Senoritis!

I cannot believe I am saying this already but I have 27 more shifts to go within the next 2 months and I will be officially done with CRNA school! Knowing this fact, I have a severe case of Senoritis. Switching between nights and days is a little tough and my cardiac experience at this last site hasn't been too kind. Now the stress is towards finishing the last bit of careplans left to do and to study, study and study!!
Prodigy and Valley are in the study plan but haven't been too consistent with it because of long shifts and alternating day and night shifts and of course, "senoritis". The nice thing, however is that time is moving closer to my graduation every minute and I cannot wait!!
Time is ticking :)

US- Guided Femoral Nerve Block

Hi everyone,

Hope everyone is having great holidays!! It's been busy at the new site I have been for the past month. Even though I only do about 4 cases a day unlike 7-8 at the last site, there is still a lot of running around. In all this busy work, I have had some great opportunities to learn how to place femoral nerve blocks using ultrasound (US). Still no where near being an expert at using the US, I have learned to get through it using a few resources like NYSORA website and RKU compact app. The site I am uses a lot of these continuous fem blocks (in conjuction with spinals and TIVA) for post op knee surgeries. So I decided to write a little bit about how I have been taught to place one. I also attached a video for the visual. 

Preoperative :

1) Ensure correct patient and the location of surgery. Check for allergies

2) Check consent. Only absolute contraindication for regional block is patient refusal

3) Equipment: Continuous FNB Tray (2-4mm stimulating needle), dermabond if available, EKG pad for nerve stimulator, sterile gloves. Medications to include Versed and Fentanyl, monitors ( spo2), Ropivacaine 0.5% = 30ml (or similar alternative), another RN or CRNA for assistance. Emergency equipment

4) Inform patient about the procedure. 

Procedure: 

5) Connect monitors, give versed and fentanyl as appropriate. Expose groin/ inguinal area on correct side

6) Don sterile gloves after opening Kit.

7) Prep site with chloroprep as place drape. Prepare local 1% Lidocaine and open femoral Catheter and place it on the sterile portion of drape for easy access.

8) Drop end of the extension cord for assistant to connect and flush stimulating needle with local anesthetic. Do the same to connect nerve stimulator at turn on at 2mA

9) Set up US probe by adding lubricant in the sterile sleeve provided and covering the unsterile probe with sterile sleeve with the help of assisting RN.

10) Place remaining sterile lube at site and orient self to US. Make sure the probe side on your end and on the US screen are matching to avoid confusion.
11) Identify anatomy in the inguinal region. Vein, artery, nerve (medial to lateral). Vein is more compressible when pressure is applied with the probe. Also, identify the two fascias, fascia lata and fascia iliaca that present as white lines under US. Two distinctive "pops" must be observed as these fascias are penetrated.
12) Once structures have been identified, nerve stimulating needle is inserted at 2 mA and patellar "snap" is identified. The bevel of the needle should be facing towards the patients head to ease guiding the catheter. A medial sartorius twitch may by corrected by repositioning the stimulating needle more lateral. Negative aspiration for blood is confirmed as needle is moved. Patellar "snap" should be present up to 0.5 mA of voltage. If still present under 0.2 mA then the needle should be withdrawn slightly as it may be too close to the nerve bundle.

13) When patellar "snap" has been identified and a good view of the needle is seen on the US, 5 cc increments of local anesthetic are injected with periodic checks for negative aspiration.
14) Correct placement of local anesthetic can also be confirmed with the US. Once injected, the needle should be held stable and injecting catheter should be disconnected so that the catheter can be threaded.
15) Correct marking for the catheter may vary but is generally placed at the 15 mark. The catheter cap is applied and it can then be secured with a tegaderm dressing.

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Considerations: Laminectomy

Here are few tips to consider for a Neuroskeletal case. (Laminectomy, Fusion etc) It is not complete but has few tips that may be helpful as a quick review.

Preoperative

1) Assess patient's baseline pain status. Ask if patient is feeling any numbness, tingling or pain to  a certain area and document.

2) If patient is undergoing a cervical fusion or laminectomy. It is very important to make sure patient does not have limited neck extension. Some limitation in neck movement would most likely be seen which may make it a difficult intubation

3) Assess patient's baseline vision status. Lying prone for extended period of time can lead to vision impairment or loss. Even though our goal is to keep pressure off of the eye using a prone pillow, vision loss may occur.

Intraoperative

Induction: For intubation, it is ideal to use fiberoptic to limit extension of neck as all laryngoscopies cause some degree of neck extension. Fast-track LMA can be use to aid in intubation but LMA placement may increase pressure on spinal cord.

Agents: Prior to induction, check to see if neuromonitoring will be performed.
If motor evoked potentials are used, long acting muscle relaxants cannot be used.
If SSEP are being monitored, TIVA may be the best choice. Muscle relaxants may actually help by limiting artifact. Propofol/Remifentanyl drip may provide for best results from SSEP monitoring. Barbiturates are known to increase latency and decrease amplitude; magnesium and alpha 2 antagonists also decrease amplitude.

Propofol, narcotics, midazolam, droperidol, clonidine and precedex result in minimal SSEP changes.

On the other hand, Ketamine and Etomidate both are known to increase amplitude.

Volatile anesthetics will also cause dose dependent increase in latency and decrease in amplitude. N20 is worse than other volatile agents.

Positioning: Prone pillow should be used and pressure points must be assessed frequently. No pressure should be placed on the eyes. Ensure that tubing and monitoring leads are not leaving pressure on patient's body. Maintain proper alignment during transfer and it is safe to disconnect the ETT from the circuit and the monitors for transfer to avoid accidental extubation.

Prior to incision: If no paralytics are used, be sure patient is adequately narcotized for pain to avoid moving with stimulation. BIS monitoring is a good tool is use along with other monitors to ensure adequate depth of anesthesia.

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Tips to make your way in.

Hi guys, I wanted to discuss a bit about the qualifications I had prior to applying to CRNA school that helped me get in. These aren't set in stone and may differ based on school requirement and obviously no guarantees but something that I noticed helped me.

School: Honestly, I was only a B Student in nursing school and my GPA wasn't the greatest (considering the fact the first class I ever had to retake in my whole schooling... OB). I started my BSN six months after school and worked hard to improve my grades. Luckily my GPA improved tremendously, which then I could use to promote myself during the interview.

Work: My work experience wasn't full of versatility (as I was repeatedly told I needed to help me get in). So, I worked hard to get a broader experience. My confidence on this section was low as the job I was hoping to get the experience from didn't start until 1 week prior to my interview. Another luck factor, I think, as I could tell them that I am focused towards making myself a better candidate for admission. So, my total work experience, 1.5 years. F.Y.I when I talked to the students currently in the program, most of them had only one year ICU experience ( only based on one school though, that's their minimum requirement). I only have med-surg ICU experience but having cardiac experience is considered better.

Certification: The third thing I did was to work towards getting my CCRN certification. Again, got that six days before the interview... I wouldn't suggest doing that, HIGHLY stressful if you do it so close to your interview. It may not be required but definitely looks good on your resume. I think if you have strong application and add things like CCRN when you are in the interview, it boosts you up greatly.

Let me know if you have any more questions. Hope it helps. :)