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Monitored Anesthesia

Care

Darma Wirawan Soeredi, MD


Anesthesia Department
Adventist Medical Center Manila

Source: Clinical Anesthesia 7th Edition


Distinguishing MAC From Moderate
Sedation/Analgesia (Conscious Sedation)

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

Terminology

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

Monitored Anesthesia
Care

MAC

GRAY ZONE

GENERAL ANESTHESIA

Usual Services Performed by the


Anesthesiologist

Usual noninvasive cardiocirculatory and


respiratory monitoring.
Oxygen administration, when indicated.
Administration of sedatives, tranquilizers,
antiemetics, narcotics, other analgesics, betablockers, vasopressors, bronchodilators,
antihypertensives, or other pharmacologic
therapy as may be required in the judgment of
the anesthesiologist.

Preoperative
Assessment

As usual preop evaluation


Additional:
ability to remain motionless and actively
cooperate?
Patients psychological aspect?
Is there sensorineural of cognitive deficit?

MAC

GENERAL
ANESTHESI
A

Techniques of Monitored Anesthesia


Care

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

Observer's Assessment of
Alertness/Sedation Scale

MAC

Consciousness
Patent Airway
Spontaneous Breathing

Safety Risk

Conscious
Factors ThatCooperative
Contribute the
Communicative
Success
of capacity
MAC
Functional
IV
difference betwe
propriate case selection & ASA PC I Knows
and GA
patient preparation Manageable anxiety
PATIENT
Manageable
pain role of sedative
ws difference between MAC
Knows
and GA
Able to follow commandsmanagement
ws role of sedative vs pain
Able to lie still / flat Cool Calm
management
Cataract extraction Bedside Manner
ANESTHESIOLOGIST
SURGEON
Cool
Calm Bone marrow biopsy
Able to manage pa
Lumpectomy
Talks vs Sedates
Cooperative
to manage pain &Pacemaker
sedation - AICD insertion
Cooperative Inguinal Hernia repairsCommunicative
arthroscopy Clinical experienc
PROCEDURE
Communicative Knee
TEE Cardioversion
Knows Dr / Patient limits
Rhinoplasty
ows how / when to convert
rd

3 Molar extraction

Pharmacologic Basis of MAC


Techniques

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

The Elimination Half-life (T 1/2)


Context-sensitive Half-time

Context-Sensitive Halftime

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

Distribution of Drugs

Following the administration of IV drugs:

VRGs

Plasm
a
Poorly
Perfuse
d
Tissues

Context-Sensitive HalfTime

T 1 /2 :
462min

T 1/ 2 :
111min
T 1/2 :
557min

Drugs Commonly Used in


MAC

Hypnotics
Propofol
Fospropofol
Dexmedetomidine

Opioids

Fentanyl
Alfentanil
Remifentanil
Sufentanil

Benzodiazepines
Midazolam
Diazepam

Ketamine

Drugs Commonly Used in


MAC
Drug
Advantage(s)
Disadvantage(s)
Propofol

Fast in- fast out


Pain at injection site
(+) amnesia
Hypotension effect
(+) effect on PONV
Hyperlipidemia
Sense of well being

Fospropofol

(+) amnesia
Longer onset of
(+) effect on PONV
action than propofol
Sense of well being (4 to 13 minutes)
(-)pain at injection

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

(-)amnesia
(-)slow onset
Potential for

Typical Dose Range

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: 0.51 g/kg over 1020 min
Maintenance infusion: 0.20.71 g/kg/h

Diazepam
2-10 ,mg
Midazolam 1-2 mg prior to propofol or
remifentanil infusion

Typical Dose Range

Fentanyl 0.52.0-g/kg bolus 24 min prior to


stimulus
Alfentanil 520-g/kg bolus 2 min prior to stimulus
Remifentanil

Infusion 0.1 g/kg/min 5 min prior to stimulus


Wean to 0.05 g/kg/min as tolerated
Adjust up or down in increments of 0.025 g/kg/min
Reduce dose accordingly when coadministered with
midazolam or propofol

Reversal

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

No Reversal agent for


Hypnotics other than TIME
Use of antagonists is NOT a
sign of failure, but rather
PRUDENT PATIENT SAFETY

Thank You, Po