underdog

Is that so deepz? Last time I checked, Midwestern had exactly zero clinicals in Colorado where your user name says you are from. As for the original poster, Arizona is a highly dominated anesthesiologist state. That is why this program ships you all over to obtain the necessary clinical experience (rural AZ, New Mexico, North Carolina). That is just one of the reasons I feel you should look elsewhere. UNDERDOG

I am not a Midwestern grad, but have a very good friend who is a member of their first graduating class. Based on what I have heard, I would not worry about their interview, and would concentrate on looking elsewhere for school.

Vinny- Try not to stress too much....I know that is easier said than done. A bright spot however is that the CCNA randomally selects people to recieve all 160 questions no matter how well or how bad they do on the exam. This provides them with a way of asuring questions are "tested". So in your case, you probably aced it at 90, but were one of the poor suckers selected to sweat through all 160 brutal questions. Underdog

Come on...who need U/S for a-line placement. Feel the pulse....be the pulse.....stick the pulse!!! SIMPLE!!!

Hey Sigma- I took cert exam last September. I was one of about five people that I know of in my class that did not attend a Valley review course. My study partner and myself obtained a year old Valley Sweat Book and Memory Master. I devoted probably 95% of my time to studying these, and the other 5% to some review materials provided by my program. I felt I knew the sweat book very well, but I went through the entire memory master only once. I got the minimum 90 questions and passed, as well as my study partner. Good Luck!!

Ami, Emerald, and Chanson....you all are right on the money with your concerns about autonomic hyperreflexia. First of all, a little more history on the case. She did have a complete SCI with sensory level at T-6. Her surgical history included a LEEP procedure being done since the SCI. She reported that she had a general anesthetic for that case. As the story goes, she developed full-blown autonomic hyperreflexia with severe HTN and bradycardia requiring an ICU admission and Nipride infusion. She was very well versed in the pathophys of autonomic hyperreflexia, as I have found many SCI patients are. For this case, regional anesthesia was definitly my first choice. Her spine anatomy was not the greatest, but it was decent considering the circumstances (no plates/rods/screws). Before the case I was very deliberate about determining her sensory level. I chose to do an epidural as opposed to a SAB with reasoning being that I wanted to assure that I obtained a high enough level with my block to prevent autonomic hyperreflexia. Yea, it is relatively easy to get a t-4 level with SAB, but if by chance I did not get it up high enough with one-shot SAB, I was screwed. Therfore I chose epidural route and brought block up with 2% lidocaine to a T-4 level. In addition, I had some nipride in the room just in case. As it turns out, case went very smooth with no s/s of autonomic hyperreflexia. Thanks for the replies. J

Wassup Big "D"....Glad to say no issues intra-op or post-op, case went very smooth. Hope all is well with you in Ole Miss country. J

Hey all.....Figured I would throw a little clinical stuff out there. Recently had a 26 y.o. paraplegic for a repeat C-Sxn. PMHx was negative except for SCI from MVA eight years prior with resultant paraplegia. Sensory level checked prior to procedure and was found to be T-6. How would you proceed and what would be your concerns for the case? I will post more on the outcome once a few repiles are up.

By no means am I an expert at awake FOI, as I have only done about five of these. I did however do one just the other day. Patient was a 74 yo male who was riding a four-wheeler ATV and did not see a barbed wire fence. He ran right into it and ended up with a DEEP laceration from ear-to-ear. Mandible was clearly visible, and he was within 1/2 cm from lacerating BIG RED!! Amazingly, the patient was A&OX3 in ED with very good hemostasis. Upon interview he stated that it was difficult to take a deep breath and to swallow. He also had a full thickness laceration to the middle of his tongue with significant edema from biting it. For fear of losing airway once he was put to sleep, I opted for an awake nasal FOI with general surg on standby for emergent trach/cric. Gave him 0.2/0.2 mg of Robinol in divided doses. Packed both nares with cocaine pledgets soaked in 4% lido and phenyleperine spray. Titrated in Versed 5mg and Fentanyl 100 mcg. Did not buck/gag/cough one bit until tube was passed through the cords. I guess it is better to be lucky than good sometimes;)

Thanks Tranman....for some strange reason the coagulation pathway is one of the FEW things that has stuck in my head since taking boards last year. It is amazing how fast some of that info diappears.

Hey All- Just got done watching a very sad but interesting story on Dateline NBC. Healthy pregnant female in mid 20's comes into hospital for birth of baby. Labor is uneventful, recieves labor epidural and delivers healthy baby boy. A few hours later, she starts complaining of a headache which is progressively getting worse, and starts to run a fever. OB doc notified, percocet given for H/A and Ampicillin ordered for increased temp and possible infection. H/A and fever get worse and worse, 12 hours after delivery of infant, she develops altered LOC and begins to seize. Rushed to ICU, placed on "life support" and spinal tap done. Dx is staph bacterial menningitis/encephalitis with severe edema and "irreverisble brain damage" on CT. Life support is later discontinued and mother dies. Hospital claims no wrong-doing and states pt was probably already infected prior to admission. Family is stating that bacteria was acquired inside hospital, and specifically mentioned a possible infected epidural needle as a possible route for bacteria to go straight into CSF (Wet tap must have occured?). They went on to specifically mention that the anesthesia provider did not wear a mask during placement of the epidural. Hence my question....Do you guys wear a mask when placing your labor epidurals. I will start by stating that I do not. Underdog

I was waiting for other posts on this topic, but thus far there has been only the two, so I figured that I would chime in. First of all, I agree with a couple of athomas' points that Vit K would help, but not until later down the road. I also like the idea of the IV heparin "bridge" for this patient after D/Cing the Coumadin. Furthermore, I agree with piper that I would like to see the INR at least 1.5 if not lower before proceeding with surgery. I do however have a differing view of trying to get the elevated PT and INR back to acceptable levels. The PT/INR are measures of the extrinsic (& common) coagulation pathway, and are affected by Coumadin and not heparin. Heparin affects the intrinsic (& common) pathway and is monitored with the lab value PTT. I believe that the reason for the elevated PT/INR was that the labs were drawn too close to the cessation of the Coumadin. I would re-draw these pre-op and expect to have values closer to normal after the four days the OP mentioned had passed. If the labs still came back with an elevated PT/INR, this would show lingering effects of the Coumadin and not LMWH. Coumadin works by binding to Vit K receptors in the liver and thus competitively inhibiting Vit K and the production of Vit K dependent clotting factors (II, VII, IX, X). Factor II (Thrombin) is inhibited by Coumadin as stated above. Thrombin is essential in activating platelets by combining with a thrombin receptor on the surface of the platelet to release mediators such as thromboxane and ADP, both of which promote platelet aggregation. Hence, without Factor II which is inhibited by Coumadin, you could give all the platelets you wanted but they would not be activated or be able to aggregate because of the lack of thrombin. Therefore the correct way to normalize the elevated PT/INR for surgery would be to give FFP which contains the necessary clotting factors such as thrombin to be able to initiate the process of platelet activation/aggregation.

How about checking some labs....could hypocalcemia or hypermagnesemia be contributing to muscle weakness??

As stated previously, do not even worry about injecting a small amount of air into the catheter. One technique used to identify the epidural space when placing a catheter actually involves injecting as much as 5-7 cc of air into the space....so don't sweat a small amount of air. It does seem odd however to be responsible as a med-surg RN for injecting epidural catheters. There are quite a few things to watch for, none of which you were educated with in school, or should be responsible for knowing. It seems to me that the anesthesia department may be slacking a bit by having you do this. I would definitly check into it. In the interim, be very careful with the epidural catheters. I have heard some horror stories involving staff and catheters....TPN infusing into epidural; Marcaine for epidural infusion infusing into peripheral IV:eek: