MD to CRNA knowledge gap

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JPSmyth

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I want to ask in the attending and resident anesthesiologists about the difference in knowledge that an MD/DO anesthesiologist has versus a CRNA/DNP/anything else.

I'm only a med student, but from the shadowing I have done in anesthesia I really enjoyed it. I always hear that the field is doomed due to CRNA takeover and they are getting equivalent practice rights in some states etc.

Aren't there some circumstances when there is a clear mastery of the field exhibited by an MD that a CRNA just won't have? When I shadowed, the CRNA could not place an epidural and kept poking for a while. The MD stepped in and did it in 5 seconds. I understand that the field is money driven, and CRNAs are cheaper, but is it really sustainable for the field to flood it with CRNAs to "replace" anesthesiologists?

Also, I have seen physicians say online that CRNAs think they are just as good of a clinician as an attending anesthesiolgoists. Once again, isn't there a lot of things that you know but they don't? How can the practice rights be equal in some states when an attending has so much more training and knowledge?

Also, does doing a fellowship set you further apart as an attending?

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Trust me, it's not even close. I've been at a place where CRNAs practice independently for two weeks and I'm shocked someone doesn't die everyday

Examples, sure, to name a few:

- facia iliaca block as sole anesthetic on anterior hip
- 15mg marcaine for EVERYONE via CSE (c sections) regardless of height
- inadequate ASRA guidelines for neuraxial procedures
 
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Trust me, it's not even close. I've been at a place where CRNAs practice independently for two weeks and I'm shocked someone doesn't die everyday

Examples, sure, to name a few:

- facia iliaca block as sole anesthetic on anterior hip
- 15mg marcaine for EVERYONE via CSE (c sections) regardless of height
- inadequate ASRA guidelines for neuraxial procedures

ASRA guidelines are probably overrated i guess
And why die from 15mg marcaine?
 
they know enough to hook up some monitors, push some drugs, intubate the patient, and wake them up. They have superficial knowledge of disease states, but have almost no training in diagnosing problems on the fly and adjusting the plan as needed. They also can confuse appropriate therapies for similar disease states. A frequently confused thing I'll hear is them not wanting to give too much fluid to somebody with a creatinine of like 1.5. They confuse the ESRD patient not wanting much fluid at all to the CKD patient that needs to be kept hydrated to maintain their kidney function.
 
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First off, you should never denigrate yourself by say, " I am only a medical student." There are millions of people incapable of getting to where you already are, and your future is very bright. So be proud of where you are and what you have already accomplished.

As a decade-long CRNA, who went back to Med School/anesthesia residency thirty years ago , I can tell you with certainty that there is a vast knowledge difference, both in content and rigor, between the two categories of anesthesia providers. Medical education requires 4 college years filled with rigorous sciences, four very rigorous years of Medical School sciences education ( our school sported 25-27 credit hours of hard science each semester for the first two years ), followed by two years of demeaning clinical education, then 4-8 years of internship and residency. There is no way you can stuff all that into 4 years of Nursing school, 2 or so years of carrying out an ICU Physician's orders, then 2 and 1/2 years of anesthesia school, again following physician orders.

All the time we've all spent in ICU, getting old COPD patients on and off ventilators, getting big postoperative vascular surgery patients through crises, delivering babies, taking care of sick kids in PICU, etc., etc. You cannot stuff that type of valuable experience into the CRNA curriculum.

As a physician with a very soft spot in my heart for CRNAship, I am sorry to say that you just cannot stuff all that into the time a CRNA spends getting their certificate.

Luckily, almost to a man/woman, the CRNAs I have worked with in the past 25 years know, and appreciate, the difference.

Maybe I have been lucky, and have not run into the really militant minority.

Maybe my career has been so congenial because I take pains not to stuff all of the above down the CRNA's throat each day in the OR. I don't know.

I have had three surgeries under the ACT practice model; everyone made their respective contributions to my care. I am very pleased with everyone's part in my care in the OR.
 
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Luckily, almost to a man/woman, the CRNAs I have worked with in the past 25 years know, and appreciate, the difference.

Maybe I have been lucky, and have not run into the really militant minority.

If true, why are there virtually zero CRNAs willing to stand up publicly in writing saying that what we (anesthesiologists) do actually makes a difference?
 
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ASRA guidelines are probably overrated i guess
And why die from 15mg marcaine?

Ha ha what!?

You wouldn't be worried about a high spinal in a 5 foot pregnant chick? Clearly you don't do much OB
 
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If true, why are there virtually zero CRNAs willing to stand up publicly in writing saying that what we (anesthesiologists) do actually makes a difference?

I can tell you that none of ours are interested in going solo and taking care of the sickest kids having these crazy surgeries. We are a team and it works well for us. That wasn't the case in the .mil. If the practice was a lot of healthy people, routine cases, outpatient, etc. and the sickest ones and biggest cases were always going to the resident/anesthesiologist team or some other hospital, I can see where they might start to think that they don't need any supervision. But that doesn't mean that they don't because as we all know things can change 180 degrees in a just a couple of seconds. That's where the rubber meets the road and where we can absolutely make a difference. Our CRNAs get that because they do big cases on sick kids and see that things don't always go according to Pedi Plan A, sometimes not Plan B either.
The AANA's answer to that would be that they could do the job, just as well, or even better, if they just had the chance, and that some specialty hospital isn't representative of the real world anyway.
PS I place a lot of the blame on the 4:1 coverage, not coming in on call for an epidural, head in the room 3 times for 5 minutes, PP attendings for making this problem what it is today. They are the majority, they enabled this practice, and they profited greatly from it. Now after decades of slide the norm has changed. Management companies want to take the profit, and it will change again to 6:1, or fireman ICU style, or whatever.


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Il Destriero
 
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I can tell you that none of ours are interested in going solo and taking care of the sickest kids having these crazy surgeries. We are a team and it works well for us. That wasn't the case in the .mil. If the practice was a lot of healthy people, routine cases, outpatient, etc. and the sickest ones and biggest cases were always going to the resident/anesthesiologist team or some other hospital, I can see where they might start to think that they don't need any supervision. But that doesn't mean that they don't because as we all know things can change 180 degrees in a just a couple of seconds. That's where the rubber meets the road and where we can absolutely make a difference. Our CRNAs get that because they do big cases on sick kids and see that things don't always go according to Pedi Plan A, sometimes not Plan B either.
The AANA's answer to that would be that they could do the job, just as well, or even better, if they just had the chance, and that some specialty hospital isn't representative of the real world anyway.
PS I place a lot of the blame on the 4:1 coverage, not coming in on call for an epidural, head in the room 3 times for 5 minutes, PP attendings for making this problem what it is today. They are the majority, they enabled this practice, and they profited greatly from it. Now after decades of slide the norm has changed. Management companies want to take the profit, and it will change again to 6:1, or fireman ICU style, or whatever.


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Il Destriero

Thinking of the CRNAs that you have worked with for many years:
Would you bet good money that around their kitchen tables they don't trash talk anesthesiologists as a profession?
Would you bet good money that they don't write letters to legislators about expanding CRNA scope because anesthesiologist supervision doesn't improve care?
Would you bet good money that none of them contribute to CRNAPAC?
 
I was unaware of the term but very familiar with the concept, Thanks
I have also always wondered about my abilities and the fact that it seems easy therefore it must be. "The corollary to the Dunning–Kruger effect indicates that persons of high ability tend to underestimate their relative competence, and erroneously presume that tasks that are easy for them to perform also are easy for other people to perform.[1]"
I was made aware of this just yesterday when a pair of surgeons commented on my pracrice. I assumed everyone in my group had similar outcomes as me. And yes I am aware of the way that sounds. ;)
 
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Ha ha what!?

You wouldn't be worried about a high spinal in a 5 foot pregnant chick? Clearly you don't do much OB
I used to do plenty of OB and never ever adjusted my dose for height.

It's hyperbaric bupivacaine. Dose depends on the person operating, not the patient (i.e. duration). Tilt the table, get the level you want.
 
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If true, why are there virtually zero CRNAs willing to stand up publicly in writing saying that what we (anesthesiologists) do actually makes a difference?

fear of being ostracized by their friends and colleagues. The silent majority of CRNAs have no desire to practice independently. I am 100% sure of this. The vocal minority of their profession dominates their national organization and political lobbying.
 
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fear of being ostracized by their friends and colleagues. The silent majority of CRNAs have no desire to practice independently. I am 100% sure of this. The vocal minority of their profession dominates their national organization and political lobbying.

I have always looked at it the other way. The only reason that more CRNAs are not openly militant is fear of the resentment that anesthesiologists who supervise them now or in the future. I still believe that most CRNAs' attitude towards militant AANA types is "good luck and god bless. I just don't want to own what you say and do."
 
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I used to do plenty of OB and never ever adjusted my dose for height.

It's hyperbaric bupivacaine. Dose depends on the person operating, not the patient (i.e. duration). Tilt the table, get the level you want.

I achieve adequate levels with 10.5 mg most times. You have an epidural. No sense in tanking their pressure with huge spinal dose and if you need to achieve better block, use the epidural catheter. I respectfully disagree
 
I have always looked at it the other way. The only reason that more CRNAs are not openly militant is fear of the resentment that anesthesiologists who supervise them now or in the future. I still believe that most CRNAs' attitude towards militant AANA types is "good luck and god bless. I just don't want to own what you say and do."

That is not my experience and I have extensive long term and family relationships with many CRNAs. I hear it all. While you may want to believe your opinion is correct, I find very little evidence of it.
 
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That is not my experience and I have extensive long term and family relationships with many CRNAs. I hear it all. While you may want to believe your opinion is correct, I find very little evidence of it.

And exactly in how many departments with CRNAs have you worked? Have you ever worked with CRNAs who were not directly employed by the anesthesiologists?
 
And exactly in how many departments with CRNAs have you worked? Have you ever worked with CRNAs who were not directly employed by the anesthesiologists?

I guess about 5 or 6 different departments and yes I've done plenty of cases with hospital employed CRNAs in several different small community hospitals and I have lifelong friends and many relatives that are CRNAs.

I'm well aware of the militant minority and what they think and what they claim. What I'm telling you is that it is a minority.
 
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Thinking of the CRNAs that you have worked with for many years:
Would you bet good money that around their kitchen tables they don't trash talk anesthesiologists as a profession?
Would you bet good money that they don't write letters to legislators about expanding CRNA scope because anesthesiologist supervision doesn't improve care?
Would you bet good money that none of them contribute to CRNAPAC?
I wouldn't bet a cent on any of the above statements.
 
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I'm with Mman. CRNAs have such a sweet gig as it is. They get to do all the fun parts of anesthesia with minimal responsibility and when things get too hard or it gets late in the day, they can just go home or pass the sick patients onto someone else. On a per hour basis, they make almost as much as a lot of anesthesiologists (more than a lot of IM or FM docs) with a lot less stress. They may say they want independence etc, but I think it's mostly they just want the respect that MDs get. I doubt most of them really wanna have their names on the chart as the most responsible person.

I definitely think CRNAs gather together and complain about attendings. There are plenty of attendings who don't look up patients or are minimally involved with the anesthesia. I can't blame the CRNAs for thinking they are equivalent when maybe they're working with attendings who let them do everything with minimal oversight. What do you expect if you supervise the anesthesia from the lounge?!
 
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I'm with Mman. CRNAs have such a sweet gig as it is. They get to do all the fun parts of anesthesia with minimal responsibility and when things get too hard or it gets late in the day, they can just go home or pass the sick patients onto someone else. On a per hour basis, they make almost as much as a lot of anesthesiologists (more than a lot of IM or FM docs) with a lot less stress. They may say they want independence etc, but I think it's mostly they just want the respect that MDs get. I doubt most of them really wanna have their names on the chart as the most responsible person.

I definitely think CRNAs gather together and complain about attendings. There are plenty of attendings who don't look up patients or are minimally involved with the anesthesia. I can't blame the CRNAs for thinking they are equivalent when maybe they're working with attendings who let them do everything with minimal oversight. What do you expect if you supervise the anesthesia from the lounge?!

When an MD is overseeing 4 ORs at once with CRNAs in each one can they bill/be reimbursed for all 4 of them?
 
They ain't doing it for free.

I meant how does the reimbursement compare to doing 4 back to back surgeries in which the MD would complete the entire case?
 
I meant how does the reimbursement compare to doing 4 back to back surgeries in which the MD would complete the entire case?

When medically directing (meeting TEFRA conditions), the anesthesia billing is split 50/50 between MD and CRNA. When performing solo anesthesia, the MD (or CRNA, for that matter) receives 100% of the collection for that case. In general, the total billing/collections for MD (or CRNA) only and MD/CRNA medical direction are about the same. So with comparable cases (same number of units, same amounts of time), the MD medically directing at a 4:1 ratio will make about twice as much.

There are some caveats to this. Some payors will pay at a higher rate for MD only anesthesia. Also, while people are always going on about supervising 4:1 as though it is a constant, never-ending string of cases, during a day of real-world "4:1" medical direction, your time-averaged case ratio is always less than 4:1. If I am covering 4 rooms (which is actually pretty rare in my practice), I probably only actually have 4 rooms running (and producing revenue) simultaneously well under 100% of the time (based on case types, surgeon schedules, turnover times, random delays, etc). We get a report every quarter or so indicating what our actual "average case concurrency" is. Mine is usually somewhere in the 2-3 range, because we do some solo anesthesia (10-20% of the time) and rarely have 4 rooms.

Short answer is that efficient "4:1 supervision" probably produces something like 1.5-2 times as much revenue as solo MD anesthesia for a given time period. And you only see any of that if you work for yourself, not a hospital or AMC. They love 4:1 (and frequently demand it) because that is where the profit is.
 
fear of being ostracized by their friends and colleagues. The silent majority of CRNAs have no desire to practice independently. I am 100% sure of this. The vocal minority of their profession dominates their national organization and political lobbying.

Having no desire to practice independently is not mutually exclusive with supporting AANA positions. It is about having the choice and advancing their profession (at the expense of ours). I submit that many CRNAs who prefer working in an ACT environment actively write letters and PAC checks and undermine us when they think that it is safe to do so.
 
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A frequently confused thing I'll hear is them not wanting to give too much fluid to somebody with a creatinine of like 1.5. They confuse the ESRD patient not wanting much fluid at all to the CKD patient that needs to be kept hydrated to maintain their kidney function.

Great post, great example of how a superficial understanding/knowledge of a disease or physiology can easily lead one astray.
 
I achieve adequate levels with 10.5 mg most times. You have an epidural. No sense in tanking their pressure with huge spinal dose and if you need to achieve better block, use the epidural catheter. I respectfully disagree
That is the opposite of my approach.
 
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I have always looked at it the other way. The only reason that more CRNAs are not openly militant is fear of the resentment that anesthesiologists who supervise them now or in the future. I still believe that most CRNAs' attitude towards militant AANA types is "good luck and god bless. I just don't want to own what you say and do."

Your statement is 100% correct and that's the AANA official position on the matter: Militancy helps all CRNAs and the "organization" will take the heat for those wishing to remain "cordial" in an ACT.

Those who fail to see that the militant 20% of the AANA drives the overall agenda of the entire organization are either ignorant or foolish. The vast majority of CRNAS tacitly support the AANA agenda across the board and provide the funding via their membership dues and PAC money in order to do so.

http://www.aana.com/advocacy/federalgovernmentaffairs/Documents/mya2017-crna-fast-facts1.pdf

That document is clear that the AANA with the overwhelming support of its membership does not value the role of an Anesthesiologist in perioperative care.


AANA Membership: More than 50,000 of the nation’s nurse anesthetists (including CRNAs and student registered nurse anesthetists) are members of the AANA (or, 90 percent of all U.S. nurse anesthetists). More than 40 percent of nurse anesthetists are men, compared with less than 10 percent of nursing as a whole.
 
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The political battles are never-ending because the AANA wants full autonomy practice rights for its membership. Such rights are simply not in the best interests of the public. The CRNA provides a valuable component to the care team but is a second tier level provider and as such, lacks the education and training to work alone in high acuity situations.

http://www.llw-law.com/wp-content/u...ion-3-22-17-00778068xBA9D6-00783171xBA9D6.pdf
 
When medically directing (meeting TEFRA conditions), the anesthesia billing is split 50/50 between MD and CRNA. When performing solo anesthesia, the MD (or CRNA, for that matter) receives 100% of the collection for that case. In general, the total billing/collections for MD (or CRNA) only and MD/CRNA medical direction are about the same. So with comparable cases (same number of units, same amounts of time), the MD medically directing at a 4:1 ratio will make about twice as much.

There are some caveats to this. Some payors will pay at a higher rate for MD only anesthesia. Also, while people are always going on about supervising 4:1 as though it is a constant, never-ending string of cases, during a day of real-world "4:1" medical direction, your time-averaged case ratio is always less than 4:1. If I am covering 4 rooms (which is actually pretty rare in my practice), I probably only actually have 4 rooms running (and producing revenue) simultaneously well under 100% of the time (based on case types, surgeon schedules, turnover times, random delays, etc). We get a report every quarter or so indicating what our actual "average case concurrency" is. Mine is usually somewhere in the 2-3 range, because we do some solo anesthesia (10-20% of the time) and rarely have 4 rooms.

Short answer is that efficient "4:1 supervision" probably produces something like 1.5-2 times as much revenue as solo MD anesthesia for a given time period. And you only see any of that if you work for yourself, not a hospital or AMC. They love 4:1 (and frequently demand it) because that is where the profit is.

that is awful
 
First off, you should never denigrate yourself by say, " I am only a medical student." There are millions of people incapable of getting to where you already are, and your future is very bright. So be proud of where you are and what you have already accomplished.

As a decade-long CRNA, who went back to Med School/anesthesia residency thirty years ago , I can tell you with certainty that there is a vast knowledge difference, both in content and rigor, between the two categories of anesthesia providers. Medical education requires 4 college years filled with rigorous sciences, four very rigorous years of Medical School sciences education ( our school sported 25-27 credit hours of hard science each semester for the first two years ), followed by two years of demeaning clinical education, then 4-8 years of internship and residency. There is no way you can stuff all that into 4 years of Nursing school, 2 or so years of carrying out an ICU Physician's orders, then 2 and 1/2 years of anesthesia school, again following physician orders.

All the time we've all spent in ICU, getting old COPD patients on and off ventilators, getting big postoperative vascular surgery patients through crises, delivering babies, taking care of sick kids in PICU, etc., etc. You cannot stuff that type of valuable experience into the CRNA curriculum.

As a physician with a very soft spot in my heart for CRNAship, I am sorry to say that you just cannot stuff all that into the time a CRNA spends getting their certificate.

Luckily, almost to a man/woman, the CRNAs I have worked with in the past 25 years know, and appreciate, the difference.

Maybe I have been lucky, and have not run into the really militant minority.

Maybe my career has been so congenial because I take pains not to stuff all of the above down the CRNA's throat each day in the OR. I don't know.

I have had three surgeries under the ACT practice model; everyone made their respective contributions to my care. I am very pleased with everyone's part in my care in the OR.

Dejavu -

Thank you for the eloquent note. It was exactly this type of message that I had hoped former ASA President Jane Fitch would have put forth during her tenure, but, to the best of my knowledge, nothing like this ever came from her. I almost feel like the "opportunity door" closed when she ended her term as ASA President without getting in front of the lay public or lawmakers with the message you typed...

I can't tell a nurse what it's like to be a nurse anymore than a nurse can tell me what it's like to be a doctor. But for the few of you that have walked in both sets of shoes...it is a compelling message.
 
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That is the opposite of my approach.

My point was I never have to use the epidural with lower dose but could should I need to. Whatever, more than one way to skin a cat. Many of my attendings used this approach. Makes sense to me
 
My point was I never have to use the epidural with lower dose but could should I need to. Whatever, more than one way to skin a cat. Many of my attendings used this approach. Makes sense to me

Why on earth are you routinely doing CSEs for c-sections in the first place? Are your OBs that slow and that unpredictable?

Compared to a spinal, an epidural is an inferior anesthestic for a c-section. No question.

Deliberately underdosing the spinal so you can limp through the section with the epidural makes no sense to me.
 
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Haha underdosing? How is it I rarely, if ever, have to dose the epidural while at a teaching institution where they take longer? I get adequate levels without having as pronounced sympathectomy. Density is as it would be with full dose? The physiology is what it is. The increased intraabdominal pressure compresses the intrathecal space, thus, a smaller dose is tolerated/recommended. Get out chestnut
 
My point was I never have to use the epidural with lower dose but could should I need to. Whatever, more than one way to skin a cat. Many of my attendings used this approach. Makes sense to me


The literature is pretty clear that all you need is about 10 mg of hyperbaric Bupivacaine to perform a C section. I typically use 12-13 mg of hyperbaric Bupivacaine via single shot SAB technique with almost a zero conversion rate to GA (99% or greater success rate). The spinal block reliably lasts for more than 90 minutes as well.

Thus, I totally agree with your technique but in a more simplified approach for private practice.
 
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My typical dose is 12-13 as well, I was merely stating for a extremely short statute I'd drop the dose to 10.5. My typical dose is 11.25 to 12 with 10 mcg of fentanyl
 
Haha underdosing? How is it I rarely, if ever, have to dose the epidural while at a teaching institution where they take longer? I get adequate levels without having as pronounced sympathectomy. Density is as it would be with full dose? The physiology is what it is. The increased intraabdominal pressure compresses the intrathecal space, thus, a smaller dose is tolerated/recommended. Get out chestnut
If you rarely, if ever, have to dose the epidural, why are you inserting one in the first place?

Increased intrabdominal presure compressing intrathecal space causing high spinals in pregnant women is dogmatic myth. Parturients tend to get higher (hyperbaric) spinal levels because the larger hindquarters they usually carry effectively put them in Trendelenburg, even when the table is flat. I think Datta's complicated OB book discusses this but my copy is in a box somewhere.

pregnant-trendelenburg.png


I've read Chestnut. I'm well aware of what that text says on the subject. It's not gospel. Neither is the dogma about difficult airways and general anesthesia in pregnancy.

It's OK if you do things differently ... :)

nobody-perfect.jpg



With a fast OB you can get away with 1.4 mL of 0.75% hyperbaric bupivacaine (10.5 mg of bupiv). I've pushed that envelope down to 1.2 mL (9 mg) for the private practice 20 minute sections, but I find that you really need to have some fentanyl in there too. But it works well and gets them out of the PACU quickly.

My typical dose for an academic OB teaching a resident was 1.6 mL 0.75% hyperbaric bupivacaine + 15 mcg fentanyl + 0.2 mg morphine.

It has probably been the better part of a decade since I've had an OB so slow that I put in a CSE for a c-section.
 
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Haha underdosing? How is it I rarely, if ever, have to dose the epidural while at a teaching institution where they take longer? I get adequate levels without having as pronounced sympathectomy. Density is as it would be with full dose? The physiology is what it is. The increased intraabdominal pressure compresses the intrathecal space, thus, a smaller dose is tolerated/recommended. Get out chestnut
$100 says you change your practice within your first few years out.
 
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I give everyone 1.4 or 1.6ml depending on height. > or < 5'2. I only give 1.8 or 2 to patients who have other complications that may extend the surgery. Works fine. No epidural. Sometimes it seems a tad low on my quick scratch test, but it still gives a good surgical block.
They also get ~50mcg epi, 20 of fent and 0.15 morphine.
If it failed for some reason they'd get a GA or a bit of ketamine.
Some of my partner's give 2ml to everyone, and I think that's excessive. They also sometimes use neo drips and tell the moms that it's normal that their fingers are tingly.


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Il Destriero
 
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^^^ makes sense to me. Giving 15 mg risking high spinal, N/V, tons of pressor/fluid 2/2 to sympathectomy. I don't do CSE bs I need the epidural per se. I'm already there w the spinal, can use GM 28G to decrease incidence of PDPH, so why not. You never know if they'll run into trouble. I also like to give duramorph for post op pain control
 
CSE for C/S is kind of a self fulfilling prophecy. You spend the extra time with them sitting to thread the cath, and the end result is the level is just barely high enough at the beginning and too low by the end forcing you to bolus the cath - then you pat yourself on the back for having the forsight to thread the cath in the first place.:rolleyes:

I'm a 10.5mg (1.4mL) Bup + 20 fent + 0.2 duramorph for all comers guy. Lower dosing than that, and I've seen too much nausea with uterine manipulation. I've seen no reason to dose higher in a PP setting even if it's a repeat x3-4 or whatever.

I'm gonna disagree with @Noyac on the fen causing itching. Itching is almost all duramorph induced. Pt's never complain about itching until we are rolling to PACU which fits with the IT duramorph dynamics. I also routinely put 20mcg fent in my ortho joint spinals, and never once has one of those patients ever told me they've itched (we don't do duramorph for joints here).

I've wrestled with the whole "pulling the functional epidural and placing a spinal for section" thing, and I can't justify it. I totally agree that a spinal is a better anesthetic, but as long as the epidural was solid they work just fine for sections. If I was having to limp through a lot of sections under epidural or supplement or whatever I'd probably change my mind, but it just hasn't happened yet.
 
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My practice is very similar to that of @SaltyDog. I don't remember the last CSE I did for CS. My volume is 1.6ish. I add fentanyl and duramorph. I don't believe IT fentanyl causes the pruritis. When I've left fentanyl out of the mix, it just doesn't seem as smooth/solid of a block. Right shoulder pain is also frequent (referred pain from peritoneal/diaphragmatic irritation), and I anecdotally feel the IT fentanyl decreases the incidence of that (as it helps with the block).

I also don't pull a well working epidural for CS. SAB is certainly a better anesthetic, but I'll use the epidural provided it's been a very solid epidural for labor.
 
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