Different ways to skin the cat..

One of my nurse anesthesist colleagues doubles as a scrub nurse sometimes. Being an anesthesia competent scrub nurse has an interesting bonus - in that position she can observe the different ways we nurse anesthesists work and deal with the situations. Different ways to skin the same cat.

Nurse anesthesists works mostly solo. Yes, we have scrub nurses, nurses aides and surgeons in the same OR, but seldom our own colleagues.

So, I thought it would be nice to discuss a little about how we do our thing? And as always - there is very little rights and wrongs.

I´ll go first.
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*Anesthesia induction for small kids unable to cooperate usually goes smoothly when you do the "balloon play". I´ll prefill the circuit with 70/30 nitrous/oxygen and show the kid the "funny balloon". Takes a couple of breaths in the mask myself and show how the balloon moves. (Few tips: the balloon under the teddybear is fun too, or under a pillow ). And after that, of course - let the kid test the balloon play. After sedated, I turn on the Sevo vaporizer on max (8%) and they fall asleep with a giggle, without crying or coughing.

* My way of terminating general anesthesia (intubated). As soon as there is no further need of relaxation, I reverse it away (0.5mg glycopyrrulate + 2,5mg neostigmine), usually when the surgeons put the final sutures in the fascia. At the same time I remove the nitrous, increase oxygen to 80% and increase fresh gas flow to reduce rebreathing. To compensate for the loss of nitrous, I increase sevoflurane slightly to remain at the same MAC level.

When most of the nitrous is exhaled (according to gas analysis), I maintain the same tidal volume, but reduce frequence from perhaps 12 to 3-4 breaths/minute to accumulate carbon dioxide. The 80% oxygen usually keeps hypoxemia away. Final train-of-four checks to be sure that no remaining relaxation exists.

When spontaneous breathing reoccurs, I switch off the ventilator. And then I just wait for the surgeon to finish. At the last skin sutures, I turn the agent off and put fresh gas flow on max (18 litres/minute with a Dräger Primus). Removal of NG-tube and suction of pharynx.

I usually extubate deeply, before the patient reaches excitation - if no contraindication such as gastric reflux och a full stomach exists. When endtidal sevo is 0.5%, spontaneus ventilation of good quality and a endtidal carbon dioxide is acceptable - out goes the tube. Chin lift and perhaps a little supplemental oxygen.

I keep the patients chin until lifted to the hospital bed. If they dont maintain a free airway, I turn them on their sides. And off to the PACU.

/Anders Kohkoinen, Nurse Anesthesist, Sweden