CRNA | Sedate Patients


Some patients are just harder to sedate than others. As someone going through the CRNA journey, you are bound to confront this challenge sooner or later. In this special episode, we have guest host and Nurse Anesthesia Resident Paulene to share the different aspects of sedating patients. Join us as she navigates the complexities of sedation, delving into various factors that impact this process—from the influence of red hair to alcohol consumption, drug use, and opioid tolerance. Pauline also provides invaluable insights into anesthesia practice as well as practical strategies for managing challenging cases. Tune in for an engaging discussion unveiling the nuanced world of sedation as a CRNA.

Have you gained acceptance to CRNA school? Congratulations! Prepare with the #1 pre-anesthesia curriculum, as recommended by CRNA program faculty. Start the NAR Boot Camp today: https://www.cspaedu.com/bootcamp

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Patients That Are Hard To Sedate And Why With Guest Host Paulene, Nurse Anesthesia Resident

I have a very special episode lined up for you and it is part of our guest host series where I am bringing current SRNAs on the show for you as a guest host on the CSPA show. My thought process behind doing this is I wanted you to hear from a variety of current students who are at different stages of their CRNA journey and allow you to step into their world. Hear them talk about what it’s like to be a current student dealing with things like difficult preceptors or different anesthesia topics, clinical topics, maybe even things like time management or stress management, things like that.

These episodes are going to be gold and I hope you enjoy as much as I always do hearing from students. I know for a fact that the reason why the show is where it is now, and the reason why I have learned so much is from diving all in and listening to current students along with CRNAs share a wealth of information. Also taking all of that information in compiling it into the system that we have created now. I know that you’re doing the same thing by tuning into the show week after week, developing your method, your strategy, and your system for success. I hope you enjoy these episodes. Let’s go ahead and get into the show.

I’m Pauline, @SRNA.Paul on Instagram and YouTube. I am the guest speaker for this week’s episode. This is my very first episode on this show, and we’re going to talk about patients who are harder to sedate than others and why. A little bit of background about me. I am in my second year of CRNA School. I’ve been in clinical for a full year now. Our first six months have been general surgeries and we jumped straight into specialties in the last half of this year. I’ve done my OB, Neuro, and Pediatric rotations so far. I was a travel nurse before starting CRNA school and I remember going to my different assignments and listening to this show while I was applying to CRNA school. It’s an honor to be here and talk to you about anesthesia.

After being in clinical for quite some time, you’ll notice that some patients are harder to sedate than others. I’ve found myself having to give more propofol or turn up my anesthetic gases for them to go to sleep. You would give the appropriate weight-based dosages of the medications and they would still be wide awake with their eyes open and staring at you.

To start things off, let’s talk about the different types of patients that we see that are harder to sedate than others. The most common patients that we see who are harder to sedate are patients with red hair or redheads, patients who consume a lot of alcohol or recreational drugs, patients with high anxiety, and patients with tolerance to opioids and sedatives. Before we talk about the reasons why these patients are harder to sedate, let’s talk about MAC.

The Minimum Alveolar Concentration or MAC is the concentration of anesthetic gas that suppresses movement in response to a surgical stimulus in 50% of people. Inhalation and anesthetic requirements are usually quantified using MAC. Some factors increase and decrease MAC. Factors that increase MAC are chronic alcohol consumption, emphasis on the chronic, increased central nervous system neurotransmitter activity such as acute cocaine or amphetamine intoxication, hypernatremia or high sodium, infants 1 to 6 months old, hyperthermia, and red hair.

Factors that decrease MAC are acute alcohol consumption. Acute alcohol consumption decreases MAC while chronic alcohol consumption increases MAC. Sedative drugs, hyponatremia or low sodium, old age, and pregnancy- all of these factors decrease MAC, meaning that they would need less anesthetic requirements. With these factors that increase MAC, it would mean that they would need more anesthetics on board. MAC is a core concept in our anesthesia practice and it’s something that is tested in CRNA school. You need to know the different factors that affect it.

CRNA | Sedate Patients
Sedate Patients: MAC (Minimum Alveolar Concentration) is a core concept in our anesthesia practice.

A lot of you may have already heard that patients with red hair or redheads are harder to sedate compared to non-red-haired patients. There are many studies done on this and they show that redheads require way more IV anesthetic and anesthetic gases compared to non-redhead patients. The phenotype of nearly all red-haired individuals can be traced to a distinct mutation of the Melanocortin 1 Receptor gene or MC1R. This is a key regulator in the intracellular signaling biosynthetic pathway governing pigment formation. This identifiable human phenotype can be traced to a distinct genotype that has a genetic influence on anesthetic sensitivity just as redheads do.

I found it very interesting that the anesthetic sensitivity is affected by a genetic mutation in redheads. In my experience, so far, the most common patients that I see that are harder to sedate are those who consume a lot of alcohol and recreational drugs. Sometimes patients don’t tell you exactly how much alcohol and recreational drugs they intake and you only find out during induction. It’s taking them a long time to go to sleep or you’re having to give them a lot more medication and gases. I’ve found that this is more common in patients who are older men or women, or in younger patients from ages 18 to 40 years old who consume marijuana and vape daily.

A heavy dose of alcohol also increases your gastric acidity and volume. It also impairs your laryngeal reflexes, making them prone to aspiration. Patients going through withdrawal can show symptoms of tremors, tachycardia, cardiac dysrhythmias, hypertension, and nausea and vomiting. These are all symptoms that can affect our anesthetic plan. You need to do your full assessment of these patients.

Cannabis has a high fat solubility, which leads to prolonged effects in this system. These patients can show symptoms of anxiety, tachycardia, and even seizures. Cannabis shows an increase in the sympathetic nervous system causing tachycardia and cardiac dysrhythmias. It causes a decrease in the parasympathetic nervous system leading to myocardial depression. If you know that your patient has taken any cannabis, amphetamines, or cocaine, you have to be careful of the medications that you give in your anesthetic plan. These medications that you have to be careful with are ketamine, atropine, or epinephrine, which can increase heart rate even more.

Some patients are on chronic opioid and seizure medications. These patients may present for surgery exhibiting opioid tolerance secondary to chronic opioid therapy for chronic pain. They may also have active opioid use disorder or a history of opioid use disorder treated with medication. These patients can be challenging to take care of in the perioperative period due to their tolerance, opioid-induced hyperalgesia, and higher post-op pain scores. When you do your neuro rotation and when you start learning about Remifentanil, you’ll learn about hyperalgesia, which is a big side effect of Remifentanil.

You have to be mindful of those things, especially with these patients who are already in chronic pain. They may require up to 3 to 4 times higher doses of opioids compared to the non-tolerant patients. During the procedure, you may find it challenging to deal with their rising blood pressure and heart rates and you have to constantly treat those vital signs. Giving a lot of opioids leads to a risk of complications such as excessive sedation, respiratory depression, and increased hospital stay length and cost. Pre-op, make sure you check for the medications that they take, any fentanyl patches, and their baseline levels for their pain. Take this time to talk to your patient about your plan for the management of their pain and expectations for the type of surgery they’re going to have and the recovery from it.

Different surgeries produce different types of pain, so it’s good to be realistic about what they can expect post-op. If it’s a short quick procedure, you may not have to give any opioids, but if it’s a long more than 3, 4-hour procedure, expect that you may have to give a little longer-acting opioid. How do we manage the anesthetics for these patients who are harder to sedate or who have tolerance to pain medication and sedatives?

Where I practice my anesthesia, we use a lot of multimodal analgesia. This can optimize pain control and reduce the amount of opioids that you give to your patients. Examples of medications that we use for multimodal analgesia are PRECEDEX, ketamine, gabapentinoids, non-steroidal, anti-inflammatory agents, and Tylenol. In pre-op, they can get Tylenol, Celebrex or Gabapentin. It depends on the provider and during the procedure, you can also give other medications that can add to that full coverage of pain control. If they haven’t gotten anything in pre-op, you can do it yourself and give the extra multimodal analgesia.

We can also use regional or neuraxial anesthesia for targeted isolation of painful or noxious stimuli. I think regional anesthesia is one of the best things that we can do as anesthesia providers and being able to do epidurals and spinal for OB for ortho cases, we can do so many different types of blocks for that and it just gives us a lot of options as anesthesia providers to relieve that pain. For these patients who are harder to sedate during induction, we usually give them a higher dose of propofol, so always have your extra syringes of propofol ready. This is a very helpful tip if you’re just starting. This is something that I always do now because it has helped me so many times.

For patients who are harder to sedate during induction, we usually give them a higher dose of propofol. So always have your extra syringes of propofol ready. Click To Tweet

Always drop an extra syringe of propofol. You want to have it available next to you so that you can grab it and give a little more propofol and bolus them if they need a little more sedation. We can also turn on the anesthetic gas while we’re masking them so they can inhale the anesthetic gas and go to sleep faster. You’ll notice that they will relax, and masking them will get easier as their body gets more relaxed, and they are off to sleep. You can also give your fentanyl or Dilaudid or whatever it is that you like in combination with your sedatives during induction that can also help.

You want to use all of the resources you have that can help you sedate your patients faster. With that being said, we do have to be more mindful of how these medications affect our patients. This warrants careful assessment of their vital signs, their respirations, and their pupils. When you’re starting and you’re very new to clinical, you’re so hyper-focused on your task at hand that you don’t always notice what’s going on with your vital signs. Your blood pressure and heart rate may be dropping fast. You have to be cognizant of all those things while you’re giving these medications.

Always have your emergency equipment ready just in case. If it makes you feel better, have your stick of neo or ephedrine nearby, just to help you out during induction. Have that emergency equipment ready in case you run into trouble with the airway or anything else that can happen. If you have a known difficult airway, always be prepared and have plans in place just so you’re ready and you don’t lose any time trying to get an airway on that patient.

For post-op management, we’re going to continue that multimodal approach and ensure that their pain levels are controlled and that they’re monitored closely for sedation, respiratory depression, and any behavioral changes. Our job doesn’t stop after we leave the OR we still have to take care of our patients and manage them post-op. A lot of things can happen post-operatively: codes, airway issues, surgical site issues, delirium, psychotic episodes, nausea and vomiting, eye injuries, and the list goes on. Since I’ve just had my pediatric rotation, I figured I could add this in since it takes a lot of anesthetic for these little guys to go down.

If you haven’t done your pediatric anesthesia rotation yet or you don’t know anything about pediatrics, sometimes they require a lot of anesthetics to get to sleep. The dosage of propofol is higher in pediatrics compared to adults. The dose for propofol in kids is 2.5 to 3.5 milligrams per kilogram compared to adults, which is 1 to 2 milligrams per kilogram. These kids can be extremely anxious because they’re separated from their parents, they’re in an unfamiliar environment, and their emotions are at an all-time high.

For kids who do not have an IV, if they’re less than 7 or 8 years old, we do a mask induction and if they’re calm and able to breathe through the mask without any issues, we start them off with nitrous oxide. If they are crying, thrashing around and uncontrollable, we turn up our anesthetic gas to its maximum level, place that mask over their face, and have them breathe that gas in until they’re asleep. Once they’re asleep, we place an IV and we’re able to push any other medications that we want to through that IV.

When you have your anesthetic gas at a very high level, make sure that you are very mindful of their heart rate because, with pediatrics, their heart rate goes down very quickly. When you hear them breathing down, turn down your gas right away. That is always the first thing you do when you have your gas up during induction and you see them breathing down. Emergence Delirium is also a very big thing in this population. It’s very common in toddlers. I’ve seen it many times during my pediatric rotation.

A lot of providers like giving PRECEDEX before the case ends, and that gives a smoother wake-up for these kids. I hope you guys enjoyed this episode. It’s been a pleasure talking to you guys about patients who are harder to sedate and what we see in clinical practice. You can reach me on Instagram and YouTube at SRNA Paul and I will see you guys again next time. Thank you. Bye.


Important Links

Have you gained acceptance to CRNA school? Congratulations! Prepare with the #1 pre-anesthesia curriculum, as recommended by CRNA program faculty. Start the NAR Boot Camp today: https://www.cspaedu.com/bootcamp

FREE! CRNA School Interview Prep Guide: https://www.cspaedu.com/uc9a5ih4

Get access to planning tools, mock interviews, valuable CRNA Faculty guidance, and mapped-out courses that have been proven to accelerate your CRNA success! Become a member of CRNA School Prep Academy:  https://www.crnaschoolprepacademy.com/join

Book a mock interview, personal statement, resume and more at https://www.TeachRN.com

Join the CSPA email list: https://www.cspaedu.com/podcast-email

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