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there are differences in the anesthetic between when a physician administers and directs it compared to when a crna is allowed to "go it alone" or is even just given a long leash. i've seen them firsthand. they make a difference. not all of them have been studied and quantified, and it would likely be incredibly difficult to do so. i'm not talking about m&m; i'm talking about normal day-to-day stuff.
most of what we do is a "black box" to most other services we consult and provide care for. it's incredible how little even the surgeon understands about what it is we do. many non-anesthesia providers think our field is like a light switch: easy to turn on and off. and, the great anesthesiologists make it look that way.
but, there are differences... and i've seen them. i admit they are anecdotal, but they make a difference. here are some i observed during my residency when i was in the (relatively uncommon) situation where i would either be working in the same environment (alternate site anesthesia) or take over a case from a crna.
(1) inappropriate ventilator settings for the patient. examples: the patient would be a small child who was getting way too much tidal volume, peep (via pop-off) with an lma while the patient was spontaneously breathing, and too much oxygen mixture in a patient who already had significant atelectasis. in one case, when i was getting a crna out for a lunch, i walked in the room to see the peak pressures near 40cmH2O. the patient's i:e ratio was 1:2.5 and they had a belly full of gas. i immediately switch the vent to pressure control, lowered the pressure setting to 32, and dropped the flow rate. i didn't lose any tidal volume, and there was no breath stacking. i explained what i'd done to the crna (who looked at me like i was speaking chinese), and then she laughed at me said "okay, professor", clearly a back-handed compliment.
(2) poor pain-control planning strategy. either patients would get an unnecessarily high amount of narcotic, or they'd get no narcotic at all. the dose of the narcotic intended would not meet the post-operative requirements. for example, i once saw a routine gyny procedure where the patient got 20mg of morphine. the case was an hour-and-a-half. the patient was going home that same day. and there was no anticipation of significant post-operative pain. when i asked the crna why so much morphine, she told me that she always gives that much. 😱 toradol would've been a much better choice.
(3) poor drug choice/inappropriate drug administration. i took over an ankle case one time in a patient who was having a distal tibia hardware revision for infection and non-union. the patient was a smoking diabetic who'd had a regional block. the crna had given 8mg of decadron for PONV prophylaxis. this was a low-risk PONV case, and there was no need to give decadron.
(4) "cookie-cutter" anesthesia. the "one size fits all" anesthetic approach is often seen. patients get unnecessary anesthetic interventions because "this is the way i do a case" mentality. for instance, a patient who doesn't need to get tubed and paralyzed gets tubed and paralyzed. everyone gets reversed at the end of the case, even if they've been spontaneously breathing for the last two hours and pulling adequate tidal volumes. in another case, sometimes too simplistic of an anesthetic is offered. i was sent to the mri scanner to "get a crna out" when he was getting ready to start an mr case for a two-year-old. his plan was to just give propofol sedation. the kid had a history of puking (had puked that morning) and they were doing a full head, thorax, and abdomen scan that was going to possibly take upwards of four hours and require breath holding for certain portions. needless to say we tubed the kid and gave him vapors as well as full PONV prophylaxis. and that's not mentioning the fact that the purely sevoflurane anesthetic i gave him was about 1/4th the cost of a propofol infusion.
(5) inappropriate fluid administration for the case. chf patients not getting enough volume. simple procedures without a lot of surgical exposure getting too much. formulaic calculations followed religiously. i once saw a patient get repeatedly bolused because not enough urine was coming back from the foley. the patient was in low lithotomy with soft trendelenburg, and happened to have a twist in the foley line. needless to say, the patient "dumped" a lot of very low spec grav looking urine when flattened out and tension was taken off the foley line.
these are the types of things that make me bristle when i hear some crnas claim that they deliver the "exact same" anesthetic in the OR that an anesthesiologist does.
still, i admit these patients all wake up. they all go to the pacu. they will go back to their hospital rooms and/or go home. does it always matter? some might say "no" if they were to focus on m&m as the yardstick. but, we're talking about patient's impressions about their procedure. we're talking about occult changes that may show-up later that other primary clinicians taking care of the patient may not understand or be able to connect the dots back to the anesthetic. it's more than just how the patient "feels" afterwards, and often about subtle changes that cannot always be easily measured. and, some of the stuff we "do" to the patient may matter down the road and have a real impact on their underlying disease process (eg, tight peri-operative glucose control, appropriate intra-op fluid and pulmonary management, etc.).
i've seen some crna's who get this and understand the impact their interventions may have on more "physician knowledge base" level. but, they are few and far between - definitely the exception and not the rule. this has led me to the real, visceral understanding that to blanketly allow crna's - all crnas - to practice without supervision is a timebomb.
we've made such great advances in our field that monitors are better and we have a better understanding of what's happening when it happens intra-operatively. what we need a better understanding of is what subtle things we do, that make physiologic sense, to the patient affects them post-operatively. many of this know this already. you don't use a hammer when a screwdriver would work better. and, if the only tool a crna has is a hammer, then every problem looks like a nail. iow, let's not try to fix what's not broken. let's continue to advance our field and put a finer focus on the things we do and the potential impact they have down the road... things that are not always immediately obvious when you only take a patient from the pre-op area to the OR and then to the pacu, never seeing them again.
most of what we do is a "black box" to most other services we consult and provide care for. it's incredible how little even the surgeon understands about what it is we do. many non-anesthesia providers think our field is like a light switch: easy to turn on and off. and, the great anesthesiologists make it look that way.
but, there are differences... and i've seen them. i admit they are anecdotal, but they make a difference. here are some i observed during my residency when i was in the (relatively uncommon) situation where i would either be working in the same environment (alternate site anesthesia) or take over a case from a crna.
(1) inappropriate ventilator settings for the patient. examples: the patient would be a small child who was getting way too much tidal volume, peep (via pop-off) with an lma while the patient was spontaneously breathing, and too much oxygen mixture in a patient who already had significant atelectasis. in one case, when i was getting a crna out for a lunch, i walked in the room to see the peak pressures near 40cmH2O. the patient's i:e ratio was 1:2.5 and they had a belly full of gas. i immediately switch the vent to pressure control, lowered the pressure setting to 32, and dropped the flow rate. i didn't lose any tidal volume, and there was no breath stacking. i explained what i'd done to the crna (who looked at me like i was speaking chinese), and then she laughed at me said "okay, professor", clearly a back-handed compliment.
(2) poor pain-control planning strategy. either patients would get an unnecessarily high amount of narcotic, or they'd get no narcotic at all. the dose of the narcotic intended would not meet the post-operative requirements. for example, i once saw a routine gyny procedure where the patient got 20mg of morphine. the case was an hour-and-a-half. the patient was going home that same day. and there was no anticipation of significant post-operative pain. when i asked the crna why so much morphine, she told me that she always gives that much. 😱 toradol would've been a much better choice.
(3) poor drug choice/inappropriate drug administration. i took over an ankle case one time in a patient who was having a distal tibia hardware revision for infection and non-union. the patient was a smoking diabetic who'd had a regional block. the crna had given 8mg of decadron for PONV prophylaxis. this was a low-risk PONV case, and there was no need to give decadron.
(4) "cookie-cutter" anesthesia. the "one size fits all" anesthetic approach is often seen. patients get unnecessary anesthetic interventions because "this is the way i do a case" mentality. for instance, a patient who doesn't need to get tubed and paralyzed gets tubed and paralyzed. everyone gets reversed at the end of the case, even if they've been spontaneously breathing for the last two hours and pulling adequate tidal volumes. in another case, sometimes too simplistic of an anesthetic is offered. i was sent to the mri scanner to "get a crna out" when he was getting ready to start an mr case for a two-year-old. his plan was to just give propofol sedation. the kid had a history of puking (had puked that morning) and they were doing a full head, thorax, and abdomen scan that was going to possibly take upwards of four hours and require breath holding for certain portions. needless to say we tubed the kid and gave him vapors as well as full PONV prophylaxis. and that's not mentioning the fact that the purely sevoflurane anesthetic i gave him was about 1/4th the cost of a propofol infusion.
(5) inappropriate fluid administration for the case. chf patients not getting enough volume. simple procedures without a lot of surgical exposure getting too much. formulaic calculations followed religiously. i once saw a patient get repeatedly bolused because not enough urine was coming back from the foley. the patient was in low lithotomy with soft trendelenburg, and happened to have a twist in the foley line. needless to say, the patient "dumped" a lot of very low spec grav looking urine when flattened out and tension was taken off the foley line.
these are the types of things that make me bristle when i hear some crnas claim that they deliver the "exact same" anesthetic in the OR that an anesthesiologist does.
still, i admit these patients all wake up. they all go to the pacu. they will go back to their hospital rooms and/or go home. does it always matter? some might say "no" if they were to focus on m&m as the yardstick. but, we're talking about patient's impressions about their procedure. we're talking about occult changes that may show-up later that other primary clinicians taking care of the patient may not understand or be able to connect the dots back to the anesthetic. it's more than just how the patient "feels" afterwards, and often about subtle changes that cannot always be easily measured. and, some of the stuff we "do" to the patient may matter down the road and have a real impact on their underlying disease process (eg, tight peri-operative glucose control, appropriate intra-op fluid and pulmonary management, etc.).
i've seen some crna's who get this and understand the impact their interventions may have on more "physician knowledge base" level. but, they are few and far between - definitely the exception and not the rule. this has led me to the real, visceral understanding that to blanketly allow crna's - all crnas - to practice without supervision is a timebomb.
we've made such great advances in our field that monitors are better and we have a better understanding of what's happening when it happens intra-operatively. what we need a better understanding of is what subtle things we do, that make physiologic sense, to the patient affects them post-operatively. many of this know this already. you don't use a hammer when a screwdriver would work better. and, if the only tool a crna has is a hammer, then every problem looks like a nail. iow, let's not try to fix what's not broken. let's continue to advance our field and put a finer focus on the things we do and the potential impact they have down the road... things that are not always immediately obvious when you only take a patient from the pre-op area to the OR and then to the pacu, never seeing them again.
