Just before the crna intubates...

rn29306 · Apr 27, 2006

... a patient, what stats or sats or vital signs are they watching just before they take off the mask to intubate? I was recently shadowing a crna who was vigorously watching the monitors as the patient was loosing consciousness and just before he took the mask off. I wanted to ask him what he was watching but when it was time, he handed me the laryngoscope and let me put the tube down. (ssshhh... dont tell nobody! the MDA and CRNA knew it was an easy intubation.) Needless to say i soo excited i completely forgot to ask after the procedure was over.

Screw the monitor in this case. Do you honestly need a monitor to tell you someone who's head is near your stomach that he or she quit breathing??

Its like watching someone pass out right in front of you. That clear plastic mask they are breathing through is clear for a reason. They fog the mask while breathing, right?.....You see their face go flaccid (man do i hate that word....), they quit breathing (no fog of mask).. If using a muscle relaxant, you do have to give time for this to work and you have to help them breathe. Tap them gently on the forehead and ask them to take a breath.. No breath? Time to tube. Easy as that.

The IV agents are almost instantaneous in their action. Need to have fentanyl on board 2 minutes prior to the induction. It is more of a timing thing than anything else.

Don't think I was being mean about "watching the monitor". Unless you are breathing for a patient with inhalational agent turned on and want to see what end-tidal amount is present or if they tanked their BP from the induction agent and need some laryngoscopy stimulation, there is really no need to look at the monitor. So many students attempt to mask a patient while looking for ET CO2 on the monitor. Drives me nuts. Look at the patients always. You can see if you are ventilating them by the compliance of the bag, the equal and symmetrical chest rise, and the condensation on the mask.

Congrats on the intubation.

athomas91 · Apr 27, 2006

everyone has their own way - i personally have eye contact with my patients until they close their eyes and lose lid reflex...

but i have seen some who like to see an exhaled 02 of greater than 90% ... some want ot make sure a BP isn't bottoming out on an unstable patient... etc... i am sure there was a specific reason the CRNA was watching the monitor so closely...

London88 · Apr 28, 2006

Watch the monitor for your B/P before intubating because it is never a good time to DL a pt with a elevated B/P. Most of my pts have A-lines but I always cycle a B/P right before I DL if I do not have an A-Line. There is more to looking at monitors than just checking for ETCO2! I can assure you that the CRNA was not looking at the monitor to see if the pt had stopped breathing. He or she was looking to see if intubating conditions were optimal.

crnabrian · May 21, 2006

Everybody does anesthesia a little differently. That does not mean someone is doing it wrong, just different from you! About the only thing I look at while bagging is tidal volumne.

Tranman · May 22, 2006

... a patient, what stats or sats or vital signs are they watching just before they take off the mask to intubate? I was recently shadowing a crna who was vigorously watching the monitors as the patient was loosing consciousness and just before he took the mask off. I wanted to ask him what he was watching but when it was time, he handed me the laryngoscope and let me put the tube down. (ssshhh... dont tell nobody! the MDA and CRNA knew it was an easy intubation.) Needless to say i soo excited i completely forgot to ask after the procedure was over.

All good responses, BUT to answer your question, he was probably looking at the ETFi (End Tidal Fraction of Inspired O2). Should be .90 and above. Most patients will reach this level with 3-5 slow big breaths of 100% O2 or at least 1 min of preoxygenation. If you are inducing a big fat patient with asthma who is a long time smoker without proper preoxygenating, the patient can drop their Sats very quickly after induction if you don't/can't get the tube in right away. Sometimes it takes a long time to get their Sats up after that drop.

Also, he was prolly looking at the Sat. level. Just one last time to make sure everything is hunky dory. As a general rule, you should eventually learn to 1st read the patient without the monitor and not just the monitor all the time. Meaning you should be able to give an anesthetic with just a BP cuff. That being said, I would never say screw the monitors. Learn to use them and look up at them often (along with monitory the patient). Vigilance is one of the most imporatant skillz of anesthesia. This means monitoring the patient and the monitors together. To prove my point. You can't see that the patient is having an arrythmia by looking at a sleeping patient. By the time he turns blue, it's prolly too late so don't forget the monitors! You also can't see low BP's reliably either by looking at a patient. You can feel for a pulse (or lack of one) but having the monitor to tell you just verifies it. Also having a monitor tell you that the patient is having an arrythmia or low BP is useless if you can't identify it immediately and treat it properly right away.

You asked, so I'm telling you.

rn29306 · May 22, 2006

Meaning you should be able to give an anesthetic with just a BP cuff. That being said, I would never say screw the monitors. Learn to use them and look up at them often (along with monitory the patient). Vigilance is one of the most imporatant skillz of anesthesia. This means monitoring the patient and the monitors together. To prove my point. You can't see that the patient is having an arrythmia by looking at a sleeping patient. By the time he turns blue, it's prolly too late so don't forget the monitors! You also can't see low BP's reliably either by looking at a patient. You can feel for a pulse (or lack of one) but having the monitor to tell you just verifies it. Also having a monitor tell you that the patient is having an arrythmia or low BP is useless if you can't identify it immediately and treat it properly right away.

I said screw the monitor in THIS case. You really shouldn't need a monitor to tell you that someone has ceased breathing after induction. Did I honestly say that you shouldn't examine the monitor for HR and BP during the case? No I didn't.

You are right, vigilance is the key to anesthesia. Take pulse oximetry for a minute. There is a tone for a reason. If you cannot name the pulse ox within 1 point of what the monitor is showing by simply listening to the tone while doing all your other required eyes-off-the-monitor actions, then you shouldn't be doing anesthesia. And you should be able to tell when 1% increments change during the case. Hopefully you can catch this before YOUR patients turn blue in your above situation.

Tranman · May 23, 2006

I said screw the monitor in THIS case. You really shouldn't need a monitor to tell you that someone has ceased breathing after induction. Did I honestly say that you shouldn't examine the monitor for HR and BP during the case? No I didn't.
You are right, vigilance is the key to anesthesia. Take pulse oximetry for a minute. There is a tone for a reason. If you cannot name the pulse ox within 1 point of what the monitor is showing by simply listening to the tone while doing all your other required eyes-off-the-monitor actions, then you shouldn't be doing anesthesia. And you should be able to tell when 1% increments change during the case. Hopefully you can catch this before YOUR patients turn blue in your above situation.

THAT one word made the difference. You said nothing wrong. I was just reading too fast. It kinda reminded me of when I was in school and all the old gas passers who never had monitors coming up made a big stink about students using the monitors. True that many students overly rely on the monitors and don't know how to read the patient. Again, this is a process that takes some time to learn. It can not be taught in a few months. Only experience can teach you.

Also true that you can get by without monitors, just as you can get by without pagers, cell phones, and email. But we have technology now, and it's nice to be able to have the options and the assitance of monitors.

After rereading the original post, I too am a bit confused as to why the anesthetist was overly watching the monitor as the patient was losing conciousness. Could be a bunch of different reasons. But it does sound odd. I'm with you, when the patient goes out, I usually do an eye lid reflex check. There are too many signs the patient is exhibit that they are unconscious. A very brief glance at the monitors will do me fine. After induction, I find that I am constantly looking at the patient and monitors though. I always set my bp cuff to 2.5 mins. on all cases. I know others who use 5 min marker for healthier patients. I do 2.5 out of habit. will also recycle the BP periodically between the 2.5 min intervals, especially if I'm treating a low BP. 2.5min is also a good measure for giving regular doses of propofol when doing a MAC case without an infusion pump. A

Anyways sorry if this is confusing for all those who don't yet give anesthesia. PM me and ask if you need clarification. This thred contains good info for those interested in anesthesia and it hope it helps.

London88 · May 23, 2006

I thoroughly agree that you do not want to rely on the monitor too much. In our ORs the alarm on the EKG monitors are turned off ( that is a topic for another discussion). I remember being a student and watching an elderly pt go asystole after a dose of propofol. Yep full blown CPR in progress. It was nice to quickly be able to glance at the monitor and know this was happening. The bottom line is that the monitors are your friend and not your enemy. However i must confess that by the time we hook up the BIS and the cerebral Oxemeter and who knows maybe an EEG for a carotid you would think the pt was an astronaut ready to go to the moon rather than undergoing general anesthesia!

Tranman · May 24, 2006

In short turning off the monitors is a BAD idea. People, the humans that we are can become inattentive at times. People have died b/c alarms were turned off and anesthesia provider wasn't looking at the monitor. Many turn off the alarms b/c they can be annoying. My suggestion is turning down the volume of the alarm but not off completely. Try it a few cases and you'll change your mind about turning off the alarms.

London88 · May 24, 2006

Actually I had a hard time adjusting to the monitor alarms being turned off. However in the heart rooms they are turned off for various reasons one being that one of our surgeons would go berserk if the alarm was to keep going off. That being said I am all for the monitor alarms being turned on but i choose to go with the flow.

Tranman · May 24, 2006

go with the flow? R U kidding me? I understand the need to work with the surgeon, but that sounds rediculous. How bout telling the surgeon that you'll lower the volume of the alarm. I would refuse to turn off the alarms. What if you had a bad outcome because of having the alrm off. Always think, how would you explain that to the family members or the judge. Uhhh, this bad outcome could've been avoided but the surgeon doesn't like the sound of the alarms so I turned them off. You think if you got into a mess like that the surgeon would back you up? He'd sell you down the river in 2 secs. He'd say, "I never told him to turn the alarms off, he did that out of his own volition"

Another pearl for you aspiring CRNAs out there.

-Try to avoid doing anything that you're uncomfortable with or not sure about. I hesitate to say never, but life is not that black and white. Sometimes you feel like you have to make a decision without being 100% about it. But that should be rare or sometimes, NOT often. The name of the game is to avoid problems, not seek them out. You'll have a more enjoyable career if you can avoid problems.