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RedCell specializes in CRNA.

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  1. RedCell

    Ketamine during an emergent intubation

    Cuppla thoughts: 1) If anesthesia reported the patient was a difficult intubation it would have been optimal for anesthesia to have been there to reintubate the patient. Preggos are already documented as being a potential airway disaster and in this patient's case, it was made known by anesthesia during the c-section. 2) Micro aspiration is not usually caught with a bronch. Doesn't mean the patient did not aspirate, it just means that it was not observed initially by the dude doing the scoping. The chest film proves this point. 3) Preoxygenating this patient is not going to buy much time. FRC is crap already in this population and she has ARDS. Still should make an attempt though while getting toys and drugs ready. She needs PPV and PEEP to fix her. 4) Being that she recently delivered she remains at high risk for aspiration and I would have treated her as such. RSI with cricoid pressure until ETCO2 verified sort of thing. 5) Pick any induction drug you want. If dosed properly they all give you the same desired response. With a HR in the 130's and elevated BP, ketamine would not have been my first choice. Not giving any midaz with that dose is odd. Dissociative anesthesia without benzos is wrong (unless you are Jerry Garcia). The Wolf is right, etomidate is a nasty drug. Propofol 2mg/kg would get the job done nicely. Quick onset with fewer side effects. Arguing that propofol decreases oxygen supply to tissues is weak in my opinion. It lowers CRMO2 so that is good enough for me. 6) Rocuronium is nice too, but it is a long acting paralytic that takes a while to give you desirable relaxation for intubation. Also, if you cannot place your tube correctly, you have potentially hosed the patient. You guys do have sugammadex over in Europe so at least you have an out if intubation cannot be accomplished. In the United States that drug was burned down in phase III trials and is unavailable. I like succinycholine for these scenarios. Quick onset and unless you have a pseudocholinesterase deficiency, it is gone quickly. 7) I think my 5 year old could still beat me on the Xbox with 50mcgs of fentanyl in her. 8) I don't think things were too bad yet. Take a look at the ASA difficult airway algorithm ASA Difficult Airway Algorithm - Ether - Resources for Anesthesia Research and Education - Stanford University School of Medicine There are many pathways to take before slashing the neck. Video assisted laryngoscopy is not listed in the algorithm yet, but should certainly be considered an option with this patient probably before direct laryngoscopy since anesthesia has already declared this patient difficult to intubate. Like Wolfman says, it is easy to Monday morning quarterback a case. Don't mean to sound harsh, just wanted to post a few thoughts that crossed my mind upon reading this.
  2. RedCell

    Max on Levophed?

    Low-Dose Dopamine in Patients with Renal Dysfunction: No Benefit http://www.turner-white.com/memberfile.php?PubCode=jcom_feb01_orrrenal.pdf "Renal Dose" Dopamine in Surgical Patients Dogma or Science? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1191298/pdf/annsurg00014-0022.pdf Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Meta-analysis: low-dose dopamine increases ur... [Ann Intern Med. 2005] - PubMed - NCBI
  3. RedCell

    Max on Levophed?

    Sounds like you are dealing with some variation of septic shock. This game is about MAP and preservation of end organ perfusion. There is no "Max" dose of norepinephrine. It is just a nursing myth similar to renal dose dopamine. Your doc was correct and he was referring to mostly observational studies done in the late 1990's up to present day. Norepinephrine has also been shown in some research to reduce mortality and protect end organ perfusion more efficiently than other pressors available. When you are up to 40mcg/min of norepi or higher, what else can you give that is going to press the patient more?? Okay, hang some vasopressin. You most likely will see a higher MAP because you are shunting more blood from the periphery back to central perfusion, but what do you think splanchnic perfusion looks like? The kidneys turn into the Sahara and the gut will be dead. It would be interesting to know the pH and SID in this patient. Receptor sites for pressors and inotropes do not work so well after you start dropping below 7.1. Sometimes Jesus wins and protoplasm loses. Here is a retrospective study that looks at conservative vs liberal use of pressors in septic patients. Liberal vs. conservative vasopressor use ... [intensive Care Med. 2008] - PubMed - NCBI
  4. RedCell

    Ketamine for adults while intubated?

    Ketamine is an excellent drug with outstanding analgesic, amnestic and sedative capabilities. The trick is to avoid the dissociative effects if benzodiazepines are not being administered. I use it quite frequently on my patients, especially the ones who associate a bottle of oxycodone with a Pez dispenser. I think you will probably be seeing it used much more in the ICU setting now that fentanyl is on a national shortage.
  5. RedCell

    How do you pick your vein for an IV?

    I pick the one that is the best fit for my 3/4" 14 gauge. Typically that will be either the cephalic vein or somewhere in the dorsal venous network.
  6. RedCell

    Anti-CRNA website= such B.S.!!!!

    There are hate groups, anti-this or anti-that fan clubs for just about anything and everyone. What are you going to do. Look at the stinky hippies on wallstreet....they hate capitalism and free enterprise. Everyone needs their moment to shine. I personally hate name tags with an alphabet soup following their title. You should check out my website. Don't get your panties in too much of a wad though, pretty soon McSleepy will replace all anesthesia providers and the gravy train will come to an end. Newly minted Anesthesiologists, CRNAs and AAs will be the new guys marching in New York (in desperate need of a shower) demanding Obama refund our student/goverment loans. You would probably get a bigger rise and find you original post more fulfilling if you posted it on the “other” website…..You know which one I am talking about dude.
  7. RedCell

    Does it bother CRNA's that MDA's get so much more...?

    Carol, when a poster comes into a CRNA forum and chooses to inaccurately describe our profession, education, licensing and even our title....they are going to get called out on it. The original question was answered. I think the "tangent" was the most beneficial topic discussed in this thread. Hopefully those reading these posts will come away slightly more enlightened and tangents such as the ones you described above will not be necessary in future communication.
  8. RedCell

    Does it bother CRNA's that MDA's get so much more...?

    A fairly large part of nurse anesthetist education focuses on the history of anesthesia and that of nurse anesthetists. CRNAs have NEVER been called assistant anesthesia RNs. Aside from anesthesiologists and CRNAS, the only other provider in the United States that is legally licensed to provide anesthesia is an anesthesiologist assistant. JWK would know this better, but I believe they first opened their doors to education in 1969 at Case Western Reserve. Again, how about taking a look at that book I recommended.
  9. RedCell

    Does it bother CRNA's that MDA's get so much more...?

    the level of ignorance regarding the nurse anesthetist profession on this website is absolutely astounding. that is why you do not find too many crnas posting. crnas have actually been around for more than 100 years and "otjt" ended in sister mary bernard's day (1880's). i have never heard of an "assistant anesthesia rn". i have heard of anesthesiologist assistants. they are not necessarily nurses but they have been practicing for over 32 years. there are also no programs that run 15-18 months and you cannot get your degree online. we do not practice under a physician's license. we practice under our own license. we are allowed to administer anesthesia independently. in fact there are many crna only groups throughout the united states. do you think crnas in the armed services practice under the license of an anesthesiologist? may i suggest reading a book called watchful care by marianne bankert. it will give you a pretty solid history lesson concerning nurse anesthetists. also, if you really want to know what we can or cannot do, check out a more reliable site, aana.com. that way, the next time a poster would like to comment on the practice rights of a crna they will be accurate. if one is angry with their salary or resentful of someone else because they make more...welcome to life. it is not always fair. there is no rule that says it has to be. crnas are paid what they are worth because of market demand and location. want to make more, go work in independent practice, moonlight or move to a rural location. no one is stopping you. http://www.amazon.com/watchful-care-history-americas-anesthetists/dp/082640510x
  10. RedCell

    Lactated Ringers vs .9NS

    Sorry, but many of these statements regurgitate perpetual nursing dogmas that once investigated are easily proven wrong. The crystalloid with the most physiological resemblance to plasma is plasmalyte not ringer's lactate. Ringer's Lactate is actually very common in the hospital setting. Normal saline is not the only crystalloid that can be given with blood. The fact is multiple solutions can be co-administered with packed cells. Plasmalyte A and LR are two that are perfectly safe. Yeah many quote the whole citrate/calcium interaction creating the proverbial clot formation. This is way overblown. Think how much calcium is in LR....2.7-3mEq/L. Will this really cause problems? Maybe if that blood sits in the tubing for six hours. Multiple studies from 1980 up till present day have concluded that this is more myth than fact. Students, do more than read your textbooks. By the time you enter your nursing program and start reading them they will already be out of date. Push your instructors to give you data to back up their claims and do your own research. The more you explore, the more myths you will uncover.
  11. Women
  12. RedCell

    Why no air bubbles in IV lines for cardiac patients?

    If there is a communication between the left and right heart and right sided pressures exceed left, air can get into the aorta where it enters the arterial circulation. This is bad. Actually, air in the heart can do some interesting things when there is a defect. You should go to youtube and check out some echos where bubble tests are performed.
  13. RedCell

    Why no air bubbles in IV lines for cardiac patients?

    Look up right to left shunts and this will give you a good idea of the people at risk. The majority of the time a small amount of air in the venous system goes to the right side of the heart, into the pulmonary artery and gets blown out in the lungs. It doesnt matter if they are "cardiac" patients or Lance Armstrong.
  14. That is not exactly the best way to answer that question. Mreicher pretty much was correct in regards to blood loss. Think of a bag of packed red cells. The hematocrit averages 70%. Pour out half of the blood and while the volume has decreased the remaining blood will still have a hematocrit of 70%. In acute blood loss doing a CBC will not help. There would be no difference between hemoglobin and hematocrit from what it was before the bleeding occurred. After a few hours plasma volume will be replaced by fluid from the interstitial space and you will then see a decrease in H&H. Also, there are many other methods that aid in assessing blood loss and volume deficit. Lactic acid and base excess are a good place to start looking if you want to read into this topic further.
  15. RedCell

    Can I be a CRNA with Malignant Hyperthermia?

    I find this statement quite amusing. What do you think YOUR healthcare provider (FP or even internist) knows about MH? I guarantee you it is less than that of a first year SRNA or AA student. Based on a recent event I was involved with regarding MH, it is quite surprising what little is actually known of this condition once you leave the OR.
  16. RedCell

    I want to know

    Look up Cushing's triad