Is an EGD w prop GA or MAC

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turnupthevapor

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ASA says GA is no purposeful response w deep stimulation. This would make Every EGD and colon I adminster Anethesia for a GA. That being said articles such as the one below refer to Prop anesthesia for EGD as a MAC. What are all you jedi referring to prop induced unconsciousness with no GAG from prop, GA or MAC????

Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction - PMC

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
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turnupthevapor said:
ASA says GA is no purposeful response w deep stimulation. This would make Every EGD and colon I adminster Anethesia for a GA. That being said articles such as the one below refer to Prop anesthesia for EGD as a MAC. What are all you jedi referring to prop induced unconsciousness with no GAG from prop, GA or MAC????

Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction - PMC

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
I always just consent my patients for GA, because that's what it is.

The way I see it though, is GA is MAC, but MAC is not necessarily GA. The same way a square is a rectangle but rectangles are not necessarily squares.

MAC does not define the depth of sedation. It just indicates that you are there monitoring the patient.
 
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It is whatever we need it to be. For the purposes of the credentialing paperwork to allow GI docs to “supervise” CRNAs it is MAC.
To get the procedure done it is often a GA.
 
Our consent forms say MAC, and I specifically tell the patients it's not GA, because I mention the possibility of recall, and I emphasize that it is not uncommon for sedated patients to remember portions of procedures. I tell them, in a reassuring way, that my intent and expectation is for them to be asleep start to finish, but awareness is possible and non-scary.

There are already too many dumb, uninformed, misinformed, and/or attention-seeking people in the world telling their friends and talk show hosts how they were awake during surgery. The last thing the world needs is more endo patients being explicitly told they're getting GA.

All that said. It obviously winds up being GA about 98% of the time.
 
pgg said:
Our consent forms say MAC, and I specifically tell the patients it's not GA, because I mention the possibility of recall, and I emphasize that it is not uncommon for sedated patients to remember portions of procedures. I tell them, in a reassuring way, that my intent and expectation is for them to be asleep start to finish, but awareness is possible and non-scary.

There are already too many dumb, uninformed, misinformed, and/or attention-seeking people in the world telling their friends and talk show hosts how they were awake during surgery. The last thing the world needs is more endo patients being explicitly told they're getting GA.

All that said. It obviously winds up being GA about 98% of the time.
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This. I tell the patient very rare chance of recall. Then right after the gi doctor goes in and explains to the patient that they will be completely asleep and not remember or feel anything.
 
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It's GA.

Mac doesn't define anesthestic level
 
I say, it’s not “general anesthesia” because usually I won’t put a breath tube in your throat. If you want to be “completely”under…. There’s better ways I can do it for sure.

Let them choose their poison, so to speak….

I chart GA regardless. I think we get paid the same, either way.
 
GA no airway, but I usually chart MAC now because (1) it can fluctuate and I don't want to get sued for awareness or something like that if a patient wasn't 100% asleep 100% of the time and (2) I got exhausted of trying to explain the difference to proceduralists and nurses who work there every day but don't get it.
 
If a patient ever asks what the difference is between general anesthesia and MAC (which is rare), I usually just say it's a billing distinction.
 
IMGASMD said:
I say, it’s not “general anesthesia” because usually I won’t put a breath tube in your throat. If you want to be “completely”under…. There’s better ways I can do it for sure.

Let them choose their poison, so to speak….

I chart GA regardless. I think we get paid the same, either way.
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Definition of general anesthesia is non responsive to painful stimuli.

Anesthesia services” in a hospital subject to the anesthesia administration requirements at 42. CFR 482.52(a): • General Anesthesia: a drug-induced loss of consciousness during which patients are not. arousable, even by painful stimulation. The ability to independently maintain ventilatory.

General anesthesia vs mac is not defined by the method of airway.

MAC just means we are there to monitor regardless of what type of anesthetics are used or not used.

That being said, most nurses and surgeons make the distinction between the two based upon airway, so it's a matter of whether it's worth correcting them on their misinformation
 
I agree with above re: GA referring to a depth of anesthesia and MAC referring to presence of anesthesiology.

We mostly document these as MAC because everyone else thinks GA w/o airway = MAC.

There was some talk about documenting them as GA because insurance was refusing to pay for MAC, but that’s just semantic gamesmanship.

For those who document them as GA, have you run into nursing/admin pushback when sending these patients directly to phase II?
 
We have to fill out ePreop QA forms for GA but not for MAC. Even though these cases are GA, I document them as “MAC” in the preop plan. Saves me about 10 clicks per case. Same for cardioversions and TEE/cardioversions.
 
UscGhost said:
Definition of general anesthesia is non responsive to painful stimuli.

Anesthesia services” in a hospital subject to the anesthesia administration requirements at 42. CFR 482.52(a): • General Anesthesia: a drug-induced loss of consciousness during which patients are not. arousable, even by painful stimulation. The ability to independently maintain ventilatory.

General anesthesia vs mac is not defined by the method of airway.

MAC just means we are there to monitor regardless of what type of anesthetics are used or not used.

That being said, most nurses and surgeons make the distinction between the two based upon airway, so it's a matter of whether it's worth correcting them on their misinformation
Click to expand...

You’re preaching to the choir. I know the difference, you know the difference. The proceduralists, nurses and patients don’t. If I have to explain 10+ times a day, just not worth my time.

I am saying that to simplify my life. I haven’t had one that insists to be under “real” general anesthesia…..
 
IMGASMD said:
You’re preaching to the choir. I know the difference, you know the difference. The proceduralists, nurses and patients don’t. If I have to explain 10+ times a day, just not worth my time.

I am saying that to simplify my life. I haven’t had one that insists to be under “real” general anesthesia…..
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Absolutely.

I usually do "Mac" for those exact reasons haha
 
What’s stupid is that the ASA is responsible for creating this MAC vs GA language. They could also fix it. Yet they don’t.
 
MAC is a term that needs to die a fiery hell. It means nothing other than the fact that we are there monitoring the person.

Most of these are done under GA, but I consent patients for deep sedation (with GA backup) and that they might remember something. Seems like an idiot lawyer might jump on a frivolous awareness lawsuit if you bill/label it as a GA and you get an opportunistic patient that recently read the San Diego Union Tribune.
 
Maz777 said:
MAC is a term that needs to die a fiery hell. It means nothing other than the fact that we are there monitoring the person.
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It is better than what we used to call it. Local/Standby. L/S for short.
 
They're general cases by definition unless you have a very skilled and understanding scopologist.


Now these pain cases for MBB or ESI that get a little whiff of fent and midaz and say "ow" when the local needle goes in? Definitely not a general and I have to ask the anesthetists nearly daily to stop documenting them as such on the intraoperative form.
 
UscGhost said:
Definition of general anesthesia is non responsive to painful stimuli.

Anesthesia services” in a hospital subject to the anesthesia administration requirements at 42. CFR 482.52(a): • General Anesthesia: a drug-induced loss of consciousness during which patients are not. arousable, even by painful stimulation. The ability to independently maintain ventilatory.

General anesthesia vs mac is not defined by the method of airway.

MAC just means we are there to monitor regardless of what type of anesthetics are used or not used.

That being said, most nurses and surgeons make the distinction between the two based upon airway, so it's a matter of whether it's worth correcting them on their misinformation
Click to expand...
No, sort of. MAC means you are there but not providing a general anesthetic. If you are there just charting and giving nothing it’s a MAC, so is versed/fentanyl, so is low dose propofol as long as the patient will respond to a painful stimulus.
Almost no one does MACs for GI, but everyone outside of anesthesia refuses to accept the definition of GA, so it wrongly gets called a MAC.
 
Small update for this.

I learned today that calling it GA may not change our fee, but it may drastically increase the facility fee. Talking to someone from Endo today, it literally doubled their facility fee from $1071 to $2110. (It came up because I had charted my endos recently ad GA and they were asking if I'd be willing to change them to MAC.)

One small consideration.
 
abolt18 said:
Small update for this.

I learned today that calling it GA may not change our fee, but it may drastically increase the facility fee. Talking to someone from Endo today, it literally doubled their facility fee from $1071 to $2110. (It came up because I had charted my endos recently ad GA and they were asking if I'd be willing to change them to MAC.)

One small consideration.
Click to expand...

They don’t want to collect their fee?
 
IMGASMD said:
They don’t want to collect their fee?
Click to expand...
She didn't want the patient to be charged as much!

Part of me would love for them to charge the insurance company more, however I know those A-holes will just pass the cost onto the patients with higher premiums next year and more rejected care.
 
abolt18 said:
Small update for this.

I learned today that calling it GA may not change our fee, but it may drastically increase the facility fee. Talking to someone from Endo today, it literally doubled their facility fee from $1071 to $2110. (It came up because I had charted my endos recently ad GA and they were asking if I'd be willing to change them to MAC.)

One small consideration.
Click to expand...

Probably because of the recovery
 
For patient consent I tell the patients that this is called monitored anesthesia care, which is basically sedation, but that there are 3 levels of sedation, light, moderate, and deep. In light and moderate I can talk to you, though you might not remember it. For GI cases we tend to do deep sedation, which is close to general anesthesia, but I don't put a breathing tube in. I don't guarantee complete memory loss or recall, but almost no one has memory.

When I do some sedation for pain procedures, I start off informing that patients similarly, but make clear that this will be light sedation because the pain doctor might want to ask you questions about the location of your pain compared to what he is doing. I make sure they know this will not be deep sedation like a colonoscopy.
 
Maz777 said:
MAC is a term that needs to die a fiery hell. It means nothing other than the fact that we are there monitoring the person.

Most of these are done under GA, but I consent patients for deep sedation (with GA backup) and that they might remember something. Seems like an idiot lawyer might jump on a frivolous awareness lawsuit if you bill/label it as a GA and you get an opportunistic patient that recently read the San Diego Union Tribune.
Click to expand...
It’s GA if at any point they are unresponsive to a painful stimulus. That doesn’t guarantee they will have no recall at any point.

I don’t mind that surgeons and GI docs call TIVA without an airway a MAC because it communicates what they think they need for anesthesia, but it’s still incorrect.
 
Impromptu said:
For patient consent I tell the patients that this is called monitored anesthesia care, which is basically sedation, but that there are 3 levels of sedation, light, moderate, and deep. In light and moderate I can talk to you, though you might not remember it. For GI cases we tend to do deep sedation, which is close to general anesthesia, but I don't put a breathing tube in. I don't guarantee complete memory loss or recall, but almost no one has memory.

When I do some sedation for pain procedures, I start off informing that patients similarly, but make clear that this will be light sedation because the pain doctor might want to ask you questions about the location of your pain compared to what he is doing. I make sure they know this will not be deep sedation like a colonoscopy.
Click to expand...
Most of my patients want the guarantee that they won't remember or hear anything during GI cases because of how traumatic they think it could be, when I try to tell them they will be comfortable regardless. How do you deal with explaining that this isn't possible? I find it annoying to have to do this frequently.
 
Impromptu said:
For patient consent I tell the patients that this is called monitored anesthesia care, which is basically sedation, but that there are 3 levels of sedation, light, moderate, and deep. In light and moderate I can talk to you, though you might not remember it. For GI cases we tend to do deep sedation, which is close to general anesthesia, but I don't put a breathing tube in. I don't guarantee complete memory loss or recall, but almost no one has memory.
Click to expand...
I just tell them I’m doing general anesthesia, and then I do general anesthesia with a natural/unprotected airway.
 
turnupthevapor said:
ASA says GA is no purposeful response w deep stimulation. This would make Every EGD and colon I adminster Anethesia for a GA. That being said articles such as the one below refer to Prop anesthesia for EGD as a MAC. What are all you jedi referring to prop induced unconsciousness with no GAG from prop, GA or MAC????

Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction - PMC

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
"MAC" at our institution is over 95% of the time a GA without an airway.

The term gets thrown around incorrectly by both surgeons and anesthesia providers so much that it's meaningless now. When surgeons ask for "conscious sedation", they want a GA without an airway. When they say, "MAC is ok", they want a GA without an airway.

"Monitored Anesthesia Care" refers essentially to the presence of an anesthesia provider during a procedure. It may involve varying degrees of sedation, but it isn't defined by the administration of sedation - e.g. an outpatient cataract where the patient declines any sedation and does it under topical is still considered (and billed as) MAC if an anesthesiologist provides peri-operative care.
 
sakata8242 said:
"MAC" at our institution is over 95% of the time a GA without an airway.

The term gets thrown around incorrectly by both surgeons and anesthesia providers so much that it's meaningless now. When surgeons ask for "conscious sedation", they want a GA without an airway. When they say, "MAC is ok", they want a GA without an airway.

"Monitored Anesthesia Care" refers essentially to the presence of an anesthesia provider during a procedure. It may involve varying degrees of sedation, but it isn't defined by the administration of sedation - e.g. an outpatient cataract where the patient declines any sedation and does it under topical is still considered (and billed as) MAC if an anesthesiologist provides peri-operative care.
Click to expand...

Also a reason why if it’s booked under local, I don’t get anywhere near it.
 
pgg said:
Our consent forms say MAC, and I specifically tell the patients it's not GA, because I mention the possibility of recall, and I emphasize that it is not uncommon for sedated patients to remember portions of procedures. I tell them, in a reassuring way, that my intent and expectation is for them to be asleep start to finish, but awareness is possible and non-scary.

There are already too many dumb, uninformed, misinformed, and/or attention-seeking people in the world telling their friends and talk show hosts how they were awake during surgery. The last thing the world needs is more endo patients being explicitly told they're getting GA.

All that said. It obviously winds up being GA about 98% of the time.
Click to expand...
100% this.

Almost once a day when I consent people for real surgeries and ask if they’ve ever had any issues with anesthesia a patient will say they woke up during the procedure, and 100/100 times it’s a damn c-scope.
 
coffeebythelake said:
Probably because of the recovery
Click to expand...
If you bill GA the hospital bills an anesthesia facility fee like an OR case which assumes utilization of an anesthesia machine, techs, volatiles, additional drugs, limited resource etc. Not saying it’s cool, just saying that’s what they can do. Your fee? Pennies. Hospital’s fee for providing you and presumably the host of anesthesia equipment/support? Thousands.
 
Robotic Wis-Hipple said:
If you bill GA the hospital bills an anesthesia facility fee like an OR case which assumes utilization of an anesthesia machine, techs, volatiles, additional drugs, limited resource etc. Not saying it’s cool, just saying that’s what they can do. Your fee? Pennies. Hospital’s fee for providing you and presumably the host of anesthesia equipment/support? Thousands.
Click to expand...
It’s kind of scary that we don’t even really know what the faculty fee is or whether there’s a difference… and this is by design.
 
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