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.

I can't really answer your questions directly but a couple of your statements require exploration: 1)"Also, 180 of succs (why propofol then??)" Patients need hypnosis not just paralysis for intubation Intubating someone w/just sux is really inapropriate except in exreme cases. So the propofol bolus/gtt was indicated (the gtt for sedation p/ intubation.) We can debate the dose and whether generic propofol is the best agent for the job. 2)"The reason i say that is both the aspiration risk," This makes no sense, the choice of induction drugs has no effect on aspiration. 3) "So, I arrive to find a patient who is still very hypotensive (80-85 systolic with a map of about 59-65)" A MAP of 60 is NOT considered very hypotensive. Unless you know the LVEDP you can't say the coronaries weren't filling. 4) "Anywho , after taking over management of the patient i ended up D/C'ing the propofol drip and giving fentanyl and vecc for the ride. Well, you took all of her sedation away, since when is fentanyl (except in extreme doses and even then that is questionable) a sedative? Cardiac anesthesia was done with huge doses of fentanyl or sufentanil with high rates of recall. 5) A decrease in HR from 130 to 120 is a major accomplishment? 6) I submit, there is less of a serious question here than you want to prove how clever you are. Sorry

Here's my take on the situation. Anesthesia is about the relief of pain so I do what I can to begin that process early. If I'm putting in the IV either because I'm at the bedside early or the pre-op nurse needs help, I'll put a little lidocaine in. I always tell the patient what I'm going to do and if they don't want the lidocaine, they don't get it. MOST patients prefer the small sting to the larger IV start. Not all but MOST. There are plenty of times where the pre-op nurse has tried and I am able to get one in (using lidocaine) and the patients express gratitude. This isn't the ER remember, this is pre-op, we are here to provide comfort first and foremost. Some of you are a little dogmatic about what you'll do or won't do. Lighten up a little and use your best judgement. On another note, the common IV site many choose is the lateral side of the wrist. There is often a big vein there. I submit this isn't a good 1st choice. The skin is thick and TENDER there, the radial nerve runs right through that area (there are reports of radial nerve injuries) and the dressing or IV always interferes with my A-Line start.

My suggestion is you put down the palm, give up the cheat sheet, hide the tables that you have been relying on in the ICU and pick up a paper and pencil each time you need to calculate and get over your weakness, yes, even put down the calculator. Daily I have SRNAs tell me I'm so weak at math, let me use my "aids" what ever they are and get through the day. I have them put down their crap, and we learn to do it a couple of times and guess what, the weakest ones learn eventually. You'll learn it to if you want to.

When encountering difficulty threading the wire, try dropping the needle more and more parallel to the patient as you try and thread. If you still have trouble SLIGHTLY withdraw the needle as you try and thread the wire, just sort of enough to tug on the vein wall I imagine. This almost always allows me to avoid a second stick.

Actually, the answer is probably more medial. If you don't find the IJ as you probe laterally you must move medially. Consider that the carotid A. lies medial to the IJ, so probing increasingly medial SHOULD result in IJ cannulation before sticking a needle in the carotid. Tips: don't turn the head excesivally, just enough for access, locate the 2 heads of the SCM, find the carotid pulse, find the cricoid cartilage. I place my fingers on the carotid pulse, and insert my needle at the level of the cricoid cart. just lateral to my fingers that remain over the carotid pulse. I find that the IJ is encountered just medial to that angle that is often reccomended, towards the ipsilateral nipple. Don't be afraid of sticking the carotid if you maintain your fingers over the pulse. This procedure takes practice, I've done hundreds and still occasionally (although infrequently) need to call for help. BTW, there are at least 15 different approaches to the IJ. The book Handbook of Percutaneous Central Venous Catheterisation by Rosen, Platto and Ng covers the topic completly.

As a CRNA who works with students frequently I'll give students a second chance if the patient was not in need of a RSI, is unstable, truly looked difficult or is desaturating. As long as we can ventilate, I'll usually give at least a second but not always a third try. Just use proper technique and most CRNAs will allow a repeat try. Intubating is rarely a matter of strength, it is however a matter of practice. Keep your arm as straight as your shoulder muscles can participate that way. that position leads you to stand back a bit which should help also.

I believe that it takes soemwhere around 50 epidurals and a similar number of central lines before one becomes comfortable doing them. I did about this many during school. This doesn't mean your proficient, just that the straight forward procedures should be handled without difficulty and you should recognize you are getting into trouble. After placing a couple of hundred central lines and probable a similar number of epidurals, I don't hesitate to call for someone to assist (that may well be a CRNA rather than a DR.) if I can't locate the vessel or the epidural space after a couple of attempts. At our hospital, it is possible you are the only provider evenings, weekends, holidays so there may be no backup. But knowing when to stop is an important thing to learn. The rationals that MDA gave you is plenty lame. I have to say, many MDA groups encourage regional/line placement/independant practice if you work for them. They make money whoever does the procedure. The conflict raises its head if the CRNAs are paid by the hospital. It is mostly about control - IMHO.

Yes, residents almost always get preferential treatment. For those of you choosing a school there are 3 questions here you should be asking when interviewing. Do you also train residents? What kind of regional training will I get? What kind of line placement experience will I get? On the other hand, hospitals/groups that allow CRNAs to do regional or line placement will usually train those that are interested. Just be ready for frustration if you choose a school that doesn't do much regional/line training. You WILL get to hold the patient when god comes into the room to place that SAB tho ;P

I've got to suggest that you merey calculate with a calculator. Never lets one down and continuously reinforces the basic math involved. Everyone here does know Lester's No Math Rule right...right... right?

IMHO your last statement is the correct position. All those MACs that have an unconcious patient are GAs. For safety, the airway reflexs should remain intact is reflux is a potential issue. If the patient cannot tolerate the procedure then the sturgeon needs to localize better, we need to do a conduction block or insert ETT. Does this mean I never cross the line? No, frequently on cases such as breast biopsies, or foot blocks I provide a minute or so of GA while the local is injected. I think the risk/reward ratio is OK for MOST patients. The ones that can't lie flat as in your example get "squeeze my hand" anesthesia to get them through the localization. BTW, we consider as if all those MAC cases are GAs when it comes to consents and billing.