FockerRN

No offense intended to anisettes, but isitpossible's explanation is more accurate. Hypotonic - solution has less sodium (as was stated later by @Isitpossible, tonicity is about solute, though na is the greatest component in osmolarity of the human body, it is not necessarily the best way to think about it...think solute. Also, I deleted this part from above but water follows sodium in general, not the other way (in the human body that is) and that is what makes the choice of a solution so important. If i give a hypotonic solution (d5 for example) the water in the solution will "attempt" to equalize the osmolarity across membranes (water generally flows freely across membranes....a few exceptions such as parts of the kidneys...but sodium and other ions require help in some form or another [active transport and membrane proteins that act as channels] to cross cell membranes) and since water moves freely the area with the higher osmolarity (the inside of the cell now that i added water to the outside) will attract the water and thus cause the cell to swell.) than that of the patient's currently circulating plasma. Would be used to push (minor point here but the water is being pulled into the cell) fluid from the vascular spaces into the cells. Too much and the cells will explode. Will decrease circulating volume, so you'd use it when you don't want increased pressure like cerebral edema (this is the major reason i responded and did not just let this all go because it is mostly somewhat academic. The lesson that needs to be heard is that you do not ever give hypotonic solutions to patients with cerebral edema, the cellular swelling can be very detrimental to the pt's icp and any possible vascular decrease will be outweighed by the cellular edema. In fact, you give patients with high icp's hypertonic solutions to draw water from the cells to reduce that portion of the cerebral mass...no room for an icp discussion here), or in a dehydrated patient with very high electrolytes, etc... Isotonic - Has same sodium concentration of plasma. Use to replace volume in cases of blood loss, or to maintain hydration. No fluid shift between vascular spaces and cells (again a minor point but it would probably be better to think of it as there is no/minimal fluid shifts between the extracellular space and the cells...again minor but the interstitial space needs to be accounted for in these equations)- they're equalized. Hypertonic - Has a greater concentration of sodium than circulating plasma. Pulls fluid from the cells into the vascular spaces. Too much and the cells will crenate or shrivel up like prunes. Will rapidly expand circulating volume and might be used to treat bad burns, septic shock (again, somewhat minor, but use of hypertonic solutions in these circumstances are generally, at least in the us, saved for prehospital and battlefield wounds. In the hospital you would almost certainly be use ns/lr for these patients because the benefit of hypertonic solutions is quickly lost and become damaging once intracellular and interstitial volumes start to become depleted. You also would end up with ridiculously high na concentrations in the blood which is not good. As a note, most all of what i am saying is based on us practice and there may be differences in other countries.), etc... Hypo and hyper tonic solutions should be used carefully and patient observed for signs that treatment has progressed beyond the theraputic response could not agree with this statement more. People tend to take more care with hypertonic solutions but too often it seems that we overuse d5 especially.. As an aside, this makes me think of a great set of podcasts I have listened to in the past that might help with this and a number of other tricky subjects. The podcast is icu rounds and is by dr. Geoffry (jeffery?) guy who is the director of the burn center at vanderbilt university. Very informative and very good. Again, no offense is meant by my response but i felt the need for some minor disagreement. Of course if anyone feels that i have said something wrong please feel free to correct me, i'm always interested in learning.

I stand corrected about STP availability. All I know is that generally in the area I am in there is narry a drop to be had. The problem with STP and Propofol are that they are not money makers for the drug companies and thus they are not going to do too much extra to manufacture the drugs.

Thiopental is no longer available for use in the United States and if you had some you could probably get a pretty penny for it from one of the states that has a current backup of executions. The last manufacturer of STP moved their operations to Italy and the Italian government essentially blackmailed them into not selling it in the US because of it's use in lethal injections. So, unless you are at a place that stockpiled the stuff it isn't generally available on any anesthesia cart. D-tubo curare has not been on the market for quite a long time due to it's nasty side effects (lots of histamine being one of the worst). While it may be that the strict ASA definition of RSI is as you have said, however due to the inability to acquire the drugs stated it is an impossibility and thus merely semantics. RSI can be accomplished with a higher dosage of Rocuronium instead of Sux if necessary (with an MH patient or a patient with high K) and this may be more correctly termed a "modified RSI" but in the end it is semantics. Some questioned the use of etomidate but it may be that this person was best sedated with it due to unstable hemodynamics. In the end though the OP is correct because, as has been stated, the difference in duration of action is quite different the patient was in need of something to sedate them. So, you aren't crazy....

Goodness, you starting to sound like a broken record. The whole "war" thing was saying that if you want to argue a subject such as this then you need to come armed with something other than "because I said so and I'm a doctor so I must be right" and "a doctor automatically makes it all safer". I am fine with people knowing who their anesthesia provider is and the AANA is working so that the public knows who CRNA's are and how they are safe and exceptional providers of anesthesia; with or with out an anesthesiologist "supervising" them. I didn't mean supervision in the sense that you mean it, I meant a collaborative environment where CRNA's work together (even with MD's *gasp* THE HORROR) and provide assistance to one another and the ability to...collaborate. Of course the ACT model is all about MD supervision, it is the pet of the ASA so it automatically is all about the doc being "captain of the ship" and all that BS. I'm sure there is a place for it, but in the economics of today's healthcare the number of places is dwindling. You see, there are multiple studies that show that CRNA vs. ACT vs. MDA solo are all equally safe and guess which one is the cheapest model? There is not a comparison of the educations of MDAs and CRNAs, both very different but as studies show (most recent from Health Affairs) the outcome is not different. You come around and say that it is obvious that having an MD involved in a supervisory role is automatically safer...prove it. That is purely an opinion that has been proven wrong by fact (peer reviewed studies in reputable journals). I know this is going to make you mad, but the argument that the ASA has against CRNAs is not about safety. That is a losing argument, but it is all they have. The ASA and the MD's that agree with them can atempt to scare the public and smear CRNAs but the facts do not support their dictates of safety and superiority. It sounds like the Wizard from Oz "do not look behind the curtain!" The reason the ASA argues so hard is not altruistic love for their patients (not that docs don't care about their patients, so don't try to put words in my mouth) it's all about the all mighty dollar. As each healthcare dollar is scrutinized and it is seen that CRNA solo practice is safe and economical then the money to the MD's start disappearing. Stipends to support their salaries disappear, ACT practices where they can bill for half of the work that they had no part in disappear etc... In the end the argument is not at it's heart about safety it's about money. Do I blame them for trying to protect their pocket books? No, not really, but to try to put it in terms of safety is just dishonest. Your turf? Fine, whatever you want but when you decide to start spouting your dictats on a website for nurses and CRNA's don't be surprised when you are challenged.

Way to avoid the point all together and try to get out of it by taking the "high road". You come and say that anyone in the "know" wants a MDA and that CRNA solo practice is unsafe. First, as the money gets tighter in healthcare all those hospital administrators that "prefer" a doctor providing anesthesia will start changing their tune when they look at the stipends that they have to pay their anesthesiologists to keep them around. Second, and more importantly, where is your proof that solo CRNA practice is unsafe? Journal article? AHRQ data? Anything? Do you have anything other than "I said so and people think doc's are super cool and smart so they are obviously superior"? Your perspective is not unique it is just the party line of the ASA. So, when you find some data (evidence based and peer reviewed) that solo CRNA practice is unsafe then feel free to share. Until then I think this discussion is closed.

No, sitting on the fence essentially makes you holier-than-thou.... Patient safety? Research study after research study has shown that independent CRNA practice is as safe as ACT practice and MDA only practice, period. You were uncomfortable? Fine, don't work in that area if you don't feel qualified. CRNA's have been providing safe care (and economic as well) for quite a long time, as long as or longer than physicians. Physicians, historically, jumped into the anesthesia circle when the money showed up, not when they thought that it would benefit the patient. As far as professional parity, if nothing else, inside the operating room there is parity in skill and ability. What really irks me in these arguements is the assumption that because someone went to med school that they are inherently superior in all things. One final thing for another poster, supervision is all about billing. That is not opinion, nor arrogant, it is fact. The reason the wording is in federal law is to try to keep MDA's and hospitals from defrauding medicare. You see, historically doctors were "supervising" for the most difficult parts of a case (induction and emergence) but were not actually around. They billed as if they did something but in fact were doing nothing. This made the government angry so they said that for the doc to bill they actually have to be there. There is nowhere in federal or state law that says a CRNA has to work "supervised" by an anesthesiologist. It infuriates me that a question about fraud from one group (anesthesiologists) has been spun into a question of safe practice. If anyone wants to find a real, evidence based and peer reviewed article that shows that independent CRNA's are less safe than their MDA colleagues please bring it forward. Otherwise those on the side of MDA's (docs or those carrying their water) are arguing a loosing battle based on their misguided and baseless opinions.

CRNA 2012, I was just messing with you...sorry . I know the internet is a bad place for such humor but I couldn't help myself. Focker

CRNA2012, You are right they don't need to worry about the first few posts but the OP asked what got us into school. I wrote what got me into school. I'm glad that you are an expert on me and my psyche. Give me your email so I can ask you some questions about why I say the things I say on any given day. You can also help me to be humble like you so I don't sound so arrogant in the future. Many different things get many different people into school. Some get in due to their great experience with marginal grades and GRE. Some get in because of grades and GRE with minimal experience. Some ace the interview and really impress the adcom. There are many ways to skin a cat, you just gotta figure the best way for you to skin that cat and not necessarily the way someone else would.

Your right, Ca channel blockers are a big no-no, but why not LR? I guess the K? It didn't think it had enough to make a huge difference but NS would probably be best and safest. Watching the CO2, as one person suggested, is the earliest sign but if they transferred them to the floor then they were not watching CO2. This whole situation sounds somewhat strange to me. Did they not find out about the MH until after the case was done? Was it a direct relative or was it the 2nd cousin once removed? If they knew there was a chance before hand then they should have prepared the room without triggers (new or thoroughly flushed machine and no succ's within a mile of the room). If there was a real threat then they should never have left PACU. Also, if you would have caught the MH by his temp then it was probably too late. Temp is the latest sign, as someone said, and the whole process has been going on way too long if you caught it that way. If there was a real concern about MH then whoever sent them to the floor was negligent.

I'm glad you brought up about the slow correction of hypernatremia. We had a couple residents decide to correct a particularly high Na with D5 one day and the next day they dropped the persons Na by a significant amount (greater than 6 I think but I don't remember for sure). When the attending saw this, he was somewhat cross.

What you have to realize is that just about every solution we have is "scary if overused". Little that is done to patients is benign but you have to weigh the costs and benefits. Especially in the critically ill, which I am most familiar with. If treating hypernatremia IV many of the docs I worked with would use D5 because it is essentially free water in the veins. I've never seen them use 1/2NS but it seems that it would have a similar effect and have less effect on a patient's blood sugar. The best way to correct hypernatremia is through free water via DHT or NG. We need to ultimately dilute the high sodium levels in the blood. One thing to also note is that with crystalloid, in a healthy patient, only about 33% remains intravascular and the 1/2 life is liek 20-30 minutes. So, if a patient gets a lot of fluid (hypo or isotonic) they are going to swell until back near homeostasis. In a sick patient the number drops to 25%, so only 250mL of a liter bag will stay IV. I also have to agree with kindaquazie. Nursing students begrudgingly trudge through chemistry and biology (if they even take it at all) and are glad when done with physiology. However, these classes are more important ot what you are going to do on a day to day basis than 50% or more of your nursing classes. If you understand the chemistry and physiology behind drugs, disease processes and treatments you can be much more effective. Nursing schools and nurses do themselves a disservice by not emphasizing these aspects...I will now step down from my soap box and go back to studying opioids and IV induction agents.

I agree that I didn not answer the question, but I would say that they are asking the wrong question. Trying to track down meaningless stats is not useful.

What they are in for is spending their life as they know it studying and in the OR. It is a time commitment that takes up most all of your life while you are in it. Asking the number of clinical hours is not going to tell you a thing. How many semesters is it over, will I work through Christmas and every other holiday in a year? Asking the number of clinical hours doesn't make sense. Understanding that it is a massive commitment of your life for the length of the program is what you need to come to grips with.

What difference does it make? It is a full time job between classes and clinical. You are there until you go home, and then you study until you go to bed. Number of cases of various kinds you do is relevant, when you start clinical is relevant but number of clinical hours is not.

ummm, I'm sorry you are having a difficult time finding a job and all, but discrimination? Please! Hospitals have every right to "discriminate" when there is more supply than demand. As you noted the experienced nurse provides a cost benefit to the hospital that you do not. When given a choice they will most likely hire someone with experience over an unproven, experienceless new grad. I'm sorr that the nursing fantasy world of limitless job opportunities has dissolved into a world where you have to work to get a job (God forbide!), but that is what has happened. Grads in most every other discipline (especially those with only undergraduate or associates) have to beg borrow and steal to get a job theses days. Nurses are faced with the options of working a little harder than in the past or having to move to get a job and all they do is complain. If they looked at you and decided you were too old, the wrong color or maybe even the wrong sexual orientation to do the jobe then you could claim some kind of discrimination. Looking at you and thinking you don't have enough experience? That's just good business sense.