CRNAs doing hearts?

[RxBoy]

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Do CRNAs ever do hearts independently in unsupervised states?

At our institution our CRNAs are not allowed to do any central lines, PACs, blocks, fiberoptics, U/S. I know this is definitely not the case at some private hospitals. But one skill I can not imagine them possessing is TEE. Has anyone heard/know of CRNAs that actually perform TEE exams?

 

[Pooh & Annie]

I would sue the s$&@ out of anyplace that would let a nurse put a TEE down my throat, much less let them interpret it. And I am NOT a CRNA hater.

 

[TrustMe]

I know some that think they can but I have never actually witnessed this. I think there was a publication a couple of years ago by the AANA that had a CRNA on the front cover holding an echo probe. I doubt they actually know what to do with it and even if they did I don't know that I would trust them. Unfortunately, there are enough greedy anesthesiologists out there offering courses on just about every anesthesia topic and they open the courses to everyone, including CRNA's wanting to claim that they can do a TEE exam.

 

[RxBoy]

I know some that think they can but I have never actually witnessed this.

Same here, I heard it through the grapevines and maybe read somewhere at some point.

I mean somewhere in rural mountain america an unstable dude must of rolled into a ER with an ascending thoracic dissection involving the aortic valve needing emergent bypass. I guess a cardiologist could do the TEE exam in that case but even then could a CRNA steer a DHCA case.

 

[Pooh & Annie]

Same here, I heard it through the grapevines and maybe read somewhere at some point.

I mean somewhere in rural mountain america an unstable dude must of rolled into a ER with an ascending thoracic dissection involving the aortic valve needing emergent bypass. I guess a cardiologist could do the TEE exam in that case but even then could a CRNA steer a DHCA case.

I'd be interested to know where in rural mountain America there's an ER that has immediately available a CPB capable OR, cardiac surgeon, bypass tech, TEE, and all the other necessary accoutrements but has no access to an anesthesiologist. I'm not saying these kinds of scenarios don't exist because they probably do. I just hope they're rare.

I wouldn't be surprised if I'm just naive on the subject.

 

[Surfer]

hate to break it to you all, but you don't have to be good at TEE to do hearts. Most hearts in the country are done by bread-and-butter anesthesiologists without any formal heart training. I'm comfortable placing and doing doing a basic echo exam, but don't have any certifications. I'd be comfortable doing any common heart or valve surgery. many of my friends and colleagues do hearts straight out of residency.

anyways, my point is, doing hearts doesn't have a lot to do with echo cert. and, i will add, most hearts in private practice are incredibly routine, algorithm, easy cases, that don't take more than 3 hours.

 

[Pooh & Annie]

hate to break it to you all, but you don't have to be good at TEE to do hearts. Most hearts in the country are done by bread-and-butter anesthesiologists without any formal heart training. I'm comfortable placing and doing doing a basic echo exam, but don't have any certifications. I'd be comfortable doing any common heart or valve surgery. many of my friends and colleagues do hearts straight out of residency.

anyways, my point is, doing hearts doesn't have a lot to do with echo cert. and, i will add, most hearts in private practice are incredibly routine, algorithm, easy cases, that don't take more than 3 hours.

Sounds about right

 

[RxBoy]

hate to break it to you all, but you don't have to be good at TEE to do hearts. Most hearts in the country are done by bread-and-butter anesthesiologists without any formal heart training.

I totally understand that, especially for routine CABGs. I'm not talking about the heart transplant or complicated elective cardiac case. Those are usually done in tertiary centers with full staff.

But what about the emergency valve repair. I have no doubt non fellowship trained anesthesiologists can do the case. You don't have to be a TEE god but you still need the basic skills. My question can CRNAs swing these cases? Do they ever use TEEs as this is the standard of care for valve repairs?

 

[W222]

I totally understand that, especially for routine CABGs. I'm not talking about the heart transplant or complicated elective cardiac case. Those are usually done in tertiary centers with full staff.

But what about the emergency valve repair. I have no doubt non fellowship trained anesthesiologists can do the case. You don't have to be a TEE god but you still need the basic skills. My question can CRNAs swing these cases? Do they ever use TEEs as this is the standard of care for valve repairs?

I know of one place where CRNAs were doing hearts, but to say they actually did a "heart" was a real stretch. The anesthesiologist would place all the lines and do the TEE, the CRNA would do the airway and get the patient on bypass, attending would come back to get off bypass. In my opinion, it isn't the TEE exam that makes a cardiac anesthesiologist; it is the skill of getting an 85 yo DM, CKD, obese patient off bypass after a complicated 4V CABG and making sure they don't crash back on the pump. The **** may only hit once every couple dozen cases, but knowing what to do is very important to overall patient survival.

 

[BLADEMDA]

I totally understand that, especially for routine CABGs. I'm not talking about the heart transplant or complicated elective cardiac case. Those are usually done in tertiary centers with full staff.

But what about the emergency valve repair. I have no doubt non fellowship trained anesthesiologists can do the case. You don't have to be a TEE god but you still need the basic skills. My question can CRNAs swing these cases? Do they ever use TEEs as this is the standard of care for valve repairs?

It isn't just the valve repair; it is which portion of the mitral valve that needs repairing. Many surgeons rely on TEE and 3 D Echo to assist in making the diagnosis and evaluating the surgical repair.


http://www.mitralvalverepair.org/content/view/124/ (click on this link and see for yourself)


http://www.escardio.org/communities...ho-atlas/mitral-valve/Pages/valve-repair.aspx

 

[jwk]

I know of one place where CRNAs were doing hearts, but to say they actually did a "heart" was a real stretch. The anesthesiologist would place all the lines and do the TEE, the CRNA would do the airway and get the patient on bypass, attending would come back to get off bypass. In my opinion, it isn't the TEE exam that makes a cardiac anesthesiologist; it is the skill of getting an 85 yo DM, CKD, obese patient off bypass after a complicated 4V CABG and making sure they don't crash back on the pump. The **** may only hit once every couple dozen cases, but knowing what to do is very important to overall patient survival.

I think this is fairly common at a lot of places. There are plenty of CRNA's and AA's doing hearts every day, including placing Swans/central lines, but I don't know anywhere that they're being done without the supervision or direction of an anesthesiologist.

 

[btbam]

hate to break it to you all, but you don't have to be good at TEE to do hearts. Most hearts in the country are done by bread-and-butter anesthesiologists without any formal heart training. I'm comfortable placing and doing doing a basic echo exam, but don't have any certifications. I'd be comfortable doing any common heart or valve surgery. many of my friends and colleagues do hearts straight out of residency.

anyways, my point is, doing hearts doesn't have a lot to do with echo cert. and, i will add, most hearts in private practice are incredibly routine, algorithm, easy cases, that don't take more than 3 hours.

None of the attendings at our hospital are cardiac trained, but most of them do cardiac cases and TEE. If they want a 2nd opinion, a cardiology fellow is usually available to look around as well.