Maximus

This is the topic my class strugled with the most the 1st semester, so yes it is very tricky and not just you. Lets continue with alfentanil since you brought it up... 1st you have to know whether the actual drug compound is a base or an acid. As you know bases have a ph > 7.0 and acids have ph 2nd you need to know wether the drug solution is an acid or a base. This is easy if you know what the drug compound is. Alfentanil solution is an acid. It has to be for the drug to mix in the solution. If alfentanil were mixed with a basic solution it would stay unionized (hydrophobic) and precipitate. It must be mixed with a acidic solution where it turns ionized (hydrophilic) and can mix in solution. This is why you see a clear solution w/o precipitate when you look at a vial. 3rd you need to know the pka. For alfentanil is is 6.5. We know that alfenanil is in an acidic solution that is lower than 6.5 (probably somewhere less than 4.0 to make sure it is almost completely ionized). 4th you need to know physiologic ph which is usually around 7.4. So we inject the alfentanil solution into blood and the drug moves across its pka where it becomes about 90% nonionized (hydrophilic). This allows it to move across the BBB to its effect-site very quickly. It does it even faster than fentanyl or sufentanil for this reason. That is it very basic drugs in acidic solutions. Then there are acidic drugs in basic solutions like thiopental. It is an acidic compound that disolves in a solution that has a ph of 10.5 (very basic). When it is injected it crosses its pka at 7.6 and becomes more nonionized. Then there are drugs you don't want to change when injected like NDMR. Whe vecuronium is injected it does not cross its pka and remains entirely water soluble like it was in solution so it never crosses the BBB. Then there are a few weird ones like propofol which is in an emulsion so is never in a water-soluble form of the drug. It never has to dissolve in anything. As far as the ph of the blood varying, it matters more when the pka is closer to 7.4. You may see varying effects of thiopental b/c its pka is 7.6. But really in practice you give how much drug is needed and never consider this. Hope this helps.

R4 is also used in the same way in hemodynamic equiations as the radius of arteriols that affect systemic vascular resistance. All these calculations are based on Ohm's Law: flow= pressure/resistance.

It sounds like you great experience, prestigious undergraduate degrees, and the maturity it takes. I agree that your GRE is the weakest area you discussed. If you don't get it maybe you should try taking it again. Good luck!

I live on the west coast where there are few CRNA programs so I am moving cross country even though I love where I live. My wife fortunately is able to come with me. All schools are different. Some have all local clinicals and others you commute to or stay long term in another area. I would think that things would be pretty close together in Florida. My thought is that if this is your dream and you really want it then even big barriers like geography and family seperation won't prevent it from happening. Everyone has a different marriage, but the way I feel about it is that in the long-term my wife and my family are the main priority but in the short term I may have to make something else a priority to make a better life for us. A sense of delayed gratification really can bring a lot of happiness down the road.

Lasix would not make sense in chronic renal failure unless they are trying to use it as a venodilator to allow the large veins to store more fluid and take the workload of the heart. But nitro is much better at that. If the pt is in oliguric acute renal failure then lasix can help to jump start the kidneys. The difference is that CRF is irreversible damage to the kidneys. The pulmonary and arterial pressures don't help determine much with this patient unless you also look at the filling pressures (CVP & PCWP or wedge), cardiac ouput, SVO2, and SVR. In order to determine why your pulmonary and systemic pressures are so high you have know whether the problem is with preload or afterload. Preload is represented by the filling pressures and they help to determine if this pt is fluid overloaded which is very possible in this pt. My guess from the info you provided is that the pt is fluid overloaded and may need dialysis soon. In the meantime, nipride and/or esmolol would help control his BP and decrease the chances of any surgical bleeding from occuring.

I only had to interview once and my interview focused mainly on what type of person I am and what I had done to prepare for a vigorous graduate program. I would recommend being prepared for different types of interviews. Then when you get into the interview you will be able to see by the direction that they take what they want to find out about you - clincal competentce, knowlege of CRNA profession, how much you planned for grad school, or what type of person you are. If you go into the interview focusing on the interviewers needs then your more likely to address their concerns. My interview focused on me as a person and how much I had prepared for grad school financially, in relationships, and by having realitstic expectations. I had to drop all the weeks of planning for clinical questions and focus on those issues. Also by focusing on their needs in the interview, I think it shifts your focus off of your own nervousness. I don't mean to be totally flexible though. It is still good to have a few important points that you want to come across in the interview. For me, since I was younger than most applicants, I wanted them to be assured that I have the maturity level for grad school so I conveyed that in many of my answers. I think a few other things are important. Blow off steam that morning, no caffeine, have meaningful questions, and write a follow-up thank you letter or e-mail within a couple of days. Good luck!

I get five days off a year, 10 additional days at Christmas, and 5 educational days a year. No breaks between semesters.

Please listen to yogaCRNA. He represents the profession unlike many who are posting here. I start CRNA school in January and really hope that my fellow students demonstrate better ethical judgement than the student you are talking about. I almost got kicked out of my BSN program b/c another student got ahold of one of my papers and used my ideas and wording without me knowing anything about it. It took a lot of effort to clear my name. It is a very scary thing to almost have your dreams shattered b/c of people who are willing to cut corners. Cheating is disrespectful to colleagues, the grading system, your institution, and your profession.

I was just reading my post and I meant to say 40000 patients a YEAR experience awareness.

I find this subject fascinating, and that is why I wrot an essay about it a few months ago for a scholarship. The incidence of awareness in noncardiac and nonob cases is 0.2% (Anesthesia, 1991). It is much higher in ob, cardiac, and trauma surgeries. At that rate it amounts to at least 40000 pt's at day. Luckily most of the patients who experience awareness do not also experience recall. So they experienced all the suffering at the time but don't remember it afterwards. There actually is a lot of research about the bis monitor that is totally independent from Aspect Medical Systems. Research does show that is a good indicator of depth of anesthesia. It can do this even better than blood concentration levels of certain anesthetis (Anesthesiology, 1997). But not perfectly, a case report showed that a child demonstrated awareness at a bis score of 47 - supposed to be deep anesthesia (Anesthesia and Analgesia, 2001). How many of our monitoring systems are perfect though. However there is no research that says BIS monitoring can prevent intraoperative awareness. It may help indicate depth of anesthesia but it is a little bit of a leap to turn that into preventing awareness. The reason there is no research is b/c at an incidence rate of 0.2% a powerful enough study would require a huge sample and thus very expensive. I would argue that we need this study though. 40,000 people is way to many. Awareness is real and it is a major fear of patients. Anesthesia providers may believe they have a perfect record but some studies show that it is underreported or disregarded by health care professionals.

Anyone have experience with BIS monitors or other monitors that monitor level of consciousness? Are they effective? If they are available at your institution, do people use them?