conversely, if you pay the premium with after-tax dollars, then the benefit won’t be subject to tax.

“Own-Occupation” vs. “Any-Occupation”: Own-occupation disability insurance pays benefits if you can’t work as a CRNA, even if you can work in another field with your disability. This ensures better income protection, since you’re not likely to match your CRNA salary doing any other type of work. Conversely, any-occupation policies only pay if you are unable to work in any job, meaning you could be denied benefits if you can still perform a lower-paying role outside of anesthesia.

🔍 APEX Insights

• If your employer pays for your disability insurance, check whether they report premiums as taxable income. This will help you understand the net benefit if you ever need it in the future.
• If your employer lacks its own-occupation policy, consider a private supplemental plan to protect your CRNA income. Choose a reputable insurer with coverage that defines disability specific to your clinical anesthesia role.

Malpractice Insurance

There are two types of malpractice insurance, and they can have profound implications spanning your entire career.

Claims-Made Policies: Only cover incidents reported while the policy is active (i.e., when working for your current employer). If you leave the job, you’ll need to purchase tail coverage to protect yourself from future claims, otherwise you risk being uninsured for previous cases. Not all employers will provide tail coverage if you leave, and those that do may require you to work for them for a specified period before offering this benefit.

Occurrence-Based Policies: Cover incidents that happened while you were employed, regardless of when a claim is filed. These policies are more expensive but eliminate the need for tail coverage.

Tail Coverage: If you have a claims-made policy, tail coverage ensures you’re protected after leaving the job for another job or retirement. Without it, you could suffer a significant financial burden if you leave your job and someone files a claim against you. One key issue is that tail coverage is expensive, costing up to three times (or more) of your current malpractice premium. Some states require you to carry tail coverage, so you should understand the laws for all states where you maintain your CRNA license.

Nose Coverage: While tail coverage protects you after you leave a job with a claims‑made policy, nose coverage (sometimes called “prior‑acts” coverage) protects you before your new policy’s start date. When you switch employers, the incoming group can add a nose endorsement that backdates your new claims‑made policy to cover any incidents that occurred under your previous employer but haven’t yet been reported. In effect, nose coverage shifts the liability gap from the old job to the new policy, eliminating the need to buy expensive tail coverage.

If the new employer provides nose coverage, you may be able to walk away from your old job without purchasing tail insurance, saving you thousands! However, many groups refuse to assume that risk, so nose coverage is less common than tail.

Coverage Limits: Your policy will list two limits of liability:

• First limit of liability: The amount the insurance company will pay for any one claim.
• Second limit of liability: The amount the insurance company will pay in total during the coverage period (typically annually).

Standard coverage options are typically $1M per claim (first limit) and $3M annually (second limit), but requirements vary by state.

While some CRNAs opt to get the minimum required by the state, others elect higher coverage. Some will argue that higher coverage limits or coverage separate from your employer that is covering you will make you appear to have “deep pockets” and, thus, a bigger target by attorneys trying to maximize their client’s benefit.

If your employer is paying for coverage, keep in mind that if a claim is filed, your employer may not have your best interests in mind. Understand if you need to consent before your claim is settled (vs. taking it to trial). Often, it’s in the employer’s best interest to settle, even if this isn’t what’s best for the CRNA.

🔍 APEX Insights

• Always ask if the employer provides tail coverage or if you’ll need to purchase it yourself. If they don’t cover it, negotiate a higher salary to offset the cost.
• Ask if tail coverage is fully paid, partially paid, or employee-funded, and get it in writing before signing a contract.
• Never assume your new policy automatically covers prior acts. Without a nose endorsement or tail coverage, you could be personally liable for past cases.
• How does the malpractice policy cover expenses incurred while defending you? Some policies pay on top of your limits, while others deduct these costs from your limits.
• The best policy is one that requires your consent before a claim is settled out of court.

Paid Time Off

Time is Money: Paid time off (PTO) is essentially part of your salary. It represents paid hours you’re not working, so it has real financial value. A job with more PTO may have a lower base salary but could be worth more overall when factoring in the paid time off.

For example, a job with a base salary of $200,000 with 8 weeks of PTO is financially equivalent to a job that pays $218,182 with only 4 weeks of PTO. In both cases, the total compensation (salary + PTO value) equals $236,364, proving that more PTO can offset a lower base salary in overall earnings.

Accrual vs. Lump-Sum: Accrual-based PTO means you’ll receive PTO throughout the year (e.g., 1.5 days per month). If you leave before the year ends, you may not get your full PTO allotment. Lump-sum PTO means you’ll get your annual PTO upfront, meaning you can use it anytime. However, some policies require repayment if you leave before a certain period.

Rollover PTO: Some employers allow unused PTO to carry over into the next year, while others limit how much can be retained.

Use-It-or-Lose-It: If unused PTO expires at the end of the year, the benefit is lost if you can’t take time off.

PTO Buyout: Some employers allow cashing out unused PTO upon termination or at the end of the year.

Holidays, Sick Leave, and Separate PTO Banks: Some employers bundle vacation, sick leave, and personal days into one PTO bank, while others keep them separate. A job with 6 weeks of PTO might be misleading if it includes sick leave and holidays.

🔍 APEX Insights

• Get clear on your values and priorities (time or money) as you evaluate job offers.
• PTO is only good if you can actually use it when you want. Ask the employer about their process of approving PTO, especially around times of high demand (e.g., holidays, spring break).

Sign-On Bonus

Contract Commitment: Nearly all sign-on bonuses require a commitment to work for the company for a specified period (typically 1–3 years). Leaving early may require full or partial repayment (this is called a clawback clause). Before accepting a sign-on bonus, get clear on what happens if your employment is terminated (either by you or your employer) if you don’t serve the full term. You should have this in writing.

Payout Timing: Bonuses may be paid upfront, in installments, or at contract completion. Delayed payouts reduce their immediate value. Also, consider how the timing of installments affects your tax bracket for the year. For instance, you’ll keep more of a $50,000 bonus when you have no or little other taxable income for the year (i.e., you’re in your senior year, and you’ll start your job next year). As always, consult your tax advisor to discuss your unique situation. If you spend the money, you’ll be locked into satisfying your commitment term if you don’t have another way to return the payment to your employer.

Market Demand: Employers offer sign-on bonuses out of need (even if they truly are great people), so you’re less likely to receive one in highly desirable locations, where the market is more likely to be saturated. Adjust your expectations accordingly.

🔍 APEX Insights

• Negotiate payout terms to receive at least 50% of the bonus upfront.
• Read the fine print to understand the clawback clause and whether the bonus is guaranteed if the company is acquired or terminates you without cause (e.g., the anesthesia group loses its contract with your hospital).
• Reduce your expectations of a signing bonus in oversaturated or highly desirable markets.

Retention Bonus

Like a sign-on bonus, understand the length of service required, as it may require you to commit for several years before you receive your bonus.

CRNA turnover average is ~9–12% annually. High turnover workplaces may use retention bonuses as a Band-Aid solution to keep providers.

🔍 APEX Insights

• A big retention bonus may signal ongoing workplace issues. If staff turnover is high, ask why and what else is being done to improve retention.
• Factor in base salary. A lower salary with a big retention bonus may not be a great deal long term.

Professional Development and Mobility Benefits

Continuing Education Funds: Most employers set an annual dollar amount (often $1,000–3,000) to cover conference fees, online courses, certifications, travel, and lodging. Clarify whether the allowance renews each calendar year, rolls over, disappears if unused, and what happens if you spend it and leave your job before the end of the year. Ask if CE days are separate from PTO. Burning vacation time to attend a conference dilutes the value of the benefit.

Student Loan Repayment: Hospitals in high‑need or rural areas frequently offer fixed annual payments or lump‑sum forgiveness in exchange for a multi‑year service commitment. Confirm the total dollar amount, the payout schedule, and any clawback clause if you leave early. For CRNAs working at non‑profit facilities, pair employer repayment with the federal Public Service Loan Forgiveness program to maximize savings.

Tuition Assistance: If you plan to pursue a DNP, MBA, or leadership certificate, tuition assistance can offset tens of thousands in future costs. Some organizations reimburse per credit hour, while others pay a percentage of tuition after you complete the course with a minimum grade. Verify whether the assistance covers only degree programs or also specialty courses like ultrasound‑guided regional workshops (this might be covered by your CE funds, instead).

Relocation Assistance: Moving packages can include professional movers, airfare, temporary housing, and lump‑sum stipends for incidentals. Get the offer in writing. Is it paid upfront or reimbursed? Most packages carry a repayment clause if you quit within a defined period of time, so weigh the benefit against your long‑term commitment.

🔍 APEX Insights

• Stack benefits. Use CE funds to attend a conference that also satisfies tuition requirements for an advanced degree. Double dipping may be allowed if expenses fall within policy limits.
• Student loan repayment and relocation assistance may be reported as taxable income unless specifically structured otherwise. Build the tax hit into your cash‑flow plan before you sign.

Final Thoughts

Total compensation is a puzzle with many interlocking pieces. Base pay, benefits, bonuses, insurance, and time off each tell part of the story. Use this guide to run the numbers, weigh the lifestyle impact, and spot red flags before you sign. When you approach every offer with a clear grasp of the market and a firm handle on your priorities, you turn the negotiation into a data‑driven conversation: one that positions you, not the employer, in the driver’s seat.

Before we get to the possibility of whole eye transplants, the story needs to begin many years ago. Early experiments in organ transplantation, often quite gruesome in their design, began in animals long before the first human kidney transplant in 1939 by the Russian Yurii Voronoy. Like Victor Frankenstein, the protagonist in Shelly’s epic story of a reanimated 8-foot creature cobbled together with organs and tissues of the deceased, Voronoy placed a deceased person’s kidney, hoping for a miracle, into a recipient who died two days later. Then, in 1953, a Parisian mother donated a kidney to her 16-year-old son, the first living human-to-human transplant, which proved only briefly successful.

A milestone was reached in 1954 when Dr. Joseph Murray transplanted the kidney of a brother into his identical twin in Boston, MA. The recipient survived, as did his fully functional transplanted kidney, for eight years until he died of causes unrelated to his relocated organ. Murray was ultimately awarded a Nobel Prize for his pioneering work in the domain of organ transplantation.

It wasn’t until 1962 that genetically unrelated donor-to-recipient transplantation occurred under the protective shielding of immunosuppressive agents. Today, the picture is bright, given the evolution of immunosuppressive agents, surgical techniques, anesthetic advances, and careful matching of the donor-recipient using national databases and artificial intelligence tools. The most recent data reveals a 5-year organ and patient survival rate of 80% for kidney and liver transplants. Survival for decades is not uncommon. Today, organ transplants of many different organs are performed routinely and with enormous success.

When need and human ingenuity intersected

In 2005, a woman in France was severely disfigured by a dog attack, and surgeons restored her face using a transplanted nose and mouth from a recently deceased donor—demonstrating the potential for both aesthetic and functional recovery in extremely complex procedures. Ethical considerations, rejection potential, quality of life issues, and cost were aggressively discussed in the literature and at national conferences. The patient lived for 11 years, eventually succumbing to lung cancer.

As with Murray’s success with the kidney, this first partial face transplant catalyzed international interest. A 2024 paper in JAMA, reported that 50 face transplants have been performed, or at least formally reported, in 18 academic surgical centers from 11 countries worldwide. As of this writing, the transplants include 39 men and 9 women, the majority having experienced a life-threatening trauma where options for restoration were either not working out as hoped or simply unavailable. One patient’s transplant failed and the procedure was repeated, thus bringing the total to 50 actual transplantations. Marshaled on by human ingenuity and technological advances, whole face transplantation evolved with bone reconstruction and innovations in facial surface treatments. Like outcomes with kidney and liver procedures, the report in JAMA cites survival rates for 5- and 10-year facial transplantation of 85 and 74%, respectively.

Transplantation of an entire eye?

Complete loss of the eye can result from catastrophic injury or severe pathophysiological conditions. For a long time, the immense anatomical and physiological challenges associated with whole-eye transplantation have discouraged serious consideration of the procedure. A formal consensus statement by the U.S. National Eye Institute Advisory Council in 1978 read that “… any effort to transplant a mammalian eye is doomed to failure…” citing the cutting of nerves, trauma to axons, inability to ensure blood flow, and immune system issues.

Undeterred by even the most knowledgeable skeptics, researchers have now reported a truly astonishing procedure in a recent JAMA article. With an enormous amount of research, innovation, and preparation leading up to the procedure, a team of clinicians from ophthalmology, radiology, plastic surgery, and anesthesiology at New York University performed a 21-hour surgery, implementing innovations not previously employed in a living person.

Microsurgical techniques and instrumentation, along with stem cells injected into the optic nerve, resulted in a combined nearly full-face and eye transplant in a victim of a catastrophic high-voltage electrical injury. Over a year later, his face has maintained remarkable form and function, and the eye, while not restoring vision, maintained its baseline geometry, normal intraocular pressure, blood supply, and some retinal structure. Evoked potentials and functional MRI studies demonstrate some response of the retina and the visual cortex to light but not the ability of the brain to perceive it. The figure shows a “drone view” of the operative infrastructure, harvested from a deceased donor whose tissues were kept viable.

The challenges in whole eye transplantation are extraordinary, and this case represents a truly monumental first step, demonstrating a potential pathway for future restoration. The JAMA report of an entire eye being transplanted with a nearly full facial transplant reveals that allograft survival of a whole eye without rejection, and with some evidence of the retina responding to light, is promising. The anesthetic care challenges involved in such a procedure are prodigious and are chronicled in detail by those involved in the case. CRNAs involved in such cases provide care that spans all the perioperative phases and play an enormously important role in optimizing the procedure’s chances of achieving a favorable outcome.

The renowned poet Robert Frost penned his beautiful poem, Stopping by Woods on a Snowy Evening, where he metaphorically speaks to life, death, the tug between optimism and pessimism, and the journey of life that we all deal with. In the final stanza of his poem, he wrote,

The woods are lovely, dark and deep,
But I have promises to keep,
And miles to go before I sleep,
And miles to go before I sleep.

CRNAs care for patients, often at the most difficult and stressful times in their patients’ lives. We become part of their life’s journey and, in that role, assume a promise to provide exquisite and humanistic care that can prove challenging, if not downright daunting. It’s what we do, offering hope and promise to those we care for, even if that journey ahead is long, dark, and deep.

As CRNAs ourselves, we understand the challenge of fitting CRNA continuing education credits into your busy schedule. When you’re ready, we’re here to help.

Burnout is pertinent among healthcare professionals. According to the CDC, nearly half of health workers reported feeling burned out in 2022. That same year, the American Association of Nurse Anesthesiology (AANA) reported that 80% of Certified Registered Nurse Anesthetists (CRNAs) declared high levels of disengagement and exhaustion.

The statistics are a daunting reality and one of the many reasons CRNA work-life balance is of the utmost importance. As a healthcare professional, you deserve to care for yourself as much as you care for your patients.

We’re here to help. Learn how to create your ideal work-life balance with the guidance below.

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Table of Contents

• A typical work schedule for CRNAs
• Factors that influence CRNA work-life balance
• 5 tips on maintaining a healthy work-life balance as a CRNA
• How APEX Anesthesia can improve your work-life balance

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A typical work schedule for CRNAs

CRNA work schedules are highly variable with some finding employment as part-time or locum tenens. For full-time positions, the schedule often spans 40 to 60 hours per week, typically over four to five days. Additionally, holiday, weekend, and overtime shifts, which can exceed 12 hours, may be required, depending on the employment setting.

When work occupies most of your week, it’s challenging to make time for yourself. Let’s discuss the influential factors impacting CRNA work-life balance below.

Factors that influence CRNA work-life balance

The U.S. Department of Health and Human Services states that excessive workloads, administrative burdens, limited say in scheduling, and lack of organizational support are common causes of health worker burnout. These issues, alongside cultural, financial, and societal pressures, create obstacles when fostering a healthy work-life balance.

Financial stress

Financial stress is burdensome no matter the circumstance. The pressure of working overtime to meet economic needs and the strain of an unmanageable workload typically lead to declining work performance. In fact, 44% of U.S. employees reported personal finance issues as a distraction at work in 2023.

Workload

Work overload is a strong contributing factor to CRNA burnout. A study published in the Journal of General Internal Medicine reported that healthcare workers undergoing work overload had up to 2.9 times the risk of experiencing burnout.

Work location and environment

Long commutes have been associated with poorer mental health and may present a challenge in balancing your professional and personal obligations. A negative workplace environment may also instill stress and unease.

Stress

You’re not alone if you’re experiencing high stress levels at work—work issues account for 49% of stressors among healthcare workers. If you fall into this common category, the AANA provides suggestions for recognizing and managing stress.

5 tips on maintaining a healthy work-life balance as a CRNA

Learn how to avoid CRNA burnout and improve your well-being with the following tips.

Change a factor

We know it’s easier said than done—some factors are simply beyond your control. But you can proactively manage your outlook and maximize existing opportunities. For example, try utilizing long commutes to engage with resources such as audiobooks or podcasts. Implementing small changes helps improve the commuting experience, positively impacting your mental health.

Practice mindfulness

Mindfulness techniques alleviate stress and increase focus. Methods vary by individual preference, but some standard practices are breathing exercises, paying attention to the five senses, and monitoring your internal dialogue.

Quality time with friends and family

Maintaining strong connections with family and friends is highly beneficial for your well-being. Psychological research demonstrates that social connections help individuals lead a long, healthy life and reduce the chances of mental health issues.

Schedule me time

Life as a CRNA should not be exclusively devoted to work. It is highly recommended to allocate time for self-care and participate in activities that alleviate stress, such as exercise. Furthermore, the AANA suggests using time off to combat burnout.

Set healthy boundaries

The desire to be a high-performing CRNA is understandable, but the benefits do not always outweigh the costs. Maintaining clear boundaries between your professional and personal life is essential. Exercise caution when accepting additional responsibilities, as extended work hours often lead to fatigue, which harms your physical health and causes patient safety issues.

How APEX Anesthesia can improve your work-life balance

APEX Anesthesia was created by CRNAs for CRNAs. We understand better than anyone else how busy you are balancing life and work. That’s why we offer CRNA continuing education (CE) online!

Use a desktop or mobile device with APEX to learn anytime, anywhere. Our CE courses are convenient and easy to navigate, helping you earn Class A credits at your own pace and be the most knowledgeable CRNA you can be.

We’ve helped more than 50,000 students and nurse anesthetists. And we can help you, too. Explore our CE bundles and pick the right fit for you.

We knew and greatly admired Dr. John Nagelhout, PhD, CRNA, FAAN, a CRNA whose life of teaching, research, clinical work, and program leadership eclipsed others of his generation. He was revered locally by his students and fellow colleagues and known widely as the principal architect of the book Nurse Anesthesia, the definitive treatise of our specialty. To the tens of thousands who have turned to his text seeking clarity or illumination, the book took on a kind of mythology of its own, referred to by most not by the formal rubric cataloged by the Library of Congress but simply as “Nagelhout.”

John recently passed. He was an elegant, soft-spoken, and humble man whose genius was evident in many ways. Today, we wish to revisit just one of his many accomplishments – our personal way of immortalizing and giving thanks to the man. We must start with the Taiwanese banded krait, a serpent nearly unrivaled for its hellacious venom. This krait’s neurotoxin kills many in its Southeast Asia and Northern China habitats. The primary active ingredient in that venom is α-bungarotoxin (α-Btx), a proteinaceous concoction that binds irreversibly to the nicotinic acetylcholine receptor (nAChr). Like a heat-seeking missile whose sole task is to bore down with savage intensity onto an enemy plane’s heat signature, α-Btx does the same with exquisite biochemical precision as it seeks out the nAChr, blocking the action of ACh. An agonizing paralysis, respiratory failure, and death await the envenomated victim in near-time. John knew this.

The banded krait (Bungarus fasciatus)

John also knew that skeletal muscle saturated with α-Btx, irreversibly affixes itself to every Ach receptor on a one-to-one basis. Knowing the total amount of α-Btx that is exposed to the skeletal muscle (we will call that ‘α-Btx Total’), and armed with the knowledge that once attached to the nAChr, it stays put (we will call that ‘α-Btx Blocking’), then the amount of free α-Btx recovered (we will call that ‘α-Btx Recovered’) permits the precise quantification of the number of Ach receptors in the muscle sample. That is:

(α-Btx Total) – (α-Btx Blocking) = (α-Btx Recovered)
Now take that little equation a bit further:
(α-Btx Total) – (α-Btx Recovered) = (α-Btx Blocking)
Therefore,
(α-Btx Blocking) = quantification of the amount nAChr

The elegance of the pharmaco-biochemical rationale is foundational to a good deal of past, present, and likely future neuromuscular and neurophysiological research and clinical work. While we’ve simplified the complexities of its measurement, this gives us a good sense of how to determine the density of nAChr in skeletal muscle.

A life-saving observation

As entry-level students in the specialty, we all learned that the administration of succinylcholine to a burn patient (among a few other scenarios as well) could produce nearly instantaneous cardiac arrest due to profound hyperkalemia. Before John’s time, the mechanism was poorly understood, and several hypotheses were proposed, but the science had not kept up.

We contacted a close CRNA colleague and friend of John’s, Valdor Haglund, who worked with him on various clinical and research activities. He shared details about a patient John and other colleagues cared for. The unfortunate man experienced devastating 2nd and 3rd-degree burns over 80-90% of his body and was tended to in the institution’s burn unit for many procedures over a period of many months. John and colleagues designed a study to address their hypothesis, and with full consent, while the patient was under anesthesia for regular burn debridement and grafting procedures, skeletal muscle tissue samples were harvested and exposed to α-Btx. A remarkable observation was made, which lives in infamy and provides a mechanistic explanation that has prevented many deaths, warning us of the perils of using succinylcholine in burn-injured patients. An explanation directly traced back to John.

Here, published with permission, is the original graph from John’s momentous publication in the journal Anesthesiology decades ago. This graph clearly and quantitatively demonstrates the time course of the proliferation of extra-junctional nAChr in a burn patient.

With kind permission. Anesthesiology. September, 1994;81:A1089.

The nAChr in skeletal muscle is usually positioned strategically at the edges of the junctional folds at the neuromuscular junction on the postsynaptic side. Following ACh activation, Na+ and K+ diffusion results in depolarization, permitting muscular contraction in a graded manner. This gradation allows us to precisely quantify skeletal muscle activation, permitting us to lightly brush a baby’s cheek or heave a heavy load of dirt into a wheel barrel. Despite a high intracellular K+ concentration, what is usually liberated into the serum with succinylcholine administration is physiologically insignificant. However, with extrajunctional proliferation of nAChr, creating new “spigots” on the muscle cell membrane for K+ to emerge, serum K+ can rise dramatically and potentially catastrophically. We can look to John for illuminating the precise mechanism for why we must avoid succinylcholine in scenarios of extrajunctional spread of nAChr in burn injury and other scenarios like paralysis, immobilization, and certain myopathies. Thank you, John.

A life that inspired others

John may have been the first CRNA to obtain a PhD in a basic science, who then marshaled that knowledge and skill set to inform the evidence-based practice of anesthesiology using the tools of science guided by a keen intellect. His students and contemporaries lauded him as a polymath, and for good reason. To this day, few can put forth a comparably eclectic and accomplished curriculum vitae of professional and life experience.

Rest in peace, John Nagelhout. We are all grateful for what you accomplished and your legacy of teaching, research, clinical work, and program leadership, which continues to inspire many of us.

Understanding the requirements for Certified Registered Nurse Anesthetist (CRNA) recertification doesn’t have to be so challenging. Created by the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA), recertification ensures CRNAs remain at the appropriate skill level to administer safe and proper care.

If you want help understanding the steps to take toward CRNA recertification, you’re not alone. Let us walk you through the requirements!

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Table of Contents

• The Maintaining Anesthesia Certification (MAC) Program
• The Continued Professional Certification (CPC) Program
• CPC glossary: What you need to know about the requirements
• How to earn CRNA continuing education credits

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The NBCRNA offers two distinct programs to maintain your CRNA certification: the Continued Professional Certification (CPC) Program, and the newly introduced Maintaining Anesthesia Certification (MAC) Program. However, it’s important to note that the CPC Program will be sunsetting on August 1, 2025. After this date, the MAC Program will be the sole pathway for CRNA recertification. We’ll explore both options, so you’ll know exactly what you need to recertify regardless of the program you’re in.

The Maintaining Anesthesia Certification (MAC) Program

NBCRNA recertification requirements have evolved. The new MAC Program will replace the CPC Program, and all CRNAs will be enrolled in the program by 2026.

The MAC Program simplifies the recertification process; it’s a consistent 4-year cycle with the same requirements every cycle!

In the MAC Program, you’ll complete:

• MAC Ed (A new name for 60 Class A credits – see details in the Class A Credits section above)
• MAC Dev (A new name for 40 Class B credits – see details in the Class B Credits section above)
• MAC Check (Replaces the CPCA)

Although CPC Core Modules aren’t required for the MAC Program, they’re an efficient way to stay at the forefront of anesthesia practice while earning Class A credits.

What is the MAC Check?

Available on computers and mobile devices, the MAC Check is a longitudinal, quarterly assessment that tracks your progress and performance over a longer period of time.

The MAC Program is divided into 16 quarters. You’ll complete the MAC Check in 13 of the first 15 quarters, and you’ll get to pick 2 quarters where you can skip the MAC Check. Also, you won’t have to complete the MAC Check in your 16th quarter.

How does the MAC Check work?

In your 1st quarter, you’ll complete 25 multiple-choice and multi-select questions. Each question is timed for 1 minute, and you can bank unused time and apply it to subsequent questions. The platform will provide immediate feedback after each question, including the rationale for correct answers. You’ll also be able to view areas for improvement to guide your CE and development activities. In subsequent quarters, you’ll complete up to 30 questions.

If you answer a question incorrectly, you’ll encounter it again in a subsequent quarter. Re-administered questions make up to 5 incorrectly answered questions in each quarter, totaling between 25 to 30 questions.

Once you have completed 4 Mac Check quarters, you’ll receive preliminary feedback to see where you stand in regards to the performance standard. After the 13th knowledge check is completed, you’ll receive a final measurement for that cycle.

Explore the MAC sample to familiarize yourself with the new platform.

What happens if I “fail”?

If you don’t meet the performance standard, you must earn additional 5 MAC Ed (Class A) credits per domain where you don’t meet the passing standard. These credits are in addition to your 60 Class A credit requirement. Like the CPCA, MAC Check is not a pass/fail assessment, and you will not lose your certification so long as you complete the remediation requirements prescribed by the NBCRNA. However, completion of the MAC Check is required.

For more information on credit requirements based on MAC Check performance, please read What Every CRNA Needs to Know about the MAC Program.

The Continued Professional Certification (CPC) Program

The CRNA recertification program you may be most familiar with is the CPC Program.
The CPC Program consists of two 4-year cycles, totaling 8 years.

In the first 4-year cycle, CRNAs complete:

• 60 Class A credits
• 40 Class B credits
• CPC Core Modules
  • Airway Management
  • Applied Clinical Pharmacology
  • Physiology/Pathophysiology
  • Anesthesia Equipment and Technology

In the second 4-year cycle, CRNAs complete:

• 60 Class A credits
• 40 Class B credits
• CPC Core Modules
  • Airway Management
  • Applied Clinical Pharmacology
  • Physiology/Pathophysiology
  • Anesthesia Equipment and Technology
• CPC Assessment

Each cycle requires a midpoint check-in where you must validate your state licensure, confirm active practice, and update your contact information with the NBCRNA.

At the end of each 4-year cycle, you’ll log into the NBCRNA portal to complete your application and pay the fee, provide documentation of current licensure, demonstrate you’ve completed the CPC Program, and submit a record of anesthesia practice.

CPC glossary: What you need to know about the requirements

Class A Credits

Class A credits can be earned by completing continuing education courses, webinars, and Core Modules. They must have prior approval by the American Association of Nurse Anesthesiology (AANA) and include an assessment.

Class B Credits

Class B credits can be earned by various methods including conducting research, teaching, publishing, and more. Check out our Guide on CRNA Class B Credits to learn more. You must keep an accurate record of these credits as they don’t require prior AANA approval or an assessment. You can also earn additional Class A credits after completing the required 60 to satisfy your Class B requirements.

CPC Core Modules

The CPC Core Modules are specialized Class A credits that teach up-to-date, evidence-based practice trends in the four domains of CRNA practice. Although CPC Core Modules aren’t required for the MAC Program, they’re an efficient way to stay at the forefront of anesthesia practice while earning Class A credits.

CPC Assessment (CPCA)

The CPCA is a three-hour, 150-question assessment. You must complete the assessment for CRNA recertification, but it is not a pass-fail exam. It’s a tool to measure your knowledge, and your results will help you identify focus areas for additional study.

How to earn CRNA continuing education credits

Meeting your CRNA continuing education requirements is simple with the right resources. Whether you’re in the CPC Program or MAC Program, APEX offers convenient, cost-efficient bundles to support your recertification.

As CRNAs, we understand how challenging it can be to fit CRNA continuing education credits into your busy schedule. That’s why our online courses are available anytime, anywhere, and award Class A credits, meeting the CPC Program Standards as well as the MAC Ed and MAC Dev requirements.

 

We’re here to help you on your CRNA recertification journey. Choose a bundle that works best for you today.

Before we talk about the future of anesthesia, let’s look back at how things change. Change can come slowly or with astonishing suddenness. If you were training or practicing—or know of someone who was—in the early 1980s, the anesthetic recipe might very have involved:

• Thiopental for induction
• Halothane and nitrous oxide for maintenance
• Meperidine, morphine, or fentanyl for analgesia
• Laryngoscope
• Innovar (a fixed combo of fentanyl & droperidol)
• Succinylcholine, curare, or pancuronium for relaxation
• Manually inflated BP cuff, ECG, nerve stimulator (maybe)
• Pneumatic-powered anesthesia machine
• Black rubber breathing circuit and Ohio mask
• Pen and paper charting

While a few items have survived the cut, consider what’s missing from the list, interventions that are now staples of contemporary practice. Today we have sevoflurane, propofol, rocuronium, dexmedetomidine, oscillometric BP, pulse oximeters, infrared agent analyzers for carbon dioxide and our potent inhaled agents, accelerometers, video laryngoscopes, and ultrasound devices. You get the message, change is a constant.

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Table of Contents

• Star Wars, Doug Quaid, Tony Stark, and many others!
• Besides being entertaining, what does all that have to do with us?
• Predicting what will (might) happen to our patients
• Important questions to ask with no easy answers
• The past is what you’ve done – the future is what you have learned

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The acceleration of technology and knowledge in our specialty continually creates—at an astonishing pace—additive and synergistic applications of innovative devices, new approaches, and how we interact with our patients. Throw in a large dose of human inventiveness, entrepreneurial spirit, industrial competitiveness, open-minded regulators, and what’s happening in popular opinion, what seems like futuristic thinking may already be knocking on our door.

Star Wars, Doug Quaid, Tony Stark, and many others!

The motion picture industry can conjure magical moments that later appear in real life. We love films, and with the theme of visionary technology, consider just a few of our favorites:

• Video calling is displayed in the 1927 film Metropolis.
• One of the “smartest” sci-films of all time, The Day the Earth Stood Still. This 1951 film’s robot, Gort, may be the first true artificial Intelligence (AI) in the history of motion pictures.
• The 1968 film 2001: A Space Odyssey depicted a fully functional tablet and machine learning (ML).
• Dick Tracy’s smart-watch, in 1946, ok, not a film, but we like comic strips too!
• Autonomous cars, 1990, in Total Recall.
• And oh, so many more!!!

Now think of the original Star Wars, where the ever-resourceful R2-D2 creates a hologram of Princess Leia requesting help from Obi-Wan Kenobi. And what about the first Total Recall film, where Doug Quaid (future governor of California Arnold Schwarzenegger!!) uses his watch to project a full-body holographic image of himself into a previously empty space?

Then we have Tony Stark (Robert Downey, Jr.) in Iron Man 2, where holograms are extensively used, providing him with superhuman capacities to invent, analyze, and utilize them as centerpieces in the film.

Besides being entertaining, what does all that have to do with us?

The technology company IKIN has created remarkable 3D holographic devices that project holographic content in color and ambient light in a large format. Their approach allows the human side of the interface to enlarge and manipulate projection elements without the need for goggles. Euclideon, an Australian tech company, uses a similar approach. The RYZ Holographic System™ seeks to optimize and maximize the technology’s applications.

There is no shortage of interest in the field, with companies with intriguing names like Vivid Q, Haloxica, HyperVsn, and many others aggressively developing their approaches. The company Humane, an AI-intense entrepreneurial effort, has patented technologies that use laser projections, three-dimensional cameras, and biosensors. And let’s not forget what Apple, Amazon, Google, Microsoft, NVIDIA, Tesla, and Meta may be up to! Many of these technologies have yet-to-be-defined targets, and they are quietly pursuing applications of these and offspring that may replace the computers, smartphones, and smartwatches we currently use.

Exactly how this will play out in healthcare, specifically in the CRNAs’ milieu where the display, analysis, and management of physiological data are key to what we do, requires clarification. But what we see in movies, where holographic images and icons hang in the air for protagonists to manipulate—well, that “fantasy” may be a lot closer to our reality than we might think.

Predicting what will (might) happen to our patients

It’s not all speculative science fiction that is shaping our future workplace. In some ways, the future of anesthesia has already arrived with what may best be characterized as a punctuated evolution. Many new initiatives are focusing on innovative monitoring that guides clinical decisions to:

• Maintain or improve brain health
• Avoid failure-to-rescue (FTR)
• Lower the risk of acute kidney injury
• Reduce MINS (myocardial injury after noncardiac surgery)
• Lessen postop opioid use disorder
• Reduce the risk of cardiac arrest

A batch of approaches are in the works or already with us termed medical early warning systems (MEWS) designed to assist us in recognizing warning signs of a deteriorating patient before human identification. The general view is that these will become commonplace throughout our specialty, not only in the OR, but also in the PACU, ICU, and postop hospital wards. MEWS can warn us about the implications of what might only be a subtle, easily overlooked change in a patient’s condition and predict conditions like hypoxemia, hypotension, embolic issues, metabolic disturbances, and neurological insult. This is based on exquisite, real-time monitoring of key physiological parameters with ongoing AI or ML integration.

The Edwards’ Hypotension Prediction Index is an existing system with a research and clinical track record. It uses machine learning to predict intraoperative hypotension before it happens.

This is complicated stuff. It is not just about measuring HR and BP but rather using biosensors to collect and integrate data that might include breathing patterns, cognitive function, genetics, body position, stress level, infection risk, level of consciousness, biomolecules, and other factors limited only by our imagination.

A British Journal of Anaesthesia paper recently demonstrated an AI platform’s keen ability to use intraop data analysis to predict postop hypotension. Another fascinating paper in Nature Reviews Bioengineering, revealed the uncanny ability of an AI tool called ‘Prescience,’ to forewarn of hypoxemia. The key theme in all these technologies is looking beyond the immediate at what may be coming.

Consider that there is a well-recognized 10-30% in-hospital risk of patients experiencing dangerous postop complications. Continuous postop surveillance monitoring systems, aided by AI, can decrease the risk of failure-to-rescue events by predicting which patients might deteriorate before clinical evidence appears. Integrating AI and ML with existing monitoring strategies can detect patterns of subtle, nuanced changes in patient parameters that providers will likely overlook.

Important questions to ask with no easy answers

Let’s finish by asking questions relevant to CRNAs and all healthcare workers. While we do not presume to have all the answers, we hope to get you thinking about some of the implications of new technologies.

What potential does healthcare technology have for patient care?

It will be revolutionary as AI allows us to access, analyze, and apply superhuman amounts of data to diagnostic and healthcare decision-making at speeds, with certainty (errorless), and at lower cost than what a human alone can muster.

What limits are envisioned for healthcare technology?

Besides immediate application to patients, AI, and virtual reality will be increasingly used in teaching, diagnostics, problem-solving, and administrative tasks. That is, they have no limits. Biosensor technology is rapidly growing. Miniaturized autonomous sensors will be self-learning and never need maintenance, as they will be self-calibrating.

What are the challenges that new technologies create?

Data security and integrating new technology with that currently used will pose problems. As many of us have seen with EMRs, its incorporation into the institution’s existing platforms is rarely seamless. Also, who pays for these technologies, and what are their environmental impacts?

The past is what you’ve done – the future of anesthesia is what you have learned

Consider the original anesthetic recipe we presented at the start. In the early 1980s, the risk of dying from anesthesia was 1:10,000; today, it’s almost unmeasurable in ASA 1-3 patients. Advances in technology play an enormous role in enhancing the safety of our work.

Allow us to speculate. In the not-too-distant future, you may voice activate a hologram powered by AI to consult with an expert in real-time as you care for a patient. A synthesis of data gleaned from myriad biosensors displayed in a user-friendly interface will be available to you. With finger or voice activation, you have immediate access to all the world’s published information relevant to the patient you care for.

This all may be closer than you can imagine. Yet that’s just it, as our imagination is the driver behind all of what is coming.

As CRNAs ourselves, we understand the challenge of fitting CRNA continuing education credits into your busy schedule. When you’re ready, we’re here to help.

If you’re a nurse anesthetist in the Continued Professional Certification (CPC) or Maintaining Anesthesia Certification (MAC) Program, you’re in the right place. Regardless of the program you’re in, the National Board of Certification & Recertification for Nurse Anesthetists (NBCRNA) requires you to complete 100 hours of continuing education and professional development, including 60 Class A credits and 40 Class B credits. We understand it can be difficult to earn these credits with a busy lifestyle. That’s why we’ve created a one-stop shop for everything you need to know about CRNA Class B credits.

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Table of Contents

• • What are Class B credits?
  • How to earn Class B credits
  • Class B credit documentation
  • Submitting Class B Credits

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What are Class B credits?

Class B credits are a type of continuing education nurse anesthetists are required to earn for recertification. Unlike Class A credits, Class B credits don’t require AANA approval, have an assessment, or undergo a prior-approval process. Whether you are enrolled in the CPC or MAC program, you must earn 40 Class B credits per four-year cycle.

How to earn Class B credits

Qualifying activities for CRNA Class B credits must meet one of the following criteria:

• Enhance knowledge of anesthesia practice
• Support patient safety
• Foster an understanding of the broader healthcare environment

From teaching to mission trips, there are various activities that qualify as Class B credits. They include:

1. Class A: Assessed Continuing Education (CE)
2. Subspecialty or Austere Clinical Practice Role
3. Non-Prior Approved and/or Non-Assessed CE
4. Integration of a New Clinical Practice Technique
5. Academic Credits
6. Service – Seated or Elected Activity
7. Presentations
8. Service – Mission or Diplomacy Activity
9. Publication – Book
10. Service – Advocacy or Public Relations Activity
11. Publication – Chapter
12. Life Support Courses
13. Publication – Peer Reviewed
14. Quality Improvement Initiatives
15. Publication – Grant
16. Discovery
17. Teaching in the Clinical Setting
18. Research or Practice Inquiry Project – Member of Committee or Team
19. Clinical Administrative
20. Research or Practice Inquiry Project – Principal Investigator or Individual Completion of Dissertation, Thesis, or DNP/DNAP Project

Earning Class B credits from Class A credits

If you earn over the required number of 60 Class A credits, you can roll those over to count towards your Class B requirement. With APEX Anesthesia Review, you can fit earning Class A and Class B credits into your busy schedule. Get everything you need for your 4-year cycle with one of our CRNA continuing education bundles, which include hundreds of AANA-approved Class A credits delivered in multiple methods and are more than enough to cover your Class B credits requirement.

Class B credit documentation

Each Class B category has a required audit document you’ll need to keep on file. There is also a category reporting document you can download. View the NCRNA Class B table to see the corresponding documents to keep a record of.

Maintaining your activity records is essential for reporting Class B credits in your credential renewal. Even though the NBCRNA has an honor system, they may still audit you for your corresponding documents.

One of the key benefits to applying excess Class A credits to your Class B requirement is that APEX will save you time and give you peace of mind by reporting these credits to the AANA for all active members.

Submitting Class B credits

If you’re an active American Association of Nurse Anesthesiology (AANA) member, you can record and track AANA Class B credits as well as submit documentation on the AANA website. Not an AANA member? You’ll need to report your Class B credits during your 4-year credential renewal. If you’re not an AANA member, you’ll report your Class B credits to the NBCRNA.

Using APEX for your NBCRNA Class B credits? Perfect! APEX reports credits for active AANA members during business hours Monday through Friday, saving you the extra step of submitting Class B credits yourself. If you’re not an AANA member, you can also print your APEX credit transcript to submit to the NBCRNA.

APEX makes it easy to get everything you need for your entire 4-year CPC cycle or MAC cycle! Ready to get started? Check out our courses for CRNA Continuing Education credits.

There is an undercurrent of neuroscience-grounded activity underway in our professional community. Niches of CRNAs nationwide, working alone or in concert with like-minded physicians, are challenging some of the historical and contemporary foundations of general anesthesia. Largely quiet in their activities, representing a very small circle inside a much larger circle on a Venn diagram, they are pursuing their ambition to eliminate the use of potent inhaled agents in their practices and turning to total intravenous anesthesia (TIVA).

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Table of Contents

• What we learn about general anesthesia in our basic programs
• Targeting specific receptors and an introduction to our term, “C-FAN”
• The downsides to potent inhaled agents
• The emergence of clinician-friendly measurements of CNS activity
• C-FAN is not a processed EEG!
• Should our ether hybrids be abandoned?

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While rubrics like “radical,” “maverick,” or “intrepid” come to mind, these fall short of singularly capturing the mindset, passion, intellect, and purpose of these devotees. For now, we will dispense with labeling them; instead, leave that up to you as we describe just what these clinical practitioners and thinkers are up to.

What we learn about general anesthesia in our basic programs

Let’s journey back to your early training days when you first truly appreciated what general anesthesia was all about. Regardless of your vintage, you likely learned a contemporary descendant of an ether-based compound brought it on. We’ll give a quick shout-out to halothane (an alkane), but otherwise, we’ll confine our discussion to the three halogenated ethers in current use—isoflurane, sevoflurane, and desflurane.

You came to know that ether-based anesthetics are “total” anesthetics. In a dose-dependent manner, they produce unconsciousness, amnesia, analgesia, areflexia, and akinesia, collectively representing the required components for a general anesthetic state. Miss one of these targets, and oops, something important is missing. But in the case of our current ether hybrids, one drug does it all.

These clinical goals are not achieved with a uniform dose; each pharmacological target demands a specific concentration at the respective effect site. The dose of sevoflurane needed to achieve akinesia differs from that required to produce unconsciousness, and so forth. One MAC of an agent fails to address the individual components of general anesthesia and only gives us an overall potency metric in preventing purposeful movement to a nociceptive stimulus like a skin incision. Achieving a particular clinical target with a potent inhaled agent may result in unacceptable hypotension.

Targeting specific receptors and an introduction to our term, “C-FAN”

We circumvent this limitation by using what some refer to as “balanced” anesthesia (old-timers may prefer “garbage anesthesia”), in which we add specific drugs targeting unique receptors that mediate the precise response we want. Nicotinic, muscarinic, GABA, NMDA, 5-HT3, and alpha-2 receptors, among others, come to mind.

We have two broad approaches to achieving a general anesthetic state: inhalational and TIVA. Both are safe, titratable, and effective. These approaches have been with us for a long while, with the inhalational approach having about a century’s head start! But what’s happened over the last 25 years is a systematic and methodologically sophisticated understanding of what’s going on grounded in what we term “Clinician-Friendly Actionable Neuroscience,” or, for simplicity, C-FAN.

Googling C-FAN, you’re not going to come up with anything as it’s a term we created, and currently, it’s more of an evolving idea than a thing. We’ve only now put it out there for others—like you—to consider. So, what’s going on here, and what’s up with C-FAN?

The downsides to potent inhaled agents

First, there are a lot of concerns about traditional, potent inhaled agents. Among these are that in animal models and even in some human observational studies, there are concerns that general anesthesia induced by our potent inhalants may have neurodegenerative effects. Some suggest that these effects may be particularly concerning in young children (subsequent learning impairment, attention deficit disorder, behavioral issues) and older adults (cognitive impairment), prompting an FDA warning that’s just a hair shy of a boxed warning. The literature also suggests a high incidence of emergence delirium—acutely or in the first hours or day or so)—in pediatric and adult patients.

There are also concerns that long-term occupational exposure to even trace amounts of these agents may have biological consequences for us and other members of the operative team. Added to this is the now well-appreciated contribution that the potent inhaled agents have on greenhouse gases and their deleterious effects on the ozone level when they are vented to the outside air ending up in our atmosphere. Some even suggest they play a consequential role in what is described as global warming. Then there is the issue of cardiovascular depression, often caused by incidental overdosing to achieve a desired state with attendant adverse events like acute kidney injury.

These issues are widely discussed in the literature and have gained traction in the minds of some providers who, armed with C-FAN, have sought alternatives. These forward-thinking, early adopters of TIVA, to the point of eliminating potent inhaled agents from their practice, come grounded in what they believe is an evidence-based, practical, safe, and highly effective respite from inhalants. They’ve become iconoclasts with total avoidance of the potent agents from their practices. Their view is to use the tools and understanding that neuroscience offers to employ precision medicine in their clinical care of patients.

The emergence of clinician-friendly measurements of CNS activity

There is a bit of an irony that everything we’ve ever seen and know about life on planet Earth comes to us from an organ that resides in an encapsulated enclosure devoid of light. Its matrix is such that if you were to scoop it out of its enclave and hold it in your hands (use both, or you might drop it!), you’d perceive it as feeling a bit—on the “tofu scale”—as middling between regular and firm. But continually coursing through this extraordinary organ, via its neuronal circuitry, is an inconceivably large flood of electrical activity. That activity can be captured by now common and relatively compact devices that display the electrical activity permitting clinician analysis, and providing a real-time opportunity to achieve targeted outcomes pharmacologically.

The entire May 15, 2024 issue of Neuron, a high-impact journal, is devoted to clarifying what consciousness is and how unconsciousness is induced. Using easily acquired electrical signaling, MIT researchers revealed that disrupting the brain’s normal balance between stability and excitability makes its activity increasingly unstable until unconsciousness ensues. The researchers note that the brain operates on what might be termed a “knife’s edge” between excitability and chaos. It must be excitable for neurons to interact with each other, but if it becomes too excitable, chaos can rule.

This research underscores the value of using and analyzing specific electrical patterns induced by drugs such as propofol or those targeting the other receptors mentioned earlier. It offers a pathway to developing ways to control a patient’s level of anesthesia more precisely.

The foundations for these TIVA devotees come from a large body of bench and clinical research grounded in neuroscience, a field of biology that is only now beginning to receive its due recognition in our domain. What we now know is that:

• When humans “go under” general anesthesia, the brain is hardly “turned off” but rather pulses with dynamic electrical activity
• The drugs we use alter our normal arousal by inducing and maintaining oscillations in electrical activity.
• The activity is easily captured and observed with electroencephalography (EEG) acting like a simple voltmeter.
• The oscillations have “signatures” that permit tracking of the anesthetic state.
• A drug like propofol, or sevoflurane, acting on the GABA-A receptors allows negatively charged chloride ions to enter the cells of the CNS and quiet them–observable with that voltmeter.
• The oscillations change as the anesthetic depresses the CNS, with characteristic waveforms occurring.
• The waves initially get bigger, with slow oscillations revealing a depressed brain stem. Finally, burst suppression reveals a profound state of brain inactivation.

What is happening is some of these early adopters propose a new and enlightened, neuroscience-based approach to brain monitoring of patients receiving general anesthesia or sedation. They propose to train CRNAs to recognize and analyze anesthetic-induced brain states with drug-specific neurophysiological signatures gathered with an unprocessed 4-channel EEG and a spectrogram. Achieving and monitoring a desired anesthetic state using these unique signatures mirrors the molecular and neural circuit mechanisms of the activity of our drugs.

The ability to make detailed and accurate determinations is advocated by these aficionados as a way to optimize our ability to hit targets precisely and design patient-centric anesthetic care using a multimodal approach. They emphasize precise control of antinociception and simultaneously advantage the precise pharmacokinetics as the patient is controllably aroused from anesthesia.

In 2024 many envision raw EEG monitoring becoming commonplace in monitoring drug effects and see multimodal TIVA as a neurophysiological way to combine, control, and optimize the delivery of the agents. This permits second-to-second targeting of anesthetic depth and exacting control over the speed of emergence, with the hope of decreasing the adverse effects of the potent vapors.

C-FAN is not a processed EEG!

There are now compact, battery-powered EEG monitors, wireless with comfortable and adjustable headsets that leave no residue. This is not a BIS monitor or other proprietary-based, processed EEG device prone to measurement and interpretive pitfalls. C-FAN uses a raw EEG that is easy to use and interpretable with minimal training for the CRNA to gain the facility for its interpretation sufficient to guide precision TIVA. Proponents argue this technology is like moving away from auscultating BPs to automated noninvasive BP determinations, etCO2 replacing arterial blood gas analysis, and pulse oximetry supplanting indirect clinical estimations of arterial oxygen content. CRNAs use highly sophisticated technologies with aplomb—think ultrasound guidance for nerve blocks, line placements, and many other assessments. Our technological skill sets also include cardiac ECHO, TEE, quantitative neuromuscular function monitoring, and advanced ECG interpretation. Simplified EEG analysis is likewise on the horizon, and sufficient mastery is highly achievable.

C-FAN is neuroscience marshaled to the patient’s bedside, precisely using a cocktail of agents, including IV propofol, short-acting analgesics, drugs that create akinesia, and others that target specific regions of the brain, like ketamine and dexmedetomidine. This provides an alternative to inhaled agents using raw 4-channel EEG signals captured in real-time with C-FAN-friendly tools. The site of action of our anesthetics is the CNS; we should and can specifically target the effect site using emerging technologies. And once AI gets pulled into the picture, its use will be even more actionable.

Should our ether hybrids be abandoned?

No!! We are not advocating for eliminating these time-tested, reliable, and titratable members of our pharmacopeia, nor are we suggesting that TIVA is optimal for all cases and practices. We are reporting on what appears to be an undercurrent of clinical practice that is growing domestically and internationally. C-FAN monitoring tools are coming our way just as 1973 heralded the first use of the cell phone and the avalanche of technology that it foretold.

Does this represent an existential threat to “traditional” general anesthesia induction and maintenance? Or is it just the ever-evolving nature of what we do? It may be coming to an OR close to you if not already there.

As CRNAs ourselves, we understand the challenge of fitting CRNA continuing education credits into your busy schedule. When you’re ready, we’re here to help.