Comprehensive CRNA Interview Review, Exams of Nursing

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Norepinephrine Mechanism of Action (MOA) - A1, A2, B1 agonist. Primary agent used in distributive shock because it's ability to recruit venous volume and augment preload, while increasing arterial tone, and increasing cardiac output. Alpha one causing peripheral smooth muscle contraction. (low dose venous, high dose venous and arterial). Alpha 2 adrenoreceptor agonism actually antagonizes the release of norepinephrine in the CNS, but these receptors are less present in peripheral vasculature and thus, their anti-hypertensive effects are overtaken by A1 agonism. These alpha effects can increase SVR and thereby increase cardiac workload, decrease cardiac output, and increase coronary perfusion pressure. The slight B1 agonism increases inotropy and chonotropy sufficiently to overcome these A1 effects and result in a fairly "pure" vasopressor. Increasing contraction of the heart and increasing AV nodal conduction.

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**First line agent in septic shock Epinephrine MOA - A A B1 - Stimulate Heart Rate through SA node, increase conduction through AV node. Increase contractility to ATRIAL and VENTRICULAR cardiac muscle. B2 - Smooth muscle relaxation. Resulting in dilation of the bronchial tree, coronary arterial dilation. Also plays a role in insulin and glucagon secretion in the pancreas. Also increases cardiac inotropy/chonotropy B3 - Increase lypolysis and thermogenesis in brown adipose tissue. **Cardiogenic shock or other shock states with a cardiac component. Adjunctive therapy in severe septic shock IVP in cardiac arrest to augment CPP IVP while introducing PPV/intubation

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Precedex MOA - Dexmetatomadine is an alpha 2 adrenoreceptor agonist that acts both on the presynaptic neuron and postsynaptic neuron. Inihibiting norepinephrine release pre-synaptically reduces/halts the transmission of pain, while postsynaptically acts to reduce sympathetic tone. The combination of these effects is anesthesia with analgesia and anxiolysis. loading dose is 1 mg/kg while gtt is .2-1.5 mg/kg/hr **This agent is often used for patients who would not tolerate a precipitous drop in their sympathetic tone, for those patients in severe alcohol withdrawal. propofol MOA - Propofol is a lypophylic general anesthetic unlike any drugs of the class benodiazapen, barbituate, or A2 agonist. Its mechanism is proposed to be a GABA (inhibitory neurotransmitter) agonist causing global CNS depression Dosing for procedural sedation of .1-.5 mg/kg as a loading dose with repeat doses. gtt titration ranging from 10-60 mcg/kg/min **Anesthetic

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Sedation for mechanically ventilated ICU patients Procedural sedation Phenylephrine MOA - Pure Alpha adrenergic receptor agonist. Causing increase in SVR through systemic arterial vasoconstriction. This also causes a dose dependent increase in systolic and diastolic blood pressure and thereby decreasing cardiac output, especially in patients with heart failure. 40-100 mcg IVP for hypotension during anesthesia Titrated as a drip from .5-9 mcg/kg/min **used rarely as adjuncitve therapy for patients in septic shock. Used more often in vasodilatory shock states such as neurogenic shock/ shock from epidural/spinal blocks. vasopressin MOA - arganine/vasopressin receptor agonist causing potent increase in SVR through 2 different MOA.

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

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2)Sodium re-absorption across the ascending loop of HENLe. 3)Binding to V1 receptors on vascular smooth muscle, causing vasoconstriction. Normal concentrations of the drug are below it's vasoactive range, nevertheless in severe hypovolemic shock, AVP increases do contribute to increase in SVR. 1.8 u/hr **used as adjunctive therapy in septic shock. Can be used as a first line agent in a pulmonary hypertensive patient in shock states. Ketamine MOA - NMDA receptor antagonist blocking glutamate and thus introducing a cateleptic/dissociative (which is dose dependent) state. N-Methyl-D-Aspartate is a receptor in the CNS responsible for conduction of action potentials associated with memory. Antagonizing these receptors does not allow for the transmission of these signals. .1-.5 mg/kg IVP analgesia

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1-5 mg/kg IVP dissociation (procedural) 15-90 mcg/kg/min or 1-6 mg/min for maintenence of anesthesia. Care is to be taken as to not induce a subdissociative like state. DSI/RSI/RSA adjunct analgesic in opiate dependent patients. Nicardapine MOA - Voltage sensitive calcium channels regulate the influx and release of calcium in response to action potential and depolarizing signals. Nicardapine inhibits the influx of calcium through these channels thus affecting calcium concentrations. This inhibition results in vasodilation more specific to coronary and cerebral vessels. This vasodilation decreases SVR and opens up the afterload of the heart, increases oxygen delivery and blood flow during vasospastic states, regulates blood pressure during hypertensive emergencies and post transplantation where goal blood pressures need to be tightly met. Has little affect on SA/AV nodal conduction velocity.

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Begin infusion at 5 mg/hr and titrate by 2.5 every 5-15 minutes for goal blood pressure. Clavidipine MOA - Inhibiting influx of Calcium in L-type calcium channels in arterial smooth muscle to decrease SVR. Begin gtt at 1-2 mg/hr. Double dose every 90 seconds for goal blood pressure. Note: that for every 1-2 mg/hr increase in dose, a 2-4 mmHg drop in the systolic blood pressure should be seen. Midazolam - enhances GABA effects at GABA-a receptor site producing sedative/hypnotic/anxiolitic/anti- Note: this drug is not used for ICU sedation - increasing the occurence of ICU associated delerium. But can be used for procedural sedation/alcoholic withdrawal states. IVP 1-2.5 mg over 2 min with a 2 min waiting period in between dosing. Generally not exceeding 5 mg IVP.

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How do you wean a patient from the ventilator - Weaning is done on a low-stretch protocol at our ICU. Readiness testing for extubatio includes the following -Fi02<40% -Cause of RF has improved/resolved -PEEP < -patient is hemodynamically stable -patient has a cuff leak -patient has a mental status that allows for handling of secretions and protection of one's own airway. Patient can lift head off of pillow -patient is calm/comfortably breathing. RSBi<105 where RSBi = RR/Fi02 .. Ie 20/. -MIP more negative than - -Acid Base is neutral -Can the patient cough on command? What is End tidal c02? - It is the partial pressure of c02 in an exhaled breath

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

• Provides instant feedback on perfusion (how effective c02 is being transported through vascular system) -Provides instant feedback on metabolism (how effective cells are generating c Quantitative - waveform with numbers Qualitative- is color change Why do you want to be a CRNA - -Independence and autonomy in my specialization. With increased responsibility and reward. -ability to manage airway and hemodynamics. With advanced techniques/medications. To feel calm and collected as a leader in this responsibility. To improve patient outcomes by implimenting best practice. -to become a trauma anesthetist/resusitationist

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• Through my shadowing I have come to enjoy the profession -to be able to have and support a large family while mantaining my style of living and hobbies that I love. -I want membership in a small/elite profession Why will you do well in the program - work ethic - farm hand, school, societies, work drive - ability to navigate difficult life situations up to this point and will be able to employ techniques that I have already used to overcome challneges integrity - I have a strong moral compass, I am someone that you can trust, someone who will ask for help when needed, can be an example in difficult situations. emotional intelligence - ability to use others emotions coupled with my own to achieve a common goal. I am self aware, kind, and willing to be part of something bigger than myself.

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What is your greatest weakness - As a member of a small and elite profession, what obligations will you have, if any, toward this profession? - ...Advocacy - state and federal ...Time and financial help ... Continual research/publications ... educating the future ... Please explain the difference between SA02 and PA02? - Tell me everything you know about hemoglobin.. - Oxygen carrying capacity 4- sites present in PRBCs Protein Product on Bone marrow and erythropoetin from kidney Necessary to mantian perfusion/ scv oxyhhbg dissociation curve

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13.5-17.5 men 12-15 female oxyhomglobin dissociation curve. What is a shift to the R and the L. What causes these shifts? - defines different partial pressures of oxygen required to saturate the hgb molecule Usually defined as p50 (or a certain partial pressure required for 50% hgb saturation A shift to the right (reduced affinity) means that a high partial pressure of oxygen is required to mantain the same saturation. -increased temp -increased 2-3DPG -increased H+ ion (acidosis) A shift to the left means that a hgb molecule will mantain saturation with a smaller Pa02.

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• decreased temp
• decreased 2-3 dpg
• decreased H+ ion (alkalosis) Q: Tell me about a time when you had to manage a difficult clinical situation. - Q: Tell me about a time when you were working with someone who wasn't pulling their weight, and they had a different value system than yours. How did you deal with this person? - Q: Tell me about a time when you failed. What happened, and how did you recover? - Final panel interview for critical care internship - didn't make it. Interview with CICU at the University of Utah wanted more experience. Capstone at shock trauma I had kept in touch but needed to prove myself with experience as this was my final goal as RN. Worked through SLRMC ICU to IMC ICU to reach my goal after having failed. Being patient is not being passive. It is working deligently toward your goals with a hope that your hard work will pay off in the end. Q: Tell me about a time when you had an ethical dilemma at work. What did you do? - The process of death and dying... Think of one..

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Q: Tell me about a time when you felt it was you against everyone else. You thought you were right and that everyone else was wrong. What did you do? - Q: How do you handle stress? - Tell us about your work experience.** - Q: How do you describe success? - I tend to view success incrementally. As someone who is invigorated by new, complex challenges, I never want to find myself in a situation where I feel like there is nothing left to learn or achieve. Bryan Goals! integrate didactic information and clinical data plan and administer a safe and physiologic anesthetic across the lifespan - evidence based

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translate research evidence to evaluate outcomes The student will demonstrate interprofessional and intraprofessional leadership. Q: Do you foresee any barriers to your education? (finances, time commitments) - What does a CRNA do - Physical assessment - risks to anesthetic administration, risks to procedures. Development of anesthestic management and plan. Anesthetic should be individualized to patient assessment, organ fuction, laborartory values. gathering necessary equipment acting on thoughts concerning assessment (follow up diagnostic tests/labs) Pre-operative teaching/expectations/development of patient relationship

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Initial anesthetic administration/manmagement of hemodynamics initially, continual assessment and communication with providers. Monitoring vital signs every 3-5 minutes, charting accordingly. Line placement, intubation, spinal/regional nerve blocks/ epidural administration. maintenence of anesthesia, hemodynamics, continued communication with team, diagnostic studys and other management necessary. Volatile/inhaled anesthetic, intravenous anesthetic,e ct. Resolution of anesthetic in timely manner and post operative evaluation and assessment. Following patient back to specific care unit and hand off. Q: What questions do you have for us?** -

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If you saw one of your fellow students or colleagues using drugs outside of work/classroom, what would you do? - If it was a question of patient safety, I would immediately confront the collegue concerning this problem. I think this would often depend on the situation, for many people would have a risk of self-harm, or harm of others when confronted with this problem Need to further investigate.. What relationship do I have with this person In what setting did it take place? What is the chain of authority like? If you had to pick a topic for a master's thesis or doctoral dissertation, what might it be? - Ketamine facilitated Rapid Sequence Awake intubation Trauma Resusitation - damage control resucitation Use of TEG or ROTEM in MTP Ventilation in ARDS like the use of driving pressure

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Who (within the field) has influenced you the most? What do you consider the biggest issue facing the profession today? Next 5/10 years? - Scott weingart - ED critical care in NY state Richard Dutton - R. Adams Cowley Shock Trauma Center - trauma anesthesiologist Rich Levitan - ED physician and airway guru Reubon Strayer - EM physician and Airway What is your strongest trait that will help you in your academic/professional career.** - What is your most important weakness that you will struggle with, if any, toward this profession? - What do you know about XYZ School and our program? -

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What if in clinical someone told you were taping your IV wrong. What would you do? - Tell me one of your greatest accomplishments? And at your last job? - Give an example of where you showed leadership. - Give an example of community service. - Give an example of when you worked on a team. - Calcium Channel Blocker Overdose Coding x 3 ` Calcium Insulin High Dose Glucogon Drip 3 pressors Push dose epi Vomit/Aspiration/Ards Paralytic

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Sedation CRRT Give me an example of your problem solving. - Exploring ways to more quickly and effectively evaluate fluid responsiveness End Tidal CO2 with PLR/fluid bolus challenege This problem solving occurs with evaluating fluid/volume responsiveness What have you done to develop or change in the last few years?. - Change is not a passive process. Constant effort. Tranforme as a nurse and team member. -Develop a greater sense of self awareness and emotional intelligence. -Develop a strong humility -Desire to be observant, to ask be extensively curious as to the "why" -Set goals for self-improvement sipiritally, emotionally, physically, and in all aspects of nursing.

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-These goals include advance certifications, daily study of up to date techniques, evaluation of progress, and making specific detailed plans. -Not taking myself to seriously and enjoying the journey as much as the result. Do you work well under pressure? Give an example. - Trauma Gun shot wound to face/abdomen Hypovolemic shock, young. Trauma resusitation. MTP+fentanyl Calcium How do you think you will fit into the program? - What do you want written on your tombstone? - Humble, Hardworking, Father, and Bryan Graduate What will you do if you don't get into the program? - Continue to apply Normal ranges for the following

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RAP

CVP

PAP

PAWP

SVR

PVR

EF - RAP 2-6

CVP 3-8

PAP 20-30/8-15 MEAN <20

PAWP 6-12 (know that to optimize pre-load may mean higher than normal SVR 900-1400 PVR 50-150 EF >50% How do you calculate SVR - <(MAP-RAP)x80 > / CO Where are dopaminergic receptors located? What does their stimulation result in?

• Renal, coronoary, cerebral, and mesenteric - vasodilation

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Beta 1 stimulation results in.. - Inotropy Chonotropy Dromotropy - increased conduction velocity Dopamine MOA, dosing, uses Dubutamine MOA, dosing, uses - Dose 2- 20 mcg/kg/min 2-5 mcg/kg/min = dopaminergic stimulation 5-10 mcg/kg/min = beta 1 stimulation 10-20 mcg/kg/min predominant Alpha stimulation Dubutamine 2-20 mcg/kg/min primarily B1 - Chonotropy/inotropy - B2 and A1 adenergic agonist - B2 being slightly more prevalent than A1 resulting in a more vasodilatory effect.

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Dobutamine - 2-20 mcg/kg/min "inodilator" Beta 1 stimuation and vasodilation due to it's major metabolite 3-0 methyldobutamine. Methyldobutamine is an inhibitor of alpha adrenoreceptors. Milrinone - .25-1 mcg/kg/min phosphodiasterase III inhibitor does not achieve positive inotropic afects through SNS stimulation. This in turn results in increased cAMP and subsequently, increased CA ion influx into cardiac muscle cells. Increased CA in cardiac cells results in increased force of contraction. In the vascular system, cAMP accumulation results in decreased CA ion influx resulting in vasodilation. Due to the lack of SNS stimulation dysrrhythmias are less common than with other inotropes

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Tell me about the anesthesia profession - CRNAs serve in public sector, military OR, ambulatory surgical centers, physican offices, VA, maternity, military, rural anesthetic collaborative groups, free-lancing 50,000-60,000 CRNAs (50,000 in aana) - 1800's 43 million anesthetics/yr 25% more cost effective than 1:4 anesthesiologist/crna ratio.. 110% more cost effective than 1:1 supervision. How do you stay up to date in your practice - I am not one to Go through and read a complete medical journal. I study by disease process, by resusitation technique ect.