DS OR GA (with no gag, lid reflex, jaw thrust)

[wickedskillz]

---

Members do not see this ad.

The ASA definition requires purposeful movement (such as reaching towards a stimulus), and intentionally excludes non-purposeful movement such as withdrawing from pain. The REAL definition (per ASA):
If they wake up when you tap them or yell at them : moderate sedation
IF you jaw thrust / sternal rub / painful stimulus of your choice and they reach to try to stop you: deep sedation
If, after painful stimulus, they writhe around, extend, groan or don't react: GA

 

[Random Anesthesiologist]

You know what? The fact that board certified Anesthesiologists don't grasp the consensus definitions of sedation vs GA scare the crap out of me.

 

[Ronin786]

You know what? The fact that board certified Anesthesiologists don't grasp the consensus definitions of sedation vs GA scare the crap out of me.

Why? The terminology is useless as long as you know how to handle each part of the spectrum. Something I imagine most board-certified anesthesiologists do grasp.

 

[Urzuz]

Why? The terminology is useless as long as you know how to handle each part of the spectrum. Something I imagine most board-certified anesthesiologists do grasp.

This absolutely positively 100% wrong and dangerous to think. Terminology is everything. That is how we communicate with one another, from physician to physician in the hospital, in the medical chart, in journal articles, and even on this forum. Let's ignore the fact that you are implying that it is okay to be ignorant to the words you're using and it's okay to call different levels of sedation the wrong name, despite supposedly being a DOCTOR of anesthesiology. The fact that you don't understand the importance of being exact and precise with the words you use shows that you haven't truly been exposed to situations in which information delivery is critical.

Of all the posts here this one strikes me as the most idiotic (and that's saying a lot). The other posters genuinely believe they are using the correct terminology. You're saying that it simply doesn't matter, which is more scary than anything else anyone has posted.

 

[chfo]

This absolutely positively 100% wrong and dangerous to think. Terminology is everything. That is how we communicate with one another, from physician to physician in the hospital, in the medical chart, in journal articles, and even on this forum. Let's ignore the fact that you are implying that it is okay to be ignorant to the words you're using and it's okay to call different levels of sedation the wrong name, despite supposedly being a DOCTOR of anesthesiology. The fact that you don't understand the importance of being exact and precise with the words you use shows that you haven't truly been exposed to situations in which information delivery is critical.

Of all the posts here this one strikes me as the most idiotic (and that's saying a lot). The other posters genuinely believe they are using the correct terminology. You're saying that it simply doesn't matter, which is more scary than anything else anyone has posted.

Taken DIRECTLY from the guidelines:
Monitored Anesthesia Care (“MAC”) does not describe the continuum of depth of sedation,
rather it describes “a specific anesthesia service in which an anesthesiologist has been
requested to participate in the care of a patient undergoing a diagnostic or therapeutic
procedure.”


In other words, MAC includes general anesthesia when it's in the spectrum of sedation.

Here's something else to consider: reflex grimacing to jaw thrust is considered non purposeful by the sedation guidelines, and would be considered general anesthesia.

How's that for black and white?

 

[deleted87051]

Why? The terminology is useless as long as you know how to handle each part of the spectrum. Something I imagine most board-certified anesthesiologists do grasp.

I agree. Who cares....

 

[Mman]

Again,

MAC: We just check vital signs. Maybe give oxygen.
Conscious Sedation: Versed, +/- Fentanyl
Deep Sedation: Anything involving Propofol but without an LMA or ETT.
GA: Sevo/Des.

Don't make a simple issue complicated. There's no need.

It's actually far simpler and cleaner

GA - general anesthesia
MAC - any other case you are monitoring them with any degree of sedation provided

The degrees of sedation are irrelevant to whether a case is considered under Monitored Anesthesia Care or not.

 

[chfo]

It's actually far simpler and cleaner

GA - general anesthesia
MAC - any other case you are monitoring them with any degree of sedation provided

The degrees of sedation are irrelevant to whether a case is considered under Monitored Anesthesia Care or not.

On top of that, even if you slip into general anesthesia temporarily while in a MAC case, it's still MAC according to the guidelines.

 

[caligas]

On top of that, even if you slip into general anesthesia temporarily while in a MAC case, it's still MAC according to the guidelines.

Everybody, just read the CMS manual, it clarifies everything:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R59SOMA.pdf

I'm only half joking, their definitions are actually not bad and it also covered the often misunderstood supervision rules.

 

[deleted171991]

Again,

MAC: We just check vital signs. Maybe give oxygen.
Conscious Sedation: Versed, +/- Fentanyl
Deep Sedation: Anything involving Propofol but without an LMA or ETT.
GA: Sevo/Des.

Don't make a simple issue complicated. There's no need.

Again. You are confusing things.

MAC has nothing to do with the continuum of sedation. MAC simply describes “a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.” MAC simply means that an anesthesiologist is present, and the patient is not receiving general anesthesia. I have attached the ASA position paper.

GA is both a level of sedation term and a billing term. In an endoscopy, any patient who does not qualify as GA is a MAC.
"General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired."

Also, to bill as a GA, the patient only needs to be in GA even for just a minute. Most endoscopies done with propofol would qualify.

 

[deleted171991]

On top of that, even if you slip into general anesthesia temporarily while in a MAC case, it's still MAC according to the guidelines.

Which guidelines?

 

[Ronin786]

This absolutely positively 100% wrong and dangerous to think. Terminology is everything. That is how we communicate with one another, from physician to physician in the hospital, in the medical chart, in journal articles, and even on this forum. Let's ignore the fact that you are implying that it is okay to be ignorant to the words you're using and it's okay to call different levels of sedation the wrong name, despite supposedly being a DOCTOR of anesthesiology. The fact that you don't understand the importance of being exact and precise with the words you use shows that you haven't truly been exposed to situations in which information delivery is critical.

Of all the posts here this one strikes me as the most idiotic (and that's saying a lot). The other posters genuinely believe they are using the correct terminology. You're saying that it simply doesn't matter, which is more scary than anything else anyone has posted.

Because knowing the difference between deep sedation and general anesthesia, something that only depends on you actually hurting someone and seeing how they respond, is the difference between a good and bad anesthesiologist. Thats ridiculous. Not to mention that a patient can easily slip from DS to GA at any point in time during the case.

Have fun explaining GA vs DS to a nurse or surgeon when they don't see a tube in your patient.

And for the record, I do know the difference as I posted earlier in this thread. But to imply that not knowing the difference between the two is "scary" and "dangerous" is ludicrous.

 

[Ronin786]

On top of that, even if you slip into general anesthesia temporarily while in a MAC case, it's still MAC according to the guidelines.

That's not true.

"If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required."

http://www.asahq.org/resources/publ...2004/definitions-of-monitored-anesthesia-care

 

[chfo]

Which guidelines?

The guidelines we're all discussing.

"Monitored Anesthesia Care (“MAC”) does not describe the continuum of depth of sedation, rather it describes “a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.”

"Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (“Conscious Sedation”) should be able to rescue*** patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of General Anesthesia."

"Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-thanintended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation."

The guidelines do not state that going into general anesthesia temporarily turns the billing into a general anesthetic.

The guidelines plainly state that sedation is a continuum. Conscious sedation -> Deep sedation -> General anesthesia.

General anesthesia could be an unintended level of SEDATION as shown in the guidelines.

 

[chfo]

That's not true.

"If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required."

http://www.asahq.org/resources/publ...2004/definitions-of-monitored-anesthesia-care.

That's from 2003, but regardless, doesn't change the fact that the most recent guidelines do not specify whether having deeper sedation all the way down to general anesthesia, suddenly changes the billing to a general anesthetic.

I am just working with the guidelines I have.

 

[twoliter]

Have fun explaining GA vs DS to a nurse or surgeon when they don't see a tube in your patient.

As anestheisologists, we should understand a lot about anesthesia that a nurse or surgeon wouldn't fully understand. Are you suggesting we should only understand as much about anesthesia as a nurse would?

 

[deleted162650]

suddenly changes the billing to a general anesthetic.

Remeber billing is exactly the same regardless of type of anesthetic. GA/MAC/SAB/epidural/surgical block all bill exactly the same. Billing is based solely on the CPT code for the procedure + time + any modifiers.

 

[deleted87051]

I can have a patient lighter breathing 0.8% sevo thru an lma than running propofol infusion at 150mcg/kg/min with no airway. The terminology is really pointless. GA? Deep sedation? Who knows? Who cares?

 

[Ronin786]

As anestheisologists, we should understand a lot about anesthesia that a nurse or surgeon wouldn't fully understand. Are you suggesting we should only understand as much about anesthesia as a nurse would?

Yes, that's what I'm suggesting. 🙄

Way to ignore the whole premise though. Being able to define DS vs GA doesn't make a good anesthesiologist.

 

[twoliter]

Yes, that's what I'm suggesting. 🙄

Way to ignore the whole premise though. Being able to define DS vs GA doesn't make a good anesthesiologist.

Having difficulty explaining an anesthetic-related topic to someone with considerably less understanding of anesthesia in a way that they fully comprehend doesn't necessarily make that topic any less important to the field of anesthesia.

 

[fakin' the funk]

Yes, that's what I'm suggesting. 🙄

Way to ignore the whole premise though. Being able to define DS vs GA doesn't make a good anesthesiologist.

Somehow, some way, this thread found a way to get even worse.

Knowing the definitions of concepts that are fundamental to our specialty don't "make a good anesthesiologist?" Why not? What else don't anesthesiologists need to know how to define? How about minimum alveolar concentration? How about "difficult intubation"?

Asked a different way, what DO "good anesthesiologists" need to be able to define?

 

[Urzuz]

Welcome to the future of the specialty, a future in which the supposed experts/doctors feel like they don't need to define or understand the most basic concepts of anesthesia to perform their job, but will still feel entitled to a $400k/year paycheck. Zero pride in their work, zero desire to even pretend to be an intellectual or doctorly.

This thread is truly a pathetic reflection of this specialty and its members, and I'm embarrassed that the posters above are my colleagues. I'm done posting in this thread.

 

[deleted171991]

I wouldn't put it so harshly. Some of these are just billing terms.

However, if we as anesthesiologists can't explain to other specialists what our terms mean, how can we expect them to understand the differences?

The colleagues who think practice is everything and theoretical knowledge doesn't matter so much, should remember that the latter is exactly what separates us from CRNAs. We should all be scientists first, physicians second, and practitioners only third. It's not the monkey skills that make us doctors.

 

[Spinach Dip]

You know what? The fact that board certified Anesthesiologists don't grasp the consensus definitions of sedation vs GA scare the crap out of me.

Best post in this thread.

Seriously, between debates like this and CRNAs making so much progress that they are now TEACHING future anesthesiologists, I wonder why anyone would look forward to going into this specialty.

 

[deleted87051]

We need to admit that there is no substantive difference between deep sedation and general anesthesia. Especially with newer agents and techniques, the terminology has become obsolete. The patients don't care, they are asleep. The surgeons don't care, the patient is not moving. And we mentally masturbate about definitions.

 

[soorg]

EXACLTY! It's all just mental mastubation. I've done at least 5,000 EGDs without incident, so the fact that I'm not defining it as GA according to some consensus statement is bull$&t. My apologies if this "scares the crap" out of some of you, but enough with your dramatic condescension. You being scared doesn't make me a dangerous or bad anesthesiologist! As a board-certified anesthesiologist, I will call whatever anesthetic I'm using as I deem appropriate. I went through medical school, residency and the board-certification process so that I may make decisions based on my own damn judgement, and if they don't jibe with a consensus statement, so be it.

 

[Mman]

EXACLTY! It's all just mental mastubation. I've done at least 5,000 EGDs without incident, so the fact that I'm not defining it as GA according to some consensus statement is bull$&t. My apologies if this "scares the crap" out of some of you, but enough with your dramatic condescension. You being scared doesn't make me a dangerous or bad anesthesiologist! As a board-certified anesthesiologist, I will call whatever anesthetic I'm using as I deem appropriate. I went through medical school, residency and the board-certification process so that I may make decisions based on my own damn judgement, and if they don't jibe with a consensus statement, so be it.

You can be great and safe at doing something but still incorrectly label it. Whether a case is technically MAC or GA is not really open to individual judgment or interpretation. If somebody were to push 400 mg of propofol and 100 mg of succinylcholine and intubate a patient, it isn't a MAC just because they say so.

 

[Arch Guillotti]

Best post in this thread.

Seriously, between debates like this and CRNAs making so much progress that they are now TEACHING future anesthesiologists, I wonder why anyone would look forward to going into this specialty.

Because SDN is not necessarily representative of the profession.

 

[fakin' the funk]

We need to admit that there is no substantive difference between deep sedation and general anesthesia. Especially with newer agents and techniques, the terminology has become obsolete. The patients don't care, they are asleep. The surgeons don't care, the patient is not moving. And we mentally masturbate about definitions.

There is a substantive difference. These are defined terms.

I would like to know what "newer agents and techniques" you refer to.

I think the (good) point you are getting is that there is a spectrum of sedation. For trainees this is important to recognize because you can exploit it. Hopefully you have been taught during "MAC" to either go light or go deep -- no in between. In practice my patients are either very lightly sedated (like for a cataract) or under very deep sedation/GA with propofol infusions, like for EGD, sedation plus spinal for TKA/THA, that kind of thing. Surgeons think that if there is no LMA or ETT, then it is "MAC," presumably because their patients feel good in recovery and the surgeon can talk $hit about the patient if they want to. Often these are mask/cannula generals, though.

The "sedation" we typically do for EGD is usually general anesthesia. But is there an important difference in the clinical state, i.e.,(cardiorespiratory stability, versus deep sedation? Probably not. The only reason we get away with it is because there is an endoscope partially stenting open the airway.

 

[deleted87051]

There is a substantive difference. These are defined terms.

I would like to know what "newer agents and techniques" you refer to.

I think the (good) point you are getting is that there is a spectrum of sedation. For trainees this is important to recognize because you can exploit it. Hopefully you have been taught during "MAC" to either go light or go deep -- no in between. In practice my patients are either very lightly sedated (like for a cataract) or under very deep sedation/GA with propofol infusions, like for EGD, sedation plus spinal for TKA/THA, that kind of thing. Surgeons think that if there is no LMA or ETT, then it is "MAC," presumably because their patients feel good in recovery and the surgeon can talk $hit about the patient if they want to. Often these are mask/cannula generals, though.

The "sedation" we typically do for EGD is usually general anesthesia. But is there an important difference in the clinical state, i.e.,(cardiorespiratory stability, versus deep sedation? Probably not. The only reason we get away with it is because there is an endoscope partially stenting open the airway.

If there is a difference between deep sedation and GA, please explain it to me. I don't understand and I've been doing this for 20 years.

 

[twoliter]

If there is a difference between deep sedation and GA, please explain it to me. I don't understand and I've been doing this for 20 years.

Check the consensus statement.