clinical case

[sak2009]

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Well had a shoulder scope today pt. 85 Y/O whit male PVD AKA right leg, BKA left leg, macular degeneration,COPD, CAD, MIx2,71 year pack history, HTN.
EKG NSR with PAC , labs unremarkable EXCEPT Na 121
Lungs CTA, Irregular regular with grade 2 murmur at apex.

Plan general with single shot ISB

During ISB placement pt moved AFTER 5 ML .5% ropivicaine injected needle right out of the skin, dammit. Place needle again in the same spot and finish, got lucky awesome block, OR standard monitors 100mg propofol induction #3 LMA 1.1% sevo needed 30 mg esmolol on induction for tachycardia, nothing happened at all intraop, post op some ectopy couplets maybe a 7 beat run PVC's. MDA wants to admit and asks why did I go forward with such a low sodium, my reply he is asymptomatic and pt is really as optimized as they get, no arguments and pt goes to observation for 3 hours and then goes home.

Questions
1. Would you do the case with such a low sodium
2. Do you think the ectopy post-op was of any great concern?

This is not that I disagree with the questions or action but just like a different point of view.

 

[ProRealDoc]

Well had a shoulder scope today pt. 85 Y/O whit male PVD AKA right leg, BKA left leg, macular degeneration,COPD, CAD, MIx2,71 year pack history, HTN.
EKG NSR with PAC , labs unremarkable EXCEPT Na 121
Lungs CTA, Irregular regular with grade 2 murmur at apex.

Plan general with single shot ISB

During ISB placement pt moved AFTER 5 ML .5% ropivicaine injected needle right out of the skin, dammit. Place needle again in the same spot and finish, got lucky awesome block, OR standard monitors 100mg propofol induction #3 LMA 1.1% sevo needed 30 mg esmolol on induction for tachycardia, nothing happened at all intraop, post op some ectopy couplets maybe a 7 beat run PVC's. MDA wants to admit and asks why did I go forward with such a low sodium, my reply he is asymptomatic and pt is really as optimized as they get, no arguments and pt goes to observation for 3 hours and then goes home.

Questions
1. Would you do the case with such a low sodium
2. Do you think the ectopy post-op was of any great concern?

This is not that I disagree with the questions or action but just like a different point of view.

I would have fired you for insubordination and not clearing the patient with me before proceeding.

 

[huktonfonix]

why the hell would he even need a shoulder scope. With all those comorbidities it doesnt sound like he's very independent. Im sure hes not doing any heavy activity with his shoulder.

 

[sak2009]

Pt ambulates with walker and prosthesis

 

[huktonfonix]

An 85yo with AKA and BKA? Good for him.

 

[ProRealDoc]

First, your patient presentation is classic of someone who has no idea how to evaluate a patient. What's irregular regular heart sounds? Did the patient have a-fib or not? If the sodium is 121 then the labs are NOT unremarkable, are they?

Second, so you put standard monitors on the patient in the OR. What about while you were doing the block?

Third, how do you know this patient is as optimized as he could get? Do you know whether this long time smoker has some intrapulmonary pathology a la paraneoplastic syndrome or pancoast tumor that could explain his shoulder pain/hyponatremia? You would not know that, would you?

Fourth, I would have fired you for insubordination and not clearing the patient with me before proceeding.

Fifth, this is the problem when you allow nurse anesthetists who think they are physicians to control the anesthesia care in the perioperative period.

Stupid. 😡

 

[sak2009]

labs unremarkable EXCEPT Na 121
EKG shows sinus arryhmia
block done in OR

 

[Jeff05]

this is a PURELY ELECTIVE PROCEDURE.

do YOU know why the patient was hyponatremic? i don't think the patient was "as optimized" as he was going to be. if the was optimized his sodium would be better.

a long acting ISB (knock out phrenic) in someone with COPD and then send them home?

a "run of 7 PVCs..." that's called VTACH. and yes, his sodium is of great concern, as hyponatremia promotes ventricular ectopy.

what kind of murmur. grade 2? does he have an echo?

the "MDA" or the physician was likely concerned about the OVERALL management of the patient not just the prop/sux/tube routine.

 

[proman]

A sodium of 121 is very remarkable. And this case is posted from the nurse anesthesia forum, copypasta style.

 

[Jeff05]

from the CRNA threads:

"When was the last time you whipped out some calculus in a clinical situation, or organic chemistry, we are CLINICANS, not chemists or mathematicians.
These classes are used to weeed people out no more no less."

--sak2009

yea, maybe i haven't whipped out calculus in a while (umm, or maybe i have, cause i actually understand how a cardiac output calculation works). and yes, while we are clinicians (much like both the mailman and the president of the us are public servants) there is an OBVIOUSLY APPARENT world of difference in CLINICAL knowledge between us. YOU are a perioperative technician, best serving patients under the supervision of a physician.

 

[ProRealDoc]

this is a PURELY ELECTIVE PROCEDURE.

do YOU know why the patient was hyponatremic? i don't think the patient was "as optimized" as he was going to be. if the was optimized his sodium would be better.

a long acting ISB (knock out phrenic) in someone with COPD and then send them home?

a "run of 7 PVCs..." that's called VTACH. and yes, his sodium is of great concern, as hyponatremia promotes ventricular ectopy.

what kind of murmur. grade 2? does he have an echo?

the "MDA" or the physician was likely concerned about the OVERALL management of the patient not just the prop/sux/tube routine.

"Nothing happened intraop". Spoken like a true technician. For them it's all about getting the patient through the surgery alive and who cares if they die in the PACU/Floor secondary to their mismanagement. 🙄

 

[proman]

Or at home, like the patient. I would 1) repeat the test 2) only proceed if it were declared an emergency (not likely). From our perspective problems with hyponatremia happen in the postoperative period, not so much intraoperative.

 

[Licoricestick]

Disclaimer: I don't work in the US, have no experience with the CRNA/MDA divide and do not intend to participate in that debate.


so....lets discuss the case.

The Na is just the tip of the iceberg here... This guy has a crappy cardiovascular system and crappy lungs as well as a (not yet explained) significant hyponatraemia. He is at least an ASA III, more likely a IV. This guy is potentially high risk and more info is clearly required.

When were the 2 MIs?
Exercise tolerance and limiting factors?
Does he get angina? (Or his angina equivalent)
CCF symptoms/signs?
What medication is he on? Does he take it?
Does he still smoke?
Any coronary revascularisation performed?
Other than the ECG what recent cardiac investigations has he had?
What did the repeat ECG after he was clinically found to have an "irregular regular" pulse show? (the clinical picture you gave does not match the ECG description - this should prompt re evaluation)
When you say he is as optimised as he's going to get - what do you mean by that phrase? Who has he recently seen? Did you talk to his cardiologist?
Any previous anaesthetic charts - like from the vascular surgery?

As for the arrhythmia I would think that it's worth investigating (and monitoring!), especially in an 85yo who has significant cardiovascular disease with significant physiologic stress (ie an anaesthetic) superimposed shortly prior. Something happened perioperatively to irritate this mans conducting system and/or myocardium - we need to know it isn't continuing to happen. It'd also be nice to know that he manages to breathe ok with the block in. And from a purely social perspective (sorry - did a medical job last year and it hasn't ENTIRELY left me yet, I'm working on it!) how is a guy with half a leg who has just had his arm operated on going to manage to get around his house, find his painkillers, unscrew the cap, get some water and take the analgesic tablets.... all at about 2am when then block wears off and his wife is sound asleep?

"Nothing happened intraop" is an interesting statement. To start with it is never true. Even if the air went in and out, and the blood went round and round, and there was no alteration to that...something still happened. 😀
So - what sort of pulse and BP did he run at during the case? Did he need any vasopressors? If so what and in what dosage? How much fluid did he get?

 

[fakin' the funk]

Place needle again in the same spot and finish, got lucky awesome block, OR standard monitors 100mg propofol induction #3 LMA 1.1% sevo needed 30 mg esmolol on induction for tachycardia, nothing happened at all intraop, post op some ectopy couplets maybe a 7 beat run PVC's. MDA wants to admit and asks why did I go forward with such a low sodium, my reply he is asymptomatic and pt is really as optimized as they get, no arguments and pt goes to observation for 3 hours and then goes home.

What's an MDA?

 

[fakin' the funk]

Well had a shoulder scope today pt. 85 Y/O whit male PVD AKA right leg, BKA left leg, macular degeneration,COPD, CAD, MIx2,71 year pack history, HTN.
EKG NSR with PAC , labs unremarkable EXCEPT Na 121
Lungs CTA, Irregular regular with grade 2 murmur at apex.

I just wanted to point out that this is one of the few actual clinical cases in the last 2-4 weeks on this forum. I'm a puny post-match MS4; I have nothing to offer in that regard. But it was the reason I started coming to this forum in the first place, and it's now sorely lacking. Residents...attendings...JWK? Anybody?

 

[aphistis]

Well had a shoulder scope today pt. 85 Y/O whit male PVD AKA right leg, BKA left leg, macular degeneration,COPD, CAD, MIx2,71 year pack history, HTN.
EKG NSR with PAC , labs unremarkable EXCEPT Na 121
Lungs CTA, Irregular regular with grade 2 murmur at apex.

Plan general with single shot ISB

During ISB placement pt moved AFTER 5 ML .5% ropivicaine injected needle right out of the skin, dammit. Place needle again in the same spot and finish, got lucky awesome block, OR standard monitors 100mg propofol induction #3 LMA 1.1% sevo needed 30 mg esmolol on induction for tachycardia, nothing happened at all intraop, post op some ectopy couplets maybe a 7 beat run PVC's. MDA wants to admit and asks why did I go forward with such a low sodium, my reply he is asymptomatic and pt is really as optimized as they get, no arguments and pt goes to observation for 3 hours and then goes home.

Questions
1. Would you do the case with such a low sodium
2. Do you think the ectopy post-op was of any great concern?

This is not that I disagree with the questions or action but just like a different point of view.

Wow. Good thing this guy wasn't sick or anything. 🙄 Like other people have said, there's a ton of information still missing here, but this ain't a healthy patient.

Having said that, your questions:
1) Would I want to do the case? Probably not. Would I want to do the case the way you did? Definitely not. Would I have proceeded without even consulting an attending first? You've gotta be out of your bleeping mind.

2) Yes, ventricular tachycardia in a sick heart, pumping significantly hyponatremic blood, is something I consider "of great concern"...is this some kind of trick question?

 

[OB1🤙]

LOL.

That is all.

But hey- it's a case, at least.

 

[Southpaw]

Holy crap. Srsly?

 

[sak2009]

1. HX MI pt was unsure of time about 2-3 years ago
2. still smoking "just this morning"
3. No angina
4. EKG 5 days preop EKG same as the one % months ago and the same as the one that day.
5. No CABG

When I say nothing happened intraoperatively this does not indicate a total success all it means is nothing untoward happened intraop, pt received no pressers 600-700 NS and 100 propofol sevo at 1.1% with #4 LMA.

No it is not a trick question concerning the ectopy, do you think that this man heart may have many funky rhythms given his age and HX, he just is not on the monitor when they happen. He could have this a couple of times a day for all we really know.

COPD pt is not on any home O2 and like anything else it is on a continuum most COPD pt do just fine with a hemidiaphragm for a time, social well he and his family handle his medications and infirmities all of the time right know the only thing that changes he had a shoulder scope they have to get him damn near everything already he is legally blind from macular degeneration.

As for the attending I do not have one so please stop trotting that out a lot of anesthesia goes on without an anesthesiologist, this is a completely different topic which has never and will never be resolved so save it for the mid level forum.

Why is he tuned up? He is as functional as he ever is, other then the sodium he just was not that interesting, I would not bother posting the case otherwise.

 

[fastosprintini]

why did you bother the "mda" after the case was over , clearly all went well in terms of preop preparation and intraop management...?
yes, you are right, a lot of anesthesia goes on without an anesthesiologist involved and the results are obvious
just my$ 0.02 , fasto

 

[Planktonmd]

Hyponatremia pre-op has been discussed previously on this forum.
The bottom line is that with a sodium this low you need more information but it does not mean necessarily that the surgery is contraindicated.
The first question you need to ask yourself: is this chronic or acute hyponatremia? since chronic hyponatremia tend to be well tolerated.
Having old labs might help.
You also need to find out if the patient has low albumin which might be exaggerating the hyponatremia.
The next step would be to see if there is an obvious etiology for the hyponatremia that can be corrected:
Diuretic use, dehydration....
You also have to consider: SIADH especially in a patient with COPD which might be a manifestation of lung cancer.
Another thing to consider is Adrenal insufficiency especially if the patient is or was on steroids for his COPD,
Cirrhosis of the liver is also a common cause of hyponatremia in this population.
If after gathering all the available clinical data you determine that this is in fact a chronic hyponatremia and that there is no causes that can be corrected pre-op then you might be OK to proceed.
The PVC's post-op are most likely meaningless but could be caused by hypoventilation and increased Paco2 post-op.
The issue of doing an interscalene block on a patient with COPD depends on the clinical judgment of the anesthesiologist and very frequently can be done safely in the right patient, it also helps to use small volume and dilute local anesthetics (15 cc Bupivacaine 0.25 % for example).
I feel that with a small volume dilute anesthetic the phrenic nerve is less involved or at least is not fully blocked.

 

[sak2009]

I will not pretend that I went through every differential listed in planktons response, but given his HX and lack of symptoms I was sure his hyponatremia was chronic and therefore he would tolerate such a minor procedure, using ISB allows your Anesthetic "footprint" to be small you usually do not need to intervene that much in this type of case using PNB's. For all of those who asked questions and offered constructive criticism thanks.

 

[coprolalia]

I will not pretend that I went through every differential listed in planktons response, but given his HX and lack of symptoms I was sure his hyponatremia was chronic and therefore he would tolerate such a minor procedure, using ISB allows your Anesthetic "footprint" to be small you usually do not need to intervene that much in this type of case using PNB's. For all of those who asked questions and offered constructive criticism thanks.

Are you friggin' serious? NEWSFLASH: you were wrong! I not only would've fired you, I would've fired the orthopod who took this patient to the OR.

Oh man, we are in DEEP **** if CRNAs get independent practice.

-copro

 

[bullard]

Your "I'm using regional to completely circumvent dealing with this guy's medical issues" argument is bogus because:

1) He's a COPDer and you took out the phrenic nerve...hello?!
2) If your block was so good, why not just give him 2 of midaz and MAC it. Your "anesthetic footprint" was larger than it should be.

I will not pretend that I went through every differential listed in planktons response, but given his HX and lack of symptoms I was sure his hyponatremia was chronic and therefore he would tolerate such a minor procedure, using ISB allows your Anesthetic "footprint" to be small you usually do not need to intervene that much in this type of case using PNB's. For all of those who asked questions and offered constructive criticism thanks.

 

[bullard]

Does anybody know of any data to support or refute this? Does ultrasound make a difference?

The issue of doing an interscalene block on a patient with COPD depends on the clinical judgment of the anesthesiologist and very frequently can be done safely in the right patient, it also helps to use small volume and dilute local anesthetics (15 cc Bupivacaine 0.25 % for example).
I feel that with a small volume dilute anesthetic the phrenic nerve is less involved or at least is not fully blocked.

 

[Gern Blansten]

So, don't keep us in suspense, what happened post op?

Doing this surgery on this patient makes about as much sense as doing a whipple on a hospice patient.

Sounds like the family needed a doctor there willing to slam on the brakes for the orthopod. I think I would offer a steroid injection in the shoulder joint and send him home for another smoke.

I think that prorealdoc has a great thought on the lung cancer issue. Hopefully, somewhere, somebody got a CXR to rule out a pancoast tumor. Typically, diagnosis of this type of tumor is delayed because people treat shoulder pain or cervical radicular pain until they give up and finally get an x-ray. It is not uncommon for Dx to be delayed by a year or so due to misdiagnosis of the symptoms.

 

[NUGasStud]

Does anybody know of any data to support or refute this? Does ultrasound make a difference?

Ultrasound-guided low volume local (5ml of 0.5% ropivicaine)=45% ipsilateral phrenic nerve palsy

Ultrasound-guided high volume local (20ml of 0.5% ropivicaine)=100% ipsilateral phrenic nerve palsy


Br J Anaesth. 2008 Oct;101(4):549-56. Epub 2008 Aug 4.

Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block.

Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ.

Department of Anesthesia, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5.

BACKGROUND: Interscalene brachial plexus block (ISBPB) is an effective nerve block for shoulder surgery. However, a 100% incidence of phrenic nerve palsy limits the application of ISBPB for patients with limited pulmonary reserve. We examined the incidence of phrenic nerve palsy with a low-volume ISBPB compared with a standard-volume technique both guided by ultrasound. METHODS: Forty patients undergoing shoulder surgery were randomized to receive an ultrasound-guided ISBPB of either 5 or 20 ml ropivacaine 0.5%. General anaesthesia was standardized. Both groups were assessed for respiratory function by sonographic diaphragmatic assessment and spirometry before and after receiving ISBPB, and after surgery. Motor and sensory block, pain, sleep quality, and analgesic consumption were additional outcomes. Statistical comparison of continuous variables was analysed using one-way analysis of variance and Student's t-test. Non-continuous variables were analysed using chi(2) tests. Statistical significance was assumed at P<0.05. RESULTS: The incidence of diaphragmatic paralysis was significantly lower in the low-volume group compared with the standard-volume group (45% vs 100%). Reduction in forced expiratory volume in 1 s, forced vital capacity, and peak expiratory flow at 30 min after the block was also significantly less in the low-volume group. In addition, there was a significantly greater decrease in postoperative oxygen saturation in the standard-volume group (-5.85 vs -1.50, P=0.004) after surgery. There were no significant differences in pain scores, sleep quality, and total morphine consumption up to 24 h after surgery. CONCLUSIONS: The use of low-volume ultrasound-guided ISBPB is associated with fewer respiratory and other complications with no change in postoperative analgesia compared with the standard-volume technique.

 

[dhb]

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

This approach reduces the incidence of phrenic nerve block:

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

 

[sak2009]

Nothing pt went home three hours later followup phone call no problems.

 

[sak2009]

hello you treat COPD as an absolute contraindication to ISB? 1% sevo is pretty damn low, the pt needs to remain still for an hour or so, surgery you know remember no moving, can you do that with 2 of versed?
You come to my neck of the woods and do better.

 

[jwk]

I will not pretend that I went through every differential listed in planktons response, but given his HX and lack of symptoms I was sure his hyponatremia was chronic and therefore he would tolerate such a minor procedure, using ISB allows your Anesthetic "footprint" to be small you usually do not need to intervene that much in this type of case using PNB's. For all of those who asked questions and offered constructive criticism thanks.

Why don't you give the rest of the story. As I recall from the other board, your patient's Na+ was in the mid 130's a few months prior to this surgical encounter, which you knew about ahead of time, and you still barged ahead claiming "I was SURE his hyponatremia was chronic". And you're still wondering why the anesthesiologist ripped you a new one.

 

[pgg]

hello

Dear respected nursing colleague,

I don't think you're striking the appropriate tone here, given the way you presented this suboptimally managed case, ostensibly asking for a different point of view.

The overwhelming consensus here is that your management of this case left a lot to be desired and demonstrated ignorance of clinically significant issues. Now, your supervising anesthesiologist is not wholly without blame:

MDA wants to admit and asks why did I go forward with such a low sodium, my reply he is asymptomatic and pt is really as optimized as they get, no arguments and pt goes to observation for 3 hours and then goes home.

... he missed an opportunity here to sit down and teach you exactly why a Na of 121 matters in this patient, why an interscalene in this COPDer (much less a blind restick!) might be ill-advised, why runs of PVCs (ie, v-tach) isn't just some unimportant thing silly old hearts do ... and why this sort of case deserves discussion with an anesthesiologist before you open the cookbook and just do what you always do.

Although given your followups to this thread, maybe he let it go because he thinks you're unteachable.

 

[Licoricestick]

hello you treat COPD as an absolute contraindication to ISB? 1% sevo is pretty damn low, the pt needs to remain still for an hour or so, surgery you know remember no moving, can you do that with 2 of versed?
You come to my neck of the woods and do better.

1% ET sevo in 85yo = MAC of about 0.8. So you have a greater than 50% chance that any given 85yo patient will move on skin incision if your block isn't adequate. In which case you've given the patient a GA and a nerve block.... and he still moves.

No one here as said that COPD is an absolute contraindication to ISB. I think most people would consider it a significant 'flag' in their thinking process or a relative contraindication.

Even if the incidence of ipsilateral nerve block was low (and it's not - see the BJA article posterd earlier - good article btw, thanks for that!) the fact that it CAN occur means it needs serious consideration. If a high volume US guided block affects 100% of ipsilateral phrenic nerves, I'd be very surprised if a non US guided, two-shot, high volume technique is any different. So the question "can this man tolerate the loss of normal diaphragmatic excursion on one side?" is extremely important. If he doesn't then you have a patient who came in for a "minor procedure" who ends up needing to be on IPPV overnight in the ICU until the phrenic nerve block wears off because he can't move enough air. Great outcome.

 

[fakin' the funk]

Quick question for the attendings and residents in the house:

In your experience, how typical is the level of expertise/analysis/reasoning used by the OP in this case? About average, better than average, or worse than average for CRNAs?

I ask so that I can have appropriate expectations when headed into residency, to hopefully neither underestimate nor overestimate an "average" nursing colleague.

 

[sak2009]

Uhh read the chart again, I did not mention nitrous cause I did not use it so it is about .6MAC and if you read the post 2 sticks ONE high volume injection. Phrenic nerve involvement is not rare it is 100%. The very rare pt who will not tolerate it has needed supplemental oxygen not mechanical ventilation, This may come as a shock but I have placed an average of 3 ISB a week for three years now. Not the most definitive but more then enough to be aware of the risks and consequences and the ability to assess the patients ability to tolerate it.

So this "great outcome" of which you speak is based on what? A misreading of a chart and a post and is entirely theoretical it is a well this coullda happened, well gents anything could happen, following the logic posted here optimum handling of this case would have consisted of
1. not doing the case until an asymptomatic number was treated ( gotta treat those numbers)
2. No block expose his CV system to the stress of the pain of surgery and post op pain, and then give him a butload of narcotic to control this pain post-op (OH the COPD does not matter then)
Gentlemen I am astounded by the depths of your knowledge truly if I ever want to FU8K up my pt I will know where to go.

 

[Arch Guillotti]

Gentlemen I am astounded by the depths of your knowledge truly if I ever want to FU8K up my pt I will know where to go.

You come on here and want to discuss a case with us, you get our input, and then you insult us?

 

[coprolalia]

In your experience, how typical is the level of expertise/analysis/reasoning used by the OP in this case? About average, better than average, or worse than average for CRNAs?

I don't know, fake. Some CRNAs are incredibly booksmart, but mediocre technicians. Others will do everything perfectly (intubate, IV, lines, even meticulous charting, etc.), but fail to grasp the "big picture" during the anesthetic.

What I have, however, uniformly witnessed is an unwillingness to admit when they are wrong and/or rationalize whatever they might have been doing when a resident, like myself, attempts to correct something clearly wrong or mistaken (I'm not talking about preference or "finesse" stuff either, but basic pharmacology or physiology knowledge). Many CRNAs, especially the older seasoned ones, will believe that there is absolutely nothing they can learn from you... that no matter what you know, they know more.

At the very least, be prepared for that. Don't bother trying to teach them because (1) they don't want to learn from you in the first place (e.g., had a CRNA tell me once "the reason isn't something important to know and remember" when I tried to explain to her how to bring down the patient's peak pressures by adjusting the vent settings), and (2) they will see you as a "resident" and, therefore, inherently less knowledgable and instead as someone who should be learning from them (which, I'm not necessarily saying, you can't or shouldn't in certain circumstances).

Bet on that.

-copro

 

[Gern Blansten]

In my experience, CRNAs fall into very different categories, probably like we all do.
About 5% are book smart and clinically excellent (ie, the total package)
Another 10% or so are pretty close to that but are better clinically but with some minor gaps in understanding of the "why" on a lot of subjects.
Probably another 65% are what I would consider very good and safe anesthetists, but frequently miss things if not supervised closely and frequently make choices in the heat of battle that I would not have made if I was at the bedside. But overall, pretty competent.
The next tier are ones that I would prefer not to work with because they aren't very skilled clinically, frequently new grads, and they have a lot of gaps in knowledge. I would say they are about 10%
That leaves about 10% that are just plain bad and painful to work with. They might be the older anesthetist who didn't receive good baseline training and has never done a thing to improve themselves. It might be the new grad who was marginal in nursing school and continues to be marginal as a CRNA. It also includes the loud know it all beligerant CRNA who thinks they are always correct, but rarely are (these are the worst ones of all).

So, to sum it up, I think CRNAs are mostly pretty good in quality for what they are trained to do which is work as part of an anesthesia care team. There are a handful who could probably do very well on their own and practice in a safe manner. Then there are the minority who I think aren't up to par (some realize and some don't).