Coughing during MAC

[codeb1ue]

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I have had an unusual string of cases recently where I am running a simple MAC case on propofol and about an hour or so into the case, the patient will begin aggressively coughing, likely from secretions accumulating in their oropharynx.

Am I just not deep enough? Do you routinely give everyone glyco for MAC? What am I doing wrong?

 

[IlDestriero]

I don’t consider an unsecured airway for anything approaching an hour.
Prop, LMA, z z z ...


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Il Destriero

 

[coffeebythelake]

give the patient some gentle suction for oral secretions, make sure they are not aspirating gastric contents, then deepen your anesthetic.
i don't routinely give patients glyco preemptively unless i am planning to use higher doses of ketamine

 

[Psai]

What position? I've noticed that people seem to dislike secretions more in the lateral position

 

[cchoukal]

Does coughing not imply that secretions are hitting the cords? Sure, you can deepen to stop the coughing, but you’ll be permitting aspiration. Is that clinically relevant? Depends. But don’t kid yourself about what’s happening.

 

[codeb1ue]

Does coughing not imply that secretions are hitting the cords? Sure, you can deepen to stop the coughing, but you’ll be permitting aspiration. Is that clinically relevant? Depends. But don’t kid yourself about what’s happening.

Definitely not kidding myself about that. I am very hesistant to deepen the patient at this point but struggling to figure out what the best course of action is at this point when the surgeon stops what hes doing and just stares at me. Perhaps there isnt anything "wrong" per se that I'm doing and it is just a string of bad luck. Perhaps related to the cold season.

 

[OB1🤙]

If these are "big MAC" cases, one thing you can do is oral airway and put a suction catheter through it, and intermittently suction whatever is building up.

But it sounds like an LMA might be the solution to these issues...

 

[cchoukal]

Definitely not kidding myself about that. I am very hesistant to deepen the patient at this point but struggling to figure out what the best course of action is at this point when the surgeon stops what hes doing and just stares at me. Perhaps there isnt anything "wrong" per se that I'm doing and it is just a string of bad luck. Perhaps related to the cold season.

Maybe the problem is that you're already TOO deep. Moderate sedation is defined by the ASA as not requiring any airway manipulation, which implies the patient could handle/swallow their own secretions, rather than letting them pass to the cords where they stir up coughing.

 

[facted]

I don’t consider an unsecured airway for anything approaching an hour.
Prop, LMA, z z z ...


--
Il Destriero

I've done North of a 1k total joints with a spinal and prop sedation. Most cases around 2 hr mark or more. I've converted to LMA less than 10 times maybe. liberal use of nasal trumpets. And my pt population routinely pushes bmi 40. Not saying LMA is bad, but it's not necessary is most IMO.

 

[deleted162650]

I've done North of a 1k total joints with a spinal and prop sedation. Most cases around 2 hr mark or more. I've converted to LMA less than 10 times maybe. liberal use of nasal trumpets. And my pt population routinely pushes bmi 40. Not saying LMA is bad, but it's not necessary is most IMO.

Ditto

 

[codeb1ue]

I've done North of a 1k total joints with a spinal and prop sedation. Most cases around 2 hr mark or more. I've converted to LMA less than 10 times maybe. liberal use of nasal trumpets. And my pt population routinely pushes bmi 40. Not saying LMA is bad, but it's not necessary is most IMO.

What do you typically run your propofol around? And do you routinely suction periodically?

 

[facted]

What do you typically run your propofol around? And do you routinely suction periodically?

Usually around 75 for the younger ones and 50 or so the older crowd. Rarely need suction.

 

[drmwvr]

"Deepening" and "MAC" are, IMO, mutually exclusive terms. An ongoing need for an oral/nasal airway is not in the "spirit" of MAC. That's an anesthetic. An initial deep stun for local may be required, but not always and certainly isn't part of the maintenance phase of MAC. Combining agents like ketamine with the propofol, fentanyl, versed, whatever, is an effective way to allow the patient to maintain adequate ventilation with their own airway and also be light enough to let the surgeon know that more local is required.

Absurd doses of plain diprivan for a MAC (>90 or so) are just more labor intensive and unnecessary, unless of course the case is inappropriate for MAC.

 

[codeb1ue]

I think I am realizing the errors of my way. I routinely run them at 100-120 of propofol that is likely not allowing them to manage their own secretions as someone else mentioned above. I am always concerned they will awaken easily when only on something like 50 mcg/kg/min of propofol. Do most of you supplement versed/fentanyl for spinal sedation cases? I personally avoid it and run pure propofol for these cases to avoid the increased incidence of apnea.

 

[drmwvr]

I am always concerned they will awaken easily when only on something like 50 mcg/kg/min of propofol.

Why is "awakening" not good during a MAC? Snoozing with eye opening to verbal stim is perfect.

 

[deleted162650]

I think I am realizing the errors of my way. I routinely run them at 100-120 of propofol that is likely not allowing them to manage their own secretions as someone else mentioned above. I am always concerned they will awaken easily when only on something like 50 mcg/kg/min of propofol. Do most of you supplement versed/fentanyl for spinal sedation cases? I personally avoid it and run pure propofol for these cases to avoid the increased incidence of apnea.

Midaz for the spinal, then just straight prop for the rest of the case. Usually right around 75 as well.

 

[fakin' the funk]

In my experience, coughing is either from a) secretions hitting the cords/hypopharynx, or b) sudden stimulation causing lightening causing sensation of junk on/around the cords.

I typically do give 0.2mg glyco for MACs, and I like to run a lot of propofol as monotherapy (150-200 initially, weaning down as the case goes on) for cases like joints under spinal, etc. I prefer to have the pt deep enough to not move/wiggle at all.

 

[Noyac]

Not sure if anyone said this already since I can’t bring myself to read all the responses these days. My first thought is that the pt is too deep if they are allowing secretions to build up enough to cause the type of coughing you describe. You can try glyco or you can cut back on the sedation or even better take over the airway with an LMA. Any MAC case that gets so deep that they start to cough like you describe from secretions would be better off as a GA IMO.

 

[caligas]

Ok, to divert this thread a little with a hypothetical that we all face eventually;

BMI 35 patient, MP3, under propofol sedation for colonoscopy. Starts to cough and you see bile dripping from mouth. You suction and t-burg patient. Sat is 92, patient is breathing, more bile is coming. They are not responsive to verbal stim but are coughing.

What now?

 

[hankbb02]

Why is "awakening" not good during a MAC? Snoozing with eye opening to verbal stim is perfect.

If your running a "MAC" with spinal during LE ortho they would be awake the whole case from movement, and the loud ass drilling and hammering.

 

[hankbb02]

Ok, to divert this thread a little with a hypothetical that we all face eventually;

BMI 35 patient, MP3, under propofol sedation for colonoscopy. Starts to cough and you see bile dripping from mouth. You suction and t-burg patient. Sat is 92, patient is breathing, more bile is coming. They are not responsive to verbal stim but are coughing.

What now?

Ask the proceduralist to stop stimulating the patient. Maintain your lateral decub positioning. Lighten the anesthetic. Allow them to cough up anything they may have aspirated while continuing to suction the OP. If Sats come up continue. If sats don't come up, slip in a Igel and suction the stomach.

 

[caligas]

If your running a "MAC" with spinal during LE ortho they would be awake the whole case from movement, and the loud ass drilling and hammering.

I did a knee under spinal MAC with propofol recently on an educated, reasonable guy who seemed to understand the plan well. He would snooze along nicely but very 10 minutes or so he would snort back to life and shout “IM AWAKE!” And then go back to snoring. He didn’t remember anything post op.

 

[pgg]

When I do brief cases with an unsecured airway (e.g. a D&C with a propofol or ketofol infusion) some portions are objectively general anesthesia and some are more MAC-like.

A simple thing that I've found reduces the incidence of coughing from secretions when they're in that in-between state, is to ask them to cough, clear their throats, and swallow any saliva as we're starting. Even if you don't give glyco, you can start most cases pretty dry.

 

[Psai]

If your running a "MAC" with spinal during LE ortho they would be awake the whole case from movement, and the loud ass drilling and hammering.

This is not true at all.

 

[anbuitachi]

are you sure its from secretion hitting the cords? did you get a lot of stuff out w suction?

 

[codeb1ue]

are you sure its from secretion hitting the cords? did you get a lot of stuff out w suction?

i wouldn't say copious but definitely getting some stuff out suctioning. What do you think might be causing the sudden coughing fit in the middle like that?

 

[Laryngophed]

I don’t consider an unsecured airway for anything approaching an hour.
Prop, LMA, z z z ...


--
Il Destriero

I get the gist of your post and largely agree but I in no way consider an airway “secure” with an LMA.

 

[Laryngophed]

I've done North of a 1k total joints with a spinal and prop sedation. Most cases around 2 hr mark or more. I've converted to LMA less than 10 times maybe. liberal use of nasal trumpets. And my pt population routinely pushes bmi 40. Not saying LMA is bad, but it's not necessary is most IMO.

Which is really no different than an LMA. Both supeaglottic, neither protect you from laryngospasm or gross aspiration. And yes, I know an oETT doesn’t guarantee no aspiration either.

 

[facted]

Which is really no different than an LMA. Both supeaglottic, neither protect you from laryngospasm or gross aspiration. And yes, I know an oETT doesn’t guarantee no aspiration either.

I can take one to the PACU if need be, for starters. With that being said, the vast majority of my patients don't require one, i just turn their head to the side and reposition every so often. Usually enough. My point, though, was that it's not necessary to place an LMA because you're doing sedation for an hour or two.

 

[propadope]

Was the patient a smoker? Black patients tend to salivate more as well. I tend to give glyco fairly routinely if running patients deeper with no ETT or LMA.

 

[Swamp Gas]

Which is really no different than an LMA. Both supeaglottic, neither protect you from laryngospasm or gross aspiration. And yes, I know an oETT doesn’t guarantee no aspiration either.

I’d say there’s a difference in the level of anesthesia required to tolerate an LMA vs nasal trumpet.

 

[Psai]

I’d say there’s a difference in the level of anesthesia required to tolerate an LMA vs nasal trumpet.

Yeah people tolerate lmas really well but nasal trumpets are the worst. Nasal trumpets have people hemorrhaging everywhere like there's a pumper in their esophagus

 

[deleted162650]

Yeah people tolerate lmas really well but nasal trumpets are the worst. Nasal trumpets have people hemorrhaging everywhere like there's a pumper in their esophagus

Not if you know how to insert them correctly. Nasal trumpet insertion does not have to include a turbinate excision/biopsy.

 

[facted]

Yeah people tolerate lmas really well but nasal trumpets are the worst. Nasal trumpets have people hemorrhaging everywhere like there's a pumper in their esophagus

Um, not really. I *KNOCK ON WOOD* haven't had ANY nasal bleeding issues and I've probably inserted close to 500 nasal trumpets to date in my career. Surgilube works pretty well. And don't overdo the sizing.

Once the nasal trumpet is in after a bit of prop bolus, patients tolerate nasal trumpets FAR easier than LMA's. You can run a patient on 50mcg/kg/min of prop and they won't care about the trumpet. Pretty sure you can't do that with an LMA.

 

[Swamp Gas]

Once the nasal trumpet is in after a bit of prop bolus, patients tolerate nasal trumpets FAR easier than LMA's. You can run a patient on 50mcg/kg/min of prop and they won't care about the trumpet. Pretty sure you can't do that with an LMA.

Couldn’t agree more, I’m on team trumpet. My reply was misinterpreted.

 

[Psai]

Nasal trumpet bad lma good
Igel 4 for everyone

 

[vector2]

Unless your patient is 6'3" you can use a 26-28 nasal trumpet for pretty much everyone. It'll be just long enough to relieve pharyngeal obstruction without causing a bloody mess.

 

[anbuitachi]

What about nasal trumpet vs oral airway? I rarely use a trumpet and instead just shove a oral airway down to open up the obstruction

 

[deleted162650]

Nasals are tolerated much better than orals in the lightly sedated patient. If the patients is deep enough to suck on an oral airway, then just put an LMA in.

 

[pgg]

What about nasal trumpet vs oral airway? I rarely use a trumpet and instead just shove a oral airway down to open up the obstruction

Depends how much of a MAC the MAC is.

Oral airways are very well tolerated under general anesthesia. Less so in sedated patients. 🙂

 

[anbuitachi]

Oh i usually just avoided the trumpets due to risk of bleeding so i just put in an oral airway. I dont do it often but so far no issues yet. I guess i run deep MACs lol

 

[codeb1ue]

Oh i usually just avoided the trumpets due to risk of bleeding so i just put in an oral airway. I dont do it often but so far no issues yet. I guess i run deep MACs lol

You never have issues with secretions building up running MACs that deep?

Sent from my PH-1 using SDN mobile

 

[coffeebythelake]

Personally not a big fan of nasal trumpets in sedation cases. Some people have pretty superficial blood vessels that even minimal trauma can cause a lot of bleeding. Nothing like having to deal with that *plus* the airway obstruction.

 

[Onefellswoop87]

Personally not a big fan of nasal trumpets in sedation cases. Some people have pretty superficial blood vessels that even minimal trauma can cause a lot of bleeding. Nothing like having to deal with that *plus* the airway obstruction.

Ugh, had that the other week. At the start of the MAC tried one naris and even with lubricant there was a drop of blood after resistance so went to the other side and passed easily. But an hour into the IR case, plan changed and the vascular surgeon wanted a little heparin, and then that friable nasal passage turned into a headache. Good times.

 

[anbuitachi]

You never have issues with secretions building up running MACs that deep?

Sent from my PH-1 using SDN mobile

Not that i can remember.

 

[sluggs]

I am CCM, not anesthesia, but I do deep sedation for Cards (TTE and cardioversion) and GI (EGD) as I have privileges for this and sometimes anesthesia is not available. I had a lady last week, 135 lbs, 62 y/o, history of heavy opiate use but none for > 2 years, and no etoh or other drugs, who needed sedation for an emergent EGD. She had some vague "heart failure" history but no meds and my bedside echo showed good RV and LV function. She and gotten a total of 2 mg dilaudid over 3 hours for abd pain. Endoscopist was getting ready so I gave 2 mg versed and 30 mg ketamine. She goes completely out, but breathing fine. Over the course of a 15 minute egd where and ulcer was intervened upon, I gave a total of 8 mg versed, 100 mg ketamine and 100 mcg fentanyl and she coughed hard through the whole procedure (probably should have added some propofol) and as soon as it was over, she fell back asleep. Woke up 1 hour later with no recollection of the procedure.
Any pointers other than prop, and maybe she lied bout quitting opiates??

 

[anbuitachi]

I am CCM, not anesthesia, but I do deep sedation for Cards (TTE and cardioversion) and GI (EGD) as I have privileges for this and sometimes anesthesia is not available. I had a lady last week, 135 lbs, 62 y/o, history of heavy opiate use but none for > 2 years, and no etoh or other drugs, who needed sedation for an emergent EGD. She had some vague "heart failure" history but no meds and my bedside echo showed good RV and LV function. She and gotten a total of 2 mg dilaudid over 3 hours for abd pain. Endoscopist was getting ready so I gave 2 mg versed and 30 mg ketamine. She goes completely out, but breathing fine. Over the course of a 15 minute egd where and ulcer was intervened upon, I gave a total of 8 mg versed, 100 mg ketamine and 100 mcg fentanyl and she coughed hard through the whole procedure (probably should have added some propofol) and as soon as it was over, she fell back asleep. Woke up 1 hour later with no recollection of the procedure.
Any pointers other than prop, and maybe she lied bout quitting opiates??

Lidocaine the crap out of the throat. Probably coughed because there is a huge scope down her throat.

 

[coffeebythelake]

Lidocaine the crap out of the throat. Probably coughed because there is a huge scope down her throat.

yes -- topical lidocaine would have been helpful here

 

[sluggs]

would the lido last the duration of the procedure??

 

[anbuitachi]

would the lido last the duration of the procedure??

the 15 minutes? yes