Passin' Gas

can't answer most of your question, not involved with the navy. however, i would like to mention in may 2003, at the height of the military effort in iraq, 364 crnas and 77 anesthesiologists were deployed as part of operation iraqi freedom. aana website. pg

I remember hearing voices sing "Hallelujah" choruses with the first few intubations! I was so excited to see the 'pearly gates' and have the tube go into the light....I was gently brought back to earth by the CRNA whispering 'you're not finished, inflate the cuff, connect the circuit, make sure it's in the CORRECT hole!' I have to admit I still hear the Hallelujah choruses after difficult intubations. Have a great time on your first day and all that follow, PG

I sent a PM suggesting these very same groups! PG

Best of luck to you!! Congratulations and welcome to the ranks of CRNAs (I have no doubt you will sail through the certification exam!) Any thought of returning to your blog?.... PG

Thanks for the response, heartICU. PTO...PAID time off?? Was that a Freudian slip?

When are classes and exams scheduled? Is there consideration of clinical scheduling and exams, i.e. day 'off' from clinical day before exam? Do you have to go to class at 1600 for three hours after being in clinical since 0600? How difficult is it to study pain pathways, pulmonary physiology, and pharmacology after a 10-12h day in clinical? And what about call schedules...how soon do you take call? Are you required to be in class at 0800 after getting off a 16h clinical shift from 1500-0700 (and, of course, you never even saw the call room)? Both ways are challenging...just trying to bring in some other issues to the discussion. PG

FYI COA (Council on Accreditation) requires an ethics course in nurse anesthesia curricula. Nursing theory, however, (thankfully) is NOT required. PG

Just FYI, there's a few AAs and MDAs who read and post on this CRNA forum. jwk is an AA.PG

Yep, you're right. I stand corrected (and I corrected my post). I know the hypotension is more profound with propofol and knew it had arteriolar vasodilation. Somewhere in time I deleted the myocardial depression. PG

1. IMHO: In my humble opinion2. Propofol does cause myocardial depression, it also causes arteriolar vasodilation reducing SVR. Sympathetic activity is also diminished, damped baroreflex in response to decreased MAP. 3. Highly lipid soluble, fat accumulation occurs with long-term infusions i.e. 10 days in the ICU, not bolus dosing for a short procedure. In fact, the lipid solubility accounts for fast onset, the drug is then redistributed by CO to skeletal muscle and fat, decreasing the levels in CNS and this accounts for rapid awakening. 4. Anyone, I mean anyone, who administers this drug needs to be facile in airway management. None of this "I'm BLS and ACLS certified and can intubate the mannequin 1 out of 3 tries every two years." This drug needs to be administered in persons skilled in airway management including oral airways, nasal trumpets, bag-mask ventilation, and intubation. If you give the drug you need to be able to handle the effects of it. Quote from package insert for propofol: WARNINGS For general anesthesia or monitored anesthesia care (MAC) sedation, propofol should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Patients should be continuously monitored, and facilities for maintenance of a patent airway, airtificial ventilation, and oxygen enrichment and circulatory resuscitation must be immediately available. For sedation of intubated, mechanically ventilated adult patients in the ICU propofol should be administered only by persons skilled in the management of critically ill patients and trained in CV resuscitation and airway management. 5. 51 year old male for colonoscopy. Receding chin, full beard/mustache, moderately obese gets a 'little too much' propofol goes apneic. Patient becomes apneic, can't ventilate, no one in the room able to intubate since the 'bad airway' was not picked up by MD screening the patient nor by the RN 'knowledgable' in the administration of propofol. Anesthesia's all tied up in the OR (remember they're not needed). Hypoxia leading to a vegetative state in a 51 year old male with wife, two kids, and CEO of a financial firm will pay for all the anesthesia providers to cover the GI lab. 6. Proper training for RNs is called nurse anesthesia school. PG

Been in anesthesia for over ten years. I very rarely sit during cases. Enhances my sense of alertness, I'm watching the surgery, keeping up with the progress/complications/completion of procedure. Surgeons and other personnel take note of who is paying attention (if standing is a measure of attention). Yeah, I can pay attention from the stool behind the drapes but I am much more involved in the case when I'm standing, watching actively, and participating in the entire surgical procedure. On the other hand, one CRNA intoned the following advice: Never stand when you can sit, never sit when you can lie down, and never just lie down when you can actually sleep! Now, this individual did a LOT of 16 and 24h call shifts in a trauma center. Hence, conservation of energy was paramount. My current practice setting runs to 10-12h days. Usually 4-8 cases a day. Frankly, I'm too busy to sit. PG

'Tis the ART of anesthesia...Give them what they need, not necessarily what the books say. This skill takes time to hone and read patient's responses to different anesthetic agents and techniques. Good point.PG

Aaahhh, grasshopper, (rather, gaspassah), you learn well...Next, we catch flies with chopsticks.... PG

Help. I got lost with this statement. For starters, I'm assuming you are referring to sevo and des as the more modern agents. These have LOW blood:gas and brain:blood partition coefficients. Hence, they are LESS soluble in fat, so when the gas is turned off they are rapidly excreted via the lungs. On the other hand, halothane has a high blood:gas partition coefficient, a high brain:blood partition coefficient, so when this gas is turned off it is continually taken up by the fat PLUS undergoes liver metabolism, therefore leading to faster than expected awakening with such a fat soluble agent. Sevo and des do not undergo significant metabolism, the rapid awakening is accredited to their low solubilities. Numbers from Barash: (I couldn't post the table as I desired, the numbers are in order of the agents listed first) sevoflurane desflurane isoflurane halothane oil:gas partition coefficient 47 19 91 224 blood:gas part coefficient 0.65 0.42 1.46 2.5 brain:blood part coefficient 1.7 1.3 1.6 1.9 fat:blood part coefficient 47.5 27.2 44.9 51.1

First off, there isn't a truly 'right or wrong' answer. This question is intended to gain insight how you will respond in difficult situations. It's also one of those 'depends on the situation' type questions. This could go either way. Hypothetical example: You are three weeks into clinical and dutifully look up and compose the optimal care plan for a 58 year old male for transverse colon resection, hx of diverticulitis and recently discovered colon CA. Otherwise, fairly healthy, actually ht/wt proportionate. You want to use propofol, cisatracurium, sufenta infusion (case expected to last 3h, slow surgeon), desflurane in air 2L flow and oxygen 2L flow rate. The MDA decides to use pentothal, pancuronium, fentanyl, isoflurane in 1L air and oxygen 1L flow rate. Both are acceptable techniques. The MDA's plan will be less expensive for the patient who is going to be 'in-house' for a few days and for the underfunded county hospital. Propofol? Great, but he's not heading home after surgery; pancuronium, need muscle relaxation for the whole case; fentanyl is less expensive than sufenta; running lower gas flow rates reduces loss of body heat plus,you guessed it, isoflurane is cheaper. Again, patient ain't going home in three hours postop. So, I wouldn't have a great heartache with the change in plans. But say the patient had chronic renal insufficiency, elevated BUN and Cr plus a history of CAD and the doc still wanted to use pancuronium. In that situation, I would defend the use of cisatracurium. Pick your battles wisely. PG