MONITORED ANESTHESIA CARE MAC – Flashcards

GA RA MAC PNB Combined Anesthetic Technique

Preference of Patient, Anesthesia Provider, & Surgeon Providers skill level and comfort level Coexisting diseases Site of Surgery Body position of pt during surgery Elective or emergent surgery Likelihood of increased gastric contents at time of induction Suspected difficult airway management & tracheal intubation Duration of surgery or procedure Patient age Anticipated recovery time PACU discharge criteria It is important to evaluate the patient's ability to remain motionless and, if necessary, actively cooperate throughout the procedure. Thus, it is important to evaluate the patient's psychological preparation for the planned procedure. It is also important to elicit the presence of coexisting sensorineural or cognitive deficits. These factors or the inability to communicate with the patient may occasionally make general anesthesia a more appropriate alternative. Verbal communication between physician and patient is very important for three reasons: (1) as a monitor of the level of sedation and cardiorespiratory function, (2) as a means of explanation and reassurance for the patient, and (3) as a mechanism of communication when the patient is required to actively cooperate. Although cardiorespiratory disease is often cited as an indication to perform a procedure using monitored anesthesia care rather than general anesthesia, there are occasions when cardiorespiratory disease may reduce the utility of monitored anesthesia care. For example, the presence of a persistent cough may make it very difficult for the patient to remain immobile, which can be particularly dangerous during ophthalmologic or awake neurosurgical procedures. Attempts to attenuate coughing with sedation techniques are likely to be unsuccessful and potentially harmful because a significant level of anesthesia is required to abolish the cough reflex. Similarly, some patients with significant cardiovascular or pulmonary disease may be unable to lie flat for an extended period.

Incorporates pt safety & satisfaction, provides excellent operating conditions for surgeon, allows rapid recovery, and avoids postoperative side effects Low cost, early transfer or discharge from PACU, optimize postoperative pain control, permit optimal operating room efficiency, including turnover times

Procedure in which an anesthetic provider is requested or required to provide anesthetic services, which include preoperative evaluations, care during the procedure, and management after the procedure (ASA)

Informed pt who understands anesthetic techniques available, needs for accomplishing the surgery is likely to be comfortable with the anesthetic technique recommended by anesthesia provider Make sure pt understands anesthesia terminology Local Anesthesia Pts understanding and expectations of MAC Back up plan

Maintain patient safety and sense of well-being Alleviate pain, minimize discomfort Minimize psychological responses (Anxiolysis, Analgesia, Amnesia) Control behavior Return to pre-procedural state (Recognized criteria, Safe discharge)

Sedation only - ie: colonoscopy or TEE Sedation & Local - ie: Pacer or Bx Sedation & Block - ie: Cataract or Podi-

Diagnosis and treatment of clinical problems during the procedure Support of vital functions Administration of sedatives, analgesics, hypnotics, anesthetic drugs, medications necessary for pt safety Psychological support "therapeutic communication" and physical comfort Access to other services as needed to complete the procedure safely Care of pt under MAC anesthesia is held to same standard as any other anesthetic technique

Everything you would need for GA Level of sedation may progress rapidly, go beyond consciousness and lead to GA GA: Any instance in which the pt loses consciousness as defined by the ability to respond purposefully (ASA) Monitor total dose of local anesthetic given by surgeon to avoid local anesthesia toxicity

Airway equipment Monitors Intubating medications Ambu bag Ambu bag and Anesthesia Machine checked Suction

Local - Stand By Conscious Sedation Monitored Anesthesia Care

Mac ( conscious sedation) - Grey zone (deep sedation)- general anesthesia Monitored anesthesia care may include varying levels of sedation, analgesia, and anxiolysis as necessary. The provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required

Drug induced state Pts respond normally to verbal commands Cognitive function and physical coordination may be impaired Airway reflexes, respiratory, and CV functions intact

May have drug induced depression of consciousness Pts respond purposefully to verbal commands either alone or w/ light tactile stimulation Reflex withdrawal from a painful stimulus is NOT considered purposeful response No interventions required to maintain patent airway Maintenance of airway reflexes Spontaneous ventilation is adequate CV function is usually maintained Relief from anxiety and apprehension Constant assessment of anesthetic depth

Drug induced depression of consciousness Pts cannot be easily aroused but can respond purposefully to repeated painful stimuli Pts may require assistance in maintaining a patent airway Spontaneous ventilation may be inadequate CV function usually maintained

Not always possible to predict how a pt will respond In pts when sedation level is deeper than intended need to be able to rescue pts

Moderate sedation Formerly conscious sedation CPT code Physicians, dentists, nurses MAC Assessment & management of medical problems during procedure Able to convert to GA/ manage airway Sedatives, hypnotics, analgesics often used in induction GA Pre and post procedure care

MAC claims involved older and sicker patients compared with general anesthesia claims More than 40% of claims associated with MAC involved death or permanent brain damage, similar to general anesthesia claims In contrast, the proportion of regional anesthesia claims with death or permanent brain damage was less (P < 0.01). Respiratory depression, after absolute or relative overdose of sedative or opioid drugs, was the most common (21%) specific damaging mechanism in MAC claims Nearly half of claims were judged as preventable by better monitoring, including capnography, improved vigilance, or audible alarms On-the-patient operating room fires, from the use of electrocautery, in the presence of supplemental oxygen during facial surgery, resulted in burn injuries in 20 MAC claims (17%)

Considerations: Short, Manageable Pain, Position Cataract extraction Port insertion Bone Marrow biopsy "Lump and bump" surgery Pacemaker/AICD insertion Inguinal hernia repair Knee arthroscopy 3rd Molar extraction TEE/ Cardioversion Kyphoplasty Rhinoplasty Face/ Brow lift

Short/ Quick Surgeries Understands difference between GA & MAC Understands sedative vs pain management Cool, calm, collected Bedside manner Able to manage pain Cooperative Communicative Functional Capacity Clinical experience

Conscious Cooperative Communicative Functional Capacity ASA I- IV Manageable anxiety Manageable Pain Follow Commands Able to lie flat/ still Gives Informed Consent

MAC can be accomplished in any position, but the 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 deeper sedation Balance drug choices with position needs

Posterior scalp lesion? Eyelid excision of a melanoma? Axillary lipoma excision? Hemorrhoidectomy? Prone? Lateral? Trendelenburg? Table position: Pts head relative to anesthesia provider

Appropriate case selection Appropriate patient preparation Understands difference between MAC & GA Understands role of sedative vs. pain management Cool, calm, collected Able to manage pain & sedation Communicative Knows limits of pt, surgeon, and self Clinical experience Knows how & when to convert

Same Standard of Care as General Anesthesia Pre-Anesthetic Assessment Room and Equipment Preparation Professional Practice Standards Anesthetist makes final determination for MAC

Pre-procedural Assessment Psychological preparation History & Physical Exam Airway evaluation Appropriate laboratory tests Maximize physiologic function and chronic disease Fasting guidelines Aspiration/ antiemetic prophylaxis PRN Preparation & care for MAC pts should parallel care for GA pts

Assessment/ Monitoring: Verbal & visual contact Vital Signs: HR, BP, RR, Temp EKG SPO2 Capnography/ ETCO2 (when available) Advantages of Capnography: Real-time monitor Breath by breath analysis RR Adequacy of MV vs. CO2 production Immediate response to medications & stimulation Pattern of Recovery Safety Items Needed: Positive pressure delivery device Suction VS Monitors/ EKG Crash Cart/ Defibrillator Airway adjuncts

Criteria Conscious & responds appropriately Stable Absence of N/V Minimal or no pain/ discomfort Minimal or no bleeding No circulation impairment No NEW onsets of problems Responsible adult chaperone Aldrete Scoring System

Verbal Assurance Imagery - Hypnosis Music / Environmental Sounds / Headphones Aroma therapy - Light Therapy Warm vs Cold Deep breathing Control Other modalities - Acupuncture, Acupressure, TENS

Complementary methods Treatments used along with regular medical care Alternative methods Treatments used instead of regular medical care

Music Aromatherapy Deep breathing

Patients report decreased preoperative anxiety and decreased postoperative anxiety and pain compared to control groups when these techniques used preoperatively Intraoperative music shown to decrease postoperative anxiety and pain compared to control groups

NO SINGLE DRUG CAN PROViDE ALL OF THE COMPONENTS OF MONITORED ANESTHESIA CARE ANALGESIA ANXIOLYSIS HYPNOSIS BY ACTING SYNERGISTICALLY COMBOS OF DRUGS REDUCE DOSE REQUIREMENTS OF INDIVIDUAL DRUGS EX: FENTANYL DECREASES PROPOFOL DOSING FOR SUPRESSION OF RESPONSE TO SKIN INCISION MIDAZOLAM SYNERGYSTIC WITH PROPOFOL OPIOD & BENZODIAZEPINE SYNERGISTIC IN PRODUCING HYPNOSIS SYNERGISM ALSO EXTENDS TO UNWANTED SIDE EFFECTS- CARDIAC & RESPIRATORY DEPRESSION

higher pt satisfaction, less drug administered, fewer complications, low provider acceptance

7mg/kg

4mg/kg

3.2mg/kg

2.5mg/kg

Sedation, numbness of tongue & circumoral tissues, metallic taste

Restlessness, vertigo, tinnitus, difficulty focusing

Slurred speech, skeletal muscle twitching, seizures

Benzo's - Midazolam, PreOp Ativan or Valium Hypnotics - Propofol - Ketamine Opioids - Fentanyl - Alfenta - Remifentanyl Nitrous oxide Low VAA - Sevoflurane Diphenhydramine EMLA cream or Topical Lidocaine Alpha 2 agonist Precedex, Clonidine IV Tylenol, Ibuprofren, Dyloject, NSAIDS

Anxiolytic, Sedation, Anticonvulsant, Spinal-cord mediated skeletal relaxation, ANTEROGRADE amnesia

Facilitate gamma-aminobutyric acid (GABA) (Enhance the affinity of GABA, but DO NOT activate GABA GABA Alpha 1 subunits- sedative effects GABA Alpha 2 subunits- anxiolytic effects Highly protein bound

Lorazepam (Ativan);; midazolam (versed) ;;diazepam (Valium)

Usually given first Dose titrated to effect May have paradoxical effect in elderly patients Prolonged postop sedation ; psychomotor impairment Consider avoiding in elderly Potentiate ventilatory depressant effects of opioids Lowest dose possible for quick neuro assessment 1- 2.5MG IV (Onset 30-60 sec, Peak 3-5 min, Duration of sedation (15-80 min) Infusion 4MCG/KG/MIN Short elimination half life ; likelihood of concomitant drug interactions make versed superior to other benzos

0.1 MG/KG effective for treating seizures, including seizures caused by lidocaine Oral preoperative dose 50mcg/kg not to exceed 4 mg IV dose 1-4 mg (onset 1-2 min, peak 20-30 min, duration 6-10 hours)

Fentanyl, Alfentanil, Remifentanil Demerol, Morphine Synergistic with benzos and hypnotics Respiratory depression N/V Muscle rigidity Bradycardia Enhancement of pain control due to inadequate local anesthesia or uncomfortable position Will not compensate for lack of surgical pain control Pre-emptive analgesia

iv bolus 0.1-0.2 mg/kg Infusion 10-40 ug/kg/h

iv bolus 1-3 ug/kg Infusion 1-10 ug/kg/h

iv bolus 1 ug/kg Infusion 0.5-0.6 ug/kg/h

iv bolus 15-25 ug/kg Infusion 0.4-2 ug/kg/min

Bolus vs. continuous infusion Bolus Technique 10-20mg prn, titrate to desired effect (250-500ug/kg) Infusion 25-75ug/kg/min per literature for MAC Titrate to effect and allow time for adjustment Loss of lash reflex is usually a sign you have also lost protective airway reflexes Be familiar wit pump Rapid return to clear-headedness

0.2-1 mg/kg IV PRETREAT WITH BENZO Reduce incidence of hallucinations Dissociative amnesia Eyes open, slow nystagmic gaze Amnesia and intense analgesia Increased oral secretions -;laryngospasm Pre-treat with ? Onset 1-2 min, duration 20-60 min

Sedation ; analgesia Lack of pain on injection Minimal respiratory effects Target sedation level takes longer than propofol Loading dose boluses associated with bradycardia and hypotension Loading dose 0.5-1ug/kg over 10-20 min Maintenance infusion 0.2-0.7 ug/kg/hr

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 45 sec- 1 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 However $$$$$

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!

Suction Lowest FIO2 possible No O2 Know when to decrease O2 Prep dry time

The one they are most comfortable with Anesthesia care providers may perform better with techniques with which they are more experienced

COMMUNICATION With the PATIENT With the SURGEON With the MDA Attending

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 rushed is doomed to failure Muscle relaxation is NOT part 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

Poor match of "Big 4" Inadequate localization Paradoxical effects from sedation Over-sedation - stage 2 plane Painful body position - or body part i.e.: full bladder

Can they lie flat Can they breathe flat Can we communicate Do they have manageable pain Do they have manageable anxiety Do they have understanding of a MAC

Patient Procedure Surgeon Anesthesia provider

Music therapy Aromatherapy Deep breathing Guided imagery Hypnosis Light therapy Acupuncture

Unmanageable pain Loss of airway with untreatable desaturation Change in surgical plan

Propofol Precedex

Remifentanil

Machine check Ambu bag Airway equipment Intubating needs Emergency meds Suction Capnography when available Working IV access Low flow O2 delivery Access to crash cart

Versed Fentanyl Propofol Precedex Ketamine N2O Low dose VAA NSAIDS O2 Benadryl