What does a CRNA actually do?

This is a great question commonly asked by those considering becoming a Certified Registered Nurse Anesthesiologist (CRNA).

This blog entry will be written through the lens of an independently practicing CRNA because that's what I know. There are multiple practice settings, but we will examine independent practice.

Anesthesia is one of the safest disciplines of medicine. These good patient outcomes result from preparation. I always have a plan prior to performing an anesthetic. Not only do I have a plan A, but a plan B, C, D, and E.

Case Preparation

Work starts the day (or days) before surgery. Every patient scheduled for elective surgery is reviewed by a member of the anesthesia department. We check the electronic medical record for medical history, surgical history, labs, and any number of tests based on the patient's history.

Common exams are electrocardiograms and echocardiograms which provide information regarding heart function. We order any necessary tests or labs prior to surgery.

If the patient is healthy or the case minimally invasive, a minimal workup is appropriate. As complexity increases, so do the preoperative evaluations. All of this to begin forming a customized anesthetic plan and minimize surgical complications.

The workday begins…

The morning of surgery involves a great deal of preparation. After changing into surgical scrubs, I glance at the schedule showing the case load for the day. This is the blueprint for the shift.

I make my way to the operating room. It's necessary to perform a check of all equipment prior to starting cases. This includes the anesthesia machine, suction, and emergency supplies. Equipment varies from case to case.

Preoperative Interview

The last step of the preoperative process is to meet with the patient. This is an opportunity to intimately understand all aspects of a patient. Ordered exams and lab work have resulted by this point and can be reviewed with the patient.

I then discuss the plan with the patient. Together, we find a mutually agreeable “plan A.” Some cases allow for more deviations than others. Anesthesia is a foreign concept to most, so patients put a great deal of faith in your recommendation and ability to successfully execute the plan.

It's terrifying to many, so rapport, reassurance, and honesty are vital.

On to the surgery…

Next comes the fun part, delivering an anesthetic. Each case is different, but all start similarly. The patient arrives in the operating room where vital monitors are applied. Oxygen is applied. Relaxing medications may be administered during this time. Anything to comfort a patient just moments before they undergo anesthesia.

For a general anesthetic, an intravenous cocktail is administered to quickly drift the patient off to sleep. Often times, the airway needs to be secured with one of many styles of breathing tubes. Successfully placing a breathing tube is one of many ways airway proficiency is demonstrated by CRNAs who are trusted to be airway experts.

After the patient is asleep, the surgical team begins to prep the patient. This allows anesthesia time to perform other interventions or begin charting.

Compared to most healthcare professionals, anesthesia doesn't require much documentation. Aside from procedures, everything is charted in real time. No charts to complete after the workday ends.

We have reached the autopilot stage of anesthesia -- The most boring part, especially to watch if/when you shadow a CRNA. The patient is asleep and the surgery is underway.

The primary goal of this stage is to keep the patient vitally stable. The maintenance phase of anesthesia is like driving. Usually nothing exciting happens. Check your surroundings and rear-view mirrors regularly to anticipate and prevent any potential complications.

Other intraoperative responsibilities of a CRNA include patient positioning, adjusting the operative table, and tracking intake and output such as blood loss and urine output.

As the surgery comes to a close, I begin to wake the patient. CRNAs receive good marks if they remove the breathing tube and wake up the patient just as the last suture is tied. There are monitors that provide data as to how "deep" patients are, but none are perfect. There isn’t a switch that can just turn the anesthesia on and off. This is where the art form comes in.

Once the dressings are in place and the patient is stable, it's off to the recovery room, aka post anesthesia care unit (pacu).

Post Operative Care Unit

The PACU time typically lasts 30-60 minutes. During this time, I ensure the patient is vitally stable, pain is reasonably controlled, and they are not nauseated. PACU nurses typically administer the medicines in this setting. If a serious event arises, I receive a phone call to evaluate and intervene.

This sums up a typical general anesthetic.

Duties Outside the Operating Room

Independently practicing CRNAs cover far more than the operating room.

CRNAs cover obstetrics where we perform a variety of interventions including epidurals to help laboring moms.

CRNAs spend time in the emergency department. This includes cardiac arrest management, airway management, invasive line placement, and pain injections.

CRNAs may be consulted in the ICU or medical floors for any of the same interventions.

CRNAs may be responsible for operating a pain clinic within the hospital. This involves evaluating patients and using fluoroscopic imaging to inject medicine that treats chronic pain.

At the end of the day, anesthesia providers are primarily consultants. We are presented with a situation, determine the best course of action, and implement the necessary steps. It’s an amazingly rewarding profession.  CRNAs play different roles in different settings. There are a variety of factors at play that I will cover in future blog entries.

Please comment with your questions or topics you would like to see. Thanks for reading!