Anesthesia and Surgery Deconstructed: A CRNA's Perspective

Annie: The OR is a world of fascination and unknowns for those of us on the outside. As nurses in acute critical care and the emergency department, we care for our patients before they go into surgery. And after they come out, but what happens in that space in between.

Well, we're about to find out because I have certified registered nurse anesthetists, Tanner, and Cole as guests today. As founders of core anesthesia, and with experience both inside the O R and at the bedside in the ICU, they provide unique insider perspective. Tanner and Cole will walk us through the peri-operative process, step-by-step from preoperative preparation. To interoperative anesthesia. To post op recovery.

By the end of this episode, you will have a deeper understanding of that surgical experience and be better equipped to support your patient through their surgical journey.

Tanner: My name's Tanner. I'm a CRNA. Currently I'm in Indiana working and went to school.

That's where I met Cole in Illinois. And before that, did travel nursing for several years in the ICU.

I'd honestly never heard of a CRNA before when I was an ICU nurse, and so something I thought was interesting, looked into it, and

And, , I'm now the co host of core anesthesia, as you mentioned. So Cole and I started this while we were in school and this was our way to study. We wanted, basically to figure out a way that we could make use of time in the car. And so we were starting to record conversations and all of a sudden it became a podcast and.

Still riding the coattails. We have no idea where this thing will end up. It's been a wild journey, that's, that's kind of where core came from. And, and a little bit about me is from my nursing background.

Annie: Do you think it helped you , in CRNA school?

Tanner: Oh my word. Yes. That, I mean, that was like, that was our studying cold, put together the, the outlines. I would do the editing. And by the time I did, I had, you know, edited an episode you know, I'd listened to it like three times. And so then I felt like, Oh, I know this material and it honestly cut way down on our study time because we were just.

And so people joke, they're like, how did you do, you know, CRNA school is so busy. How did you start a business while you were in school? And for us, it honestly was like, it cut down on our, our workload a little bit. To some extent, because it just consolidated kind of how we studied and how we made use of our time.

So yeah, it was a great thing.

Annie: I love that. That's so smart. Cole, we'd love to hear from you.

Cole: Yes. Thank you so much for having us, Annie. Like she said, my name is, is Cole Dill and I'm a CRNA as well. Tanner and I, as he said, we met in anesthesia school in Central Illinois and started in core anesthesia and it's just been a blast and just an absolute blessing to see how much it's grown. As he said, it just started as a way for us to study and we never dreamt in a million years that it would have grown into what it has become. So.

It's just been a wild ride and we're excited to see how it continues to grow, but we're, we're really excited to be on your show today, Annie. So thanks cool. us.

Annie: I was stoked to find Tanner and coal to nurse podcasters who are so well positioned to answer my questions and provide insight into the surgical world. I sought them out after a memorable shift.

Cole: While I was in the float pool I was, called down to the, , PACU because they had to keep patients in the PACU. For longer than they were expecting. So I went in to kind of take over from the PACU level of care to, you know, post operative, depending on the patient, like telemetry or step down level of, of nursing care.

And when I was in the PACU, I was kind of looking around, like, this is just so different than what I see as a floor nurse. And I was like I have to do a podcast episode with a CRNA, anesthesiologist, someone who has insight into that area of the hospital because I just don't.

So, that brings us to, to today. The whole, goal of this discussion, is just to, to illuminate what happens in pre op. Surgery itself and post op, for bedside nurses. So kind of speaking to bedside nurses about what goes on in your arena and how that knowledge can help bedside nurses do their job better. I think that's so often in healthcare, we all are on these different units in different areas, as you just said, and it's almost like these bridges to jump from one area to the next. And it kind of discontinues patient care. So doing something like this that allows everything to kind of, I guess, see things as patients move through the different phases and their perspectives is just key. So I think it's a great idea. So I'm really excited to go through it.

Annie: yeah, absolutely. And so actually this is a great transition because I wanted to talk about pre op and You know as having worked on Medical floors before you know, I'll often have a patient who needs to have surgery for some reason This is not elective surgery. Like there's something acutely going wrong with the person and they need surgery.

But for one reason or another, they won't take them down in the OR. And then I'm left to explain to them why they're not. Being taken down so I was wondering if you could walk us through like, what is the whole pre op process?

Like I, what, what happens with screening? Like when can you take patients down? Or what are some reasons why you would not take a patient down for surgery? Even if they, they really do need it. It's not elective.

Tanner: Yeah. That's a great question because I think that. It's funny when you're sitting there in pre op and you're getting a report from the floor, like, you know, both people are talking from their own point of view. So they're like, I can't believe the floor doesn't have X, Y, or Z. And then the people on the floor are like, I've got seven patients.

I can't believe you're asking me to do X, Y, Z before they come down. And you know, you, you like, you live in your own little world. And so like Cole said, I think it's a cool place to start. I think just to break it down simply. If you have a patient that is going to be there for an elective surgery, typically for those patients, we'll send them through some sort of pre anesthesia clinic.

And so even before they get to the hospital, it'll be, you know, the week before, or maybe even two weeks before they'll go and they'll see you know, a primary or somebody who's specifically. trained to be asking questions that will coincide with what we need to know for anesthesia. So they'll be asking about home meds.

They'll be asking about their exercise tolerance. They'll be asking about any recent illnesses, any changes in medications. Are they on blood thinners? Do they have labs that are routinely drawn for different medications that they're taking? If they do have. medications where they draw labs. You know, what are those?

How can we get ahold of those? Cause a lot of times is, you know, they go to one place for their labs, they go to another place for their primary. And so that meeting is supposed to hopefully consolidate a lot of that information. So on the day of surgery, when we walk in and we're talking to them and they say, yeah, I think I had, You know, something done with my back, it was 20 years ago that you're not like, okay, well, is this like a cervical spine fusion that we need to know about?

Because when we intubate, that could be an issue. Or is this just like a disc removal in their lumbar spine? That is really no big deal. It's not going to affect anything that we do today. And so if you have a poor historian, you really, you don't want to be finding all that stuff out the day of surgery, hopefully the, the pre anesthesia clinics where that's all going to happen also in that meeting, if they have, you know, different medications that they're taking some of those, we don't want them to be taking right up to surgery.

So if you're like. You know, different types of medications like that, that will, you know, either for weight loss or if they're taking it for glucose management, but those, those we want to be stopped before, usually a week, hopefully two weeks before surgery.

Annie: What are some examples of medications that you don't want a patient to take prior to surgery, like, you know, blood thinners, you know, obviously comes to mind. Are there like cardiac medications you're, you're mentioning, diabetic medications? 

Tanner: The main ones that we think about, so blood thinners, like you, you said, depending on which ones they're on, that can either be 72 hours. That can either be seven days. So it's, it's, it's not like a hard, fast rule. If you're on a blood thinner, you know, that's not universal. There's different. Things that you would need to pay attention to and some of them you're going to want to get labs Still the day of surgery like you want an INR that morning to make sure that they're Appropriate for surgery so blood thinners would be a big one that that would be very important to know when they had stopped it And that's something that you need to communicate very explicitly talking about glucose management, obviously they're going to continue on those short acting things through the day of surgery.

There's a little bit changes that we do the night before where you can take like half your , long acting dose or if they're on metformin, we usually have them hold that the day of surgery. If they're on, cardiac meds. So if they're on their blood pressure medications or if they're on, like anything with lipids, so like if they're on the cholesterol medications or whatever, those will continue throughout the day of surgery.

But it's important that we know because. you know, anesthesia drugs will react differently with different medications that they're taking. So those are things that, that you want to know about. The other one that I was, I was just thinking about that.

If they're on any kind of a weight loss medication, The main one I think of is Phentermine, that's going to be one that we want to have very strict, timetables and when they stop that before they have anesthesia.

So again, those are all elective cases, but initially that's going to be like the first step you have that, that. pre anesthesia meeting. And then when they come day of surgery, hopefully they're all tuned up and maybe there's like a last minute lab that we need to get, or there's, you know, some things that we need to look at.

You mentioned a different scenario where you're talking about someone that's inpatient. That looks a lot different. Cause you're doing all of that. In house and you're doing that, you know, pretty much all as needed So that's that's where it gets kind of fluid when you mention if somebody comes down or needs to come down and they can't Sometimes that's labs sometimes that's just scheduling in the day where all of a sudden there was a more emergent case that came down or An or that's not available anymore because something else, you know filled that spot um Um, and then we had a patient in the nursing home who was fed their morning pills with applesauce.

So we were like, well, it's not going to work for a nine o'clock case, you know, so they can either delay it or we ended up canceling it cause they couldn't make it work later in the day. So that's another, I think an easy or kind of low level. Thing that would delay a surgery, but Cole, you work in cardiac.

So there's, there's other, you work in a whole different side of things that would delay or cancel cases. But those, those are the main ones that I think of in terms of why you wouldn't take a patient if they needed to go.

Cole: Right. And you mentioned Tanner, there's always. Seems to be this thing where we're on a phone conversation getting a report with the floor They're they're probably thinking why are they asking about these things and we're thinking why did they not do x y and z? You mentioned obviously MPO status So for a bedside nurse, if you know It's more so than the night shift if they know that a patient is scheduled Inpatient is scheduled for surgery the next morning. Obviously, we're not going to give them food after midnight It's typically the golden rule for that and then as you mentioned, Annie, blood thinning medications are the biggest one that usually depending on the case and depending on the surgeon is what I, I would say is as to when we stop those because there are, there are some patients that then are going to be at a lot more risk for having a blood clot.

And so it's not universal that we're always going to stop the same. Okay. Blood thinning medication for the same period of time. It's always risk versus reward. I think the, the thought process should be, if you're a bedside nurse, you know, your patient's going to be going to surgery and they're on some sort of blood thinning medication.

It's always worth, if you're not already told, reaching out to the surgeon or the attending and saying, Hey, what's the plan with this? Is this something that we need to continue all the way through, or should we hold it?

I do a lot more vascular cases where we're going to be giving blood thinning medications when they come in the room, we're going to give high dose heparin in the cardiac cases, I'm giving upwards of 40, 50, 000 units of heparin for these cases.

And then we reverse it with protamine at the end. So, so again, those kinds of cases. are not going to be the same as another general case. Another thing we, we always watch for is infection. I feel like this is one of the other things that cases always get canceled for delayed. You have a patient who is inpatient.

Maybe they came in from a motor vehicle accident. They have some fracture and they need to go get an ortho procedure done, but they start developing a fever. This is something that we might delay the case until we can get their, their infection or their fever resolved because the main reason being that we want to make sure the patient is able to have , an active and high functioning immune system to be able to ward off any more infections that would occur after the procedure.

But this is again, all risk versus reward. So a lot of this always falls into this. It's not a universal decision because if you have a patient that needs that procedure, maybe the infection is the reason we're going in to do the procedure. In that case, we would still do it because we need to treat.

whatever's causing that infection, for example, if it's a bowel issue or something like that. But that's something I always tell pre op nurses or, the med surgeon nurses just to know about is, is to be watching for any signs of infection and to pass that along as soon as possible. Again, it might, it might not be 100 percent we're going to cancel it but it's a good chance until we get that infection resolved.

But this is all for an elective procedure. This is totally different if it's going to be an emergent case. If it's an emergent case, we have to deal with The situation as best as we can and if they have eaten or if they had food two hours ago, we're still going back there. We're just gonna handle our anesthetic differently and we'll kind of get into that when we talk about the OR side of things.

So again, all of these things are not universal, but it's, it's things that if it's elective, we want to make sure they all line up appropriately. If it's emergent, we're going back regardless and we have to, to deal with it in the best way possible.

Tanner: only other thing I would add on there Annie is lab values such as like electrolytes. I think that's another thing that can be really frustrating if they had a really low potassium that morning and it wasn't. Replaced with their replacement protocol or whatever. and then we can't take them for surgery unless they're there's, there's a, there's limits onto and what you're willing to take to, to surgery and to do anesthesia.

So I think that's another one that when they're in house and you see, you know, a morning potassium, that's really low. And then now it's time for them to bring them down. We haven't had any replacement. That's another thing that could, could easily delay some surgeries, but That's one that I. I've seen more often with, with inpatient, obviously outpatient, we're not really rechecking those the day of if it's an elective surgery.

But yeah, inpatient, you get those numbers frequently. And so if there's something that's not treated, then we would delay for that.

Cole: And one last thing I'd quick add on this topic is is anything that is medically treatable. and not surgically treatable. If it's an elective procedure, we want it fixed medically. So, what I mean by that is, if there's any type of thing that it's not an emergent surgery, but it's something that needs to be corrected from a medical standpoint, from an anesthesia pre op setting, we want to make sure they are medically cleared for their procedure.

So, if it's, if they have a new onset of AFib, Or they have maybe their EKG shows a recent myocardial infarction or anything like that, anything new, anything medically that's changed. That is, and we are not emergently or urgently needing to do surgery. We're going to want them to get medically as best.

In their best shape as possible before we take them back to the procedure, because we want to minimize any risk factors that anesthesia is going to put them through. So that's why I basically say anything that's medically treatable. So as Tanner said, fixing electrolytes, fixing whatever the case may be, we get them medically stable first, then we go and do surgery.

So that's kind of, if you're going to sum it up in one overarching umbrella, that's the statement basically of why we would cancel or delay a procedure.

Annie: Got it. Okay. Now I'm getting to the part of the interview that I'm really excited about because it gets really nerdy I wanted to ask you to walk through the physiology of general anesthesia,

I think that discussion about pre op kind of sets us up well for this? What are we looking out for in pre op? What happens to the body under general anesthesia?

Cole: We could talk about this for five hours but to do it in a couple minutes. Basically, to run you through the process of for those of you that have not been in an OR setting before. Here's what the process looks like patient. Is wheeled into the room. we, if They can, we'll move them over to the OR bed.

Other times if it's too painful to do that, maybe we're doing an ortho procedure on their hips, something like that, we'll sometimes put them to sleep on their bed, but typically we move them over to the OR bed and. The classic saying in the OR room is we tell the patient it's like a pit crew.

There are three or four people hooking them up to a bunch of monitors all at once. They feel like they're the center of attention because they are the center of attention. We hook up EKG leads, pulse ox, blood pressure, and those are the three main things we want to get before we do any type of anesthetic.

The other thing I'm doing during that time is I put on a an oxygen mask and this is connected to my anesthesia circuit kind of looks like a CPAP mask. And I tell everybody it smells like a beach ball. It promises just oxygen. It's just because it's a fresh new mask. It's it has that plastic smell to it.

So people always think it's the gas, but it's just oxygen. And our goal here is to fill the lungs up with oxygen and pre oxygenate the patient. And the goal here is to denitrogenate What's in the lungs because there are a lot of people think that we pre oxygenate to fill up more oxygen, which is true But you're also clearing out because room air is only 21 percent oxygen, and so we want to get rid of all the excess nitrogen that is in their lungs and fill it with oxygen then and we do that for at least three minutes typically.

And so I typically put the oxygen on right away and I just tell them to take deep, full breaths and basically fill up a reserve then for when we put them to sleep that we have time that they were going to keep their pulse ox and oxygenation levels at a certain amount while I intubate them. And so while they're breathing that oxygen, we're running their blood pressure, we get everything good.

Often they will have been given about two milligrams of Versed, I would say typically. Unless they have been given that already in pre op.

Annie: And Versed, for our non critical care audience is...

Cole: it's a benzodiazepine. Yep. It's an work on the GABA receptor, which a lot of our anesthetics work on. And so I guess in one way you can say it's an anesthetic but it causes amnesia, so they're not going to remember it. And the wonderful thing is you can give it to them out in pre op.

They will have a full on conversation. If you want back to the OR, they'll completely talk to you and do, I mean, they will act like they're. Totally fine, and they'll do all the commands that you tell them to do, move over to the bed, hook them up to everything, and they'll have no memory of that whole entire thing since we went back from pre op.

So I like to give that if, in pre op if possible, because a lot of patients as they enter the OR, those nerves just really start to come out. I mean, looking around, seeing all the equipment, the bright lights I love being able to give the Versed as we're heading back to the operating room, because they have no memory of being in the OR.

As I mentioned, you really want to pre oxygenate these people, de nitrogenize the lungs, fill it with as much oxygen as possible, because once we put them to sleep, which I'll talk about here in a minute, We have a certain period of time from when they're asleep and not breathing until we're putting in an airway.

And you want to make sure you're giving yourself enough time that you're going to be having enough of that reserve or capacity of oxygen to keep supplying those tissues with oxygen until you can supply them with a new wave of oxygen.

Tanner: And nitrogen is extremely soluble. And like Cole said, so when we're intubating and we have that time where they're apneic, we're going to take away the respiratory drive. And so if we have a lot of nitrogen left in the lungs, that time is, is way, way shorter where we have time to safely get an airway and then intubate or You know, whatever type of airway you're getting.

And it's just a safety measure. Cause ideally you're going to intubate in five seconds, you know, it's going to be super fast and you don't have to mess with that. Unexpected things happen and you want to do what's, what's safe for the patient. And so that's, that's what, you know, the whole point of this is..

Cole: So basically, once we have oxygenated them for an adequate amount of time, and we have gotten the blood pressure, we've gotten all our vitals up, we're ready to go we, at least this is my process, and again, anesthesia is an art. It's just as much of an art as it is science. So everybody has their own Little spin off the way that they do this.

I'm gonna walk you through my way. So basically the majority of drugs that we give for an induction, you wanna blunt the sympathetic response to an intubation. 'cause when you put an airway into someone's trachea and one of, one of the ways that you know you're in the trachea and not the esophagus is their heart rate will just jump up.

It's really interesting. Their sympathetic response will increase. And so without even listening to the lungs, I, I can usually tell if I have. Let's say a paramedic that wants to intubate and they're in the room and I'm not seeing where they're putting the tube and it, and they put it in, if I see their heart rate jump up, I can almost guarantee you it's going to be in the right spot.

But so how do we blunt that because there are some patients where you don't want that to increase. If you have a very sick cardiac patient, or maybe you have a patient with a large aneurysm, and you don't want it to rupture, you don't want their blood pressure to spike and you don't want their heart rate to jump up.

So I usually give fentanyl, I'll give anywhere from 50 to 100 micrograms of fentanyl. To the patient about probably two minutes before I plan to intubate. And this gives it enough time to circulate into the patient. And I usually do this as they're breathing and pre oxygenating. And then as I'm about ready to intubate, I'll give lidocaine.

I'll give either 50 milligrams up to 100 milligrams of lidocaine. And this is kind of twofold. The main reason is the next drug that we typically give, I would say probably over 90 percent of the time, the induction drug that we give to make a patient go to sleep is going to be propofol. There are other induction drugs.

I know a lot of times in the ICU where I worked at, we used Etomidate. So maybe that's something that a lot of ICU nurses are familiar with. Ketamine is also one that we can use, but I'd say by and large, Propofol is the main one. And Propofol burns really bad when you give it as a rapid bolus. When you have somebody sedated in the ICU, you're not going to really see that, that burning sensation as much.

But when you give a big push of up to 200 milligrams of propofol, these patients will tell you it burns, and they'll only feel that for about 5 to 10 seconds and they'll be out. But I always preload that with lidocaine to kind of numb that vein, and that takes away a lot of that burning sensation. And it also kind of blunts that sympathetic response to in the trachea.

as well when you, when you go to intubate, but one of the main reasons is really to blunt that that pain in the IV. Once we give that induction drug though, the propofol, like I said, they're out in five to ten seconds, if you give the appropriate dose, and typically we give two milligrams per kilogram roughly.

So if I have a normal 70, , kilogram patient, then I'm looking at giving probably 150. milligrams of propofol. And if they're younger, I might give a little bit more. If they're older, I might give a little bit less. And again, that just comes with experience in patient population. Once they're asleep different anesthesia personnel will do two different forms of things.

We typically, if we're going to place a breathing tube, an trachea, we want to relax their skeletal muscles. So we'll give a muscle relaxant or a paralytic. If we are going to want to just place an LMA laryngeal mask airway, then we won't give that muscle relaxant because we want them to continue to breathe on their own.

But if we're doing an ET tube, then we will go ahead and give a muscle relaxant. Typically, this is either going to be succinylcholine or racchironium. And during that time, the racchironium takes up to 90 seconds to kick in. So we're just sitting there, then the patient is completely asleep. They're no longer breathing on their own.

We are now masking them for that 90 seconds while that racchironium kicks in. And this is just to relax their airway musculature so that we have an open airway to be able to put that tube through. You don't want that vocal cord spasming and breathing basically during that time. And then as Tanner said, hopefully the intubation is just a couple second process.

If we have any concern that it's going to be a difficult airway or difficult finding , the trachea and the vocal cords, we'll use what's called like a glide scope, which is a video.

Blade which is a great tool. If you've ever seen that using the ICU, a lot of people can be able to watch it on the screen. We basically go around the tongue and you find the epiglottis, which is hanging back there, and you put the tip of the blade up in front of that epiglottis and it flips it out of the way and it should expose hopefully the Holy grail behind that, which is the vocal cords.

And then you slip a tube through that. And then we always just double check, make sure we have our breathing ventilation on both sides, you're getting in tidal that everything looks good. But again, one of the, one of the signs that we usually see is that, that increase in heart rate, but hopefully you don't have too much of an increase if you gave enough of that fentanyl ahead of time.

So that's what gets the patient off to sleep. Now we've gotten the breathing tube in and then the big whammy hits and that's our anesthesia gas. So Tanner, do you want to go into that a little bit?

Tanner: So There's different There's different gases you can use. So we can use nitrous nitrous has higher problems that are associated with it. Typically you will not use that with somebody through a whole case, because you're going to see a lot more nausea associated with nitrous. Also, it has issues with cardiovascular.

So you can see some bradycardia. You can also see. You know, if you're doing a laparoscopic case, we mentioned about solubility of gases a little bit earlier when we were talking about denitrogenating the lungs. But if you have carbon dioxide they're using to, they, they fill up the belly basically so they can work with their instruments inside the abdomen while they're using a laparoscopic test.

And so while they're doing that, if I'm ventilating with nitrous that can actually diffuse and cause that gas to move into the abdomen and increase pressures, increase that insufflation is what it's called. That increases the gas there in the belly. So that would be not good. It can also have issues with, your bowels.

So there's, there are a lot of reasons we wouldn't use nitrous Desflourine is probably the other one that we'll use if, if you have like a really long case, you could use that. ISO is one that you would use. I think, feel like most of the time you see that mostly in cardiac call. I don't know if you use that frequently with your open heart procedures.

That's where I use ISO the most. And then sevafluorine is going to be

far and away most common gas that we use. So sevafluorine, I'll start with that. Cole mentioned you've got them off to sleep, you've given all of those drugs. Here's the tricky thing, you're trying to think about, okay, so you've given all of those things.

You've given fentanyl, you've given propofol, you've given lidocaine, all of those have sedative effects to them. And so now you're trying to turn on your gas and trying to basically reach an equilibrium state where you have enough gas that's in the lungs, that's then going to the brain and causing sedation.

But it's also going to cause massive vasodilation, and so if you've given those induction drugs, and you have this frail 87 year old lady that you just gave propofol and fentanyl to, And now you need to turn on gas and we haven't even started the surgery yet. This is where you can see really, really bad, low blood pressure.

I mean, we're just dumping in all of these agents that are basically just decreasing blood pressure. And so that that's kind of a critical point in the case where they call it the valley of the prep, where they're prepping the patient and they're prepping, you know, it takes. Cause if you're trying to assist the patient during like three minutes, five minutes, whatever.

And they're everybody's. Positioning the patient. Meanwhile, you're trying to keep them asleep. And then your blood pressure is like this massive Valley on your chart because they're, you know, bottoming out. That's what you want to avoid.

As we are thinking about, okay, how long is my propofol acting? How long is my fentanyl acting? How long is my lidocaine acting? So that's all kind of coming down while you're turning on your gas. And then when they start the case, it's obviously going to be painful. The patient's not going to know because their brain's asleep.

We've done that with the gas that we're using, but their body still knows what's happening or can't know what's happening. And so they can see a spike in blood pressure, spike in heart rate. You can see. A spike in respiratory rate if you don't have them paralyzed. And so those are all things that you're, you're looking at while you're, you know, keeping them asleep.

Annie: Can I ask a, pretty simple question, Sure.

I, I kind of thought during surgery that you were getting this constant IV drip of some kind of anesthetic or something like that to keep you asleep, but you're saying it's gas that keeps you asleep,

Tanner: Yeah. And you, and you can, that's, it's not a dumb question cause you can have that. yeah, We mentioned earlier somebody that has, like nausea associated with nitrous. So this is something that's really, really common with anesthesia and a lot of PACU nurses will attest to this.

They come out of anesthesia and there's, they're horribly nauseous. And one of the main offenders of that is the anesthetic gas. I would say the, the biggest offender is the anesthetic gas. And so, one of the ways that you can avoid that is you can just do an IV drip the whole time.

So you could use propofol the entire time and just put 'em on a rate in the ICUI can't even remember, called, do you remember what, like what rates you would put somebody on for a sedation in the ICU?

Cole: I don't remember ever going over 75. That was just my ICU though.

Tanner: and and in the OR you'd be at 200 easily for general anesthesia. So like a whole nother level of propofol administration when you're,

Annie: with the risks of associated with propofol. Like, bottoming out the blood pressure and

Cole: Which is why it's so much of an art, because as Tanner talked about, there's that role in between you put the patient to sleep, and sometimes it could take up to a half hour. If it's a very, like, if it's, let's say we're doing a spine case, and now we have to flip the patient over prone, Make sure they're padded on every surface underneath.

Everything's appropriate there. They have to go and they have to figure out which level of the spine they're going to work at. They mark it all. They prep. They get all their drapes up. They're ready to start. We do a time out. It could be a half hour. And you have this period now where you have this sick patient that has No surgical stimulation, but you have this medicine on board.

And so, as Tanner mentioned, it is this art of you, you have just enough to keep them asleep, but not enough to bottom them out. And then you slowly titrate that up so that when they make that initial incision, You hopefully got them deep enough where, where they're starting to bottom out right as that incision starts and then that increases it and it levels out that equilibrium.

So that's why it's just as much of an art and that's why I love it because every case is different, but it's also the same in a way. But that's also when you have a very sick patient and you're putting them to sleep. That's the biggest risk of them coding is during that time, especially in the cardiac world when I do a lot of open heart and things like that.

That's the time that we're the most nervous about them coding is we're going to bottom them out and we're going to take away that cardiac reserve on induction, and when we put them to sleep. And so there's different ways you can do it. But one of the best anesthesia jokes that I had heard actually while we're talking about with your question.

So what Tanner mentioned, we run an IV drip the entire time. We call that a Teva, a total intravenous anesthetic rather than a volatile or gas anesthetic. So a Teva, if we ever say we're going to do a Teva, that means we're going to put the patient to sleep and we're not going to run gas. We're just going to run.

The IV anesthetic and so there was once an anesthesia person I knew that bought a tesla and his license plate. He called the tesla, teva because it doesn't run on gas. It's

Tanner: nice.

Cole: and it's so but there's your anesthesia name or youjoke for the

Annie: I like that, that'll help you help us

Tanner: Yeah, But how, how often are you doing a TIVA? I want a Teva. When I have surgery, I want a TIVA.

Annie: Because of the post

Tanner: Yeah, I get, I get sick really easily. And, and there's different risk factors for it. If you get motion sick. That puts you at risk. If you're a female, it puts you at risk. If you're a non smoker, that puts you at risk. If you're young, that puts you at risk.

There's different, there's, there's this stratification that we go through to see if someone's more likely to be nauseous. But I get nauseous. I had my ACL repaired. And I, I was really, really nauseous afterwards. And so if anybody tells me that they have a propensity to be sick, I run a Tiva. And they wake up so nicely.

Not saying that most people don't wake up nicely from anesthesia, but in terms of feeling sick and feeling gross from the anesthetic gas Ativa is

Tanner: is is very very nice. It's the same thing if if you're getting up,

Annie: But then you would have to have the cardiovascular health, I'm guessing, to tolerate? Like, why don't we just do it on

Tanner: it's a little more expensive and I wouldn't say a little more it's more expensive and the other thing is the the Gas is is very very nice because it's very fine tuned like it's very, very specific and very, very nice for. managing the patient.

Also, a lot of times you don't have the IV access, or you can have, you don't have access to the patient, but we have access to the airway. We're the airway experts. And so we're managing all of the sedation and everything through the airway. And so that's, we're at the head of the bed. We're right there.

That's everything that we can manage. And so. It's not, it's not that common. I would say I use Tiva's more than the average person and I've probably done three this month. So not very common.

The other thing that I would tell you, we use TIVAS for is MH. And so one of the hallmark triggering factors is anesthetic gas. And so for those patients, we would, we, I mean, we literally take the gas like out of the room so you don't accidentally turn it on. So for those patients you would run TIVA as well.

Annie: For listeners who aren't familiar, MH is malignant hyperthermia, which is I think it's a highly genetic condition, thatcauses a patient to spike extremely high fevers very quickly post operatively, , often in reaction to gas what, there are other, other medications that can do it.

Cole: Suction or coagulant would be another drug that simulates it. And it's all because their ryanodine receptor in the muscle cells basically stay open, and you constantly have that muscle contracting, and you constantly are able to have carbon dioxide come out, potassium leaks out, they rapidly increase your carbon dioxide.

Actually, the hyperthermia is one of the last things that we see. Yeah, it's something that you don't want to mess with. It could be, it could be fatal. So as Tanner said, we, we actually will flush the anesthesia machine for 30 minutes or just pure oxygen and try to get any residual gas out of there and run a TIVA for those.

But to fall back on one quick thing he said with the nausea, with the risk factors, this is one of the only things I am aware of where a non smoking patient is more at risk for something than a smoking patient. So if you are a non smoker, you're more at risk for being nauseous after surgery when you wake up, which I thought was always interesting

Tanner: not telling you to smell before surgery

Annie: yeah, yeah,

Cole: not at all.

Annie: yeah, let's, let's be clear here.

Tanner: Yeah, But for sure.Yeah,

Annie: Yeah, so I think this, this, you know, segues beautifully into the post operative discussion here. You know, as, as someone who does not work in PACU, but I see patients just after PACU, you know, the, the, common post surgical, , nursing milestones we're looking at is, , pain management, nausea, getting them to go to the bathroom, mobilize.

I wanted to ask you about, what exactly is the pathophys of post operative nausea and vomiting? And also, why do patients have such a difficult time voiding after surgery? I've always, always

Tanner: for sure. I, I'll, I'll start with the, the postoperative nausea of vomiting, because this is something that I, I like, I really take seriously because I, I had felt it and it's miserable, you know, you. You just feel awful. You already have a surgery on, you know, whatever you're focused on recovering from that.

And it's such, it is such a problem when, when somebody feels, you know, horrible after, after the surgery. And the, the, the problem is like, you can talk about pain. We could spend a whole episode just talking about pain, but there's so many different ways that you can attack pain. I mean, you have from the, the moment something happens, you have these mediators that are causing the pathway to start.

And so you can, you can stop the pain pathway there. So that's, that's one place you can attack it, or you can attack it by giving opioids. And so that's going to attack it in different areas where you have your opioid receptors, or you can you know, Presidex even works on pain receptors with the alpha two.

And so there's different, there's totally different ways that you can attack the same pathway and the same thing with, with nausea and vomiting. You have different reasons that you're going to have that start. Okay. I mentioned risk factors. So non smoker is going to be a risk factor. Female gender, if you have motion sickness, that's a really big one.

I'll get into this in a second, but typically we give somebody like a scopolamine patch if they have a history of motion sickness. Younger patients will typically have that. And then you can also see just depending on the type of procedure it is. So if you have like an abdominal case or if you're working on the ear or the eye, you can see You know, increase nausea compared to maybe like a knee or something like that.

Typically when we think of where this is happening, it's happening from the CTZ, which is the chemoreceptor trigger zone, which is basically like a weak spot in your blood brain barrier.

We think that's where the anesthetic gases are causing the most effect with the nausea is in that CTZ area. And so that's one of the areas we can Try to attack the vestibular apparatus is in your ear and that's one that will again with scopolamine, or if you have someone that has motion sickness, typically, that's what we're thinking that's coming from.

The GI tract is where you have your 5HT3 receptors and also your NK1 receptors. So those are all going to be And the GI tract and that's going to be I should say not only the GI tract, that's also in the CTZ, but those are going to be specific receptors that we're trying to attack with medication.

So we can give Zofran. Decadron, I mentioned, sometimes in PACU, if they're having issues, we can give Benadryl, antihistamine will work on the H1 receptor. That will also help. Phenergan is one that you see, kind of as like a next level medication that you can give. You can see Amend typically.

You'll give that preoperatively. You can also see like Reglan. Reglan is not going to really affect your postoperative nausea or vomiting, but it's going to help your stomach clear anything that's in there. It's going to help with gastric motility. And so if they do get nauseous, it's going to hopefully decrease.

You know, any risk of vomiting or aspiration. So, those are all, those are all like the areas that we're trying to attack. What's causing the issue is going to be your, like I said, you have those risk factors. Opioids also are a high offender. And then our anesthetic gases are going to be the, the primary thing that, that you'll see.

, I had a patient today. No history of nausea. I thought that she looked really good. The whole case woke up just fine. And then I went and checked on her 15 minutes later in PACU and was just feeling really, really sick and really, really nauseous. The case didn't make me think it was anything that would make her high risk, but she just, this is her first anesthetic.

And she felt Really coming. So that's something that moving forward. Next time she has surgery, she can say, Hey, last time I felt really nauseous. So they can do all the things. They can give the scope patch. They can maybe do a Tiva. They can give, you know, all the different anti medics because typically for somebody that doesn't have a history, you might use one or two of these.

Maybe you use Dekadron and Zofran. Maybe you just use Zofran. But if I have somebody that comes to me and they say, Hey, I was really sick last time. No gas. scope patch. So Fran Decajuan Raglan, like you're getting all the things we're gonna try to attack it as many ways as possible. And so that's really, I think the quick and dirty of, of why you're seeing the more nauseousness happen after surgery.

Annie: I'm unfamiliar with Decadron as a anti emetic. Like, how does that work?

Tanner: They don't really know yeah. Yeah. Yeah.

Annie: Fair enough. That's like

Tanner: Yeah.

It's, it's shown to be effective, but yeah, the actual mechanism, it's not like specifically is for a specific, like the five HD three or the NK one or the H one receptor. It's, it's not a specific receptor that we know of that it works on.

Annie: Got it.

Cole: And that's one of the reasons I feel like we give it because one, we know it helps with nausea and vomiting afterwards, but two, it's nice because of the fact that is it, it is a steroid. So it's going to help limit the amount of inflammation from the airway that we just put in, maybe some of the inflammation from the surgery.

And so like if there was a very difficult intubation and I know they're probably going to have a very sore throat. You better believe I'm going to give a full dose of that Decadron just to help minimize any of that inflammation that they may have in the back of their throat when they wake up. So it's kind of nice to give it for two different reasons in that

Annie: Will you give it in the OR during the procedure?

Cole: Yeah, I typically, I'll give Decadron, that's one of the first things I give after they're asleep. They probably haven't even started the procedure yet and I've given Decadron just to give it time to kind of stop any inflammation before it starts., so your other question, unless you have any more on the nausea and vomiting, I was going to get into the bladder side

Annie: Yeah. No, let's, let's do the bladder side of things. I'm so interested.

Cole: so there's a couple different mechanisms at play here. So as Tanner just talked about, there's several mechanisms with nausea and vomiting, and it's nice to know the different mechanisms because we can treat it from different standpoints. Same thing is true here. So, there's really two different parts to voiding.

There's first the filling of a bladder. So this is going to be a sympathetic Nervous system innervation. So this is anywhere from the thoracic tend to the lumbar to Spine where the nerves come off of there are going to cause a sympathetic response response at the bladder so your jitrus or muscle if we Inhibit that it's going to allow the bladder to relax more and it's also going to activate the sympathetic side of things We'll activate the base of the bladder basically like the neck or the urethra part of it, which is going to basically keep it tightened and allow the bladder to fill up.

Then you have the second side of things. You have a parasympathetic innervation in coming off the pelvic nerves. And this is going to be your S2 to S4 your sacral nerves that are going to come off and they will then activate that detrusor muscle. Which causes the bladder to basically squeeze and contract.

And then they'll also relax the bottom of the erythro part of the smooth muscle and allow you to void. So there's two different sections here to filling and then voiding. So the different stuff that we do from anesthesia side of things is going to affect. Both of those side of things. So, from a general anesthetic let's talk about that first.

Because we can do general, we can do a spinal, regional anesthesia, all of those, which can cause issues here. So a general anesthetic, it in itself acts as a smooth muscle relaxant. So it's not like a full on paralytic, but that gas as itself will cause that smooth muscle to relax and it leads to decreased ability of the bladder to contract.

if that makes any sense.

So you have some lingering effects there as they're waking up in terms of the detrusor muscle kind of restarting itself and being able to fully squeeze and empty. So they may be able to avoid a little bit, but they're going to have trouble completely squeezing them and avoiding their, their bladder completely.

Same thing then with the spinal and epidural anesthetics. So if we are basically blocking the, the nerves in that area of the spine, you can see how you're not gonna be able to innervate that muscle to allow, , the diffusion muscle to squeeze and the push out that urine. So that's one of the ways.

Secondly, you have the medications that we're going to give. So opioids is one of the big factors here. So as Tanner talked about, opioids are going to affect nausea, vomiting at the same time. Opioids will also, decrease the gastrointestinal motility and then also from a voiding standpoint, it's going to decrease the sensation of the distention of the bladder.

So patients aren't going to realize they have as much distention and, ability to void and it inhibits the parasympathetic side of things. So that's the part I talked about that causes actually to squeeze and relax the urethral part of their bladder and allow them to actually void.

, Basically the theme is if you can limit opioids afterwards, you're going to do yourself a lot of favors. And that's why there's a big push in anesthesia for peripheral nerve blocks. Because let's say we're doing a shoulder case, we can do what's called an interscaling nerve block and block that whole sensation.

We can get medications that'll last even for several days. And you can limit the amount of opioids you need to give for the first couple days. And patients are able to have better motility right off the bat. Gastrointestinal mobility is better. They're able to avoid better. It's just all around better to limit opioids afterwards.

Tanner: We should do a whole nother episode on just like peripheral nerve blocks and like opioid free anesthesia, opioid sparing anesthesia, all the different things that you can do. It's just, it's, it's like, it's fascinating. It's so fun. And this is different, but like a spinal anesthetic, you can do a total knee on somebody, give them a spinal.

And, you know, they have their knee completely replaced and they can be sitting there talking to you the whole time and have no sensation, no pain. We don't do that because it's like, it's horribly gruesome. Others, you know, hacking a knee out and they're like hammering the knee, like prosthesis in and

nobody

wants,

Annie: You could probably likehear the chiseling

Tanner: nobody wants to hearthat.

Cole: they're just talking to us,you know.

Annie: Yeah.

Tanner: Fascinating.

Annie: . During my time in the float pool, I saw quite a few surgical patients with regional nerve blocks. Like for example, patients who had had shoulder surgery. And I can attest to how cool they are, and I can totally understand Tanner and Cole's enthusiasm for this kind of sub section of anesthesiology. But taking a step back here. Listening to Tanner and coal paint, a picture of the whole peri-operative setting. Has been so helpful and well, I'm not planning to pursue. Oh, R or pecky nursing.

I do think there is value in knowing what's going on in these areas of the hospital.

Tanner: I think that even from a working standpoint, a lot of times we get so focused on our own goals that then somebody else has to pick up the slack. Like, like for anesthesia, for instance, my, my thinking a lot of times is I need to get them safely through this surgery.

Like start to finish. That's my job is to get them through the surgery. And if you, if you take that too far, you don't think about, okay, well, what do they look like seven hours after this when they're back on the floor? So did I just give this dialysis patient three liters of fluid for during the case that now you guys are like chasing your tails to get back, , normalized.

And so I think , a lot of times you can think of, if you're on the floor, you know, you're trying to get through your, keep taking care of the patient and take care of all the needs that they have on the floor. And then. Pre op is thinking about, okay, well, I need to get them through pre op to surgery, PACU is how can I get them out of PACU back to the floor?

And I think that as we start to think about these other different services and what are our needs and what are our primary things that we're focusing on? I think that ultimately just provides better patient care and gives the patient a better experience. So it's not this, you know

Like you mentioned at the beginning siloed effect of people just doing what they need to do, but we can work You know, in concert together and hopefully it's a more seamless transition.

I think moving from, from PACU, they're so groggy. They're tired. A lot of times they're, you know, half our patients anymore have sleep apnea. And so we're having issues with, you know, them still being sleepy and another desetting and. The packing nurse just wants them to get to the floor, but they can't give them more pain medicine because they're going to be too sleepy.

And I think that as we, you know, broaden our horizons of like, okay, how can we really focus on the patient? How can we take care of them? I think that it's, it's helpful to have this conversation to see other people's perspective maybe. And you know, hopefully that all aligns at some point when we're taking care of the patient.

Annie: Yeah, absolutely if listeners want to hear more from you, where, where can they find out more from you about, all things CRNA?

Cole: So first and foremost, you can find us on any podcast platform. It's core anesthesia. And then if you wanted to download our app, we have an app as well called core anesthesia. And all of the content that we have on the podcast are. One package place on the app over three quarters or two thirds, three quarters of the content's free.

So for anybody that's just interested in learning about the anesthetic side of things, we, we do more than just anesthesia. We, we do episodes on cardiac pharmacology. So all the different. Indotropes and beta blockers, anything that you'd probably give in the ICU all the different forms of induction agents.

So ketamine, propofol, versed, all those type of things. We, we kind of go through things that we found have been very, impactful for, for nurses that are considering going to anesthesia school or just ICU nurses wanting to know more physiology. So if that's something you're interested in, feel free to.

To check us out either on our app, core anesthesia, or just look us up on wherever you podcast.

But again, if, if you're looking at going to anesthesia and potentially interviewing and applying for school starting a program Tanner and I have pretty much created a full curriculum of audio based content that walks through the entire curriculum of anesthesia school.

At least from our program standpoint, which we've found has been pretty. Pretty much the same through most programs around

the country. So, you can find outeither of those twoplaces.

Annie: Absolutely all right, Cole Tanner, thank you so much for being here today.

Cole: I thank you for having us. It was a lot offun.

Annie: All right. Thank you for tuning in today. If you have found value in this podcast, I would be so grateful if you could pay it forward and share it with a fellow nurse or leave a review. Leaving a five star rating and review on apple podcasts or Spotify is a really big help. It only takes a minute. By spreading the word you enabled the show to reach more nurses so we can keep learning together. It's been an honor to have you join me on this journey today. Until next time, I hope that you have upped your nursing game.