Name:
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ALLIED HEALTH STAFF
REQUEST FOR SPECIFIC PRIVILEGES
FOR CERTIFIED REGISTERED NURSE ANESTHETIST
Request
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Selection and administration of general anesthesia for major and minor surgery in elective
and emergency cases, including all ancillary methods and monitoring modalities (noninvasive and invasive) required to provide anesthesia.
Selection and administration of regional anesthesia for in- and outpatients, including all
methods required to provide the regional anesthesia.
Topical and infiltration
Subarachnoid Block
Epidural
Caudal
Bier Block
Upper and Lower Extremity
Acute Pain Management
Administration of anesthesia for specialty procedures including ancillary methods and
monitoring
Cardioversion/TEE/Echocardiograms
Cardiac Cath Lab Procedures
Radiological Procedures
Gastrological Procedures
Selection and administration of drugs for monitored anesthesia care, including analgesics,
sedatives, and hypnotics
Full participation in cardiopulmonary resuscitation measures in any location within the
hospital.
Selection and administration of fluids and blood components.
Preoperative and postoperative anesthesia care unit activities
Preoperative and postoperative evaluation and obtaining anesthesia consents.
I affirm that I am mentally and physically capable of performing the privileges requested.
Signed __________________________________________________________________________ Date ______________________
Approved:
It is recommended that the above anesthesia provider be granted the full privileges which he/she
has requested with the exception and/or limitation, if any, as noted above or as follows:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Signed ________________________________________________________________________ Date ________________________
Chairman, Department of Anesthesia
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