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39 Cards in this Set
- Front
- Back
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What is conscious sedation?
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a state produced by the administration of certain meds, PO or IV, which produces an altered level of consciousness that still allows the pt to respond to physical stimulation and verbal commands, and maintain an unassisted airway
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What is MAC (monitored anesthesia care)?
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planned procedure during which the pt undergoes LA together with sedation and analgesia while maintaining one's own airway reflexes
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Goals and advantages of MAC?
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- reduce pt anxiety
- amnesia - sedation - analgesia - no LOC*** |
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What is minimal sedation/anxiolysis?
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- response to verbal stimulation is normal
- cognitive function and coordination impaired - ventilatory and CV function unaffected |
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What is moderate sedation/analgesia?
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- conscious sedation
- depression of consciousness is drug-induced - pt responds purposely to verbal commands - airway patent w adequate spontaneous ventilation - CV fcn unaffected |
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What is deep sedation/MAC?
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- analgesia
- depression of consciousness is drug-induced - pt not easily aroused but responds to painful stimuli - independent maintenance of ventilatory function may be impaired -- possible impaired spontaneous ventilation - CV fcn maintained |
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What is general anesthesia?
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- LOC, no response to painful stim
- pt's ability to maintain ventilatory fcn impaired - requires assistance to maintain patent airway - CV fcn may be impaired |
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What are the characteristics of benzos that make them appealing for anesthesia?
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- reduce anxiety
- amnesia - sedation - anticonvulsant |
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What are the respiratory effects of benzos at low doses and when combined with opioids/sedatives?
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low doses: mild decr in TV and incr in RR
combo w opioids/sedatives: incr risk for severe resp complications/depression |
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Midazolam (Versed)
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adult dose:0.02-0.1 mg/kg IV
onset: 1-2 min duration: 30-60 min does not provide analgesia |
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Diazepam (Valium)
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adult dose: 0.05-0.2 mg/kg IV
onset: <2 min duration: 15-60 min |
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What characteristics of opioids make it appealing for anesthesia?
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analgesia and sedation
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What adverse reactions of opioids can be seen during MAC/conscious sedation which lead you to give the lowest effective dose?
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- resp depression
- chest wall rigidity w large doses |
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Fentanyl (Sublimaze)
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dose: 1-2 mcg/kg slow IVP
onset: 1-2 min duration: 30-60 min |
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Unique Characteristics of ketamine
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-elicits profound dissociative and amnestic actions
-stimulates spontaneous respirations |
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Ketamine
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dose: 1-1.5 mg/kg
onset: 1 min duration: 5-10 min |
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What are the adverse reactions associated with ketamine admin?
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- incr secretions (typically requires anticholinergic such as glycopyrrolate 0.2 mg or atropine to be given in conjunction to decr secretions)
- produces profound hallucinations, confusion and vivid dreams (given in conjunction w benzos) |
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What characteristics of propofol make it appealing for anesthesia?
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- potent, ultra-short acting sedation and anesthesia
- unknown MOA - no analgesia - short onset - anticonvulsant properties |
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Propofol (Diprivan)
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adult dose 0.5-1 mg/kg
onset <1 min duration 3-10 min |
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What adverse reactions are associated with propofol?
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respiratory depression
hypotension CV depression only should be given by trained personnel! |
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This reversal drug is used to reverse opioid induced resp depression, but all the desirable narcotic effects are also reversed
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Naloxone (Narcan)
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Naloxone (Narcan)
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dose: 0.1-0.2 mg, repeat q2-3 min PRN
onset: 1-2 min duration: 45 min |
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What are the adverse reactions associated with naloxone/narcan?
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incr BP, N/V, circulatory stress, may precipitate withdrawal in opioid dependent patients
renarcotization: may occur bc the duration of effect of opiates may exceed the duration of effect of naloxone ex: fentanyl duration 30-60 min but nalaxone duration only 45 min |
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History and physical for patients undergoing MAC include:
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- abnormalities of organ systems
- hx of adverse events - drug allergies - current meds - NPO status - tobacco/etoh/substance abuse - VS - heart/lung assessment - airway eval. |
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What equipment is required for MAC?
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- O2
- suction - airway management equipment - reversal agents - ACLS meds and equipment (crash cart, defib) - IV access supplies and fluids - monitors |
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MAC requires an appropriate _______, reliable _____ access, and continuous ______.
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consent, venous access, monitoring(BP/SPO2 /EKG/LOC/ Appearance)
don't forget documentation! |
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What are the causes for ventilatory insufficiency during MAC?
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- airway obstruction
- resp depression from drugs |
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What are the signs of ventilatory insufficiency during MAC?
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- snoring, stridor
- decr RR/depth - decr SPO2 - cyanosis (late) - apnea |
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What is the treatment for ventilatory insufficiency during MAC?
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- stimulation
- jaw thrust/support - mask ventilation - naloxone/flumenazil - intubation if indicated |
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What are causes of aspiration during MAC?
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- decr airway reflexes
- impaired consciousness - GERD |
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How can aspiration be prevented during MAC?
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8 hrs NPO prior to procedure except continue essential meds
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How is aspiration treated during MAC?
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- turn head, suction and intubate
- bronchoscopy - IPPV with PEEP - bronchodilators |
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What are the causes of hypotension during MAC?
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- OD of sedatives
- cardiovascular morbidity prior to procedure - dehydration |
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How is hypotension treated during MAC?
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- fluid challenge
- atropine if pt becomes bradycardic - vasopressors PRN |
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What are risk factors for complications during a MAC case?
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- coronary disease
- COPD - hepatic impairment - renal impairment - geriatric pt - anxious pt - pediatric pt |
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What are the discharge criteria after a MAC case?
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- stable VS >30 min
- no unexplained brady/tachycardia - no resp distress - RR > 10 and <30 - O2 sat at baseline - able to swallow and cough - cessation of bleeding - no severe N/V - mental status at baseline - pain under control |
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Important things to have prepared for or consider for MAC cases
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- appropriate pt selection
- preop communication w pt - emergency preparedness - continuous intraop monitoring - thorough knowledge of meds used - adequate and early pain control - appropriately monitoring recovery care w criteria-based discharge |
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What is matt's recipe for a MAC case < 1 hr?
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2 mg versed, a few cc of propofol, 0.2 mg glycopyrrolate, 25 mcg fentanyl, a few more cc of propofol --> start to get drunk and fall asleep --> 25 mg ketamine --> maintain rest of case w propofol and titrate all to effect
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What is matt's recipe for a MAC case > 1 hr?
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hang bag w mini dripper (for control), add 5 20-cc vials of propofol (approx 100 cc of propofol to a 500 or 1 L NS bag, remove some fluid if you want it to be more potent), add 25-50 mg ketamine into bag (can add 25 and push 25), induce w versed, propofol, glycopyrrolate and fentanyl as with shorter cases, then start mini dripper, add additional 25 mcg of fentanyl in increments up to 100-200 mcg fentanyl total (low doses to avoid resp depr), give 4 mg zofran/8 mg decadron
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