mac anesthesia...what do you use?

[m32b]

been using this propofol/alfentanil mixture for inguinal hernias, breast biopsies, podiatry and the like with excellent results...patients comfortable during the procedure and crisply awake in the or at its conclusion.

consists of 20mls/200mgs propofol mixed with 1000mcgs alfentanil infused over a range of 50-150 mcg/kg/min....small boluses as needed....midazolam 2 mg preop.

any other mixtures/techniques worth mentioning.

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[Disse]

Depends on the case and what type of "MAC" the case is (true MAC vs. basically a general but we'll call it a MAC, MAC).

Favorites I have:

Precedex--Love this drug. Heavy dose for higher stim procedures, can use little to no narcotic. Great for obese, COPD'ers, others

Propofol/Ketamine (10mg/1mg cc)--Nice combo for some procedures as the ketamine cuts the propoful dose down, provides some analgesia and less respiratory depression. However, precedex is better


Propofol/Remi (10mg/2.5ug+/- cc)--Fantastic for short extremely stimulating procedures. Usually more of a GA type MAC vs. a true MAC but fun to use (great for EGD's etc).

Of course, lots of time a little versed/fentanyl titrated to need with lots of vitamin C (comfort= you're doing great Mr. Smith.. how are you feeling? Oh, Ms. Jones it must be nice to have 50 cats...") plus good local by surgeons can work just as well as any fancy technique for a nice MAC.

My LEAST favorite technique is a propofol infusion. Provides no analgesia, for anything more stimulating than a bee sting an anxious patient will require a heavier infusion dose. Then with the heavier infusion the patient starts getting disinhibited, requiring heaving infusion.. blah.

 

[VolatileAgent]

midazolam 2 mg preop.

try doing it w/out the midaz pre-op. personally i think midaz is overrated unless you really need to erase someone's memory. i'd be interested in seeing the rate of return to baseline function w/out midaz on board after a small TIVA type case. anyone know any studies? maybe a research project i should start...

 

[jwk]

been using this propofol/alfentanil mixture for inguinal hernias, breast biopsies, podiatry and the like with excellent results...patients comfortable during the procedure and crisply awake in the or at its conclusion.

consists of 20mls/200mgs propofol mixed with 1000mcgs alfentanil infused over a range of 50-150 mcg/kg/min....small boluses as needed....midazolam 2 mg preop.

any other mixtures/techniques worth mentioning.

Midazolam, fentanyl, propofol bolus for local injection and +/- infusion or repeated dinks of propofol if needed. Patients are awake rolling to the PACU for their 15 minutes of nurse-required paperwork and getting dressed to go home. We don't carry alfenta or remi on formulary - we could never find a good use for it in our practice.

No experience with precedex, but would assume it's pretty high-cost compared to just about every other polypharmacologic regimen. Cheap and simple still work well here.

 

[jetproppilot]

Midazolam, fentanyl, propofol bolus for local injection and +/- infusion or repeated dinks of propofol if needed. Patients are awake rolling to the PACU for their 15 minutes of nurse-required paperwork and getting dressed to go home. We don't carry alfenta or remi on formulary - we could never find a good use for it in our practice.

No experience with precedex, but would assume it's pretty high-cost compared to just about every other polypharmacologic regimen. Cheap and simple still work well here.

I totally concur, and most patients dont wanna remember an operating room experience, so I like the amnestic contribution of midazolam. Costs pennies to do midazolam/generic propofol/ + - fentanyl for a mac, with just as good of outcome.