CRNA Board Preparation

When you are in the CRNA program and the "finish line" appears closer than ever, another stress starts to creep on. BOARDS! All your mentors, family and professors can keep telling you that "you are going to do just fine" (and yes you will do fine) but it is difficult to stay calm. Good preparation and planning is the key to success. So how do you prepare? Here are some tips that helped me get through.

1) Timing

Getting your appointment for your exam is a difficult decision to make. "I didn't get time to study during clinicals", "I am not ready" etc are all the questions that may deter you from taking that step. Nevertheless, you NEED to do it. People tend to do better with deadlines and that little sense of nervousness will help you study better. If you go in without a set date for the exam you will more likely procrastinate (I did :) ). Also, regardless of the date you are taking the exam, there is always a topic that can be prepared better. That should not be the reason to delay your exam since we all have topic that are difficult to understand. So, make that appointment and don't change it because you feel unprepared. 

2) Studying 

It is ideal to study throughout the program however, we all know it is unrealistic. Some clinical sites have difficult rotations, exhaustion, and family matters can all play a role in limiting your study hours. It is important to set realistic study hour goals based on clinical sites. For example, 8 hour days may allow you 2 hours of studying whereas 12 hour clinical days allow you only 1. Use them appropriately. 

3) Topics

I know everyone's learning styles and habits are unique to themselves. So, know yourself. Don't follow the group. Choosing topic to study may work better if you have something to relate to. Discuss a topic with your clinical preceptor, relate it with your case, or study about your case a day prior. Studying and relating it to real-life situation is a great way to retain information. 

4) Review Course

There are so many review courses out there that may make it almost overwhelming to choose from. Every one of them have positives and negatives that again relate to your personal learning habits. I learn better from lectures and visual information so Valley review course worked better. However, if you are interested in how the boards are set-up, then Prodigy or Apex (or others) may be ideal. 

5) Relax

Most important one for the last. Relaxation and sleep are often forgotten as a CRNA student but are key to your success. I was so exhausted after two weeks of post graduation studying that I was having a great deal of trouble retaining information. You don't want to go in tired. Eat well before the exam and drink enough water. I had to change the environment I studied in to keep it stimulating. 

At the end, remember you made it through the difficult part that is the school and this is really the easiest portion of CRNA program. Feel free to comment or email any specific questions you may have. Wish you all good luck! 

DNP for CRNAs

Hi all,
So the reason for this long delay in posting has been a number of reasons both personal and professional. I have been busy with family and my the new addition to my family, Sandy, my "rez" dog. I have been told that that is a sign that you are permanent resident of rural Indian reservation. In addition to her keeping me occupied, I have also done something I thought I would never do again.
Yes, I am back in school and this is definitely the last time! I am in my third DNP course but it is no where close to being as interesting and exciting as CRNA school. All these time consuming assignments and discussion questions and research are so draining!
So why did I do it?
I believe that CRNAs and other advanced practice nursing specialties are in a constant battle for recognition with our physician colleagues. In order for us to be able to stand up for our profession, we need to take an active part in how things get to be in the today's medical field through research. I honestly believe that it gives us a much detailed understanding of why we practice the way we do. Another way of us being able to direct the practice rather than being directed.
I also wanted to match up with the soon to be all doctorate level CRNA graduate in the near future. I have always been interested in teaching and since most CRNA programs require a doctorate degree, it made sense to just get it done.
It isn't easy but I am in it to get it done.
I am hoping to return to my usual post frequency but I apologize for the delay already if I get too tangled up with life.
Hope everyone is approaching their goals as planned.

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Independent CRNA Practice vs. Team Care Model Vs. Anesthesia Supervision

Your graduation is coming up in a few months and you are looking for your first job. A lot of questions are popping in your mind mainly to do with salary, schedule and location of your new job. All seems to be in place yet there is something you didn't think would be as important in making you happy in your new career. Working supervised or as an independent CRNA.

Now I am not here to put down one anesthesia work model for another so lets put egos aside and really think through this. People have different priorities be it family, money, social life or schedule. However, if we were to think of our profession alone, how should new graduates read that fine print in that job offer that is offering ridiculous amount of money but something just isn't right.

Working in a supervised CRNA practice can mean a lot of things. It can start anywhere from "we have anesthesiologist here as a consult or emergency supervision purposes" or "No, you as CRNAs are not allowed to push your own induction drugs". Motive behind why certain places enforce supervision to a certain degree are usually to do with how CRNAs are presented to the hospital board members by the leading anesthesia group members. These kinds of jobs are more prevalent in bigger cities ruled by anesthesia groups. So, what should you look for before accepting a job?

Working under Anesthesiologist Supervision (and Team Care Model)

1. Experience matters. This is not only true working with an anesthesiologist but also a senior CRNA. There are so many different ways of doing anesthesia but in dire situations, it is always good to have someone with more experience than you. So, as a new graduate CRNA (or an anesthesiologist) Knowledge sharing is a plus and it can be a good thing to work with someone. However, there is a very fine line where this can halt learning and turn you into a charting monkey. You cannot learn by not doing. Practical experience can only be gained by actually performing. Looking at someone else doing a regional block or putting in a central line won't mean anything until you get hands-on experience with it. Here is what you should pay attention to. It is a positive sign if you hear that anesthesiologist and CRNAs work together without restrictions and practical, hands-on teaching is promoted for all anesthesia providers. And you might want to rethink about places where you as CRNA don't do push induction drugs, call anesthesiologist for extubation and you cannot do peripheral or neuraxial blocks.
2. 2) Interpersonal Relationship- I have been through rotation where CRNAs are looked as second class citizens and treated with disrespect and constant abuse. It is important to know your limitations but equally important to know your value. If you are being trained to perform as an independent provider then you should protect that right and not disrespect yourself by working in such place. Ask the CRNAs or RNs about how anesthesiologists and CRNAs get along. Do you get lunch breaks when you have floats and how are people relieved at the end of the day. This is especially important as some places CRNAs will be the last ones to leave at the end of their day. Extremely important! Also, clarify on the things that you are and aren't allowed to do before starting.

CRNA-Only Practice

1. Now unless you are the sole provider for a facility, the pluses and minuses mentioned above still apply. Some CRNA-only practices run really efficiently with a comfortable working environment. Yet you can experience mistreatment if your group is being run by a poor leader. So be cognicent of that.
2. Are you a leader: Now we all think making it thru a CRNA school is difficult and you have to be assertive in order to make it. However, when you are really on your own its a different game. You have to be a good leader who can organize a group of people to safely provide care to patients. Surgeons can be tough to deal with but at times you will have to stand your ground and not get run over. This is especially true if you are in a private practice where every case that you cancel makes you look bad. And to make matters even worse, you work for the surgeon's patient so they can be very pushy to make you do something you don't feel like is the right thing to do. There is a fine line between keeping good relationships between your team members and being a safe anesthesia provider.

These are a few of the many pros and cons to working in team care model and CRNA-only practice. It is up to you to decide what you are comfortable with. Your schooling was supposed to make you be comfortable enough to practice independently as you are not Anesthesia Assistants (Aas). So, don't underestimate your skill level and be brave and open to learn everyday to improve yourself. Your career's future depends on you! I highly suggest against working in places where you are not valued and limited from fully practicing your scope.

P.S. Sorry about the looong delay in posts. Personal life has been challenging over the past four months and I just started the doctorate program!! Most on that later.

Feel free to add on comments, suggestions, feelings. And please “Like” “Follow” and “Subscribe”.

Precordial Stethoscope: Quick Thoughts

Anesthesia is an ever-changing field where new technology, practices and research helps us make our practice safer and more efficient. That always raises the questions of when it is time (if ever) to exchange techniques that were used in the early years of anesthesia with new ones. Precordial stethoscope has been a key tool for anesthesia providers that can be used for continuous intraoperative assessment helping diagnose number of possible pulmonary and cardiac complications. However, improvement of anesthesia technology has made me question if its really a necessary assessment tool nowadays. Use of ETCo2 monitor, pulse oximetry, esophageal stethoscope and ventilator alarms etc can help providers diagnose changes in patient status as well. So, is it worth incorporating precordial stethoscope? Following is a list of key points on how I feel we can use them to improve our practice along with some tips on its appropriate use.

Types of Cases: I can't deny that having an extra monitor as such can ever be bad for any type of case. However, certain cases or patient population definitely support its use more so than others. I have used precordial stethoscopes primarly during pediatric cases mainly for continuous pulmonary assessment. Pediatric patients are at increased risk of events such as laryngospasm especially during induction and emergence. There is also a higher chance of right main stem intubation commonly in cases such as intraoral cases where head is manipulated. Therefore, I place precordial stethoscope over the left chest wall and hear for absent breath sounds. Anesthesia providers can also benefit from a precordial in patients with reactive airway disease, smokers and other pulmonary conditions.

Surgical Positions: Some cases require patient or bed to positioned in a way that can limited to sometimes, no access to patient airway. This can result in transforming, generally easily manageable situations, into complicated emergent ones mainly due to the delay in diagnosing and treating the problem. Airway disconnect, inadvertent extubations, changes in heart tones can be easily assessed with the use of precordial stethoscopes especially in such positions. Beach chair position is a commonly used position for shoulder repairs , craniotomies etc that places patients at risk of complications such as venous embolism.

 Feel free to share your thoughts on it. Do providers you know still use it? If so, how often and during what types of cases?

Part 1: Trauma Case Management

Hi all,
Hopefully everyone is having a great start to 2015. It has been a long time since I have had the opportunity to blog. A lot of good and bad has happened in my personal and professional life over these 4 months. I have finally learned how to utilize all the good from these experiences and make myself better for the future.
I still enjoy working independently and would never settle for anything less professionally. However, there have been some situations that made me realize that there are times when you just need an extra pair of hands and a fresh, fully-caffeinated brain.
This is especially true when you get a middle of the night call for a bad trauma case that is too unstable to be transported to a larger facility. That is when your mind needs to be fresh and running full force. I got caught off guard in similar scenario recently that really tested my knowledge of managing these complex cases. Even though, the trauma committee seemed impressed on the whole OR team's performance, there are always things that can be learned from such cases. So, I wanted to talk about what we need to consider dealing with these cases.

Preoperative
When the patient comes from emergency room in an unstable condition, it is sometimes difficult to assimilate all the information that is being reported off to you (if you get a report at all). There are some key details that should never be overlooked and are definitely important to know in order to manage a trauma.

• How much fluid has the patient received?- This can get out of hand very quickly in even well managed trauma cases. The transition from administering crystalloids to blood can easily get delayed further compromising patient outcome. A poorly resuscitated patient will also be poorly responsive to vasopressors. If blood transfusions have been started it is important to note if they were type and cross matched to avoid compatibility related reaction.
• Does the patient have adequate venous access? A trauma patient going to the OR should have at least 2 IV lines (if not a central line) regardless of how severe the trauma is. Things can change quickly so preparation is key.
• Is there an arterial line? This is especially helpful if the patient is expected to have massive transfusions. ABGs and continuous hemodynamic monitoring will be needed.
• What were the recent lab values? Electrolytes and blood count should be evaluated. 
• Radiology reports: Cervical spine stability must be maintained with a  C collar especially if radiology reports were not cleared. Placement of ETT should also be confirmed.
• Degree of trauma: Talk to the surgical team to get their view on how severe the trauma is. It might seem common sense but sometimes even the most important information tends to get lost in translation.

Preoperative Setup

• Hotline with blood tubing, arterial line setup, vasopressors such as phenylepherine drip, ephedrine and vasopressin (1u/ml), level 1 rapid infusor, bair hugger, central line kit with CVP monitoring set up.

Intraoperative
It can be a daunting task to prioritize things for a trauma case. Everything seems important and it may be difficult to organize appropriately in such a high stress time. Fluid and blood administration takes high priority for me (generally, depends on the case). If the patient is very unstable it may not be appropriate to hold off on making incision. However, if the patient is hemodynamically stable it may be wise to get properly set up with vasopressor drips, bair hugger, arterial line etc. Patient may lose significant amount of blood on incision depending on the degree of trauma. Resuscitation may be difficult especially if the patient is already fluid depleted.
Another important factor to consider is temperature. Hypothermia can severely increase trauma related mortality and is unfortunately, ends up being last thing on the to-do list. Use of hotline, air humidivent, and bair hugger should all be incorporated soon after patient arrive to the OR.
Massive transfusion is bound to cause severe electrolyte imbalances that could lead to possibly fatal outcomes such as arrhythmias, and vasodilation. Therefore, correcting abnormal laboratory values such as potassium, calcium, magnesium, and arterial blood gases should not be delayed. Hyperkalemia is often noted with massive transfusion so EKG changes should be noted carefully.


I have been researching this topic to ensure that I don't miss anything but even remembering all the details and writing it for the blog is a long tiring process. So, I will continue on this topic in Part 2 to follow.

When Endoscopy Cases aren’t Quick

It has been three months since I started working as a CRNA and “I m loving it!” However, good days, bad days, so-so days are there just like any other profession. Being able to practice independently has allowed me to finally use the drugs how I learned they were meant to be used. Going out of the box is a little unnerving even though I have been practicing in my scope of practice and using well researched techniques. General anesthesia is a little more forgiving in my attempts to ensure best use of anesthetic agents and adjunct pharmacology. On the other hand, Monitored-Anesthesia Care (MAC) doesn’t allow that luxury. I remember as a student I used to be think, pushing propofol for a five minute case is not bad at all.  That all changed during clinicals when I realized that my five minutes are not five minutes for the surgeons and their understanding of MAC is simply that it is a general anesthesia without the “tube”. So, now that I am in a place where endoscopy cases can last anywhere from 30 minutes to hour and a half long, I have been challenged more than once intraoperatively. Whenever a MAC anesthetic is used, it is important to acknowledge the fine line that exists between maintaining an unassisted airway and adequate sedation. So no surprise that for the first day I was re-introduced to endoscopy, either my patients were too awake and fighting or too sedated and apneic. And starting off with an embarrassing case where the patient gags, coughs, desaturate doesn’t help your reputation as the new guy. Luckily for me, I am at a place where anesthesia providers (I will leave it at that) are known to use physical restraints to hold patients during endoscopy cases. 

After trying out a few things, here are a few tips to bring back smooth, calm endoscopy day. (Like we all know every patient is different and there are thousands of ways to"skin a cat".)

       1)     To numb them or not? Entry of EGD scope can sometimes be traumatic and lead to the patient gagging and coughing. So I was always curious to see if numbing their oropharynx with hurricane sprays or lidocaine mists would make it less stimulating. I started off with using a 2% lidocaine gel in the back of their throat and asking them to gargle. That was too much or too thick to gargle so I soon converted to using a mist of 4% lido from the LTA kits. Now I haven’t personally tasted it but noticing patients’ facial expressions, I could tell that both tasted NASTY! And that taste would last a while making them cough as I rolled them to endoscopy suites. A bit counterproductive. Another issue with numbing was its timing. It was easy to administer it either too early or too late. Surgeon didn’t come in the room right away and it was gone! Using it also caused the patient to salivate more thus increasing their risk of aspiration. Now I don’t use numbing agents at all and just request the surgeons to go slow with the initial entry while I give the patient a jaw thrust. So far I have had positive outcomes with this technique.

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          2) How to induce. Being a new grad, it is easy to let yourself think that you are taking too long when the surgeon is waiting for you holding the scope. Truth it, it doesn’t matter. If I need time to do a safe anesthetic then I am taking that time. It is critical to take this time especially in endoscopy cases because a little too much and they go apneic and start desatting as the scope goes in. Slow induction is the key. I would give them just enough initially, for example, 50mg of propofol for a young healthy male, then continue in small squirts. Goal is to keep the patient anesthetized enough to tolerate the scope without going apneic.

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          3)Ketamine is awesome but…. I started using Ketamine for endoscopy solely because it does not depress respirations. However, one of its side effects includes excessive salvation. I thought using a small dose will limit its side effects but that is not true. I had a lot of patients laryngospasm on me as the saliva would collect in their oropharynx. Using 0.2 mg robinul about 3 minutes before the procedure starts greatly decreased this side effect resulting in a smoother anesthetic.

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           4)What I use now. In preop, I administer 1-2mg of Versed and 0.2 mg of Robinul if I am using ketamine or patient has a lot of secretions. Once in the room, I connect the monitors to get a baseline set of vitals and immediately give 25 mg of Ketamine. I follow it with propofol 200mg + 25mg of Ketamine at a slow rate. If it is a colonoscopy, I will also give 25-50mcg of fentanyl as insufflation generally causes pain and causes you to use more propofol. I will push a very small amount of propofol every other or third heartbeat (which I can hear from my monitor) for the remaining case. So far that has been working great for me. Let me know what works for you.

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Being a CRNA

Hi everyone,

Believe it or not a month has gone by since I started my new job as a CRNA. And it has been amazing! It's just a different feeling knowing you are on your own and have the independence of making your own anesthetic plans. I am at a place where both MDAs and CRNAs work independently. So I fly solo but have someone available to bounce ideas off of if needed. It's a small place but I have been doing all kinds of cases on pediatric, obstetric, and general population. I have also been doing regional anesthesia such as inter scalene and femoral nerve blocks using ultrasound. It's been great learning all the new stuff that I read and can apply to better my anesthetic plan without any interference. In addition to that I love my schedule! My usual work week is three days and a night on-call with post call day off.

I know it's been a while since I got to write for you guys but that will be changing shortly as I will have more time. New thing to look forward is a review book for boards so be sure to like, subscribe and comment.

Thanks for reading! 

Graduation!

Hi all,

Its finally here! The long, exhausting journey through CRNA school is over...(well if you don't count the boards). I thank you all for following me through this process and I hope to continue updating you all on what I learn from whats to come. Hopefully, this has helped you. Thanks again! :)

Which Program to Choose? (Part 1)

Hello everyone,

Selecting a CRNA program to attend should be a process and not a one day decision. That is the key to remember in picking a program. If you are planning to attend a CRNA school, there are a number of things to keep in mind to ensure you get what you wanted from it. And for that, you must know what you aim to achieve. These are some of the topics to research before settling for a program.
 
1) "I want it easy"
During my schooling, everyday I thought my program was too tough! So I always questioned myself if attending an "easier" school would have been better. One would like to think yes, but would that help ensure a long, safe, CRNA career? Truth is, most likely not! First of all, I highly doubt there really is a CRNA school too easy! Some school may be more laid back about the rules, exams and teaching methods but overall you need to learn the same things in order to practice successfully. So, I say learn, research and understand that if its real tough to get through its most likely to make you good at what you be doing. Also if you are looking for an easy way out, this isn't for you. No pain no gain!

2) "Do I want to travel?"
This is something I would confess to as the primary reason for why I chose the school I went to. It was 20 minutes from home and so I be closer to family and friends etc. Didn't looked beyond that. Again research the school well! Make an appointment with the program director to see if it meets you need. You may think it is close to you but that might be just the didactic portion. Like my program, clinical rotations are all over the nation (which I knew BTW). That might not work for everyone. This might also be a problem when it comes to cost and safety. Do you really know where you be going before hand? Can you request site rotations? Do they pay for your housing and transport? and what kind of experience you be getting at those specific sites? MD directed or independent CRNA practices? Rural areas? These are all good questions to know. Regardless of where you plan to go, I highly suggest you go up there and assess the situation.

3) "How much money I be spending?"
Of course, nothing is done until you ask how much it costs. This a major determining factor for a lot of students decision. Private universities will cost a whole lot more than state. This might be a problem for students with families or someone who would rather not have 100,000 dollar loan. Again, ask your school if they for sure send to out of state clinical sites and if travel and housing is paid for by school. If they school is paying for your housing, is it in a safe area, in the hospital (I have seen call rooms being student housing)  

 (will be continued...Got to study for Boards :) )

Valley Anesthesia Review

What a busy weekend!! Just came back from attending Valley anesthesia and my mind is full of information. Three days to learn important anesthesia topics was a tough job. However, I was highly impressed with how the information was presented. Sometimes it felt like topics were discussed really quick and it was too much to handle. It was nice that they allowed us to voice record so I can re-listen it. I am kind of disappointed that my weekend sleep-in time was lost but I would be really glad if this helps be do good on the SEE and the boards. It was a little expensive I thought (at $750 + Hotel + Flight cost) but if it works, its better than paying for boards twice. When you sign up for the review course, they send a review book (sweat book) for you to study through prior to coming to the actual course. I be honest that I didn't even get a chance to open it before the actual course review. I highly suggest you try to do that! It was nice seeing all of my SRNA friends after a while and the new ones I met. So, good luck to everyone on the exams and let me know how you feel this review helped.

Boards and Job Search?

Quarter 3 has come to an end and as only two more remain, thoughts about being ready for SEE and boards are making me a little nervous. Reviews using Prodigy anesthesia have made me realize how much I have forgotten from the didactic portion of my school (almost all of it!). Slow and steady study review has begun. Homework is also more focused towards studying for boards which is a big relief! Careplans are still on the to-do list (basically since the first quarter). It looks like all this is going to end like it started...stressful! I am ready for it to be over though. I realized how close I am to finishing when I heard my classmates talking about job hunting. My thoughts about job hunting are scattered all over the place.I am not sure where I want to work, what I need to look for in a place I want to work and everything else that matters. To feel like I did something about it, I updated my CV today to be ready for the time I be needing a job. Then I think am I doing this too early? I haven't even thought about the SEE or more importantly the boards. Would I be able to pass them, would I make it through the last two quarters? I guess we will see. 

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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New Challenges at Home

Hello all,
Its been nice moving back home for clinicals this quarter. No more paying rent while I have a house, no more daily fast food stops, no more worries for at least 3 more months...one would think. Even though all thats been great, moving to a new clinical site does bring a lot of worries and challenges. New people, new place, new ways of doing anesthesia. So, I am not surprised that I had a stumbling first week. The last site I was at, I didn't get a chance to extubate my patients in the room, which is like saying I only did 50% of anesthesia. Coming to a site that does extubation in the room has been some task. Lowering the anesthesia by approximating when the surgery is going to end to allow patient to wake up with the last suture in is one heck of a challenge. On top of that, new charting, preop and post op routines and CRNA preferences have been hard to remember. While I was hardly ever tested at my previous site, my first week here consisted of multiple questions on medication dosages, regional anatomy and EKGs...some of which I didn't have a clue about. And therefore, here I sit on my chair at home, doing my homework early so I can brush up on these topics for Monday. Hopefully it will be helpful for later. Well...time to get back at it! Be back soon...hopefully

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End of Clinical Quarter II

Hi there dear readers,
I am happy to say that another break is here as I have finished my second clinical quarter. Now another place to move to for my next rotation. That brings in new fears, new challenges, new people...new everything. I really don't enjoy having to start everything all over again but am a little excited too. Even though, I am nervous, I do feel really lucky to have had my first experience at a wonderful site with a huge number of cases. Hopefully this continues and I can get really comfortable (especially with peds) before I graduate. Before that...a week and a half to enjoy at home after a long drive back.

Considerations: CABG On-Pump

I have had the opportunity to work with a couple of MDAs on a few CABG cases. Here are some of the things they thought were good to know when doing such cases. These are just somethings I wrote down during the case. Please let me know if you have something to add or correct.







Preoperative

• Be sure to give assessment of patient's respiratory status just as much as his cardiac status. A patient with severe CAD is generally going to be a smoker or have significant history of it. There decreased FRC may be enough to cause issues while intubation and result in a very bad situation.
• Include there activity level. They generally won't be able to climb a flight of stairs without getting short of breath. That again will help direct your decision on how you want to induce the patient.
• Diabetes. If they have history of diabetes, if may be that they have never had chest pain. So thoroughly assess the EKG.

Induction

• First thing to do when the patient comes to the OR table is start Preoxygenating! It is literally going to be the factor that can determine if patient survives the induction
• Give appropriate dose of versed. If can help keep the patient calm and is good because it is not a respiratory depressant.
• Start a radial arterial line. Use lidocaine infiltration to limit stress on patient.
• Induce with Etomidate, Lidocaine, Succinylcholine and most importantly Fentanyl (or other rapid onset opioids)
• Make the first view the best view! 
• Direct laryngoscopy is highly stimulation and repeated attempts can be detrimental. So, if you think you might need a glidescope...use it the first time!
• A BIS monitor is also helpful to have on before induction, and when you push the induction meds wait for it to go to the appropriate range (40-60) before DL.

Management

• Monitors: Central line, a femoral arterial line, PA catheter
• Drips:
• Amicar: 1g/hr=50ml/hr after 5g bolus
• Propofol (if TIVA)
• Nitroglycerin: 200mcg/ml concentration
• Levophed: 8mg/250ml concentration
• Epinephrine: 2mg/250ml concentration
• One of the most stimulating time period during surgery is during STERNOTOMY!
• So, plan ahead and give Fentanyl (large doses)
• Another thing before sternotomy is that you will need to drop the lungs to avoid puncture.
• Bypass
• Before bypass, you need to make sure the ACT is above 400. Heparin dose is usually 300 units/kg. Cardiac perfusionists may give additional doses if needed to keep ACT >400
• We gave solumedrol 1g immediately before going on bypass to help limit the inflammatory process
• During aortic cannulation, it is very important to ensure that the BP is low, or dissection of the aorta can occur.
• The perfusionists will generally check ACTs every 30 minutes
• Also mannitol to scavenge oxygen free radicals
• Lidocaine dose before cross clamp is off
• If hyperkalemia is seen, calcium chloride may also be given.
• After bypass, blood glucose are usually elevated because insulin is not as effective in cold temperatures
• Some patients may also need platelets, FFPs, and cryos. Consumptive coagulopathy may occur (generally is seen after surgery is over)
• Protamine: ONLY given AFTER patient is off bypass. If you give it before, all of patient's blood in the pump will clot and patient will not make it.
• Give it slow and watch for protamine reaction (increased PA pressure, decreased BP)
• If platelets are used. Do not infuse them through the fluid warmer as they may clump.

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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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Spinal Anesthesia

Lately, I have forced myself to overcome my fear of leaving the somewhat comfortable zone of general anesthesia and head to other types of anesthesia such as neuraxial. I have had a chance to work in OB for a couple of days now and feel better about administering spinals and epidurals even with such limited experience.

Yesterday, I had a 15 and a half hour day in the OB department. Yes, it was really long! Part of it was sitting in the surgeon lounge waiting for the doctor to come or patient to be prepped, but still...it was too long! Regardless, I had plenty of opportunities to try out spinal anesthesia for C-section.

Here is a quick run-down on how I was taught and other necessary tidbits.

• A my clinical site, a tech preps your spinal site usually and sets up the tray for you. I managed to do a few myself. The first thing before doing anything is to make sure the patient is connected to the monitors. A baseline set is needed as you will have to keep a close eye on vitals immediately after injecting spinal anesthesia. Be sure to adequately preload the patient with fluids to prevent hypotension and nausea/vomiting related to that. 
• Basic things needed: Duramorph, Spinal Kit (we use Pencan 25g), sterile gloves. 
• The next step is to ensure proper positioning. Inform nurse that the patient needs to be in a "Mad cat" position and it helps demonstrating this to the patient. Ask the patient to drop shoulders forward and push lower back outwards. Another thing that I missed was ensure the patient was not leaning to a side. I was a working with an obese patient and it was hard to tell but I was aiming my spinal needle off centered because she was leaning slightly to one side. It was easy once my preceptor made me realize that.
• Before prep it is good to identify the landmark for L3-L4 interspace. For some reason if you did not get an opportunity to find the landmarks prior to them prepping the site. Use the drape to feel for iliac crest to keep everything sterile. It is also important to follow the spine with one's fingers to make sure it is not off midline as one would notice with scoliosis. 
• Be sure to collect everything before donning sterile glove. I used duramorph so, I had to open and place the unsterile syringe standing upwards on the table so I could draw up having my sterile gloves on without touching. 
• After getting everything ready, palpate for the insertion site again and mark with a little indentation using your thumb nail. 
• Open the glass vials in the spinal kit one at a time to keep things simple. 
• #1: Lidocaine 1 % for infiltration=  3ml
• Infiltrate the insertion site, create a skin wheal and injected at the site. Skin wheal helps identify the site you choose.
• # 2: Bupivacaine 0.75% = 1.6ml and inject 250mcg Duramorph (0.5ml for me). Be sure everything is meant for spinals and is preservative free!
• By the time your spinal meds are drawn up, local infiltration gets a chance to work
• Insert the introducer straight in. Deviate as necessary to avoid bone. 
• Insert the Pencan spinal needle. Feel for pop 1, keep going and then feel for pop # 2.
• After second pop, remove stylet and check for CSF.
• Connect the syringe with medicine and check for clear CSF and aspirate to check for swirl
• Then slowly but steadily inject the medication and pull all the needles out together!
• immediately rest the patient back.
• I have been told that 1.6 can work for everyone under 6 feet as you can make it go higher or lower based on patient's bed positioning.
• And assess level to be a T4.
• If it is too low, trend the patient for sometime and reassess. If patient starts having numbness or tingling to the fingers. Straighten the bed to avoid further increase in spinal. Vice versa.
• Let patient know that it IS OK to feel pressure and touch!
• But NOT OK for pain.

This is it for now...I will keep adding to this as I learn more. Please let me know your experiences and what else I should add.   Be sure to Comment, "Like" ,Subscribe and "Follow"  for more useful info! Thanks!

Month and a Half Later

I know its been forever since I have come by to update you guys. I have missed writing...besides doing other fun things but free time has been very hard to come by these days! 10-12 hours workdays 5 days a week followed by homework over the weekend...exhausting! On the other hand, with a few ups and downs, its going alright till now. I have done a lot more cases including a couple of days of OB where I got to put in a few spinals...kind of nervous doing that but they went fine. My preceptors have been great! I have had an opportunity to see many different techniques including total intravenous techniques where patient's wake up and get extubated in less than 2 minutes after surgery and ask how the surgery went. That was pretty cool to see! Homework is something that kills me! I hate writing care plans with info that means nothing more than written words because we never actually use the plans I write in real life. All that I had learned is slowly fading away and I am trying hard to keep up with reading so I don't lose every bit I learned just last year. Thats all I have for now. I will be back a lot sooner than last time. So, talk to you soon.

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Simply Anesthesia Book

Hi folks,

Here's another great book that was found out as a day-to-day resource for all related to anesthesia. Its called Simply anesthesia and is written using great resources such as "pocket anesthesia" and "clinical anesthesiology". It's focused on the key points written with just enough information and directed straight to the point. It includes topics such as pediatrics, obstetrics, cardiovascular, thoracic, neurology along with many others. Its written by a CRNA who started writing it during school to help her with school. It is also great resource for certification exam. Here's the website where you can check it out and purchase it. It's well worth the money and not as expensive as most other resources out there. Let me know how you like it. www.simplyanesthesia.com

Here's the full table of contents:
ACLS
Anesthesia Basics
Blood & Blood Products
Cardiovascular
Drugs
EKG Basics
General & Abdominal Surgery
Geriatric Anesthesia
Neurosurgery
Obstetrics
Offsite Anesthesia
Orthopedic Surgery
Otolaryngology
Pediatrics
Regional Anesthesia
Urological Surgery
Vascular-Thoracic Surgery