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Monitored-Anesthesia-Care presentation ppt
- 1. Darma Wirawan Soeredi, MD Anesthesia Department Adventist Medical Center Manila Source: Clinical Anesthesia 7th Edition Distinguishing MAC From Moderate Sedation/Analgesia (Conscious Sedation)
- 2. 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 Objectives
- 3. MAC ≠ Sedation / Analgesia MAC is a specific anesthesia service for a diagnostic / therapeutic procedure, it has the potential to convert to a general or regional anesthetic as needed Terminology
- 4. Monitored Anesthesia Care MAC GRAY ZONE GENERAL ANESTHESIA
- 5. Usual noninvasive cardiocirculatory and respiratory monitoring. Oxygen administration, when indicated. Administration of sedatives, tranquilizers, antiemetics, narcotics, other analgesics, beta- blockers, vasopressors, bronchodilators, antihypertensives, or other pharmacologic therapy as may be required in the judgment of the anesthesiologist. Usual Services Performed by the Anesthesiologist
- 6. As usual preop evaluation Additional: ability to remain motionless and actively cooperate? Patient’s psychological aspect? Is there sensorineural of cognitive deficit? Preoperative Assessment MAC GENERAL ANESTHESIA
- 7. the desired end points is being able to provide patient comfort, maintaining cardiorespiratory stability, improving operating conditions, and preventing recall of unpleasant perioperative events administration of either individual or combinations of analgesic, amnestic, and hypnotic drugs. Always vigilant Techniques of Monitored Anesthesia Care
- 10. Factors That Contribute the Success of MAC PATIENT SURGEON PROCEDURE ANESTHESIOLOGIST ? Conscious Cooperative Communicative Functional capacity ASA PC I – IV Manageable anxiety Manageable pain Able to follow commands Able to lie still / flat Knows difference betwe and GA Knows role of sedative management Cool – Calm Bedside Manner Able to manage pa Cooperative Communicative Clinical experienc propriate case selection & patient preparation ws difference between MAC and GA ws role of sedative vs pain management Cool – Calm Talks vs Sedates to manage pain & sedation Cooperative Communicative Knows Dr / Patient limits ows how / when to convert Cataract extraction Bone marrow biopsy Lumpectomy Pacemaker - AICD insertion Inguinal Hernia repairs Knee arthroscopy TEE – Cardioversion Rhinoplasty 3rd Molar extraction
- 11. The ultimate objective of any dosing regimen is to deliver a therapeutic concentration of drug to its site of action Pharmacologic Basis of MAC Techniques
- 12. The Elimination Half-life (T 1/2) Context-sensitive Half-time Pharmacologic Basis of MAC Techniques
- 13. describes the time required for the plasma drug concentration to decline by 50% after terminating an infusion of a particular duration Is influenced by distribution, metabolism, elimination Context-Sensitive Half-time
- 14. Plasma Following the administration of IV drugs: Distribution of Drugs Poorly Perfused Tissues VRGs
- 15. Context-Sensitive Half-Time T 1/2 :462min T 1/2 :557min T 1/2 :111min
- 16. Hypnotics Propofol Fospropofol Dexmedetomidine Opioids Fentanyl Alfentanil Remifentanil Sufentanil Benzodiazepines Midazolam Diazepam Ketamine Drugs Commonly Used in MAC
- 17. Drug Advantage(s) Disadvantage(s) Propofol Fast in- fast out (+) amnesia (+) effect on PONV ↑ Sense of well being Pain at injection site Hypotension effect Hyperlipidemia Fospropofol (+) amnesia (+) effect on PONV ↑ Sense of well being (-)pain at injection Longer onset of action than propofol ( 4 to 13 minutes) Diazepam Anxiolysis, Amnesia Long duration (>20h) Pain on injection Prolonged cognitive function recovery Midazolam Anxiolysis, Amnesia, Fast acting, low CSHT Prolonged cognitive function recovery Dexmedetomidine Sedation + analgesia Minor effects on respiratory (-)pain at injection (-)amnesia (-)slow onset Potential for significant bradycardia Drugs Commonly Used in MAC
- 18. Propofol 250-500 mcg/kg boluses 25-75 mcg/kg/min infusion Fospropofol 6.5 mg/kg bolus followed by 1.6 mg/kg Dexmedetomidine Loading infusion: 0.5–1 µg/kg over 10–20 min Maintenance infusion: 0.2–0.7–1 µg/kg/h Diazepam 2-10 ,mg Midazolam 1-2 mg prior to propofol or remifentanil infusion Typical Dose Range
- 19. Fentanyl 0.5–2.0-µg/kg bolus 2–4 min prior to stimulus Alfentanil 5–20-µg/kg bolus 2 min prior to stimulus Remifentanil Infusion 0.1 µg/kg/min 5 min prior to stimulus Wean to 0.05 µg/kg/min as tolerated Adjust up or down in increments of 0.025 µg/kg/min Reduce dose accordingly when coadministered with midazolam or propofol Typical Dose Range
- 20. NALOXONE An initial dose of 0.4 mg to 2 mg, may be repeated every 2-3 minutes, up to 10 mg FLUMAZENIL Initial recommended dose of 0.2 mg If desired level of consciousness is not achieved in 45 s, repeat 0.2-mg dose, then every 60 s until a maximum of 1 mg is administered Be aware of the potential for resedation Reversal
- 21. No Reversal agent for Hypnotics other than TIME Use of antagonists is NOT a sign of failure, but rather PRUDENT PATIENT SAFETY Reversal
- 22.
Editor's Notes
- Sedation/ analgesia is the term currently used by the ASA in their recently published Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists The standards for preoperative evaluation, intraoperative monitoring, and the continuous presence of a member of the anesthesia care team, and so forth, are no different from those for general or regional 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
- Verbal communication is very important for three reasons: as a monitor of the level of sedation and cardiorespiratory function as a means of explanation and reassurance for the patient as a mechanism of communication when the patient is required to actively cooperate
- Clinical experience suggests that a level of sedation that allows verbal communication is optimal for the patient's comfort and safety If the level of sedation is deepened to the extent that verbal communication is lost, most of the advantages of monitored anesthesia care are lost and the risks of the technique approach those of general anesthesia with an unprotected and uncontrolled airway Other causes of discomfort and agitation include a distended bladder, hypothermia, hyperthermia, pruritus, nausea, positional discomfort, uncomfortable oxygen masks and nasal cannulae, intravenous (IV) cannulation site infiltration, a member of the surgical team leaning on the patient, and prolonged pneumatic tourniquet inflation.
- Short – Manageable Pain – Position
- Excessive sedation may result in cardiac or respiratory depression Inadequate sedation may result in patient discomfort and potential morbidity from lack of cooperation Continuous infusions are superior to intermittent bolus dosing because they produce less fluctuation in drug concentration, thus reducing the number of episodes of inadequate or excessive sedation. Administration of drugs by continuous infusion rather than by intermittent dosing also reduces the total amount of drug administered and facilitates a more prompt recovery
- depends on the drug concentration gradients that exist between the various compartments For example, during the early part of an infusion of a lipophilic drug, distributive factors will tend to decrease plasma concentrations as the drug is transported to the unsaturated peripheral tissues
- In the case of fentanyl, drug that is irreversibly eliminated from the plasma by hepatic clearance is immediately replaced by drug returning from the peripheral compartments despite the longer elimination half-time of sufentanil, its context-sensitive half-time is actually less than that of alfentanil for infusions up to 8 hours in duration. huge distribution volume of sufentanil, unlike alfentanil (small distribution volume)
- Naloxone Continuous infusion: 0.005 mg/kg loading dose followed by an infusion of 0.0025 mg/kg/hr
- flumazenil-antagonized midazolam sedation was more expensive than propofol sedation ($68.67 vs. $27.80)