Would the SRNAs on here like it if I started a pimp thread? The questions would be clinically related pearls or questions related to boards.

wow - this was difficult. i spent about 30 minutes researching this answer: methylene blue

great question

You have patient with Parkinson's Disease and hx of PONV. What would be your anesthetic plan to reduce the incidence of PONV and what drug(s) would be appropriate rescue antiemetics?

scop patch, H2, blocker, TIVA with propofol, maintain normotensive state (ephedrine preferably or neo), adequate hydration; ondansetron can be used for rescue N/V.

avoid droperidol

scop patch, H2, blocker, TIVA with propofol, maintain normotensive state (ephedrine preferably or neo), adequate hydration; ondansetron can be used for rescue N/V.

avoid droperidol

You notice your patient is on Cogentin, Selegiline, and Sinemet. Does this interfere with plan? Why or why not? What other antiemetics would you want to avoid? What other antiemetics could you give to this patient?

the pt's use of these drugs would modify the plan as cogentin will antagonize the ACh and histamine receptors, selegine is an MAOI and therefore ephedrine should be avoided but small doses of direct acting alpha agonist (neo) can be used for hypotension. sinemet increases the amount of dopamine available.

other antiemetics to use include decadron and I forgot to mention the use of 80-100% oxygen.

antiemetics to avoid: butyrophenones (droperidol), metoclopramide, and phenothiazines (phenergan and compazine) as these can increase the extrapyramidal side effects

What are the characteristics of modern day vaporizers?

How does the Desflurane vaporizer differ, and why is it necessary?

Name 4 methods for performing peripheral nerve blocks i.e. nerve stimulation.

What are the sites of quickest to slowest absorption of local anesthetics, and why is this important in PNBs?

What are the different preservative formulations of propofol, and which one(s) of those might be inappropriate for long-term sedation of ARDS patients?

In what state(s) are CRNAs required to be supervised by anesthesiologists?

What are the characteristics of modern day vaporizers?

How does the Desflurane vaporizer differ, and why is it necessary?

Name 4 methods for performing peripheral nerve blocks i.e. nerve stimulation.

What are the sites of quickest to slowest absorption of local anesthetics, and why is this important in PNBs?

What are the different preservative formulations of propofol, and which one(s) of those might be inappropriate for long-term sedation of ARDS patients?

In what state(s) are CRNAs required to be supervised by anesthesiologists?

modern day vaporizers can maintain volatile agent concentrations over a range of temperatures and fresh gas flows

the des vaporizer differs in that it keeps a higher temperature and pressure since des can boil away at STP; also des is ~5x less potent than iso and sevo and thus very high fresh gas flows would be needed to dilute the agent to safe levels

4 methods - landmarks/ paraesthesia, field blocks, nerve stimulation and U/S guided

IV, tracheal, intercostal, cervical, epidural, brachial plexus, sciatic, and SQ

propofol can have EDTA and Na metabisulfite, the bisulfite preservative can cause problems in ICU/ARDS pts. on a side note, in the institution I train, we have seen benzyl alcohol as a preservative and had alerts against using this formulation in the peds pts.

finally, NO state (unless you count a state of delusion) requires CRNA supervision for practice

modern day vaporizers can maintain volatile agent concentrations over a range of temperatures and fresh gas flows

the des vaporizer differs in that it keeps a higher temperature and pressure since des can boil away at STP; also des is ~5x less potent than iso and sevo and thus very high fresh gas flows would be needed to dilute the agent to safe levels

4 methods - landmarks/ paraesthesia, field blocks, nerve stimulation and U/S guided

IV, tracheal, intercostal, cervical, epidural, brachial plexus, sciatic, and SQ

propofol can have EDTA and Na metabisulfite, the bisulfite preservative can cause problems in ICU/ARDS pts. on a side note, in the institution I train, we have seen benzyl alcohol as a preservative and had alerts against using this formulation in the peds pts.

finally, NO state (unless you count a state of delusion) requires CRNA supervision for practice

What are the terms we use to describe modern day vaporizers i.e. temperature compensated.

4 Methods: Think axillary...Field block is not usually considered acceptable for a PNB (at least where I trained).

BIICEPS (Blood, Intercoast, Interthecal, Caudal, Epidural, brachial PLexus, SQ) is the easiest the way I found to remember it.

Propofol....correct. What is the concern with benzyl alcohol, and what is the condition that is caused from administration of benzyl alcohol? What age group is this a concern with?

..Yep.

Benzyl alcohol, a component of this product, has been associated with serious adverse events

and death, particularly in pediatric patients. The "gasping syndrome," (characterized by central

nervous system depression, metabolic acidosis, gasping respirations, and high levels of benzyl

alcohol and its metabolites found in the blood and urine) has been associated with benzyl alcohol

dosages >99 mg/kg/day in neonates and low-birth weight neonates. Additional symptoms may

include gradual neurological deterioration, seizures, intracranial hemorrhage, hematologic

abnormalities, skin breakdown, hepatic and renal failure, hypotension, bradycardia, and

cardiovascular collapse.

Although normal therapeutic doses of this product deliver amounts of benzyl alcohol that are

substantially lower than those reported in association with the "gasping syndrome," the minimum

amount of benzyl alcohol at which toxicity may occur is not known. Premature and low-birth

weight infants, as well as patients receiving high dosages, may be more likely to develop toxicity.

Practitioners administering this and other medications containing benzyl alcohol should consider

the combined daily metabolic load of benzyl alcohol from all sources.

from the hospira package insert for its formulation of propofol