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?

Apex Anesthesia Review Course

I have recently been approached to give my opinion on a new SRNA board review website Apex Anesthesia Review (www.apexanesthesia.com) that is available now. Before I begin, in a  recent comment, it was mentioned that they feel "A Student CRNA blog" introduces a lot of new "products". I am not sure if they were saying its a good thing or bad. The information presented about the mentioned courses are  mainly introduction to the products without any promotion or rejection of their effectiveness. Everyone has different learning styles so the idea of me discussing these is to allow an insight into the courses that can help you all determine if they meet your learning needs or not. Regardless, I wanted to start off by saying that the products that I discuss on my blog do not provide me with any monetary compensation. In fact, I look for terms that allow me to keep a neutral, unbiased stand towards the product. Thanks to the developers of Apex Anesthesia Review Course, Kevin Baker CRNA and Daniel Frasca CRNA, DNAP, I have had the opportunity to personally browse their website courses and get an insight on how it works.

Apex Anesthesia Review is an online SRNA review course that provides students with a comprehensive review including multiple tutorials and question banks on topics tested on NBCRNA board exam. The topics are divided into 9 units along with review exams and national certification practice exams. Student subscriptions allow unlimited access to all these courses from your computers and tablets. Smartphones may also be used to access review exams and full length practice board exams. Student course progress is tracked and communicated between all compatible platform allowing easy transition from computer to ipad. The courses are created with in-depth details of the anesthesia topics and are supported by necessary diagrams and illustrations. Questions have been formatted similar to the NBCRNA boards such as multiple selection, drag and drop, illustration questions, and calculations. Apex courses are stored in the cloud and are updated without the need for students to get software update.

Pricing is based on a subscription model and a group rates are available for groups larger than 10. Students are also able to contact the CRNAs who created this program for personalized help if needed. According to the developers, they currently have a 100% pass rate. However, if a student fails, they provide help to create a customized plan and also provide a full refund if the student can't pass the boards after 3 attempts.
Browsing through Apex website, there were some things that I think SRNAs will definitely benefit from and some I had to think over a bit. Initially,from a student's perspective, I was worried about it not being available offline. However, I ended up favoring this change once I compared it with downloadable review programs. It allows students to access courses from almost anywhere and on any device since there is no program to download. All you do is login and pick up where you left off. Another tool that I really like is the "index" section which provides a straight forward, to the point list of very specific topics that are easily accessible with just a click.

Overall, Apex anesthesia seems to be a well organized and to-the-point review course website for SRNAs (and CRNAs in the near future). Hopefully my  brief introduction to the website provides all anesthesia folks with enough information to see if Apex anesthesia is the way for you to study for your boards and earn those four letters behind your name...C.R.N.A.

Feel free to help out fellow SRNAs by commenting below if you would like to share your personal experience with the Apex course. Also, you can contact this developers at this link if you have any more specific questions. http://www.apexanesthesia.com/contact_apex/

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Thanks again for reading!

An Insight into CRNA Career

Hi everyone,

It’s been a while since I blogged but it has been even longer since graduation. Today it’s a year mark since graduation and it has been a great one. There have been so many things I learned and improved. I agree completely with what my preceptors told me during clinicals that “real learning begins when you are on your own”. That leads me to the topic for today, independence in the profession of Nurse Anesthesia.

If you are just considering applying for CRNA School, you might think topic about jobs is a little too far for your interest. However, I think the biggest shock for me not knowing much about the profession was realizing that there is such a vast range of independence allowed in this profession based on where you work. I am not talking about doing certain types of cases but the scope of practice you will be “allowed” as a Nurse Anesthetist. It may be a little difficult to grasp since as RNs we are all expected to be efficient in everything (and often more) than our defined scope of practice. The scope of practice for Nurse Anesthetists has unfortunately been distorted by American Society of Anesthesiologists (ASA).  So for us this means that even though skills such as placing central lines, administering neuraxial anesthesia or regional analgesia are under our scope of practice, we have to sort through multiples jobs to find a place that “allows” us practice with such independence. I have realized that the real depressing issue is that we have allowed that to happen.

I consider myself lucky to have attended a school that had clinical sites all over the nation. This allowed me to experience vast array of settings that CRNAs practice in today. These included completely supervised CRNAs practices, MDA/CRNA groups without supervision and CRNA only practices. I get goose bumps thinking about places like a clinical site that I attended where CRNAs are highly supervised by MDAs and often treated as second class to anesthesiologists. That is mostly not the norm and I have seen practices where the relationship is harmonious. My goal with this is to have you consider that if you are looking forward to a completely independent unsupervised CRNA career, you might have to sacrifice a few “must haves” on your list until we have a stronger professional organization that restricts these limitations. These may include you having to move into a rural area, work in setting where you have to take significant call days, and possibly lesser pay. So, before you make that decision of attending a school, be sure you know what clinical experience they offer. In addition, have a clear insight of the things that are important to you in your CRNA career. I HIGHLY recommend focusing your clinical time to prepare yourselves for an independent practice. It might even be worthwhile to make those tough sacrifices to better yourself as an independent practitioner during the early years of your career.  Before I get off the soap box, I do want to mention that I work in a rural area in a CRNA/MDA model with 100% independence and practice every skill I learned during school and I wouldn’t give up this freedom for anything.

CRNA School...are you Ready to Apply?

You now feel ready to take that big step towards progressing your nursing career. You have always wanted to be a CRNA or have recently started researching this field. What do you need to know in order to figure out if it is the optimum time for you to apply? Here are some things you must address before applying.

1) Are you really ready? Nurse anesthesia program is a highly demanding program that requires total commitment and dedication. And this process begins way before the school actually starts. It begins when you decide to apply. Everyone else applying along with you is your competition. If you GPA is not where you feel comfortable applying, don't apply. Work to be at your best academic and professional standing before applying. Not only that, even before making that decision to start applying for school, thoroughly assess your readiness to be able to make all the necessary sacrifices. Are you willing to move for school? Are you financially ready? Have you researched enough to determine that it is for you? Are you willing to quit work for school if needed? Do you have the requirements (GRE, CCRN etc) met? All these questions should be thought out prior to you submitting that application.

2) Is your family ready? If you go in single like I did, you may think I can skip this step. However, I would suggest you still give it a thought. You friends, parents, siblings or whoever is important to you may not understand the significant change they are going to see when you are actually in the program. It is important to discuss the changes they can expect to see in you during school. Less time at home with the family, eating out, no vacation time, emotional turmoils, traveling for clinical rotations, along with many others are common issues observed in Student Nurse Anesthetists. Your family or significant other has to be on the same page as you before you apply because even if you may not agree, your family will be sacrificing a whole lot more than you to get you through a CRNA school. Do they know you won't be able to work? Are they going to survive without your income? Can they tolerate time away from you if needed? Are they willing to move with you if needed? These are all important discussions to have before you decide its time.

3) Is this profession really for you? Great pay and "chill" job is what I kept hearing about this profession before I applied. As I got to know more about it, like every other profession this isn't for everyone. You are doing yourself and your future patients a disservice if you are doing it just for money. It is a very stressful and at times, unpredictable profession. This may not be for you, if you are the one who likes to talk to your patient and enjoy following up with patient progress throughout their hospitalization.CRNA profession has an ever going battle for their role in the anesthesia world against anesthesia assistants and anesthesiologist. This can limit the availability of job that you envisioned when you decided to be a CRNA. Like me, you may have to move to a rural area in order to find your dream job. So, you may have to continue sacrificing longer than just the duration of the your schooling. Be sure you find a CRNA (specifically a CRNA) to shadow to get an idea of how their day goes. This can give you some idea on what to expect.


Look forward for additional CRNA school related considerations. Hope this was helpful. Be sure to Like, Subscribe and 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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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 :) )

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 :)

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. 

LMA Placement

I have heard that people have a love and hate relationship with laryngeal mask airways (LMA). Lately, I have been using a lot of LMAs and the more I use them, more I like them. There are a few tricks to remember while placing one to avoid causing trauma even though micro trauma is frequent. There a variety of LMAs that I have seen at the sites I have been. LMA Supreme is my favorite (2nd picture) and has been the easiest to insert for me. However, a problem that can occur with any one of these is catching of the tongue in the opening of LMA as you are inserting it. Some patient's have large oral opening that make it easier to insert but for smaller oral opening it is important to make sure you protect the tongue.

Insertion:

One technique to help with this is to use a 4x4 gauze and hold tongue upward out of the mouth and slide the LMA over it. It can be helpful but hasn't always worked for me. Another technique I have used lately is to go in slightly sideways while inserting. I have found this technique to work better if I use the LMA exactly like its packed, without deflating the cuff. Once you get past the tongue enough, turn it straight again and your patient was saved from getting a frenulectomy.

Cuff air:
This is another thing to experiment with while inserting LMAs. I always go back and forth between deflating the cuff completely or adding in more air before insertion. The problem I have with deflating cuff completely is that its tip will almost always tend to bend on its itself and be a reason for some major struggle. So, based on my experience with them, a little bit of air always makes it easier. Now I just inflate it enough where there are no wrinkles or dips in the cuff and its worked quite well.

Anesthesia depth:
This is what makes us different from any random person trying to shove a mask down people's mouth. Figuring out how deep you need to have the patient prior to inserting the LMA may need a lot of practice especially if you like your patient to start breathing spontaneously immediately after insertion. Well, I have noticed that there is a very fine line between you having the patient too deep that they won't breath or them biting your finger when you are trying to make sure LMA's tip doesn't bend or worse...bronchospasm. Style points for putting the LMA in without patient coughing or gagging and then them breathing. However, I think its safer to give enough to have them go apneic and support their breathing until necessary either manually or with PS <20 on the vent. So, do give them the needed propofol dose! Use of opioids can also ease insertion but their administration should be very well timed. This is especially true if you are using fentanyl. There have been times when I am just a little bit delayed in pushing that fentanyl and then had to deal with them being way too comfortable to breath. Give fentanyl first thing as the patient enters the room. Sometimes, if a young, healthy person, I will even give it with the versed in preop and then bring to the OR.

Extubation:
This is one step of using LMA that I haven't seen many variations of. Almost all of the CRNAs or MDAs I worked with remove this without deflating the cuff. This prevents secretions from falling off the cuff and possibly be a reason for laryngospasm or bronchospasm.

Thats been my experience so far with LMAs. Very nice tool to use but if ever question using it in a patient that might possibly be more at risk than benefit from LMA...just intubate!! Better be safe than sorry. Hope you all liked this post. Let me know your experiences or suggestions.


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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: 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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Clinicals

Guess what?! Its time to start working on real people. Twenty hours drive to Texas with an hour and half break was a bad idea but driving on about 150 miles of dead road wasn't comforting either. Anyways, I m here and ready to start in less than a week!
So far studying has been a minimum exactly opposite of what I had in mind. Sleep schedule has been off and air mattress has been too nice to my back. Cooking for self is way harder than I thought. But as far as I have been told this would be nothing compared to what I about to get into. I guess it won't be too long before I figure that out. Anyways, will try to keep in touch and write more often once I get Internet at home.

Succeeding CRNA Interview!

Its that time huh?
You have a CRNA interview but are not sure on how you should proceed?
Even though I have discussed in my previous post what one might expect in an interview, it is hard to really pinpoint on what one might be asked exactly. So, I decided to write a post giving you some tips to consider on what YOU can do during your first (hopefully only) interview at a CRNA school to leave a good impression!

1) Dress code
NO Hawaiian shirts! As clear as it seems, its not. You be surprised what our minds can force us into doing on such big days! This is from personal experience. Don't be the one going in for the interview and being the only one without a suit. Even though, a nice shirt and tie for guys might suffice, I highly suggest buying or renting a nice, professional suit for this. And Yes...even if it is hot outside! Ladies, it is very important to limit exposure. Again, as simple as it sounds, it still happens! CRNA school applicants have a higher set of standards to meet professionally as they are already professionals as nurses and this apply right from the get go.

2) Be Humble
Had 10 years of ICU experience, 5 of ER, 5 of cath lab? Share it in your resume and I can guarantee you they have read it. So, don't flaunt it. You never know it can play for you in the right amount or against you if you promote it too much. When I walked into my first class, I was told by my instructors "leave your nursing background out the door". If you were good at certain things and knew them inside out, it may be of value but keep it with you until you need it.

3) Know your Experience
This is an add on to the one above. I did say that you will have to change your mindset from being a nurse eventually, but you better know your experience. By that I mean, if you write in your application that you are a neuro nurse, you are putting yourself out there to be tested on anything neuro...yes...anything! 
I do want to make it clear that there will be a lot that you don't know, just be honest and don't make up stuff.

4) Dealing with bad GPA
So you applied disregarding your bad GPA to see what happens and to your surprise you got an interview call (like me). What do you do? Well, the truth is that they saw something in your resume that intrigued them enough to call you. So, DON'T take it lightly! Make your bad look good.
Here's an example
My GPA was a quite low in nursing school, like Bs and Cs (I know...I was shocked too!). That was recovered a to about 3.4 after I got a 4.0 in the BSN (yes...anyone can do that with a BSN!). Even without them mentioning it, I told them that my GPA was low initially but I have worked really hard to improve it so I could make myself eligible for CRNA school. Mention any other extra things like volunteering you did, awards, that your worked two jobs and still got grades etc. Don't beg or stay focused on it, but do give them your perspective.

5) Things to take with you
Most importantly, confidence (just enough...don't overdo!), enthusiasm, smile, along with a pen and notepad. All of them are important but taking a notepad and a good working pen is a must! It shows that you are prepared.
To leave an even better impression, use your notepad and have your questions written out before you go. Again, shows that you are prepared.
And if your questions were answered, look at your notepad at the end of the interview and mention that you had some questions but that they were addressed already.

6) A Good Lasting Impression
At the end of the interview, have the same confidence, energy and smile. Don't look disheartened if you didn't get a question correct. Instead, ask them if they decide not to select your as a candidate for the upcoming class, what can you do to improve yourself? This shows that you are not ready to give up!

A little personal side note: These are the things I made sure I did before my interview and was lucky enough to hear "See you next year" with a pat on my back from a member of the panel as I stood there in the cafeteria line. Its was a wonderful feeling and a sense of relief. Probably doesn't happen often but regardless, your goal is to work hard and not worry about what happens after...because your hard work will pay off!

Hope this helps!
Let me know how it goes.
Good Luck!

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Anesthesia related topics: Soon to come!

Here's a Reason

For all those who are dealing with exhaustion, sleeplessness, low on motivation or even sick like I am. So, if you are wondering if you should do it or not? Or if you should keep doing it or give it. Here's a reason to keep doing what you are doing and NOT quit! Look in the right section. 

Great Anesthesia Apps!

Looking for "Great Anesthesia Apps". Follow the link on top or Click here for the new improved, updated version!

Helpful?
Be Sure to "Like" on Facebook and "Join the Site" for updates!

Certification Review Course

Hi guys,

Just wanted to mention a very popular name in SRNAs, "Prodigy Anesthesia". He's a CRNA who provides review courses for SRNAs and helps them organize a plan for certification exam. I am posting a video and a website link with some info.

Here's a link to there free article archives

http://www.prodigyanesthesia.com/archives.htm

I am also posting this video that shows a demo on how this program works. In addition, there is also a free itunes application called "Paces mini" available. 

56 Days!

56 days to go to rotations!! So this quarter is fluffed up with stuff I honestly don't care about this time but its been going good so far. First exam tomorrow, so really hoping to get a good start. This weekend my class attended the AZANA seminars which was long but interesting. It sort of was a review of what I have learned so far in school. Along with that, I got a chance to hear my seniors present and give tips on different rotation sites. The one thing I my having to put off is reviewing stuff for the upcoming SEE aka self evaluation exam. Another issue thats been worrying me is getting a place to live at my rotation site. Its so hard to pick a place to live at a site where I have never been. Then again, I guess I should make sure I pass this quarter before worrying about rotations. We ll see.

Back to studying! Talk to you soon!

Be sure to "Like it"on facebook. 

Daily life of SRNA

Hi all,
I have been asked by many prospective SRNA on how daily life schedule is as a SRNA. So, I decided to write a little run down of questions that everyone wonders about school. I have my parents and sisters helping me with homely stuff so, I have not much to worry about at home yet (until I head to clinicals).

1) What is your sleep schedule like?
I am one of those who loves to sleep. First two quarters I got up right away and was ready to go on with my day. However, this quarter is a different story. I am always trying to stretch it out. My weekdays have classes starting at 8 everyday and I live 20 minutes away. So, I get up between 5-6 am. And as far as going to sleep, I try to aim for midnight but that is hardly the case. For me it usually ends up being 4 hours of sleep, that is either 1-5 or 2-6. I usually catch up a bit on weekends by sleeping in a little but even weekends are short on time.

2) How many hours do you study a day?
Leaving the daily slacking, low motivation hours, and eating etc. It ends up being about 8-10 hours of study time for me besides class time. And of course, that varies a bit everyday when  I have longer class days or lab.

3) How do you try and stay focused?
I have my days where I really don't want to study but when I think of 10 people who came as far as interviewing and didn't get accepted, I feel lucky and buckle down! Still for me, internet is the biggest distraction. I have all the notes on my laptop so I will always start browsing while studying at times. To help me with this, I use this google chrome widget called strict pomodoro to set study timer. This thing really helped me by blocking me from going on things like facebook, yahoo, twitter etc.

4) How hard is it for families?
Like I mentioned previously, I get a lot of help from my family. I think it would be harder having kids and trying to do this, but then, I have like 10 classmates who do just fine with young kids. You just have to make them understand that you are doing this for them and time goes by real fast.

I hope this helps answer some question
To listen to more of my responses be sure to subscribe for my interview, Be sure to click >>
How To Be A Nurse Anesthetist

P.S: Be sure to "Like" and subscribe!

The Ultimate Guide to CRNA Career

Hi all,
So, I am at the verge of finishing my 3rd quarter and am getting a tinge of excitement and nervousness brewing in me for rotations already. Actually I can't wait to really see all of my learned knowledge being applied!
Anyways, a month or so ago, I was interviewed by a now a fellow SRNA Andria about things to know about getting in to CRNA program. I was asked stuff like how was the interview like, how much experience I had before, what hardships to get it etc. Well, she has organized all that and a lot more from other resources for anyone who is interested in knowing more about the awesome CRNA profession. Here' the link to all that you need to know about getting into and surviving CRNA school. Hope it helps :)

Click here for: The Ultimate Guide To A CRNA Career

My Upcoming Goals...if

Hi everyone, I am here after my Principles of Anesthesia Exam and want to start off with saying that I don't know if I be able to survive this quarter. It was the toughest exam yet! And unfortunately, I only get 2 exams a quarter... but then, thinking positively, if I do make it, I be heading to Texas for clinicals in the near future!! So, excited! My school sends people to a variety of different states so I don't know comparatively, how mine is going to be. I have heard good things, so as long as I get good experience, I am happy!

I wanted to share what I plan on doing before I head to clinicals. I am trying to set up either an iphone/android app with all necessary meds, doses, cart-set up, and other clinical tips, or add other pages to my blog for everyone to see. I am going to do this myself but if anyone is knowledgeable about such things let me know.

I am also sharing questions now for everyone to answer on facebook from different topics every so often. So, be sure to "Like" and learn! Let me know if thats a good, bad or you don't care idea. Hope you are having a less stressful 2012 than me!

Peace.

PS: Follow the "Like" Facebook link to the right >>>>to keep up with the questions or if you just want to ask me something.