I'm in!!!!!!

cak1219 · Jan 25, 2009

What kind of stats go you in? thanks

Putu2Sleep · Jan 25, 2009

My gpa was a 3.1 (nursing GPA probably around 3.6) with 950 on my GRE and I had a little over 3 years of ICU experience in Neuro ICU and 1 year in a Cardiothoracic ICU for 1 year with experience with VADs, Heart and Lung Transplants, IABPs, etc. Also had my CCRN. We also did our own vent weaning and reversals from anesthesia.

mammothsnw · Jan 25, 2009

Hi Putu2sleep..just curious what you meant by doing your "own reversals from anesthesia"?? Reversing at the end of a case as the pt wakes up in order to extubate is usually done in the OR...if necessary...sometimes if the pt has 4/4 or 5 sec of sustained tetany you don't even need to do it...So I guess my question is why you would reverse someone in the ICU as opposed to just letting the NDMR just wear off?? Why risk the possible side effects of neostigmine/robinul? Just curious. Thanks

Putu2Sleep · Jan 25, 2009

For our open heart cases anesthesia does not give reversals in the OR. We decide when we want to give them if the patient is stable enough. We reverse them within the first hour of coming out of the OR if they are stable. If the patient comes out with an open chest or very unstable we do not reverse them. We give 1:1 neostigmine and glyco to counteract the side effects. I've given these drugs many times and haven't had really any major issues with them.

mammothsnw · Jan 27, 2009

I guess my question is...if a pt is stable..why "reverse them within the first hour" when the longest the intermediate/long acting NMBDs last is 60-90 minutes...what is the advantage of reversing compared to to just letting the drug be metabolized/eliminated?? The side effects I mentioned seem especially important in an open heart case. Usually with the 1:1 Neostigmine:Robinul mix that you mentioned will cause transient tachycardia because as I'm sure you know the anticholinergic (tachy) will work first b/c the anticholinesterase has to bind to AChE....then you will have some who will brady from the increase in ACh on the muscarinic receptors. It just doesn't seem like the risks of using more drugs...outweigh the potential complications in this situation. I'm just curious what the rationale is of the docs who order this reversal. Prior to anesthesia school I worked in one of the largest transplant centers on the West coast and this was not part of the practice. Sorry to beat this to death but I can't imagine what the benefit is in doing this unless you are trying to expedite the extubation process (which is usually not the priority in open heart cases). Thanks for any insight.

singh1981 · Jan 27, 2009

I got accepted in Missouri State University CRNA program. Anyone else is going there?

Putu2Sleep · Jan 27, 2009

actually we do give the reversals to speed up the extubation time. that is one of our main goals upon receiving the patient from the OR. and secondly i have yet to see any real tachycardia from giving the neo. if anything our patients hearts are still slow coming out and almost always require pacing to keep their HR 90 (which we like it to be that fast). and yes i understand drugs have side effects but you are making it seem like neo can cause such severe complications like a protamine reaction or something.

our goal is extubate within 4 hours. and even like you said something like pancuronium or vec only can last at max 90 minutes giving reversal within 1 hour of arrival still will speed up extubation time compared to not giving any reversal. i understand you might not have done it this way in your old hospital but not everybody does things the same way and at worst i've seen slight tachycardia but nothing more than that. so for me the benefits do outway the risks of giving the drugs.

mammothsnw · Jan 27, 2009

OK...Not trying to argue here...just asking for rationales b/c I've never heard of doing this and still don't see the benefit of reversing...but let me explain my point again.

First you said:

"i have yet to see any real tachycardia from giving the neo" - just to clarify- it's the neostigmine (AChE) that will cause Bradycardia, and the Glyco will that causes the tachy.

"but you are making it seem like neo can cause such severe complications like a protamine reaction or something" - Yes actually the Bradycardia can be a severe complication especially in a compromised heart. And if someone has atypical psuedocholinesterase (the enzyme that breaks neostigmine down - the paraympathetic response to prolonged increased levels of ACh could cause "severe complications" and this condition usually isn't diagnosed until the pt remains paralyzed for 10 hours after a single dose of Succs).

I'm not saying reversing is wrong....I just don't see the benefit considering the bodies endogenous enzymes, the liver, or in the case of Nimbex or Tracrium you have ester hydrolysis and Hoffman elimination to do the reversing for you...well within the time frames of your extubation goals. I've just always been taught that less drugs is better if you get the same end result. Maybe once you learn more about these drugs and the serious potential side effects in school you will change your mind...maybe not...you can practice however you want once you are a CRNA...that is the beauty of it. Good luck in school

anesthesia_insomniac · Jan 27, 2009

Putu2sleep,

Have you seen residual muscular paralysis doing this type of protocol? For example, is the patient simply just sedated on a propofol drip and paralyzed when they come up from the OR, then you just reverse them in the first hour, then turn off the sedation? I only ask b/c we would turn off the sedation as soon as we admitted our hearts from the OR but they were already reversed. If the patient was not reversed yet, and sedation was turned off, I would think there would be a high chance of residual paralysis...just curious on how you go about all that. Also is this only in your transplants or even CABG patients? I'm not questioning anything, I just like to here how other hospitals do things as well.

Thanks.

Putu2Sleep · Jan 28, 2009

pts come out with propofol and still with paralytics on board. once we reverse we shut off the sedation. our aortic pts (Ao dissections, AVRs, etc) we use precedex instead of propofol and leave that on till about an hour after extubation.