Whats the deal with crnas giving every drug in the pyxis??

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
L

LowWafer8

Full Member
2+ Year Member
Joined
Jul 17, 2022
Messages
15
Reaction score
16
Members don't see this ad.
I'm talking every single elective surgery getting pepcid, reglan, glyco, precedex(!), ketamine. Wth?? Are you guys seeing this or is it specific to my particular area? Is this necessary? Isn't there some minimal responsibility not to incur additional unnecessary costs to our already out of control healthcare expense burden?
 
LowWafer8 said:
I'm talking every single elective surgery getting pepcid, reglan, glyco, precedex(!), ketamine. Wth?? Are you guys seeing this or is it specific to my particular area? Is this necessary? Isn't there some minimal responsibility not to incur additional unnecessary costs to our already out of control healthcare expense burden?
Click to expand...
They are just so danged smart and they saw a CRNA give a lecture at an NWAS conference that said they should do that.
 
Yeah, they follow a formula. I did a hand case in a 90yo, completely blocked couldn't move a finger after the previous case ran over, verbally said light propofol sedation. Look at the case (running 4:1, QZ, militant travel CRNAs): prop, ketamine, precedex...I ask the crna why in a very bland curious way to try and subvert them going ballistic and throwing a fit... 'As a nurse I practice multimodal pain control, you don't have to agree to everything I do.' Left that place shortly after, thought like asking if they practiced multimodal thinking. Wait till you get the ones that give every single patient benadryl, including every elderly patient in endo/IR/CT/MRI
 
Last edited:
LowWafer8 said:
I'm talking every single elective surgery getting pepcid, reglan, glyco, precedex(!), ketamine. Wth?? Are you guys seeing this or is it specific to my particular area? Is this necessary? Isn't there some minimal responsibility not to incur additional unnecessary costs to our already out of control healthcare expense burden?
Click to expand...
I've seen it done recently. Not sure what book they are reading.
 
It’s infected our pacu nurses. Dropped off elderly patient the other day, resting comfortably, no complaints. Nurse in PACU starts giving me the third degree about why didn’t I give this and that. Another nurse stepped and told him to back down before I lost my $hit.
 
Dr. Rude said:
running low dose propofol infusions to "lower the dose of inhalational and reduce PONV" has become a thing recently. Not sure why. Anyone have any evidence for or against this practice? I honestly don't know.
Click to expand...
Lots of studies showing benefit for PONV. Personally I think the less gas the better
 
Low dose propofol yes and I have no problem with that, and it has not 'become a thing recently' - saw it given by co-residents in Boston from MGH when I rotated at some shared institutions back in 2017 so :shrug: ; I personally haven't had the misfortune of dealing with the other nonsense in my former job, current practice, or any of the multiple places I've moonlighted and done PRN work :shrug:
 
LowWafer8 said:
I'm talking every single elective surgery getting pepcid, reglan, glyco, precedex(!), ketamine. Wth?? Are you guys seeing this or is it specific to my particular area? Is this necessary? Isn't there some minimal responsibility not to incur additional unnecessary costs to our already out of control healthcare expense burden?
Click to expand...
One of them told me that by giving several different drugs they get the benefits of all of them without any side effects.
 
Dr. Rude said:
running low dose propofol infusions to "lower the dose of inhalational and reduce PONV" has become a thing recently. Not sure why. Anyone have any evidence for or against this practice? I honestly don't know.
Click to expand...
It’s in every anesthesia book.
 
triggermaster said:
It’s not magic it’s an illusion.
Click to expand...
1720756053693.gif
 
I feel like they have a chip on their shoulder that the only way to show off is using all kinds of weird drips mixes. Had to supervise a simple one level lami and I see a locum running remi at 0.3, phenylephrine drip at 0.8 and precedex at 0.5 and they wonder why it is brady… and pt only has 1 IV. Every time I see these people, I feel like my job is well secured.
 
Dr. Rude said:
running low dose propofol infusions to "lower the dose of inhalational and reduce PONV" has become a thing recently. Not sure why. Anyone have any evidence for or against this practice? I honestly don't know.
Click to expand...
That's exactly what it does. Any sedative will lower the dose of inhalational required, as MAC is a affected by a combination of all sedatives involved.

Propofol is a known anti emetic and very useful in that regard.
 
PAC2DO said:
I feel like they have a chip on their shoulder that the only way to show off is using all kinds of weird drips mixes. Had to supervise a simple one level lami and I see a locum running remi at 0.3, phenylephrine drip at 0.8 and precedex at 0.5 and they wonder why it is brady… and pt only has 1 IV. Every time I see these people, I feel like my job is well secured.
Click to expand...
Not sure why this gives you a feeling of job security. I can assure you the bean counters (and the surgeons) neither know nor care about your anesthetic plan. So long as the patient wakes up alive and intact nobody cares…
 
pgg said:
f'in Precedex

There's a cohort here who give little 4 or 8 mcg hits of it throughout every case.

If I could take it off formulary for our hospital I would.
Click to expand...
I would just tell them to give more.
 
Now that I think of it - I had one that would give Demerol and Benadryl to almost everyone, and wouldn’t not do it when asked/told not too. She also left the ISO at 2% with 100% O2 running at 6L almost always. She clearly knew better than I everyone. Thank God I don’t work there anymore.
 
dannyboy1 said:
Not sure why this gives you a feeling of job security. I can assure you the bean counters (and the surgeons) neither know nor care about your anesthetic plan. So long as the patient wakes up alive and intact nobody cares…
Click to expand...
This is likely practice dependent but in my practice, surgeons will request MDs for certain cases. Recently had one of the outpt cases had difficult to vent/intubate situation with a CRNA and that’s all it took for surgeons to discuss having MDs during induction. Also, CRNAs don’t have the ability to staff PACU. Anyone can learn to induce/intubate and do cases but I feel like you truly need medicine background (not nursing) to take care of tricky PACU patients.
 
kidthor said:
Now that I think of it - I had one that would give Demerol and Benadryl to almost everyone, and wouldn’t not do it when asked/told not too. She also left the ISO at 2% with 100% O2 running at 6L almost always. She clearly knew better than I everyone. Thank God I don’t work there anymore.
Click to expand...
Dang….at least do low flow and pretend like you know what’s going on
 
rick roller pump said:
I have seen this mainly with new grad CRNAs. I'm talking ketamine, precedex, magnesium , lidocaine drip. Especially annoying when it is on a patient with a good block or a 90yo hip. Just tell them to stop.
Click to expand...
Yes! Exactly how it was at my first job. So glad I’m at a MD only practice now. Drove me bonkers.

Then they put the patient on the stretcher tubed, deep extubate 20 minutes after the case finished, then immediately wheel out the door with a face mask on that’s not attached to oxygen. Then I have to get called for the blue patient in PACU.
 
Gator7 said:
Yes! Exactly how it was at my first job. So glad I’m at a MD only practice now. Drove me bonkers.

Then they put the patient on the stretcher tubed, deep extubate 20 minutes after the case finished, then immediately wheel out the door with a face mask on that’s not attached to oxygen. Then I have to get called for the blue patient in PACU.
Click to expand...
And of course the “deep” extubation is at .5 MAC or so, just like they learned in “anesthesia school” - and it’s after an open abdominal case with an NG in place draining bile.
 
There is the "art" of anesthesia and then there is the "art" of anesthesia. Whether they are anesthesiologists, CRNAs, residents or SRNAs what I see described above I would describe their art of anesthesia as comparable to the so called art of Jackson Pollock. 😉
I hear a lot of guffaws when I say this but then I see the lightbulb light up in their head and I see that they understand. 🙂
 
GassYous said:
I like giving benadryl in mac cases and magnesium in spines...

Am I a crna???
Click to expand...
Magnesium may have some benefits in regards to pain.

Why benadryl? Just adds additional sedation that is unnecessary and extends beyond the case. Anti-emetic benefits are unnecessary as a propofol Mac case shouldn't have much PONV. And the anti-histamine effect is unimportant.

So I don't see any benefits to Benadryl in that type of case?
 
rick roller pump said:
I have seen this mainly with new grad CRNAs. I'm talking ketamine, precedex, magnesium , lidocaine drip. Especially annoying when it is on a patient with a good block or a 90yo hip. Just tell them to stop.
Click to expand...
Magnesium?? Lidocaine?? Infusions?? Are you serious?? Never have I ever run a Lido infusion and only time I ever ran Mg was in the ICU for an asthmatic patient. And by running it I mean the nurse at bedside. What the hell is happening at your place???
 
UscGhost said:
Magnesium may have some benefits in regards to pain.

Why benadryl? Just adds additional sedation that is unnecessary and extends beyond the case. Anti-emetic benefits are unnecessary as a propofol Mac case shouldn't have much PONV. And the anti-histamine effect is unimportant.

So I don't see any benefits to Benadryl in that type of case?
Click to expand...

For ep cases where they are manipulating the heart rate, I want to dry out their mouths so they don't cough but don't want to give glyco. Helps with sedation as well. I haven't noticed any major issues with waking up at the end of surgery or delirium in pacu.
 
triggermaster said:
Mixing multiple drugs in one bag is almost always stupid. Why give up independent control of each drug? What do you do with neo + epi if they get tachycardia? Turn both off and get hypotension? Sounds dumb.
Click to expand...
When I was a resident I had an attending who did these mixed drug single-syringe TIVAs for spines. I don't recall the exact mix but it was some ratio of propofol, midazolam, ketamine, and sufentanil in one big 50 mL syringe.

It worked great a couple cases I did with him, so I tried the technique with a different attending another time. Patient was narcotized as hell at the end. Couldn't figure it out. Had to give Narcan to wake the patient up. This attending had been skeptical of the plan from the start, and made fun of me (nicely 🙂) after the case, and I never tried the technique again.

A couple years later we learned that the first attending had been diverting sufentanil, and the reason he did his mixing trick was to obfuscate the records. Those patients woke up because they weren't actually getting any sufentanil at all. He got it all.

So to answer your question, the only logical reason I can think of to mix drugs like that is to conceal diversion. 🙂
 
UscGhost said:
Magnesium may have some benefits in regards to pain.

Why benadryl? Just adds additional sedation that is unnecessary and extends beyond the case. Anti-emetic benefits are unnecessary as a propofol Mac case shouldn't have much PONV. And the anti-histamine effect is unimportant.

So I don't see any benefits to Benadryl in that type of case?
Click to expand...
Regarding Benadryl IV, worked with an attending in residency who used this as the poor man/facility’s “drowsy wake up” from an era before Precedex. He’d give 6.25 mg to that young Marine that might wake up thrashing.
 
Multi-modal. Pain control. PONV prevention.

It's not just the CRNAs. I see the current residents do it too. Some of this began as a low hanging QI checklist, but it stuck. Idc as long as I'm not the one refilling the syringes. Just know when time comes for my dad to get anesthetized by a collegue of mine, it won't be because they know how to run a lido/mg/k/dex infusion.
 
You must log in or register to reply here.

Similar threads

I
Covering 3-4 CRNAs with SRNAs in rooms alongside them
Replies
36
Views
3K
NicholasPavona
N
N
SAD DAY FOR TENNESSEE CRNAS
2
Replies
81
Views
7K
NicholasPavona
N
Doctoscope
What's the catch with anesthesia?
2
Replies
81
Views
14K
PainInTheAnes
P
urge
Who gives the breaks…
Replies
45
Views
3K
urge
urge
urge
What’s up with the new kids?
2 3
Replies
116
Views
13K
Burned_Out
B
Top