Mully

Anyone on here in one of NYC's CRNA programs? I would be extremely appreciative if you would give me the Christmas gift of answering a few questions I have. Thanks ya'll

Interestingly enough, the BIS was never actually tested on patients who were paralyzed when it originally came out. So a few crazy anesthetists in Australia did a study where they paralyzed each other, placed a tourniquet on an arm so they could still move their arm to answer simple math questions, and put a BIS on there head to see what it would say. In some patients, it read less than 60 with a perfect SQI while they were answering questions correctly. In other words, the BIS is worthless. Check it out... http://bja.oxfordjournals.org/content/115/suppl_1/i95.long

Main thing is you don't want anything hypotonic. Isotonic or a little hypertonic (Like D5NS) is okay. Hypotonic fluid like D5W (It actually starts isotonic, but as the dextrose gets metabolized it becomes hypotonic) will cause fluid to move into cells creating edema and increased ICP. Hypertonic fluid will actually pull from fluid into the vascular space. Just keep checking BMPs.

This. Nitro is purely venodilation, with a small amount of arterial dilation at really high doses. Nipride is a mixed dilator, meaning it dilates both venous and arterial sides.

I don't believe it was either of the drips. These explanations for the bradycardia are essentially zebras when there was much more likely a horse which caused it. Fentanyl does not cause a vasovagal response. The only time you'll see a change in hemodynamics when administering fentanyl is if the hemodynamics are being held where they are due to a stress response from patient being in pain. This patient, having OD'd on narcotics, was so used to them from home that 15 mcg/hr is probably juuuust keeping them from DTs. It's not even touching them. You can give 15 mcg of fentanyl to a 80 y/o little old lady and she won't blink from it. It must have been running at 0.3 ml/hr! They probably didn't even get any in there IV lol! It just gets funnier the more I think about it. The propofol isn't "maxed out" either, maybe it is by your unit's policy. However 50 mcg/kg/hr is again, nothing for this patient. The bradycardia was certainly from another cause.

Where have you gotten this information about small IV sizes being better for pressor administration? Do you have any research or manufacturer's guidelines? You seem pretty adamant.

Subcutaneous heparin is low-dose heparin (5000 U subq). This usually doesn't even alter the INR at all. Patients get these shots right before surgery to prevent DVT post-operatively. You know... surgery. Where we cut people open and whatnot. We also perform spinals/epidurals without consideration of a patient's current subcutaneous heparin status. And if a patient were to bleed from a spinal/epidural, they could very quickly become paraplegic. What I'm trying to say is, that doc wanted a cop out. Next time politely ask the doctor to reference his research article so you can further educate your peers.

She gave me a good rec. A couple reasons I attribute to it. 1. It was a large teaching hospital and they were always giving out LORs. 2. One of my preceptors had just gone to this manager and complimented me highly on how I was doing while on orientation. This manager came and told me that as one of my first interactions with her, so I knew we were off to a good start. 3. I don't know how much this mattered but I really downplayed it. I was like "I'm only applying to this one school and I don't think I'll get in it's just more of a practice run I plan on applying to a few next year". That was mostly true, although I had confidence that I would actually get in, which I did. But talking with her I tried to make it like it was not a big deal. Idk, I've been told that I'm a good BS'er. Plus I emphasized that even if I got in, I would still work there for a full year before moving on. All ways round, it just sucks. I wish there were an easier way, but there's not.

I had the same situation. I think I asked my supervisor for an LOR after 4 months of being there! Hahaha, it sucked I didn't want to do it but I had to. I'd probably stay where you are just to avoid that. Or ask for an LOR from your current supervisor before leaving. In my opinion, experience isn't everything. Certainly it helps. But don't think there's something magical about managing 6 gtts instead of 3 gtts or whatever. That's not what teaches you anesthesia. You'll learn how to do anesthesia in anesthesia school. I think it's more important that you're not lazy and that you can learn and adapt and stay humble; that you're on top of things, extremely vigilant, anticipating problems and prepared to make a decision and act. They assume these things correlate with the best nurses with the best experience but that's not always true.

By the time I'm done next year it will have been 8 years. That includes a semester doing a CNA course and a little over 2 years as a nurse. Basically all of my young adult life lol. I'll be 28 when I graduate. Phew!

I never got my CCRN and I'm a year out from being a CRNA. That should be encouragement enough lol One quick rec for retaking it though. How you study is a big deal. Clearly what you did before didn't work. You need to change something this time. Figure it out, but just don't do the same thing as before. The road to where you want to get to, especially any expert level, is filled with failures and bumps along the way. We like to pretend that that's not true in America. We make films and teach our children to expect success no matter what. Even when a main character fails at something in a movie, its usually some quick music montage of he/she getting things back on track and the next thing you know, they've succeeded or won at whatever. That's just not how life is. CRNA school is so freaking hard. You're going to have days when you're sure you can't do it and you feel like quitting immediately. That's okay. Those days are grooming you for your future, and are entirely necessary for your success. Learning how to comeback after failure is going to be, in my opinion, the best thing that the CCRN has taught you. Good luck.

Anesthesia. The surgeons rarely have any clue what the patient's vital signs are unless we tell them (not talking down, simply because they're performing surgery). Certainly it's a team effort, but who decides what drugs to give, when, and how? Anesthesia. Who gives the drugs? Anesthesia. Most OR nurses that I've worked with aren't ACLS trained. Their roll is more r/t calling the code/anesthesia stat, and other things that I'm not sure of lol. I've experienced one almost code in anesthesia during a craniotomy. We directed the OR nurse to call anesthesia stat which resulted in an MDA and 3 CRNAs in our room in about 3 seconds. Someone along the way brought the crash cart in. Myself and my CRNA gave what drugs we decided and directed the other CRNAs as to what help we needed. The surgeon did end up re-opening the head to make sure nothing funny was going on. Patient survived, anyway. Hope this helps.

A couple things... It could in fact be a PAC, termed a "non-conducted PAC". This is when there is a P wave which occurs earlier than its expected time (hence premature), not followed by a QRS (hence non-conducted). These are relatively common and relatively benign. If the additional P wave is in time with when it is expected with no QRS, this is a second degree type II block. This is a more serious condition, as it often progresses to complete heart block. The key to differentiating the above is whether or not this additional P wave is premature or not. If it is premature, and there is no QRS, it means the conduction system distal to the AV node is refractory from the previous beat which is why there was no QRS. If it is on time and there is no QRS, this is more serious as there is some sort of block in the conduction pathway. The best leads for looking at P waves are your inferior leads which are II, III, and aVF. Since this did not appear in any of these leads, it is unlikely that it is any of the above. This makes me think it was the stupid u wave. U Wave basic ECG patterns Here's a site that explains more than you'll ever want to know about a u wave. Don't spend too much time on it though, the u wave is pretty low in specificity and doesn't really play a role clinically, at least in my experience.

I think I'd rather go through the labor than be the male nursing student on his OB rotation again... bahahaha Seriously tho. I'd rather hold my breath for 2 months than rotate through OB again. As a man, it's just something you get through to get to where you want. If you're sure about your decision, then sure quit nursing. However, if you stick with it, it gets WAY, WAY better. I'd leave nursing before I'd work in OB, but nursing in the ICU is awesome, and made my horrific OB rotation worth it.

Yes it is totally unnecessary. If you want to get into CRNA school, this is what you do: get into the ICU, work for 6 mo. to 1 year and start applying to schools. The end. If you have good grades, interview well, have good LORs etc. etc., with 3 years of ER plus some ICU you'll be in no problem. I think you're over thinking it, in my opinion.

But are the people who comprehend them better nurses? Are the people who don't comprehend them worse? That's the assumption I challenge. I think NCLEX style questions are often times wholly unfair and poor predictors of successful nurses. I'm sure you could point out people you graduated with, some who were great in the classroom and piss poor in the clinical realm, and visa versa. To me, that speaks volumes about the quality of how we test, and what we as a profession within academia consider important.

The irony of you responding to my multi-paragraph response about focussing on the point of a post rather than a small detail to correct with a spelling correction is sort of too good to make up.

Offended. Everyone on the ****** planet is endlessly and marvelously offended. I wish for once, just one mother freaking time, an article could be posted without 1/2 of the entire audience plucking ONE sentance out of it to indignantly and furiously set straight. Honestly! Is anyone mature enough to let something go? First of all, there is a difference between ADN and BSN degrees, refer to Spidey's Mom's post for clarification as she explains it quite nicely. Second, yeah the OP's statement, taken literally and out of context, can be made to sound as if she believes BSN nurses are trained to critically think in contrast with ADN nurses. HOWEVER, the mature, sensible, critical thinker reading the article will note that this sentance isn't the main point of the article, could be interpretted in multiple ways, and comes and goes quite quickly without being expounded upon. He/She then will likely decide to give the writer the benefit of the doubt to thereby FOCUS on the POINT of what's being said, rather than a flipant sentence which isn't really built upon at all. Immature people feel the need to endlessly correct everyone. Mature people recognize the vast differences in opinions out their and decide to move on. Good for you OP. Nursing questions are 1% legitimate and 99% total B.S. Glad you fought your way back into it.

GI symptoms and vomiting can be caused by a number of different mechanisms that can be quite complicated. I did a quick Google search to see if I could find an exact mechanism on this, and I found a whole lot of nothing. I will say this though, I've never heard of the SNS shunting blood from the GI tract being a cause of nausea/vomiting. High levels of parasympathetic activity, however, does cause nausea/vomiting (see SLUDGE acronym for cholinergic crisis, the E standing for Emesis). I know the PNS is "rest and digest" but super high levels beyond normal of anything can really set off the vomiting reflex. Sorry I don't have a better answer for you. I don't think there is much known on the topic actually. This is why in anesthesia, post-operative nausea and vomiting is still a problem with some people, no matter how many anti-emetics we give them.

Wait a second... he's a frail 80 something year old in LTACH?! Why are we treating him at all? I say give the man a sandwich and let him R.I.P.! bahahaha No for real though, a good motto someone taught me in anesthesia is thinking to yourself, "If I give this drug and it causes a problem, can I fix that problem?" For instance, if I give too much phenylephrine, could I fix the problem of a B/P that's now too high? Or in this case... If I give the insulin and all the fears and nightmares of this thread come true and the patient becomes symptomatically hypoglycemic, can I fix it? Well, if he's NPO because he just didn't feel like eating dinner... then the worst that could happen is you make him drink a glass of OJ. Or if he's got a PEG tube, a little OJ bolus. Or Coca-cola! Yum. Not so bad, eh? Obviously everyone has opinions on both sides of this raging 2 units of insulin debate, and both sides make valid points. It's best to make a decision and move on. I've found the above thought process can help you make that decision with confidence.

The wedge wouldn't be accurate with mitral stenosis either, so yeah I don't know why she did that. In order for a wedge pressure to accurately be a measure of LVEDP, equal pressure across the system must be present. In other words, the pressure has to be equalized across the capillaries, pulmonary veins, left atrium, and left ventricle during diastole or else your number isn't accurate. During mitral stenosis, blood backs up and increases left atrial pressure. Therefore, during diastole (when the mitral valve is open), there isn't enough time for pressure to be equalized. So your wedge never has a chance to be accurate. Better question, as pointed out, is why wedge? Ever?

Just give it. Problem solved lol.

All ways round, though, that baby needs a central line!

I see what you're saying, kind of. The physics thing I believe you're referring to is Poiseuille's law, which says (among other things) that flow is directly related to the radius of a cylinder raised to the 4th power. So although I agree which the general principle of what you are saying, I think I disagree with the idea that the baby will get less drug. As long as the heart is strong enough to pump blood through the increased systemic vascular resistance (SVR) that the dopamine is causing in the hand/arm, circulation should continue. The narrowing of the vein is analogous to the pinching off of a garden hose like you said, however as long as the heart is strong enough, the blood will burst quickly through that portion of the arm (like when you put your thumb over the end of the hose and the water shoots out far). If I'm right, the baby will get all of the drug that is infused. Maybe I'm way off. Does what I said make any sense? Also, is that true? You can massage the vein and watch the B/P go up? Also, does what you're saying only apply to babies or adults as well? Thanks for the discussion.