CRNA Interview

Norepinephrine Mechanism of Action (MOA)

A1, A2, B1 agonist.

Primary agent used in distributive shock because it's ability to recruit venous volume and augment preload, while increasing arterial tone, and increasing cardiac output.

Alpha one causing peripheral smooth muscle contraction. (low dose venous, high dose venous and arterial).

Alpha 2 adrenoreceptor agonism actually antagonizes the release of norepinephrine in the CNS, but these receptors are less present in peripheral vasculature and thus, their anti-hypertensive effects are overtaken by A1 agonism.

These alpha effects can increase SVR and thereby increase cardiac workload, decrease cardiac output, and increase coronary perfusion pressure.

The slight B1 agonism increases inotropy and chonotropy sufficiently to overcome these A1 effects and result in a fairly "pure" vasopressor. Increasing contraction of the heart and increasing AV nodal conduction.

**First line agent in septic shock

Epinephrine MOA

A1

A2

B1 - Stimulate Heart Rate through SA node, increase conduction through AV node. Increase contractility to ATRIAL and VENTRICULAR cardiac muscle.

B2 - Smooth muscle relaxation. Resulting in dilation of the bronchial tree, coronary arterial dilation. Also plays a role in insulin and glucagon secretion in the pancreas. Also increases cardiac inotropy/chonotropy

B3 - Increase lypolysis and thermogenesis in brown adipose tissue.

**Cardiogenic shock or other shock states with a cardiac component.

Adjunctive therapy in severe septic shock

IVP in cardiac arrest to augment CPP

IVP while introducing PPV/intubation

Precedex MOA

Dexmetatomadine is an alpha 2 adrenoreceptor agonist that acts both on the presynaptic neuron and postsynaptic neuron. Inihibiting norepinephrine release pre-synaptically reduces/halts the transmission of pain, while postsynaptically acts to reduce sympathetic tone. The combination of these effects is anesthesia with analgesia and anxiolysis.

loading dose is 1 mg/kg while gtt is .2-1.5 mg/kg/hr

**This agent is often used for patients who would not tolerate a precipitous drop in their sympathetic tone, for those patients in severe alcohol withdrawal.

propofol MOA

Propofol is a lypophylic general anesthetic unlike any drugs of the class benodiazapen, barbituate, or A2 agonist. Its mechanism is proposed to be a GABA (inhibitory neurotransmitter) agonist causing global CNS depression

Dosing for procedural sedation of .1-.5 mg/kg as a loading dose with repeat doses. gtt titration ranging from 10-60 mcg/kg/min

**Anesthetic

Sedation for mechanically ventilated ICU patients

Procedural sedation

Phenylephrine MOA

Pure Alpha adrenergic receptor agonist. Causing increase in SVR through systemic arterial vasoconstriction. This also causes a dose dependent increase in systolic and diastolic blood pressure and thereby decreasing cardiac output, especially in patients with heart failure.

40-100 mcg IVP for hypotension during anesthesia

Titrated as a drip from .5-9 mcg/kg/min

**used rarely as adjuncitve therapy for patients in septic shock.

Used more often in vasodilatory shock states such as neurogenic shock/ shock from epidural/spinal blocks.

vasopressin MOA

arganine/vasopressin receptor agonist causing potent increase in SVR through 2 different MOA.

1) regulate extracellular fluid volume acting on renal collecting ducts and distal convoluted tubule to increase water permeability via v2 receptors

2)Sodium re-absorption across the ascending loop of HENLe.

3)Binding to V1 receptors on vascular smooth muscle, causing vasoconstriction.

Normal concentrations of the drug are below it's vasoactive range, nevertheless in severe hypovolemic shock, AVP increases do contribute to increase in SVR.

1.8 u/hr

**used as adjunctive therapy in septic shock. Can be used as a first line agent in a pulmonary hypertensive patient in shock states.

Ketamine MOA

NMDA receptor antagonist blocking glutamate and thus introducing a cateleptic/dissociative (which is dose dependent) state.

N-Methyl-D-Aspartate is a receptor in the CNS responsible for conduction of action potentials associated with memory. Antagonizing these receptors does not allow for the transmission of these signals.

.1-.5 mg/kg IVP analgesia

1-5 mg/kg IVP dissociation (procedural)

15-90 mcg/kg/min or 1-6 mg/min for maintenence of anesthesia.

Care is to be taken as to not induce a subdissociative like state.

DSI/RSI/RSA

adjunct analgesic in opiate dependent patients.

Nicardapine MOA

Voltage sensitive calcium channels regulate the influx and release of calcium in response to action potential and depolarizing signals. Nicardapine inhibits the influx of calcium through these channels thus affecting calcium concentrations. This inhibition results in vasodilation more specific to coronary and cerebral vessels. This vasodilation decreases SVR and opens up the afterload of the heart, increases oxygen delivery and blood flow during vasospastic states, regulates blood pressure during hypertensive emergencies and post transplantation where goal blood pressures need to be tightly met.

Has little affect on SA/AV nodal conduction velocity.

Begin infusion at 5 mg/hr and titrate by 2.5 every 5-15 minutes for goal blood pressure.

Clavidipine MOA

Inhibiting influx of Calcium in L-type calcium channels in arterial smooth muscle to decrease SVR.

Begin gtt at 1-2 mg/hr. Double dose every 90 seconds for goal blood pressure. Note: that for every 1-2 mg/hr increase in dose, a 2-4 mmHg drop in the systolic blood pressure should be seen.

Midazolam

enhances GABA effects at GABA-a receptor site producing sedative/hypnotic/anxiolitic/anti-

Note: this drug is not used for ICU sedation - increasing the occurence of ICU associated delerium. But can be used for procedural sedation/alcoholic withdrawal states.

IVP 1-2.5 mg over 2 min with a 2 min waiting period in between dosing. Generally not exceeding 5 mg IVP.

How do you wean a patient from the ventilator

Weaning is done on a low-stretch protocol at our ICU.

Readiness testing for extubatio includes the following

-Fi02<40%

-Cause of RF has improved/resolved

-PEEP <5

-patient is hemodynamically stable

-patient has a cuff leak

-patient has a mental status that allows for handling of secretions and protection of one's own airway. Patient can lift head off of pillow

-patient is calm/comfortably breathing. RSBi<105 where RSBi = RR/Fi02 .. Ie 20/.4

-MIP more negative than -30

-Acid Base is neutral

-Can the patient cough on command?

What is End tidal c02?

It is the partial pressure of c02 in an exhaled breath

-verifying ETT placement

-provides instant feedback on the patients ventilatory ( how effective c02 is being eliminated by pulmonary system)

- Provides instant feedback on perfusion (how effective c02 is being transported through vascular system)

-Provides instant feedback on metabolism (how effective cells are generating c02

Quantitative - waveform with numbers

Qualitative- is color change

Why do you want to be a CRNA

-Independence and autonomy in my specialization. With increased responsibility and reward.

-ability to manage airway and hemodynamics. With advanced techniques/medications. To feel calm and collected as a leader in this responsibility. To improve patient outcomes by implimenting best practice.

-to become a trauma anesthetist/resusitationist

- Through my shadowing I have come to enjoy the profession

-to be able to have and support a large family while mantaining my style of living and hobbies that I love.

-I want membership in a small/elite profession

Why will you do well in the program

work ethic - farm hand, school, societies, work

drive - ability to navigate difficult life situations up to this point and will be able to employ techniques that I have already used to overcome challneges

integrity - I have a strong moral compass, I am someone that you can trust, someone who will ask for help when needed, can be an example in difficult situations.

emotional intelligence - ability to use others emotions coupled with my own to achieve a common goal. I am self aware, kind, and willing to be part of something bigger than myself.

What is your greatest weakness

As a member of a small and elite profession, what obligations will you have, if any, toward this profession?

...Advocacy - state and federal

...Time and financial help

... Continual research/publications

... educating the future

...

Please explain the difference between SA02 and PA02?

Tell me everything you know about hemoglobin..

Oxygen carrying capacity 4-02 sites

present in PRBCs

Protein

Product on Bone marrow and erythropoetin from kidney

Necessary to mantian perfusion/ scv02

oxyhhbg dissociation curve

13.5-17.5 men

12-15 female

oxyhomglobin dissociation curve. What is a shift to the R and the L. What causes these shifts?

defines different partial pressures of oxygen required to saturate the hgb molecule

Usually defined as p50 (or a certain partial pressure required for 50% hgb saturation

A shift to the right (reduced affinity) means that a high partial pressure of oxygen is required to mantain the same saturation.

-increased temp

-increased 2-3DPG

-increased H+ ion (acidosis)

A shift to the left means that a hgb molecule will mantain saturation with a smaller Pa02.

- decreased temp

- decreased 2-3 dpg

- decreased H+ ion (alkalosis)

Q: Tell me about a time when you had to manage a difficult clinical situation.

Trauma Resus of 21 year old male

Q: Tell me about a time when you were working with someone who wasn't pulling their weight, and they had a different value system than yours. How did you deal with this person?

CCB O.D. --> Helped her next day with busy, sick CRRT pt. Emotional intelligence is the ability to understand how different people are going to respond..

Q: Tell me about a time when you failed. What happened, and how did you recover?

24 year old female

4 months post liver transplant

GI bleed

Shifted to internal bleed and resp. compensation and

intubation, hypotension, line placement, MTP

OR, clotted atrium

Learning and meditating on mistakes and how to integrate that knowledge moving forward to improve.

Q: Tell me about a time when you had an ethical dilemma at work. What did you do?

Pregnant mom O.D. at 26 wks.

Baby in NICU

Dad charged with Homocide

Mom changed to Donor

Managing hospital security with outside police while at the same time maintaining an environment to prepare for donation.

Q: Tell me about a time when you felt it was you against everyone else. You thought you were right and that everyone else was wrong. What did you do?

Self-Awareness - check myself are these people those that I trust to tell me.

Ask myself Why I feel the need to advocate in this certain way.. Is it against the facts?

Q: How do you handle stress?

breathe - 4 7 8 - performance enhancing breathing - tactical breathing.

Talk - Positive self-talk - I have been here before - increase perception that I can perform the task at hand.

See - Visualize the scenario - preparation, skill completion, getting help. Mental rehearsal.

Focus - Word - "smoothe" slow is smooth smooth is fast.

Tell us about your work experience.**

Q: How do you describe success?

Highly individualized

Being entirely present

Obtaining a balance of things that I truly value.

An incremental experience - as I find joy in self-experimentation and self-acutalization. Finding the next thing that will push me to my mental and or physical limit.

Q: Do you foresee any barriers to your education? (finances, time commitments)

Balance of time

What does a CRNA do

Physical assessment - risks to anesthetic administration, risks to procedures.

Development of anesthestic management and plan. Anesthetic should be individualized to patient assessment, organ fuction, laborartory values.

gathering necessary equipment acting on thoughts concerning assessment (follow up diagnostic tests/labs)

Pre-operative teaching/expectations/development of patient relationship

Initial anesthetic administration/manmagement of hemodynamics initially, continual assessment and communication with providers. Monitoring vital signs every 3-5 minutes, charting accordingly.

Line placement, intubation, spinal/regional nerve blocks/ epidural administration.

maintenence of anesthesia, hemodynamics, continued communication with team, diagnostic studys and other management necessary. Volatile/inhaled anesthetic, intravenous anesthetic,e ct.

Resolution of anesthetic in timely manner and post operative evaluation and assessment.

Following patient back to specific care unit and hand off.

Q: What questions do you have for us?**

Where Idaho is a FPA state - what are primary areas of advocacy in specific to the state of Idaho at this time?

If you saw one of your fellow students or colleagues using drugs outside of work/classroom, what would you do?

If it was a question of patient safety, I would immediately confront the collegue concerning this problem.

I think this would often depend on the situation, for many people would have a risk of self-harm, or harm of others when confronted with this problem

Need to further investigate..

What relationship do I have with this person

In what setting did it take place? What is the chain of authority like?

If you had to pick a topic for a master's thesis or doctoral dissertation, what might it be?

Ketamine facilitated Rapid Sequence Awake intubation

Trauma Resusitation - damage control resucitation

Use of TEG or ROTEM in MTP

Ventilation in ARDS like the use of driving pressure

Who (within the field) has influenced you the most? What do you consider the biggest issue facing the profession today? Next 5/10 years?

Scott weingart - ED critical care in NY state

Richard Dutton - R. Adams Cowley Shock Trauma Center - trauma anesthesiologist

Rich Levitan - ED physician and airway guru

Reubon Strayer - EM physician and Airway

What is your strongest trait that will help you in your academic/professional career.**

What is your most important weakness that you will struggle with, if any, toward this profession?

What do you know about XYZ School and our program?

What if in clinical someone told you were taping your IV wrong. What would you do?

Tell me one of your greatest accomplishments? And at your last job?

Give an example of where you showed leadership.

Give an example of community service.

Give an example of when you worked on a team.

Calcium Channel Blocker Overdose

Coding x 3 `

Calcium

Insulin High Dose

Glucogon Drip

3 pressors

Push dose epi

Vomit/Aspiration/Ards

Paralytic

Sedation

CRRT

Give me an example of your problem solving.

Exploring ways to more quickly and effectively evaluate fluid responsiveness

End Tidal CO2 with PLR/fluid bolus challenege

This problem solving occurs with evaluating fluid/volume responsiveness

What have you done to develop or change in the last few years?.

Change is not a passive process. Constant effort. Tranforme as a nurse and team member.

-Develop a greater sense of self awareness and emotional intelligence.

-Develop a strong humility

-Desire to be observant, to ask be extensively curious as to the "why"

-Set goals for self-improvement sipiritally, emotionally, physically, and in all aspects of nursing.

-These goals include advance certifications, daily study of up to date techniques, evaluation of progress, and making specific detailed plans.

-Not taking myself to seriously and enjoying the journey as much as the result.

Do you work well under pressure? Give an example.

Trauma Gun shot wound to face/abdomen Hypovolemic shock, young. Trauma resusitation.

MTP+fentanyl

Calcium

MTP at TICU

How do you think you will fit into the program?

Work Ethic

Drive

Integrity

Self-Awareness

Keep it light

What do you want written on your tombstone?

Humble, Hardworking, Father, and Bryan Graduate

What will you do if you don't get into the program?

Continue to apply

Normal ranges for the following

RAP

CVP

PAP

PAWP

SVR

PVR

EF

RAP 2-6

CVP 3-8

PAP 20-30/8-15 MEAN <20

PAWP 6-12 (know that to optimize pre-load may mean higher than normal

SVR 900-1400

PVR 50-150

EF >50%

How do you calculate SVR

<(MAP-RAP)x80 > / CO

Where are dopaminergic receptors located? What does their stimulation result in?

Renal, coronoary, cerebral, and mesenteric - vasodilation

Beta 1 stimulation results in..

Inotropy

Chonotropy

Dromotropy - increased conduction velocity

Dopamine MOA, dosing, uses

Dubutamine MOA, dosing, uses

Dose 2- 20 mcg/kg/min

2-5 mcg/kg/min = dopaminergic stimulation

5-10 mcg/kg/min = beta 1 stimulation

10-20 mcg/kg/min predominant Alpha stimulation

Dubutamine

2-20 mcg/kg/min primarily B1 - Chonotropy/inotropy - B2 and A1 adenergic agonist - B2 being slightly more prevalent than A1 resulting in a more vasodilatory effect.

Dobutamine

2-20 mcg/kg/min

"inodilator"

Beta 1 stimuation and vasodilation due to it's major metabolite 3-0 methyldobutamine.

Methyldobutamine is an inhibitor of alpha adrenoreceptors.

Milrinone

.25-1 mcg/kg/min

phosphodiasterase III inhibitor does not achieve positive inotropic afects through SNS stimulation.

This in turn results in increased cAMP and subsequently, increased CA ion influx into cardiac muscle cells. Increased CA in cardiac cells results in increased force of contraction. In the vascular system, cAMP accumulation results in decreased CA ion influx resulting in vasodilation. Due to the lack of SNS stimulation dysrrhythmias are less common than with other inotropes

Tell me about the anesthesia profession

CRNAs serve in public sector, military

OR, ambulatory surgical centers, physican offices,

VA, maternity, military, rural anesthetic

collaborative groups, free-lancing

50,000-60,000 CRNAs (50,000 in aana) - 1800's

43 million anesthetics/yr

25% more cost effective than 1:4 anesthesiologist/crna ratio.. 110% more cost effective than 1:1 supervision.

How do you stay up to date in your practice

I am not one to Go through and read a complete medical journal. I study by disease process, by resusitation technique ect.

Monthly AACN Journals

New England Journal of Medicine

SMACC/FOAM/podcasts

EMcrit

EMwrap

Trauma Cast

Resus.me

ER cast

From the head of the bed

Deranged Phys

Uptodate

Life in the fast lane

Pulseless Vfib/Vtach

Immediate initiation of CPR

SHOCK

2 minutes CPR (IV/IO access)

SHOCK

2 minutes CPR (EPI every 3-5 minutes), advanced airway, etC02)

SHOCK

2 minutes CPR (amiodarone 300 mg bolus followed by 150 mg IV)

TREAT REVERSIBLE CAUSES

H and T

Hypoxia

hypovolemia

Hydrogen Ion Acidosis

Hyopglycemia

Hypo/hyperkalemia

hypothermia

Tension Pneumo

Tamponade

Coronary/pulmonary thrombosis

Toxins

asystole/PEA

CPR (IV/IO access, Epinephrine every 3-5 minutes, advanced airway etC02)

SHOCK if SHOCKABLE

CPR TREAT REVERSIBLE CAUSES

Advocacy Issues within the NP profession

NP Full Practice Authority

NP signing POLST forms

Signature Authority - Global Signature Recognition

Modernize state licensure laws

Encourage sustainable re-imbursement as primar care practitioners