It’s not MAC

[anbuitachi]

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Yeah you are right. Being a resident voids you from responsibility and logic...

Why stop at 200? You should run propofol at 500 mcg/kg/minute (or 1500), and cause cardiac arrest, do not resuscitate, and then blame the surgeon and your weak ass anesthesia attending instead because you don't want to intubate for PONV reasons.

Put their license on line. Document everything "as per surgeon" or "as per anesthesiology attending". Have fun with it - you are already putting the patient at extreme risk with hypoventilation and hypercarbia which is doing a number on their myocardium for > 1 hour, why not go the extra mile?

This is not science. I am sorry.

i sometimes see this on the case charts. residents documenting "given med xyz per surgeon" or did xyz per surgeon. If something goes wrong, the responsibility is still on you since you are a doctor as well and you should know the stuff you give instead of just give it.

 

[TheLoneWolf]

i sometimes see this on the case charts. residents documenting "given med xyz per surgeon" or did xyz per surgeon. If something goes wrong, the responsibility is still on you since you are a doctor as well and you should know the stuff you give instead of just give it.

Exactly, the surgeon recommends stuff, not pushes it into the patient. **** hits the fan and it’s just on you

 

[AKMD_1984]

i sometimes see this on the case charts. residents documenting "given med xyz per surgeon" or did xyz per surgeon. If something goes wrong, the responsibility is still on you since you are a doctor as well and you should know the stuff you give instead of just give it.

well most of the time, that sentence is used for things like administering methylene blue or tocolytics as part of the procedure...we document it to time stamp. There is no foul play assumed or intended by administering and then documenting the medications they want. Its done to be complete and record it in the anesthesia chart.

In this particular case, it is important to document in that way to share responsibility. So if and when a bad outcome occurs - and it will sooner or later, the surgeon and the attending doesnt turn their back and say "this resident is a fool, he is CA2 and ran 200 mcg/kg/min on an obese patient for 2 hour for low risk surgery and did not intubate - NOR CALLED ME".

This discussion is very important, because technically what they are allowing you to do is a "DEEP MAC", which is maintaining a balance between ventilation and excessive propofol doses. The line between that and GA is very fine, almost blur and I will say non existent.

What happens when the surgeon says "patient is light" - you push some fentanyl or bolus 2 cc of propofol on top of that background infusion and boom thats it. Now you are trying to intubate a potentially difficult airway emergently.

If a resident is "forced" into this type of anesthetic care to "not rock the boat" then that program has failed. They should be teaching the OPPOSITE, as to NOT do this. They should be teaching how to negotiate with the surgeon and use sound judgment.
The lawyer will rock your boat and your nuts by the way if you give that as your defense that "we didn't want to be chewed out".

We don't tell surgeons which suture to use. They do not tell me how to manage the airway specifically for high risk patients. You cannot have it any other way. Im sorry - please respect ourselves and our own profession before we expect CRNAs to do so.

I would decline politely stating my reasons, and just say, sorry I do not feel comfortable doing this, and I do not have much experience in this type of anesthetic (yeah, because its not standard of care). If you believe it is safer to intubate - then do it. Humble yourself and say I'm too incompetent to do this type of anesthetic - let someone else be a hero.

 

[fakin' the funk]

Couple of things:
1) propofol vs equianesthetic dose of volatile is gonna make patients feel better
2) surgeons and patients like #1
3) airway instrumentation or absence thereof does not equal type of anesthesia
4) the attendings at this institution need to give grand rounds to all the surgeons to address all of the so that they can have a f**king clue about anesthesia and everyone can be on the same page

I suspect that what you're seeing at this institution is a cultural drift based on misunderstanding of anesthesia and weak pushback from the anesthesiologists' side of things. It's not normal and it's not common.

 

[anbuitachi]

well most of the time, that sentence is used for things like administering methylene blue or tocolytics as part of the procedure...we document it to time stamp. There is no foul play assumed or intended by administering and then documenting the medications they want. Its done to be complete and record it in the anesthesia chart.

In this particular case, it is important to document in that way to share responsibility. So if and when a bad outcome occurs - and it will sooner or later, the surgeon and the attending doesnt turn their back and say "this resident is a fool, he is CA2 and ran 200 mcg/kg/min on an obese patient for 2 hour for low risk surgery and did not intubate - NOR CALLED ME".

This discussion is very important, because technically what they are allowing you to do is a "DEEP MAC", which is maintaining a balance between ventilation and excessive propofol doses. The line between that and GA is very fine, almost blur and I will say non existent.

What happens when the surgeon says "patient is light" - you push some fentanyl or bolus 2 cc of propofol on top of that background infusion and boom thats it. Now you are trying to intubate a potentially difficult airway emergently.

If a resident is "forced" into this type of anesthetic care to "not rock the boat" then that program has failed. They should be teaching the OPPOSITE, as to NOT do this. They should be teaching how to negotiate with the surgeon and use sound judgment.
The lawyer will rock your boat and your nuts by the way if you give that as your defense that "we didn't want to be chewed out".

We don't tell surgeons which suture to use. They do not tell me how to manage the airway specifically for high risk patients. You cannot have it any other way. Im sorry - please respect ourselves and our own profession before we expect CRNAs to do so.

I would decline politely stating my reasons, and just say, sorry I do not feel comfortable doing this, and I do not have much experience in this type of anesthetic (yeah, because its not standard of care). If you believe it is safer to intubate - then do it. Humble yourself and say I'm too incompetent to do this type of anesthetic - let someone else be a hero.

What I mean is we still are the ones giving methylene blue and therefore we still need to know contraindications since there are a few for methylene blue. Just documenting we gave it cause surgeon wanted it isn't going to get us out of court. In fact surgeon may be able to just put the blame on the anesthesiologist.

 

[kmurp]

Anesthesia time is billed at the exact same rates regardless of the type of anesthesia used.

But when medically directing , MAC removes the induction and emergence requirements.

 

[facted]

But when medically directing , MAC removes the induction and emergence requirements.

Bolusing 50-100 of prop and then running it at 100-150mcg is GA, not MAC. I'm not sure insurance companies or Medicare would be cool skipping those requirements no matter what you wrote down as anesthesia type.

It's an easy way for them to scour some charts and claw back some money from you

 

[fakin' the funk]

Bolusing 50-100 of prop and then running it at 100-150mcg is GA, not MAC. I'm not sure insurance companies or Medicare would be cool skipping those requirements no matter what you wrote down as anesthesia type.

This is nonsense, and you know it, so why say it?

 

[facted]

This is nonsense, and you know it, so why say it?

Say what? You're not aiming for "Unarousable even with painful stimulus" for your propofol level during these cases? You have them moving all over the place? Or are you referring to MAC vs sedation terminology?

ASA is unmistakable on this: GA is if patient is "unarousable even with painful stimulation".

http://www.asahq.org/~/media/Sites/...esthesia-and-levels-of-sedation-analgesia.pdf

 

[Twiggidy]

What I mean is we still are the ones giving methylene blue and therefore we still need to know contraindications since there are a few for methylene blue. Just documenting we gave it cause surgeon wanted it isn't going to get us out of court. In fact surgeon may be able to just put the blame on the anesthesiologist.

Exactly. If there's a contraindication I don't care who's asking for it we shouldn't be giving it. I usually reserved the "per surgeon" line for something that is out of the ordinary but doesn't really cause harm for the case, ie, in a case where we would otherwise never give a steroid and the surgeons asks for it and there's no allergy/contraindication/etc.

 

[fakin' the funk]

Say what? You're not aiming for "Unarousable even with painful stimulus" for your propofol level during these cases? You have them moving all over the place? Or are you referring to MAC vs sedation terminology?

ASA is unmistakable on this: GA is if patient is "unarousable even with painful stimulation".

I know. And I know you know.

So why are you saying it's X dose of propofol = GA? The doses you quoted are crazy low and in my experience generally wouldn't induce GA as monotherapy outside of decrepit old people. Young people and drinkers don't even blink at 50-100mg propofol.

 

[nimbus]

I know. And I know you know.

So why are you saying it's X dose of propofol = GA? The doses you quoted are crazy low and in my experience generally wouldn't induce GA as monotherapy outside of decrepit old people. Young people and drinkers don't even blink at 50-100mg propofol.

I’m on the west coast where anesthesia for endoscopy is not routine. We get called for 2 populations: decrepit old people and drug addicts. 50-100mg propofol bolus is GA and I chart it as such. Even many young drug addicts will go down with 100mg. I use that dose as monotherapy all the time.

 

[facted]

I know. And I know you know.

So why are you saying it's X dose of propofol = GA? The doses you quoted are crazy low and in my experience generally wouldn't induce GA as monotherapy outside of decrepit old people. Young people and drinkers don't even blink at 50-100mg propofol.

I do lots of endoscopy, much of it in healthy people. My initial prop dose is 50. I'd say at least 75% of my patients are out with that dose and we can start the endoscopy. At least 90% are out with 100mg.

 

[pgg]

Bolusing 50-100 of prop and then running it at 100-150mcg is GA, not MAC.

That's not going to be GA for anyone under the age of 40. 🙂

 

[facted]

That's not going to be GA for anyone under the age of 40. 🙂

So you routinely bolus people 100mg of prop and run them at 150, and they respond to you? Do they respond to pain?

I do this for literally EVERY IVF I do, most of which are under 40. It's GA.

 

[propadope]

Effects of propofol are variable between individuals so it is hard to say that x dose is GA vs deep sedation vs moderate sedation. A lot depends on the level of stimulation of the procedure as well. There is a fine line between deep sedation and GA and either way there is unconsciousness, loss of protective reflexes and the potential for respiratory depression, obstruction etc... In a given case the patient can drift from GA to deep sedation and vice versa. Don’t forget that anesthesia is a continuum. Lets not get into semantics...

 

[kmurp]

Bolusing 50-100 of prop and then running it at 100-150mcg is GA, not MAC. I'm not sure insurance companies or Medicare would be cool skipping those requirements no matter what you wrote down as anesthesia type.

It's an easy way for them to scour some charts and claw back some money from you

Really? I find this hard to believe.

 

[Arch Guillotti]

Really? I find this hard to believe.

Agree.

 

[facted]

Really? I find this hard to believe.

Which is hard to believe? The prop dosing or the insurance companies scouring your charts to check for attestations? If you don't think they're doing that, you'd better talk to your billing company!

Our billing company makes it a sticking point at every yearly meeting we have with them to talk about levels of sedation and what we're writing down as GA vs. MAC. If the patient is not responsive, it's GA (airway is irrelevant). Period. According to them, it matters BIGLY from an insurance standpoint.

 

[Twiggidy]

GA. Conscious sedation. MAC

It all just created to make the patients feel better. I don’t know how many patients I get every week who want to cause a riff because I tell their anesthetic is a general and they response, “oh I thought it was sedation”, “I thought it was twilight”.....”Fine ma’am, we’ll do twilight”.....200 mcg of propofol later....

If I’m using propofol, I’m charting GA. If I’m not, it’s likely a MAC because a little versed and a little fentanyl usually has people mostly awake, arousable, and can hold a slightly incoherent conversation.

Splitting hairs over “how much” propofol constitutes a general is crazy. It’s a general.

 

[Southpaw]

that I am there providing the service implies MAC. You guys are arguing conscious vs deep vs GA. When I use propofol, I call it GA. If I want a patient to be arousable or give a purposeful response to anything I say or do, I don't use propofol. My use of propofol implies my desire to put the patient in a state of unresponsiveness to stimulus. I call that GA.

 

[dannyboy1]

Which is hard to believe? The prop dosing or the insurance companies scouring your charts to check for attestations? If you don't think they're doing that, you'd better talk to your billing company!

Our billing company makes it a sticking point at every yearly meeting we have with them to talk about levels of sedation and what we're writing down as GA vs. MAC. If the patient is not responsive, it's GA (airway is irrelevant). Period. According to them, it matters BIGLY from an insurance standpoint.

Someone scours through all of the scribbles in the chart. A lot of people don’t even write the doses, we have paper charts and when I’m doing a sedation case i just write “gtt...” next to the propofol line. Are people documenting level of arousal and protective reflexes present or absent? For simplicities sake if I am using propofol without an ETT or LMA it is MAC. ETT or LMA with propofol, or gas even through the mask is GA, neuraxial gets billed as regional. Never had a problem with this from a billing standpoint.

 

[propadope]

Someone scours through all of the scribbles in the chart. A lot of people don’t even write the doses, we have paper charts and when I’m doing a sedation case i just write “gtt...” next to the propofol line. Are people documenting level of arousal and protective reflexes present or absent? For simplicities sake if I am using propofol without an ETT or LMA it is MAC. ETT or LMA with propofol, or gas even through the mask is GA, neuraxial gets billed as regional. Never had a problem with this from a billing standpoint.

No doses charted? Thats asking for trouble

 

[facted]

Someone scours through all of the scribbles in the chart. A lot of people don’t even write the doses, we have paper charts and when I’m doing a sedation case i just write “gtt...” next to the propofol line. Are people documenting level of arousal and protective reflexes present or absent? For simplicities sake if I am using propofol without an ETT or LMA it is MAC. ETT or LMA with propofol, or gas even through the mask is GA, neuraxial gets billed as regional. Never had a problem with this from a billing standpoint.

From a medico-legal perspective, not writing doses is a disaster waiting to happen. Also, the ASA clearly states if pt doesn't respond to painful stimuli it's GA. So you're going against what the ASA says "for simplicity sake?" This is all just a thought exercise until we end up on the witness stand and they ask you if you know your own associations guidelines in front of 12 lay people, making you look like a fool.

 

[WholeLottaGame7]

Someone scours through all of the scribbles in the chart. A lot of people don’t even write the doses, we have paper charts and when I’m doing a sedation case i just write “gtt...” next to the propofol line. Are people documenting level of arousal and protective reflexes present or absent? For simplicities sake if I am using propofol without an ETT or LMA it is MAC. ETT or LMA with propofol, or gas even through the mask is GA, neuraxial gets billed as regional. Never had a problem with this from a billing standpoint.

"I award you no points, and may God have mercy on your soul"

 

[kmurp]

Which is hard to believe? The prop dosing or the insurance companies scouring your charts to check for attestations? If you don't think they're doing that, you'd better talk to your billing company!

Our billing company makes it a sticking point at every yearly meeting we have with them to talk about levels of sedation and what we're writing down as GA vs. MAC. If the patient is not responsive, it's GA (airway is irrelevant). Period. According to them, it matters BIGLY from an insurance standpoint.

The insurance company part is what I was referring to. Our group does our own billing and for the past 30 years, it’s not been a problem. What IS a potential problem is calling a large number of your MAC cases General if you medically direct. You would then be subject to meeting all the requirements of medical direction. That would be tough and inefficient in a busy GI suite or busy ortho center where you spend a lot of time placing blocks in Preop.

 

[facted]

The insurance company part is what I was referring to. Our group does our own billing and for the past 30 years, it’s not been a problem. What IS a potential problem is calling a large number of your MAC cases General if you medically direct. You would then be subject to meeting all the requirements of medical direction. That would be tough and inefficient in a busy GI suite or busy ortho center where you spend a lot of time placing blocks in Preop.

We do that in our Ortho center all the time. No issues.

 

[Twiggidy]

Ok so that may be something I may not know. If a case is MAC are the requirements for medical direction different?

 

[deleted162650]

Just ditch the CRNAs and you don’t have to worry about it.

 

[kmurp]

Ok so that may be something I may not know. If a case is MAC are the requirements for medical direction different?

My understanding is that there is no “induction “ with MAC so you don’t need to be in the room to start the case. Also, for “emergence”.

 

[deleted171991]

It’s hard for me to imagine working in a place where the anesthesia department has had their sack cut off

Then you're dismissing 50+% of the jobs.

Castration is the first job requirement for any corporate/academic chief of anesthesia. They generally don't put mensches in charge of a service department (or even any). You know the saying: A-level people hire more A-level people, B-level people hire C-level people. And since most suits are not A-level...

 

[deleted171991]

jeezus your department is weak as **** if they let stuff like this happen.
your department chair needs to nut up and stop acting like a mid level
if you can't even claim patient safety for changing practices there is no excuse

Welcome to the real world. There are various degrees of this in most places. That's why I say that anesthesiologists are not treated like doctors. The surgeon is king, especially the kind that brings a lot of patients/money.

You walk away from a case like this (I would), unsafe as it is, you'd better have another job lined up.

 

[deleted171991]

i sometimes see this on the case charts. residents documenting "given med xyz per surgeon" or did xyz per surgeon. If something goes wrong, the responsibility is still on you since you are a doctor as well and you should know the stuff you give instead of just give it.

Yeah, sure. I would love to hear the conversation that begins with "I don't want to give this medication because I think it's inappropriate for this patient", especially when coming from a resident.

 

[deleted171991]

Someone scours through all of the scribbles in the chart. A lot of people don’t even write the doses, we have paper charts and when I’m doing a sedation case i just write “gtt...” next to the propofol line. Are people documenting level of arousal and protective reflexes present or absent? For simplicities sake if I am using propofol without an ETT or LMA it is MAC. ETT or LMA with propofol, or gas even through the mask is GA, neuraxial gets billed as regional. Never had a problem with this from a billing standpoint.

This is the typical PP/AMC setting geared towards productivity and money, personal malpractice/fraud risk be damned. These are the employers who will badmouth computerized intraop charting when asked (that's the red flag at interview time).

 

[anbuitachi]

Yeah, sure. I would love to hear the conversation that begins with "I don't want to give this medication because I think it's inappropriate for this patient", especially when coming from a resident.

well that's when id call my attending. luckily it hasn't happened often but i've had a couple surgeons ask for Novo 7 (prophylaxis for bloody surgery), and i was not comfortable giving it so i had to call my attending who then said no

 

[coffeebythelake]

well that's when id call my attending. luckily it hasn't happened often but i've had a couple surgeons ask for Novo 7 (prophylaxis for bloody surgery), and i was not comfortable giving it so i had to call my attending who then said no

That's crazy, novo7 for prophy?????

 

[Twiggidy]

That's crazy, novo7 for prophy?????

Yeah, that's pretty ridiculous...not to mention expensive.

 

[facted]

Yeah, that's pretty ridiculous...not to mention expensive.

Not nearly as bad but once had an IDIOT surgeon tell my CA-1 to give protamine to reverse all the bleeding on the field IN CASE we had given heparin. Put a quick kibosh on that. I told them patient had a severe case of hypoprolinemia 🙂

 

[pgg]

Yeah, that's pretty ridiculous...not to mention expensive.

There are much cheaper ways to cause strokes and MIs. :/

 

[deleted162650]

I’ve seen people instantly turn into bricks from Novo7

 

[Arch Guillotti]

well that's when id call my attending. luckily it hasn't happened often but i've had a couple surgeons ask for Novo 7 (prophylaxis for bloody surgery), and i was not comfortable giving it so i had to call my attending who then said no

Trauma? Or something else?

 

[anbuitachi]

Trauma? Or something else?

transplant

 

[abolt18]

I told them patient had a severe case of hypoprolinemia 🙂

Hilarious!

 

[deleted162650]

You’ll notice hypoprolinemia commonly presents in patients who also suffer from acute bovie deficiency.

 

[sigrhoillusion]

You’ll notice hypoprolinemia commonly presents in patients who also suffer from acute bovie deficiency.

I heard the only cure for bovie deficiency is more cowbell...

 

[T-burglar]

I’ve seen people instantly turn into bricks from Novo7

no kidding. Systemic Novo7 is a questionable therapy in my opinion for ANY situation, let alone prophylaxis in someone who is not at present bleeding to death. I would only consider using it if my patient was exsanguinating with major coagulation defects and nothing seems to be stopping it. Generally speaking I almost always opt against giving novo7. My strategy for lethal coagulopathic hemorrhage is usually just warm 1:1:1 transfusion with a belmont and 1 or 2 introducers. And multiple bair huggers. Anecdotally I believe warmth is one of the most important factors in stopping coagulopathic bleeding, despite the research that shows little impairment down to a temp of 33 or whatever. If there is a drug in the system that needs reversing I may give the reversal but after you've shed a whole blood volume how much of that **** could possibly be left. If im massively transfusing i usually start magnesium, calcium, and TXA continuous infusions too.

Novo7 has definitely been the cause of death in at least one case that I can think of in recent memory, in my fellowship. Low cardiac output post bypass, with a new mechanical mitral, won't stop bleeding. Gave novo7 really slowly. With the sluggish flow through the heart, and the new thrombogenic surface, the left atrium clotted off entirely, death on the table. I would almost never give novo7 if the patient has any thrombogenic hardware or other propensity.

 

[nimbus]

no kidding. Systemic Novo7 is a questionable therapy in my opinion for ANY situation, let alone prophylaxis in someone who is not at present bleeding to death. I would only consider using it if my patient was exsanguinating with major coagulation defects and nothing seems to be stopping it. Generally speaking I almost always opt against giving novo7. My strategy for lethal coagulopathic hemorrhage is usually just warm 1:1:1 transfusion with a belmont and 1 or 2 introducers. And multiple bair huggers. Anecdotally I believe warmth is one of the most important factors in stopping coagulopathic bleeding, despite the research that shows little impairment down to a temp of 33 or whatever. If there is a drug in the system that needs reversing I may give the reversal but after you've shed a whole blood volume how much of that **** could possibly be left. If im massively transfusing i usually start magnesium, calcium, and TXA continuous infusions too.

Novo7 has definitely been the cause of death in at least one case that I can think of in recent memory, in my fellowship. Low cardiac output post bypass, with a new mechanical mitral, won't stop bleeding. Gave novo7 really slowly. With the sluggish flow through the heart, and the new thrombogenic surface, the left atrium clotted off entirely, death on the table. I would almost never give novo7 if the patient has any thrombogenic hardware or other propensity.

Bump.

When the force is out of balance.

Kinda feels like a snuff film. Not Novo7 but PCC in this case...

 

[ProRealDoc]

That’s a GA TIVA with an unprotected airway in the setting of arrogant surgeons and subservient anesthesiologists.

That’s about all I’ve got to add to this discussion.

That’s a GA TIVA with an unprotected airway in the setting of arrogant surgeons and subservient anesthesiologists.

That’s about all I’ve got to add to this discussion.

I would have walked on day one. No need to risk your livelihood.

 

[ProRealDoc]

Very reputable regional and national institution, big name. Heavily advertises, tv, radio, billboard, sports team sponsor.

Pays well but salaried, calls not too bad, no ED so few emergencies. Nice deal on paper but I have never seen attendings so stressed and insulted on a daily basis by their surgical "peers". When you see the department chair chewed out by a head and neck surgeon over tiny trivial items really puts the big stuff in perspective.

Surgeons interfering with how I perform an anesthetic is ridiculous. Its the same as if I pointed to random items on their standard trays and said they cant use it.

Lets out it.

 

[abolt18]

Bump.

When the force is out of balance.

Kinda feels like a snuff film. Not Novo7 but PCC in this case...

Watching that thrombus and its migration was like watching a train crash in slow motion. Seriously crazy!