Interested in becoming a CRNA? Not sure exactly what that means? This guest post takes a closer look at what do nurse anesthetists do!
Most operating rooms release the schedule the night before. Unlike bedside nurses, nurse anesthetists don’t start their day with Nurse Drama Hour. You know, the hand-off that details all the hard, brilliant work the last shift did. Usually, the more impressive the nurse’s report, the more likely you’ll find a patient who didn’t get their pain or constipation medicine amusing themselves by playing Jenga with their poop. So what do nurse anesthetists do?
I told myself, “This is going to be a long, serious post. Please act professional.” Oops, let’s start over.
What Do Nurse Anesthetists Do?
Starting your Shift – Preop Assessment
For a typical CRNA, the day begins in the preoperative area where the first nervous patient awaits. For healthier patients undergoing minor procedures, a quick clinical examination coupled with questions about every organ system is all that is required—similar to a yearly physical but with more detailed questions about prior surgeries and anesthetics. The airway exam is also an opportunity to ask if the patient snores and to assess for other issues that may make intubation and extubation more difficult. I made an unkind meme with Jabba the Hut denying his need for CPAP, but I can’t find it now so you’ve been spared.
Patients and surgeries entailing more risk require extensive testing beforehand. Electrolyte imbalances should be corrected and blood cell counts and clotting ability considered adequate for the procedure. Everything is documented on a pre-op form. During surgery, I will document vital signs every five minutes, along with details about the airway and intubation, positioning, the time and dosage of the drugs I selected for the patient, and anything else that will assist the next provider. Planning for the “worse-case scenario” always involves placing intravenous access sufficient to rapidly administer fluids and blood products if needed. Invasive monitors for arterial and venous pressures may be placed before surgery for critically ill patients. If the patient has heart disease, part of the preoperative work-up can include acquiring an EKG, cardiac echo, stress test results, and clearance from a cardiologist.
Preparing the OR Room
After seeing the patient, I gather the necessary drugs and equipment, based upon the preoperative assessment and the type of surgery. Drug shortages, cost, efficiency, surgeon characteristics (such as speed and how much blood they typically lose for this type of procedure) and the availability of a good crosswords puzzle are important variables. Well, not the puzzle, but anesthesia truly requires personalized care. A drug perfect for stabilizing the vital signs in one patient could easily harm the next patient. Just to put a patient to sleep, a half dozen different drugs may be used at individualized doses, with several other drugs prepared for emergencies and to keep the heart rate and blood pressure at reasonable levels.
Equipment preparation includes testing the anesthesia machine. Mouth-to-mouth resuscitation is a decidedly “old school” response to an anesthesia circuit leak in most circles, so check that $50,000 piece of machinery thoroughly! Once the surgeon has seen the patient, the CRNA often graciously augments empathy and reassurance with calming pharmaceuticals before the patient travels to the OR. In most cases, I prefer a fun joke and interesting conversation to 2mg of Versed, but everyone has their own “recipe.”
The next five minutes tend to be the most exciting of the day. Once monitors are attached, the patient is quickly anesthetized, paralyzed, intubated with an endotracheal tube, and positioned securely for surgery. Since the patient won’t be purposely moving during surgery, nerve injuries would be the CRNA’s fault, so sometimes it’s a balance between the exposure the surgeon prefers and what’s most comfortable for the patient. Depending on the vital signs, the CRNA may give more anesthetic gas, narcotics, or other medications to adjust blood pressure and other variables. This process continues throughout the surgery, but toward the end of the case, the CRNA adjusts the ventilator settings, anesthetic gas, and any infusions to slowly wean the patient off the ventilator and wake them up. After a successful extubation, the patient is merrily transported to the recovery room. Once the CRNA is satisfied with the patient’s condition and reports blood loss, medications used, patient history, and similar data to the nurse, they begin again with the next patient.
There you have it. That’s all we do. Over and over again. The process is slightly different for sedation cases, and epidurals, spinals, and regional nerve blocks are other important CRNA tasks, but most of it happens in the OR or the units immediately adjacent. It’s a narrow, highly specialized field that doesn’t easily lend itself to a “second career” the way a frustrated ICU nurse can go start her own home health care company. As a certain unemployed cardiologist in California can attest, home health anesthesia works poorly—yes, I just went there. If it’s any consolation, few highly specific and sought-after skills do transfer easily, unless your name is Bo Jackson or Charlie Ward. I suppose our potential readership will drop significantly if I explain all of my stupendous conclusions with outdated sports analogies, so an alternative example would be the dismal failure that greets most movie actresses who attempt to also become singing sensations.
Drugs & Choices
ICU experience at the baccalaureate level is required for prospective CRNAs in part because we use some of the same drugs, though usually in more aggressive ways. I misspelled “baccalaureate” so badly Spellchecker invited me to a bachelorette party and then rescinded the invitation. Moving on, I use Fentanyl or occasionally its more powerful cousin Sufenta to provide analgesia (relief from pain) even while the patient is asleep. Unless the anesthesia for the actual procedure is also delivered intravenously with Diprivan (propofol) and the possible addition of Ketamine, Precedex, or Ultiva, I give Diprivan once. It renders the patient unconscious at about 2mg/kg after some Lidocaine so it won’t sting like 2% milk in the veins (I’ve never tried it, but it’s probably not worth the extra calcium). A Laryngeal Mask Airway (LMA) or similar device doesn’t require paralysis, but most anesthetized patients will cough if you try sneaking a tube through their vocal cords without first paralyzing their skeletal muscles.
Once assured I can ventilate the patient with a mask and the Ambu-like bag attached to my anesthesia machine, I’ll now paralyze the patient. My choices are a quick-acting depolarizing agent (meaning the muscle contracts before going flaccid) or a paralytic similar to Tracrium or Nimbex, which are used long-term in the ICU since they don’t require much organ metabolism. I’ll have to reverse non-depolarizing muscle blockade at the end of the case (the alternative is Dr. Phil). Using a laryngoscope, I’ll pass the endotracheal tube through the vocal cords, blow up the balloon to keep it there (along with a mess of tape on their face and to protect their eyes), and listen for breath sounds while monitoring end tidal CO2. Besides nitrous oxide, most hospitals have three different anesthesia gasses to choose from. The patient’s smoking or asthma history, my desire to have a crisply awake patient with the same personality they had going to sleep, and my favorite color of the day are all factors in choosing which gas to use. The gas diffuses from alveoli to blood to brain, so the needed concentration to add to oxygen and air coming out of the anesthesia circuit is much less variable than the way other routes of drug administration interact with liver enzyme systems and renal metabolism. That said, it takes skill and experience for surgery and anesthesia to consistently end simultaneously.
So there are a lot of choices, but like every type of nursing, the question always is, “What is my goal?”
- Do I just want the patient unchanged, so they leave the OR in roughly the same shape they came in?
- If not, how far am I willing to go to fix them? Potassium and magnesium drips and beta blockers all around?
- Is the surgeon using local anesthetic and the patient’s vital signs don’t reflect painful stimulation, or is this a particularly painful procedure and I need to think of multi-modal combinations for pain relief, like Baclofen and Neurontin preoperatively and Ofirmev in recovery?
- Anesthetized patients lose auto-regulation of temperature and vital signs. Do I need to use vasopressors like Ephedrine and Neosynephrine to support blood pressure, and do they need blood or albumin?
- If I give a lot of crystalloid fluids, do they have a catheter, and are they prone or in a head down position, increasing the risk of edema near the airway?
- What’s the plan as I turn off the anesthesia gas near the end of the procedure and the patient is waking up? Do I want to give more narcotic so they won’t cough as much on the tube, or am I more worried about sleep apnea and want to sit them up and insert an oral or nasal airway before I take out the endotracheal tube?
Learning the Culture
Anesthesia is a job similar to a soccer goalie: no one pays much attention unless you mess up. Contrary to the operating room persona of working behind the scenes, CRNA personalities tend to be anything but invisible. Does it take a strong personality to stand up to surgeons when necessary, and a peculiar one to enjoy meticulously controlling the vital signs of anesthetized patients every day? Not necessarily. Dull and boring personalities can be just as successful as sparkling ones. For students, there are certainly traits and attitudes that will increase the chance at success, but I’m going to touch on embracing the paradox.
- As a main revenue generator for the hospital, management scrutinizes everything that happens in the operating room, but it is a top location for bullying and outlandish behavior.
- You need to give either more or less anesthesia–a patient’s saturation is decreasing as they cough on the tube that provides them with a safe, reliable source of oxygen.
- You must exude confidence and take control of situations, but also fly below the radar. Also, please stand your ground and roll with the punches.
These are all examples of paradoxes, and the healthy tension between two opposing truths is often the only way forward. Much like multiple-choice questions on nursing school tests, it can be discouraging for almost identical actions to be the correct choice one time and wrong the next.
“The way forward” as described last paragraph was as abstract as your patient’s last hallucination, so let me try again. Swallow pride and remember your role as a patient advocate. As always, everyone thinks their specialty or intervention is the most important, but what’s best for the patient? Sometimes, the conservative route of an endotracheal tube and central line can do more damage than an LMA and a patient breathing on their own. Surgeons, surgical techs, nurses in preop, recovery, and in the OR, and anesthesiologists can all be part of the team, depending on where you work. Rather than just slogging through the day and the immediate details, look at the picture holistically as only a nurse can.
Guess what? Sometimes you still get a chance at Nurse Drama Hour! When relieved during surgery for a break, lunch, or to go home, I get to tell another nurse anesthetist about how awesome I am and all the wonderful things I did for the patient. This is similar to the report I give a nurse in recovery, except it includes details like, “They were a Class III airway so next time I’ll use a Miller 3 blade on my laryngoscope to lift the epiglottis”, or, “Their blood pressure dropped when I gave Dilaudid, but they’re a bit sensitive to phenylephrine so I’m raising their blood pressure with 50 micrograms at a time. Oh, and they might wake up wild and swinging. OK, thanks, Bye!”
I don’t really “K Thnx Bye” anyone, but in line with what I wrote earlier about holistic care, it really helps to check back on how your patients fared. I’m always asking the recovery nurses to make sure the patients didn’t have nausea or pain as soon as I walked away to take care of the next patient. In that regard, this job is almost like ER nursing, so sometimes it takes a little sleuthing to make sure that interventions worked well and should be repeated. This is especially important for clinicians like me who continually stress an individualized approach over cookie-cutter care. Feel free to ask questions in the comments!
More CRNA Resources:
- Top Tips for New Nurses Working with Ventilators
- CRNA VS NP, How Do You Choose?
- Advanced Practice Nursing, Preparing Yourself
- Clinical Differences Between Your BSN and MSN