Prone MAC cases

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amyl

amyl

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A crna in a nearby hospital just killed a guy.... Prone and trying to Mac.... I know it depends on a ton of factors but in general what are your collective thoughts on prone macs. IR guy second guessed me for geta today for his 2 level vertebroplasty. Guy was admitted a week ago for copd exacerbation and pneumonia on 4L around the clock. Sats on admission were 80%. On daily steroids for copd too. thoughts? Stress dose steroids?
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With the right patient, right procedure, and right surgeon, I think it's fine. If any of those three are off, they get an ETT.

For the example you provided, it shouldn't be a discussion of MAC vs GA. You should cancel the case and reschedule him. Your patient isn't optimized to go shopping at the local grocery store, much less to undergo any type of elective procedure under any type of anesthesia.
 
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Urzuz said:
For the example you provided, it shouldn't be a discussion of MAC vs GA. You should cancel the case and reschedule him. Your patient isn't optimized to go shopping at the local grocery store, much less to undergo any type of elective procedure under any type of anesthesia.
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Yeah. That's what I was thinking. The patient needs a tune-up. The second you give him any sort of sedation, he'll need an intubation, from falling sat and worsening CO2. Local vs tune up and comeback
 
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We do prone MAC for kyphos and vertebros, usually pretty easy sedation cases as the patients don't usually require much. If things go south it can be difficult to get the needle guy to pull the big needles in the back if you need to flip, but you have to do what you need to do. In your example, I agree with above. Reschedule, not optimized. If IR guy wants to go local only, go for it. I would not stress dose steroids, very little evidence and it's a very low stress procedure.
 
Agree with the others. Was this an unsupervised CRNA situation?
 
I guess I wasn't clear... He was 80% on admission a week ago. He's back to baseline 4 liters nasal cannula asking for a cigarette.
 
I do prone MAC's on a semi regular basis. Obviously patient and procedure factors come into play (for instance all my ERCP's get tubed after enough of my colleagues have had issues with MAC's), but I don't think there's anything inherently wrong with a prone MAC. Take a spinal cord stim implant for instance, that one kinda requires a prone MAC approach.
 
I do prone ketafol MACs for ERCPs sometimes, with the right patient and a proceduralist I know and trust. But I tube most of them these days, since I'm back in the academic world of forever-scopes and I seldom work with those cases.


amyl said:
I guess I wasn't clear... He was 80% on admission a week ago. He's back to baseline 4 liters nasal cannula asking for a cigarette.
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To tell the truth I probably would have MAC'd this guy. Kypho's don't need much, and a tube in this guy's trachea sounds like it could be more trouble than no tube. Some encouraging words, a whiff of midaz and ketamine, a nice motivating talk about how I don't want to stick a plastic tube in your lungs sir so we're going to do this with some local ...

To be clear, I'm not 2nd guessing you; any time you think "hmm I should probably tube this guy" it's nearly always the right decision.

And the IR needle jockey has NO business questioning you.
 
amyl said:
A crna in a nearby hospital just killed a guy.... Prone and trying to Mac.... I know it depends on a ton of factors but in general what are your collective thoughts on prone macs. IR guy second guessed me for geta today for his 2 level vertebroplasty. Guy was admitted a week ago for copd exacerbation and pneumonia on 4L around the clock. Sats on admission were 80%. On daily steroids for copd too. thoughts? Stress dose steroids?
Click to expand...
I had a close one during a similar case as a young CA1. Chronic pain patient getting some sort of facet joint injection. Prone propopfol drip titrated to arousal. Pain guy asks for a bolus because he is going to another level. I listened to the older wiser attending and bolused a few ml (don't remember how much, maybe 30 mg). Shortly after the pt is apneic and I'm paging my attending while trying to do the most painful jaw thrust ever imagined. By the time the attending came she had started breathing again. Sat went to 70's. I learned my lesson: don't listen to older attendings, they might not be that wise. In hindsight I might have bolused a few ml from the syringe, but bolused also propofol inside the line in the process.

This is back in the days when LMA's were re-usable and there were only 2 or 3 for 20 ORs hidden in the supply room. LMA would be my go to reaction nowadays but not then.
 
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Will selectively do prone MAC, or prone spinal. When I do I almost never use fentanyl. Small doses of ketamine/midazolam.
 
I tubed this guy. IR guy wanted a Mac. I said no. He's a locums... I'm sugar detoxing right now dude, don't mess with me :). I just don't get delaying as he was in pain from fracture and was back to, albeit bad, baseline. I tube my ercps (in general Asa 1s) don't get ercps... Most of ours are sick or fat so they get a tube. I have done these as macs but not this guy. I do prone Mac on spinal cord stims too....
 
For prone positioning, it depends on the case.

I haven't tubed anyone for ERCP since residency where they were all tubed. I do straight propofol MAC, ASA 1-3, ages 20-90, all PP GI attendings, no fellows.
 
It depends as much on the person giving the MAC sedation as it does on the pt receiving it.
 
Great thread here...I rarely do kyphos and our surgeon who does this wants them tubed so I don't argue. But how does this patients poor pulmonary status persuade you toward an ETT vs. MAC?

In this dilemma I lean toward an ETT if patient is a fatty, OSA, difficult airway, bad GERD/GI stuff, situations where I have a high probability of losing an airway and may have difficulty ventilating and getting a tube in quickly (which would be difficult in a prone case).
On the other hand, patients with bad lungs I tend to try to avoid instrumenting their airways if I can help it since tubing this guy probably exposes him to increased risk of pulm complications all from our anesthetic.

Not 2nd guessing you at all, just want to better understand your logic. Was this patient currently hypoxic as in satting in low 90s on 4 liters? Was he truly at baseline a week out from a COPD exacerbation/PNA admission? Was he a fatty? I find that COPDers tend to be thin and have class 0 airways.

What agents do you use for MAC? Were you worried that you might overly sedate him and his poor pulmonary status meant he would desat faster than expected if he became apneic? Would carefully titrated ketamine, fent, midaz, along with high flow O2 nasal cannula not have been enough to ensure that ventilation was maintained?
 
Colba55o said:
Great thread here...I rarely do kyphos and our surgeon who does this wants them tubed so I don't argue. But how does this patients poor pulmonary status persuade you toward an ETT vs. MAC?

In this dilemma I lean toward an ETT if patient is a fatty, OSA, difficult airway, bad GERD/GI stuff, situations where I have a high probability of losing an airway and may have difficulty ventilating and getting a tube in quickly (which would be difficult in a prone case).
On the other hand, patients with bad lungs I tend to try to avoid instrumenting their airways if I can help it since tubing this guy probably exposes him to increased risk of pulm complications all from our anesthetic.

Not 2nd guessing you at all, just want to better understand your logic. Was this patient currently hypoxic as in satting in low 90s on 4 liters? Was he truly at baseline a week out from a COPD exacerbation/PNA admission? Was he a fatty? I find that COPDers tend to be thin and have class 0 airways.

What agents do you use for MAC? Were you worried that you might overly sedate him and his poor pulmonary status meant he would desat faster than expected if he became apneic? Would carefully titrated ketamine, fent, midaz, along with high flow O2 nasal cannula not have been enough to ensure that ventilation was maintained?
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Prone patient with baseline hypoxia gets geta from me. Pretty much no brainer. Easy way vs hard way. Generally easy relaxed way is safer for the patient.
 
amyl said:
A crna in a nearby hospital just killed a guy.... Prone and trying to Mac.... I know it depends on a ton of factors but in general what are your collective thoughts on prone macs. IR guy second guessed me for geta today for his 2 level vertebroplasty. Guy was admitted a week ago for copd exacerbation and pneumonia on 4L around the clock. Sats on admission were 80%. On daily steroids for copd too. thoughts? Stress dose steroids?
Click to expand...
A vertebroplasty can be done under local anesthesia and very mild sedation (like 1 mg of Midazolam), if the radiologist thinks he needs more than that, and called a consultant anesthesiologist to determine what's appropriate for the patient, then what that consultant anesthesiologist says should be the plan of action.
 
2ndyear said:
Lets just say there are corners of the world where EVERY pain injection gets propofol...
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+1

In this case, local plus minimal sedation.

If it were elective, I would have said postpone 4-6 weeks.
 
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I do plenty of prone cases with MaC, including Ercp, hemorrhoids, pilonidal abscess , back masses , spinal cord stimulators ,etc. Pt is hypoxic before anesthesia , then all bets are off.
 
amyl said:
I tubed this guy. IR guy wanted a Mac. I said no. He's a locums... I'm sugar detoxing right now dude, don't mess with me :). I just don't get delaying as he was in pain from fracture and was back to, albeit bad, baseline. I tube my ercps (in general Asa 1s) don't get ercps... Most of ours are sick or fat so they get a tube. I have done these as macs but not this guy. I do prone Mac on spinal cord stims too....
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It wasn't clear he's back to baseline.
You have to determine the risk/benefit of proceeding and if delaying a day or 2 for optimization is prudent or of any benefit.
 
Pilonidal with MAC? Good surgeon. My dinosaur does it with GA only.
 
When I was at the adult hospital next door doing an ercp with a resident on a child, an adult attending of his came in randomly and busted his balls about intubating him, it got a little uncomfortable when I opened up on him and pointed out that there is a reason I am credentialed to care for patients at his hospital and he is not credentialed to provide care at mine, and maybe he should gets ta steppin'!
GTFO-HOUSE.png
 
amyl said:
A crna in a nearby hospital just killed a guy.... Prone and trying to Mac.... I know it depends on a ton of factors but in general what are your collective thoughts on prone macs. IR guy second guessed me for geta today for his 2 level vertebroplasty. Guy was admitted a week ago for copd exacerbation and pneumonia on 4L around the clock. Sats on admission were 80%. On daily steroids for copd too. thoughts? Stress dose steroids?
Click to expand...
you don't need the IR guys to agree with you. These folks barely know their patient's name let alone what their co morbidities are. If you feel he needs a geta, he gets a geta. Period. That is the safest thing.
 
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Here is what I don't understand...who is on the hook when an unsupervised CRNA assassinates somebody like this? And more importantly who tracks this data? I always hear them (the nurses) arguing that if they are so dangerous there should be a trail of bodies where they work unsupervised, and there's no proof of this. I realize there are a number of reasons if that is indeed true (all low-risk procedures on ASA 1-2 patients, everything else turfed out), but is there anybody keeping track of deaths like this (I can only assume not the AANA)?
 
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Noyac said:
http://www.asahq.org/quality-and-pr...ment/physicians-quality-reporting-system/qcdr
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Thanks for the link, but still not sure exactly how this system works. So the CRNA (or in this case their employer) has to self-report the morbidity/mortality?What are the repercussions of not doing so/ incentives to do so? And can you search that database specifically for morbidity/mortality associated with unsupervised CRNAs?

Sorry for all the questions but I can only assume the attendings on this board are more familiar with this system than I am.
 
nimbus said:
Prone patient with baseline hypoxia gets geta from me. Pretty much no brainer. Easy way vs hard way. Generally easy relaxed way is safer for the patient.
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Neither amyl or nimbus have said why this is a nobrainer GETA. Positive pressure ventilation is not a benign process, especially if you have bad lungs to begin with. It may be easier to tube this patient but is it necessarily safer? Give some rationale besides "I'm the consultant anesthesiologist and my decision is the best"
 
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NightNight said:
Thanks for the link, but still not sure exactly how this system works. So the CRNA (or in this case their employer) has to self-report the morbidity/mortality?What are the repercussions of not doing so/ incentives to do so? And can you search that database specifically for morbidity/mortality associated with unsupervised CRNAs?

Sorry for all the questions but I can only assume the attendings on this board are more familiar with this system than I am.
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You hit the nail on the head.
What's to stop people from under reporting?
What should be reportable?
Is or will there be a data base?

Until this is implemented fully, it is only a deterrent.
But there are mandatory reportable cases at this time. It's the hospitals duty to report.
 
We do a fair number of prone MAC cases. Single-level microdiscectomies under spinal + propofol, propofol for facets and RFAs (I know, crazy right), spinal + propofol for quick butt cases. Not all surgeons and not all patients qualify. For the pain stuff they just turn their head on a pillow, for the spine surgeries they self position in the Proneview.

amyl said:
A crna in a nearby hospital just killed a guy.... Prone and trying to Mac.... I know it depends on a ton of factors but in general what are your collective thoughts on prone macs. IR guy second guessed me for geta today for his 2 level vertebroplasty. Guy was admitted a week ago for copd exacerbation and pneumonia on 4L around the clock. Sats on admission were 80%. On daily steroids for copd too. thoughts? Stress dose steroids?
Click to expand...

Like others said, prone MAC not my #1 concern with this patient.
 
More deets and a question.

For these prone cases I do just the gas-sampling nasal cannula @ 4L. It seems pretty common that after 30 minutes or so they get pretty nasally congested and/or the cannula's sampling lumen can get clogged with snot or whatever, and your gas sampling can get crappy.

I usually give glycopyrrolate anyway so they don't drool, it doesn't really help with the nasal congestion. Sometimes I then rig the sampling line to a 16g angiocath and get that into the nose.

You can use the Proneview to traction their head into a sort of "chin lift" but usually airway patency isn't an issue.

Anyone have any tips or tricks for this situation?
 
Colba55o said:
Neither amyl or nimbus have said why this is a nobrainer GETA. Positive pressure ventilation is not a benign process, especially if you have bad lungs to begin with. It may be easier to tube this patient but is it necessarily safer? Give some rationale besides "I'm the consultant anesthesiologist and my decision is the best"
Click to expand...

These patients are routine in my practice. Believe me I've tried sedation. It's a lot more work with worse outcomes. For instance, awake and dyspneic, moving and struggling to breathe, or sleepy and hypoxic and hypercarbic. All in the prone position. I know what's worked best in my hands. My first priority is getting him through the procedure safely. He's already hypoxic. GA/ETT will assure that I won't be struggling with hypo ventilation and hypoxemia during the procedure. That's why it's a no brainer to me.

Since you are asking for rationales, how is sedation safer than GA in this case? And how is PPV harmful? It's some fantasy of ancient anesthesia professors. I just haven't seen it and I've been doing this 22yrs.
 
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Colba55o said:
Great thread here...I rarely do kyphos and

Not 2nd guessing you at all, just want to better understand your logic. Was this patient currently hypoxic as in satting in low 90s on 4 liters? Was he truly at baseline a week out from a COPD exacerbation/PNA admission? Was he a fatty? I find that COPDers tend to be thin and have class 0 airways.

Yes. Yes. No. Wanted to secure the airway up front because I thought I might have to mid procedure.... Which involves breaking sterility, problems if there's instruments sticking out of the back, plus a lack of support staff to help flip and secure the airway quickly. Controlled situation instead of possible chaos. Besides my IR guy is a whining little bitch and would have a coronary if I told him to get the instruments out of the back to flip and secure the airway. Pt had a h/o svt and CAD and although he was sinus tachy at the moment I didn't want to use ketamine. He did just fine
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Good indication for Precedex perhaps? Seems like a great drug for a prone MAC
 
fakin' the funk said:
Prone MAC is for short cases. Outpatient stuff.

Dex is slow on and slow off. Not for outpatient stuff. Bad drug in this setting.
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I have been using Dex in an outpatient
setting. No infusion. Just small boluses.
 
propadope said:
Good indication for Precedex perhaps? Seems like a great drug for a prone MAC
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Precedex is a drug with essentially no analgesic effect with a slow onset and meh-at-best "sedation" effects.

Easy arousability is one of its selling points and why it's maybe a good choice for ICU sedation ... but that property is not exactly desirable for procedural sedation. People keep trying to talk me into liking it but I really can't think of a situation where I'd choose it for sedation before straight ketamine or midazolam/ketamine. It seems that the cases where it works well for procedural sedation are cases where sedation isn't really needed in the first place.

Sure, you can take just about any drug with sedative/hypnotic effects and make it work, but man, from my perspective, people are just trying too hard to make Precedex work when there are better choices out there.
 
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pgg said:
Precedex is a drug with essentially no analgesic effect with a slow onset and meh-at-best "sedation" effects.

Easy arousability is one of its selling points and why it's maybe a good choice for ICU sedation ... but that property is not exactly desirable for procedural sedation. People keep trying to talk me into liking it but I really can't think of a situation where I'd choose it for sedation before straight ketamine or midazolam/ketamine. It seems that the cases where it works well for procedural sedation are cases where sedation isn't really needed in the first place.

Sure, you can take just about any drug with sedative/hypnotic effects and
make it work, but man, from my perspective, people are just trying too hard to make Precedex work when there are better choices out there.
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I thought Precedex does provide analgesia...

I think it is more useful as an adjunct than a single drug, however. It is a very polarizing drug. You either like it or you don't.
 
propadope said:
I thought Precedex does provide analgesia...

I think it is more useful as an adjunct than a single drug, however. It is a very polarizing drug. You either like it or you don't.
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It provides analgesia the way clonidine provides analgesia. Adjunct is a good word.
 
2ndyear said:
Lets just say there are corners of the world where EVERY pain injection gets propofol...
Click to expand...

This is the expectation at my practice and I've personally done thousands of these cases. Most patients do beautifully with fent + versed and a total of 50mg propofol pushed slowly. There are a few pain "docs" who brings us patients on such astronomical doses of narcs that I can push 3 bottles of propofol and they are still trying to climb off the table. I can think of exactly 1 time where I oversedated the patient and had to flip them in a hurry.. it was for a cervical facet injection and the neck roll had shifted under the drapes basically strangling that patient. She was fine when she could support her own neck, but quickly obstructed with the fent and midaz kicked in. Luckily I work with experienced nurses that were rolling the stretcher in before I even asked for it and the patient recovered without even needing to be bagged.

These days most of our pain docs are so fast that even a single 50mg dose of propofol gets them sleepy enough to tolerate the local and keeps them from remembering the procedure. We do all kinds of "seat of the pants" cases in my practice especially with office based pain and gyn and you can really develop a level of skill at propofol sedation that makes it look like some sort of voodoo magic. As for the small percentage of cases where things go bad.. just remember your training and have plans B, C and D all lined up and ready to go. An oral airway, #3 lma, ambu bag and narcan should be all that tools you need to solve just about any sedation induced airway crisis.

As for the OP's case.. I'd probably ask for the patient to be brought to the OR and tube him. They can bring 2 c-arms and do the case there. Give him and extended recovery in pacu and extubate when he's ready to pull the tube himself. If the surgeon doesn't like this you can always play the patient safety card.. even the biggest tools in the shed understand those 2 magical words and what it may imply for them if things happen to go bad. If the patient doesn't like the idea of being intubated present him with the possibility of doing it straight local. If I feel that my anesthetic may kill someone I have no problem telling them that and letting them know that I would never allow this to be done to a member of my family. Simple, honest and to the point.
 
SaltyDog said:
I don't really think it's a great drug for anything.
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It's a good drug for sedation in the ICU. It, along with an opioid infusion, and maybe some antipsychotics, is a good benzo-free, HR-reducing sedation regimen when you're talking about days-to-many-days timeframe.

In the OR, I have yet to see a situation where it's the best drug.
 
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