Monitored Anesthesia Care Notes Jag2007

8/3/2019 Monitored Anesthesia Care Notes Jag2007

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Monitored Anesthesia Care

A good MAC case will be harder to perform well,than an easy GA case any day of the week . . . . .

quote to recall in the futureJeffrey Groom, PhD, CRNA


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History of Monitored Anesthesia Care

Local

Stand By

Conscious Sedation



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Objectives

Understand the purpose of MonitoredAnesthesia Care (MAC)

Discuss levels of MAC andappropriateness by type of case

Discuss special circumstances in which

MAC may not be appropriate

Discuss techniques of MAC anesthesia


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MAC GRAY ZONE GENERAL ANESTHESIA



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Is MACSaferthanGeneral Anesthesia orRegional Anesthesia

?


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Closed Claims Review of MAC Cases


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MAC Closed Claims Review by Severity


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Consciousness

Safety Risk

Patent AirwaySpontaneous Breathing


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Sedation only ie: colonoscopy or TEE

Sedation & Local ie: Pacer or Bx

Sedation & Block ie: Cataract or Podi-


The 3 faces of MAC


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4 Critical Flaws when Providing MAC AnesthesiaFailure to consider the procedure

Failure to consider the patient

Failure to consider MAC skills of the surgeon

Failure to consider MAC skills of the anesthetist


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Monitored Anesthesia Care Example Procedures Performed under MAC

Short Manageable Pain MIP Position Cataract extraction Infusion port placement Bone marrow biopsy

lump and bump surgeries Pacemaker - AICD insertion Inguinal Hernia repairs Knee arthroscopy Kyphoplasty TEE Cardioversion Rhinoplasty 3rd Molar extraction Face/Brow lift

PATIENT

DR.

PROCEDURE

CRNA

?


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Patients Suitable for MAC Conscious

Cooperative

Communicative

Functional capacity

ASA PC I IV

Manageable anxiety

Manageable pain Able to follow commands

Able to lie still / flat

Gives informed consent

PATIENT

DR.

PROCEDURE

CRNA

?


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Monitored Anesthesia Care Surgeons Able to Perform MAC Procedures

Short Manageable Pain MIP Position

Knows difference between MAC and GA

Knows role of sedative vs pain management

Cool Calm - Collected

Bedside Manners

Able to manage pain

Cooperative

Communicative

Functional capacity

Clinical experience

PATIENT

DR.

PROCEDURE

CRNA

?


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Anesthetists able to Performed MAC Procedures

Appropriate case selection & patient preparation Knows difference between MAC and GA

Knows role of sedative vs pain management

Cool Calm - Collected

Talks vs Sedates

Able to manage pain & sedation

Cooperative

Communicative Knows Dr / CRNA / Patient limits

Clinical experience

Knows how / when to convert

PATIENT

DR.

PROCEDURE

CRNA

?


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Same Standard of Care as General Anesthesia

PreAnesthetic Assessment

Room and Equipment Preparation

Professional Practice Standards

Anesthetist makes final determination for MAC


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PreAnesthesia Assessment

- Aspiration and/or antiemetic prophylaxis, prn


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Assessment and Monitoring During MAC


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Discharge Criteria After MAC


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Conscious Sedation

Relief of anxiety

Relief from apprehension

Maintenance of airway reflexes

Maintenance of spontaneous ventilation

Maintenance of consciousness Constant assessment of anesthetic depth


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Local anesthetic toxic ranges:

Lidocaine with epinephrine 7mg/kg

Lidocaine plain 4mg/kg

Bupivicaine with epinephrine 3.2mg/kg

Bupivicaine plain 2.5mg/kg

Mixed ?


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2mg Versed

50 mcg fentanyl

10 mg bolus Propofol prn

CookbookMAC Case


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Patient Controlled Sedation

Higher patientsatisfaction

Less drugadministered

Fewer

complications

Low provideracceptance
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Medications used for MAC Benzos Midazolam, PreOp Ativan or Valium

Hypnotics - Propofol Pentothal Brevitol - Ketamine

Opioids - Fentanyl Alfenta Remifentanyl

Other

Nitrous oxide

Low VAA Sevoflurane

Diphenhydramine

EMLA cream or Topical Lidocaine


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Midazolam

Usually given first

Dose titrated to effect

Anxiolysis, amnesia, sedation

May have paradoxical effect in elderly patients

Synergistic with opioids


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Opioids

Fentanyl, Alfentanil, Remifentanil

Demerol, Morphine

Synergistic with benzos and hypnotics

Respiratory depression

Bradycardia

Enhancement of pain control due to inadequate local

anesthesia or uncomfortable position Will not compensate for lack of surgical pain control

Consider non-narcotics or pre-emptive analgesia


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Hypnotics: Propofol Bolus vs. continuous infusion

Bolus Technique 10-20mg prn, titrate to

desired effect Infusion 25-75ug/kg/min per literature for

MAC

Frequently will use more than that

Titrate to effect and allow time for adjustment

Loss of lash reflex is usually a sign you have alsolost protective airway reflexes

Be sure you know the pump before you use it!


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Therapeutic Range

Bolus prn Bolus + Infusion


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Supplemental Oxygen

Oxygen vs Room Air

Cannula vs. mask

ETCO2 monitoring

Fire precaution when near Bovie or Laser

May need to chin lift or jaw thrust

Oral/Nasal airway with caution CO2 accumulation & CO2 narcosis

Put O2 where the air is moving in and out!


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Reversal Agents

NALOXONE (Narcan) An initial dose of 0.4 mg to 2 mg of naloxone hydrochloride may be

administered, may be repeated up to 10 mg

FLUMAZENIL (Romazicon) Benzodiazepine Sedation Reversal

Initial: 0.2 mg IV over 15 seconds

Titrate: 0.2 mg each minute to 1 mg total

Overdose Reversal

Initial: 0.2 mg IV over 30 seconds Titrate: 0.3-0.5 mg q30 seconds to 3 mg total

No Reversal agent for Hypnotics other than TIME

Use of antagonists is not a sign of failure, but

rather prudent patient safety


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Positioning concerns

MAC can be accomplished in any position, butthe RISK increases when airway is less

accessible and/or patient is less visible Continually weigh airway management

position vs. patient position & patient access

Position related injury increases with deepersedation

Balance drug choices with position needs


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Other Adjuncts to MAC Verbal Assurance

Imagery - Hypnosis

Music / Environmental Sounds / Headphones

Aroma therapy Light Therapy

Warm vs Cold

Control Other modalities

Acupuncture, Acupressure, TENS


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NarcoTrend

MonitoringSedation

Aspect Medical SystemsBispectral Index Monitoring

Hospira - PSA 4000


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Aspect -Bispectral Index Monitor


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50% of the success of MAC is

COMMUNICATION

With the PATIENTWith the SURGEON

With the MDA Attending


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Pearls of wisdom (AKA Voice of experience) Always be prepared for emergency management of the airway

..you never know how a patient is going to respond Always have a Plan A and Plan B Level of Sedation is Inversely Proportional to Level of Risk A Functional and Secure IV is a MUST A MAC that is rushedis doomed to failure Muscle relaxation is NOTpart of MAC There is a fine line between Sedation and GA MAC patients should be arousable, if not, they are GA patients MAC patients should maintain their airway, if not, they are GA patients

A vigilant anesthetist is the best monitor you can have A communicative anesthetist is the best sedative your patient can have


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When does MAC fail? Poor match of Big 4

Inadequate localization Paradoxical effects from sedation

Over-sedation stage 2 plane Painful body position or body

part ie: full bladder


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33 y/o male with no medical problems

for Left Inguinal herniorraphy


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62 year old female with history of

seizures, chronic renal failure, andasthma for AV fistula repair


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80 year old female with COPD, HTN,

and HOH for Kyphoplasty L1-3


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72 year old male with

NIDDM, CAD, HTN,and Arthritis in his neck forECCEw/IOL OD


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61 year old female with rheumatoid

arthritis, gout, CHF, CAD, andrecurrent atrial fibrillation forcardioversion and TEE


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16 year old male with asthma,

mental retardation, MH positive forlarge lipoma removal fromback/scapular region


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Its just aMAC

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Monitored Anesthesia Care Notes Jag2007

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