CRNAs running open heart procedures?

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y2janitor

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I just started my surgery rotation. I've noticed that on all the cardiothoracic cases, CRNAs stay in the room to run the case and another non physician runs the bypass. The anesthesiologist comes in maybe twice throughout the whole thing. Is this how it normally works? Shouldn't there be an anesthesiologist in the room at all times to run the show? I can see how CRNAs can run small cases, but these CABGs/valve replacements seem too intense to rely on only CRNAs. And sometimes theres only an SRNA in the room.

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I just started my surgery rotation. I've noticed that on all the cardiothoracic cases, CRNAs stay in the room to run the case and another non physician runs the bypass. The anesthesiologist comes in maybe twice throughout the whole thing. Is this how it normally works? Shouldn't there be an anesthesiologist in the room at all times to run the show? I can see how CRNAs can run small cases, but these CABGs/valve replacements seem too intense to rely on only CRNAs. And sometimes theres only an SRNA in the room.

No happens all the time, CRNA's do not just do "small cases"
 
I just started my surgery rotation. I've noticed that on all the cardiothoracic cases, CRNAs stay in the room to run the case and another non physician runs the bypass. The anesthesiologist comes in maybe twice throughout the whole thing. Is this how it normally works? Shouldn't there be an anesthesiologist in the room at all times to run the show? I can see how CRNAs can run small cases, but these CABGs/valve replacements seem too intense to rely on only CRNAs. And sometimes theres only an SRNA in the room.
The CRNA that you see in the heart room is not "running" the case, that CRNA is part of a care team headed by an anesthesiologist who is most likely supervising this CRNA and others, that anesthesiologist is usually present at key events like induction of anesthesia and coming off bypass in a heart case, he is also immediately available for any problems.
 
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The CRNA that you see in the heart room is not "running" the case, that CRNA is part of a care team headed by an anesthesiologist who is most likely supervising this CRNA and others, that anesthesiologist is usually present at key events like induction of anesthesia and coming off bypass in a heart case, he is also immediately available for any problems.

The CRNA's are great at what they do, but they're not "running" the heart room. We're I'm at, a cardiac trained anesthesiologist plans the anesthestic, is present for induction, performs the TEE, and is present to come off pump.

From induction to CPB, things can be very formulaic and the anesthesiologist may not be in the room, but is immediately available for consultation.

Mick
 
I just started my surgery rotation. I've noticed that on all the cardiothoracic cases, CRNAs stay in the room to run the case and another non physician runs the bypass. The anesthesiologist comes in maybe twice throughout the whole thing. Is this how it normally works? Shouldn't there be an anesthesiologist in the room at all times to run the show? I can see how CRNAs can run small cases, but these CABGs/valve replacements seem too intense to rely on only CRNAs. And sometimes theres only an SRNA in the room.

Most bypass cases are pretty easy from an anesthetic standpoint.
 
The only one "running" the show is really the Surgeon. I don't think CRNAs are qualified to "run" a CPB cases b/c they cannot perfrom TEE exam. How will the CRNA tell you if the new valve is seated properly and has no gradient? That being said some hospitals don't have a CV trained anesthesiologist on staff. Patients will get second rate care here, by the SRNA/CRNA. IMHO.
 
These situations exist. I did a locums gig once to cover a facility with no CV anesthesiologist and was a little suprised to see what they usually did.

No CV anesthesiologist.
CRNA (nice person I met who had broken arm).
All lines preop per CT surgeon protocol ("I usually put them in, but if you think you can put them in, I'll just watch").
Cardiologist was to do echo exam at beginning of case and at end of pump run (CABG/AVR).
CT surgeon told me that he runs everything, including wanting Pavulon, Fentanyl 1000 mcg up front and at end of pump run, lidocaine/levophed/milrinone/propofol infusions at end of pump run, planned overnight intubation regardless.

My response: "Have a nice day."

Aside from having a very tough time understanding his English, the CT surgeon was being a large horse's rear and I don't do cookie cutter CV anesthesia especially on a 72 y/o otherwise healthy normal size male farmer who worked a full day every day until the day of the surgery.
 
som monitoring systems allow a simultaneous slave display of the vitals off the monitor to be displayed in another room; at a couple of the programs i'm familiar with, attendings watch vitals in another room outside the OR when they are not in the room
 
These situations exist. I did a locums gig once to cover a facility with no CV anesthesiologist and was a little suprised to see what they usually did.

No CV anesthesiologist.
CRNA (nice person I met who had broken arm).
All lines preop per CT surgeon protocol ("I usually put them in, but if you think you can put them in, I'll just watch").
Cardiologist was to do echo exam at beginning of case and at end of pump run (CABG/AVR).
CT surgeon told me that he runs everything, including wanting Pavulon, Fentanyl 1000 mcg up front and at end of pump run, lidocaine/levophed/milrinone/propofol infusions at end of pump run, planned overnight intubation regardless.

My response: "Have a nice day."

Aside from having a very tough time understanding his English, the CT surgeon was being a large horse's rear and I don't do cookie cutter CV anesthesia especially on a 72 y/o otherwise healthy normal size male farmer who worked a full day every day until the day of the surgery.

Unfortunately, that is probably more common than you think around the country.

BTW...how do you guys do your CPB runs.

- body temp...and where do you measure.
- what type of cardioplegia....blood or not...anyone there does the V'fib thing
- pump time...clamp time per vessel
- how do you manage your pH on pump.(alpha stat/ph stat)
- steroids? or not
- drugs coming off....protocolized or MD choice
- amicar / aprotinin or nothing
- what pressures do you run on pump and along that vein...who manages the pressure...you or the pump tech?..what kind of flows?
- propofol and dexmedetomidine on re-warming? if you rewarm..
- definition of fast track for you guys?
- what do you do for patients who can't get heparin?
- any fem/fem bypass runs?
- anything else..that anyone else wants to know?
 
- body temp...and where do you measure. My esophageal probe and perfusionist display.- what type of cardioplegia....blood or not...anyone there does the V'fib thing
- pump time...clamp time per vessel
- how do you manage your pH on pump.(alpha stat/ph stat) I-stat before, during, and after pump- steroids? or not
- drugs coming off....protocolized or MD choice usually just NTG if a LIMA graft was used. Occasionally (rarely) dopamine- amicar / aprotinin or nothing used aprotinin by the gallon before the recent bad news. now use amicar on everyone (surgeon request)- what pressures do you run on pump and along that vein...who manages the pressure...you or the pump tech?..what kind of flows? done by perfusionist- propofol and dexmedetomidine on re-warming? if you rewarm.. precedex throughout case, into ICU
- definition of fast track for you guys? on-table extubation for off-pump case if just LIMA to the LAD- what do you do for patients who can't get heparin?
- any fem/fem bypass runs?
- anything else..that anyone else wants to know?

..
 
Unfortunately, that is probably more common than you think around the country.

BTW...how do you guys do your CPB runs.

- body temp...and where do you measure.
- what type of cardioplegia....blood or not...anyone there does the V'fib thing
- pump time...clamp time per vessel
- how do you manage your pH on pump.(alpha stat/ph stat)
- steroids? or not
- drugs coming off....protocolized or MD choice
- amicar / aprotinin or nothing
- what pressures do you run on pump and along that vein...who manages the pressure...you or the pump tech?..what kind of flows?
- propofol and dexmedetomidine on re-warming? if you rewarm..
- definition of fast track for you guys?
- what do you do for patients who can't get heparin?
- any fem/fem bypass runs?
- anything else..that anyone else wants to know?

Temp: bladder/nasal, Swan
CP: No blood unless starting Hct <24-27
Pump time: 30-90 minutes (depends on procedure)
Alpha stat
No steroids
MD choice for RX coming off pump
Amicar. Aprotinin off limits.
I manage pump pressure and flow
Precedex for fast track, propofol for long term intubation
Fast track: Extubation within 30 minutes of surgery end time
Can't get heparin: lepirudin
Rarely do fem/fem unless elephant trunk, etc.
 
I don't remember how to do a pump case. All the CABG's I did b/4 my current gig were off-pump. :luck:

But from what I do remember
Swan temp
No blood in cardioplegia unless really anemic
pump time, I don't remember
MD choice for coming off but we mostly liked dobutamine and I usually added some NTG. Then volume.
No steroids
Used volatile mostly ad some precedex for fast track (definition of fast track was early extubation 1-4 hours usually and d/c from ICU the following morning.)
Didn't give aprotinin at all, amicar on occasion but usually neither.
 
I just started my surgery rotation. I've noticed that on all the cardiothoracic cases, CRNAs stay in the room to run the case and another non physician runs the bypass. The anesthesiologist comes in maybe twice throughout the whole thing. Is this how it normally works? Shouldn't there be an anesthesiologist in the room at all times to run the show? I can see how CRNAs can run small cases, but these CABGs/valve replacements seem too intense to rely on only CRNAs. And sometimes theres only an SRNA in the room.

To answer the OP concerning the "other" non-physician...

The dude running the bypass is a perfusionist (sp??), someone who has received training specifically to do that job. I think it's standard procedure to have a perfusionist running the bypass in cases involving CPB. Feel free to say otherwise if this is incorrect.
 
Temp: bladder/nasal, Swan
CP: No blood unless starting Hct <24-27
Pump time: 30-90 minutes (depends on procedure)
Alpha stat
No steroids
MD choice for RX coming off pump
Amicar. Aprotinin off limits.
I manage pump pressure and flow
Precedex for fast track, propofol for long term intubation
Fast track: Extubation within 30 minutes of surgery end time
Can't get heparin: lepirudin
Rarely do fem/fem unless elephant trunk, etc.

What does the perfusionist do? You stay in the OR while on pump?
 
While rotating at hospital up north perfusionist made a slight error during a heart transplant. Went something like this:

Perfusionist: Glucose is 185, do you want to do anything?

CA-3: Give 10 of Insulin

ten minutes pass

CA-3: what was the follow up glucose?

Perfisionist: one sec...

3 minutes pass

Perfusionist: (mumbling) 17, wait a second...

3 minutes pass

Perfusionist: Fifteen?

CA-3: (Stands and anxiously asks) WHAT did you give???

Perfusionist: (holding empty vial) Ten of insulin (with a sarcastic tone)

CA-3 immeidately runs out of room returns with D50, glucagon, etc...




She gave 10cc of insulin-- 1000 units!!!

Now only MDs can give intra-operative insulin there!
 
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What does the perfusionist do? You stay in the OR while on pump?

It depends on how much I trust the particular perfusionist. There are some I am comfortable leaving in charge of the patient on pump, some I feel I have to watch for the patient's benefit and manage the flows and pressure almost constantly. It's gotten better after one particular perfusionist left and most of the CABG's are off pump in any event.
 
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