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MAC
MAC
26
Nursing
Graduate
06/26/2011

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Cards

Term

What is MAC (monitored anesthesia care)?

What aspects of anesthesia care does it include?

Definition

a specific anethesia service in which an anesthesia provider has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure

 

MAC includes all aspects of anesthesia care - preop visit, intraop care, postop care

Term
 MAC often includes the administration of doses of medications for which the loss of ____ _____ or _____ is likely.
Definition
MAC often includes the administration of doses of medications for which the loss of normal reflexes or LOC is likely
Term

Can the patient typically protect their own airway throughout a MAC case?

 

Can this become a GA?

Definition

yes, patient can typically protect their own airway

 

yes-if, for an extended period of time, the pt is unconscious and/or loses normal protective reflexes, the anesthetic is considered a general

(currently no clear definition of "extended period of time")

Term

What is the purpose of MAC? (5)

 

Is MAC safer than GETA?

Definition

anxiolysis

amnesia

analgesia

comfort

safety 

 

yes it is in some populations

 

Term
Advantages of MAC vs GETA (6)
Definition

safety

decreased PACU time

decreased N/V

improved OR turnover

patient satisfaction

decreased operating costs; increased profits

Term
During the patient evaluation, what are you looking for?
Definition

patient (& surgeon) cooperation

physical status

Term
What physical status indicators are you assessing?
Definition

sleep apnea/morbid obesity

(best if you can be close to the airway the whole time..may need to do occasional jaw thrusts etc)

COPD (coughing)

neurological disorders (Parkinson's, RLS)

chronic back pain (prop knees)

age**

CV function

verbal and auditory function

mental retardation

positioning

prone vs supine vs lateral

NPO status

Term

MAC is safer with elderly pts d/t less manipulation of their airway etc T/F?

 

Can MAC be done with a mentally retarded pt?

 

Is there an NPO requirement before a MAC case?

Definition

True

 

Yes, but Richard sts he would never try...."just put them to sleep"

 

Yes...time frame varies but often about 4 hours or so per lec.

Term
What drugs are utilized for MAC?
Definition

midazolam

fentanyl/sufenta/alfentanil

propofol

ketamine

remifentanil

doxapram (dopram)

narcan

flumazenil (romazicon)

Term

Propofol

Why is this a good choice?

 

Infusion dose & duration?

When do they regain consciousness?

 

Advantages? (2)

 

Be aware?

Definition

its pharmacokinetic profile makes it easily titratable with an excellent recovery time

 

infusions of 50-70mcg/kg/min for 100 min.

regain consciousness in ~4 min

 

low incidence of N/V

clear-headed upon awakening

 

be aware: no analgesic properties or amnestic properties at sub hypnotic doses

Term

What bolus dose of propofol will usually not cause apnea?

 

Is there quicker recovery with an infusion pump or int. bolus doses of propofol? why?

Definition

~30-70mg bolus for injection of local or painful stimulus usually will not cause apnea

 

infusion via pump will usually yield a lower accumulative dose than intermittent boluses and therefore quicker recovery

Term

T/F: Midazolam is the most commonly used BZD

 

Midazolam

 

properties?

 

elderly dosage?

 

short elim. 1/2 life of ____ yet...?

Definition

true

 

anxiolytic, amnestic, & hypnotic properties

 

significantly reduced doses needed in the elderly - 1/3 to 1/4 normal dose 

 

short elimination half-life of 1-4hrs, yet prolonged psychomotor impairment when used as a large portion of your MAC

(give 1-2mg not 5mg as an adjunct to other meds like propofol)

Term

Should midazolam be given alone or in combination with propofol? Why?

 

Reversal agent & dose? Max dose?

 

Effects of mdz may recur in ___ min

 

Disadvantage?

Definition

much more advantageous to use at small dose for amnestic properties along with propofol for hypnotic properties (doses of propofol given for MAC are usually sub-amnestic & thus a lil benzos is needed) 

 

Reverse w/ Flumazenil - 0.2mg q 60sec to max of 1mg


Effects of mdz may recur in 90 min

 

cost prohibitive ($60-70 per 5cc vial)

Term

What do opioids provide in MAC?

 

Lack?

 

Limiting adverse effects? (4)

Definition

provide the analgesic portion of a balanced technique

 

Lack amnestic properties

 

Limiting adverse effects:

respiratory depression

mm rigidity

emesis

pruritus

Term

Are opioid effects predictible?

 

How do we deal w/ the above?

 

reversal?

Definition

No, effects of opioids unpredictable from patient to patient

 

problem can be overcome in practice by giving small incremental doses

 

Narcan 40mcg boluses effective in reversing respiratory depression

Term

Opioids + Benzos

 

Are they additive or synergistic?

 

Dose to produce hypnosis in 50% of patients?

 

What about complications?

Definition

significantly synergistic

 

~25% of ED50 dose of each needed in cobmination to produce hypnosis in 50% of patients

 

this synergism extends to their unwanted life-threatening complications of respiratory & cardiac depression

Term

What med is used most commonly for opioid boluses?

 

Remi bolus dose & uses?

 

Remi infusion dose & uses?

 

Remi will provide a bit of post procedure pain relief as well T/F?

Definition

fentanyl most common 25-100mcg boluses

 

Remi boluses of 0.5-1mcg/kg over 60-90sec effective for brief painful stimulation such as retrobulbar blocks

 

remi infusions of 0.025-0.1mcg/kg/min to provide analgesic effect w midazolam for amnesia

 

False, need to cover post procedure pain with something else

Term

Ketamine

A __________ derivative

Intense __________ agent

Bolus dose & use?

Is it assoc. w/ resp or cardiac depression?

Produces what kind of state?

Definition

phencyclidine derivative

intense analgesic

 

0.025-0.5mg/kg bolus for painful stimuli


Not usually assoc. w/ resp. or cardiac depression

 

Produces dissociative state; eyes remain open with nystagmic gaze

Term

Ketamine

Why should you consider a bzd for amnesia when you give Ketamine?

 

What increases likelihood of laryngospasms with this drug? What attenuates this?

 

Ketamine also may increase ____ and ____?

Definition

intense hallucinations; consider bzd for amnesia, also will attenuate the excitatory effects of ketamine.

 

Increased oral secretions increasing likelihood of laryngospasms - Glycopyrrolate 0.2mg IV or 0.4mg IM

 

may increase IOP & ICP

Term

Doxapram (Dopram)

 

Action?

 

At reg doses of _______ what 2 things increase?

 

SE (5)

Definition

Stimulates chemoreceptors in the carotid arteries - which then stimulates the respiratory centers of the brain stem = causes pt to breath!

 

20-40mg (1-2cc) = increase RR & Vt

 

SE:

increased BP

tachycardia

 sweating

 vomiting

tremors

Term

What type of monitoring is used for MAC?

 

What must we be prepared for?

 

What is the most imp monitor?

 

What does most litigation pertain to w/ a MAC?

Definition

same for all anesthetics

 

always be prepared for GETA

 

you are the most important monitor, Vigilance!

 

most litigation pertaining to MAC are related to respiratory failure that then leads to cardiac failure

Term

ABC's of MAC

 

Think ______of respirations.

Supplemental __.

______ head and neck.

Monitor______.

__ vs ___airway.

Communicate with _____.

Be aware of risk for _______ ______.

Definition

Think quality of respirations

Supplemental O2

Reposition head and neck

Monitor ETCO2

oral vs nasal airway

Communicate with patient

Be aware of risk for pulmonary embolism

Term
How can you prevent LA toxicity?
Definition
know LA doses
Term

Describe toxicity escalation with LA.

low, medium, high levels

Definition

low levels 

 tongue & circumoral tissue numbness

 

medium levels

restlessness

difficulty focusing

vertigo

tinnitus

 

higher levels 

 slurred speech

skeletal mm twitching

tonic-clonic seizures

Term

Initial TX of LA toxicity (4)

 

Definition

1. airway mgmt

2. seizure suppression

and, if needed

3. CPR

4. alert the nearest facility having cardiopulmonary bypass capability

Term

TX LA toxicity

 

 

Administer 20% ________

 

Describe 5 steps of administration of this

Definition

administer 20% lipid emulsion

(values in parenthesis are for 70kg):

 

1. bolus 1.5ml/kg IV over 1 min (~100ml)

2. continuous infusion 0.25ml/kg/min (~500ml over 30min)

3. repeat bolus q 5 min for persistent CV collapse

4. double infusion rate if BP returns but remains low

5. continue infusion for a minimum of 30 min

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