Category Archives: Anesthesia

Happy CRNA Week 2023 and the Importance of Previous Anesthetic Records

Posted on by

Every year in January, we celebrate CRNA week. Most people don’t even know we exist, what we do, or what we are capable of. Let me illustrate a story of how we make a difference everyday and the importance of the previous anesthetic record.

Last week, I encounter a patient that I’ve taken care of twice before (how likely is it amongst 30 CRNAs at the hospital that I get to take care of him 3 times in a row?). I was able to connect with this person and spouse quickly and go over the previous anesthetic record. Since I remembered how it took much longer from him to recover from anesthesia, I adjusted my anesthetic and he recovered much more quickly.

Another patient had a history of postoperative nausea and vomiting so I performed a Total IV Anesthesia (TIVA) and the patient wasn’t nauseous postoperatively.

Another patient had a true history of a difficult airway so we were able to perform a spinal for this particular case.

Another patient had a history of requiring a lot of vasopressors so a drip was used throughout the case and led to a smooth and stable anesthetic (otherwise known as railroad tracks, one of our favorites).

Another patient required extra TLC, explanations and a calming presence prior to the induction of anesthesia. Frequently how you feel going to sleep is how you wake up.

Another patient had a history of emergence delirium and that allowed me to provide additional medication to reduce its occurrence.

Many patients state that their previous anesthetic went well so you can repeat a similar anesthetic and expect it to go well, especially if it is a similar type of surgery or procedure.

As they say, you’re only as good as your last anesthetic. Every case, you find ways to improve your anesthetic technique and tailor the anesthetic based on the individual.

Happy CRNA Week- How to have a happy breastfeeding and pumping CRNA

Posted on by

Disclosure: I share some affiliate links below of products that I personally use. If you purchase I may earn a commission. I only share products that I really enjoy using and hope that it’ll help you too.

First of all, happy CRNA Week. Today I’d like to talk about how to have a happy pumping CRNA.

Before I became a first time mom, I really had no idea what breastfeeding and pumping entailed. It’s not really talked about anywhere online especially regarding those working in healthcare and how they managed to work and pump. Now that’s been more than 8 months, I’d like to share my experience to encourage new moms to continue their breastfeeding journey once they return to work.

It’s good to share than the American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Personally, I set my breastfeeding goals to the first month, then 3 months, and then every 3 months to one year.

What I’ve discovered that the breast pump represents freedom from the baby and the ability to still provide the best and complete nutrition for your baby. You don’t need to have your baby attached to your hip to be a good breastfeeding mom. The breast pump gives you freedom to express milk whenever you want and it is not dependent on when the baby is ready to eat or if the baby has trouble latching. Also in the beginning, nipples take a beating (boo… I highly recommend Motherlove Nipple Cream and Lansinoh Hot/cold pack and Ameda gel pads especially for the first week or two) from breastfeeding so pumping gives your nipples a break.

Ever since I got back to work, I’ve had the support of my colleagues and family and the opportunity to continue feeding my baby breast milk. I have to be thankful for the positive nursing culture and a built-in system in the surgical department. That really is key!

It is super helpful to have supportive CRNA leadership, especially from someone who’s done it before. It’s also helpful to have an understanding from all the other CRNAs who can give me a little extra time to pump (getting a 20 minutes break instead of the usual 15 minute breaks).

For me, I take 10 minutes to pump. 5 minutes to clean my pump parts and use the bathroom. 5 minutes for walking to and from the pump room and getting my cooler bag. However, some moms may take more time to pump, usually up to 20 minutes.

My cooler bag from RTIC includes:

In addition, I just wear my nursing/pumping bra to reduce the time that I have to put on and take off a specific pumping bra. I love the one from Kindred Bravely.

When I get to work every morning, I write down my pumping times on the assignment board so that someone can get my pump break at those times. Breastfeeding is a matter of supply and demand and requires you to pump at least every 4 hours to maintain your supply throughout the day. It is extremely helpful to try to maintain this. It is ok to seldomly miss it but not on a regular basis. Otherwise your supply will take a hit.

Anyways, I try to pump at 5am, 9am, 1pm, 5pm, 9pm. However I do adjust my schedule and move it one hour earlier to accommodate the OR schedule. For example, at 5am (at home), 8am, 12pm, 4pm, 8pm. Many moms will try to pump around the same time she would feed her baby.

Having a dedicated private pump room that is close by to the OR is extremely helpful. When the pump room is far away, it takes so much more time to walk there and back, which cuts into the pump time (and every minute counts!). Also, when there are more than 2 pumping moms in the same unit, it is extremely helpful to have additional pump rooms available nearby. The reason is that frequently, pumping moms will have a similar pump schedule. Our unit has multiple pumping moms. We started with one room when I returned to work 5 months ago. Now we have 4 private pumping rooms near the OR. This will ensure timely pump times.

Here are “must haves” to a private pump room:

  • A lock to lock the room or curtains to separate the space in a large pump area
  • Private room with no windows or a screen if the room has indoor windows so no one can peek in
  • A table large enough to put all the pump bag and supplies (for example, a bedside table typically found in hospitals)
  • Chair where your feet touches the ground
  • Trash (housekeeping should empty this daily)
  • A whiteboard and a dry erase marker for the outside of the door when there’s more than one pumping mom to indicate the estimated “out” of the door time so the next pumping mom knows when the room will be available. It’ll help her decide to either wait for the room or try to find another room.

Here are “nice to haves” (but you can have workarounds):

  • Sink to wash parts
  • Paper towel to dry parts, clean off sink and pump area
    • Workaround: Use the wipes from above
  • Mini-fridge to keep the milk/breast pump parts cold
    • Workaround: get a cooler bag and place an ice pack in there. Or put the whole pump bag or just the milk bottles into your work refrigerator (but it may take more space)
  • Nice ambiance conducive to a relaxing environment. Stress decreases milk production so thinking or looking at pictures of videos of the baby helps
  • Extra pumping supplies. If the hospital already has a mother/baby unit that has a hospital grade breast pump, having this extra set is extremely helpful when something breaks (your own breast pump, parts) or is missing (you forgot to pack it!).
    • I always keep a manual breast pump (the hospital gave it to me after giving birth before I left for home) in my locker for those “just in case” times. I’ve used it several times and I could actually empty one breast in 5 minutes but it definitely requires using one hand to pump and the other to manually pressing the breast towards the nipple to empty the milk ducts.
  • Snacks such as lactation cookies- breastfeeding requires an additional 500 calories a day. Moms are feeding for two!

Whenever possible when I’m home, I’ll directly nurse the baby. Once you get the hang of breastfeeding, I find it to be easier than exclusively pumping. However, there are definitely pros and cons to both.

In conclusion, having a happy pumping mom at work is so vital to prevent burnout and help moms do great work and feed her little one. Having a private pump room close to the OR and a respected pump break time helps immensely.

If you’re a potential or current pumping mom, what would or has made your pumping journey easier?

If you’re in management, what can do you to implement a better pumping culture to reduce burnout for new pumping moms?

My First Labor and Delivery

Posted on by

I can’t believe it’s been twelve weeks since I had my baby. My entire life has completely changed in so many ways. I’ve become a first-time Asian American mother during a pandemic as a CRNA. Because it has completely changed my mind and body, I’d like to share my labor and delivery story, and later on, I’d like to share some products that made my life easier as a first-time mom.

As a first-time mom throughout the entire third trimester, the body is getting ready for labor by widening the hips. About 1.5 weeks before I went into labor, I lost my mucous plug. For me, it was a yellowish sticky blob.

First Stage

Early Labor

I was exactly 38 weeks along and wished my baby would come that weekend due to my work situation. On an early Saturday morning, my water broke while I was sleeping 3:20 am. A sudden wet gush woke me up! The water breaks before labor in about 15% of women. I called the midwife to let her know. We agreed that since my water was clear and GBS was negative, I could stay at home during my early labor. FYI, a GBS test checks if you have this common bacteria. If you are positive for GBS, you will get an antibiotic through an IV at the hospital during labor.

My goal was to rest and relax as much as possible. I went for a walk, ate breakfast, lunch, and dinner, watched a movie, and took a nap. Around 6:10 pm, my contractions became more regular, and by 8:15 pm, my contractions were 2-4 minutes apart, 45 sec to 1:15 min long, for at least an hour. They wanted me to go to the hospital when it’s about 4-1-1 (4 minutes apart, 1 min long, for an hour) so that they know you’re in active labor. 

Active Labor 

Triage

I got to the hospital around 9:15 pm and went to the OB triage with my husband (I could only have one support person, so I trained my husband to be there for me!). My primary midwife happened to be on that night, which was awesome!! They checked fetal heart tones (FHT) and external contraction pressure. Normally, I think they would do a cervical exam in the triage area, but I asked to have it done once I was admitted to a room, and my midwife made that happen. 

Hospital Admission

They used a soft belly band to hold the two monitors in place and drew a CBC and type and screen (they draw blood just in case you need a blood transfusion). They asked if I wanted an IV, and I agreed to it since I know it sometimes may be more difficult to place one later. 

My midwife did a cervical exam and found that I was already 5 cm dilated, 100% effaced, and -1 station. 

Later on, my nurse Emily was able to find wireless monitors, so I didn’t have to be attached to the wall. Since I already had regular contractions, and my baby had accelerations during the contractions throughout the admission time, my midwife was comfortable with just periodic checks every 30 minutes. I was monitor free for a few hours and free to move around the room.

For the next 4-5 hours, I used a birthing ball and bounced on it. I breathed through my contractions, mindfully thinking about the pressure I felt.  I tried out different positions: “slow danced” with my husband, had my husband pull up on my belly from behind (or I called it a penguin pull). I even got into the water tub. The water distracted and dulled the immense contraction pressure. But at 3 am, I couldn’t take it anymore and asked for an epidural. As a first-time mother, I wanted to labor as long as possible without an epidural, because once an epidural is in, the laboring process slows down.

A Combined Spinal and Epidural (CSE)

I got out of the tub, and my midwife did another cervical exam and found I had dilated to 8cm. There was only another 2 cm left, but I knew that the transition phase was coming, and through my readings, I learned that the transition phase is the most painful part, and I just couldn’t take it anymore. Also, I had attended the AANA Annual Congress last year. I learned that the latest literature indicated that a combined spinal and epidural was a great anesthetic choice for a laboring mother. I couldn’t wait to get relief.

At 3:30 am, the anesthesia resident got the CSE quickly, and I immediately felt relief through the spinal. In case you don’t know, a spinal numbs you quickly, and an epidural keeps you numb. They used a 0.1% bupivacaine with 3 mcg fentanyl concentration solution, and I loved that it was a bolus every 30 minutes rather than a continuous infusion. I felt little light pins from my chest down and slight itchiness from the fentanyl. But it was much easier to tolerate a little itchiness all over than the pain, especially as it neared the transition phase. Once the epidural was in, I did have to be on continuous monitoring, but I had to be in bed anyway. The nurse placed a foley catheter, which drains the urine. Shortly after pain relief, I fell asleep for a few hours until the morning.

Second Stage

In the morning, the nursing staff helped me move into different positions in the bed. Moving into different positions encourages the baby to move down into the canal on his own. At 11 am, the midwife broke the forebag, which prevented the baby from moving into the canal. My body continued contractions, but with the epidural, I didn’t feel any of them. The nursing staff continued to monitor the baby’s heart rate. The baby had accelerations with every contraction that came every 2-3 minutes. The accelerations indicate that the baby was tolerating the contractions perfectly. Finally, after I felt rectal pressure, the midwife came to assist with the delivery. I pushed for about 1 hour lying on my side, and he was born at 3:46 pm!

Third Stage

My baby immediately went on my chest for an hour of skin to skin time. He looked healthy (a APGAR score of 9 at 1 minute and 9 at 5 minutes. The APGAR score was created in 1952 by Dr. Virginia Apgar MD, an obstetrical anesthesiologist, to determine how well the newborn tolerated birth in the first minute and five minutes of his life). so they were happy to wait to do the height, weight, and give 3 medications. He was calm and quiet, having gone through such a traumatic experience! The midwife delayed the cord clamping until it stopped pulsating so that majority of the blood went back to the baby. My husband then clamped the cord. Shortly after, I delivered the placenta as well.

Placenta and Umbilical Cord Blood Donation

The midwife and nurse then gathered the placenta and umbilical cord tissue to prepare it for donation. I decided to donate the cord blood and placental tissue to research and some went to storage to help others cure diseases. I picked Cellsure because it was free to donate the tissue that would’ve otherwise went in the trash. I also checked my hospital to see if they routinely donated tissue but they did not. Around 28 weeks, I spoke to my midwife about donating my tissue. I found Cellsure online that accepted donations. About a month before my due date, I filled out an online questionnaire to qualify. Once I was done, Cellsure sent me a box for me to bring to the hospital when I was in active labor (4-1-1). I let my midwife and nurse know about the donation and they took care of everything. After delivering the baby, the nurse did draw one more set of blood for the Cellsure. They called Cellsure and someone came around 4 hours after the baby’s birth.

During the first hour, my baby tried to nurse but was just figuring out how to latch on. Latching is probably the most important part about breastfeeding!

The next day, I was super sore all over. I had the first-degree tear, so the midwife didn’t think I needed stitches. For pain relief, I used lidocaine spray and cooled witch hazel pads provided at the hospital. When I ran out, I used benzocaine spray.  I took ibuprofen and acetaminophen whenever offered (every 6 hours in the hospital, and I slowly cut back over the following two weeks). I also took Miralax once a day for the first four days after birth to help with bowel movements. My first few poops were all nice and soft so, I was happy about that. 🙂

The COVID-19 Crisis: CRNAs to the Rescue

Posted on by

One of the most memorable photos from the COVID-19 pandemic is an image of two healthcare workers in full PPE embracing, face shield to face shield. It’s an even prouder moment for the nursing community as the two are a certified registered nurse anesthetist (CRNA) couple from Tampa General Hospital. 

These two CRNAs, Mindy Brock and Ben Cayer, are on the hospital’s airway team. When a COVID patient is in respiratory distress and requires intubation, they are there to sedate and intubate the patient. This is a high-stress situation where time is of the essence, as a COVID-19 patient’s oxygen saturation is known to drop rapidly.

Mindy and Ben are just one example of the roles that CRNAs have played in helping fight COVID-19 across the country. Keep reading to find out more about how CRNAs are contributing to this health crisis.

How CRNA Qualifications Help 

CRNAs are advanced practice nurses who are trained in skills such as intubation, arterial line insertion, central line insertion, and pain management techniques, such as regional blocks. Prior to earning their degree and certification, CRNAs are required to have intensive care unit (ICU) experience so they are well-versed in managing critically ill patients. 

This education and training takes a CRNA to the head of the bed in an operating room, surgery center, or doctor’s office, but the COVID-19 pandemic has CRNAs finding new opportunities to pitch in. 

Continuing the Fight in Medically Underserved Areas

CRNAs have full practice authority in 29 states. This means they can practice without a physician’s supervision. As a result, CRNAs often provide care and airway expertise in traditionally underserved areas. An example would be in a community access hospital where hiring a CRNA can be a cost-effective practice. 

According to the American Association of Nurse Anesthetists, on March 30, 2020, the Centers for Medicare & Medicaid Services issued a temporary suspension of supervision requirements for CRNAs. This suspension meant hospitals and health systems could utilize CRNAs to the fullest extent of their practice. In a press release about the suspension, Kate Jansky, the AANA President, said this decision allows CRNAs to manage and staff intensive care units as well as staff operating rooms without a physician’s supervision.   

Traveling to the Front Lines

Lots of facilities canceled their elective surgeries to slow the spread and preserve their PPE, and many furloughed CRNAs took the opportunity to travel to some of the hardest-hit areas to provide their services. One example of this was when 30 CRNAs from the North American Partners in Anesthesia (NAPA) group traveled to New Jersey to join in the fight against COVID-19. 

CRNAs traveling to states that were hit hard would work on intubation teams as well as resuscitation teams. When a COVID-19 patient coded in the hospital, the CRNAs would provide assistance in airway management, medication administration, and other potentially life-saving tasks. 

Many CRNAs left behind families and risked their personal health to serve those most in need. Some have even come out of retirement to volunteer. 

Recommended reading: Love Thy Neighbor: Wear a Mask

Even with the right PPE, the work is dangerous. CRNAs are working with the airway, which means they are especially at risk for getting contaminated droplets on their clothing or breathing them in. An estimated 20 percent of the anesthesiology department at Mount Sinai Health System in New York City had contracted the virus as of April 2020, according to the Associated Press. Even with the increased risk many have voluntarily given their time and knowledge.

Returning to the Bedside

Because CRNAs have worked in different ICU settings before going to graduate school, some have opted to return to the bedside during the pandemic. For example, many have stepped into roles helping manage ventilators and airways in ICUs as well as taking patient assignments. 

With elective surgeries on hold in many parts of the country, working in the ICUs or in emergency triage settings allows CRNAs to utilize their hard-earned skills. 

The Takeaway

While 2020 has looked very different for the healthcare community than anyone had anticipated, there are countless stories of nurses, including CRNAs, who have answered the personal call to help. The pandemic has also shined a light on CRNAs’ services and engaged politicians and communities to lobby for expanded practice rights. 

Where there is a health need, nurses — including CRNAs — will answer the call. 

Guest Post by:

Words Create Reality

Posted on by

Words create thoughts.

Thoughts create reality.

Change your words, change your reality.

Good thing words are free.

In a Ted video, Lera Boroditsky described a tribe that didn’t use the words left and right and rather described direction only in terms of north, south, east, and west. The tribal members were better with a sense of direction compared to anyone else.

In Russian, it’s common to use varying descriptions of the color blue. Whereas in English, we say blue. It is much easier for a Russian to differentiate the different shades of blue compared to an American.

In a book called “Bringing up Bebe,” the American mom says in France, there are descriptors for “a behavior of small annoyance,” which help differentiate small bad behaviors from horrific acts. Because such a word does not exist in English, a kid who doesn’t finish his carrots versus a kid who kicks a dog may be all labeled “bad kids”. It doesn’t help distinguish the level of “badness” and the behavior from the child.

According to the Rich Dad’s Guide to Investing, if you use the words of a rich person, then you will become rich. Gaining a financial education is one of the key factors that will get you there. You gain education through the words you use.

One of the new advances in medicine and nursing that are rocking the world right now is the use of pocket ultrasound. While ultrasound has been available for years, it has remained prohibitively expensive, especially in rural and poor countries. However, the Butterfly IQ has come out, and I believe it will change how people are diagnosed. Some healthcare providers may be reluctant to use it because it was not utilized in their initial training, but as with any advances, it will be imperative to learn new words (and images) and ultrasound education, to fully embrace the new technology and change the way people are diagnosed.

In each field, we use different words to give us more details, and it dictates our thinking. Our thinking turns into action (or inaction), and that becomes our reality. So to become a better anything, you have to learn the words.

That is why if you say you can’t do something, then that is your reality. That is why if you say you do something, then that becomes your reality.

So if you believe you belong in nursing school, then you will do everything you can to get there. If you believe you will become a great nurse anesthetist, then you will find the resources to become one. If you believe that you can make a difference, then you will learn great behaviors from your role models.

Whatever your dreams are, believe in the new words to create a better reality for yourself.

Nurse Jess in Top 20 Nursing Blogs

Posted on by
Top 20 Nursing Blogs 2018

I received an email about a week ago from Theresa Frost stating that I was on the Top 20 Nursing Blogs list on the Online Nursing Degrees website. I feel honored. But more importantly, I’d like to introduce two other blogs that are great for learning more about CRNAs (certified registered nurse anesthetist).

  • Life as a CRNA – There are some detailed information about what to expect on a day to day basis as a CRNA. There is also some advice for getting into anesthesia school.
  • CRNA Career Guide – It provides a comprehensive guide along with advice from several presidents of state associations of nurse anesthetists.

The Speed of Trust

Posted on by

I recently subscribed to the Blinkist, an app that summarizes nonfiction books and gets to the core of the book. I highly recommend it if you enjoy learning (and being a human, you naturally have curiosities in your life, right?).

One of the books is called the Speed of Trust by Stephen Covey. It tells us that trust affects everything, especially how fast communication and events go. For example, if you trust that the restaurant prepared your food safely, you’ll have no problem eating the food. However, if you had concerns over the food safety, you will hesitate and question the chef before maybe consuming the food (or even throwing it away).

Trust is one of the most powerful forms of motivations and inspiration. People want to be trusted. They respond to trust. They thrive on trust.

You must have self-trust so others can trust you. Because if you don’t trust yourself, then who will?

The way to gain trust in yourself is by following the Four Cores.

Integrity

Integrity is gained by making commitments to yourself and following through on them. Integrity is being honest with yourself. For example, if you tell a patient that you will return to them with information, then do that. If you tell yourself you will go to 50 crunches, 20 squats, 10 burpees, and jog a mile, then commit and do it! If someone blames another person for your mistakes, own up to it and take the blame. If you commit to waking up to the alarm clock and getting to work or school on time, then do it.

Intent

Having positive motives and behaviors will point you towards good intentions. Are you listening or do you just want to “win”? In many circumstances you can increase trust if you have good intentions.

Capabilities

Developing capabilities will improve your confidence. And life is always changing which requires you to keep learning. In the health field, learning what is the latest evidenced based practice and working towards incorporating it in your practice will keep you on the top of your game.

Results

When you build a track record of your results, you build self trust. In the world of anesthesia, you are constantly evaluating your actions– how well did the induction, maintenance, emergence go? How well did the patient do? What could I do differently to improve my results?

 

After developing trust in yourself, you develop trust in others

You develop trust through your actions and your truth. This includes understanding yourself — your strengths and weaknesses, your moods and behaviors, your actions and inactions. By knowing yourself, you can better understand others’ critiques of you and owning it.

You will also demonstrate trust by caring about others. Giving others credit when due. Being thankful for others’ actions. Showing that you are aligned in the same goals.

This will increase your credibility. This is important especially in the healthcare field and in the OR. You trust that the scrub tech stays sterile. You trust that the circulator nurse has the room and everyone responsible ready. You trust that the surgeon is able to safely complete surgery. You trust that the pre-op nurses get an IV and come talk to you if they have any questions. The more you trust yourself and gain trust in others, the faster things move and better the outcome.

With the lack of trust, everything and everyone is questioned. Only more delays occur. And that is why it is so important to gain trust in yourself and in others.

As a side note and reference to what’s going on in the real world…

Christine Blasey Ford showed tremendous courage in speaking out about her experience with Judge Brett Cavanaugh. She was incredibly credible — she had nothing to gain and everything to lose by speaking out, and the fear that her world would shatter and none of it would matter.

On the other hand, Judge Cavanaugh may have been a credible judge with many people who backed him up. He may have had a very credible record and people trusted his judgment. However, I feel that after his hearing, the American people, or at least me, do not feel that he would be impartial. He doesn’t seem like he would have the temperament of a judge. While one hearing doesn’t seem like it should change the fate of this candidate, he is also up for a LIFETIME job as a Supreme Court Justice. In my humble opinion, I believe that there are other candidates who would be better suited for this position. If he is confirmed, I believe that the American people will continue to lose faith in its institutions. Instead of trying to work together, we will continue to divide the nation.

I feel that problem with Judge Cavanaugh is not that he necessarily was a horrible drunk as a teenager and college student, but that he denied it and lied to the Senate. I believe that our principles and values are more important than ‘which party’ sits on the highest courts of our land.

Awake Fiberoptic Nasal Intubation

Posted on by

So all the times that you practiced your craft (handling a fiberoptic scope such as during the difficult airway class weaving down the bucket with little holes; placing double lumen tubes),

all the times you’ve asked experienced providers what they did (for an awake fiberoptic intubation),

all the times you watched one (once for an awake fiberoptic oral intubation),

all the times that you performed one (under optimal conditions with a Glidescope and an asleep patient),

and all the times that you did something similar (nasal intubations),

it prepares you for this moment — for this call:

“There’s an emergency intubation for you and it must be done as an awake fiberoptic intubation nasally.”

You call your partner who’s already bedside and workout a plan

He’s optimizing the patient – Afrin drops, nasal trumpets, racemic epi nebulizer, and 4% lidocaine nebulizer

You’re ready – 7.0 oral ETT in warm saline, lubricated tube and fiberoptic scope, ketamine, precedex drip, an ENT surgeon and team for possible trach

The patient arrives, looking more perky, sats 96%, sitting up, switch monitors, fluids, ETT on the tip of the fiberoptic, suction on, sedation is in

Standing in front of the patient on the right side with the camera on the left

ETT inserted 1/3 in, cameras in, orientation, following the bubbles, past the epiglottis, vocal cords, tracheal rings

Holding still, inserting the rest of the ETT, cuff up, fiberoptic scope out, circuit on, positive end tidal CO2, sats 99%

Smooth, success 

Optimizing Patients for Urgent Surgeries – Non-Elective Surgery Triage

Posted on by

Urgent surgeries — such as appendectomies, cholecystectomies, are common. Sometimes the patients are healthy and other times they are a train wreck. When they are of the latter sorts, the goal should be the optimize the patient for surgery so they are prepared to undergo the stress of surgery.

Understanding the classifications of semi-urgent, urgent, and emergency surgeries informs us of the time that we have to optimize a patient. For example…

It is the weekend call shift with limited resources. The surgeon schedules a laparoscopic cholecystectomy on a patient. Great, you go and look up the patient and find out that:

  • She’s scheduled for a CABG (coronary artery bypass graft) aka open heart surgery next week
  • There’s no echo, angiogram report, no cardiology note on the patient
  • BP 160/110, HR 115
  • Diabetic
  • On the kidney transplant list

So what do you do? The surgeon insists that it is urgent and must be done that day (later you find out that he has scheduled long cases for the next day).

Well, first the goal is to optimize the BP and HR so the BP is below 140/90 and HR below 100. We titrated in metoprolol to effect. We waited for vitals to stabilize before we went. Unfortunately, the surgeon later insisted that it was an emergency case so we had to go on the weekend.

However, was it really an emergency case? Could the case go the next day when there are more resources?

Without additional information, the goal for the patient was to do a slow induction, maintain perfusion, and gentle emergence.

Based on Non-Elective Surgery Triage (NEST), the acute cholecystitis could’ve been scheduled the next day on a Monday where there are more resources.

Non-Elective Surgery Triage (NEST) Level
Non-Elective Surgery Triage (NEST) Classification

Nurse Jess in Top 30 Anesthesiology Blogs

Posted on by

Anesthesiology Blogs

This morning I woke up to an email sent by Anuj, the founder of Feedspot. I will admit, I haven’t heard of Feedspot before today (and maybe for you as well). I’ve never been listed as a top blog so I was surprised and honored to be awarded one of the top 30 anesthesiology blogs.

As I browsed the list, I noticed that I was the only personal nurse anesthetist blog. The rest consists of anesthesiologists and larger organization blogs. I will do my best to continue to represent the nurse anesthesia community.

As I transition from a graduate to a new nurse anesthetist in a new community, I learn a lot. Part of becoming an anesthesia professional is

  • recognizing your limitations and when you need an extra set of hands,
  • asking your colleagues for their professional opinion as you develop your anesthetic plan (especially for cases you’re less familiar with, for cases with different surgeons, for cases with different patient populations),
  • asking for mentorship and help for improving your weaknesses, and
  • knowing that the health field will change.

For example, the United States has a shortage of several anesthetic drugs. And there’s an opioid epidemic that has torn this country apart. The healthcare costs continue to rise, and the length of stay continue to decrease. To help prevent potential complications such as respiratory depression and opioid addiction and to improve pain management strategies, I believe that it begins preoperatively with the patient, continues intraoperatively, and postoperatively.

After the Enhanced Recovery After Surgery (ERAS) protocol came out for colorectal surgery, many more ERAS protocols have developed for different surgeries (and each institution has their protocols). The ERAS peaked my interest in providing opioid-free anesthesia. Part of that process requires providing blocks (or ‘numbing’) for a specific area of the body. Tom Baribeault, one of the founders of the Society for Opioid Free Anesthesia (SOFA), spoke at the University of Michigan-Flint’s anesthesia conference last year. He added fuel to this fire.

After speaking with several of my colleagues who already provide opioid-free anesthesia, reading peer-reviewed journal articles, and completing the American Association of Nurse Anesthetists (AANA) course on enhanced recovery after major abdominal surgery, I set off to do just that. In between my cases, I’ll follow up with the patient and the post-anesthesia recovery unit (PACU) nurse and see how the patient did. I will continue to improve this technique.

In the end, the goal is to provide safe and effective patient care for every patient.