Ketofol

@Tampa Two I understand your concern with NMBD allergic reactions. Definitely something to consider. With that said, I've had CRNA preceptors that paralyze everytime there's an ETT in and the anesthetic is smoother, less hypotension, less pressors/fluid, and more room to work with when giving analgesic medications. I don't understand why people would "cringe" at the thought of paralyzing when it's not required.... In the days of superior medications (sugammadex) why not take full advantage of it? Reversal with sugammadex is so fast and residual paralysis is unlikely if dosed appropriately. Side effects are also minimal....Running someone on 1-1.3 MAC or loading them up with a ton of narcotics is so unnecessary when you could just give 30-40 mg of Roc and keep twitches around 2/4. Then work in meds that will help out with postop pain/discomfort instead of battling HoTN with high volatile which does nothing for the patient postop (big source of N/V and delrium). Remember, sedation to prevent movement is significantly more than what is required for amnesia, unconsciousness, and pain. A complete anesthetic is using meds for their intended purpose (amenesia, analgesia, and areflexia).....IDK, maybe I missed something. It just seems people are stuck in the "old mindset", similar to video-blades and qualitative neuro-monitoring.

@offlabel Setting up a Neo gtt also takes more work as well haha Paralyze, 0.6-0.7 Mac of Volatile, a little dilaudid and Precedex/ketamine, PCV-VG on the vent w/ necessary PEEP, open Sodoku and put feet up LOL.

@Nurse Pompom The level of sedation/analgesia that's needed to prevent awareness and block nociception is so much less than what's needed to block reflexive muscle movements (or reflexive autonomic actions such as aspiration and spasm). For example, a cysto, bronch, or breast biopsy is actually not super painful AFTER the surgery is done. No much sedation and pain meds are needed, but a significant amount of "sedation " of some sort is required to prevent movement. Sorry, just trying to figure this out and it's bothering me. Clearly im wrong because its a thing haha. Completely appreciate any and all responses

I'm a senior SRNA and gonna be graduating soon. I have a question that I have to ask because I can never get a straight answer. For cases where paralytic is not needed, but you have an ETT in (d/t airway control, NPO status, etc...) why wouldn't you just paralyze anyways so you use significantly less volatile gas and have better hemodynamics. This is considering that you have sugammadex available. This way you can give narcotics, precedex, ketamine, whatever you want, with plenty of blood pressure to work with? Some preceptor say it's better to not to paralyze if you don't have to, but I don't understand when you have sugammadex? Preceptors recommend not paralyzing and just turning down the gas for hypotension, yet when I get under 1 MAC, that's when I've had times when patients either move or buck (or laryngospasm with an LMA). I'll try to titrate narcotics in to keep respiratory rate low but there's still NO guarantee that the patient won't flip out. I feel it's either: 1) Paralyze regardless, use gas for amnesia/unconsciousness, and analgesic meds for HR & BP 2) Don't paralyze but keep patient on more than 1 MAC gas and accept having to give pressors or start a neo gtt a lot! Sorry for the long question. I just don't understand what I'm missing here. Is the risk of coughing, bucking, spasming, hypotension, and pissing off the surgeon worth not having to paralyze?

I have 2 good job offers and need some advice on which to choose. Both offer excellent pay as a full time 1099 (1 slightly more than the other). Job #1: Larger Variety of cases (except Peds). 8:1 supervision model. Spinals, Epidurals/OB, and New peripheral nerve block program (less blocks than Job #2). In a boring unfavorable location. More pay tho! Job #2: Decent variety of cases but less than job #1. 8:1 supervision model. Does include Peds but NO OB/Epidurals. Heavy peripheral nerve blocks and Heavy Ortho. Every peripheral block imaginable is done there but no Epidurals or labor Epidurals. Older equipment! Nicer and favorable place to live. Do you think getting excellent at peripheral nerve blocks or at OB/Labor Epidurals is more important for a new CRNA/1st job?? I know just getting confident running a room is most important, but I wanna know btw blocks and Epidurals, which is a more marketable skill??

I'm a SRNA just starting my 3rd year (Senior year). Despite having amazing grades and solid clinical sites/experience, I feel as though I am not where I should be. I believe most of my class is ahead of me and simple physical tasks are huge hurdles for me (which they shouldn't be in Senior year). I still struggle with mask ventilation (also im useless in breaking a laryngospasm with positive pressure!), my intubations are sometimes successful but Rough and not smooth, LMA insertions are 50/50 but haven't gotten good enough that I can insert them from the side if needed (HOB turned away), and still don't have a solid work flow down, leading to accomplishing tasks too slow for quick surgeries. I realize that regardless of my hardwork and persistence, I don't have the "IT" factor and what's required. IF I make it thru school, I feel I probably should stay away from the OR considering my inability. Does anyone know any non-patient careers you can do as a CRNA. It's unfortunate because I love Anesthesia, but after hundreds of attempts I realize it's not in the cards for me.