Cardiac Anesthesia Techs

[DocVapor]

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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.

Except, of course, their vital signs techs aka NA's.

 

[echolab]

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.

I would say about half of my cardiac patients are properly induced after 2mg of midazolam before the arterial line. They really don’t need much at all.

 

[deleted87051]

I would say about half of my cardiac patients are properly induced after 2mg of midazolam before the arterial line. They really don’t need much at all.

Patient age is relevant. Some in their 80s (like POTUS and much of Congress) won’t remember anything for days after versed 2mg.

 

[pgg]

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 just plug my infusions into the peripheral IV. Usually it's easy enough to grab some gauze and push buttons on the pump while staying sterile, if I need to adjust.

Never had a circ RN refuse to push one cc of that purple syringe for me. Maybe if JC was watching they would.

 

[deleted87051]

I just plug my infusions into the peripheral IV. Usually it's easy enough to grab some gauze and push buttons on the pump while staying sterile, if I need to adjust.

Never had a circ RN refuse to push one cc of that purple syringe for me. Maybe if JC was watching they would.

Even though they are OR circulators, they are still RNs and can administer meds😉

 

[DocVapor]

Even though they are OR circulators, they are still RNs and can administer meds😉

Can you please tell that to the boss of my pre-op nurses? She unilaterally decided that they were no longer trained to push versed and fentanyl prior to blocks ... With orders.... With us standing right there.

 

[2Fast2Des]

Even though they are OR circulators, they are still RNs and can administer meds😉

Uhhh yeah you'd be surprised. They are glorified technicians. I have asked RNs in the past to help, dear God it was mind boggling, it's like they've never held a syringe or let alone ever administered a medication before, it's scary. It would actually save me more time to ungown and regown up than to ask for help giving meds. Still don't know why a circulator needs to be an RN... Nothing medical is needed to be known, and they can't even spell some of the specimens that surgeons want them to label.

 

[Twiggidy]

Uhhh yeah you'd be surprised. They are glorified technicians. I have asked RNs in the past to help, dear God it was mind boggling, it's like they've never held a syringe or let alone ever administered a medication before, it's scary. It would actually save me more time to ungown and regown up than to ask for help giving meds. Still don't know why a circulator needs to be an RN... Nothing medical is needed to be known, and they can't even spell some of the specimens that surgeons want them to label.

I really love my OR nurses, I really do, but the RN skill just disappears once they're on OR duty. If you really think about it, outside the occasional "code brown" it's probably the sweetest gig in all of nursing on a pay to actual work done ratio. I know other nurses get paid more, like ICU, OB, and probably PACU, but they have to do actual work.

 

[PpfSuxTube]

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??

When ive 2 opcabs im walking into the hospital at 7.40am and leaving at 3.15pm.
Not all cardiac places are 6am starts. Are they?

 

[deleted87051]

I really love my OR nurses, I really do, but the RN skill just disappears once they're on OR duty. If you really think about it, outside the occasional "code brown" it's probably the sweetest gig in all of nursing on a pay to actual work done ratio. I know other nurses get paid more, like ICU, OB, and probably PACU, but they have to do actual work.

But the charting and all those specimens.

 

[Beeftenderloin]

When ive 2 opcabs im walking into the hospital at 7.40am and leaving at 3.15pm.
Not all cardiac places are 6am starts. Are they?

I’d love to hear what your minute to minute work flow is and what kind of support you and surgeon have to reliably get 2 CABGS done in 7.5 hrs? Not being facetious at all, genuinely curious what that looks like. Do you have a second room getting prepped while first case is going? What kind of lines you placing? You gotta provide some deets. My gut says you have to be supervising nurses for this to work but I’d love to be wrong.

 

[GassYous]

I’d love to hear what your minute to minute work flow is and what kind of support you and surgeon have to reliably get 2 CABGS done in 7.5 hrs? Not being facetious at all, genuinely curious what that looks like. Do you have a second room getting prepped while first case is going? What kind of lines you placing? You gotta provide some deets. My gut says you have to be supervising nurses for this to work but I’d love to be wrong.

just need a surgeon that doesn't suck

i heard that back in the day at texas heart they would do 4 opens per room and be done before dinner

 

[Twiggidy]

I’d love to hear what your minute to minute work flow is and what kind of support you and surgeon have to reliably get 2 CABGS done in 7.5 hrs? Not being facetious at all, genuinely curious what that looks like. Do you have a second room getting prepped while first case is going? What kind of lines you placing? You gotta provide some deets. My gut says you have to be supervising nurses for this to work but I’d love to be wrong.

Depends on the surgeon and the case. If it's one or two vessels with a good assistant a good CV surgeon can take down a mammary and do 1 or 2 vessels fairly quickly, and I would assume if it's off pump it's probably 1 to 3 vessels at most. If all the CV anesthesiologist are being honest, a straight forward off pump really only needs an a-line and a cvp and those shouldn't take all day to place. If there's no lolly gagging to first base, I could see 2 off pumps being done from 730-4ish.

 

[sethco]

I’d love to hear what your minute to minute work flow is and what kind of support you and surgeon have to reliably get 2 CABGS done in 7.5 hrs? Not being facetious at all, genuinely curious what that looks like. Do you have a second room getting prepped while first case is going? What kind of lines you placing? You gotta provide some deets. My gut says you have to be supervising nurses for this to work but I’d love to be wrong.

Mine is something like this when I have two rooms available. I'll give it a try...

0645-0720: Show up, get dressed, set up room, see patient, get cup of coffee, bathroom
0725: In room
0730: Induction, Art line, Central Line x 2, PAC, b/l Subpectoral Blocks in that order
0755-0810: Pt prepped/positioned
0815: Incision
0840: Heparinized. Surgeon takes down LIMA very quick and doesn't wait for the PA to get the Vein out before started the LAD
1030: Proximals done and giving Protamine. Surgeon is very meticulous about bleeding before closing. Get about 1-2 bringbacks per year out of about 300 or so. While closing, I'm drawing up drugs and drips for next case. My Anesthesia tech will take these to the other OR where the second OR team is set up and waiting for me
1130: Out of the room. Give Report to ICU staff
1145: Grab a quick bite to eat, +/- go to bathroom, see next patient
1200: In room, repeat same timeline as first and usually done around 1530-1600

 

[sethco]

Depends on the surgeon and the case. If it's one or two vessels with a good assistant a good CV surgeon can take down a mammary and do 1 or 2 vessels fairly quickly, and I would assume if it's off pump it's probably 1 to 3 vessels at most. If all the CV anesthesiologist are being honest, a straight forward off pump really only needs an a-line and a cvp and those shouldn't take all day to place. If there's no lolly gagging to first base, I could see 2 off pumps being done from 730-4ish.

Number of bypasses have nothing to do with whether on or off pump. Regularly do 4 or 5 Grafts. 6 is definitely not unheard of for off pump.

I still line up my patients the same. I also heparinize assuming I'm going on pump with every patient, even though I stay off pump with ~95% of my CABGs

 

[vector2]

Mine is something like this when I have two rooms available. I'll give it a try...

0645-0720: Show up, get dressed, set up room, see patient, get cup of coffee, bathroom
0725: In room
0730: Induction, Art line, Central Line x 2, PAC, b/l Subpectoral Blocks in that order
0755-0810: Pt prepped/positioned
0815: Incision
0840: Heparinized. Surgeon takes down LIMA very quick and doesn't wait for the PA to get the Vein out before started the LAD
1030: Proximals done and giving Protamine. Surgeon is very meticulous about bleeding before closing. Get about 1-2 bringbacks per year out of about 300 or so. While closing, I'm drawing up drugs and drips for next case. My Anesthesia tech will take these to the other OR where the second OR team is set up and waiting for me
1130: Out of the room. Give Report to ICU staff
1145: Grab a quick bite to eat, +/- go to bathroom, see next patient
1200: In room, repeat same timeline as first and usually done around 1530-1600

Same, although I supervise. Surgeon and PA doing vein and LIMA simultaneously and then proceeding to grafting ASAP is what makes a CAB take 4 hrs instead of 8. Surgeons I work with do everything on pump but I can count the number of times they've had to give more than one dose of del Nido for a CAB on one hand.

 

[Twiggidy]

Number of bypasses have nothing to do with whether on or off pump. Regularly do 4 or 5 Grafts. 6 is definitely not unheard of for off pump.

I still line up my patients the same. I also heparinize assuming I'm going on pump with every patient, even though I stay off pump with ~95% of my CABGs

You're correct. That's why I said depends on the surgeon. At my institution, we probably should do more off pumps than we do but I think our surgeon is more comfortable with people on pump.

So you fully heparin every off pump? Because with the few we've done we really only give like 5-10k of heparin.

 

[Teillard]

Mine is something like this when I have two rooms available. I'll give it a try...

0645-0720: Show up, get dressed, set up room, see patient, get cup of coffee, bathroom
0725: In room
0730: Induction, Art line, Central Line x 2, PAC, b/l Subpectoral Blocks in that order
0755-0810: Pt prepped/positioned
0815: Incision
0840: Heparinized. Surgeon takes down LIMA very quick and doesn't wait for the PA to get the Vein out before started the LAD
1030: Proximals done and giving Protamine. Surgeon is very meticulous about bleeding before closing. Get about 1-2 bringbacks per year out of about 300 or so. While closing, I'm drawing up drugs and drips for next case. My Anesthesia tech will take these to the other OR where the second OR team is set up and waiting for me
1130: Out of the room. Give Report to ICU staff
1145: Grab a quick bite to eat, +/- go to bathroom, see next patient
1200: In room, repeat same timeline as first and usually done around 1530-1600

You had me until the +/- go to bathroom part.

 

[sethco]

You had me until the +/- go to bathroom part.

Diuretic effects of my coffee kick in around noon 😂

 

[sethco]

You're correct. That's why I said depends on the surgeon. At my institution, we probably should do more off pumps than we do but I think our surgeon is more comfortable with people on pump.

So you fully heparin every off pump? Because with the few we've done we really only give like 5-10k of heparin.

Every time I try to do an off pump with a surgeon that does nearly all on pump, it almost always ends with going on pump 😂

It's gotten to the point where they won't even try anymore and will instead just hand the case off to the other surgeons that do off pump

Yes, I fully heparinize for all CABGs. Nothing worse for me than dealing with a crashing patient waiting for a therapeutic ACT, but to each their own. Even so, our surgeons still want a minimum ACT of 300 at all times until Protamine is given. 5-10k units of Heparin single bolus wouldn't cut it

 

[2Fast2Des]

Mine is something like this when I have two rooms available. I'll give it a try...

0645-0720: Show up, get dressed, set up room, see patient, get cup of coffee, bathroom
0725: In room
0730: Induction, Art line, Central Line x 2, PAC, b/l Subpectoral Blocks in that order
0755-0810: Pt prepped/positioned
0815: Incision
0840: Heparinized. Surgeon takes down LIMA very quick and doesn't wait for the PA to get the Vein out before started the LAD
1030: Proximals done and giving Protamine. Surgeon is very meticulous about bleeding before closing. Get about 1-2 bringbacks per year out of about 300 or so. While closing, I'm drawing up drugs and drips for next case. My Anesthesia tech will take these to the other OR where the second OR team is set up and waiting for me
1130: Out of the room. Give Report to ICU staff
1145: Grab a quick bite to eat, +/- go to bathroom, see next patient
1200: In room, repeat same timeline as first and usually done around 1530-1600

25 minutes from induce to prep, that's pretty fast. Dang, I feel like I'm quick but no way I could complete all those tasks by myself unless there's a good pair of hands who can help facilitate

 

[deleted641888]

25 minutes from induce to prep, that's pretty fast. Dang, I feel like I'm quick but no way I could complete all those tasks by myself unless there's a good pair of hands who can help facilitate

Our cardiac setup is the same. Room time to position/prep is usually 20-25 mins for art line, ETT, double stick + PAC, TEE (although some partners are less motivated). We have excellent anesthesia techs who set everything up for us and can usually stay a couple of steps ahead (tape in the art line while we induce, prep the neck and position while we gown, PAC ready to go as soon as we’re suturing, TEE probe ready to go, etc.). Usually takes me <20 mins to turnover since I pre-make syringes and hang drips once we’re prepped/positioned. We have a pretty tight cardiac team, so they appreciate the expediency on most days. That being said, some of our surgeons will still casually stroll in after their morning coffee, so it’s useless on most days to be any quicker than 35-40 mins.

 

[PpfSuxTube]

I’d love to hear what your minute to minute work flow is and what kind of support you and surgeon have to reliably get 2 CABGS done in 7.5 hrs? Not being facetious at all, genuinely curious what that looks like. Do you have a second room getting prepped while first case is going? What kind of lines you placing? You gotta provide some deets. My gut says you have to be supervising nurses for this to work but I’d love to be wrong.

Absolutely no nurses just an AA and one of us. Non us. Anesthesia start up time 15 to 20 mins usually. Usual lines aline, swan. 1st patient tf to icu by 11.30 sometimes 11.15. Second patient in room by noon.

Actually for the last few months we've had only the most junior rt's as help... like guys that have no clue whats going on in any OR not to mind cardiac...


We do have probably 3 of the fastest cardiac surgeons ive ever seen for opcabs. They do max opcabx4 rarely 5. No residents or fellows allowed ever basically. Apparently years ago they used to do 3 opcabs a day per room...

Also we have an endless supply of south asian ppl with their associated accelerated cad

 

[Teillard]

Diuretic effects of my coffee kick in around noon 😂

Huh...favorable genetic traits for anesthesia...who knew?

 

[drmwvr]

surprised at the all the PAC's....

 

[pgg]

surprised at the all the PAC's....

Surgeons want them for their postop management in the ICU. Just about every heart here gets one.



I'll find another hill to die on ...

 

[drmwvr]

Surgeons want them for their postop management in the ICU. Just about every heart here gets one.



I'll find another hill to die on ...

they're the ones that get the calls...they can have at it...

 

[BobBarker]

At my shop, we have cardiac anesthesia techs also. I roll in at 6:55 for the 7am case. Drips set up already, patient has foley and all lines placed in PACU prior to induction by the circulator, anesthesia tech, and cardiac PA. The circulator usually gives about 5mg of versed for line placement so the anesthesia tech usually tapes the eyes before I get there. Sometimes they use fentanyl too. Occasionally the tech will
have to place an LMA and bag the patient but no big deal. The tech will push the patient to the room and get them over on to the OR table. I will push the induction drugs and intubate. Tech tapes the tube. Gas and drips on and then tiktok time. Thank God for AirPods.

 

[Hork Bajir]

At my shop, we have cardiac anesthesia techs also. I roll in at 6:55 for the 7am case. Drips set up already, patient has foley and all lines placed in PACU prior to induction by the circulator, anesthesia tech, and cardiac PA. The circulator usually gives about 5mg of versed for line placement so the anesthesia tech usually tapes the eyes before I get there. Sometimes they use fentanyl too. Occasionally the tech will
have to place an LMA and bag the patient but no big deal. The tech will push the patient to the room and get them over on to the OR table. I will push the induction drugs and intubate. Tech tapes the tube. Gas and drips on and then tiktok time. Thank God for AirPods.

If you’re serious about all this… Wow. Why show up at all? “Tech turns the gas on, drops a probe and shows the surgeon a ME 4 chamber and they interpret it, surgeon does the case. I show up around lunchtime to move the table up and down while on pump” lolol

Maybe a bit facetious, but still… If you show up and the eyes are taped with the patient getting bagged, your tech just induced anesthesia without you present

 

[Beeftenderloin]

If you’re serious about all this… Wow. Why show up at all? “Tech turns the gas on, drops a probe and shows the surgeon a ME 4 chamber and they interpret it, surgeon does the case. I show up around lunchtime to move the table up and down while on pump” lolol

Maybe a bit facetious, but still… If you show up and the eyes are taped with the patient getting bagged, your tech just induced anesthesia without you present

lol I had similar thoughts when reading that. This scene from The Big Short came to mind.

 

[sevo00]

At my shop, we have cardiac anesthesia techs also. I roll in at 6:55 for the 7am case. Drips set up already, patient has foley and all lines placed in PACU prior to induction by the circulator, anesthesia tech, and cardiac PA. The circulator usually gives about 5mg of versed for line placement so the anesthesia tech usually tapes the eyes before I get there. Sometimes they use fentanyl too. Occasionally the tech will
have to place an LMA and bag the patient but no big deal. The tech will push the patient to the room and get them over on to the OR table. I will push the induction drugs and intubate. Tech tapes the tube. Gas and drips on and then tiktok time. Thank God for AirPods.

Can’t tell if serious

 

[vector2]

If you’re serious about all this… Wow. Why show up at all? “Tech turns the gas on, drops a probe and shows the surgeon a ME 4 chamber and they interpret it, surgeon does the case. I show up around lunchtime to move the table up and down while on pump” lolol

Maybe a bit facetious, but still… If you show up and the eyes are taped with the patient getting bagged, your tech just induced anesthesia without you present

He's joking.

 

[IMGASMD]

Maybe a bit facetious, but still… If you show up and the eyes are taped with the patient getting bagged, your tech just induced anesthesia without you present

But but but…. They may already put in a LMA!

Like you, I am still not sure how real this description is. Without the obligatory /s at the end…. I don’t know man.

 

[GassYous]

At my shop, we have cardiac anesthesia techs also. I roll in at 6:55 for the 7am case. Drips set up already, patient has foley and all lines placed in PACU prior to induction by the circulator, anesthesia tech, and cardiac PA. The circulator usually gives about 5mg of versed for line placement so the anesthesia tech usually tapes the eyes before I get there. Sometimes they use fentanyl too. Occasionally the tech will
have to place an LMA and bag the patient but no big deal. The tech will push the patient to the room and get them over on to the OR table. I will push the induction drugs and intubate. Tech tapes the tube. Gas and drips on and then tiktok time. Thank God for AirPods.

If you get a medic in the room for the intubation and a cardiologist for the tee you could roll in at 8

 

[Beeftenderloin]

If you get a medic in the room for the intubation and a cardiologist for the tee you could roll in at 8

Throw in an ICU nurse to titrate drips, RT for vent and POOF anesthesia-less cardiac surgery. Cheaper too. Anesthesia tech + paramedic + nurse + RT + cardiologist just popping in to bill for pre/post TEE = probably still cheaper than an anesthesiologist’s salary. Hopefully no one from admin is reading this.

 

[abolt18]

Throw in an ICU nurse to titrate drips, RT for vent and POOF anesthesia-less cardiac surgery. Cheaper too. Anesthesia tech + paramedic + nurse + RT + cardiologist just popping in to bill for pre/post TEE = probably still cheaper than an anesthesiologist’s salary. Hopefully no one from admin is reading this.

Not at the rates our traveler nurses are getting!

 

[kidthor]

Throw in an ICU nurse to titrate drips, RT for vent and POOF anesthesia-less cardiac surgery. Cheaper too. Anesthesia tech + paramedic + nurse + RT + cardiologist just popping in to bill for pre/post TEE = probably still cheaper than an anesthesiologist’s salary. Hopefully no one from admin is reading this.

Cardiologist? They can’t show up till 9am at the earliest! Maybe just throw in the echo tech to do the whole exam, the cardiologist will read that remotely in a few days.

 

[Twiggidy]

they're the ones that get the calls...they can have at it...

We place a cvp for all hearts and we're right there in the neck. it's more a courtesy and not terribly hard to do

 

[deleted87051]

We place a cvp for all hearts and we're right there in the neck. it's more a courtesy and not terribly hard to do

+10units 🙂

Won’t find many anesthesiologists fighting the surgeons not to use them.

 

[drmwvr]

We place a cvp for all hearts and we're right there in the neck. it's more a courtesy and not terribly hard to do

Sure...same goes...I was wondering about PA catheters.

 

[Twiggidy]

Sure...same goes...I was wondering about PA catheters.

I'm admittedly bad with terminology. When I say CVP, I mean, we double stick and 3 lumen and 9F intro for all our hearts. Since the intro is going in, floating the PA catheter not a big deal since the surgeons/ICU nurses are more comfortable taking care of a patient post op with a PA catheter. As said above, "not my hill to die on". I've tried planting the seed for our straight forward "healthy hearts" that we just place a single triple lumen CVP since if they are hypotensive post op we most likely know the cause and don't need a PA catheter, but quite honestly, even if I did grow that seed, in the ICU the minute they're hypotensive they're calling our in-house anesthesiologist asking for a PA catheter insertion (again, another hill that some have already died on and I dont feel like fighting that battle)

We all know that PA catheters provide little to if any benefit in the OR especially when a TEE is sitting right there, but our surgeons are all old/oldish and stuck in their ways.

 

[vector2]

I'm admittedly bad with terminology. When I say CVP, I mean, we double stick and 3 lumen and 9F intro for all our hearts. Since the intro is going in, floating the PA catheter not a big deal since the surgeons/ICU nurses are more comfortable taking care of a patient post op with a PA catheter. As said above, "not my hill to die on". I've tried planting the seed for our straight forward "healthy hearts" that we just place a single triple lumen CVP since if they are hypotensive post op we most likely know the cause and don't need a PA catheter, but quite honestly, even if I did grow that seed, in the ICU the minute they're hypotensive they're calling our in-house anesthesiologist asking for a PA catheter insertion (again, another hill that some have already died on and I dont feel like fighting that battle)

We all know that PA catheters provide little to if any benefit in the OR especially when a TEE is sitting right there, but our surgeons are all old/oldish and stuck in their ways.

If you really wanna avoid the PAC just have the ICU get some Flotracs, nicoms, or some other cardiac output monitor capable of spitting out a random number for them to treat.