Title: Monitored Anesthesia Care NGR 6091 Principles of Anesthesiology Nursing I
1Monitored Anesthesia CareNGR 6091 Principles of
Anesthesiology Nursing I
Jeffrey Groom, PhD, CRNA, ARNPClinical Associate
ProfessorAnesthesiology Nursing Program
2Monitored 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
3History of Monitored Anesthesia Care
Local Stand By Conscious Sedation Monitored
Anesthesia Care
4Objectives
- 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
5Monitored Anesthesia Care
MAC GRAY ZONE GENERAL
ANESTHESIA
6Monitored Anesthesia Care
7Is MAC Safer than General Anesthesia or Regional
Anesthesia?
8Closed Claims Review of MAC Cases
9MAC Closed Claims Review by Severity
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12Monitored Anesthesia Care
Consciousness
Patent Airway Spontaneous Breathing
Safety Risk
13Monitored 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-
14Monitored 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
15Monitored 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
16Monitored 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
17Monitored 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
18Monitored 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
19Monitored Anesthesia Care
- Same Standard of Care as General Anesthesia
- PreAnesthetic Assessment
- Room and Equipment Preparation
- Professional Practice Standards
- Anesthetist makes final determination for MAC
20PreAnesthesia Assessment
- Aspiration and/or antiemetic prophylaxis, prn
21Assessment and Monitoring During MAC
22Discharge Criteria After MAC
23Aldrete Score
10 0
24Monitored 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
25Monitored Anesthesia Care
26Monitored 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 ?
27Cookbook MAC Case
2mg Versed 50 mcg fentanyl 10 mg bolus
Propofol prn
28Patient Controlled Sedation
- Higher patient satisfaction
- Less drug administered
- Fewer complications
- Low provider acceptance
29Monitored 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
30Monitored Anesthesia Care
- Midazolam
- Usually given first
- Dose titrated to effect
- Anxiolysis, amnesia, sedation
- May have paradoxical effect in elderly patients
- Synergistic with opioids
31Monitored 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
32Monitored 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!
33Monitored Anesthesia Care
Therapeutic Range
Bolus prn
Bolus Infusion
34Monitored 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!
35Monitored 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
36Monitored 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
37Monitored 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
38NarcoTrend
Monitoring Sedation
Aspect Medical Systems Bispectral Index
Monitoring
Hospira - PSA 4000
39Aspect -Bispectral Index Monitor
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41Monitored Anesthesia Care
- 50 of the success of MAC is COMMUNICATION
- With the PATIENT
- With the SURGEON
- With the MDA Attending
42Monitored 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
43Monitored 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
44Monitored Anesthesia Care
- 33 y/o male with no medical problems for Left
Inguinal herniorraphy -
45Monitored Anesthesia Care
- 62 year old female with history of seizures,
chronic renal failure, and asthma for AV fistula
repair
46Monitored Anesthesia Care
- 80 year old female with COPD, HTN, and HOH for
Kyphoplasty L1-3
47Monitored Anesthesia Care
- 72 year old male with NIDDM, CAD, HTN, and
Arthritis in his neck for ECCEw/IOL OD
48Monitored Anesthesia Care
- 61 year old female with rheumatoid arthritis,
gout, CHF, CAD, and recurrent atrial fibrillation
for cardioversion and TEE
49Monitored Anesthesia Care
- 16 year old male with asthma, mental
retardation, MH positive for large lipoma removal
from back/scapular region
50Monitored Anesthesia Care
Its just a MAC