TABLE OF CONTENTS

“DISCUSSION TOPICS FOR VERSION 1.0”

Lessons
Lesson One “Anesthesia History”. ........................................................................................................................................... 3

Lesson Two “Basic Anesthesia Concepts” ............................................................................................................................ 10

Lesson Three “Pharmacology of Anesthesia” .......................................................................................................................... 15

Lesson Four “Proper Patient Positioning” .............................................................................................................................. 21

Lesson Five “Gases and The Circuit System” ....................................................................................................................... 24

Lesson Six “Learning The OR” ........................................................................................................................................... 27

Lesson Seven “Anesthesia Machine Check” ............................................................................................................................ 31

CRNA School Prep Course

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 LESSON ONE
“HISTORY OF ANESTHESIA”

Objectives
Know the history and progression of Anesthesia:

1. Identify important figures.

2. Development and uses of pharmacological agents.

INTRODUCTION
Anesthesia: Interventions that eliminate the pain of surgery, and provides partial or total loss of sensation. Loss of
ability to feel pain by medical intervention.

There was surgery before anesthesia, however it wasn’t very pleasant. Most of our anesthetics started out by trial and
error. However, most were not trialed with the intent of relieving the suffering of human kind. Most were trialed as
recreational chemicals (opium, alcohol, coca leaves). Other methods included phlebotomy (bleed patient until
unconscious), nerve compression, and cold. Surgeons just wanted their patients to hold as still as possible to
maximize exposure. Keep screams to a minimum to decrease distractions to the surgeon. This was due to the limited
advances in anesthesia for that time.

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Trial & Error
• Surgery - Has existed for a lot longer than anesthesia has been around.
‣ Opium: “juice of the poppy”
- Mu (µ 1,2,3) receptor agonist are still used today to dull the pain of surgery.
- This is where we get morphine.

• Alcohol: has been used for centuries for anesthesia.

• Coca Leaves: (Cocaine)

‣ Was used for anesthesia, however was not very cardiac stable.
‣ Local anesthetics came out of this.

• Phlebotomy
‣ Exsanguinate the patient until they lost consciousness. Not an efficient method even for that time.

• Nerve Decompression
‣ This was considered fairly effective.

• Cold - Was only available in certain areas during certain times of the year. Not readily available or created upon demand.

• Mandigorria:
‣ A plant that produces scopolamine type compound. Great sedation qualities.
‣ The scopalamine patch used today is a great antiemetic.

History of Pain
• Considered a distraction to the surgeons.
• Pain and illness was considered punishments for sin or misdeeds.
• Was not considered ethically reasonable to diminish these peoples’ pain.
• Before anesthesia the best surgeons where fast.
• The patients would be held down by strong assistants, so the surgery could be performed.

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 Significant Figures in Anesthesia

Oliver Wendell Holmes (1846)

• He was an anatomy & physiology professor who defined anesthesia.
• “Anesthesia is a sleep like state that allows painless surgery”

Dr. Robert Listen (1842)

• He was one of London’s best surgeons, because he could amputate a leg in a little
over 45 seconds. However, one particular surgery resulted in 2 deaths. He was
amputating a leg in this rather rapid fashion, and accidentally cut off the fingers of
one of his assistants. While the assistant was screaming, the doctor moved over to
see what had happened. He accidentally got blood all over the coat of one of the
residents who was observing the surgery. The resident thought that his vital organs
had been punctured, and had a heart attack. The patient later died from infection resulting in 2 deaths in one surgery.

Valerius Cordus (1540)

• He synthesized and wrote the formula for the purified form of ether.
• Ether was made from ethyl alcohol and sulfuric acid. From there it was formulated as a recreational drug that was drank.

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Joseph priestly (1773)
• A clergymen in England who purified nitrous oxide.
• Created by burning ammonium in the presence of iron molecules.
• Also discovered photosynthesis.
• Purified oxygen: He burned mercuric oxide, and got an oxygen production that would increase the flame in the burning of the
candles, and they thought it was some form of fire starter.

Humphrey Davy (1800)

• He investigated the use of nitrous oxide on patients and himself.
• He quit school when he was 16, and discovered that the exchange of oxygen and carbon dioxide took place in the tissues, and not in
the lungs. He noticed that ether also had the same properties, but did not promote it as an anesthetic.
• Wrote a 500pg book on the effects of nitrous oxide, and that is why today we are so familiar with his experiments. (Laughing gas)

Henry Hill Hickman (1824)

• Also was looking for a painless way to do dental procedures. He experimented with carbon dioxide, however the patients would
become hypoxic, and usually died. Fortunately most of his patients were dogs, and his experiments did not continue after several of
the dogs did not recover.

Samuel Colt (1835)

• Learned how to make nitrous oxide in a tanning factory. Traveled the country selling hits of nitrous oxide for 25 cents a piece.
• He used this money to pay for a patent. His invention was a gun, one with six chambers that would advance every time it was
cocked (Colt revolver)
• He sold his invention to the U.S. government.

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Jean Baptiste Andre Dumas (1834)
• Purified Chloroform
• Chloroform is a liquid and very potent. One draw back is that it can explode, and is very toxic.
• It was commonly used for anesthesia if a person needed to have a bone set or teeth pulled.

Crawford Long: 1842

• He gave ether as the first anesthetic in March of 1942 to a gentleman who had two tumors on his neck. The reason why the
gentleman agreed to take the ether was because, he had used it in the past, and had felt pretty good. Crawford charged the
gentleman $2 for the ether administration, and it worked very well.

Horace Wells (Dentist)

• During that time dentists experimented with anesthesia, because people would not come and have their teeth pulled due to the pain.
• The motive was financial: if they could prevent pain, they would have more business. Horace Wells went to a traveling nitrous
oxide show, and one of the participants took the nitrous oxide and accidentally fell off the stage. He was significantly injured, but
he didn’t seem to notice. Wells went home, took the nitrous oxide, and had one of his medical students pull out his own tooth. He
then organized a presentation of this drug at Harvard Medical School. The patient that was supposed to be used for the experiment
was going to have a leg amputation, but backed out. One of the medical students who had a toothache volunteered. They
administered the nitrous oxide, and while pulling the tooth the student groaned. Because the student groaned, Wells never got credit
for administering a good anesthetic, and later became addicted to the compound.

William Morton (1846)

• Morton was looking for a way to prevent pain, and get more money from putting in dentures. He took lessons from Horace Wells
on how to prepare and administer nitrous oxide, then skipped town without paying him.
• He speaks to a chemist named Charles Jackson who suggests Ether as a better drug, because it was more potent, easier to transport,
slower acting, more stable, and also has little respiratory depression.
• Morton gave a presentation at a Massachusetts hospital in 1846. He wanted to make money, so he disguised the ether by inventing
a vaporizer. The presentation was successful, and by the end of the year there were ether anesthetics being given all over London.

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Edmund Andrews (1868)
• Mixed oxygen with nitrous oxide to help prevent the patients from becoming hypoxic.
• He was famous for teaching A&P with human specimens. During this period of time cutting up human bodies was considered
desecration of a corps. He spent a ton of time in jail, because him and his medical students were caught digging up graveyards for
bodies for class the next day.

Sir James Simpson (1847)

• Went back to studying Chloroform.
• Was looking for an anesthetic that did not have the problems that ether had like slow onset and nausea/vomiting.
• He promoted the use of chloroform, but also promoted the idea that pain came from actual tissue damage. He overturned the idea
that pain was a punishment from God.

Dr. John Snow (1853)

• 1st Anesthesiologist
• First person who dedicated their entire practice of medicine to anesthesia.
• Also known for delivering Chloroform to Queen Victoria for the birth of Prince Leopold.

Nightingale (1854-1856)
• Brought cleanliness/public health changes.
• Decreased the death rates drastically in all hospitals.

Lister (1867)
• Used Carbolic Acid to clean up operating rooms.

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Pasteur
• Developed the Germ Theory and no one believed him.

Sister Mary Bernard (1877 )

• 1st Nurse Anesthetist, however nurses were administering anesthesia during the civil war.
• She was trained with postgraduate nursing education in anesthesia. Most of the training back then was hands on.

Alice Magaw:
• “Mother of anesthesia”
• Published and helped develop anesthesia machines.

Agatha Hodgins
• Canadian nurse that came to Ohio.
• Established the AANA.
• Helped change the face of anesthesia, and lowered the death rate.

Dr. Arthur Guedel (1919)

• He wanted to be surgeon, but had no money to go to medical school.
• Created a chart about the 4 stages of an anesthetic.
• He also invented oral airways.

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! ! LESSON TWO
“BASIC CONCEPTS OF ANESTHESIA”

Objectives
Know basic terminology and concepts:
1. Ideal anesthetic
2. Five phases of an anesthetic
3. Four Components of anesthesia
4. Stages of anesthesia
5. Standards of Care

INTRODUCTION
Cost of SNS response:
• This is what kills patients, and is the new focus of research (controlling the stress response). The SNS response helps
you get through the event, but it sets you up for complications in the future.
‣ Hypermetabolism: attacks the proteins first.
‣ Increased cardiac workload: ↑ myocardial oxygen demand, predisposes patients to myocardial infarctions.
‣ Impaired pulmonary function: pneumonia
‣ Pain: hurts more the 2nd day due to hyperalgesia from ↑ inflammation, swelling, and local response.
‣ Decreased GI motility: N/V, hypoperfusion which leads to infection from bacterial transmigration
‣ Hypercoagulation: DVT
‣ Immunosuppression
‣ Loss of muscle mass: due to less insulin circulating, because it’s being used by the brain.
‣ Decreased cognition
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The Perfect Anesthetic
• Few side effects.
• 100% reversible.
• Reliable, dependable, solid drug.
• Quick onset & quick offset.
• Generalizable drug that works well with different ages and illnesses.
• Cost effective.

Five Phases of an Anesthetic

• Pre Operative period:
‣ Patient assessment. May use sedative/hypnotics to decrease the patient’s anxiety about the surgery.

• Induction of Anesthesia:
‣ Mainly bringing the patient from a conscious to unconscious state. Might be a peripheral nerve block or a regional anesthetic.

• Maintenance of Anesthesia:
‣ Adjust and readjust anesthetic to match surgical stimulus, and keep homeostasis.

• Emergence from Anesthesia:

‣ Waking up the patient. We usually only reverse the neuromuscular blockade, and the rest we titrate to finish.

• Post Operative Period:

‣ Return to the normal physiologic state.

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4 components of balanced anesthesia (we must provide these for the patient)
1. Analgesia
• Pain control
• Somatic response to pain: (highly localized and pinpoint.)
‣ Easy to stop by blocking the pathway up to the brain.
• Autonomic response to pain: (response of the vital signs to painful stimuli. Controlling pain reduces SNS response to pain.)
‣ Most post-op complications come from not blunting the sympathetic response to stress.
• Visceral response to pain: (Organ pain is very hard to control - synapses cross and rises all through the spinal tracts).
‣ Ex: a quadraplegic patient getting bladder surgery will still have a visceral/autonomic responses to pain.

2. Muscle relaxation
• Keeping patient still for surgery.
• Stopping spasms in the muscles.
‣ Muscles don’t like being manipulated, and you get increased risk of tissue damage with muscle spasms.
• You want to relax skeletal muscles, (ie we don’t want to block cardiac muscle)

3. Amnesia
• Amnesia: loss of conscious recall or the inability to recall past experiences.
‣ Patient doesn’t have to be unconscious to have amnesia.
• Sedation: a relaxed state with lessened anxiety.
‣ We can give patients sedation that removes their ability to recall. Reduces the incidence of anesthesia awareness.
• Hypnosis: unconscious and unresponsive to verbal stimuli.
• Retrograde amnesia: makes you forget things that are in the past. (not possible)
‣ This is a fallacy and doesn’t actually happen. There is no pharmacologic evidence of this occurring.
‣ What’s happening is that there is antegrade anesthesia that is occurring after the sedation is given.

4. Physiologic homeostasis
• A lot of people refer to this now as the cost of SNS response.
• Maintain balance of the body for optimal function.
‣ Ex: fluid volume, body positioning (taping eyes close, reducing pressure spots).
• Surgical trauma is stressful to the physical organism. We have to blunt the body’s response to the surgical trauma.
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Scopes and Standards of Practice:
• Standard 1: Perform a thorough and complete pre-anesthesia assessment.
‣ Responsibility for the care of patient begins with the pre-anesthetic assessment. Except in emergency situations, the
CRNA has an obligation to complete a thorough evaluation, and determine that relevant tests have been obtained.

• Standard 2: Obtain informed consent for the planned anesthetic intervention from the patient or legal guardian.
‣ Must have permission to proceed. The patients don’t really have any idea of how risky the anesthesia is.
‣ There is no presumed consent.
‣ CRNA shall obtain or verify that an informed consent has been obtained by a qualified provider. Discuss anesthetic
options and risks with the patient and/or legal guardian in language the patient can understand. Document in the patient’s
medical record that informed consent was obtained.

• Standard 3: Formulate a patient-specific plan for anesthesia care.

‣ Plan of care developed by the CRNA is based upon comprehensive patient assessment, problem analysis, anticipated
surgical or therapeutic procedure, patient and surgeon preferences, and current anesthesia principles.
‣ A care plan will be made for every patient that receives anesthesia. Most of them will be in the head.
‣ Surgeon will have requests also and sometimes we will override those requests. However, the patient needs the surgery is
why they are getting the anesthesia.

• Standard 4: Implement and adjust the anesthesia care plan based on the patient’s physiological response.
‣ Continually monitor the patient’s status to give anesthesia.

• Standard 5: Monitor the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs.
‣ Monitor ventilation continuously
‣ Continuously monitor ETCO2 during controlled or assisted ventilation including any anesthesia or sedation technique
required artificial airway support. (If they’re breathing by themselves then this isn’t required)
‣ Monitor oxygenation continuously by clinical observation, pulse oximetry, and if indicated, arterial blood gas analysis.
‣ Monitor CV status continuously with EKG and heart sounds. (Record BP and HR at least every 5 minutes.)
‣ Monitor temp continuously on all pediatric patients receiving general anesthesia and when indicated on all other patients.
‣ Monitor neuromuscular function and status when NMB agents are administered.
‣ Monitor and assess the patient positioning and protective measuring.
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• Standard 6: There shall be complete, accurate, and timely documentation of pertinent information of the pt medical record.

• Standard 7: Transfer the responsibility for care of the patient to other qualified providers in a manner which assures continuity of
care and patient safety.
‣ Assess patient’s status and determine when it is safe to transfer the responsibility of care to other qualified providers.

• Standard 8: Adhere to appropriate safety precautions, as established within the institution, to minimize the risks of fire,
explosion, electrical shock and equipment malfunction. Document on the patient’s medical record that the anesthesia machine and
equipment were checked.
‣ Inspect anesthesia machine and monitors
‣ Readiness, availability, cleanliness, and condition of equipment
‣ Monitor the integrity of the breathing system

• Standard 9: Precautions shall be taken to minimize the risk of infection to the patient, the CRNA, and other healthcare providers.

• Standard 10: Anesthesia care shall be assessed to assure its quality and contribution to positive patient outcomes.
‣ Anesthesia medications and machines change during your career. You will continuously improve and learn about things as
they come out.
‣ Review quality and appropriateness of anesthesia care. Look introspectively on the outcomes and figure out what can be
done to improve your practice continuously.

• Standard 11: The CRNA shall respect and maintain the basic rights of patients.
‣ Patient can’t protect themselves in any way. You have to stand up for the patient.

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 Lesson Three
“PHARMACOLOGY OF ANESTHESIA”

Objectives
Know the basic pharmacology of anesthesia and
concepts:
1. Pharmacokinetics
2. Receptors
3. Concentration and steady state
4. Context sensitive half time (t1/2)
5. pH and pKa
6. Metabolism (Phase 1 & Phase 2)

INTRODUCTION

Pharmacokinetics: An understanding of how the drugs move around in the body will determine how much to give, when to
give it, etc.
• Absorption
• Distribution
• Metabolism
• Excretion

Anesthesia medications are can have a huge impact on patient safety. This is why it is so important for you to
know how they work, why we use them, and the effects they have on the patient.

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Drug Timing
• Blood flow
‣ How fast a drug works depends on blood flow to the effect site.
• Concentration gradient
‣ Drugs flow down their concentration gradient.
‣ Steeper the hill the faster it goes.
• Volume of distribution
• Tissue capacity
• Receptor/Drug Complex
‣ How many drug complexes (receptors) does a drug have to occupy before we get an effect?
‣ Does the drug just bind to the receptor, or is there a conformational change? (which means we will have to wait for that
change to take place).
• Note: we will only reverse one class of drugs (muscle relaxers), the rest we will let wear off. It is important to time their
wearing off to the end of the surgery.

Receptors
• Voltage gated receptors
‣ No drug triggers a voltage gated receptor.
• Ligand gated receptors (cell surface)
‣ All the drugs we will use are effecting ligand gated receptors.
• Transmembrane proteins

Concentration at Steady State (concentration)

• Definition: the concentration in all the compartments are the same (infusing in as much as is being metabolized).
• It is method for comparing the efficacy/potency of drugs.
• Removes interference from pharmacokinetics.
• Even at “concentration steady state”, the amount of drug in each compartment is different. (concentration will be the same)

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Effect to site equilibration (time of onset)
• Time between achieving a plasma concentration of a drug, and a measurable effect of the drug.
• 1/2 life between administering a bolus and the onset of the effect (NOT PEAK).

Pulmonary Uptake (sequestration)

• The proteins that make up the tissues in the lungs really like lipid soluble compounds.
• The lungs get 100% of cardiac output.
• With all of the following drugs, 65% of the initial dose will have significant uptake in the lungs.
‣ Fentanyl
‣ Sufentanil
‣ Alfentanil
‣ Meperidine
‣ Lidocaine
‣ Propranolol

• This isn’t a 1st pass phenomenon, because even though the drug is filtered, it is not eliminated (the drug remains active).
• The lungs act as a reservoir.
• May cause renarcatization in the PACU.

Termination of Action
• ½ life – amount of time for the drug to be cleared from “body”.
• ½ time – amount of time for the drug to be cleared from “plasma”.
• Clearance = amount totally cleared from plasma (L/min).
• Most anesthetics will depend on distribution for termination of action instead of clearance.
• It takes 5 half-lives for a drug to get to a steady state.
• It takes 5 half-lives before drug is cleared from the body.

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Stopping the effect
• Context sensitive t1/2: this is how long it will take after stopping an infusion for the plasma concentration to decrease by half .
• MACawake: MAC (Minimum Alveolar Concentration) level at which patient will wake up to verbal commands.

Context Sensitive t1/2 (For infusions)

• Context sensitive half-time will not tell you when the patient will wake up.
• The patient will wake up when the concentration drops below therapeutic.
• In a long back surgery, the patient will be on the table for a long time (6 hours). They will need an anesthetic to control the
pain, and keep their blood pressure stable (we can’t do with boluses, so we need an infusion).
‣ Fentanyl - isn’t good for infusion, because if we infuse fentanyl for 6 hours, it will take 250 minutes for the plasma
concentration to decrease by half.
‣ Sufentanil - better choice. (if we infuse it for 1 hour or 6 hours, the patient will still wake up in 30 minutes.)

pH & pK
• pKa: this is the pH at which half of the drug is ionized and half of drug is un-ionized.
• What you must know to calculate a pKa/pH problem:
‣ Is the drug an acid or a base?
‣ Drug pKa and pH (pH of body: 7.4)
‣ Acid + base = salt + water

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Protein Binding
• Albumin - abundant
• Alpha1 – acid glycoprotein
‣ The more lipid soluble something is, the more apt it is to have high protein binding.
‣ Net effect of protein binding is negligible unless protein binding is > 90%.
• Changes in protein binding
‣ Saturation can occur.
‣ Competition can occur.
‣ In low protein states:
- during bolus administration of a drug (you will decrease dose because of free drug)
- Steady state: the total drug concentration is lowered because of more free drug available for metabolism.

‣ Uremia in renal failure alters albumin’s ability to bind drug, so you will have higher fraction of unbound drug.

Metabolism
• Oxidation
• Reduction
• Hydrolysis
• Conjugation
• Goal of metabolism: change lipid soluble drugs to water soluble drugs, so they can be excreted by the kidney.
• Rate of metabolism is going to depend on concentration of drug, and the rate at which that drug is cleared.

• Two phases in metabolism reactions:

1. Phase 1 (functional reaction)
 Oxidation, reduction, hydrolysis
 Addition or removal of a group to make the molecule more water soluble.
2. Phase 2 (conjugation reaction)
 Addition of a group to make the molecule more polar.
• Some drugs go through both stages, and other drugs just through one of them (i.e. just phase II)
• Liver is most important organ in metabolism

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 • Types of liver metabolism
‣ First order metabolism: constant fraction of drug is cleared (no matter how much you bring, the liver will metabolize
a fraction of it).
‣ Zero order metabolism: a constant amount of the drug is cleared (no matter how much you bring, only the same
amount will be metabolized).

Phase I
• Cytochrome P450
‣ Enzyme responsible for most anesthesia metabolism.
‣ Involved in oxidation (more common): removal of an electron (oxygen molecule needed).
‣ Involved in reduction (less common): addition of an electron (usually under anaerobic conditions).
‣ Genetic polymorphism: means that people make more than one kind, so they might metabolize faster or slower than
usual (genetically driven).
‣ Usually formed in the endoplasmic reticulum
‣ Two to memorize:
1. CYP3A4/5: most abundant, responsible for metabolism of > 50% of all drugs, women have more than men
2. CYP2D6: responsible for the metabolism of 25% of drugs

Phase II
• Conjugation
• All transferases

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 Lesson Four
“Proper Patient Positioning”

Objectives
Have an understanding of the different surgical
positions, and their importance to patient safety.

1. Importance of proper positioning.

2. Nerve injury
3. Positions
4. Post-op assessment

INTRODUCTION
Why Proper Positioning is so Important
Nerve injury is the primary problem that develops during anesthesia due to poor patient position. Under anesthesia a patient
cannot change position in response to pain due to position problems. The American Society of Anesthesiologists (ASA)
database indicates that nerve injury is the 2nd most settled cause of malpractice claims (32%death, 16%nerve injury, 12%
brain damage).

Ulnar neuropathy at (28%) is the most common nerve injury, and occurs more often in men than women. The extent of
nerve injury is dependent on the duration of pressure that the nerve undergoes. This compression injury can result in loss of
conduction with delayed recovery and nerve degeneration. This is why proper positioning is so important as a CRNA. While
you are a CRNA student you need to practice good positioning techniques that will carry over in you career.

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Positions
• Supine: Most common position used in surgery with the patient laying flat on their back. Patient’s arms can be placed in a few
different positions depending on the type of surgery. You can place them to the patient’s side in a tucked position, or extending out
to the side making sure they are angled less then 90 degrees to prevent nerve injury. This allows for great exposure for abdominal
cases.

• Contoured Supine: Also known as the “Lawn Chair” position, and it provides an anatomical neutral position for the hips and
knees.

• Frogleg Supine: This position is great for perineal exposure. It allows for access to the medial thighs and perineum. The thighs are
flexed and rotated at the hip to keep heels together.

• Lithotomy: Legs are placed up in stirrups and allows for access to the perineum. Most cystoscopy cases are done using this
position.

• Prone: The patient is in the face down position which allows access to the spine. The prone position requires special attention to
eyes and face. Any pressure on eye can cause corneal abrasions, ocular edema, or blindness. Many different foam head and face
supports with cut out portion are available to keep the eyes free from pressure.

• Sitting: the sitting position is good because it takes pressure off the patient’s eyes, and makes diaphragmatic excursion easier
which allows lowers airway pressures. Complications that can arise from this position include hypotension, ventilation problems,
and venous air embolism.

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Post-op Assessment
Assessing the patient post operatively for any injuries that may have occurred from positioning is very important. Motor and sensory
function of upper and lower extremities must be assessed.

• Upper extremities: (especially after any procedure requiring extensive manipulation of arms)
- Median: normal sensation on palmer surface on index finger
- Ulnar: normal sensation of palmer surface of 5th finger.
- Radial: ability to abduct thumb

• Lower extremities: (especially after being in lithotomy position)

- Sciatic: ability to flex leg at knee.
- Peroneal: ability to dorsiflex great toe.
- Tibial: ability to plantarflex great toe.
- Femoral: ability to extend leg at knee.
- Anterior Cutaneous: normal sensation on lateral surface of thigh.
- Saphenous: normal sensation on medial surface of leg.

 Being a CRNA is more important then just putting people to sleep. It requires constant diligence and focus, so that the patient
receives a safe and effective anesthetic. Start practicing safe techniques early, so that you will continue to form a strong foundation
and grow professionally as a CRNA.

“The great thing in this world is not so much where you stand, as in what direction
you are moving.” (Oliver Wendell Holmes)
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 Lesson Five
“Gases and The Circuit System”

Objectives
Have an understanding volatile anesthetics, vaporizers,
and anesthesia machines.

1. Why a gas?
2. Speed of onset
3. Gas properties
4. Vaporizers
5. System types

INTRODUCTION
Anesthesia Vaporizer: Vaporizers are needed to convert the liquid-form of the anesthetic to a vapor-form.
They enable us to give accurate amounts of an inhaled anesthetic. Each vaporizer is color coded, which
makes them easy to identify. The filling port will only accept the correct gas when being filled. This prevents
the wrong gas from being inserted into the wrong vaporizer. Only one vaporizer can be switched on at any
one time. This prevents an unsafe mixing of inhaled anesthetics.

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Why gas works so well
• Can administer a lot of medication
‣ You give a gas as a percentage of what the patient is breathing.
- if you give 6% Sevoflurane to a patient with a with minute ventilation of 5L/min.
- This equals = 500-600 mL of Sevo/min
‣ Plus no side effects of having to give it in fluid.

• Speed of onset
‣ 100% of cardiac output goes to the lungs.
‣ All are non-ionized, lipophilic.
‣ Very small molecular weight.
‣ Non-protein bound.
‣ Large concentration gradient.

• Titratable
‣ Very rapid onset and offset.

• Very potent

• Little to no metabolism
‣ Patient gets rid of the gas by breathing them out.
‣ A lot of IV drug side effects come from metabolites, however with these gases there really aren’t any metabolites.

• Ability to measure
‣ We can measure what’s going in and what they’re breathing out to measure the dose.
‣ VERY easy to measure.

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Vaporizer: (5 Characteristics)
1. Gas specific
2. Variable bypass:
• Inside the vaporizer, a portion of the fresh gas flow will be diverted to pick up the volatile agent. Fresh gas is diverted into
the mixing chamber.

3. Flow-over:
‣ The fresh gas that was diverted is going to skim the surface of the volatile agent.
‣ It does not bubble up through the volatile agent.

4. Temperature compensated:
• As fresh gas flows through the mixing chamber it picks up particles of the volatile agent.

5. Agent specific:
• Each vaporizer is calibrated with oxygen for a single agent at sea level.

Seven Parts to a Circle System: System Types:

1. Fresh gas inlet. • Closed System
2. Inspiratory and Expiratory tubing. ‣ Minute ventilation > fresh gas flow
3. Inspiratory and Expiratory Unidirectional valves. ‣ Adding only amount of O2 to meet their metabolic demands.
4. Y piece.
5. Adjustable Pressure Limiting (APL) valve (pop off valve) • Semi-closed system
6. Reservoir/rebreathing bag ‣ Some fresh flow added.
7. CO2 absorber. ‣ Most commonly used.
‣ Economical, faster changes.
‣ Must have CO₂ absorber.

• Open system
‣ Does not rebreathe any of exhaled gas.
‣ We supply all minute ventilation gas via fresh gas flow.
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 Lesson Six
“Learning The OR”

Objectives
Form a good understand of how the operating room is
designed, important staff, and general rules for the OR.

1. Starting the clinical phase of your program.

2. Quality anesthesia care
3. OR setup
4. OR staff

INTRODUCTION
As you begin the clinical phase of the CRNA program you will faced with a whole new set of
stressors. Your initial goal will be to become more comfortable in the OR. Make sure you have
the right attitude, and remember your main focus is the patient. Most CRNA students come
from a critical care setting where they worked their way to the top of the food chain. Clinical
is a whole new game, and you must once again work your way back up. The most important
thing to remember is that pride has no place at the head of the table.

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Quality Anesthesia Care
• This can best be achieved by coordinating your efforts with all the others in the OR. Quality anesthesia is a team effort. Don’t
make the same mistake that most CRNA students make and gravitate to the chart. This is your time to learn new skills, sharpen old
ones, and learn how to give a good anesthetic. In order to do this you must watch the patient and not just the monitors. After
awhile your tunnel vision widens, and awareness of others in the OR becomes more apparent. This will help to make your
coordination efforts with others in the room much easier and second nature.

OR Setup
• Main Desk - is for delivering supplies from other areas of the hospitals. You are allowed to wear street cloths in this area. You will
also find a receptionist there, and we recommend that you become their friend. The receptionist can make a CRNA student’s life a
lot easier.

• Dressing Room - is usually located off of the outer corridor. The dressing rooms may also communicate with the outer and inner
corridor. This is a great place for CRNA school students to lock up valuables and store street clothes.

• Inner Corridor - requires you to wear scrubs at all times. The lay out is usually either arranged in a circle or square. You will also
need to find the hat and mask rack which is usually located at the entrance of the inner corridor, and don’t forget your shoe covers.

• Pre-op Area - is where CRNA students will spend a lot of their time, and is usually adjacent or close to the ORs. This is where
patients from the outside or floor can be placed in a gown, assessed, get an IV, and start to get “pre-oped” by the CRNA , CRNA
student, or MDA.

• PACU - is usually located pretty close to the OR rooms, and this is to maintain safety. If distance is far it is a good idea to keep
oxygen on the patient.

• ICU - is another place that you will frequently be taking patients after surgery. Pre-op assessments for ICU patients will be done in
ICU. Many patients are intubated with a lot of pumps and drips. This can make picking up and delivering patients to the ICU
difficult.

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• Anesthesia Workroom - is a place where all the IV start kits, arterial line supplies, airway supplies, ETT’s, and anything needed
for backup will be located. Most of supplies for a standard case should be in the room on the cart or machine.

• Anesthesia Lounge - is where a CRNA school student can eat, study, or just relax in-between cases. If it is too loud and you are
trying to prepare for your next case just find a place that is a little more quite.

People in The OR
• Board Coordinator - individual responsible for assigning cases and personnel (RNs and Techs) to the different rooms. They
assigns rooms to the OR staff, and also write where the anesthesia providers and surgeons will be in which room. They make sure
the OR runs smoothly, and that the cases get done in an efficient manner.

• Pre-op Nurse - this is the person who gets the patient ready to go. Pre-op nurses mainly work within hospital settings,
administering care to patients prior to surgery. Pre-op nurses administer pre-surgery medicine if necessary, evaluate and access
admission documents, identify emergency procedures, and adhere to necessary pre-operation policies and procedures.They will
admit the patient, take initial vitals and prepare the patient for surgery. They will make sure the chart, lab work, X-rays, etc, are all
up to date.

• Circulating Nurse - This is a CRNA student’s BEST friend! They can be an incredible help or make your life difficult. Having a
good working relationship with the circulator is very important. It is also very important to not sedate the patient until they have
spoken with the patient. Throughout the procedure, circulating nurses monitor the condition of the patient and the needs of the
surgical team. Other tasks that the circulating nurse is assigned with include: surgical prep of site, completing OR record, handling
communication in the room, answering phone and pagers, retrieving any needed instruments to room, retrieving any more extra
medications that are needed, and applies the wound dressings.

• Operating Room Technician - these are the scrub techs and scrub nurses. They will assist the circulator in gathering equipment
for a particular case. They also open items to create the sterile field. This is your cue to put your mask on. They also help the
surgeon to glove. You might have to help them put their gown on (strap around neck, tie inside, tie outside)

• Surgeon & First Assistant - primary operator & the second pair of hands. The surgeon may want to see the patient one last time
to check right pt and right procedure. Once surgeon is there it is ok to put the patient to sleep and start anesthetic.
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• Anesthesiologist - can be a tremendous asset. It is nice to have MDA that enjoys to teach. Listen to what they have to say. Most of
the sites have MDA’s working with CRNA’s, and are usually present for induction. They also may want to be present for
emergence and extubation.

• CRNA & RRNA - They are there to guide and protect. Working with CRNA school students keeps the knowledge base fresh.
Each CRNA has a different way of performing everything, and expansion of different ideas should come after basics are
understood. CRNA school students are practicing on CRNA and MDA license so they must protect their license and patient, and
some will be more brusque than others. The stress level is high and being courteous to one another is important.

• Anesthesia Tech - they keep carts stocked and will provide extra supplies during the case. Sometimes equipment will not be
anticipated and techs will retrieve the equipment. They will also clean machine between cases.

• Orderly - most ORs have own housekeeping staff. These people will clean the OR between cases, and make sure that the room is
ready to go for the next case.

• Patient transport - help move patients from floor to pre-op and help take patients from recovery room back to floor.

• PACU Nurse - admits post-op patient. These nurses have great knowledge of surgical procedures, techniques, and are able to
recognize emergency situations and assist in corrective action. PACU nurses are typically trained to use a variety of medical
equipment and supplies that may be necessary to deal with issues that are peculiar to recovery rooms. You need to be sure and
provide a clear idea of patient’s history, type of procedure done and current condition. Report should be as clear and concise as
possible

Important To Remember
• This can be a stressful time during CRNA school, however it is important to take it one day at a time. Try not to get
overwhelmed, and just remember you will have plenty of time to learn the ropes. The OR requires everyone to work as a team.
There isn’t one person that can do everything, so try and be respectful and work as a team.

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 Lesson Seven
“Anesthesia Machine Check”

Objectives
Understand the importance of a proper machine check
and case setup.

1. SAMMTIDE

SAMMTIDE
Setting up your anesthesia machine for a case is very important and needs to be done every time you have a case.

This is how you maintain safety and make sure your case goes smoothly. There are very important safety checks
that need to be completed before every case. A lot of times the turn over rate is so fast you only have a few minutes

to set up. This can make it very easy to forget something which could result in a disaster. For this very reason you
can use the following to help you remember: (SAMMTIDE)

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S- uction

A- irway (ETT, oral airways, laryngoscope with properly sized blade)

M- achine check

M- onitors (BP cuff, Pulse ox, EKG, temp probe, etc)

T- ape (for eyes and ETT)

I- V (extra IV start kit)

D- rugs

E- quipment (fluid warmer, warming blanket, blood tubing, etc)

“Your imagination is your preview of life’s coming attractions.” (Albert Einstein)

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