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Everyone who wishes to enter a CRNA school is required to have ICU experience. But you can further leverage your learnings in that area to build a career in anesthesia. In this episode, guest host Rick Heuermann, a Nurse Anesthesia Resident, explains how to utilize your ICU knowledge to reduce your learning curve toward anesthesia school. He breaks down the four essential things to focus on, detailing how to hone them in the ICU and then use them in CRNA school.
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
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 critique, resume review and more at https://www.TeachRN.com
Join the CSPA email list: https://www.cspaedu.com/podcast-email
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How To Use Your ICU Experience To Prepare For CRNA School With Guest Host Rick Heuermann, Nurse Anesthesia Resident
Future CRNA, welcome to the show. I have a very special episode lined up for you. It is part of our Guest Host Series, where I am bringing SRNAs on the show for you as a guest host on the show. My thought process behind doing this is I wanted you to hear from a variety of students who are at different stages of their CRNA journey and allow you to step into their world and hear them talk about what it’s like to be a student dealing with things like difficult preceptors or different anesthesia or clinical topics, maybe even things like time management, stress management, and things like that.
These episodes are going to be gold. I hope you enjoy it as much as I always do. Hearing from students, I know for a fact that the reason why CRNA Prep Academy is where it is now, and the reason why I have learned so much, is from diving all in and listening to students along with CRNAs share a wealth of information. I’m taking all of that information and compiling it into the system that we have created. I know that you’re doing the same thing by tuning into the show week after week, developing your own method, strategy, and system for success. I hope you enjoy these guest episodes. Let’s go ahead and get into the show.
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My name is Rick Heuermann. I will be your guest host. We’re going to talk about how to use your ICU experience to prepare for CRNA school. If this is your first time tuning in to us, thank you for joining us. If you want to be a CRNA, you’re in the right place here with CRNA School Prep Academy. If you’re a returning listener, thank you for continuing to trust us here on your CRNA school journey.
A bit of background on myself for those who haven’t seen me on social media or the internet. I am a third-year SRNA. Prior to attending CRNA school, I always had decent grades at school. I had three years of experience as a medical ICU nurse at a large community hospital and tele experience. I applied to two CRNA schools. I was fortunate enough to get accepted into both of them. I have one semester left of school, and I can see the light at the end of the tunnel. I am done in May 2024, and I couldn’t be happier with my decision to pursue CRNA school and be where I am now.
I’m excited to talk to you about using your ICU experience to prepare yourself for CRNA school. As most of you know, if you’ve pursued the idea of being a CRNA to the point where you’re tuning in to this, you know that you need ICU experience to be a CRNA. It’s required for everyone, but there are ways that you can use that experience and build that bridge into CRNA school by understanding how your skills in the unit translate to anesthesia. Once you get into school, you will learn everything regardless of how you approach your ICU experience. Making those connections between the ICU and anesthesia now might serve you well moving forward and in interviews that have clinical questions involved in them.
ICUs are not all created equal in the eyes of CRNA schools. Some schools even have a point system where if you’re in certain ICUs, that’s looked upon more favorably in the admissions process. For example, CVICUs and surgical trauma ICUs at level-one hospitals are considered the most desirable ICUs, but others are acceptable. I’m an example. I worked in a medical ICU. We had a non-trauma center and a large community hospital. We had 30 beds in our ICU, and it turned into a COVID ICU during the pandemic. That’s my main background.
Regardless of what ICU you work in, what’s important in terms of understanding what you’re going to be doing as a CRNA is your knowledge of critical care. What are the four aspects of critical care? You have mechanical ventilation, invasive monitoring, use of vasopressors, and taking care of complex patients. Regardless of what ICU you’re in, you should be getting exposure to those four aspects of critical care, and that’s why CRNA schools take students from different ICUs. It’s because they have exposure to those four things.
We’re going to take each one of those four things during this episode and break down how you use them in the ICU versus how you’re going to use them as a CRNA. Hopefully, in your ICU training, you can visualize how your experience applies to being a CRNA versus showing up and punching the clock on your ICU shifts.
Mechanical Ventilation
We’re going to start with mechanical ventilation. When you are in the ICU, at least in my ICU, the doctors and the respiratory therapists are the ones in charge of addressing the settings. All I can recall is being on the night shift in the ICU, hearing the ventilator alarm, going in there, hitting the 100% button, suctioning the patient, and turning up the propofol if I wasn’t at the max dose and hoping that the patient wouldn’t alarm the ventilator because we all know that the ventilators start to sing to each other from across the unit. It was so much fun up there in the ICU.
In the ICU, I wasn’t paying a lot of attention to the setting because the doctors adjusted the setting. There are all these different settings, like volume control, pressure control, and pressure support, when you’re weaning the patient off the ventilator. I put off all those things because I wasn’t in charge of adjusting the settings.
In anesthesia, you have to understand those vent modes because we are the respiratory experts. We decide what vent mode is best for the patient. Different surgeries, patient comorbidities, and things that happen throughout the case will affect how we adjust the vent settings. Sometimes, in anesthesia, you’re adjusting vent settings several times during a single case versus up in the ICU, a lot of times, I’ve left it on one setting for a long time up there.
I remember up in the ICU, if the vents kept alarming and my three interventions were 100% propofol and suction not working, I would call respiratory. Respiratory would show up, hit some buttons, and they’d say, “It’s gonna be better now.” I would say, “Thank you.” I hope it doesn’t happen again. In anesthesia, we have to know how to troubleshoot those alarms.
ICU Experience: In anesthesia, you have to understand vent modes. You will decide which vent mode is best for the patient depending on their surgery or comorbidities.
There are high-pressure alarms, low-pressure alarms, and all these other alarms that I didn’t even know about as an ICU nurse. In anesthesia, I understand all of these alarms and how to troubleshoot them because when a patient is under anesthesia, they can desaturate and decompensate quickly from a respiratory perspective. We are trained and we learn exactly how to spot what is wrong with a ventilator and how to fix it immediately.
In anesthesia, we’re deciding the settings and troubleshooting quickly. We are completely responsible. It’s a huge responsibility, and I didn’t even realize it as an ICU nurse. What can you do in the ICU to prepare yourself for that? Pay attention to the setting on the ventilator, like volume control. Try to do some research. Ask RT and doctors, “What is that? Why are they using that? What’s pressure control? Why is pressure support good for weaning the patient off of a ventilator? Those are questions that you can research yourself and try to make that connection.
For the ventilator alarms, instead of absentmindedly doing a few interventions, figure out why this ventilator has a high-pressure alarm. Is the tube clogged? Is the tube kinked? Is there something wrong with the circuit? Is the circuit leaking? Those are things that you can challenge yourself to work through in the ICU as you’re collaborating with RT because those are what you’re going to be doing in anesthesia. Keep those things in the back of your mind.
Vent modes and vent alarms are the big things that you’re going to know inside and out as an anesthesia provider that you don’t know as an ICU nurse. Also, extubation criteria. I remember in my ICU, there were objective extubation criteria that patients had to meet to be extubated. That is what you’re going to be doing in every anesthesia case. There are different types of extubations like deep and awake extubations.
I’d encourage you to go check out Emergence and Extubations, but I’m not going to go into that during this episode. Weaning a ventilator, you do that in every single case of anesthesia. You intubate the patient. Most of them are extubated before surgery is over. You have to know that the patient is ready to be extubated.
When working in the ICU, challenge yourself to work and collaborate with respiratory therapists. That’s what you will be doing in anesthesia. Click To TweetIn your ICU training, I encourage you to pay attention to a patient’s readiness to extubate and understand when they need to remain on the ventilator and when they need to be extubated. That’s mechanical ventilation for you. You don’t need to be a vent expert as an ICU nurse but challenge yourself to learn more about it. Ask questions and do your own studying if you want to make that experience better for the OR.
Invasive Monitoring
The next aspect of critical care is invasive monitoring. That’s your A-lines, PA cast, and central lines. A-lines in the ICU are put in on a case-by-case basis. Usually, patients coming up from certain surgeries that require them or patients on pressors because of sepsis or other comorbidities. Even in the ICU, you want to understand the waveform and what each part of it means and know when it’s not accurate. Is it under-dampening? Is it over-dampening? How do you fix over-dampening and under-dampening? What’s the right height for your transducer? Those are things that I remember that I had to know in the ICU that were important.
The good news is, in anesthesia, it’s the same. Troubleshooting is important because you want to know that you’re dealing with and treating accurate blood pressure. We deal with low blood pressure and high ones frequently in anesthesia more often than in the ICU. We have to be able to treat them immediately. In anesthesia, you change positions during procedures a lot. You need to be conscious of where your a-line is, like the height of the a-line, and you’re constantly reevaluating the accuracy of your waveform. For a-lines, ICU and anesthesia are the same concepts that apply to what you need to know.
For PA catheters, all you see is that the ICU people out there are always dealing with PA catheters. It’s cool cardiac output PA pressures. The reality is that in anesthesia, you are not going to see a lot of PA catheters until your cardiac rotation or if you take a job that specializes in cardiac. What you can do to prepare yourself for that is take note of normal values, abnormal values, and the waveforms and assess for changes in them because you need to know if your PA cath is in the pulmonary artery. If you have PA catheter training in the ICU, you have yourself a headstart for managing these sick hearts, cardiac cases, and patients getting non-cardiac surgeries with bad hearts that may need a PA catheter for whatever reason.
CVP with central lines is the same thing. You need to know the normal versus the abnormal waveforms and values and try to understand the waveform because in anesthesia school, you’re going to want to understand the waveform, and you need to know what a high and low CVP is. If you can gain that experience in the ICU, keep that mentally in your head, and take that with you, that will benefit you.
Vasopressors
We’ve covered mechanical ventilation and invasive monitoring. Our next topic is vasopressors. It’s our next aspect of critical care. In the ICU, from my experience, vasopressors are ordered for us. At the time they were ordered, norepinephrine and Levophed were 0.02 to two mics per kg per minute. It would be a whole-range dose for one medicine, and we would get the power to titrate it. It was titrated to a blood pressure. If a certain dose of norepi wasn’t cutting it, we’re looking at adding vasopressin and epi with the same titration parameters. I’m sure you can all relate to this.
We’re chasing blood pressure, not exactly knowing every little thing about how the drug works and this and that, but knowing that we had to stack vasopressors to achieve a certain outcome. My relationship with drugs as an ICU nurse is a lot different than it is in anesthesia. In the ICU, drugs are ordered. I know a little bit about them. We give them. In anesthesia, we order the drugs and decide what drugs to give, what vasopressor you use, and what sedatives. It’s different.
In the ICU, drugs are ordered. In anesthesia, you decide which drugs to give. Click To TweetIn anesthesia, we assess the patient’s situation, comorbidities, and heart function. A lot of times, especially their heart function is going to dictate the best vasopressor for your patient. You decide the drug and dose. There’s no order put in for you. If we have a patient with an EF of 25% and they have a low-pressure blasting, phenylephrine or norepi may not be our best option. Some epi, some fluids, or norepi might be better. In anesthesia, we also push vasopressors. In the ICU, it’s always infusions. In anesthesia, you’re going to learn how to push vasopressors as well as antihypertensives up there.
My word of advice to you would be to try to learn the function of those vasopressors, the receptors they work on, and the dosing in the ICU. That’s going to give you a lot more confidence when you use them in anesthesia. Those are also common interview questions if you get an interview that has a lot of clinical questions.
Complex Patients
The last main aspect of critical care that is important to schools and translates well to anesthesia is complex patients. If you think about it, all those ICU patients you take care of in the ICUs. Patients who are sick are not generally candidates for regular elective surgeries. Most of the surgeries that you do are going to be on somewhat healthy patients. You’re not going to be slinging norepi, vaso, and epi all the time like you do in the ICU.
Your ICU training for those complex patients and those vasopressors is critical. The more coaching you can do, the better off you’re going to be. In your ICU training, a big part of it that translates over to anesthesia is taking care of complex patients with comorbidities. In anesthesia, we need to know how each of those comorbidities is going to affect our anesthetic. We want to be accustomed to, tuned into, and not intimidated by complex patients when we get them on the operating table.
In the ICU, all these patients would be septic, have COPD, smoking, diabetes, hypertension, asthma, kidney disease, and liver disease. It all runs together into this label of an ICU patient. It is the saddest thing for the patients up there, but it helps us get tuned in for when we start to become CRNAs and go into anesthesia.
ICU Experience: In your ICU training, a big part of it that translates over to anesthesia is taking care of complex patients with comorbidities.
When we look at a list of comorbidities, things should trigger in our brains. That was the way that it was put to me by one of my preceptors. When I see asthma, that makes me think certain things by anesthesia. When I see high blood pressure, it’s the same thing. When I see diabetes, certain things pop into my mind. My treatment of different patients under anesthesia is altered based on the patient’s comorbidities. My anesthesia plan changed.
Pharmacology is the same. Patients are on all these different drugs in the ICU, and you see this laundry list of home meds. It’s easy to skim over these meds, why they’re on them, and what they do. It would serve you well to try to learn a little bit about some of those meds. I would highlight in the ICU if you can try to dig deeper into anticoagulants and antihyperglycemic medicines like diabetic medicines and antihypertensive.
Beta-blockers, ACEs, ARBs, and medicines like that have a huge impact on how we do anesthesia, the timing of them, and what they do. If someone is on Xarelto, we want that patient to be off that for 2 or 3 days before we do surgery on them. It is an anticoagulant. Eliquis has guidelines. Patients on heparin have different guidelines. All these different drugs have different impacts on our anesthesia. The new big one is the anti-diabetic drug ozempic. That creates a lot of changes in how we do anesthesia on patients because of the delayed gastric emptying it has.
Those are a couple of examples of different drugs. If you can start to familiarize yourself in the ICU with the different drug classes that all these complex patients are on, you can translate that over into anesthesia and trigger certain things in your brain when you see a patient on those drugs before you put them to sleep.
In summary, the four aspects of critical care that are important to get in ICU are mechanical ventilation, invasive monitoring, titration of vasopressors, and taking care of complex patients. My advice to you would be to try to dig into those topics as best you can in the ICU deeper than you need as an ICU nurse because that’s going to help you when you start to get in the ORs of CRNA. In anesthesia school, you do learn all of it, but you can reduce that learning curve for yourself by starting to prepare it now.
That’s all I have for this episode. That’s going to wrap it up. Please continue to tune in to the show. I encourage you to consider joining and becoming a member of CRNA School Prep Academy. I’ve seen their stuff. They have resources like a step-by-step A to Z of how to go from being a nurse to being a CRNA. They have different packages that have mentorship options and coaching. They even have a program that guarantees CRNA school admission if you look into that CRNASchoolPrepAcademy.com, check it out. Like this channel, leave a review, leave a comment, and find us on any platform. That’s going to wrap us up for now. My name is Rick Heuermann. I am your guest host, and hopefully, I’ll be back for another episode in the future. Thanks again, and good luck on your journey to becoming CRNAs.
Important Links
- Rick Heuermann – TikTok
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/irptwqbx
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 critique, resume review and more at https://www.TeachRN.com
Join the CSPA email list: https://www.cspaedu.com/podcast-email
Send Jenny an email or make a podcast request!
