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 future Jeffrey Groom, PhD, CRNA

History of Monitored Anesthesia Care

Local Stand By

Conscious Sedation

Monitored Anesthesia Care

Objectives
Understand the purpose of Monitored
Anesthesia Care (MAC) Discuss levels of MAC and appropriateness by type of case Discuss special circumstances in which MAC may not be appropriate Discuss techniques of MAC anesthesia

Monitored Anesthesia Care

MAC GRAY ZONE GENERAL ANESTHESIA

Monitored Anesthesia Care

Is MAC Safer than General Anesthesia or Regional Anesthesia

Closed Claims Review of MAC Cases

MAC Closed Claims Review by Severity

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Consciousness

Patent Airway Spontaneous Breathing

Safety Risk

Monitored Anesthesia Care The 3 faces of MAC

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

Monitored Anesthesia Care

Critical Flaws when Providing MAC Anesthesia

Failure 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

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 PATIENT Pacemaker - AICD insertion Inguinal Hernia repairs Knee arthroscopy DR. Kyphoplasty CRNA TEE Cardioversion Rhinoplasty 3rd Molar extraction PROCEDURE Face/Brow lift

Monitored Anesthesia Care

Patients Suitable for MAC

Conscious Cooperative Communicative PATIENT Functional capacity ASA PC I IV Manageable anxiety DR. CRNA Manageable pain Able to follow commands Able to lie still / flat PROCEDURE Gives informed consent

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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 PATIENT Bedside Manners Able to manage pain Cooperative DR. CRNA Communicative Functional capacity Clinical experience PROCEDURE

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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 PATIENT Talks vs Sedates Able to manage pain & sedation Cooperative DR. CRNA Communicative Knows Dr / CRNA / Patient limits Clinical experience PROCEDURE Knows how / when to convert

Monitored Anesthesia Care

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

PreAnesthesia Assessment

- Aspiration and/or antiemetic prophylaxis, prn

Assessment and Monitoring During MAC

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 ?

Cookbook MAC Case

2mg Versed
50 mcg fentanyl 10 mg bolus Propofol prn

Patient Controlled Sedation

Higher patient
satisfaction

Less drug
administered

Fewer
complications

Low provider
acceptance

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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

Monitored Anesthesia Care

Midazolam

Usually given first Dose titrated to effect Anxiolysis, amnesia, sedation May have paradoxical effect in elderly patients Synergistic with opioids

Monitored Anesthesia Care

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

Monitored Anesthesia Care

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 also lost protective airway reflexes Be sure you know the pump before you use it!

Monitored Anesthesia Care

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

Benzodiazepine Sedation Reversal
Initial: 0.2 mg IV over 15 seconds Titrate: 0.2 mg each minute to 1 mg total

FLUMAZENIL (Romazicon)

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, 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

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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

NarcoTrend

Monitoring Sedation
Hospira - PSA 4000 Aspect Medical Systems
Bispectral Index Monitoring

Aspect -Bispectral Index Monitor

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50% of the success of MAC is

COMMUNICATION

With the PATIENT With 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 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

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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

Monitored Anesthesia Care

33 y/o male with no medical problems for Left Inguinal herniorraphy

Monitored Anesthesia Care

62 year old female with history of seizures, chronic renal failure, and asthma for AV fistula repair

Monitored Anesthesia Care

80 year old female with COPD, HTN, and HOH for Kyphoplasty L1-3

Monitored Anesthesia Care

72 year old male with NIDDM, CAD, HTN, and Arthritis in his neck for ECCEw/IOL OD

Monitored Anesthesia Care

61 year old female with rheumatoid arthritis, gout, CHF, CAD, and recurrent atrial fibrillation for cardioversion and TEE

Monitored Anesthesia Care

16 year old male with asthma, mental retardation, MH positive for large lipoma removal from back/scapular region

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Its just a MAC