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A CRNA's Observations

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Joined: 13 Aug 2009
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    Posted: 31 Aug 2009 at 9:26pm
A CRNA's Observations

I find it interesting how people set up their equipment and use muscle relaxants and other drugs. The following is just opinion based upon three decades of anesthesia and working with people trained through the years.


The "old" anesthesia providers who learned anesthesia before all the fancy equipment came along sit facing the patient, back table to the left, machine to the right. (The set up is in such a way they never have to turn their back to the patient.) They tend to monitor respirations with a precordial stethoscope, oxygenation by lips and blood on the field, etc. They also tend not to paralyze patients unless it is necessary for intubation (using sux most often) or for the surgery (using a non-depolarizer). They tend not to give a drug unless it is needed or there is a strong indication for it. If the surgeon says the patient is tight, they say "OK" and give more muscle relaxant. At the end of a belly case, when the muscle relaxant is starting to wear thin, they stand up and hand bag the patient, timing the ventilation with the movement of the surgeon's hands to help with the closure and thus avoiding having to give more muscle relaxant. Often by this approach, they need no reversal. Since they know they can give an anesthetic without all the monitors, when one breaks/quits during the case they just fall back to the old methodology while someone gets a new monitor. When a new drug comes out, they sit back and let someone else experiment with it and find out all the problems. Does wonders for their "QA" report as they do not get burned very often. (Remember Raplon?) Outstanding skills with a mask, having done cases with them for years. They can go out on a deployment or to a third world nation and give anesthesia with nothing more than a stethoscope, BP cuff and their own two eyes.


The "new" anesthesia providers who learned anesthesia after all the fancy stuff came along face the machine, patient to the left, back table to the right. When they need something off their back table it does not bother them in the least to have their back turned to the patient. They monitor the monitors which monitor the patient. They tend to paralyze all of their patients for the entire case so intubate with a non-depolarizer like Roc. (Sux seems to scare them.) They use a poly-pharmacy approach as a routine, giving lidocaine before all propofol, and a H2 blocker and anti-emetic on all cases.(except droperidol, which also seems to scare them. If they ever do use the stuff, they give 0.625 mg.)When the surgeon says the patient is tight, they will push the button on the PNS and then argue with the surgeon. At the end of a belly case when the muscle relaxant starts wearing thin (according to the PNS), they just give more relaxant and stay seated on their chair (often reading a magazine and relying on the machine alarms to tell them when they have to pay attention.) Reversal is routine and fits with their poly-pharmacy approach. When a monitor breaks, never having done a case without it, replacing the monitor becomes their #1 priority. Very willing to try the new drugs and consider the "old" CRNAs too cautious. Not so hot with a mask as it is easier just to thrown in an LMA or ET. If deployed or going to a third world nation they MUST have a some other kind of portable monitoring system along as they feel they can not do anesthesia without it.

Just my observations. I am sure people will be able to bring up exceptions, but next time you see someone doing anesthesia, watch to see how they do it. I bet 90% of the time my observations are correct.

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Edited by ASA Follower - 31 Aug 2009 at 9:26pm
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