Cardiac Anesthesia Techs

[Hork Bajir]

Curious to hear from other cardiac docs out there, particularly those who do their own cases without residents/fellows (or god forbid “cardiac CRNAs”)…

What sort of tech support do you have? What sort of tasks do your techs so- set up drips? Place lines, or scrub in to facilitate? Help with any perfusion tasks? Check ACTs? Do they take call, and how much are they paid?

At my shop we have CV anesthesia techs who set up all the drips, prep our art line kits, hook the line up and dress it while we induce, check labs for us during the case, and act as perfusion assistants while on pump. They do take call, and most of them (especially the more experienced ones) are quite knowledgeable. However, they’re also hard to hire and even harder to retain- many end up moving on to go to med school, PA school, perfusion school, etc. Some of them have also expressed interest in doing more- placing IVs, art lines, using ultrasound, perhaps intubation, etc. i’m wondering if getting them involved with some of these tasks may increase their job satisfaction and improve retention, even if it doesn’t necessarily save time (as long as it’s safe for the patient of course).

What are other peoples thoughts, experiences?

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[GassYous]

Yeah I heard the same song and dance about crnas. "We need to let them do blocks and lines so they will stay". Nope they demanded higher pay and left anyway but now they know how to do blocks and lines. Great job!

Why not let them intubate and read tee? Manage drips? Bill for the case for you? So short sighted.

 

[Hork Bajir]

I hear what you’re saying, but anesthesia techs and CRNAs are light years apart. There is ZERO percent chance that anesthesia techs will take the job of cardiac anesthesiologists

 

[amyl]

Techs used to be able to do alines and ivs at my hospital but they’re not allowed to anymore by hospital policy. RTs can’t intubate either - weird how they have let mid levels expand practice rights while lessening their training and techs practice has narrowed

 

[anaesthetic]

Our techs do a lot for us, but I don’t think letting them do art lines or PIVs would help with retention. The only thing that would help is more money, IMO, and nobody wants to pay up.

 

[drmwvr]

and act as perfusion assistants while on pump.

what possible assistance could a perfusionist need?

 

[IMGASMD]

Our techs do a lot for us, but I don’t think letting them do art line or PIVs would help with retention. The only thing that would help is more money, IMO, and nobody wants to pay up.

This.

If they take calls, then they need to be compensated, if they’re “cardiac” anesthesia tech, they need to be compensated. If they’re “certified” then they need to be compensated.

At my current shop, OR tech (orderly) actually get paid more. The “certification” doesn’t mean anything. When they’re chasing seasoned RNs away and paying more for newly graduated BSNs. It just makes no sense to me anymore. Do I need to collect more titles or not?!

 

[nimbus]

Techs used to be able to do alines and ivs at my hospital but they’re not allowed to anymore by hospital policy. RTs can’t intubate either - weird how they have let mid levels expand practice rights while lessening their training and techs practice has narrowed

15+ yrs ago, our techs did the same. In fact, a couple of our techs were better at Alines than some of our anesthesiologists and would do them for those anesthesiologists all the time. Shameful, I know. When my larger group learned this, we thought there could be billing and compliance issues from having an unlicensed person perform these procedures so that was stopped.


One of our techs left and became an AA. Another one was an MD from Vietnam. She actually scrambled a GS spot and completed a year but surgery wasn’t her thing. She still works as an anesthesia tech per diem but also works as part of a rapid response/code team at a chronic vent facility.


Our techs take a lot of call…they have separate trauma call, heart call, and neuro IR call. I’ve been told the busier ones make about $150k/yr.

 

[IMGASMD]

Our techs take a lot of call…they have separate trauma call, heart call, and neuro IR call. I’ve been told the busier ones make about $150k/yr.

Wow. 6 figure for a technologist?! Good for them!

 

[UscGhost]

You wouldn't be able to bill for the lines so it's a no go.

 

[nimbus]

Wow. 6 figure for a technologist?! Good for them!

They earn it. When I was doing hearts, they made it possible for me to show up at 06:00 for a 06:15 room time. Everything was set up for me the way I like it.

 

[2Fast2Des]

They earn it. When I was doing hearts, they made it possible for me to show up at 06:00 for a 06:15 room time. Everything was set up for me the way I like it.

This is why I could never do cardiac... Can't do those early morning starts, bad enough when I have an occasional 7am day that breaks the 730am start routine. You're lucky to have good techs who can make your life awesome to avoid coming in even earlier.

But to teach techs to line up and intubate, etc, what the hell! Tech's role is to be supportive, not replace... What's your role then??

 

[ryanjmy]

Most heart rooms have 2 circulators that can be very helpful for the scut work.

 

[jwk]

15+ yrs ago, our techs did the same. In fact, a couple of our techs were better at Alines than some of our anesthesiologists and would do them for those anesthesiologists all the time. Shameful, I know. When my larger group learned this, we thought there could be billing and compliance issues from having an unlicensed person perform these procedures so that was stopped.


One of our techs left and became an AA. Another one was an MD from Vietnam. She actually scrambled a GS spot and completed a year but surgery wasn’t her thing. She still works as an anesthesia tech per diem but also works as part of a rapid response/code team at a chronic vent facility.


Our techs take a lot of call…they have separate trauma call, heart call, and neuro IR call. I’ve been told the busier ones make about $150k/yr.

Must be nice to have the hospital pay the personnel costs so your group doesn't have to. Just remember - the liability falls on you. Regardless of what you think their "training" is, these are folks with no license and zero formal training (unless they're certified, and those are few and far between) and by utilizing them, you accept 100% of the liability. Many "techs" have associate and bachelor's degrees in their fields (radiology techs, respiratory therapists, neuro-monitoring techs, etc.), and are far removed from the OJT of most anesthesia techs (don't get me wrong, we love ours). Your "larger group" was correct - there are huge compliance, billing, and liability issues involved. I still have issues with surgical first assistants, with a huge range of education from OJT to masters degrees, largely unlicensed, and doing a whole lot of things that many would consider "surgery".

 

[kidthor]

I still have issues with surgical first assistants, with a huge range of education from OJT to masters degrees, largely unlicensed, and doing a whole lot of things that many would consider "surgery"

It's been awhile but I've worked with some RNFAs and they are absolutely terrible. They have the ego of a surgeon with skills of only retractor holding and skin closure. It'd be the equivalent of us having an arrogant undergrad sit in the room for awhile while we got coffee.

 

[sevoflurane]

I think it’s ok for them to set up drips, help out with alines, scrub for central lines and hold the probe…. When it comes down to access/lines/intubation, etc… we should be doing those procedures.
There is enough erosion in our profession as it is. We don’t need surgeons thinking an anesthesia tech can do our jobs.
Just not a good look for us if a technician is doing some of these procedures. Beyond that, I am not sure about billing/legality of such actions.

 

[nimbus]

This is why I could never do cardiac... Can't do those early morning starts, bad enough when I have an occasional 7am day that breaks the 730am start routine. You're lucky to have good techs who can make your life awesome to avoid coming in even earlier.

But to teach techs to line up and intubate, etc, what the hell! Tech's role is to be supportive, not replace... What's your role then??

Yeah…since I stopped doing hearts, it feels like I’m working part-time even though I am working full-time with a full call schedule. Because we are MD only, our call schedule is light with pre and postcall days off. No more early mornings. No more q3 and q4 heart call. Only 1 weekend/mo of call.

The techs who were doing the lines came to us with that background. The anesthesiologists who were using them for that purpose certainly weren’t in a position to teach them. They were the worst and they’ve moved on.

 

[nimbus]

Must be nice to have the hospital pay the personnel costs so your group doesn't have to. Just remember - the liability falls on you. Regardless of what you think their "training" is, these are folks with no license and zero formal training (unless they're certified, and those are few and far between) and by utilizing them, you accept 100% of the liability. Many "techs" have associate and bachelor's degrees in their fields (radiology techs, respiratory therapists, neuro-monitoring techs, etc.), and are far removed from the OJT of most anesthesia techs (don't get me wrong, we love ours). Your "larger group" was correct - there are huge compliance, billing, and liability issues involved. I still have issues with surgical first assistants, with a huge range of education from OJT to masters degrees, largely unlicensed, and doing a whole lot of things that many would consider "surgery".

Agree 100%. As I said, I thought it was shameful.


That said, one of our anesthesia techs was some type of anesthesia assistant in Australia. He said he would conduct anesthetics there under the supervision of an anesthesiologist, including intubation and LMA insertion. Another had some type of anesthesia background in the Czech Republic, he eventually went on to become an RN and another came to us with a background as a navy corpsman. Some had more clinical background than others. Still another came without much clinical background but he went on to AA school in Atlanta and is now working in South Carolina. You may know him

 

[psychbender]

You guys and your pre-0730 starts are making us look bad. Our hospital hired consultants to examine the program, and seem fixated on 0700 starts as 'industry standard,' as though starting thirty minutes earlier would make the surgeons finish a case in fewer than eight hours.

As for techs, we have a couple that do our pumps, line, and transducer setups, and get us what equipment and drugs we need from the central core pyxis. One is an LPN, so is the only one that is officially allowed to give any meds under our direction (like phenylephrine while we're scrubbed in for a line).

 

[jwk]

Agree 100%. As I said, I thought it was shameful.


That said, one of our anesthesia techs was some type of anesthesia assistant in Australia. He said he would conduct anesthetics there under the supervision of an anesthesiologist, including intubation and LMA insertion. Another had some type of anesthesia background in the Czech Republic, he eventually went on to become an RN and another came to us with a background as a navy corpsman. Some had more clinical background than others. Still another came without much clinical background but he went on to AA school in Atlanta and is now working in South Carolina. You may know him

I might - although the days of me knowing everyone are long gone.

There are generic "anesthesia assistants" in several different countries, none of which have the master's degree level of training of the CAAs in the US. I think at least one of the Canadian provinces has them (I seem to recall they're respiratory therapists with some extra training). We used to send some of our AA students for an optional rotation in the UK - they use a similar provider, again, not with the same level of training. They could however sit with cases without the anesthesiologist present. Of course their whole medical education setup is quite different over there. The students were also amused that their anesthesia staff could drink coffee and did not have to wear masks "in theatre". We've had quite a few inquiries from non-US anesthesia personnel, but because of the huge educational differences, there's no real way to offer reciprocity or transfer credits. There is significant foreign interest in duplicating the CAA concept we have here. Interestingly, except for the countries that already have them, there's little interest in nurse anesthesia, largely due to the political issues here.

 

[GassYous]

You guys and your pre-0730 starts are making us look bad. Our hospital hired consultants to examine the program, and seem fixated on 0700 starts as 'industry standard,' as though starting thirty minutes earlier would make the surgeons finish a case in fewer than eight hours.

As for techs, we have a couple that do our pumps, line, and transducer setups, and get us what equipment and drugs we need from the central core pyxis. One is an LPN, so is the only one that is officially allowed to give any meds under our direction (like phenylephrine while we're scrubbed in for a line).

I don't get the point of starting so early. Will it help you get an extra case in? If not then what's the point? 7 am starts are way more miserable.

 

[vector2]

allowed to give any meds under our direction (like phenylephrine while we're scrubbed in for a line).

I was wondering how this works in MD only cardiac. If the pt needs a bump of levo or propofol while I'm scrubbed, who pushes the meds?

 

[anaesthetic]

I was wondering how this works in MD only cardiac. If the pt needs a bump of levo or propofol while I'm scrubbed, who pushes the meds?

Our lines are usually in by the time the levo bolus wears off. Jk.

I tell the circulator RN to push 1 cc of “that purple syringe right there.” They trust us enough and trust themselves enough that it’s usually not an issue. I’ve had to do this twice in the past two years, so it doesn’t happen often. Sometimes I jiggle the ETT to buy a bit more time, and the MAC introducer going through the neck usually acts as a poor man’s ephedrine as well.

 

[Potatoman1800]

I was wondering how this works in MD only cardiac. If the pt needs a bump of levo or propofol while I'm scrubbed, who pushes the meds?

Your line should be in within a couple of minutes. If floating the PA is tricky, and BPs are looking soft, then finish the dressings, treat the patient, and fix the Swan later.

 

[GassYous]

I was wondering how this works in MD only cardiac. If the pt needs a bump of levo or propofol while I'm scrubbed, who pushes the meds?

Just use the extra finder needle to stab the patient. That'll bring the pressure up!

 

[DocVapor]

Just use the extra finder needle to stab the patient. That'll bring the pressure up!

I was gonna say just get the butcher PA to start harvesting.

Edit: or have circulator place Foley, if your place will let the central line and Foley happen concurrently.

 

[thinkorswim]

I don't get the point of starting so early. Will it help you get an extra case in? If not then what's the point? 7 am starts are way more miserable.

I don’t understand why it even has to be 730am when most ORs start coming down around 3-4pm. Why not just push it all back an hour and work 830am to 5pm like the rest of society?

 

[IMGASMD]

I don’t understand why it even has to be 730am when most ORs start coming down around 3-4pm. Why not just push it all back an hour and work 830am to 5pm like the rest of society?

Because our ortho and heart bros think they so fast, they can squeeze one more case in, by two rooming. until something happens and you start a total something at 5 pm, holding two teams hostage.

 

[GassYous]

I don’t understand why it even has to be 730am when most ORs start coming down around 3-4pm. Why not just push it all back an hour and work 830am to 5pm like the rest of society?

no traffic tho

 

[psychbender]

I was wondering how this works in MD only cardiac. If the pt needs a bump of levo or propofol while I'm scrubbed, who pushes the meds?

I leave something in line on the peripheral, and tell the LPN (could probably also get the circulator) how much to give. In my old practice, we placed the lines in the OR pre-induction with light to moderate sedation, and the two perfusionists we had would help, if needed. Overall, it's really rare that we need to give anything during the short time the lines are being placed.

 

[drmwvr]

This was a major focus for me when looking for jobs. I ruled out most practices that ever did starts before 7am. In Charlotte there are several places that do 6am starts!

The surgeons must not be hospital employees....0715 (0600 ?) in room times ended when the "health" system bought those practices.....now it's when the surgeons get done with putting raisin eyes. smiles and whipped cream noses on their little darlings pancakes before pre-kindergarten morning opening ceremonies for the day. They roll in when they roll in...meanwhile, the schmuck free standing anesthesia groups outside of the privileged class of hospital employed physician groups can
pound sand....

 

[Status Sciaticus]

I was wondering how this works in MD only cardiac. If the pt needs a bump of levo or propofol while I'm scrubbed, who pushes the meds?

You could use some gauze or a blue towel to grab the syringe and bolus the meds and then toss the gauze/blue towel away.

no traffic tho

underrated comment.

 

[Hork Bajir]

Also, if it’s someone who I am particularly worried about hemodynamics, sometimes I’ll squirt some phenylephrine or ephedrine into the central line tray before getting sterile. you can always give it through the line before you sew it in or put your dressing on

 

[abolt18]

Also, if it’s someone who I am particularly worried about hemodynamics, sometimes I’ll squirt some phenylephrine or ephedrine into the central line tray before getting sterile. you can always give it through the line before you sew it in or put your dressing on

I really like that idea.

 

[jwk]

I really like that idea.

OMG - then you have to label it!

 

[Twiggidy]

I was wondering how this works in MD only cardiac. If the pt needs a bump of levo or propofol while I'm scrubbed, who pushes the meds?

How much are you guys giving to induce? Lol

I’m just messing with you…..

In all seriousness, as someone who does solo hearts there are two options. If I have a patient that’s on the edge during line placement, I show the circulator the IV access and have the Neo on line with a flush ready. Our nurses in CV are some of the best and they know how to give 1cc if needed. Worst case, I put some neo in a compartment t of the kit with a syringe and give it in the neck…..usually buys me enough time to finish the line

 

[GassYous]

You guys are taking way too long to line up the patient
They're in trendelenburg for christ's sake

 

[Twiggidy]

This was a major focus for me when looking for jobs. I ruled out most practices that ever did starts before 7am. In Charlotte there are several places that do 6am starts!

There’s no reason to start that early. Even 730 can be argued as ridiculous. It’s as if no one in medicine has kids that need to go to school

 

[kidthor]

There’s no reason to start that early. Even 730 can be argued as ridiculous. It’s as if no one in medicine has kids that need to go to school

Yeah plus then they have the patients show up at 05:30, which is not cool.

 

[Hork Bajir]

You guys are taking way too long to line up the patient
They're in trendelenburg for christ's sake

Dude, get over yourself. Can you put in a CVC and an introducer with a PAC in less than 5-7 minutes? Maybe you forget, but some of our patients in the heart room have Supra-systemic pHTN, 99% LM disease, EF 10%, RV failure, autonomic dysfunction from long-standing DM… These aren’t always patients with much room for error. If you let the MAP fall to the low 50s for more than a minute or two on some of the above examples, game over. Not to mention that Trendelenberg doesn’t always help (RV failure) nor do you need it for most lines.

Sorry though. Go ahead and tell me how you place a line in 30 seconds with train track vitals every time

 

[Status Sciaticus]

You guys are taking way too long to line up the patient
They're in trendelenburg for christ's sake

Dude, get over yourself. Can you put in a CVC and an introducer with a PAC in less than 5-7 minutes? Maybe you forget, but some of our patients in the heart room have Supra-systemic pHTN, 99% LM disease, EF 10%, RV failure, autonomic dysfunction from long-standing DM… These aren’t always patients with much room for error. If you let the MAP fall to the low 50s for more than a minute or two on some of the above examples, game over. Not to mention that Trendelenberg doesn’t always help (RV failure) nor do you need it for most lines.

Sorry though. Go ahead and tell me how you place a line in 30 seconds with train track vitals every time

 

[sevoflurane]

Although we are all into being as efficient as possible… it’s not a race and efficiency is always second to patient safety.

 

[Twiggidy]

Yeah plus then they have the patients show up at 05:30, which is not cool.

We've had a few patients refuse surgery and find another place to have their procedure because the surgeon wanted them to show up so early. Obviously first world problem

 

[Twiggidy]

Dude, get over yourself. Can you put in a CVC and an introducer with a PAC in less than 5-7 minutes? Maybe you forget, but some of our patients in the heart room have Supra-systemic pHTN, 99% LM disease, EF 10%, RV failure, autonomic dysfunction from long-standing DM… These aren’t always patients with much room for error. If you let the MAP fall to the low 50s for more than a minute or two on some of the above examples, game over. Not to mention that Trendelenberg doesn’t always help (RV failure) nor do you need it for most lines.

Sorry though. Go ahead and tell me how you place a line in 30 seconds with train track vitals every time

I mean, I think their comment in somewhat tongue-in-cheek and the issues you raise are certainly noted

I think the overall sentiment is that if you're solo and have a very sick patient, line placement takes a bit of "planning" so you can safely and cleanly get the line placed without hurting the patient. I reference my comment above, if you don't over do it on induction, the stimulation from TEE insertion, needle sticks, and pressure to float the lines are often enough to keep the pressure decent for line insertion.

Not on "anesthesia-explain" but nearly all of my inductions are like 1 or 2 of midazolam (depending on the patient, no more than 50 mcg of fentanyl, and whatever amount of "sleep medicine" (whether propofol or etomidate) that gets then asleep for the next step. Get the tube in and either iso 0.4 or sevo 0.6-1.0. Again, as said above, if there's trouble while i'm scrubbed I either have the nurse push a pressor or have some pressor sterile squirted in to my kit so i can use a syringe in the kit and deliver directly in the IJ. Worst case, scrub out, fix the patient and the clean up again and finish the line.

That's just my routine for solo practice. I'll say this, if the patient is THAT sick that the above would off them, then they probably need awake lines (CVP at the very least). I think I've had to awake triple lumen someone maybe once because they were a bit sick and a hard vascular access.

 

[nimbus]

I usually started a low dose phenylephrine (25-50mcg/min) or norepi (2-4mcg/min) infusion through a peripheral line prior to induction, then switched it over once the central line was in. Usually gave rock steady vitals during induction/lines/prep.

 

[sevoflurane]

We've had a few patients refuse surgery and find another place to have their procedure because the surgeon wanted them to show up so early. Obviously first world problem

8am start for my avr today. 🌝
Usually 7:30 however.
6:30 starts are brutal for those doing them.

Ireland had 9:00 starts when i was there. That was 🙌🏽

 

[okayplayer]

I mean, I think their comment in somewhat tongue-in-cheek and the issues you raise are certainly noted

I think the overall sentiment is that if you're solo and have a very sick patient, line placement takes a bit of "planning" so you can safely and cleanly get the line placed without hurting the patient. I reference my comment above, if you don't over do it on induction, the stimulation from TEE insertion, needle sticks, and pressure to float the lines are often enough to keep the pressure decent for line insertion.

Not on "anesthesia-explain" but nearly all of my inductions are like 1 or 2 of midazolam (depending on the patient, no more than 50 mcg of fentanyl, and whatever amount of "sleep medicine" (whether propofol or etomidate) that gets then asleep for the next step. Get the tube in and either iso 0.4 or sevo 0.6-1.0. Again, as said above, if there's trouble while i'm scrubbed I either have the nurse push a pressor or have some pressor sterile squirted in to my kit so i can use a syringe in the kit and deliver directly in the IJ. Worst case, scrub out, fix the patient and the clean up again and finish the line.

That's just my routine for solo practice. I'll say this, if the patient is THAT sick that the above would off them, then they probably need awake lines (CVP at the very least). I think I've had to awake triple lumen someone maybe once because they were a bit sick and a hard vascular access.

Ever worry about awareness at these homeopathic sevo levels? A lot of things to balance on those cases, I get it.

 

[abolt18]

Ever worry about awareness at these homeopathic sevo levels? A lot of things to balance on those cases, I get it.

I think you typically expect some residual effect of the induction agent through line placement (unless that takes an unusually long time), not to mention the MAC reducing effect of whatever other drugs you gave (narcotic, benzo, etc.).

 

[Twiggidy]

Ever worry about awareness at these homeopathic sevo levels? A lot of things to balance on those cases, I get it.

I don't. In my humble experience, patients done need 1 MAC anesthetic for line insertion. In our patient population, "a little versed","a little fentanyl", and "a little induction agent" can go quite a long way....again, all patient dependent.

 

[OptionOffense]

Techs used to be able to do alines and ivs at my hospital but they’re not allowed to anymore by hospital policy. RTs can’t intubate either - weird how they have let mid levels expand practice rights while lessening their training and techs practice has narrowed

Its the duplicity of the nursing lobby. They are dead set against techs of all kinds. Surgical techs, anesthesia techs, EMTs, paramedics. I feel the paramedic is the most underutilized skillset in medicine. That can be used as a springboard to a lot of professions in medicine.