Supervision of CRNAs

[georgia_aa]

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Many of you know that when I was looking into medical school, I also considered going the AA route. I spent a day down at Case Western's program and chatted with the director as well as interacted with senior AA's and student AAs (impressive bunch and a great program down there).

Anyway, and this is no slam on AA's, the director knew I was also considering going to medical school. But, he came right out and stated (this is the director of the AA program whom is also an AA, but mostly is in admin at this point) that AA's are technician's. Highly trained, master's level technicians in providing anesthesia. But, if I wanted to be an anesthesiologist, then go to medical school.

I think this difference in self-perception is monumental in terms of how the two mid-level providers are being educated from day one. AA's aren't trying to be anesthesiologists, but apparently many CRNA's (and those at the AANA) think they're "equivalent" to you guys. Whatever.

This is a great post and it cuts directly to the principal difference between the two groups.

I have been a practicing AA for 15 years now. I graduated from the Emory program in 1992. Prior to that I earned a BS with a double major of EE and Computer Science. I spent two years working with an Anesthesiologist at Emory who did alot of early pioneering work on the use of computers in the OR and we actually developed and presented a computerized anesthesia record in 1984 long before anyone was even thinking of such a thing. I then worked for Hewlett Packard's medical products group doing R&D on EKG interpretation systems and Cardiac Cath lab data analysis. I then entered the Emory AA program in 1990. My point here is that the AANA likes to portray us as forestry majors with our thumbs up our you-know-whats and that we have no business training as anesthesia providors without prior clinical experience. While I had no direct patient care background, I guarantee that I understood hemodynamics and cardiac anatomy and physiology better than any nurse - I don't care how much ICU time they had under their belt. This is true of many AA students and graduates. The key is that these are highly intelligent people with varied backgrounds, many of whom would have very solid med school applications. Also, contrary to the AANA rhetoric, many AA school applicants have clinical backgrounds as well. We are then trained in the medical model of anesthesia delivery that includes medical direction by an anesthesiologist. I have no interest in practicing solo even though I am afforded a fair amount of autonomy by my supervising docs. They know that if the shiit is really hitting the fan, that they would have been involved long before it got out of hand.

I do take issue with your characterization of AAs as technicians (and I understand that those were not your words but the Case Western Director's), as I do make decisions and take care of the typical issues that arise in the course of an anesthetic without necessarily involving the anesthesiologist. I take care of alot of ASA 3 and 4s and do big cases on a daily basis including cardiac. I know what I'm doing, but I understand very well what my limitations are. The anesthesia plan is usually mine, but for complex cases, it's a collaborative effort with both my attending and myself exchanging ideas and coming up with the best way to care for the patient. This is how it should be - the TEAM approach.

 

[cfdavid]

This is a great post and it cuts directly to the principal difference between the two groups.

I have been a practicing AA for 15 years now. I graduated from the Emory program in 1992. Prior to that I earned a BS with a double major of EE and Computer Science. I spent two years working with an Anesthesiologist at Emory who did alot of early pioneering work on the use of computers in the OR and we actually developed and presented a computerized anesthesia record in 1984 long before anyone was even thinking of such a thing. I then worked for Hewlett Packard's medical products group doing R&D on EKG interpretation systems and Cardiac Cath lab data analysis. I then entered the Emory AA program in 1990. My point here is that the AANA likes to portray us as forestry majors with our thumbs up our you-know-whats and that we have no business training as anesthesia providors without prior clinical experience. While I had no direct patient care background, I guarantee that I understood hemodynamics and cardiac anatomy and physiology better than any nurse - I don't care how much ICU time they had under their belt. This is true of many AA students and graduates. The key is that these are highly intelligent people with varied backgrounds, many of whom would have very solid med school applications. Also, contrary to the AANA rhetoric, many AA school applicants have clinical backgrounds as well. We are then trained in the medical model of anesthesia delivery that includes medical direction by an anesthesiologist. I have no interest in practicing solo even though I am afforded a fair amount of autonomy by my supervising docs. They know that if the shiit is really hitting the fan, that they would have been involved long before it got out of hand.

I do take issue with your characterization of AAs as technicians (and I understand that those were not your words but the Case Western Director's), as I do make decisions and take care of the typical issues that arise in the course of an anesthetic without necessarily involving the anesthesiologist. I take care of alot of ASA 3 and 4s and do big cases on a daily basis including cardiac. I know what I'm doing, but I understand very well what my limitations are. The anesthesia plan is usually mine, but for complex cases, it's a collaborative effort with both my attending and myself exchanging ideas and coming up with the best way to care for the patient. This is how it should be - the TEAM approach.

Nice post georgiaAA. I honestly wasn't trying to minimalize the role of the AA. The "technician" comment was truly that of the AA director at Case. Perhaps he was purposefully trying to make a point because he knew I was also thinking of applying to med school, and wanted to make sure I would make the right decision without looking back with regret etc...

 

[ruggerdoc123]

This is a great post and it cuts directly to the principal difference between the two groups.

I have been a practicing AA for 15 years now. I graduated from the Emory program in 1992. Prior to that I earned a BS with a double major of EE and Computer Science. I spent two years working with an Anesthesiologist at Emory who did alot of early pioneering work on the use of computers in the OR and we actually developed and presented a computerized anesthesia record in 1984 long before anyone was even thinking of such a thing. I then worked for Hewlett Packard's medical products group doing R&D on EKG interpretation systems and Cardiac Cath lab data analysis. I then entered the Emory AA program in 1990. My point here is that the AANA likes to portray us as forestry majors with our thumbs up our you-know-whats and that we have no business training as anesthesia providors without prior clinical experience. While I had no direct patient care background, I guarantee that I understood hemodynamics and cardiac anatomy and physiology better than any nurse - I don't care how much ICU time they had under their belt. This is true of many AA students and graduates. The key is that these are highly intelligent people with varied backgrounds, many of whom would have very solid med school applications. Also, contrary to the AANA rhetoric, many AA school applicants have clinical backgrounds as well. We are then trained in the medical model of anesthesia delivery that includes medical direction by an anesthesiologist. I have no interest in practicing solo even though I am afforded a fair amount of autonomy by my supervising docs. They know that if the shiit is really hitting the fan, that they would have been involved long before it got out of hand.

I do take issue with your characterization of AAs as technicians (and I understand that those were not your words but the Case Western Director's), as I do make decisions and take care of the typical issues that arise in the course of an anesthetic without necessarily involving the anesthesiologist. I take care of alot of ASA 3 and 4s and do big cases on a daily basis including cardiac. I know what I'm doing, but I understand very well what my limitations are. The anesthesia plan is usually mine, but for complex cases, it's a collaborative effort with both my attending and myself exchanging ideas and coming up with the best way to care for the patient. This is how it should be - the TEAM approach.

that's a really nice post. what differences do you think there are between being trained in the medical model (like PAs) vs nursing model (at least for bsn/dnp).

 

[BLADEMDA]

that's a really nice post. what differences do you think there are between being trained in the medical model (like PAs) vs nursing model (at least for bsn/dnp).

Let us rerurn to political reality. It just doesn't matter that AA's are better educated than CRNA's. The AANA juggernaut can't be stopped and won't be deterred by the facts. Propoganda, rhetoric and $$$ PAC's are what the AANA does best.

Unless you are willing to wage the kind of war I have discussed in the private forum (FULL METAL JACKET) the AANA will not be defeated. Yes, every now and then the ASA wins a battle or two. But, overall the trend is toward Independent CRNA practice and Lema knows it.

The AANA is extremely adept at bribery and corruption in order to get its way (see North Carolina recently). The little things like formal education and knowledge won't deter its campaign for equality. The online DNP and "A CRNA is by your side" slogan will see to that

 

[johankriek]

Let us rerurn to political reality. It just doesn't matter that AA's are better educated than CRNA's. The AANA juggernaut can't be stopped and won't be deterred by the facts.

dont say that because they can and must be stopped for the sake of the safety of the american public and the future of our specialty.. we have a viable option in the form of physician assistants.. we can use them and AAs to defeat the CRNA propoganda.. not to mention the american public..

 

[BLADEMDA]

dont say that because they can and must be stopped for the sake of the safety of the american public and the future of our specialty.. we have a viable option in the form of physician assistants.. we can use them and AAs to defeat the CRNA propoganda.. not to mention the american public..

Current strategy of "containment" not good for the long term. All it takes is a few liberal judges ruling that "CRNA's can practice Pain Management" because they are "adequately trained" and are under the supervision of a family practitioner.

Then, a few more liberal Governors and Legislatures decide to OPT-OUT in order to save money in MEDICAID areas. Relying on LAWYERS and POLITICIANS to save our Medical specialty from Nurses is a poor long term strategy.

We must be proactive and bring in the PA's plus the PUBLIC. The time has come for ACTION on this issue. The defeat of the AANA and the incorporation of the PA into the O.R. must be our priority.

Blade

 

[johankriek]

Current strategy of "containment" not good for the long term. All it takes is a few liberal judges ruling that "CRNA's can practice Pain Management" because they are "adequately trained" and are under the supervision of a family practitioner.

Then, a few more liberal Governors and Legislatures decide to OPT-OUT in order to save money in MEDICAID areas. Relying on LAWYERS and POLITICIANS to save our Medical specialty from Nurses is a poor long term strategy.

We must be proactive and bring in the PA's plus the PUBLIC. The time has come for ACTION on this issue. The defeat of the AANA and the incorporation of the PA into the O.R. must be our priority.

Blade

write out a letter so we can print out and send off to all of our politicians... its a start

 

[rmh149]

Are you asking use if it fine to do a spinal in someone that has been off Lovenox for 24 hrs? What do you think?

What do you think may have caused her INR to be 3.0?

12 hours is OK, 24 hours is best. But not with this patient with that INR.

INR being 3.0.....look at other drugs she is on, heparin, coumadin, aspirin, ibuprofen, maybe a heavy drinker or in the hospital on antibiotics.

With an INR of 3.0, I wouldnt have put in a spinal in this woman.

Your thoughts

 

[VentdependenT]

12 hours is OK, 24 hours is best. But not with this patient with that INR.

INR being 3.0.....look at other drugs she is on, heparin, coumadin, aspirin, ibuprofen, maybe a heavy drinker or in the hospital on antibiotics.

With an INR of 3.0, I wouldnt have put in a spinal in this woman.

Your thoughts

Ibuprofen affects INR?

Aspirin affects INR?

Heparin affects INR?

Antibiotics affect INR?

Not that I know of.

Why 24 Hours? Why not just 12?

Heavy drinker....ok I'll give you that someone in complete FULMINANT liver failure will have a high INR.

That TEG is sounding pretty good right about now eh?

This will be comming to an end very soon.

 

[Noyac]

12 hours is OK, 24 hours is best. But not with this patient with that INR.

INR being 3.0.....look at other drugs she is on, heparin, coumadin, aspirin, ibuprofen, maybe a heavy drinker or in the hospital on antibiotics.

With an INR of 3.0, I wouldnt have put in a spinal in this woman.

Your thoughts

Why do I bother to teach you anything. I am convinced you are an srna at best.

You don't know the dosing of Lovenox do you? That is obvious.

You don't know which drugs affect the INR/PT and which ones affect the PTT. Which I suspected and which is why I asked you. You are extremely dangerous if you are out there practicing alone. It is only a matter of time b/4 you do someone a serious injustice.
You may think that I am picking on you unnecessarily but if I ever may the same mistakes you have made here while I was in residency I would have been treated much worse until I learned. These are basic principles and you are clueless.

I have a suggestion. Step back, pay attention, ask questions if you wish but don't make comments b/c you are out of your league.

 

[Gern Blansten]

12 hours is OK, 24 hours is best. But not with this patient with that INR.

INR being 3.0.....look at other drugs she is on, heparin, coumadin, aspirin, ibuprofen, maybe a heavy drinker or in the hospital on antibiotics.

With an INR of 3.0, I wouldnt have put in a spinal in this woman.

Your thoughts

 

[deleted59964]

12 hours is OK, 24 hours is best. But not with this patient with that INR.

INR being 3.0.....look at other drugs she is on, heparin, coumadin, aspirin, ibuprofen, maybe a heavy drinker or in the hospital on antibiotics.

With an INR of 3.0, I wouldnt have put in a spinal in this woman.

Your thoughts

rmh149, i'm a nurse - now a med student. I'm still very much supportive of the many excellent nurses who make a huge contribution to patients' care everyday. Some nurses are incredibly smart, no doubt nurses have bailed out some of the gurus here when they were getting started - but nurses are still limited by the education they got.

The reason i went to med school is that I didnt want to take any short cuts - i dont want an expanded role till i get a better education. The idea that you are sticking needles in peoples spine's and dont know which drugs affect INR is SCARY😱 And here's the thing - you will learn which drugs alter INR now, but this is just one sign of the flaws in your education - what else dont you know?

 

[swpm]

12 hours is OK, 24 hours is best. But not with this patient with that INR.

INR being 3.0.....look at other drugs she is on, heparin, coumadin, aspirin, ibuprofen, maybe a heavy drinker or in the hospital on antibiotics.

With an INR of 3.0, I wouldnt have put in a spinal in this woman.

Your thoughts

You need to find another line of work.

What I was thinking about is if the patient has been off lovenox for 24 hours then the spinal should be fine, right? Was she on anything else that would have caused her INR to be 3.0?

So after two days of ridicule and education in this very thread, you still don't have a clue what things affect INR.

Are you really this hopelessly untrainable, or do you just not care if you hurt your patients?

I'm sure you are aware of the "ignore" function. Feel free to use it.

This is a cop out. The ignore function doesn't tidily snip out replies to or quotes of the ignored. It doesn't repair derailed threads that started out with promise but end up with flamewars, locks, or no hint of the original subject matter. There comes a point when killfiles aren't sufficient.

Perhaps I should read SDN with one eye covered while chanting "La la la la la la la la la" over and over again? Nah, this is just a little too close to the approach taken by my real-world superiors in their daily interactions with CRNAs.

 

[rmh149]

Ibuprofen affects INR?

Aspirin affects INR?

Heparin affects INR?

Antibiotics affect INR?

Not that I know of.

Why 24 Hours? Why not just 12?

Heavy drinker....ok I'll give you that someone in complete FULMINANT liver failure will have a high INR.

That TEG is sounding pretty good right about now eh?

This will be comming to an end very soon.

.

 

[All4MyDaughter]

INR being 3.0.....look at other drugs she is on, heparin, coumadin, aspirin, ibuprofen, maybe a heavy drinker or in the hospital on antibiotics.

Ibuprofen affects INR?

Aspirin affects INR?

Heparin affects INR?

Antibiotics affect INR?

Heavy drinker....ok I'll give you that someone in complete FULMINANT liver failure will have a high INR.

All of those medications plus ethanol do have an indirect effect on the PT/INR because they interact with coumadin. At our coag-clinic (VA) we try to keep the INR between 2-3 for most patients. I'm not certain how our management strategy changes when a patient is scheduled for surgery, other than d/c'ing coumadin a few days pre-procedure. There may be a target INR we shoot for pre-op. I can ask the next time I'm up on the surgical floor.

As far as this particular patient, if the patient is on coumadin therapy then rmh's suggestions are not out of line for things that could be pushing up the INR. If the patient isn't on coumadin, then I'm not sure.

 

[Noyac]

All of those medications plus ethanol do have an indirect effect on the PT/INR because they interact with coumadin. At our coag-clinic (VA) we try to keep the INR between 2-3 for most patients. I'm not certain how our management strategy changes when a patient is scheduled for surgery, other than d/c'ing coumadin a few days pre-procedure. There may be a target INR we shoot for pre-op. I can ask the next time I'm up on the surgical floor.

As far as this particular patient, if the patient is on coumadin therapy then rmh's suggestions are not out of line for things that could be pushing up the INR. If the patient isn't on coumadin, then I'm not sure.

True, but the topic changed when it became obvious that rmh didn't understand which medications affect which coag studies. I don't think anyone here would argue that there is a synergistic effect b/w any of these meds. This is well understood by every anesthesiologist. If someone is on plavix for example we want them off of it for 7 days b/4 any neuraxial block but if they continue with ASA then we may increase the 7 day rule. We all understand this. I think we all understood that this pt was on coumadin which is why theoriginal poster didn't need to mention coumadin. But rmh obviously did not understand this.

By the way, you work in coumadin clinic and you don't know the target INR for surgery in your pts.😱 Let me help you which seems to be what many of us are doing here on this thread for those that don't know. Generally, an INR of 1.5 is acceptable for most cases. There are many cases we can perform when the INR is higher but as a rule 1.5 or <.

 

[VentdependenT]

All of those medications plus ethanol do have an indirect effect on the PT/INR because they interact with coumadin. At our coag-clinic (VA) we try to keep the INR between 2-3 for most patients. I'm not certain how our management strategy changes when a patient is scheduled for surgery, other than d/c'ing coumadin a few days pre-procedure. There may be a target INR we shoot for pre-op. I can ask the next time I'm up on the surgical floor.

As far as this particular patient, if the patient is on coumadin therapy then rmh's suggestions are not out of line for things that could be pushing up the INR. If the patient isn't on coumadin, then I'm not sure.

I am aware of drugs effects on displacement of Coumadin from albumin and some effects on the P450 system. I took basic pharmacology in medical school.

BUT you have to be on COUMADIN first! This was not the scenerio brought up by rmh my friend. No mention of coumadin AND a combo of these drugs...but so what if the patient was on these medications AND coumadin! The problem is the COUMADIN not the antibiotic/displacer.

If he/she would have said tylenol....ok. But that patient would be in the ICU on a vent with bicarb and acetylcystine drips and a liver transplant awaiting. Hardly the candidate for a spinal now is it. In fact, anything that mentioned severe liver pathology (thrombi, thromboemboli,hepatitis, etc) would have been acceptable.

The judges will also accept DIC/sepsis.

 

[VentdependenT]

All of those medications plus ethanol do have an indirect effect on the PT/INR because they interact with coumadin. At our coag-clinic (VA) we try to keep the INR between 2-3 for most patients. I'm not certain how our management strategy changes when a patient is scheduled for surgery, other than d/c'ing coumadin a few days pre-procedure. There may be a target INR we shoot for pre-op. I can ask the next time I'm up on the surgical floor.

As far as this particular patient, if the patient is on coumadin therapy then rmh's suggestions are not out of line for things that could be pushing up the INR. If the patient isn't on coumadin, then I'm not sure.

What should happen is a Lovenox bridge.

 

[Planktonmd]

All of those medications plus ethanol do have an indirect effect on the PT/INR because they interact with coumadin. At our coag-clinic (VA) we try to keep the INR between 2-3 for most patients. I'm not certain how our management strategy changes when a patient is scheduled for surgery, other than d/c'ing coumadin a few days pre-procedure. There may be a target INR we shoot for pre-op. I can ask the next time I'm up on the surgical floor.

As far as this particular patient, if the patient is on coumadin therapy then rmh's suggestions are not out of line for things that could be pushing up the INR. If the patient isn't on coumadin, then I'm not sure.

Ok:
Here is a simple explanation:
1- PT and INR are measured by adding tissue factors to plasma and this will activate the EXTRINSIC coagulation pathway which depends on Factor VII
(the shortest half life among Vit K dependent factors).
2- PTT is done by adding Thromboplastin to plasma and it measures the INTRINSIC pathway.
Both pathways intersect at factor X.

So the results of this very brief explanation:

1- Vitamin K inhibitors (Coumadin) primarily inhibit the extrinsic pathway because of factor VII but eventually Factor IX and X get involved as well and this cause some inhibition of the intrinsic pathway, in other words: Coumadin starts by prolonging the PT/INR then in high doses or long term treatment it might also increase PTT.

2- The same is not true for heparin and LMWH because the extrinsic pathway is not affected by antithrombin III activity, so Heparin and LMWH work exclusively on the intrinsic pathway and DO NOT INCREASE PT and INR.

3- Aspirin Does not increase PT and INR although it makes it more likely to bleed on Coumadin ( Platelet dysfunction).
4- Antibiotics can prolong PT, INR and even PTT because of killing the bacteria that produces Vitamin K in the intestine, PT/INR is affected more than PTT because of the short half life of factor VII.

I hope this was not too boring but I couldn't make it any simpler.

 

[fval28]

All you out there who are placing epidurals for post op pain mgmt (not OB), I would like to ask your opinions.

Do you restrict DVT prophylaxis for these patients?

Do you just allow sq heparin or do you allow LMWH, etc.

Typically we allow what the surgeon/intensivist wants once the catheter has been in for 12 hours and then follow ASRA guidelines for pulling the catheter- do not routinely check coags b4 pulling unless pt is showing any signs of coagulopathy (in that case I may not pull it even if coags are wnl).

What do you all do?

Thanks

 

[Taurus]

12 hours is OK, 24 hours is best. But not with this patient with that INR.

INR being 3.0.....look at other drugs she is on, heparin, coumadin, aspirin, ibuprofen, maybe a heavy drinker or in the hospital on antibiotics.

With an INR of 3.0, I wouldnt have put in a spinal in this woman.

Your thoughts

Hey captain,

What you should take away from this isn't about INR. It's about how CRNA's aren't competent enough to work independently by spending 2 years in school and thinking that they can fill in the knowledge gap compared to anesthesiologists by reading up on topics they didn't learn on UpToDate or textbooks at night and on weekends. You learn this stuff by being in a structured and supervised learning environment that residents go through. It becomes second nature after a while. This is how you ensure patient safety and why solo CRNA's are so dangerous.

Someone please sticky this thread. It is an eye-opening example for the public of the gap in knowledge and competence between anesthesiologists and CRNA's.

 

[milrisome]

All you out there who are placing epidurals for post op pain mgmt (not OB), I would like to ask your opinions.

Do you restrict DVT prophylaxis for these patients?

Do you just allow sq heparin or do you allow LMWH, etc.

Typically we allow what the surgeon/intensivist wants once the catheter has been in for 12 hours and then follow ASRA guidelines for pulling the catheter- do not routinely check coags b4 pulling unless pt is showing any signs of coagulopathy (in that case I may not pull it even if coags are wnl).

What do you all do?

Thanks

I don't feel comfortable leaving catheters in with lovenox (or any lmwh) running. Epidurals get pulled out all the time on the floor, and removal is just as risky as putting them in. So if the surgeon insists on lovenox, I pass on the epidural. ASRA guidelines state that twice daily dosing should not be given with an indwelling catheter, or with once daily dosing, a 10-12 hour delay should exist between injection of lovenox and removal. That means that if a catheter accidently gets pulled, there is a 50% chance it will get pulled in the risk period.

I don't check coags before pulling unless there is a concern.

 

[VentdependenT]

All you out there who are placing epidurals for post op pain mgmt (not OB), I would like to ask your opinions.

Do you restrict DVT prophylaxis for these patients?

Do you just allow sq heparin or do you allow LMWH, etc.

Typically we allow what the surgeon/intensivist wants once the catheter has been in for 12 hours and then follow ASRA guidelines for pulling the catheter- do not routinely check coags b4 pulling unless pt is showing any signs of coagulopathy (in that case I may not pull it even if coags are wnl).

What do you all do?

Thanks

We follow ASRA guidelines.

No restriction on DVT prophylaxis with hep sq or lovenox.

all of our ortho lower extremity patients start coumadin their post op day one or the night of the operation. We check INR's before pulling the epidural.

We typically do not do epidurals on folks who will be systemically anticoagulated even if that anticoagulation isn't started 2 hours for lovenox/1hour for heparin institution.

 

[Noyac]

We follow ASRA guidelines.

No restriction on DVT prophylaxis with hep sq or lovenox.

all of our ortho lower extremity patients start coumadin their post op day one or the night of the operation. We check INR's before pulling the epidural.

We typically do not do epidurals on folks who will be systemically anticoagulated even if that anticoagulation isn't started 2 hours for lovenox/1hour for heparin institution.

Same here. ASRA guidelines.

But we rarely place epidurals any more b/c of all the DVT prophylaxis going on and the risks of the catheter being pulled out accidentally as milrisome stated. We just do intrathecal duramorph or dilaudid.

 

[fval28]

I don't feel comfortable leaving catheters in with lovenox (or any lmwh) running. Epidurals get pulled out all the time on the floor, and removal is just as risky as putting them in. So if the surgeon insists on lovenox, I pass on the epidural. ASRA guidelines state that twice daily dosing should not be given with an indwelling catheter, or with once daily dosing, a 10-12 hour delay should exist between injection of lovenox and removal. That means that if a catheter accidently gets pulled, there is a 50% chance it will get pulled in the risk period.

I don't check coags before pulling unless there is a concern.

good point about inadvertent catheter removal- I neglected to mention that in my post

reason I am asking is I have patient, right now ex lap loa- POD 4, COPD, hi risk for thrombus formation (hx of CA, previous DVT), who I have an epidural running and is working great. pt is rating pain 0-2 with coughing, is walking the halls and doing super, this was his 3rd abd surgery that I have done, he has had at least 2 others. Any way, IM doc approaches me today and asks me if we restrict DVT prophylaxis options with an epidural running. I was on the fence as to putting this thin in preop but he has such crappy lungs I was worried he would box if he got a lot of opiates. not too worried about epi hematoma formation as long as he is still walking and is continent🙂. anyway thanks for the replies.

 

[Noyac]

good point about inadvertent catheter removal- I neglected to mention that in my post

reason I am asking is I have patient, right now ex lap loa- POD 4, COPD, hi risk for thrombus formation (hx of CA, previous DVT), who I have an epidural running and is working great. pt is rating pain 0-2 with coughing, is walking the halls and doing super, this was his 3rd abd surgery that I have done, he has had at least 2 others. Any way, IM doc approaches me today and asks me if we restrict DVT prophylaxis options with an epidural running. I was on the fence as to putting this thin in preop but he has such crappy lungs I was worried he would box if he got a lot of opiates. not too worried about epi hematoma formation as long as he is still walking and is continent🙂. anyway thanks for the replies.

Pull the epidural and let them start the lovenox. 4 days is long enough.

 

[All4MyDaughter]

By the way, you work in coumadin clinic and you don't know the target INR for surgery in your pts.😱 Let me help you which seems to be what many of us are doing here on this thread for those that don't know. Generally, an INR of 1.5 is acceptable for most cases. There are many cases we can perform when the INR is higher but as a rule 1.5 or <.

Eh, I'm a student. Still learning. I'm sure the real anti-coag pharmacists now. But anticoagulation pharmacists wouldn't be managing the pre-op coumadin dosing changes to get a target INR for surgical patients anyway. That would be managed by the surgical team. Now, post-op the patient would be discharged to the anti-coag clinic and we'd work with them to get their INR back into the appropriate target range.

Ok:
Here is a simple explanation:
{saving space}
I hope this was not too boring but I couldn't make it any simpler.

Not boring at all and very helpful. 🙂

 

[Noyac]

Now, post-op the patient would be discharged to the anti-coag clinic and we'd work with them to get their INR back into the appropriate target range.

Don't you just start them back on their regular dose and keep giving them heparin or lovenox until they are therapeutic on their coumadin?

If this is the case then I don't see they need to go back to their clinic. But I am not at the VA so things are obviously different there.

 

[All4MyDaughter]

Don't you just start them back on their regular dose and keep giving them heparin or lovenox until they are therapeutic on their coumadin?

If this is the case then I don't see they need to go back to their clinic. But I am not at the VA so things are obviously different there.

From my understanding of it they will be seen 48-72 hours post-discharge and their INR is checked at that time. If it is in range at the discharge dose then that will become their new dose. If it is high/low the pharmacist will adjust and they'll come back in 3-7 days for re-check. Once they are stable I believe they see the anti-coag pharmacist every 2-3 months for maintenance.

I also believe that the INR is sometimes kept higher than normal in certain patients post-op (such as artificial heart valve patients). In that case, they will be seen more frequently while the dose of coumadin needed to hit the target INR is established.

 

[VentdependenT]

Nurses aren't allowed to pull epidurals on the floors. Only on OB. The resident must review anticoagulation meds and recent INR's (for those on coumadin).

Unfortunately some of the patients who would benefit the most from regional anesthesia, obese/elderly, often are at the highest risk for DVT/PE. Point being I would be far far more hesitant to place an epidural on someone who was going to be on BID DVT prophylaxis lovenox therapy. Its too risky because mix-ups do happen and patients do get lost in the mix sometimes.

Single Shot spinal can do justice for the surgery and for immediate post op pain and avoid the disasterous hematoma (or worse abscess in the big fattie with DM...different story all together).

Speakin of Single Shot Spinals do any of you guys put clonidine in there? 15ucgs or so?

 

[Noyac]

Nurses aren't allowed to pull epidurals on the floors. Only on OB. The resident must review anticoagulation meds and recent INR's (for those on coumadin).

Unfortunately some of the patients who would benefit the most from regional anesthesia, obese/elderly, often are at the highest risk for DVT/PE. Point being I would be far far more hesitant to place an epidural on someone who was going to be on BID DVT prophylaxis lovenox therapy. Its too risky because mix-ups do happen and patients do get lost in the mix sometimes.

Single Shot spinal can do justice for the surgery and for immediate post op pain and avoid the disasterous hematoma (or worse abscess in the big fattie with DM...different story all together).

Speakin of Single Shot Spinals do any of you guys put clonidine in there? 15ucgs or so?

No.

i find the duramorph drops their BP enough and dilaudid drops it almost too much. I don't use dilaudid in any pt that won't tolerate a 20% or greater drop in BP. I can run neo for the case and keep the BP up but on the floor they are still at risk.

 

[dhb]

Yes we use clonidine 10ug for spinals for c-sec and up to 50ug for fem/pop bypass. I like to use it with bupi instead of sufentanil but most attendings use it only on top of bupi and sufenta to prolong the block.

We don't use morphine because of iching and nausea.

We don't have injectable dilaudid, do you have less side effects than with morphine?

 

[Noyac]

We don't use morphine because of iching and nausea.

We don't have injectable dilaudid, do you have less side effects than with morphine?

The itching with morphine is easily treated with nubain.

Dilaudid does have less itching but more hypotension.

 

[dhb]

What about the nausea/vomiting?
(we don't have nubain either)

 

[fval28]

I usually use 0.1 mg duramorph in c-section patients, treat all of them with 4 of zofran and 50 of benadryl as soon as I get a good level and I have seen a remarkable decrease in the incidence of itching and nausea. Pain relief seems to be about the same as when I used 0.2 mg- maybe I'm just picking the right patients now🙂

Our Ob's really like the duramorph, one of them almost takes it personally if the patient doesn't want it- he's a funny sort of fellow anyway...

 

[BuzzPhreed]

This is a bump for a very information rich thread on multiple different levels. And to illustrate how little has changed in 7 years! I wonder if we'll be have these same discussions in 2021?!

 

[Sirach38]

This is a bump for a very information rich thread on multiple different levels. And to illustrate how little has changed in 7 years! I wonder if we'll be have these same discussions in 2021?!

This is an extremely interesting and eye opening thread. It would make a good sticky.

 

[Planktonmd]

Wow... 2007

 

[BLADEMDA]

This is a bump for a very information rich thread on multiple different levels. And to illustrate how little has changed in 7 years! I wonder if we'll be have these same discussions in 2021?!

A lot has changed but it will take time to see them all:

1. AMCs have gained significant market share since 2007. I would say they now have over 40% of the market vs 10% or less in '07.
2. The ACA (Obamacare) is now law and will change healthcare. Medicaid expansion is now over 10 million and the number of US Citizens with CMS is at record levels and growing each year. The ACA provides free healthcare to tens of millions of people; millions of kids (ChiP) get big govt. subsidies even though their parents earn $90,000. This translates into very low anesthesia reimbursement rates.
3. Hospital subsidies are being slashed.
4. Partnerships are now scarce unlike in '07.
5. Salaries are down for new graduates significantly
6. Job openings are fewer as groups hire more CRNAs
7. Record number of groups have sold to AMCs and more will sell out (see point number 1)
8. Fellowship applicants are at record levels as job opportunities are harder to find
9. CRNAs/AANA have gained market share of Gi and ASCs. More centers use CRNAs only now than in '07.
10. Taxes are much, much higher than '07

I completely disagree that things haven't changed much since 2007.

 

[BLADEMDA]

While enrollment on government-run Obamacare exchanges gets the bulk of media attention, sign-ups for Medicaid have been even greater, in no small part due to another part of the Affordable Care Act.

Since October 2013, enrollment in Medicaid and the related Children's Health Insurance Program had grown by about 9.7 million people as of this past October, according to data released Thursday by the federal government. That's 17 percent higher than what was the average monthly enrollment level seen from July through September 2013.

That bump brings total enrollment in the programs that provide coverage without a premium charge to the poor and young, respectively, up to 68.5 million people nationally. A bit more than half of those people are children.

 

[BLADEMDA]

As of January 2015 here are the estimates within a few hundred thousand:

Medicare: 54 million people
Medicaid plus Chips: 68.5 million
Tricare 5.5 Million (even more are eligible)

Total: 128 Million

So we now have 128 Million people enrolled in plans which pay Anesthesia peanuts.

Uninsured and illegals in the USA: 40 million

Total Population 316 million. 168 Million people or 53% don't pay enough into the healthcare system to keep Anesthesia going in a hospital setting.

It gets worse. Since the ACA was passed many families receiving govt. subsidies have the Bronze plan with $6,000 deductibles. This means these people won't be paying the bill either as they can't afford that much money per year out of pocket.

 

[BLADEMDA]

The facts are clear here. 53% of people in the USA rely on the Govt. for healthcare insurance. Another 10% are expected to enroll in the ACA to buy healthcare insurance and get huge subsidies.

I submit to you that by the end of the next Presidential term over 60% of all US Citizens will be reliant on the govt. to get or keep their healthcare plan.
Obama will have succeeded in transforming the healthcare system to a Socialized system but without true governmental control. That is coming next to the USA as the system will fall under its own weight.

 

[BLADEMDA]

Since 2007 more Groups are hiring employees only and using more CRNAs. Supevision rates are higher and hospitals are cutting subsidies. Groups have lost lucrative ASCs and GI centers to the OWNERS who hire cheap labor and siphon off the anesthesia money.

From where I stand the sun isn't shining any longer and the clouds are rolling in slowly. Those who can avoid CMS get to enjoy the sunshine longer than the rest of us.

 

[Consigliere]

Eye opening, Blade. And right on target, as usual.

 

[Mman]

Since 2007 more Groups are hiring employees only and using more CRNAs. Supevision rates are higher and hospitals are cutting subsidies. Groups have lost lucrative ASCs and GI centers to the OWNERS who hire cheap labor and siphon off the anesthesia money.

From where I stand the sun isn't shining any longer and the clouds are rolling in slowly. Those who can avoid CMS get to enjoy the sunshine longer than the rest of us.

My personal goal is to keep the good times rolling as long as possible. But while I hope that's the case, I save, save, save for a rainy day.

If I had a kid in HS or college, I would not recommend medical school as a solid career choice.

 

[Sirach38]

The US is moving to a socialized system and this seems to be the end of anesthesiology as we know it. Question, how does anesthesia survive in other socialized healthcare systems in Europe?

 

[murdoc9]

If I had a kid in HS or college, I would not recommend medical school as a solid career choice.

Agreed.
The cost of med school tuition has become criminal and will make financial solvency for the new generation of doctors a real problem, myself included. I would be fine with salaries coming down if I didn't have the debt.

It no longer makes sense to put in 4 yrs college + 4 yrs medschool at 30 - 50k per year, then be paid like a peasant for 3 - 8 yrs, then have salaries approach those of professions that require way less schooling and blood sweat and tears to achieve.

But premeds will keep on coming.

 

[murdoc9]

The US is moving to a socialized system and this seems to be the end of anesthesiology as we know it. Question, how does anesthesia survive in other socialized healthcare systems in Europe?

They don't have CRNAs and are the primary critical care practitioners of the hospital, would be my guess.

 

[deleted171991]

The US is moving to a socialized system and this seems to be the end of anesthesiology as we know it. Question, how does anesthesia survive in other socialized healthcare systems in Europe?

Most of Europe has numerus clausus, which the US does not. One will not get an increase of 30% in the number of anesthesia graduates without an equivalent increase in the demand for anesthesiologists. Plus Europe does not have CRNAs, and barely any APRNs.

AFAIK, the market is pretty balanced, although it's balanced at apparently lower income levels than in the US. I say apparently because I have a feeling that their hourly pre-tax income is not much worse than ours.

 

[deleted126335]

The facts are clear here. 53% of people in the USA rely on the Govt. for healthcare insurance. Another 10% are expected to enroll in the ACA to buy healthcare insurance and get huge subsidies.

I submit to you that by the end of the next Presidential term over 60% of all US Citizens will be reliant on the govt. to get or keep their healthcare plan.
Obama will have succeeded in transforming the healthcare system to a Socialized system but without true governmental control. That is coming next to the USA as the system will fall under its own weight.

It is even more if you include Federal, State, County and Municipal employees who technically usually have private insurance, but paid for by the government.