Monitored Anesthesia Care NGR 6091 Principles of Anesthesiology Nursing I

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Monitored Anesthesia CareNGR 6091 Principles of
Anesthesiology Nursing I
Jeffrey Groom, PhD, CRNA, ARNPClinical Associate
ProfessorAnesthesiology Nursing Program
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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 future Jeffrey Groom, PhD, CRNA
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History of Monitored Anesthesia Care
Local Stand By Conscious Sedation Monitored
Anesthesia Care
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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

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Monitored Anesthesia Care
MAC GRAY ZONE GENERAL
ANESTHESIA
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Monitored Anesthesia Care
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Is MAC Safer than General Anesthesia or Regional
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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Monitored Anesthesia Care
Consciousness
Patent Airway Spontaneous Breathing
Safety Risk
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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-

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Monitored Anesthesia Care

• 4 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

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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.
CRNA
PROCEDURE
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Monitored Anesthesia Care

• 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.
CRNA
PROCEDURE
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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.
CRNA
PROCEDURE
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Monitored Anesthesia Care

• 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.
CRNA
PROCEDURE
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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

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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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Aldrete Score
10 0
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Monitored Anesthesia Care

• 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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Monitored Anesthesia Care
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Monitored Anesthesia Care

• 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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Cookbook MAC Case
2mg Versed 50 mcg fentanyl 10 mg bolus
Propofol prn
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Patient Controlled Sedation

• Higher patient satisfaction
• Less drug administered
• Fewer complications
• Low provider acceptance

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Monitored Anesthesia Care

• 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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Monitored Anesthesia Care

• 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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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

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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!

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Monitored Anesthesia Care
Therapeutic Range
Bolus prn
Bolus Infusion
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Monitored Anesthesia Care

• 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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Monitored Anesthesia Care

• 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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Monitored Anesthesia Care

• 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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Monitored Anesthesia Care

• 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
Monitoring Sedation
Aspect Medical Systems Bispectral Index
Monitoring
Hospira - PSA 4000
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Aspect -Bispectral Index Monitor
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Monitored Anesthesia Care

• 50 of the success of MAC is COMMUNICATION
• With the PATIENT
• With the SURGEON
• With the MDA Attending

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Monitored Anesthesia Care

• 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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Monitored Anesthesia Care

• 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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Monitored Anesthesia Care

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

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Monitored Anesthesia Care

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

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Monitored Anesthesia Care

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

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Monitored Anesthesia Care

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

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Monitored Anesthesia Care

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

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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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Monitored Anesthesia Care
Its just a MAC