Episode 24: Perioperative Hypovolemia…The Tank Is Empty!

In this episode of The Nurse Anesthesia Podcast, Jeremy discusses questions and answers from previous TNA podcast episodes 22 – BIS Monitoring During Anesthesia, 24–Perioperative Hypovolemia: The Tank is Empty, & 25–Albuterol & Epinephrine for the Treatment of Intraoperative Bronchospasm.Here are several examples of questions he discusses in the episode. For a complete review of all the questions, check out the episode wherever you listen to podcasts!1.     Which EEG waveforms is most commonly associated with deep anesthesia and may indicate a patient who is excessively sedated or in a deeplyhypnotic state?a. Alpha waves (8-13 Hz)b. Beta waves (13-30Hz)c. Theta waves (4-8 Hz)d. Delta waves (0.5-4Hz)2.     Which hemodynamic finding is most consistent with severe intraoperative hypovolemia?a. Widened pulse pressure and bradycardiab. Elevated central venous pressure (CVP) and warm extremitiesc. Narrow pulse pressure and tachycardiad. Hypertension and bounding pulses3.     Which is the primary mechanism of action of albuterol causing bronchodilation?a. Inhibition of muscarinic receptorsb. Inhibition of acetylcholine release at the neuromuscular junctionc. Activation of G-proteins causes increased cAMP & smooth muscle relaxationd. Direct inhibition of calcium channels in bronchial smooth muscleAbout the Nurse AnesthesiaOur goal is to build acommUNITY of learning in anesthesia and critical care! Please consider sharing our podcast with your colleagues and friends. Follow us on Instagram@thenurseanesthesiaSign up for The Nurse Anesthesia Coursesour CRISIS MANAGEMENT SERIES is available! RNs can get CEs when they take this course.Learn more about it at www.thenurseanesthesia.comLegal DisclaimerThe Nurse Anesthesia INC. expressly disclaims any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party.Music by Alex Grohl 

Episode SummaryIn this episode of the nurse anesthesia podcast, Jeremy dives into some Airway Management Adventures! He discusses three airway cases from the Emergency Department to the Operating Room. Each case illustrates critical decision-making under challenging circumstances where key actions by the CRNA are essential. The cases include information on preoxygenation with nasal cannula and a non-rebreather mask, RSI, successful first-pass intubation using video-laryngoscopy, cricothyrotomy, and awake intubation. Major themes discussed in this episode involve preparation with airway plans, checklist use, stress preparation, adaptability, team coordination, and continuous learning from both success and difficulty in airway management. Resources/information discussed in podcast·         Get your free The Nurse Anesthesia Crisis Checklists at www.thenurseanesthesia.com·         Sign up for our Crisis Management Video Series. You’ll get 10 different crisis management videos packed full of the most up-to-date information. ·         Nurses…you can get CE credits when you sign up for the Crisis Management Video Series. About The Nurse AnesthesiaWe are building a commUNITY of learning in anesthesia and critical care! We are educators and clinicians who want to provide valuable information to anyone interested in anesthesia and critical care. We’re here for you!For anyone who wants to learn or review anesthesia concepts…we will set you up for a successful educational jOURney by providing short, meaningful courses to accelerate your nurse anesthesia learning, tackle your training, and become the successful CRNA you have always dreamed of. Let's do this together. It's Go Time! Sign up for The Nurse Anesthesia CoursesOur CRISIS MANAGEMENT SERIES is currently available! RN’s get CE credits when they purchase this series.Learn more about it at www.thenurseanesthesia.com   Follow us on Instagram @thenurseanesthesia Legal DisclaimerThe Nurse Anesthesia INC. expressly disclaims any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party. Music by Alex Grohl  

In Episode 26 we welcome a special guest…Rhea Temmermand from the Atomic Anesthesia Podcast! Jeremy talks with Rhea about cognitive aids—like crisis checklists—which are essential tools in anesthesia for guiding rapid decision-making during high-stakes medical emergencies. Originally inspired by aviation’s Crew Resource Management, these aids were adapted for anesthesia…giving rise to Anesthesia Crisis Resource Management (ACRM). Using crisis checklists can help enhance performance, boosts patient safety, and supports better outcomes in perioperative care. This was a great conversation with Rhea!Oh yeah…and don’t forget to grab your FREE Anesthesia Crisis Checklists from www.thenurseanesthesia.com About The Nurse AnesthesiaWe are building a commUNITY of learning in anesthesia and critical care! We are educators and clinicians who want to provide valuable information to anyone interested in anesthesia and critical care. We’re here for you!For anyone who wants to learn or review anesthesia concepts…we will set you up for a successful educational jOURney by providing short, meaningful courses to accelerate your nurse anesthesia learning, tackle your training, and become the successful CRNA you have always dreamed of. Let's do this together. It's Go Time!Sign up for The Nurse Anesthesia CoursesOur CRISIS MANAGEMENT SERIES is currently available! RN’s get CE credits when they purchase this series.Learn more about it at www.thenurseanesthesia.com  Follow us on Instagram @thenurseanesthesiaLegal DisclaimerThe Nurse Anesthesia INC. expressly disclaims any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party.Music by Alex Grohl Mixed & Edited by Next Day [email protected]

Asthma is a chronic inflammatory disorder of the airways characterized by hyperresponsiveness, variable airflow obstruction, and airway remodeling. In the OR, we’re less concerned about chronic control and more focused on acute airway events…namely, bronchospasm.Bronchospasm during general anesthesia can be insidious. You may see rising peak airway pressures, decreased tidal volumes, wheezing if you’re lucky…and if you’re unlucky…desaturation and hypotension. Time is tissue. That’s when it’s time to get medications like albuterol and epinephrine out of the anesthesia cart.In today’s episode, Sass and Jeremy discuss the pharmacology of albuterol and epinephrine as they relate to the management of intraoperative bronchospasm. ReferencesMaddah SA, et al. The Effect of Albuterol Spray on Hypoxia and Bronchospasm in Patients with Chronic Obstructive Pulmonary Disease (COPD) under General Anesthesia: A bouble-Blind Randomized Clinical Trial. Ethiop J Health Sci. 2023;33(3):491-498. von Ungern-Sternberg BS, et al. Effect of Albuterol Premedication vs Placebo on the Occurrence of Respiratory Adverse Events in Children Undergoing Tonsillectomies: The REACT Randomized Clinical Trial. JAMA Pediatr. 2019;173(6):527-533.Resources/information discussed in podcastGet your free copy of The Nurse Anesthesia Crisis Management Checklists at www.thenurseanesthesia.com  About The Nurse AnesthesiaWe are building a commUNITY of learning in anesthesia and critical care! We’re educators and clinicians who want to provide valuable information to anyone interested in anesthesia and critical care. We’re here for you!For anyone who wants to learn or review anesthesia concepts…we will set you up for a successful educational jOURney by providing short, meaningful courses to accelerate your nurse anesthesia learning, tackle your training, and become the successful CRNA you’ve always dreamed of. Let's do this together. It's Go Time!Sign up for The Nurse Anesthesia CoursesOur CRISIS MANAGEMENT SERIES is currently available! Registered nurses get continuing education credits (CEUs)Learn more about it at www.thenurseanesthesia.com  Follow us on Instagram @thenurseanesthesiaIf you have an idea for a show, please let us know. Legal DisclaimerThe Nurse Anesthesia INC. expressly disclaims any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party.Music by Alex Grohl 

Episode 23 begins with Jeremy and Sass discussing the historical background of cannabis or “marijuana” use, and then dive into how this psychoactive drug affects each body system. They focus on what you need to know when providing anesthesia for an individual who is a chronic user or acutely intoxicated. Get ready…it’s go time! ReferencesHorvath C, et al. “Marijuana Use in the Anesthetized Patient: History, Pharmacology, and Anesthetic Considerations.” AANA journal vol. 87,6 (2019): 451-458.King DD. Anesthesia for Patients Who Self-Report Cannabis (Marijuana) Use Before Esophagogastroduodenoscopy: A Retrospective Review. AANA J. 2021 Jun; 89(3): 205–212.Kraft B. Lack of analgesia by oral standardized cannabis extract on acute inflammatory pain and hyperalgesia in volunteers. Anethesiology. 2008 Jul;109(1):101-10. Teitel A, Bozimoski G. A review of the pharmacology and anesthetic implications of cannabis. AANA J. 2020;88(3):237-243.Wiseman LK, et al. The Effect of Preoperative Cannabis Use on Postoperative Pain Following Gynaecologic Oncology Surgery. J Obstet Gynaecol Can. 2022;44(7):750-756.About The Nurse AnesthesiaWe’re educators and clinicians who want to provide valuable information to anyone interested in anesthesia and critical care. Our goal is to build a commUNITY of learning in anesthesia and critical care. It’s go time!Sign up for The Nurse Anesthesia CoursesOur CRISIS MANAGEMENT VIDEO SERIES is currently available! Get 50% off the current price with the code: TNA50Get our FREE Crisis Checklists – seriously…get them for FREE. They’re a great resource for anyone working in anesthesia or critical care.Learn more about it at www.thenurseanesthesia.com  Follow us on Instagram @thenurseanesthesiaLegal DisclaimerThe Nurse Anesthesia INC. expressly disclaims any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party.Music by Alex Grohl 

Episode SummaryMonitoring the depth of anesthesia, as a CRNA, is important for any surgical or medical procedure. In this episode of The Nurse Anesthesia Podcast, Jeremy and Sass review the bispectral index (BIS) monitor. They discuss the various electroencephalographic (EEG) waveforms the BIS monitor uses to determine depth of anesthesia, and identify the factors and medications that influence the BIS monitor. They finish the episode with an interesting set of studies that investigated at how electromyographic (EMG) activity is incorporated into the BIS algorithm. This is definitely one episode you’ll want to download and catch up on! References1.    Gu, Yichun et al. “Effectiveness Assessment of Bispectral Index Monitoring Compared with Conventional Monitoring in General Anesthesia: A Systematic Review and Meta-Analysis.” Anesthesiology research and practice vol. 2024 5555481. 7 Aug. 2024. 2.    Messner, M et al. “The bispectral index declines during neuromuscular block in fully awake persons.” Anesthesia and analgesia vol. 97,2 (2003): 488-491. 3.    Schuller, P J et al. “Response of bispectral index to neuromuscular block in awake volunteers.” British journal of anaesthesia vol. 115 Suppl 1 (2015): i95-i103.  About The Nurse AnesthesiaWe are building a commUNITY of learning in anesthesia and critical care! We are educators and clinicians who want to provide free and valuable information to anyone interested in anesthesia and critical care. We’re here for you!For anyone who wants to learn or review anesthesia concepts…we will set you up for a successful educational jOURney by providing short, meaningful courses to accelerate your nurse anesthesia learning, tackle your training, and become the successful CRNA you have always dreamed of. Let's do this together. It's Go Time! Sign up for The Nurse Anesthesia CoursesOur CRISIS MANAGEMENT SERIES is currently available! Get 50% off the current price with the code: TNA50Learn more about it at www.thenurseanesthesia.com   Follow us on InstagramWe post about all things anesthesia. Follow us on Instagram @thenurseanesthesia Legal DisclaimerThe Nurse Anesthesia INC. expressly disclaims any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party. Music by Alex Grohl 

In this episode of The Nurse Anesthesia Podcast, Jeremy discusses questions and answers from the previous TNA podcast episodes 14 - POCUS of the Cricothyroid Membrane, 15 - How Anesthesia uses Ketamine, 19 - Push-dose Vasopressors, and 20 - Vasoplegic Syndrome.Here are several examples of questions he discusses in the episode. For a complete review of all the questions, check out the episode wherever you listen to podcasts!1. Which artery extends the length of the cricothyroid membrane?a. Superior thyroid artery b.Inferior cricoid arteryc.Transverse cricothyroid arteryd.Anterior tracheal artery 2. Which are two situations where ketamine can be used as an induction agent to secure an airway during an emergency situation? (SELECT 2)a. An agitated patient in the ED requiring intubation*b. Malignant hyperthermiac. Neuroleptic malignant syndromd. Massive hemorrhage with hypotension* 3. Which medication can be administered at the site of a norepinephrine intravenous extravasation?a. Epinephrineb. Methylene bluec. Phentolamine*d. Labetalol4. After vasopressors, IV fluids, and vasopressin have been administered for suspected vasoplegic syndrome, which is the next most effective treatment? a. Methylene blue*b. Verapamil c. 5% Albumind. Calcium chlorideAbout The Nurse AnesthesiaWe are building a commUNITY of learning in anesthesia and critical care! Follow us on Instagram @thenurseanesthesiaSign up for The Nurse Anesthesia Coursesour CRISIS MANAGEMENT SERIES is currently available! Learn more about it at www.thenurseanesthesia.com  Legal DisclaimerThe Nurse Anesthesia INC. expressly disclaims any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party.Music by Alex Grohl Mixed & Edited by Next Day [email protected]

In this episode of The Nurse Anesthesia Podcast, Jeremy & Sass discuss what happens when the routine treatments for intraoperative hypotension don’t work, and focus on the interventions you can consider when refractory hypotension occurs. They talk about different causes of refractory hypotension with a focus on vasoplegic syndrome. They discuss the differences between refractory hypotension and vasoplegic syndrome, and then identify the potential causes and specific treatments for this rare condition. ReferencesArevalo VN. Methylene Blue as an adjunct to Treat Vasoplegia in patients undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass: A Literature Review. AANA J. 2018;86(6):455-463.Habib MA. Methylene Blue for Vasoplegic Syndrome Postcardiac Surgery. Indian J Crit Care Med. 2018;22(3) 168-173.Hosseinian L. Methylene Blue: Magic Bullet for Vasoplegia. Anesthesia and Analgesia. 2016;122(1):194-201.Levy B. Vasoplegia Treatments: The past, the present and the future. Critical Care. 2018;22(1):52.Liu H. Vasoplegic syndrome: An update on perioperative considerations. Journal of Clinical Anesthesia. 2017;40:63-71.About The Nurse AnesthesiaWe are building a commUNITY of learning in anesthesia and critical care! For anyone who wants to learn or review anesthesia concepts…we will set you up for a successful educational jOURney by providing short, meaningful courses to accelerate your nurse anesthesia learning, tackle your training, and become the successful CRNA you have always dreamed of. Let's do this together. It's Go Time!Sign up for The Nurse Anesthesia Coursesour CRISIS MANAGEMENT SERIES is currently available! Learn more about it at www.thenurseanesthesia.com  Follow us on InstagramWe post about all things anesthesia. Follow us on Instagram @thenurseanesthesiaLegal DisclaimerThe Nurse Anesthesia INC. expressly disclaims any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third party.Music by Alex Grohl Mixed & Edited by Next Day [email protected]

Anesthesia induced hypotension is commonly treated with push dose vasopressors. Today Jeremy & Sass dive into what the evidence is showing us about the use of phenylephrine, ephedrine, and norepinephrine IV bolus doses. We talk about cerebral oxygen concentrations and cardiac output when administering these vasopressors, and ultimately ask ourselves…should we be less pushy?ReferencesKee W, et al. Randomized double-blinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. Anesthesiology. 2015 Apr;122(4):736-45. Larson S, et al. Effect of phenylephrine on cerebral oxygen saturation and cardiac output in adults when used to treat intraoperative hypotension: a systematic review. BI Evid Synth. 2020 Sep 15;19(1):34-58. Meng L,et al. Effect of phenylephrine and ephedrine bolus treatment on cerebral oxygenation in anaesthetized patients. Br J Anaesth. 2011 Aug; 107(2): 209–217.  Mohta M, et al. Comparison of the potency of phenylephrine and norepinephrine bolus doses used to treat post-spinal hypotension during elective caesarean section. Int J Obstet Anesth. 2019 May;38:25-31. Nissen P, et al. Phenylephrine but not ephedrine reduces frontal lobe oxygenation following anesthesia-induced hypotension. Neurocrit Care. 2010 Feb;12(1):17-23. Pelaez A, et al. Effect of adrenergic agonists on coronary blood flow: a laboratory study in healthy volunteers. Physiol Rep. 2016 May;4(10):e12806. Pancaro C, et al. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg. 2020;131(4):1060-1065. Sharkey  A. Comparison of Intermittent Intravenous Boluses of Phenylephrine and Norepinephrine to Prevent and Treat Spinal-Induced Hypotension in Cesarean Deliveries: Randomized Controlled Trial. Anesth Analg. 2019 Nov;129(5):1312-1318. Simons C. The Safety and Efficacy of Peripherally Administered Norepinephrine during the Perioperative Period. AANA J. 2022;90(5):387-395.Thiele R, et al. The physiologic implications of isolated alpha(1) adrenergic stimulation. Anesth Analg. 2011 Aug;113(2):284-96. Vallee F, et al. Norepinephrine reduces arterial compliance less than phenylephrine when treating general anesthesia-induced arterial hypotension. Acta Anaesthesiol Scand. 2017 Jul;61(6):590-600. About The Nurse AnesthesiaWe are building a commUNITY of learning in anesthesia and critical care! For anyone who wants to learn or review anesthesia concepts…we will set you up for a successful educational jOURney by providing short, meaningful courses to accelerate your nurse anesthesia learning, tackle your training, and become the successful CRNA you have always dreamed of. Let's do this together. It's Go Time!Sign up for The Nurse Anesthesia Coursesour CRISIS MANAGEMENT SERIES is currently available! Learn more about it at www.thenurseanesthesia.com  Follow us on InstagramWe post about all things anesthesia. Follow us on Instagram @thenurseanesthesiaComments or Suggestions?We’re here to help you improve your anesthesia learning and practice, and we want to make sure our content is relevant for you. Please contact us on Instagram with suggestionsLegal DisclaimerThe Nurse Anesthesia INC. expressly disclaims any liability in connection with the use of any content in its podcasts, social media posts, and all other published content by any third partyMusic by Alex Grohl