MONITORED ANESTHESIA CARE MAC – Flashcards

question
ANESTHETIC TECHNIQUES
answer
GA RA MAC PNB Combined Anesthetic Technique
question
FACTORS THAT INFLUENCE ANESTHETIC TECHNIQUE
answer
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.
question
IDEAL ANESTHETIC
answer
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
question
MONITORED ANESTHESIA CARE
answer
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)
question
INFORMED CONSENT MAC
answer
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
question
MONITORED ANESTHESIA CARE GOALS
answer
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)
question
MONITORED ANESTHESIA CARE " The 3 faces of MAC "
answer
Sedation only - ie: colonoscopy or TEE Sedation & Local - ie: Pacer or Bx Sedation & Block - ie: Cataract or Podi-
question
MONITORED ANESTHESIA CARE ANESTHESIA PROVIDER RESPONSIBILITIES
answer
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
question
routine preparation before induction
routine preparation before induction
answer
question
WHAT IS PREPARATION FOR MONITORED ANESTHESIA CARE?
answer
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
question
ROOM SETUP
answer
Airway equipment Monitors Intubating medications Ambu bag Ambu bag and Anesthesia Machine checked Suction
question
HISTORY OF MONITORED ANESTHESIA CARE
answer
Local - Stand By Conscious Sedation Monitored Anesthesia Care
question
ANESTHESIA IS A CONTINUUM
answer
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
question
Conscious sedation, deep sedation, general anesthesia
Conscious sedation, deep sedation, general anesthesia
answer
question
CONTINUUM OF DEPTH OF SEDATION: DEFINITION OF GENERAL ANESTHESIA AND LEVELS OF SEDATION/ANALGESIA* (ASA, 2014)
CONTINUUM OF DEPTH OF SEDATION: DEFINITION OF GENERAL ANESTHESIA AND LEVELS OF SEDATION/ANALGESIA* (ASA, 2014)
answer
question
MINIMAL SEDATION/ ANXIOLYSIS
answer
Drug induced state Pts respond normally to verbal commands Cognitive function and physical coordination may be impaired Airway reflexes, respiratory, and CV functions intact
question
MODERATE SEDATION ANALGESIA/ "CONSCIOUS SEDATION"
answer
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
question
DEEP SEDATION/ ANALGESIA
answer
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
question
SEDATION AS A CONTINUUM
answer
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
question
MODERATE SEDATION VS. MONITORED ANESTHESIA CARE
answer
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
question
Injury and liability associated with monitored anesthesia care: a closed claims analysis.
answer
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%)
question
EXAMPLES OF PROCEDURES PERFORMED UNDER MAC
answer
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
question
SURGEON CHARACHTERISTICS FOR INCREASED SUCCESS FOR MAC PROCEDURES/ SURGERIES
answer
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
question
PATIENTS SUITABLE FOR MAC
answer
Conscious Cooperative Communicative Functional Capacity ASA I- IV Manageable anxiety Manageable Pain Follow Commands Able to lie flat/ still Gives Informed Consent
question
POSITIONING CONCERNS FOR MAC
answer
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
question
POSITIONING OF OR TABLE & PT
answer
Posterior scalp lesion? Eyelid excision of a melanoma? Axillary lipoma excision? Hemorrhoidectomy? Prone? Lateral? Trendelenburg? Table position: Pts head relative to anesthesia provider
question
CRNAs ABLE TO PERFORM MAC
answer
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
question
MONITORED ANESTHESIA CARE
answer
Same Standard of Care as General Anesthesia Pre-Anesthetic Assessment Room and Equipment Preparation Professional Practice Standards Anesthetist makes final determination for MAC
question
PRE-ANESTHETIC ASSESMENT
answer
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
question
ASSESSMENT AND MONITORING DURING MAC
answer
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
question
DISCHARGE CRITERIA FOR MAC
answer
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
question
Adrete score 10-0
Adrete score 10-0
answer
question
ADJUNCTS TO MONITORED ANESTHESIA CARE
answer
Verbal Assurance Imagery - Hypnosis Music / Environmental Sounds / Headphones Aroma therapy - Light Therapy Warm vs Cold Deep breathing Control Other modalities - Acupuncture, Acupressure, TENS
question
COMPLEMENTARY VS. ALTERNATIVE TREATMENT
answer
Complementary methods Treatments used along with regular medical care Alternative methods Treatments used instead of regular medical care
question
COMPLEMENTARY METHODS
answer
Music Aromatherapy Deep breathing
question
COMPLEMENTARY TREATMENTS
answer
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
question
MEDICATIONS FOR MAC
answer
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
question
Patient Controlled Sedation- PCA
answer
higher pt satisfaction, less drug administered, fewer complications, low provider acceptance
question
MAC Local anesthetic toxic ranges: Lidocaine with epinephrine
answer
7mg/kg
question
MAC Local anesthetic toxic ranges: Lidocaine plain
answer
4mg/kg
question
MAC Local anesthetic toxic ranges: Bupivicaine with epinephrine
answer
3.2mg/kg
question
MAC Local anesthetic toxic ranges: Bupivicaine plain
answer
2.5mg/kg
question
LA toxicity effects on CNS @ low doses:
answer
Sedation, numbness of tongue & circumoral tissues, metallic taste
question
LA toxicity effects on CNS as dose increases:
answer
Restlessness, vertigo, tinnitus, difficulty focusing
question
LA toxicity effects on CNS @ Higher concentrations:
answer
Slurred speech, skeletal muscle twitching, seizures
question
MEDICATIONS USED FOR MAC
answer
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
question
BENZODIAZEPINES FOR MAC 5 Pharmacologic effects
answer
Anxiolytic, Sedation, Anticonvulsant, Spinal-cord mediated skeletal relaxation, ANTEROGRADE amnesia
question
BENZODIAZEPINES FOR MAC - GABA
answer
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
question
Comparative pharmacology of Benzes
Comparative pharmacology of Benzes
answer
question
potency from greatest to least of Benzos
answer
Lorazepam (Ativan)>> midazolam (versed) >>diazepam (Valium)
question
Anxiolytic and sedative
Anxiolytic and sedative
answer
question
MONITORED ANESTHESIA CARE Midazolam
answer
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
question
DIAZEPAM
answer
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)
question
MOA benzo
MOA benzo
answer
question
MONITORED ANESTHESIA CARE Opioids
answer
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
question
Morphine iv bolus and infusion dose
answer
iv bolus 0.1-0.2 mg/kg Infusion 10-40 ug/kg/h
question
Fentanyl iv bolus and infusion dose
answer
iv bolus 1-3 ug/kg Infusion 1-10 ug/kg/h
question
Remifentanil iv bolus and infusion dose
answer
iv bolus 1 ug/kg Infusion 0.5-0.6 ug/kg/h
question
Alfentanil iv bolus and infusion dose
answer
iv bolus 15-25 ug/kg Infusion 0.4-2 ug/kg/min
question
Hypnotics: Propofol
answer
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
question
MONITORED ANESTHESIA CARE Ketamine
answer
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
question
PRECEDEX
answer
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
question
MONITORED ANESTHESIA CARE Reversal Agents
answer
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 $$$$$
question
MONITORED ANESTHESIA CARE Supplemental Oxygen
answer
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!
question
FIRE PRECAUTIONS
answer
Suction Lowest FIO2 possible No O2 Know when to decrease O2 Prep dry time
question
What is the safest anesthetic technique for an anesthesia provider to perform?
answer
The one they are most comfortable with Anesthesia care providers may perform better with techniques with which they are more experienced
question
50% of the success of MAC is
answer
COMMUNICATION With the PATIENT With the SURGEON With the MDA Attending
question
MAC Pearls of Wisdom
answer
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
question
WHEN DOES MAC FAIL?
answer
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
question
Questions to answer about patients to ensure successful MAC
answer
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
question
Name the 4 variables needed for a successful MAC case
answer
Patient Procedure Surgeon Anesthesia provider
question
Name complementary techniques used in anesthesia
answer
Music therapy Aromatherapy Deep breathing Guided imagery Hypnosis Light therapy Acupuncture
question
When should you consider converting to GA
answer
Unmanageable pain Loss of airway with untreatable desaturation Change in surgical plan
question
Name drugs that drop BP during MAC
answer
Propofol Precedex
question
Name drugs not metabolized by liver or kidney
answer
Remifentanil
question
What do you need to prepare for a MAC case
answer
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
question
Name drugs used in MAC
answer
Versed Fentanyl Propofol Precedex Ketamine N2O Low dose VAA NSAIDS O2 Benadryl
1 of

Unlock all answers in this set

Unlock answers
question
ANESTHETIC TECHNIQUES
answer
GA RA MAC PNB Combined Anesthetic Technique
question
FACTORS THAT INFLUENCE ANESTHETIC TECHNIQUE
answer
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.
question
IDEAL ANESTHETIC
answer
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
question
MONITORED ANESTHESIA CARE
answer
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)
question
INFORMED CONSENT MAC
answer
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
question
MONITORED ANESTHESIA CARE GOALS
answer
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)
question
MONITORED ANESTHESIA CARE " The 3 faces of MAC "
answer
Sedation only - ie: colonoscopy or TEE Sedation & Local - ie: Pacer or Bx Sedation & Block - ie: Cataract or Podi-
question
MONITORED ANESTHESIA CARE ANESTHESIA PROVIDER RESPONSIBILITIES
answer
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
question
routine preparation before induction
routine preparation before induction
answer
question
WHAT IS PREPARATION FOR MONITORED ANESTHESIA CARE?
answer
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
question
ROOM SETUP
answer
Airway equipment Monitors Intubating medications Ambu bag Ambu bag and Anesthesia Machine checked Suction
question
HISTORY OF MONITORED ANESTHESIA CARE
answer
Local - Stand By Conscious Sedation Monitored Anesthesia Care
question
ANESTHESIA IS A CONTINUUM
answer
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
question
Conscious sedation, deep sedation, general anesthesia
Conscious sedation, deep sedation, general anesthesia
answer
question
CONTINUUM OF DEPTH OF SEDATION: DEFINITION OF GENERAL ANESTHESIA AND LEVELS OF SEDATION/ANALGESIA* (ASA, 2014)
CONTINUUM OF DEPTH OF SEDATION: DEFINITION OF GENERAL ANESTHESIA AND LEVELS OF SEDATION/ANALGESIA* (ASA, 2014)
answer
question
MINIMAL SEDATION/ ANXIOLYSIS
answer
Drug induced state Pts respond normally to verbal commands Cognitive function and physical coordination may be impaired Airway reflexes, respiratory, and CV functions intact
question
MODERATE SEDATION ANALGESIA/ "CONSCIOUS SEDATION"
answer
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
question
DEEP SEDATION/ ANALGESIA
answer
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
question
SEDATION AS A CONTINUUM
answer
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
question
MODERATE SEDATION VS. MONITORED ANESTHESIA CARE
answer
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
question
Injury and liability associated with monitored anesthesia care: a closed claims analysis.
answer
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%)
question
EXAMPLES OF PROCEDURES PERFORMED UNDER MAC
answer
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
question
SURGEON CHARACHTERISTICS FOR INCREASED SUCCESS FOR MAC PROCEDURES/ SURGERIES
answer
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
question
PATIENTS SUITABLE FOR MAC
answer
Conscious Cooperative Communicative Functional Capacity ASA I- IV Manageable anxiety Manageable Pain Follow Commands Able to lie flat/ still Gives Informed Consent
question
POSITIONING CONCERNS FOR MAC
answer
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
question
POSITIONING OF OR TABLE & PT
answer
Posterior scalp lesion? Eyelid excision of a melanoma? Axillary lipoma excision? Hemorrhoidectomy? Prone? Lateral? Trendelenburg? Table position: Pts head relative to anesthesia provider
question
CRNAs ABLE TO PERFORM MAC
answer
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
question
MONITORED ANESTHESIA CARE
answer
Same Standard of Care as General Anesthesia Pre-Anesthetic Assessment Room and Equipment Preparation Professional Practice Standards Anesthetist makes final determination for MAC
question
PRE-ANESTHETIC ASSESMENT
answer
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
question
ASSESSMENT AND MONITORING DURING MAC
answer
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
question
DISCHARGE CRITERIA FOR MAC
answer
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
question
Adrete score 10-0
Adrete score 10-0
answer
question
ADJUNCTS TO MONITORED ANESTHESIA CARE
answer
Verbal Assurance Imagery - Hypnosis Music / Environmental Sounds / Headphones Aroma therapy - Light Therapy Warm vs Cold Deep breathing Control Other modalities - Acupuncture, Acupressure, TENS
question
COMPLEMENTARY VS. ALTERNATIVE TREATMENT
answer
Complementary methods Treatments used along with regular medical care Alternative methods Treatments used instead of regular medical care
question
COMPLEMENTARY METHODS
answer
Music Aromatherapy Deep breathing
question
COMPLEMENTARY TREATMENTS
answer
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
question
MEDICATIONS FOR MAC
answer
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
question
Patient Controlled Sedation- PCA
answer
higher pt satisfaction, less drug administered, fewer complications, low provider acceptance
question
MAC Local anesthetic toxic ranges: Lidocaine with epinephrine
answer
7mg/kg
question
MAC Local anesthetic toxic ranges: Lidocaine plain
answer
4mg/kg
question
MAC Local anesthetic toxic ranges: Bupivicaine with epinephrine
answer
3.2mg/kg
question
MAC Local anesthetic toxic ranges: Bupivicaine plain
answer
2.5mg/kg
question
LA toxicity effects on CNS @ low doses:
answer
Sedation, numbness of tongue & circumoral tissues, metallic taste
question
LA toxicity effects on CNS as dose increases:
answer
Restlessness, vertigo, tinnitus, difficulty focusing
question
LA toxicity effects on CNS @ Higher concentrations:
answer
Slurred speech, skeletal muscle twitching, seizures
question
MEDICATIONS USED FOR MAC
answer
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
question
BENZODIAZEPINES FOR MAC 5 Pharmacologic effects
answer
Anxiolytic, Sedation, Anticonvulsant, Spinal-cord mediated skeletal relaxation, ANTEROGRADE amnesia
question
BENZODIAZEPINES FOR MAC - GABA
answer
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
question
Comparative pharmacology of Benzes
Comparative pharmacology of Benzes
answer
question
potency from greatest to least of Benzos
answer
Lorazepam (Ativan)>> midazolam (versed) >>diazepam (Valium)
question
Anxiolytic and sedative
Anxiolytic and sedative
answer
question
MONITORED ANESTHESIA CARE Midazolam
answer
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
question
DIAZEPAM
answer
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)
question
MOA benzo
MOA benzo
answer
question
MONITORED ANESTHESIA CARE Opioids
answer
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
question
Morphine iv bolus and infusion dose
answer
iv bolus 0.1-0.2 mg/kg Infusion 10-40 ug/kg/h
question
Fentanyl iv bolus and infusion dose
answer
iv bolus 1-3 ug/kg Infusion 1-10 ug/kg/h
question
Remifentanil iv bolus and infusion dose
answer
iv bolus 1 ug/kg Infusion 0.5-0.6 ug/kg/h
question
Alfentanil iv bolus and infusion dose
answer
iv bolus 15-25 ug/kg Infusion 0.4-2 ug/kg/min
question
Hypnotics: Propofol
answer
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
question
MONITORED ANESTHESIA CARE Ketamine
answer
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
question
PRECEDEX
answer
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
question
MONITORED ANESTHESIA CARE Reversal Agents
answer
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 $$$$$
question
MONITORED ANESTHESIA CARE Supplemental Oxygen
answer
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!
question
FIRE PRECAUTIONS
answer
Suction Lowest FIO2 possible No O2 Know when to decrease O2 Prep dry time
question
What is the safest anesthetic technique for an anesthesia provider to perform?
answer
The one they are most comfortable with Anesthesia care providers may perform better with techniques with which they are more experienced
question
50% of the success of MAC is
answer
COMMUNICATION With the PATIENT With the SURGEON With the MDA Attending
question
MAC Pearls of Wisdom
answer
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
question
WHEN DOES MAC FAIL?
answer
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
question
Questions to answer about patients to ensure successful MAC
answer
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
question
Name the 4 variables needed for a successful MAC case
answer
Patient Procedure Surgeon Anesthesia provider
question
Name complementary techniques used in anesthesia
answer
Music therapy Aromatherapy Deep breathing Guided imagery Hypnosis Light therapy Acupuncture
question
When should you consider converting to GA
answer
Unmanageable pain Loss of airway with untreatable desaturation Change in surgical plan
question
Name drugs that drop BP during MAC
answer
Propofol Precedex
question
Name drugs not metabolized by liver or kidney
answer
Remifentanil
question
What do you need to prepare for a MAC case
answer
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
question
Name drugs used in MAC
answer
Versed Fentanyl Propofol Precedex Ketamine N2O Low dose VAA NSAIDS O2 Benadryl