CRNAs and epidurals

[flashgordon]

Just out of curiosity, what kind of neuraxial blocks are the SRNA/CRNAs at your program allowed to do?

How many are they performing per year?

Do they manage epidurals after they place them?

Below is an abstract from this month's RAPM. Interesting eh?

Background: Subarachnoid blocks are considered routine anesthetic procedures important in the daily practices of most anesthesiologists. However, few data exist regarding modern failure rates or quality-compromising behaviors.

Methods: Sixty adult patients having orthopedic surgery under spinal anesthesia were enrolled in this prospective and observational video study. Through a detailed high definition video review, we aimed to define our subarachnoid block failure rate and identify associated quality-compromising behaviors.

Results: An intrathecal injection either failed to generate a surgical block or was aborted secondary to difficulty in 7 patients (11.6%). A procedurally difficult subarachnoid block occurred in 17 patients (29%). Eight patients required greater than 10 mins of needling to complete the subarachnoid block. Body mass index represented an independent risk factor for long procedure times. There were 27 incidences of quality-compromising behaviors that included likely violation of aseptic technique, hemorrhage, poor positioning, damaged needles, thecal sac transfixation, high-lumbar needle placement, repetition of previously failed maneuvers, failure to provide skin anesthesia, and prolonged procedure times. Certified registered nurse anesthetist status predicted a greater-than-4-fold risk of subarachnoid block failure.

Discussion: The failure rate and quality-compromising behaviors identified in this study challenge the generalized assumption that performing a subarachnoid block in the orthopedic population is a simple procedure. The number and nature of the combined failed and difficult subarachnoid blocks suggest the need for quality improvement. Further research is needed to assess whether the use of image guidance may be a possible solution to navigate difficult anatomical pathology and confirm correct needle and drug placement.

I'm glad medicare revised their epidural rule.

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[NotAMD]

Just out of curiosity, what kind of neuraxial blocks are the SRNA/CRNAs at your program allowed to do?

How many are they performing per year?

Do they manage epidurals after they place them?

Below is an abstract from this month's RAPM. Interesting eh?

Background: Subarachnoid blocks are considered routine anesthetic procedures important in the daily practices of most anesthesiologists. However, few data exist regarding modern failure rates or quality-compromising behaviors.

Methods: Sixty adult patients having orthopedic surgery under spinal anesthesia were enrolled in this prospective and observational video study. Through a detailed high definition video review, we aimed to define our subarachnoid block failure rate and identify associated quality-compromising behaviors.

Results: An intrathecal injection either failed to generate a surgical block or was aborted secondary to difficulty in 7 patients (11.6%). A procedurally difficult subarachnoid block occurred in 17 patients (29%). Eight patients required greater than 10 mins of needling to complete the subarachnoid block. Body mass index represented an independent risk factor for long procedure times. There were 27 incidences of quality-compromising behaviors that included likely violation of aseptic technique, hemorrhage, poor positioning, damaged needles, thecal sac transfixation, high-lumbar needle placement, repetition of previously failed maneuvers, failure to provide skin anesthesia, and prolonged procedure times. Certified registered nurse anesthetist status predicted a greater-than-4-fold risk of subarachnoid block failure.

Discussion: The failure rate and quality-compromising behaviors identified in this study challenge the generalized assumption that performing a subarachnoid block in the orthopedic population is a simple procedure. The number and nature of the combined failed and difficult subarachnoid blocks suggest the need for quality improvement. Further research is needed to assess whether the use of image guidance may be a possible solution to navigate difficult anatomical pathology and confirm correct needle and drug placement.

I'm glad medicare revised their epidural rule.

At my program (that also trains SRNAs) neither do any CEntral Lines, Nerve Blocks, srnas average about 5-10 total labor epidurals and otherwise CRNAS never cover OB (Except caudals for pedi, never any thoracic), double lumen tubes, fiberoptic scopes, rarely any pedi other than pedi gi, no managing epidurals or nerve catheters, no pain consults

 

[rsgillmd]

Where I am now, CRNAs/SRNAs do epidurals. When I am working in OB it is just me and two CRNAs, and possibly one SRNA. I'm not sure what it was like when there was a residency program here, but I doubt it was too much different because I don't think we ever had large numbers of residents.

They are also the ones that are called for maintenance issues.

Probably because the CRNAs that work in OB have been there for a while, they are generally pretty good about inserting them. I rarely have to bail them out.

I'll have to look at that RAPM article in closer detail to be able to comment more meaningfully. The abstract just doesn't give much information.

 

[Idiopathic]

with only 60 patients it could easily be an issue of too few providers, i.e. maybe its not "crna" faut but rather "provider x" fault - although im sure everyone around here will believe the former

 

[IlDestriero]

At my Children's Hospital, the CRNAs don't do any blocks, caudals, central lines, etc.
When I was doing adult anesthesia we had one CRNA who would get a wet tap every month. Really. It was reportable to our CQI system which I managed. One a month. I had one in my entire career (>1000) When I pointed that fact out, he got quite defensive and absolutely refused to consider that his technique could be the problem. I'm sure he's still at it.

 

[pgg]

An intrathecal injection either failed to generate a surgical block or was aborted secondary to difficulty in 7 patients (11.6%).

Small sample size, but 11.6% seems an awfully high failure rate, regardless of who's doing the procedure.

I mean, we're talking about a task that's the purest of monkey skills. I bet I could teach my uneducated immigrant neighbor to poke a hole in the dura and get him proficient given enough repetitions, and he's still learning English.


What were the CRNAs in this study systematically or repeatedly doing wrong that caused such a high failure rate?


The CRNAs I work with, good ones and bad ones, all do spinals for ortho cases - in the military hospital, they also do epidurals for labor. Where the bad ones really lag is in knowledge, diagnosis/differentials, and decision making skills. They get in trouble not because they have fat fingers and screw up the technical stuff, but because they choose to do stupid stuff or think Plan B is just a contraceptive. Their procedural skills are usually fine, except for the areas where they get few reps or were never taught (central lines, a-lines, blocks).

 

[Coastie]

CRNAs belong in the uncomplicated ASA 1/2, cysto, and GI cases..supervised. Period.

 

[iwumd07]

.

 

[iwumd07]

CRNAs belong in the uncomplicated ASA 1/2, cysto, and GI cases..supervised. Period.

agreed.


Last Thursday on urology rotation, one of my patients was getting an outpatient cysto in a surgicenter. I was talking with the 20-year-veteran CRNA about the types of cases he does and what he feels comfortable with. He said that my 63-year-old patient had a previous liver transplant and has BPH, so pt is an ASA IV, and he's perfectly comfortable taking care of IIIs and IVs. He then reassured me that not much varies from patient to patient regarding their physiological status, regardless of their ASA status or surgery the patient is having (unless it's trauma...just fluid resucitation), and that he's perfectly comfortable handling any and every case that comes through the door. I feel much better about CRNAs now. Thank you for your reassurrance.

 

[Coastie]

Pretty much says it all, doesn't it?

agreed.


Last Thursday on urology rotation, one of my patients was getting an outpatient cysto in a surgicenter. I was talking with the 20-year-veteran CRNA about the types of cases he does and what he feels comfortable with. He said that my 63-year-old patient had a previous liver transplant and has BPH, so pt is an ASA IV, and he's perfectly comfortable taking care of IIIs and IVs. He then reassured me that not much varies from patient to patient regarding their physiological status, regardless of their ASA status or surgery the patient is having (unless it's trauma...just fluid resucitation), and that he's perfectly comfortable handling any and every case that comes through the door. I feel much better about CRNAs now. Thank you for your reassurrance.

 

[Idiopathic]

the biggest problem i have with that statement is the claim that it was an ASA IV patient

 

[Socrates25]

You attendings are wimps. In your own damn hospitals you let CRNAs pull these stunts? WTF?

No wonder your field is compromised. I hope the extra 150k per year for "supervising" CRNAs was worth it.

 

[proman]

the biggest problem i have with that statement is the claim that it was an ASA IV patient

People probably will disagree but I think if your life depends on another person's liver lungs or heart, you're an ASA IV. We have pulmonologists who think that a patient s/p BOLT with bronchial stenosis is an ASA II.

 

[jwk]

CRNAs belong in the uncomplicated ASA 1/2, cysto, and GI cases..supervised. Period.

I'm willing to bet you won't find such a practice. You're overly idealistic and horribly unrealistic.

Our practice is a by-the-book TEFRA medically directed ACT practice. Our anesthetists, both AA's and CRNA's, do about 98% of our cases, in all specialties, ASA I-VI, however they do not do blocks or insert central lines.

And if you assume that cystos and GI cases are uniformly the easiest and lowest risk cases, or that ASA I/II cases can't be quite challenging as well as go horribly wrong, then you clearly haven't done enough cases yet.

 

[fakin' the funk]

People probably will disagree but I think if your life depends on another person's liver lungs or heart, you're an ASA IV. We have pulmonologists who think that a patient s/p BOLT with bronchial stenosis is an ASA II.

I'm with you on lungs and heart.

Liver though? Unless the pt is like POD#1 from their transplant, do you really think having someone else's liver in you is a "constant threat to life?"

 

[OB1🤙]

I'm with you on lungs and heart.

Liver though? Unless the pt is like POD#1 from their transplant, do you really think having someone else's liver in you is a "constant threat to life?"

How do you think transplanted heart or lungs is any different from liver from a "constant threat to life" point of view?

 

[lord_jeebus]

I think "constant threat to life" is unfortunate wording that leads to a wide range of interpretation. The way I think of it,

3 = If surgery were scheduled in a week, I would be surprised if this patient died before then. My reaction would be "I didn't think he was that sick."
4 = I would not be that surprised. "It was going to happen sooner or later" or "I didn't think it would be so soon, but these things happen when you have ____"