CRNA Induction Sequence List

1. In room

2. Versed 2.5mg

3. Move pt. to bed, hook up monitors, routine VS

4. Pre-Oxygenate

5. Zemuron 5mg (if using sux for muscle relaxant)

6. Sufenta 10-20mcg

7. Lidocaine 50-100mg. (clamp off IV when Lido gets to catheter, for about 30sec to allow numbing of vein)

8. Propofol induction dose

9. Check lash reflex, ask pt to open eyes etc...Tape eyes

10. Oral a/w

11. Ventilate

12. Muscle relaxant of choice

13. Ventilate again, using inhalation agent of choice if needed.

14. Turn off agent and Intubate (use Miller :) ) watch tube go through cords!!!

15. Check placement, BBS, ETCO2, and tape in place. Turn agent back on!

16. Place oral a/w again if you want.

17. Place oral gastric and esophageal if needed (I find an oral airway makes placement of these 2 things much easier)

18. Place your humidivent if you use them.

19. All fluids on warmer and warming blanket on patients if needed.

As for extubation, timing is difficult when you're learning. Ask your CRNA how fast the surgeon is and gauge by that. Also, you should be watching and listening at all times. Key words are usually from the circulator (Dr. so and so, what suture do you want to close with? To the tech: Let's count now) tells you that they are closing and you can start reducing your agent and get the patient back breathing if possible. When you are trying to get them back breathing, I learned to ventilate them every 20 sec. Soon the ETCO2 will rise enough that they'll take over themselves. Titrate in your long acting narc if needed (mso4 or dilaudid are great choices) Good luck, hope this helps

1. Beginning of day--machine check, suction, circuit check O2 calibration, check all monitors-Especially CO2, Laryngoscope check, airway devices ETT check, drugs checked and drawn, IV ready especially for the kiddos.

2. Versed in holding area

3. In room

4. Monitors placed

5. Double check suction is locked and loaded

6. Denitrogenated--Fentanyl 250-500 ug

7. Propofol- usually a lower dose about 50-100mg

8. Ensure dosage is sufficient (lid reflex)

9. Ventlilate and adjust if neccesary

10. Muscle relaxant of choice-usually SUX-

11 Intubate with Phillips blade-its the bomb

12. Connect tubing and listen to lung sounds

13. Flip Omehda to ventilator--Quickly check another blood pressure.

14 Tape tube,eyes shut airway in place, drop an 18 fr OG tube, decompress

the belly and drop an esophageal temperature probe--

15. If BP allows turn on the DES, N2O adjust the settigns as needed

16. Check twitch and give non-depolarizer if the case needs it.

17. Hook up my earpiece if its a kiddo--don't use it on adults

18. Chart and wait for my piss break----HA HA :chuckle

Extubation--If you pumped in enough narcotics, you will look like a champ instead of a chump. Emergence just takes years of experience, knowing the surgeons abilities and YOUR abilities. I let the ventilator blow off the gas, its more efficient. (assuming you have already reversed residual relaxation). When they open their eyes, suction ask for commands, usually open your mouth, which they readily do with a goard full of narcotics. Don't pop the cork till they pull in 1/2 their tidal volume. Again, the more cases the more comfortable you will be with emergence. Always remember how difficult the intubation or mask ventilation-it will also influence your extubation.

Mike CRNA

Thanks Skip,

I have a file of references I am saving for clinical and this sounds helpful. Especially after an email where I read someone was excited they had inubated and forgot to ventilate.

Thanks,

PT

We CRNAs tend to be compulsive about setting up. I know that I essentially do it the same way I was taught over 40 years ago. I start with the anesthesia machine, check circuit, fill vaporizors, etc. Then I set up medications and airway equipment. Check the suction and a final check of the machine.

Place all monitors on patient, check anesthesia machine again. Get first set of vitals and proceed with induction.

I don't use set drugs or dosages of drugs as was stated in the previous posts. I am opposed to recipe card anesthesia and select agents according to each individual patient, the surgical procedure and other related factors. I am concerned that one would give a standard dose of narcotics, induction agents and muscle relaxants.

Knowing how to do an emergence is when the art and science of anesthesia merge. I watch the surgery carefully, talk with the surgeons and nursing staff and can pretty much tell when the last stitch is being put in. I haven't reversed a muscle relaxant in years (I just had to replace an unopened via of edrophonium because it expired). Pre-emptive post-op analgesia is very much a part of my technique. Mostly, I have the surgeons infiltrate the field with local anesthesia and I may give an IM dose of nalbuphine to smooth out the emergence.

Understand that I have a limited practice of cosmetic surgery and the needs of those patients are different than many you see in the hospital. I do not want my patients "bucking" on the tube, doing anything that increases their blood pressure or vomit. Also, I run the surgical facility and am not rushed by the nurses (they work for me) or the surgeons to move fast so they can get another case on the table. It is wonderful to have the opportunity to give patient oriented anesthesia.

i have had awesome (i can't stress enough) instructors at my clinical site...they have taught me amazing ways to utilize anesthesia...

i tape the eyes prior to mask ventilating (if not a 400lb patient who will desat during this) -- just to protect them

get them back breathing prior to end of case - great way to judge if your narcotic usage is adequate (RR) --

and i likewise agree w/ yoga on the muscle relaxant use - i have been taught to only use relaxant when actually needed - still then - i have been taught to keep them with 1-2 twitches at all times...and usually before the end of the case they have 4/4 and sustained tetany....BTW - they actually will breath w/ only 2 twitches...amazing!!

of course - these won't help all of those who are already CRNA's or SRNA's - but for those of you starting - good luck - hope it helps.

oh - TORADOL!!!!!!!!!!!!

17. Hook up my earpiece if its a kiddo--don't use it on adults

A Precordial or esophageal steth, hooked up to an earpiece as a dynamic monitor, is NOT an option. Continuous monitoring via a stethoscope has been identified as one of the basic monitors required for anesthesia by the Mass General group. Have a bad outcome that winds up in litigation and see how successful you are in defending the notion that listening to your patient breathe and monitor the heart beating is optional. You won't be. My students all use these monitors when doing cases with me, or they don't do the case.

A Precordial or esophageal steth, hooked up to an earpiece as a dynamic monitor, is NOT an option. Continuous monitoring via a stethoscope has been identified as one of the basic monitors required for anesthesia by the Mass General group. Have a bad outcome that winds up in litigation and see how successful you are in defending the notion that listening to your patient breathe and monitor the heart beating is optional. You won't be. My students all use these monitors when doing cases with me, or they don't do the case.

I wasn't aware Mass General set the standards for the country.

I don't use set drugs or dosages of drugs as was stated in the previous posts. I am opposed to recipe card anesthesia and select agents according to each individual patient, the surgical procedure and other related factors. I am concerned that one would give a standard dose of narcotics, induction agents and muscle relaxants.

I agree that there should not be "cookie cutter anesthesia" for patients. I also select for the individual patient, but these dosages are what I generally see for the hypothetical "non-complicated patient" which the poster asked about.

Don't worry, Yoga CRNA, if I gave you your anesthetic, it would be tailored to your needs

I wasn't aware Mass General set the standards for the country.

Several years ago, as part of the Patient Safety Foundation's work, they asked for a consensus list of basic monitoring in anesthesia. Mass General, being well-regarded, provided a standard which was endorsed by the ASPF. If you don't accept this as a standard, that's fine, but I will let you imagine the court room scenario that might take place if you had a bad outcome and were not using a stethoscope. The defense of "I never use them for adults," will most likely be inadequate. I stand by my previous statement; if the students don't want to use this monitor, they can find another room; another case.

Several years ago, as part of the Patient Safety Foundation's work, they asked for a consensus list of basic monitoring in anesthesia. Mass General, being well-regarded, provided a standard which was endorsed by the ASPF. If you don't accept this as a standard, that's fine, but I will let you imagine the court room scenario that might take place if you had a bad outcome and were not using a stethoscope. The defense of "I never use them for adults," will most likely be inadequate. I stand by my previous statement; if the students don't want to use this monitor, they can find another room; another case.

I just do not know who sets the standard.

But I remember being made to read an AANA document on anesthesia monitoring standard. We talked about O2 sat, bp, hr, CO2 etc, in class. In the theater, I consult with my CRNA or MDA of the day and hook up as they mandate.

On that topic of emergence, in the theater, I can make an induction go as smoothly as silk air-brushed with 25% humidified air but my emergence has been nothing to write home about. I work with sometimes a different CRNA/MDA every clinical day. They insist on their own particular method, It has made it difficult for me to master any particular technique.

Several years ago, as part of the Patient Safety Foundation's work, they asked for a consensus list of basic monitoring in anesthesia. Mass General, being well-regarded, provided a standard which was endorsed by the ASPF. If you don't accept this as a standard, that's fine, but I will let you imagine the court room scenario that might take place if you had a bad outcome and were not using a stethoscope. The defense of "I never use them for adults," will most likely be inadequate. I stand by my previous statement; if the students don't want to use this monitor, they can find another room; another case.

I didn't say that I disagreed with you about stethoscopes. I simply questioned whether Mass General, or any other single learning institution, sets "the standard" for everyone else. They don't.

I have been unable to locate the standard you are referring to on the APSF website. I have been unable to locate such a standard on the AANA website as well, and the ASA does not require it. If you have the cite, I'd love to see it.

In years past (many years...) it was customary to always have a finger touching the patient, preferably over the temporal artery as that was often easy to do from the head of the table. I had instructors give me stern warnings about always touching the patient. Interesting advice, certainly not ignored as a student, but not a standard either.

There are lots of ways to monitor our patients' many vital signs. Most of them can be monitored in a number of ways. For example - do I get my heart rate from my SaO2, EKG, A-Line, or by counting as I listen to or palpate the pulse? There's nothing wrong with listening to precordials. It's just not my #1 monitor. And before you start thinking I depend too much on my electronic monitors, think again. I've been doing this long enough to remember not having pulse oximetry and ETCO2 monitors, and actually used Ploss valves to both auscultate breath sounds and Korotkoff sounds when (gasp ) listening for a blood pressure. I still mess with my students and turn off the pulse ox or end tidal, just to see how they'll react (hopefully they're paying attention). It's amazing how many depend so much on "the monitor" and forget "the patient".

I have been doing this stuff probably as long as JWK and I agree with him/her. There is no standard for wearing a precordial stethescope and I still won't use them on adults. There are better monitors (for me), I just prefer not to use precordials. Adequate ventilation and heart rates can be monitored with pulse oximetry, ECG's, tidal volumes peak pressures etc....What are you gonna do if your have problems? Tear off the earpiece and check your monitors, and get your drugs out. What are the lawyers gonna say then? Their gonna say what is the standard of care or standard monitors--precodial stethescopes are an adjunct but NOT standard.