Different ways to skin the cat..

Specialties CRNA

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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 :clown: ). 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

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not trying to cause an argument..but if you are extubating when your ET sevo is 0.5... you aren't extubating deep..

deep extubation occurs when full MAC or close to it is instituted... you (IMHO) are right around stage 2 time... and just to reference - although still a student i was trained by a CRNA who like you extubated everyone w/o contraindication deeply and was phenomenal at it...

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not trying to cause an argument..but if you are extubating when your ET sevo is 0.5... you aren't extubating deep..

deep extubation occurs when full MAC or close to it is instituted... you (IMHO) are right around stage 2 time... and just to reference - although still a student i was trained by a CRNA who like you extubated everyone w/o contraindication deeply and was phenomenal at it...

Over here, we usually call pre excitation extubation "deep", post excitation extubation "shallow" (or at least the swedish equivalent of that word).

If "deep" means full MAC, then I never extubate deep. So you made a good point there.

/Anders Kohkoinen, Nurse Anesthesist, Sweden

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I agree athomas91. Our facility favors iso vs sevo and most MDs prefer not to extubate OETTs deep but will pull LMAs deep every time. Not that they are around on most extubations with CRNAs, but we as senior students have to call when we extubate. We leave iso on whatever was running during the case, D/C N2O, and pull LMAs with at least .7 - .6 ET.

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I, for one, prefer to extubate deep if the patient's comorbidities (or lack thereof) warrant it. Slip the oral airway in, assist with ventilation if needed, they open their eyes and get rid of the airway themselves. Unfortunately, a lot of the CRNAs I've worked with don't like to extubate deep (unless it's in the one-day surgery center). So I take advantage of the technique whenever the opprtunity arises!

For other cases with normal extubations, I prefer to get the patient back breathing, titrate my narcotics per RR and wake them up.

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i as well appreciate the deep extubation - as a student - of course - only practice it with CRNA's who also use it in their practice....

i don't know though about legal standing IF something should occur.. of course it is just mask anesthesia at the point of deep extubation but ... i don't believe that is a standard of care in adults...

yoga - do you know???

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When I awake my patients, I´ll go from full MAC to 0.5% rapidly. When the patient reach 0.5% sevo, they are still in full surgical anesthesia (small centered pupils etc). Extubating then is in my opinion pretty much the same (stimulationwise) as extubating at full MAC. Only difference is that I dont have to wait so long for the patient to open their eyes (and of course, I have to be gentle and not stimulate the patient into excitation).

I use no Guedel or nasal airway after extubation unless really needed to - gentle chin lift is usually sufficient.

Removing a laryngeal mask deeply (yeah, 0.5% sevo is still "deep" for me) makes good sense, because its a bit frustrating to have a patient biting down on the LM shutting off their own airway with their teeth.. Its also easier to clean up the pharynx without causing laryngospasm after removal of the LM if the patient is a little deeper. However - I routinely use glucopyrrulate (Robinul) 0.2 mg preinduction to minimize the need for suctioning.

/Anders Kohkoinen, Nurse Anesthesist, Sweden

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i don't believe that is a standard of care in adults...

standard of care is what a prudent practitioner would do in a similar situation, not some written standard that all practicitioners must adhere to, unless its a policy written by the hospital or surgery center.

so i think you may find as many that ext deep as those who dont.

i like to extubate kids and adults equally deep, i feel for the kids the transition to fully awake is more tolerated when ext deep, of course there must be little stimulation by recovery staff.

for adults, adequate tv and rr with muscle relaxation reversed (if used) and i will ext deep, adhering to no contraindications.

d

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gasspassah...thanks...i just wonder what a lawyer would try to portray it as if something were to go wrong... i guess they will paint it however they want...like everything else..

thanks again.

andrea

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gasspassah...thanks...i just wonder what a lawyer would try to portray it as if something were to go wrong... i guess they will paint it however they want...like everything else..

thanks again.

andrea

I don´t think that "lawyers opinion" is a valid medical parameter anywhere in the civilized world, Athomas :chuckle

Patients are individuals, and so are anesthesia providers. Experienced anesthesia workers finds their own "style", based on knowledge about both different techniques, drugs, comorbidities and - themself. And thats not stranger than the fact that different painting artists develop their own style over time.

So.. Be careful to wish for rigid "standards" - they may be easy to learn and adhere to for unexperienced beginners, but will severily hamper your own artistery of anesthesia later.

/Anders Kohkoinen, Nurse Anesthesist, Sweden

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