Monitored Anesthesia Care NGR 6091 Principles of Anesthesiology Nursing I

1. Monitored Anesthesia CareNGR 6091 Principles of Anesthesiology Nursing I

2. Monitored Anesthesia Care

3. History of Monitored Anesthesia Care

4. 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

12. Monitored Anesthesia Care

13. Sedation only – ie: colonoscopy or TEE Sedation & Local – ie: Pacer or Bx Sedation & Block – ie: Cataract or Podi- Monitored Anesthesia Care“ The 3 faces of MAC ”

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

24. 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

25. Monitored Anesthesia Care

26. 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 ?

28. Patient Controlled Sedation

29. Monitored Anesthesia Care Medications used for MAC Benzo’s – 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

30. Monitored Anesthesia Care Midazolam Usually given first Dose titrated to effect Anxiolysis, amnesia, sedation May have paradoxical effect in elderly patients Synergistic with opioids

31. 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

32. 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!

33. Monitored Anesthesia Care

34. 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!

35. 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

36. 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

37. 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

39. Aspect -Bispectral Index Monitor

41. Monitored Anesthesia Care 50% of the success of MAC is COMMUNICATION With the PATIENT With the SURGEON With the MDA Attending

42. 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

43. 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

44. Monitored Anesthesia Care 33 y/o male with no medical problems for Left Inguinal herniorraphy

45. Monitored Anesthesia Care 62 year old female with history of seizures, chronic renal failure, and asthma for AV fistula repair

46. Monitored Anesthesia Care 80 year old female with COPD, HTN, and HOH for Kyphoplasty L1-3

47. Monitored Anesthesia Care 72 year old male with NIDDM, CAD, HTN, and Arthritis in his neck for ECCEw/IOL OD

48. Monitored Anesthesia Care 61 year old female with rheumatoid arthritis, gout, CHF, CAD, and recurrent atrial fibrillation for cardioversion and TEE

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

50. Monitored Anesthesia Care