gaspassah

from what i understand the dnp will be awarded primarily due to the amount of clinical hours most crna programs are completing. many are just a few hours shy, probably just end up doing a couple months more in clinical, with a few extra classes.

i have given it bolus by mixing in the standard fashion then drawing some in a 10 cc syringe to give by 1 ml increments. i will also free flow cardene on regular iv tubing if the patient has an art line. i use it alot for intracranial interventional radiology stuff, aneurysms and the like. it is a very safe drug and has a relatively fast half life. doesnt stick around for very long. d

if doing motor evoked potentials mep's you shouldnt use nmba, the tech is supposed to monitor for the quality of the twitch, not just is there one, it's kinda like measuring tof ratio for us. sseps, some say you can use nmbas some say you cant, usually 1/2 mac with agent and propofol gtt, or straight tiva. we do tiva at my intitution. prop and remi g

i think they are fine, ive used them in the past. only thing is make sure your emergency drugs are in an open drawer for easy access.

dont forget that although halothane was used for many years and was a good agent, it sensitizes the heart to catacholamines. if you give local with epi, you can get vtach vfib rather easily. this is one main reason it fell out of favor. d

it's a great block, i too learned it at the navy when training at kaiser. however noone knows what it is here in miss and trying to get them to learn or try it is like beating your head against the wall. it's much easier than an interscalene imho. d

where i did my anesthesia peds training they didnt want you to use sux on kids for spasms. their treatment was major positive pressure and time, as hypoxia has a muscle relaxant property when it gets low enough. the few i had to handle would usually break around a sat of 72%. you may need to treat with atropine but not always. secondly, kids are very parasympathetically invervated so if you do choose to use sux always give atropine with it or you may get significant bradycardia.

2. OR warm and QUIET during induction and wake-up. this is a biggie for me, and the scrubs banging instrument trays all over the place on the metal carts doesnt help either.

suzanne, i was wondering if you had evidence to support this statement. as a practicing crna i have been under the impression that crna's can work independantly in all 50 states. the only restriction to practice being hospital policy, not state nursing law.

never fear!! underdog is here!! for those of you old enough to remember that cartoon, i would reply to this but we already talked about this one, what's up underdogdude? anymore issues in recovery? d

i dont normally use defasicualting doses. i read somewhere that nmb can cause myalgia just as using sux can, and just surgery can cause it. i also like to see some twitching, just another way to know when the pat is ready. during the end of my training and now that i have been out about a year, i have been using narcs more heavily (i get to make more of the decisions now :) i have found in your normal ((whatever normal is really) just not elderly or infirm)) i give 5 ccs of fent before prop and lma placement and find that the patients return to spontaneous breathing in about 5 min. this is for cases as short as 45min to 1 hour, i dont titrate anymore in and they usually awake really smooth and comfortable. if you are familiar with the dose response curve, this is what i base this technique on. i do roughly the same thing for longer cases with a tube, i just give larger doses of fent.

i first concider the use of an lma to be no different than using a mask. the risks are the same as the airway is not protected. therefore my use of the lma is for spontaneously breathing patients. i never use nmb for lma, we have an attending that will put proseal lma's in trauma pts, put them in prone cases etc. when i am staffing his room, we have had words on this practice, i tell him to get another crna cause i wont do it. the point of this story is if you are just starting in anesthesia, these are the times when you begin to develop your own practice and decide how you will practice in the future. you will hear alot of anecdotal evidence that is hardly ever backed up with hard science. if it sounds fishy and smells fishy it probably is fishy. now more directly to the point, nmb agents should not be needed for lma insertion, you can intubate patients if they are deep enough without nmb. give some prop and mask with sevo.

i dont usually use much more than about 5 mg versed titrated. i usually do the transtracheal nerve block with superior laryngeal nerve block and lido 4% nebs/

in the OR cric... in the field, have someone do a chest compression and intubate the bubble. d

i do about 1/2 to 2/3 of my work as a peds crna. there are no specialty schools per se. there are specialty rotations at about every school for peds tho. i think to be a peds crna, work somewhere with a peds hospital, or one that does a rather large peds service. most ppl don't like peds and anywhere you pony up to do peds they will train you and or get you the experience. d

first i would like to start off with the statement that i usually try to stay out of these arguments as they tend to go nowhere. however, this time i'll jump in and give my 2 cents. i am a crna and work in an institution that trains both SRNA's and residents. some of my training was also in this type of setting and i have seen how both are done. to make the statement that physicians are better trained or have more experience because they are md's and go through residency programs that offer many different experieces is just not accurate. are they trained more in medicine, sure, in mediciine. nursing has it's own advantages when it comes to anesthesia that medicine does not have. i'll use the icu as an example as that is where my nursing experience comes from. while the resident sees the patient and writes orders on the care of the patient. i am the practicioner that delivers that care, i sit at the bedside for 12 hours titrating gtts, pushing med, manageing fluids etc. and documents and observes the effects on the patient and adjusting the plan within parameters. so delivery, observation and titration of all sorts of agents, i think, gives the nurse the advantage when assessing changes in the patients dynamics while under anesthesia as this is what we do at the bedside. this is what i'll call vigilence. residents will get to manage, through the nurses for delivery, the care of pts with htn, pe's diabetes etc. but the management of these under anesthesia is different than trying to optimize the patient for daily living. any emergency in the OR can be treated equally well by any well trained anesthesia provider. the key is knowing what drugs to use when, in some cases, which is why we take pharmacology. other times it's just abc's and supportive actions at other times. neither of which require a residency rotation in ER, ICU, Internal medicine etc etc. airway management that was mentioned earlier is a skill that a monkey can be taught, thats why as CRNA's in training, youre paired with a CRNA to teach you these skills, i now residents and attendings that couldnt start an iv if their life was on the line. so that argument holds no water. also it has been stated on the board more than once that anesth. residents have better training in anesthesia. that is just plain bogus. i have no randomized control trial study to back this up, its anectdotal at best, but i have witnessed 3 residency training programs, which for reasons known i can't state who they are, put first year, first week residents in a case, when the only anesthesthesia training they had was when they were given a copy of morgan and makhail a day earlier and were told to read the first 3 chapters, and were left alone with the patients, to manage the case. i have actually had residents, just a couple mind you, whom i was paired with as a senior student state they felt they had no idea what they were doing and that we were much more prepared to be in the OR initially. this was after several discussions on patient management during the case. medical anesthesia and nurse anesthesia get to the same destination but often get there by different routes. i can tell, with about 95% certainty, after observing an anesthesia provider for about 15 minutes if they are a doc or a nurse. most seasoned providers will tell you the same thing. i dont dislike residents, or attendings, and i think there is enough pie to go around also, however i dont like mda's trying to dictate NURSE anesthesia, and the parameters or levels at whick we can practice. nurses do not interfere with the practice or medicine, medicine should stay out of the state boards of nursing and nursing practice. we all have the best interests of the patients in mind. we both put out well trained providers, with a very few exceptions. anesthesia politics revolves mostly around money, to believe otherwise is a mistake. the root of most political smoke, is the result of buring money. there is alot more i could go on about, but i'll stop here for now. d

i will take a stab at this one, again be assured different ppl have different opinions. when you graduate you will think that you are the smartest you have ever been. be advised, as much as you think you know, there is at least that much more that you dont. i dont advocate being in an ACT specifically, but you need to work in an environment where there is anesthesia support, whether it be other crna as in a crna only practice or with docs. the learning curve for crna's has been purported to be 2 years. meaning, the first 2 years you are out, you will probably learn as much then as you did in school. your basic and i mean basic clinical skills should be there, but there is alot that goes along with the decision making that experience will account alot for. so i suggest a group job first few years, then venture to private, clinic, office stuff later. just my 2 cents. d

i was going to put my 2 cents in earlier but i thought i would let things die down a little. i have 2 techniques where i use propofol and ketamine together. in a 100 cc bag a saline i add 200 mg propofol, 100 mg ketamine and 100 mcg of fentanyl and drip it though a micro drip to desired effect. i used this one just the other day for a cold knife conization. worked really well. second one is 1 mg of ketamine to every cc of propofol and run it on an infusion pump at propofol doses. have used this one in conjunction with paracervical blocks when doing d and c's and this new ob thing where they put a coil in the fallopian tube under hysteroscopy for sterilization. both of these techniques are for mac cases and work well for me. \ and i understand neither of these constitutes an induction scenario. as for intubation, 1. i'll sometimes use propofol only after a mask induction on kids, 2 i rarely if ever don't use a paralytic in an OR pt (adult), 3 I often refrain from paralyzing in icu or a code. and if it's a pt that has been down i won't use prop either. just a caution about paralytics. for the pt BREATHING IS ALWAYS GOOD! meaning paralyze only when conditions warrant it. once you paralyze, you own the airway until.... spontaneous breathing resumes (depends on the agent for length of time) secured airway is achieved pt dies. paralytics are dangerous and should only be handled by ppl with good airway skills.

i'm sure it has been stated before but i will do so again for completeness. if the ed/gi doc is pushing the propofol, who is in charge of the airway while they are doing the procedure, ie setting bone or doing the colonoscopy. the point of propofol administration by anesthesia personel is that we are responsible for airway control and maintenance and not involved in the procedure.

lol i appreciate the vote of confidence, but dont tell anyone you'll ruin my rep as a slacker! how are things going for you, hope all is well, i may be coming out in august, may try to teach a lecture or do some clinical scenario stuff. later.

yoga, i work at a large university hospital with a big tech staff, they do a good job of keeping good batteries, plus we have lots of students that during machine checkouts etc are keen to decreasing battery power as am i myself, i hate it when your batteries start fadiing, so i replace them at the first sign. i like the small handle because it helps me finesse the airway, with the bigger handles you have to grip them with the whole hand and to me this leads to being more "aggressive" with the blades, while the peds handle i can hold more in the fingers and i dont feel like i have to grapple as much. plus it makes minute movements with the tip of the mil blade in the airway easier. again for those of you who like the miller, give the 4 a try, i think you'll be suprised. you would be suprised to find how many ppl "attendings" "preceptors" who would argue that point. i firmly suggest to students i work with, set up your workstation the way you like it and do the things that make you most comfortable, this is your career and your comfort leads to increased success. (this is for the more seasoned students, not ones who don't have a way of their own yet, they have to start somewhere so why not my way or preceptor way until they find their own way etc.)

well you'll probably look at me strange like everyone else but i like the small pediatric handle with a miller 4 blade, i intubate 99 percent of my patients like this. if you like a miller blade try a mil 4, you get almost the same if not more exposure than a mac, but all the miller attributes. and yes i use it on little old ladies too. d

politics, 99% of the time it's politics

standard of care is what a prudent practitioner would do in a similar situation, not some written standard that all practicitioners must adhere to, unless its a policy written by the hospital or surgery center. so i think you may find as many that ext deep as those who dont. i like to extubate kids and adults equally deep, i feel for the kids the transition to fully awake is more tolerated when ext deep, of course there must be little stimulation by recovery staff. for adults, adequate tv and rr with muscle relaxation reversed (if used) and i will ext deep, adhering to no contraindications. d

i would be interested to know what percentage is front line and what percent is stateside, crna vs mda