Funny you should mention that, i did buy 3 books from amazon recently!
I spent about 2 weeks shadowing various CRNAs (since you all do a different job really). I thought it was awesome. I didnt, however, like the surgi center stuff Boring. The rest was awesome.
Yes i have come accross chest rigidy once and quickly reversed it with narcan. I had a BREATHING patient who had a pelic and femur fx. Bar none, the best drug for break through pain is fent., i have him 150 and in about one minute he was complaining of D/B SOB. since it occured with the fent i gave him narcan and fixed it. Sadly, he was still in alot of pain so i eneded up dosing him with etomidate and droperidol. That, at least, kept him from screaming as loud.
here is part of a study i had read a few years ago
Low-dose fentanyl, 2.2 to 6.5 micrograms per kilogram body weight, induced chest wall rigidity in 8 of 89 (9%) term or preterm neonates, who received a total of 204 doses (incidence, 4%). Doses were administered as a slow intravenous bolus over 2 to 3 minutes. One infant developed chest wall rigidity 9 hours after the infusion had been discontinued. Laryngospasm occurred in 2 of the infants. Naloxone immediately reversed rigidity in all cases (Fahnenstich et al, 2000).
Don't forget that fentanyl can cause a rigid chest, While it happens infrequently, it can get your attention. It happened last Friday to a patient who I was anesthetizing for a facelift. Oxygen sat dropped quickly, but I was able to ventilate her after the muscle relaxant started to work.
Mike,
You are asking good questions. Try to spend some time in the operating room with a good CRNA. It will be invaluable for you and get a good perspective of the level of knowledge need to be a CRNA. Also, pick up a basic anesthesia text on Amazon and read, read, read.
The fentanyl issue is one of the big differences in what you do and what I do as a CRNA. I honestly can not tell you the last time I reversed a narcotic (maybe 20 years ago). When you are giving fentanyl as part of the induction, intubation regimen for general anesthesia, it is best to proceed with the general and not reverse.
Sorry that outpatient surgery was so boring. I practice all alone in a plastic surgery office and have had most of the exciting moments in my career in that setting. I just try to keep those moments as few as possible.
Will an non-depolatizing (like roc) or depolarizing (like succs) paralytic reverse this chest rigidity and is it simply beause of the paralytic effect? If thats the case then it sortof seems irrelevant when performing RSI, dont you think?
Im thinking this way: 60 seconds before intubation fent, 50 seconds before intibation etomidate, 10 seconds before intubation succs, wait for paralysis bag until ready intubate.
Its so fast for me that by the time chest rigidy set in, they'd be paralyzed!
Will an non-depolatizing (like roc) or depolarizing (like succs) paralytic reverse this chest rigidity and is it simply beause of the paralytic effect? If thats the case then it sortof seems irrelevant when performing RSI, dont you think?
Im thinking this way: 60 seconds before intubation fent, 50 seconds before intibation etomidate, 10 seconds before intubation succs, wait for paralysis bag until ready intubate.
Its so fast for me that by the time chest rigidy set in, they'd be paralyzed!
Not mush exp with chest ridgity here but in most anesthesia texts say that a relaxant can help this. However though man times in anesthesia you may start the titrate the fentanyl early. Like earlier than the minute or so you stated b/f giving the relaxant. Your titrating a bit in and preoxygenating the pt while you and others are positioning and what not. It is here that the chest ridgitiy cause larger issues. Miller says a small defisiculating dose of nondepolarizer can help prevent but not all the time. They think this is a centrally mediate issue so you can give relaxant, which doesnt cross the BBB and it have no effect in the CNS.
Watchful Care: A History of Americas Nurse Anesthetists
I already own millers and Rosens EM along with Hursts The Heart. I teach most of that stuff weekly.
What do you think of the other three?
Very good choices might I add, esp since the Handbook was my idea...
Anesthesia Secrets is an excellent book. Good start.
In my previous EMS gig there was a flight medic and flight RN hubby/wife team that came to Atlanta after working flight in AZ. I'll ask them what company they used to fly for and get back to ya.
Good Books. I haven't read Watchful Care, but always wanted to. Don't have time for it right now. too many other required readings. physio is kicking my ass, but I'm getting through. Anesthesia school is hard, and will probably be the hardest thing you do. I'm only 3 months into it, and I'm spent.
Another one useful for clinical besides anesthesia secrets is secrets of anesthesia. I know, sounds the same, but it's a different book. also if you have a pda, get The Manual of Anesthesia, and soto's drug book. I have a pda, but don't use it much at this point. Actually, I think the thing is a piece of garbage, but they made us buy it.
Keep coming back and posting. we need more topics on this site.
Any other suggestions feel free. I have some time now to read but im sure i wont when i get into school. Let them know I work at AE here in arizona.
Very good choices might I add, esp since the Handbook was my idea...
Anesthesia Secrets is an excellent book. Good start.
In my previous EMS gig there was a flight medic and flight RN hubby/wife team that came to Atlanta after working flight in AZ. I'll ask them what company they used to fly for and get back to ya.
Dont worry about me posting, im a talker. Im very excited about my decision to goto CRNA school. It took me quite some time to decide MD vs CRNA and in the process finished about 1/2 of the pre reqs for med school.
Until i went and shadowed a few CRNA's in different roles i had a total misconception of what they did. I just cant wait!
Good Books. I haven't read Watchful Care, but always wanted to. Don't have time for it right now. too many other required readings. physio is kicking my ass, but I'm getting through. Anesthesia school is hard, and will probably be the hardest thing you do. I'm only 3 months into it, and I'm spent.
Another one useful for clinical besides anesthesia secrets is secrets of anesthesia. I know, sounds the same, but it's a different book. also if you have a pda, get The Manual of Anesthesia, and soto's drug book. I have a pda, but don't use it much at this point. Actually, I think the thing is a piece of garbage, but they made us buy it.
Keep coming back and posting. we need more topics on this site.
well first let me say I am from Canada where there were no CRNAs. I had not heard of them until 2 years ago when i happened to be doing intubation clincials and met some in the OR. The MDAs took charge of my education/training but the CRNAs were very nice.
After asking a few ppl about it, i got the impression working as a CRNA was like working on an assembly line. One came in you tube them and sit there and read a book until the procedure was over then send em to the PACU.
heh, feel free to laugh about my ignorance I do now!
Im sure there are some jobs where it could be that way but that certainly isnt the norm from what ive seen since!
MmacFN
556 Posts
Hey Yoga
Funny you should mention that, i did buy 3 books from amazon recently!
I spent about 2 weeks shadowing various CRNAs (since you all do a different job really). I thought it was awesome. I didnt, however, like the surgi center stuff Boring. The rest was awesome.
Yes i have come accross chest rigidy once and quickly reversed it with narcan. I had a BREATHING patient who had a pelic and femur fx. Bar none, the best drug for break through pain is fent., i have him 150 and in about one minute he was complaining of D/B SOB. since it occured with the fent i gave him narcan and fixed it. Sadly, he was still in alot of pain so i eneded up dosing him with etomidate and droperidol. That, at least, kept him from screaming as loud.
here is part of a study i had read a few years ago
Low-dose fentanyl, 2.2 to 6.5 micrograms per kilogram body weight, induced chest wall rigidity in 8 of 89 (9%) term or preterm neonates, who received a total of 204 doses (incidence, 4%). Doses were administered as a slow intravenous bolus over 2 to 3 minutes. One infant developed chest wall rigidity 9 hours after the infusion had been discontinued. Laryngospasm occurred in 2 of the infants. Naloxone immediately reversed rigidity in all cases (Fahnenstich et al, 2000).