January 19, 2026 • 32 mins
A still body can hide a restless mind. We take you inside the judgment calls that separate safe care from silent suffering, breaking down why sedation must come before paralysis, how to pick the right agent for the job, and what real monitoring looks like when movement disappears.
Featuring CSPA faculty coach and Assistant Program Director at the University of Evansville Dr. Matthew Harmon, DNP, CRNA, tune in as we map the core properties of propofol, midazolam, ketamine, and dexmedetomidine, explaining where each shines, where they fall short, and how to combine them for ventilator tolerance, alcohol withdrawal, and smoother wake-ups.
From there, we get precise with neuromuscular blockade. Succinylcholine’s speed comes with serious risks—hyperkalemia, myalgias, malignant hyperthermia—while rocuronium offers rapid onset with the safety net of sugammadex for true reversal. Cisatracurium’s Hofmann elimination makes it the ICU favorite when organ failure limits options. We walk through high-yield RSI pairings for unstable patients, asthmatics, and trauma, emphasizing hemodynamic stability and airway planning with backup routes before giving the first dose.
Monitoring ties it all together. Learn how to set RASS targets, use BIS thoughtfully, interpret autonomic red flags like tachycardia and lacrimation, and titrate train-of-four to match goals in the ICU versus the OR. We also cover reversal pitfalls—flumazenil in benzodiazepine dependence, naloxone’s catecholamine surge—and share practical tips on IV integrity, ventilator settings, and post-intubation stabilization. If you’re preparing for CRNA school or refining ICU practice, this is a clear, actionable roadmap to safer sedation, smarter paralysis, and better outcomes at the bedside.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Jenny Finnell (00:00):
Welcome to the CRNA School Prep Academy
podcast, where we have helpedguide more than 10,000 ICU
nurses on their path towardsCRMA school.
Our mission is to combineeducation, guidance, and
professional growth so you canmove comfortably towards your
dream of becoming a CRNA Whetheryou're still a nursing school
or a seasoned IC nurse, thispodcast is here for you.
Let's get into today's episode.
(00:23):
Welcome back to Cyrus CoverAcademy Podcast.
Today you're listening to oneof our faculty led sessions,
stream live on CSPA's Instagram.
Depend on the minute, this maybe an open QA where we take your
questions in real time or afocus topic discussion where we
go deep on the area that canstrengthen your knowledge and
build your confidence.
If you want to follow along,join us live, make sure you're
following CSPA on Instagram andwatch for session announcements.
(00:46):
You can also join CSPA's freecommunity where we'll share the
schedule of upcoming sessions.
When you turn on live, you canask questions, get clarity on
the spot, and then learnalongside other nurses
navigating the same path.
And as a quick reminder aboutwho you're learning from, every
session is led by CSBA coachesand faculty who are deeply
committed to your success inpursuing this career.
Without further ado, let's getinto today's show.
Dr. Harmon (01:08):
Hello.
Welcome to today's livesession.
My name is Dr.
Matthew Harmon.
I have over eight yearsexperience as a CRNA and have
been involved in CRNA educationand admissions since 2020.
I'm one of the faculty coachesand mentors with CRNA School
Prep Academy.
So just a couple generalhousekeeping rules for tonight.
(01:32):
Okay.
This is going to be a sessiontopic, so what we're going to do
is I'm going to talk aboutsedatives and paralytics, a
little bit knowing thedifference, some things that are
very good for ICU practice andcare, but also are important for
anesthesia.
Additionally, we rotate throughTikTok and Instagram for our
(01:54):
live sessions with CRNA SchoolPrep Academy.
And you can learn more aboutour upcoming in-person
conference at CRNASchoolprepacademy.com.
That's going to be inLouisville, Kentucky in June
2026.
You can join our free communitythrough the link tree in our
bio.
And let's jump into this topicnow.
When we talk about uh sedativesversus paralytics, it's
(02:17):
important to understand thedifference and use them
intentionally.
Anytime a patient can't move,it's incredibly for it's
incredibly easy for us as uhproviders to assume that
somebody is comfortable, butthat's not always the case.
Paralysis can hide uh thatpain, that fear, and that
awareness.
Sometimes you'll see that inyour vital signs with
(02:40):
tachycardia and hypertension.
Other times, if the patient isuh very ill, you might not see
that.
So we're gonna focus today onindications and timing for these
drugs, good drug combinationsand some rationales, uh,
monitoring tips, red flags, andthen of course, reversal
considerations.
Because if you're heading intoCRNA school, you're gonna be
(03:01):
asked a lot about these drugs,and it's important that you
demonstrate your knowledge thatyou can go above and beyond.
So when it comes to sedatives,sedatives are going to alter
consciousness, uh, they affectour brain.
And you're gonna hear someterms uh used, and some of these
are used interchangeably, butyou need to know the difference.
Anxiolysis.
When a drug is an anxiolytic,it's going to reduce anxiety.
(03:23):
If a drug is an amnestic, itprevents the formation of
memory.
If a drug provides somehypnosis, this can induce sleep
and unresponsiveness.
And if we're using drugs thatprovide analgesia, you may think
of narcotics, opioids, uh,fentanyl, uh, ketamine and
presidex uh provide someanalgesia.
(03:44):
However, propofol does not.
Now, getting into some of oursedative drugs, propofol, it's a
GABA-A agonist.
It has a very quick and rapidonset.
Uh, the duration of action isactually fairly short, somewhere
between five and ten minutes.
It does not give any analgesia.
(04:04):
So you, if you have a patientwho is uncomfortable, you need
to pair it with an agent that isgoing to provide some pain
control.
Propofol has some anti-emeticproperties, it can lower ICP,
reduce cerebral metabolism.
And the reason why its durationof action is so short is it
works by redistribution becausewhen you inject propofol into a
vein, very quickly does thatdrug circulate around, go to the
(04:28):
brain, and very quickly will itredistribute.
And that's why it has thatshort duration of action.
Another drug you may see usedas a sedative in the ICU is
medazlam, okay, or versed.
Versead being a versatilesedative.
Midazlam is a benzodiazepine.
It's going to give goodanxiolysis.
It's going to give goodamnesia.
(04:51):
All right.
It's not going to giveretrograde amnesia.
It's not going to make youforget what's happened, but the
moment you give it, you get thatantigrade amnesia.
So going forward, thosememories become harder to form.
Versus, and a lot of thebenzodazpines, uh, minus rhyming
masolam, that's a veryanesthesia-specific drug, but
the majority of benzodazabineshave very long contact-sensitive
(05:14):
half-lives.
They accumulate.
They're not really reliable fordeep sedation or a very rapid
and brisk wake up.
Ketamine is used in sometimesthe ICU and a lot in anesthesia.
It provides a disassociativetype of anesthetic.
Ketamine is a unique drugbecause it works on our NMDA
(05:36):
receptors.
It's an NMDA antagonist.
And so what's unique aboutketamine is, and you may have
seen this in uh the ICU, butketamine can be used to help
preserve those airway reflexes,that respiratory drive.
It can give some analgesia.
It's great in asthmatics, ithas some bronchodilatory
properties, and it can uhincrease your heart rate, uh,
(05:59):
your blood pressure.
There's a little bit ofresearch on talking about
increasing that ICP unlessthey're well sedated.
But ketamine is a very usefuldrug, and we use it a lot in
anesthesia.
Dexamedatomidine, uh, this is aselective alpha-2 agonist.
Um, I love Prestodex.
Love Prestodex and anesthesia.
Funny, I didn't really like itin the ICU.
Because at that time, and I wasin the ICT many, many years
(06:21):
ago, 2012, 2013, um, Prestodexwas uh oftentimes used by
itself, and now I think it'spaired a lot.
But it gives that sedation-likenatural sleep.
It's not a respiratorydepressant, which is very useful
in anesthesia.
It's great for somebody whoneeds some help, being
comfortable on BIPAP, maybesomebody who's going through
(06:41):
alcohol withdrawal, weaning ventmodes, great, great to use.
Pressidex, slower onset.
You give that bolus dose, thatone mic per kilo, over 10
minutes, and you're gonna seethat bradycardia.
It also causes transienthypertension.
I said PrestX is an alpha-2agonist.
It has a specificity for thealpha 2 to alpha 1 receptor of
(07:04):
about 1600 to 1, whilequonidine, another alpha 2
agonist, is much less, that 200to 400 to 1.
So when you rapidly bolusPrestex, you may have seen this,
you may not.
You'll really see it if youhave an art line in, but you'll
get transient hypertension.
Okay?
So that pressure will go up andvery quickly will go down.
It takes about a minute for itto hit because you lose
(07:24):
specificity because you'rebolusing so much, so you're
gonna affect your alphainterceptors as well, and then
it will very quickly go backdown, and then you'll see that
ridicardia.
Now, let's talk aboutparalytics.
Paralytics are going to stopthat skeletal muscle movement,
but they don't do anything tothe brain.
The scariest thing you can everhave is a patient who is
(07:46):
paralyzed, but they can hear,they can feel, they can
remember, but they can'trespond.
Paralytics give no anxiolysis,no amnestic, no pain control.
There are two types ofparalytics or muscle relaxants.
Depending on who you're talkingto, sometimes whenever you're
giving report an anesthesia andyou say, Oh, um, we paralyzed
(08:11):
and reverse them, patients willreally, what happened?
So many times what we say ismuscle relaxants.
You have two types.
You have depolarizing andnon-depolarizing.
The only depolarizer weroutinely use is substantial
choline.
And it chemically is twoacetylcholine molecules joined
together.
It mimics that action ofacetylcholine, it will
(08:32):
depolarize and it will stayattached until it dissipates
away.
The non-depolarizers, and youhave steroidal like rock
uronium, you also havecisacicurium or nimbex.
They competitively blockacetylcholine at those nicotinic
receptors.
All right, and you all areprobably very familiar with
cisatricurium or nimbex.
(08:54):
Succinyl choline should onlylast a couple minutes, it has a
duration of about five to tenminutes, and it has a very, very
quick onset.
We use it for rapid sequenceinductions or intubations.
And there are some risks withsuccinyl choline.
It's not benign.
There it can be a malignanthyperthermia trigger, which is
um, you know, a pharmacogeneticdisorder that can uh very easily
(09:16):
uh lead to uh patient death,and is something we talk about
in anesthesia that's associatedwith our volatile anesthetics as
well.
Succinyl choline can also causea rapid increase in your
potassium, can causehyperkalemia.
It's contraindicated inpatients who uh have uh burns,
uh crush injuries, have been uhlaying in the bed for days on
(09:37):
end because your extrajunctionalreceptors can proliferate, and
then whenever you give it uhgive succinyl choline, uh it
will cause a huge amount ofpotassium to leak outside and
cause that hyperkalemia.
Now, rock uronium, this isprobably one of the paralytics I
use the most.
So it's a non-dipolarizer, it'sa steroidal.
(09:58):
And you can always remember thesteroidal muscle relaxants
because uh they're gonna be rockuronium, vecuronium,
pancuronium, I would sayrhonsomroids.
So that's a good way toremember the steroidal muscle
relaxants.
Quick onset, 45 to 60 seconds.
You can use it in a place ofsuccinylcholine as uh your RSI
(10:21):
dose.
And then it can lastapproximately 35 to 70 minutes,
and uh it can be reversible withSegamidex or Neosigmine.
Segamidex is a completely uhtrue reversal, kind of how
protamine can encapsulate thatheparid molecule.
Segamidex encapsulates thatrock eronium molecule.
(10:42):
All right.
Neosygnine was the older rev wewould call it a reversal, but
it's not really a reversal, it'scompetitive antagonism and had
a lot of bad side effects.
Uh cisatricurium or nimbex, sothis is great because it has a
little organ uh-independentelimination.
As long as somebody is warm, aslong as somebody um is given
(11:06):
enough time, NIMBEX metabolizespretty quickly.
All right, you can't usepsychotics for it.
Um, it's great for liver orrenal failure patients, and it's
uh often used in a prolonged,extended stay.
Um, but it's great for uhparalysis.
Now, when it comes to uhsedation, sedation changes the
(11:30):
brain.
All right, paralysis changesthe body.
Okay, sedation is going tocreate that anxiolysis while
paralysis is going to stop youfrom moving.
So if you see a paralyzedpatient and their heart rate
increases, they go from a normalsize rhythm, a heart rate of 75
to 80, to 120.
(11:52):
What could that mean?
Could that mean pain?
Could that mean panic?
Could that mean hypoxia?
Could that mean all three?
All right.
When you think of paralysis,all right, you need to be giving
some anxiolysis, some paincontrol.
So there are times where youdon't need paralytics, you just
(12:12):
need sedation.
What are some examples of this?
Ventilator tolerance.
Sedation will decrease thatanxiety, that dyspnea.
Severe anxiety, okay, forpatient comfort.
Maybe somebody has a veryelevated ICP, propavol can
decrease your CMRO2.
That's ruthless metabolic rateof oxygen consumption.
(12:33):
Alcohol withdrawal, press X isgreat for it.
It decreases those uhcatecholine surges and uh
seizures.
It is uh a wonderful uh some ofthe said it does propovol can
suppress that cortical activity,benzogasines are very commonly
used in seizures.
So, what are your sedationgoals?
All right, you're very familiarwith the RAS scores, negative
(12:55):
one to negative two, to helpwith that ventilator tolerance.
And if you want that uh deepersedation, a RAS of negative four
to negative five, preventingICT spites, severe respiratory
failure, things like that.
In anesthesia, sedation israrely the only plan, especially
in airway manipulation.
All right.
Now, when might we useparalysis?
(13:17):
So paralysis all is all aboutmechanics and not comfort.
It's great for that rapidsequence induction to prevent
those reflexive lottic closuresto make intubation easier.
Paralysis is great in Rs.
We need to get those low tidalvolumes in, that's strict
control.
Proning is very, very useful.
Controlling ICP so there's nocoughing, no shivering, or
(13:40):
refractory event uh desyncrasy,all right, to remove that
muscular effort.
If you can't get somebody totolerate the ventilator, you
need to sedate them and then youcan relax them or truthfully
paralyze them.
So the order matters sedation,then paralysis.
All right.
You want to see that patient'srespiratory drive, that's just
(14:01):
because we're talking about anintubated and ventilated
patient.
You want to see thatrespiratory drive, you want to
see that ventilator be able towork.
Think of that arts patient.
Okay, so you may have to treatthat pain, you may have to treat
that discomfort with not only asedative, maybe a narcotic for
(14:22):
pain control, and then aparalyzed patient.
But you never want to havesomebody who is just getting a
paralytic.
That's why in anesthesia we usea balanced approach.
And so we think of anesthesiawith multiple needs.
Do we need amnesia?
Do we need anxiolysis?
Benzovazepines can be veryuseful.
(14:43):
Do we need hypnosis or sedationor induction drugs?
Propofol, very, very commonlyused.
Do we need pain control?
Opioids, ketamine,dexaminatomidine helps uh
prevent pain and reduce opioidconsumption.
And then if we need somebodyimmobile for a procedure, we're
going to use a paralytic or amuscle relaxant.
(15:03):
Now, some very commoncombinations of drugs you'll see
is your RSI combinations,propofol and raw uronium.
That rapid sequence induction,no coughing, fast on, fast off,
great in the OR, great in theICU.
That hemodynamically unstablepatient.
Maybe we're going to useautomatate.
(15:23):
All right.
Automatate can help preservethat blood pressure and heart
rate.
Sometimes it's ketamine aswell.
If you're using succinylcholine, okay, rapid airway
control, maybe that patient hasthe full stomach.
All right.
But do they have anycontraindications for succinyl
choline?
Because if you give enough rockuranium, it will have almost as
quick of an onset as succinylcholine, but without those
(15:46):
dangerous side effects.
Ketamine and rock, great forthat asthmatic.
Maybe somebody who is somewhathypotensive because ketamine
will help maintain thatsympathetic tone, but you really
need, you really need to makesure that patient has
catecholamine reserves.
And then Prestidex, a wonderfuldrug.
It's not a paralytic, it's notan opioid, it's the alpha-2
(16:09):
agonist, and it can help reduceyour opioid consumption.
It's great for sedation.
Anytime you do an awakefibroptic intubation, I love
Prestadix.
I give it to almost everyanesthetic.
It's great for pediatricwake-ups, for vent weeding,
things like that.
What might be your go-to ICUcombo, all right, for your RSIs?
You're probably seeing propopoland rock, ketamine and rock.
(16:31):
Now, when it comes tomonitoring for paralysis, some
very important questions.
Is that patient adequatelysedated?
And are you seeing vital signsto reflect that?
How are you infusing thesedrugs?
If it is a peripheral IV, youneed to make sure that it is
actually in, that it is running.
(16:52):
Because if you're giving lowdose through a peripheral IV, it
may take hours before you seethat it is infiltrated.
This is why it's great if youhave a central line, check it,
make sure that you are using it.
Is the airway manageable ifsomething changes?
Okay.
If you're if I'm there in theICU about to intubate somebody,
(17:13):
I need to have not only a planA, but a plan B and a plan C for
managing that airway.
If I can't get that airway,what am I going to do?
How am I going to breathe forthat patient if I paralyze them?
And you probably see this oftenas a good critical care nurse.
How do you handle hypotensionafter you give these drugs?
Is the vent right there dialedin?
Do you have an ambu bag?
(17:34):
Do you have everything youpossibly need?
Now, when it comes tomonitoring for sedation, some
people use the bispectral indexmonitor, the biz monitor.
40 to 60 is going to be thatanesthetic level state.
Okay.
60 to 80 is going to be thatgood sedation state.
When you start seeing uh 20 to40, all right, when you start
seeing 0 to 20, you're talkingabout almost an isoelectric
(17:57):
line, heavy, heavy sedation.
Tachycardia, hypertension.
These can be signs of pain,anxiety.
This can be a patient that istoo light.
Okay?
Anytime you see lacrimation ortearing, all right, that is a
sign that that sedation was alittle light.
(18:19):
All right.
Maybe you even see themwincing.
Remember, a paralyzed patientcannot tell you that they're
hurting, but their autonomicsystem still can react.
How do you monitorneuromuscular blockade?
Oftentimes you use the train offour monitor.
In the ICU, a lot of timeswe're looking for one to two
twitches.
In the OR, we like deepparalysis.
(18:40):
Okay?
Typically, no twitches to onetwitch, where the majority of
those receptors are blocked.
Now we don't want deepparalysis for so long that we
have to give extremely highdoses of our reversal agent, but
there are consequences for notenough neuromuscular blockade on
board.
In the ICU, all right, this issomeone fighting the vent,
(19:00):
coffin.
In the OR, this is a patientmoving.
Maybe a laryngeospasm uh withlight anesthesia during LMA
youth.
Anything like that can happen.
So we have to be very consciousof the drugs we use.
When we remove that movementfrom the patient, we can remove
(19:21):
feedback.
So we want to monitor them.
We want to make sure that theyare safe.
And a few things to mention forthinking about these drugs.
What are the reversals forthem?
For our benzodasbenes, we haveor mazocon or flumazinyl.
For our opioids, we have narcanor naloxone.
Propofol doesn't have areversal agent, it's time.
Ketamine is the same way.
(19:42):
Prestex is the same way.
You have to use some cautionwith flumazenil and
benzodasmines if they're achronic benzodaspine user.
Naloxone or narcan can causethat catecholamine surge, can
cause pulmonary edema.
For your paralytics, cegamatexfor your steroidal, or neositz.
For your non-steroidal.
(20:03):
Alright.
Neostigmine, once again, not atrue reversal.
It works by competitiveantagonism.
So that surium and the ICoftentimes are turning off for
time.
And substantial choline, allright, is metabolized by
pseudocolonesterase.
So someone can bepseudocolinesterase deficient.
And substance choline can gofrom lasting to five to ten
minutes to twenty to thirty, tosometimes hours and hours.
(20:26):
Remember, set effects are goingto affect the mind, paralytics
are affecting the body and themovement.
They're different co uh they'redifferent tools for
accomplishing different goals.
And it's very important thatyou understand the safety with
them.
Alright?
So whenever you are thinkingabout coming into anesthesia
doing and practicing as a CRNA,it's important that you
(20:48):
understand these drugs.
And the best way to understandthese drugs is to do what you're
doing now, working in the ICU.
So I'm gonna go back through,add a couple of things in the
chat, and then we'll open it upto some QA's.
Alright?
Oh yeah, my uh sure, it says uhsynesthesia.
(21:08):
So uh um I own uh syneshesiaCRNA.
I do we have a company thatdoes uh education tracking, and
um we use it for C RNA programsto track your evaluations, your
cases, uh things like that.
Alright.
Any questions in the chat forme related to NC or any of the
(21:30):
topics we talked about today?
It's important to remember thatwhenever you have patients that
are receiving thesemedications, that you are
monitoring them.
Uh, what is my favoriteanesthesia drug and why what is
(21:54):
my least favorite?
Honestly, I think my favoritedrug is Presidex.
I love Dexmedatomidine.
Uh why?
It's smooth wake up.
Patients, uh patients just doreally well with it.
Whenever I think aboutformulating an anesthetic plan
and uh postoperative uh goals,I'm gonna think about a patient
(22:14):
who is back to themselves, who'srelaxed, who doesn't have much
anxiety, and that's why.
My least favorite, you know, Inever I never take a drug out of
the out of the toolboxcompletely.
There's always an indicationfor one.
I would say my least favorite,and it's not truly an anesthetic
drug, but it's metaclopromideor reglin.
Um, you know, it's a gastricprokinetic.
(22:34):
It makes some people very, veryanxious and it uh can cause
them a lot of anxiety.
It it was a very old schoolthing, you would give it before
C-sections, and by the time uhyou left the uh labor room, got
them into the OR to put in theirspinal, they're even more
nervous.
So um I don't really likegiving Reglin unless there's
that true indication for it.
(22:55):
Uh why am I checking uh CKwhenever my patient's on a
propofol drip?
So uh there's a syndrome, uhpropofol uh infusion syndrome,
whenever you give propofol forextended periods of time.
All right, propofol is uh haslipid content in it, and it can
cause some interesting sideeffects whenever given for a
prolonged period of time.
So you'll see in the ICU, wewill look at caloric intake from
(23:18):
propofol.
We will look at uh we'llmonitor urine because it can
change the color of the urine,and we're gonna monitor um how
much uh of uh other changes uhit may have whenever it comes to
not only your kidneys, but yourliver, anything like that,
whenever you have that extendeduh amount of propool station.
Normally that happens after aday or two or super, super high
(23:41):
uh injection uh super highdoses.
Why why injections suctionchlorine is not used these days?
Umx has honestly fallen out offavor.
The bad side effects, it gets abad rap, it causes um a lot of
uh muscle pain.
The myologies from suctionalcholine can be very, very
severe.
(24:02):
And sometimes you'll hearwhat's uh the myelgies are often
related to fasiculation.
So when you give sux, if youdon't give what we call a
defasiculating dose, you'll seetheir muscle spasm.
Okay, and it can be very, veryintense.
And patients have a lot ofdiscomfort afterwards.
Any golden rules specific toPEDs versus adults with
anesthesia?
(24:22):
Uh certainly.
Um when it comes to kids, uhkids can be very, very
challenging.
All right.
You need um the the highestanesthetic requirements in in a
person comparatively, uh sixmonths to one year, all right.
Oftentimes kids need a muchhigher dosage relative to their
(24:43):
body weight.
Okay?
And so we're always usingweight-based uh dosages as well,
but kids you have to keep deep.
Um, you have to be very carefulwith waking them up.
Uh kids can laryngeosm.
And there are uh stages ofanesthesia.
And that stage, there's uh fourwe talk about stage two is that
hyperexcitability, that's themost dangerous that's when a
child can laryngeosm.
(25:05):
So with kids, wake them up orkeep them deep.
All right, don't try toexcavate them in between.
Um, with adults, I would say mybiggest thing is pay close
attention to your vital signsand look at your entitled CO2.
Your entitled CO2 can be a gooduh good representation of your
cardiac output.
So if suddenly your entitledCO2 drops, you're automatically
(25:25):
thinking, okay, hey, mypatient's cardiac output has
dropped, they are not, they'renot doing well, that's why my
blood pressure guff is cyclingso much, or maybe my A-line's
alarming, my pressure'sdropping, I need to correct it
immediately.
What would be a uh good adviceto prep for CRNA school?
What book can you recommend tostart getting ahead of the game?
That's a really good question,but I tell people this once
(25:48):
you're accepted into CRNAschool, don't do anything except
take keep taking thechallenging patients in the ICU
and take certainly take sometime off before you stop before
you take some time off beforeyou uh start CRNA school.
Have a little time foryourself.
If you are bound and determinedto read anything, I think a
(26:10):
good EKG book is really useful.
You'll get into studyinganesthesia.
I wouldn't uh I wouldn't readmore than about it than you want
to.
If you read if you're bound anddetermined to study anything,
anesthesia, um, I think uh thebasics of anesthesia,
anesthesia, uh, I think this isby Miller and Pardo.
Um one of the easiest books toread.
(26:30):
It's a great intro to allthings anesthesia.
What type of complications uhhave I faced in my practice
before uh intubation or afterextubation?
Um I've seen anything andeverything.
Um one of the most scarycomplications is somebody who's
a full stomach, or maybesomebody who lied about their
NPO status, or it's anemergency, and we have to
(26:52):
intubate them anyways, and theybegin to vomit.
And so trying to preventaspiration, you know, if you
can't get the airway right away,things like that.
So those are things that can bevery complicated.
Or after extuation, making surethat person is awake, making
sure I leave them in care of thePACU nurse in a safe state,
making sure that they're nothaving uh any complications.
(27:13):
All right, we've got about fiveminutes left.
Uh qualifications to becomeCRNAs.
So CRNAs are advanced practiceregistered nurses.
So the United States areprimarily aware of CRNAs
practice, like um, I don't thinkthere's another country that
truly has the practice modelthat we have in the United
States of giving all types ofanesthesia and being involved in
(27:34):
every aspect of it.
Um you would need a bachelor'sdegree, at least a year of
critical care experience, andthen it's a three-year program
where you're going to dohundreds and hundreds of cases,
spend thousands of hours in theOR, and become really, really
good at all types of things,anesthesia.
Oh, um uh the basics ofanesthesia is the name of the
(27:56):
book.
Um if you I I I think any ofthe EKG books, if you just read
like a page or two a day, keepit on your nightstand, it will
dramatically change how you'reable to look at and interpret um
your EKGs.
Um would you move to a levelone if you live uh only by level
two hospital?
You don't have to.
(28:16):
As long as you're taking sick,critically ill patients that are
intubated, sedated, that haveuh pressure requirements, that
you're dealing with art lines,central lines, other bedside
procedures.
Um, if you if you can, ifyou're in a C V ICU where you
see swans, things like that, um,you're right where you need to
be.
(28:37):
Is it possible to work a shoutout in the ICU prior to passing
the NPLEX while studying foryour BSN?
Hung, did you work in the ICUbefore CRNA school?
Uh totally.
I I I would hope most nursingschools have you do a rotation
there.
And you should be able to pick,um, you should be able to pick
your ideal um place to preceptin uh in the ICU.
(28:59):
So if you're able to do that,uh spend your spend your time
there.
This way you can see if that'swhere you want to be.
The ICU is challenging.
Um for me personally, I had uhI started applying to school
right at a year and uh got inpretty quickly after that.
So by the time I started uhCRNA school, I had almost two
years.
What is my personal preferredapproach on induction for trauma
(29:22):
patients?
Trauma is very challenging.
It depends on the type oftrauma, depends on what I'm
there for.
If they're already intubated,all right, I just need to take
them to VOR, get them sedated.
If I'm called, um, if I'mcalled to the ER to help
intubate a trauma coming in,thinking about vital signs, I'm
thinking about uh securing theairway quickly.
Oftentimes it's ketamine androck uronium because I don't if
(29:45):
I don't know their history, I'mvery cautious with just getting
substance calling blindly.
Um and then I'm gonna getsecure their airway, probably
very quickly have uh respiratorystart uh suction them out while
I have things set up for an artline, and then this way I can
monitor blood pressure if we'redoing CPR and you know then
start making sure I haveadequate access.
(30:06):
Because normally they're gonnacome in with like at least one
IV or an IO or something.
If if it's uh you knowhemorrhagic trauma, you know,
maybe I'm gonna get uh nineFrench in the neck to where we
can rapidly infuse uh prettyquickly.
Um what would be my personalpreferred approach on induction
for trauma patients?
I should have an IC beforegetting into nursing school.
Uh we're in the hospital helpstotally.
(30:27):
Working in the hospital is agreat way to do it.
Uh, can you explain steroidalversus non-uh steroidal
paralytics, um, just how theyare metabolized?
So you have your steroidal andyour non-steroidal.
Non-steroidal would be likecisatricurium or atricurium.
Uh, those are metabolized byHoffman elimination.
Okay, so really independent ofuh much liver or kidney
(30:50):
involvement, your steroidal aregoing to have some type of uh
liver or renal involvement.
And so for somebody that hasvery, very complex issues, a lot
of times in the ICU we preferto use cysatural or nimbex so
you can just turn it off.
Now in the OR, 99.9% of thetime I'm using rock uronium
(31:12):
because I have a true reversalfor it, and very quickly I can
go ahead and give rock tointubate, it will last about the
procedure and reverse it at theend.
All right.
You guys asked some excellentquestions.
All right, always enjoy doingthis.
Um follow CSPA on both platformor on all platforms, uh,
(31:33):
Facebook, uh follow us onInstagram, TikTok.
We really love the good uhcommunication in these live
sessions.
Um get on our website at crnaschoolprepacademy.com.
Uh check if you can make it tothe conference in uh Louisville
in June.
It would be phenomenal.
We'd love to meet uh a lot ofyou there.
And um really enjoyed the uh QAand uh shout out to Cynthese
(31:55):
CRNA, um, like I said, mycompany that uh is support
anesthesia education software.
Thank you all so much and havea wonderful uh rest of your day.
Jenny Finnell (32:06):
Thank you for joining us on the Syrian school
prep academy podcast.
We hope today's episode gaveyou clarity and confidence for
the road ahead.
Keep showing up for your goals,keep learning, and keep
believing what's possible foryou.
We're always rooting for you inyour future as a CRNA.
Until next time, take care.
Welcome to the CRNA School Prep Academy
podcast, where we have helpedguide more than 10,000 ICU
nurses on their path towardsCRMA school.
Our mission is to combineeducation, guidance, and
professional growth so you canmove comfortably towards your
dream of becoming a CRNA Whetheryou're still a nursing school
or a seasoned IC nurse, thispodcast is here for you.
Let's get into today's episode.
(00:23):
Welcome back to Cyrus CoverAcademy Podcast.
Today you're listening to oneof our faculty led sessions,
stream live on CSPA's Instagram.
Depend on the minute, this maybe an open QA where we take your
questions in real time or afocus topic discussion where we
go deep on the area that canstrengthen your knowledge and
build your confidence.
If you want to follow along,join us live, make sure you're
following CSPA on Instagram andwatch for session announcements.
(00:46):
You can also join CSPA's freecommunity where we'll share the
schedule of upcoming sessions.
When you turn on live, you canask questions, get clarity on
the spot, and then learnalongside other nurses
navigating the same path.
And as a quick reminder aboutwho you're learning from, every
session is led by CSBA coachesand faculty who are deeply
committed to your success inpursuing this career.
Without further ado, let's getinto today's show.
Dr. Harmon (01:08):
Hello.
Welcome to today's livesession.
My name is Dr.
Matthew Harmon.
I have over eight yearsexperience as a CRNA and have
been involved in CRNA educationand admissions since 2020.
I'm one of the faculty coachesand mentors with CRNA School
Prep Academy.
So just a couple generalhousekeeping rules for tonight.
(01:32):
Okay.
This is going to be a sessiontopic, so what we're going to do
is I'm going to talk aboutsedatives and paralytics, a
little bit knowing thedifference, some things that are
very good for ICU practice andcare, but also are important for
anesthesia.
Additionally, we rotate throughTikTok and Instagram for our
(01:54):
live sessions with CRNA SchoolPrep Academy.
And you can learn more aboutour upcoming in-person
conference at CRNASchoolprepacademy.com.
That's going to be inLouisville, Kentucky in June
2026.
You can join our free communitythrough the link tree in our
bio.
And let's jump into this topicnow.
When we talk about uh sedativesversus paralytics, it's
(02:17):
important to understand thedifference and use them
intentionally.
Anytime a patient can't move,it's incredibly for it's
incredibly easy for us as uhproviders to assume that
somebody is comfortable, butthat's not always the case.
Paralysis can hide uh thatpain, that fear, and that
awareness.
Sometimes you'll see that inyour vital signs with
(02:40):
tachycardia and hypertension.
Other times, if the patient isuh very ill, you might not see
that.
So we're gonna focus today onindications and timing for these
drugs, good drug combinationsand some rationales, uh,
monitoring tips, red flags, andthen of course, reversal
considerations.
Because if you're heading intoCRNA school, you're gonna be
(03:01):
asked a lot about these drugs,and it's important that you
demonstrate your knowledge thatyou can go above and beyond.
So when it comes to sedatives,sedatives are going to alter
consciousness, uh, they affectour brain.
And you're gonna hear someterms uh used, and some of these
are used interchangeably, butyou need to know the difference.
Anxiolysis.
When a drug is an anxiolytic,it's going to reduce anxiety.
(03:23):
If a drug is an amnestic, itprevents the formation of
memory.
If a drug provides somehypnosis, this can induce sleep
and unresponsiveness.
And if we're using drugs thatprovide analgesia, you may think
of narcotics, opioids, uh,fentanyl, uh, ketamine and
presidex uh provide someanalgesia.
(03:44):
However, propofol does not.
Now, getting into some of oursedative drugs, propofol, it's a
GABA-A agonist.
It has a very quick and rapidonset.
Uh, the duration of action isactually fairly short, somewhere
between five and ten minutes.
It does not give any analgesia.
(04:04):
So you, if you have a patientwho is uncomfortable, you need
to pair it with an agent that isgoing to provide some pain
control.
Propofol has some anti-emeticproperties, it can lower ICP,
reduce cerebral metabolism.
And the reason why its durationof action is so short is it
works by redistribution becausewhen you inject propofol into a
vein, very quickly does thatdrug circulate around, go to the
(04:28):
brain, and very quickly will itredistribute.
And that's why it has thatshort duration of action.
Another drug you may see usedas a sedative in the ICU is
medazlam, okay, or versed.
Versead being a versatilesedative.
Midazlam is a benzodiazepine.
It's going to give goodanxiolysis.
It's going to give goodamnesia.
(04:51):
All right.
It's not going to giveretrograde amnesia.
It's not going to make youforget what's happened, but the
moment you give it, you get thatantigrade amnesia.
So going forward, thosememories become harder to form.
Versus, and a lot of thebenzodazpines, uh, minus rhyming
masolam, that's a veryanesthesia-specific drug, but
the majority of benzodazabineshave very long contact-sensitive
(05:14):
half-lives.
They accumulate.
They're not really reliable fordeep sedation or a very rapid
and brisk wake up.
Ketamine is used in sometimesthe ICU and a lot in anesthesia.
It provides a disassociativetype of anesthetic.
Ketamine is a unique drugbecause it works on our NMDA
(05:36):
receptors.
It's an NMDA antagonist.
And so what's unique aboutketamine is, and you may have
seen this in uh the ICU, butketamine can be used to help
preserve those airway reflexes,that respiratory drive.
It can give some analgesia.
It's great in asthmatics, ithas some bronchodilatory
properties, and it can uhincrease your heart rate, uh,
(05:59):
your blood pressure.
There's a little bit ofresearch on talking about
increasing that ICP unlessthey're well sedated.
But ketamine is a very usefuldrug, and we use it a lot in
anesthesia.
Dexamedatomidine, uh, this is aselective alpha-2 agonist.
Um, I love Prestodex.
Love Prestodex and anesthesia.
Funny, I didn't really like itin the ICU.
Because at that time, and I wasin the ICT many, many years
(06:21):
ago, 2012, 2013, um, Prestodexwas uh oftentimes used by
itself, and now I think it'spaired a lot.
But it gives that sedation-likenatural sleep.
It's not a respiratorydepressant, which is very useful
in anesthesia.
It's great for somebody whoneeds some help, being
comfortable on BIPAP, maybesomebody who's going through
(06:41):
alcohol withdrawal, weaning ventmodes, great, great to use.
Pressidex, slower onset.
You give that bolus dose, thatone mic per kilo, over 10
minutes, and you're gonna seethat bradycardia.
It also causes transienthypertension.
I said PrestX is an alpha-2agonist.
It has a specificity for thealpha 2 to alpha 1 receptor of
(07:04):
about 1600 to 1, whilequonidine, another alpha 2
agonist, is much less, that 200to 400 to 1.
So when you rapidly bolusPrestex, you may have seen this,
you may not.
You'll really see it if youhave an art line in, but you'll
get transient hypertension.
Okay?
So that pressure will go up andvery quickly will go down.
It takes about a minute for itto hit because you lose
(07:24):
specificity because you'rebolusing so much, so you're
gonna affect your alphainterceptors as well, and then
it will very quickly go backdown, and then you'll see that
ridicardia.
Now, let's talk aboutparalytics.
Paralytics are going to stopthat skeletal muscle movement,
but they don't do anything tothe brain.
The scariest thing you can everhave is a patient who is
(07:46):
paralyzed, but they can hear,they can feel, they can
remember, but they can'trespond.
Paralytics give no anxiolysis,no amnestic, no pain control.
There are two types ofparalytics or muscle relaxants.
Depending on who you're talkingto, sometimes whenever you're
giving report an anesthesia andyou say, Oh, um, we paralyzed
(08:11):
and reverse them, patients willreally, what happened?
So many times what we say ismuscle relaxants.
You have two types.
You have depolarizing andnon-depolarizing.
The only depolarizer weroutinely use is substantial
choline.
And it chemically is twoacetylcholine molecules joined
together.
It mimics that action ofacetylcholine, it will
(08:32):
depolarize and it will stayattached until it dissipates
away.
The non-depolarizers, and youhave steroidal like rock
uronium, you also havecisacicurium or nimbex.
They competitively blockacetylcholine at those nicotinic
receptors.
All right, and you all areprobably very familiar with
cisatricurium or nimbex.
(08:54):
Succinyl choline should onlylast a couple minutes, it has a
duration of about five to tenminutes, and it has a very, very
quick onset.
We use it for rapid sequenceinductions or intubations.
And there are some risks withsuccinyl choline.
It's not benign.
There it can be a malignanthyperthermia trigger, which is
um, you know, a pharmacogeneticdisorder that can uh very easily
(09:16):
uh lead to uh patient death,and is something we talk about
in anesthesia that's associatedwith our volatile anesthetics as
well.
Succinyl choline can also causea rapid increase in your
potassium, can causehyperkalemia.
It's contraindicated inpatients who uh have uh burns,
uh crush injuries, have been uhlaying in the bed for days on
(09:37):
end because your extrajunctionalreceptors can proliferate, and
then whenever you give it uhgive succinyl choline, uh it
will cause a huge amount ofpotassium to leak outside and
cause that hyperkalemia.
Now, rock uronium, this isprobably one of the paralytics I
use the most.
So it's a non-dipolarizer, it'sa steroidal.
(09:58):
And you can always remember thesteroidal muscle relaxants
because uh they're gonna be rockuronium, vecuronium,
pancuronium, I would sayrhonsomroids.
So that's a good way toremember the steroidal muscle
relaxants.
Quick onset, 45 to 60 seconds.
You can use it in a place ofsuccinylcholine as uh your RSI
(10:21):
dose.
And then it can lastapproximately 35 to 70 minutes,
and uh it can be reversible withSegamidex or Neosigmine.
Segamidex is a completely uhtrue reversal, kind of how
protamine can encapsulate thatheparid molecule.
Segamidex encapsulates thatrock eronium molecule.
(10:42):
All right.
Neosygnine was the older rev wewould call it a reversal, but
it's not really a reversal, it'scompetitive antagonism and had
a lot of bad side effects.
Uh cisatricurium or nimbex, sothis is great because it has a
little organ uh-independentelimination.
As long as somebody is warm, aslong as somebody um is given
(11:06):
enough time, NIMBEX metabolizespretty quickly.
All right, you can't usepsychotics for it.
Um, it's great for liver orrenal failure patients, and it's
uh often used in a prolonged,extended stay.
Um, but it's great for uhparalysis.
Now, when it comes to uhsedation, sedation changes the
(11:30):
brain.
All right, paralysis changesthe body.
Okay, sedation is going tocreate that anxiolysis while
paralysis is going to stop youfrom moving.
So if you see a paralyzedpatient and their heart rate
increases, they go from a normalsize rhythm, a heart rate of 75
to 80, to 120.
(11:52):
What could that mean?
Could that mean pain?
Could that mean panic?
Could that mean hypoxia?
Could that mean all three?
All right.
When you think of paralysis,all right, you need to be giving
some anxiolysis, some paincontrol.
So there are times where youdon't need paralytics, you just
(12:12):
need sedation.
What are some examples of this?
Ventilator tolerance.
Sedation will decrease thatanxiety, that dyspnea.
Severe anxiety, okay, forpatient comfort.
Maybe somebody has a veryelevated ICP, propavol can
decrease your CMRO2.
That's ruthless metabolic rateof oxygen consumption.
(12:33):
Alcohol withdrawal, press X isgreat for it.
It decreases those uhcatecholine surges and uh
seizures.
It is uh a wonderful uh some ofthe said it does propovol can
suppress that cortical activity,benzogasines are very commonly
used in seizures.
So, what are your sedationgoals?
All right, you're very familiarwith the RAS scores, negative
(12:55):
one to negative two, to helpwith that ventilator tolerance.
And if you want that uh deepersedation, a RAS of negative four
to negative five, preventingICT spites, severe respiratory
failure, things like that.
In anesthesia, sedation israrely the only plan, especially
in airway manipulation.
All right.
Now, when might we useparalysis?
(13:17):
So paralysis all is all aboutmechanics and not comfort.
It's great for that rapidsequence induction to prevent
those reflexive lottic closuresto make intubation easier.
Paralysis is great in Rs.
We need to get those low tidalvolumes in, that's strict
control.
Proning is very, very useful.
Controlling ICP so there's nocoughing, no shivering, or
(13:40):
refractory event uh desyncrasy,all right, to remove that
muscular effort.
If you can't get somebody totolerate the ventilator, you
need to sedate them and then youcan relax them or truthfully
paralyze them.
So the order matters sedation,then paralysis.
All right.
You want to see that patient'srespiratory drive, that's just
(14:01):
because we're talking about anintubated and ventilated
patient.
You want to see thatrespiratory drive, you want to
see that ventilator be able towork.
Think of that arts patient.
Okay, so you may have to treatthat pain, you may have to treat
that discomfort with not only asedative, maybe a narcotic for
(14:22):
pain control, and then aparalyzed patient.
But you never want to havesomebody who is just getting a
paralytic.
That's why in anesthesia we usea balanced approach.
And so we think of anesthesiawith multiple needs.
Do we need amnesia?
Do we need anxiolysis?
Benzovazepines can be veryuseful.
(14:43):
Do we need hypnosis or sedationor induction drugs?
Propofol, very, very commonlyused.
Do we need pain control?
Opioids, ketamine,dexaminatomidine helps uh
prevent pain and reduce opioidconsumption.
And then if we need somebodyimmobile for a procedure, we're
going to use a paralytic or amuscle relaxant.
(15:03):
Now, some very commoncombinations of drugs you'll see
is your RSI combinations,propofol and raw uronium.
That rapid sequence induction,no coughing, fast on, fast off,
great in the OR, great in theICU.
That hemodynamically unstablepatient.
Maybe we're going to useautomatate.
(15:23):
All right.
Automatate can help preservethat blood pressure and heart
rate.
Sometimes it's ketamine aswell.
If you're using succinylcholine, okay, rapid airway
control, maybe that patient hasthe full stomach.
All right.
But do they have anycontraindications for succinyl
choline?
Because if you give enough rockuranium, it will have almost as
quick of an onset as succinylcholine, but without those
(15:46):
dangerous side effects.
Ketamine and rock, great forthat asthmatic.
Maybe somebody who is somewhathypotensive because ketamine
will help maintain thatsympathetic tone, but you really
need, you really need to makesure that patient has
catecholamine reserves.
And then Prestidex, a wonderfuldrug.
It's not a paralytic, it's notan opioid, it's the alpha-2
(16:09):
agonist, and it can help reduceyour opioid consumption.
It's great for sedation.
Anytime you do an awakefibroptic intubation, I love
Prestadix.
I give it to almost everyanesthetic.
It's great for pediatricwake-ups, for vent weeding,
things like that.
What might be your go-to ICUcombo, all right, for your RSIs?
You're probably seeing propopoland rock, ketamine and rock.
(16:31):
Now, when it comes tomonitoring for paralysis, some
very important questions.
Is that patient adequatelysedated?
And are you seeing vital signsto reflect that?
How are you infusing thesedrugs?
If it is a peripheral IV, youneed to make sure that it is
actually in, that it is running.
(16:52):
Because if you're giving lowdose through a peripheral IV, it
may take hours before you seethat it is infiltrated.
This is why it's great if youhave a central line, check it,
make sure that you are using it.
Is the airway manageable ifsomething changes?
Okay.
If you're if I'm there in theICU about to intubate somebody,
(17:13):
I need to have not only a planA, but a plan B and a plan C for
managing that airway.
If I can't get that airway,what am I going to do?
How am I going to breathe forthat patient if I paralyze them?
And you probably see this oftenas a good critical care nurse.
How do you handle hypotensionafter you give these drugs?
Is the vent right there dialedin?
Do you have an ambu bag?
(17:34):
Do you have everything youpossibly need?
Now, when it comes tomonitoring for sedation, some
people use the bispectral indexmonitor, the biz monitor.
40 to 60 is going to be thatanesthetic level state.
Okay.
60 to 80 is going to be thatgood sedation state.
When you start seeing uh 20 to40, all right, when you start
seeing 0 to 20, you're talkingabout almost an isoelectric
(17:57):
line, heavy, heavy sedation.
Tachycardia, hypertension.
These can be signs of pain,anxiety.
This can be a patient that istoo light.
Okay?
Anytime you see lacrimation ortearing, all right, that is a
sign that that sedation was alittle light.
(18:19):
All right.
Maybe you even see themwincing.
Remember, a paralyzed patientcannot tell you that they're
hurting, but their autonomicsystem still can react.
How do you monitorneuromuscular blockade?
Oftentimes you use the train offour monitor.
In the ICU, a lot of timeswe're looking for one to two
twitches.
In the OR, we like deepparalysis.
(18:40):
Okay?
Typically, no twitches to onetwitch, where the majority of
those receptors are blocked.
Now we don't want deepparalysis for so long that we
have to give extremely highdoses of our reversal agent, but
there are consequences for notenough neuromuscular blockade on
board.
In the ICU, all right, this issomeone fighting the vent,
(19:00):
coffin.
In the OR, this is a patientmoving.
Maybe a laryngeospasm uh withlight anesthesia during LMA
youth.
Anything like that can happen.
So we have to be very consciousof the drugs we use.
When we remove that movementfrom the patient, we can remove
(19:21):
feedback.
So we want to monitor them.
We want to make sure that theyare safe.
And a few things to mention forthinking about these drugs.
What are the reversals forthem?
For our benzodasbenes, we haveor mazocon or flumazinyl.
For our opioids, we have narcanor naloxone.
Propofol doesn't have areversal agent, it's time.
Ketamine is the same way.
(19:42):
Prestex is the same way.
You have to use some cautionwith flumazenil and
benzodasmines if they're achronic benzodaspine user.
Naloxone or narcan can causethat catecholamine surge, can
cause pulmonary edema.
For your paralytics, cegamatexfor your steroidal, or neositz.
For your non-steroidal.
(20:03):
Alright.
Neostigmine, once again, not atrue reversal.
It works by competitiveantagonism.
So that surium and the ICoftentimes are turning off for
time.
And substantial choline, allright, is metabolized by
pseudocolonesterase.
So someone can bepseudocolinesterase deficient.
And substance choline can gofrom lasting to five to ten
minutes to twenty to thirty, tosometimes hours and hours.
(20:26):
Remember, set effects are goingto affect the mind, paralytics
are affecting the body and themovement.
They're different co uh they'redifferent tools for
accomplishing different goals.
And it's very important thatyou understand the safety with
them.
Alright?
So whenever you are thinkingabout coming into anesthesia
doing and practicing as a CRNA,it's important that you
(20:48):
understand these drugs.
And the best way to understandthese drugs is to do what you're
doing now, working in the ICU.
So I'm gonna go back through,add a couple of things in the
chat, and then we'll open it upto some QA's.
Alright?
Oh yeah, my uh sure, it says uhsynesthesia.
(21:08):
So uh um I own uh syneshesiaCRNA.
I do we have a company thatdoes uh education tracking, and
um we use it for C RNA programsto track your evaluations, your
cases, uh things like that.
Alright.
Any questions in the chat forme related to NC or any of the
(21:30):
topics we talked about today?
It's important to remember thatwhenever you have patients that
are receiving thesemedications, that you are
monitoring them.
Uh, what is my favoriteanesthesia drug and why what is
(21:54):
my least favorite?
Honestly, I think my favoritedrug is Presidex.
I love Dexmedatomidine.
Uh why?
It's smooth wake up.
Patients, uh patients just doreally well with it.
Whenever I think aboutformulating an anesthetic plan
and uh postoperative uh goals,I'm gonna think about a patient
(22:14):
who is back to themselves, who'srelaxed, who doesn't have much
anxiety, and that's why.
My least favorite, you know, Inever I never take a drug out of
the out of the toolboxcompletely.
There's always an indicationfor one.
I would say my least favorite,and it's not truly an anesthetic
drug, but it's metaclopromideor reglin.
Um, you know, it's a gastricprokinetic.
(22:34):
It makes some people very, veryanxious and it uh can cause
them a lot of anxiety.
It it was a very old schoolthing, you would give it before
C-sections, and by the time uhyou left the uh labor room, got
them into the OR to put in theirspinal, they're even more
nervous.
So um I don't really likegiving Reglin unless there's
that true indication for it.
(22:55):
Uh why am I checking uh CKwhenever my patient's on a
propofol drip?
So uh there's a syndrome, uhpropofol uh infusion syndrome,
whenever you give propofol forextended periods of time.
All right, propofol is uh haslipid content in it, and it can
cause some interesting sideeffects whenever given for a
prolonged period of time.
So you'll see in the ICU, wewill look at caloric intake from
(23:18):
propofol.
We will look at uh we'llmonitor urine because it can
change the color of the urine,and we're gonna monitor um how
much uh of uh other changes uhit may have whenever it comes to
not only your kidneys, but yourliver, anything like that,
whenever you have that extendeduh amount of propool station.
Normally that happens after aday or two or super, super high
(23:41):
uh injection uh super highdoses.
Why why injections suctionchlorine is not used these days?
Umx has honestly fallen out offavor.
The bad side effects, it gets abad rap, it causes um a lot of
uh muscle pain.
The myologies from suctionalcholine can be very, very
severe.
(24:02):
And sometimes you'll hearwhat's uh the myelgies are often
related to fasiculation.
So when you give sux, if youdon't give what we call a
defasiculating dose, you'll seetheir muscle spasm.
Okay, and it can be very, veryintense.
And patients have a lot ofdiscomfort afterwards.
Any golden rules specific toPEDs versus adults with
anesthesia?
(24:22):
Uh certainly.
Um when it comes to kids, uhkids can be very, very
challenging.
All right.
You need um the the highestanesthetic requirements in in a
person comparatively, uh sixmonths to one year, all right.
Oftentimes kids need a muchhigher dosage relative to their
(24:43):
body weight.
Okay?
And so we're always usingweight-based uh dosages as well,
but kids you have to keep deep.
Um, you have to be very carefulwith waking them up.
Uh kids can laryngeosm.
And there are uh stages ofanesthesia.
And that stage, there's uh fourwe talk about stage two is that
hyperexcitability, that's themost dangerous that's when a
child can laryngeosm.
(25:05):
So with kids, wake them up orkeep them deep.
All right, don't try toexcavate them in between.
Um, with adults, I would say mybiggest thing is pay close
attention to your vital signsand look at your entitled CO2.
Your entitled CO2 can be a gooduh good representation of your
cardiac output.
So if suddenly your entitledCO2 drops, you're automatically
(25:25):
thinking, okay, hey, mypatient's cardiac output has
dropped, they are not, they'renot doing well, that's why my
blood pressure guff is cyclingso much, or maybe my A-line's
alarming, my pressure'sdropping, I need to correct it
immediately.
What would be a uh good adviceto prep for CRNA school?
What book can you recommend tostart getting ahead of the game?
That's a really good question,but I tell people this once
(25:48):
you're accepted into CRNAschool, don't do anything except
take keep taking thechallenging patients in the ICU
and take certainly take sometime off before you stop before
you take some time off beforeyou uh start CRNA school.
Have a little time foryourself.
If you are bound and determinedto read anything, I think a
(26:10):
good EKG book is really useful.
You'll get into studyinganesthesia.
I wouldn't uh I wouldn't readmore than about it than you want
to.
If you read if you're bound anddetermined to study anything,
anesthesia, um, I think uh thebasics of anesthesia,
anesthesia, uh, I think this isby Miller and Pardo.
Um one of the easiest books toread.
(26:30):
It's a great intro to allthings anesthesia.
What type of complications uhhave I faced in my practice
before uh intubation or afterextubation?
Um I've seen anything andeverything.
Um one of the most scarycomplications is somebody who's
a full stomach, or maybesomebody who lied about their
NPO status, or it's anemergency, and we have to
(26:52):
intubate them anyways, and theybegin to vomit.
And so trying to preventaspiration, you know, if you
can't get the airway right away,things like that.
So those are things that can bevery complicated.
Or after extuation, making surethat person is awake, making
sure I leave them in care of thePACU nurse in a safe state,
making sure that they're nothaving uh any complications.
(27:13):
All right, we've got about fiveminutes left.
Uh qualifications to becomeCRNAs.
So CRNAs are advanced practiceregistered nurses.
So the United States areprimarily aware of CRNAs
practice, like um, I don't thinkthere's another country that
truly has the practice modelthat we have in the United
States of giving all types ofanesthesia and being involved in
(27:34):
every aspect of it.
Um you would need a bachelor'sdegree, at least a year of
critical care experience, andthen it's a three-year program
where you're going to dohundreds and hundreds of cases,
spend thousands of hours in theOR, and become really, really
good at all types of things,anesthesia.
Oh, um uh the basics ofanesthesia is the name of the
(27:56):
book.
Um if you I I I think any ofthe EKG books, if you just read
like a page or two a day, keepit on your nightstand, it will
dramatically change how you'reable to look at and interpret um
your EKGs.
Um would you move to a levelone if you live uh only by level
two hospital?
You don't have to.
(28:16):
As long as you're taking sick,critically ill patients that are
intubated, sedated, that haveuh pressure requirements, that
you're dealing with art lines,central lines, other bedside
procedures.
Um, if you if you can, ifyou're in a C V ICU where you
see swans, things like that, um,you're right where you need to
be.
(28:37):
Is it possible to work a shoutout in the ICU prior to passing
the NPLEX while studying foryour BSN?
Hung, did you work in the ICUbefore CRNA school?
Uh totally.
I I I would hope most nursingschools have you do a rotation
there.
And you should be able to pick,um, you should be able to pick
your ideal um place to preceptin uh in the ICU.
(28:59):
So if you're able to do that,uh spend your spend your time
there.
This way you can see if that'swhere you want to be.
The ICU is challenging.
Um for me personally, I had uhI started applying to school
right at a year and uh got inpretty quickly after that.
So by the time I started uhCRNA school, I had almost two
years.
What is my personal preferredapproach on induction for trauma
(29:22):
patients?
Trauma is very challenging.
It depends on the type oftrauma, depends on what I'm
there for.
If they're already intubated,all right, I just need to take
them to VOR, get them sedated.
If I'm called, um, if I'mcalled to the ER to help
intubate a trauma coming in,thinking about vital signs, I'm
thinking about uh securing theairway quickly.
Oftentimes it's ketamine androck uronium because I don't if
(29:45):
I don't know their history, I'mvery cautious with just getting
substance calling blindly.
Um and then I'm gonna getsecure their airway, probably
very quickly have uh respiratorystart uh suction them out while
I have things set up for an artline, and then this way I can
monitor blood pressure if we'redoing CPR and you know then
start making sure I haveadequate access.
(30:06):
Because normally they're gonnacome in with like at least one
IV or an IO or something.
If if it's uh you knowhemorrhagic trauma, you know,
maybe I'm gonna get uh nineFrench in the neck to where we
can rapidly infuse uh prettyquickly.
Um what would be my personalpreferred approach on induction
for trauma patients?
I should have an IC beforegetting into nursing school.
Uh we're in the hospital helpstotally.
(30:27):
Working in the hospital is agreat way to do it.
Uh, can you explain steroidalversus non-uh steroidal
paralytics, um, just how theyare metabolized?
So you have your steroidal andyour non-steroidal.
Non-steroidal would be likecisatricurium or atricurium.
Uh, those are metabolized byHoffman elimination.
Okay, so really independent ofuh much liver or kidney
(30:50):
involvement, your steroidal aregoing to have some type of uh
liver or renal involvement.
And so for somebody that hasvery, very complex issues, a lot
of times in the ICU we preferto use cysatural or nimbex so
you can just turn it off.
Now in the OR, 99.9% of thetime I'm using rock uronium
(31:12):
because I have a true reversalfor it, and very quickly I can
go ahead and give rock tointubate, it will last about the
procedure and reverse it at theend.
All right.
You guys asked some excellentquestions.
All right, always enjoy doingthis.
Um follow CSPA on both platformor on all platforms, uh,
(31:33):
Facebook, uh follow us onInstagram, TikTok.
We really love the good uhcommunication in these live
sessions.
Um get on our website at crnaschoolprepacademy.com.
Uh check if you can make it tothe conference in uh Louisville
in June.
It would be phenomenal.
We'd love to meet uh a lot ofyou there.
And um really enjoyed the uh QAand uh shout out to Cynthese
(31:55):
CRNA, um, like I said, mycompany that uh is support
anesthesia education software.
Thank you all so much and havea wonderful uh rest of your day.
Jenny Finnell (32:06):
Thank you for joining us on the Syrian school
prep academy podcast.
We hope today's episode gaveyou clarity and confidence for
the road ahead.
Keep showing up for your goals,keep learning, and keep
believing what's possible foryou.
We're always rooting for you inyour future as a CRNA.
Until next time, take care.
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