WntrMute2

Assuming you are a good student with the usual godd to excellent grades, then the test shoukd be what you have been preparing for these past 2 years. So, don't sweat it too much. I found a lot of the questions were in Valley but the answerrs weren't. So my reccomendation is to sit down with the big Miller or Barash and as you review each question, see what 1 other authority has to say about it. Personally, I studied w/ Barash, but since then I aquired Miller and find it much easier to read. Just pick 1 reference as you'll soon be gererating more questions if you use > than 1.

In school I was able to do a couple of dozen. We had a spine surgeon at our primary site that liked them done on all his cervical spine patients. As a practicing CRNA I do them aboout once a month on patients that I put to sleep and then do a FOB placement of an ETT. Any patient that doesn't need a rapid sequence intubation is a candidate. Pick your surgeon tho as some get their panties in a wad if you delay them. Awake patients are even easier as their breathing efforts keep the tissues from collapsing. Once i started doing asleep ones regularly, the MDAs were only too happy to allow me to to do the truely needy ones.

Well, organize youself a bit and with a united front tell them no. Then negotiate a deal that is fair to you. If all of you refuse to comply then you'll have some real power. I know it sounds a little like a union (I hear the gasps and see the heads shaking now) but don't let them push you around. Most places are desperate for CRNAs so use your bargining strength.

We do these about 1 per month. Pavulon just prior to CPB cesation, so they don't try to breath and get an air embolus. Big dose of methyl-prednisolone 10-15 mg/kg. Mannitol by perfusion, lasix 10 mg., 50 mg benadryl and 20 mg pepcid for GI protection d/t steroids. Some do give a whopping dose of pentathol but it makes it hard to get off pump and hasn't been shown to improve outcomes. Place a nasopharyngeal probe prior to heparinization, pack the head in ice. Pray if you think it helps.

Well managing a patient in the ICU or during transport is different than managing a patient with PHT after a 4 hr pump run or even a 60 min run and the patient suddenly tanks as the surgeon closes the pericardium. I have to know SVR/CO now. not 2 min from now, now! I also maintain, it is not the trend you need to worry about, it is the practice at the hospital you are training at as well as what the school thinks is important. Whe i ask you in the OR about waveforms and you tell me that the trend is not to place them any longer, we'll have trouble.

I must be working in a backwater hospital. We put PA caths in ALL hearts and thoracic or AAAs. I would reccomend being familiar with waveforms, complications. instertions as the board questions may certainly cover them. Also, if you do clinicals where they are used, you'll be expected to be used to them. You certainly will be expected to place, manage and interpert them when you train our heart or vascular rooms. Our students place up to 8 per week. BTW, quickly decide for me whether to start Levo or epi in the patient coming off pump who is hypotensive. SVR problem or CO issue? You decide without a cardiac output. It is easy to blow them off when you don't use them frequently.

You know what's really weird, I interviewed at 4 schools and had exactly no clinical questions. All each school wanted to know was how I was going to manage the academic, personal and financial stress. I kept asking do you have any clinical questions for me and they all said "no, your resume and reccomendations speak for themselves." I thought it was a bit wierd but I was offered a spot at all the schools where I interviewed. Go figure.

So I have a question for you MmacFN, truly I don't mean this in anything other than curiosity, no attack intended so don't see one please. Your posts have been filled with excitment about your present job as a flight nurse and you seem to have lots of autonomy as well as intubating regularly and generally exposed to some very sick patients in precarious situations. Why the interest in being a CRNA? You'll spend lots of time sitting on your hands as you do your 4th knee replacement under SAB of the day. I personally love the big complex cases but I do my share in the eye room or doing ortho (yawn). Just curious. I left an extremly exciting job in a big trauma center to be a CRNA, mostly because I was feeling I soon may be too old to push crashing patients in mast suits to angio when I'm 60. I still miss that job although the pay as a CRNA is much better, I is not an order of magnitude better. Thanks Dave

I have to agree w/ the Doc here (despite my usual position). Pain management seems clearly diagnosis and treatment, which makes it a Medical issue clearly. That doesn't mean we couldn't learn to deal with chronic pain, it just might mean we do it in a collaborate model.

Well, there is also the simple plan of JUST NOT USING IT. Seems pretty simple, but it works. The reasons textbooks don't tell you when and when not to use it is because clinical judgement is in the hands of the provider. Actually, Pete, the texts are telling you to use it when terms such "it is the drug of choice in X situation." are being used. You are right that the literature doesn't say you must use a particular drug. But "drug of choice" is pretty strong language for a text and seems pretty clear to me and most others. Especially as a student,(Not that there is anything wrong with being a student mind you) arguing against without some experience to the contrary seems weak. Give me some peer reviewed articles or texts to the contrary.

Usually I just use 1 induction agent plus muscle relaxant plus fentanyl. On big cases like AAAs valves etc. I might do a narcotic induction w/ sufentanil. I have given combinations before but that is usually begun w/ STP and if the patient isn't deep enough w/ a single dose (400 mg.) I'll draw up propofol or etomidate as those don't require mixing like STP. I am not the worlds greatest propofol fan but I use it frequently as an induction agent in outpatient cases. Almost never "alone" if I'm going to intubate. A muscle relaxant is usually called for to place an ETT. Propofol alone with a little narcotic for LMA placement or for mask cases.

Pete495 says: "Can't argue with Barash. There's no doubt about Ketamine's bronchodilating effects. I think the question is do you use it in a rapid sequence w/ sux, and do you use it with hemodynamically unstable patients....Personally, just my opinion, but I still think it was a poor choice" But you are arguing with Barash and every other textbook out there. Ketamine is the perfect drug in the unstable status asthmatic. And you are worried about the mental altered state of the patient? Lets get her to survive and then we'll worry about that. Barash also clearly addresses the phsycotropic effects and how to mitigate them (BZD, barbs, propofol). This is a typical error in judgement. Since one has little experience with something it should be avoided DESPITE CLEAR EVIDENCE TO THE CONTRARY. It is the drug of choice. Try defending another choice during M&Ms or even in court. Find me some literature to back up your position. MmacFN says: How about ketamine drips? Have you ever seen or heard of one? Yes I use them for sedation occasionally in the elderly w/ hip fractures. Isobaric tetracaine and midazolam usually but occasionally, ketamine with its hemodynamic, analgesic and respiratory effects will allow a comfortable patient without oversedation. Have you ever used this sortof combo in your practice? How about using propofol for the initial induction by itself? Ive read about it, and seen it in the OR but never in the ER or ICU. I'm not sure of your question here. What combo are you asking about? I intubate w/all induction drugs, ketamine the least as there are pretty well defined uses, but I do sedate with it. It is also a wonderful analgesic @0.2mg/kg.

From Barash, Clinical Anesthesia:"Ketamine has well-characterized bronchodilatory activity. In the presence of active bronchospasm ketamine is considered the iv induction agent of choice. Ketamine has been used in subanesthetic doses to treat persistent bronchospasm in the operating room and ICU. It is also used with midazolam to provide sedation and analgesia for asthmatic patients. (pg.337)....The incidence of these reactions (hallucinations, nightmares, altered short-term memory and cognition) is dose dependent and can be reduced by co-administration of benzodiaziapines, barbituates or propofol. (pg 337). So according to Barash, one of the major texts of anesthesia, the ketamine, sux, propofol routine seems appropriate. BTW, etomidate inhibits the release of cortisol for 8-24 hrs. maybe the doc figured the patient might need their own stress hormones. Just a thought. Sorry for the earlier remark but anytime someone says if I'm not treated with respect I'm going home. Well, they asked for it.

"I was asking questions that related to an actual case. I thought it might be interesting but if your going to be an as* about it i wont bother posting anymore" Cool

Actually, most of the time the surgeons ask why do we have MDAs when the CRNAs do all the work. There are moments where a surgeon may ask if the MD can step into the room. That's happened exactly twice. Both times to yell at them for a decision made in pre-op BTW. The scariest thing is to watch how quickly things turn bad when the MDA gives me a bathroom break in the heartroom. Most surgeons realize we provide excellent care and quickly learn to trust us.