MAC Anesthesia

[Dryacku]

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We do a lot of MAC cases at our hospital on ESRD patients for perma cath placements and removals

Most of these patients have elevated BP prior to the case and then once I put them on a propofol drip their BP crashes and I end up having to chase the pressure with Phenylephrine or ephedrine

Some attendings suggest using a little glyco and ketamine and then using less propofol during the case and this seems to work about half the time

What are some other ways to handle these patients and what do most people pick as there starting doses of meds, both drips and boluses (if they use a bolus)

Thanks

 

[Consigliere]

Versed, ketamine, lower dose of propofol and phenylephrine if need be.

 

[rsgillmd]

We do a lot of MAC cases at our hospital on ESRD patients for perma cath placements and removals

Most of these patients have elevated BP prior to the case and then once I put them on a propofol drip their BP crashes and I end up having to chase the pressure with Phenylephrine or ephedrine

Some attendings suggest using a little glyco and ketamine and then using less propofol during the case and this seems to work about half the time

What are some other ways to handle these patients and what do most people pick as there starting doses of meds, both drips and boluses (if they use a bolus)

Thanks

I'm assuming permacath is the same thing as a Tescio. I give Versed, a little bit of Fentanyl. If needed, Propofol -- usually don't need it. If they pt. is having pain, tell the surgeon to give more local.

Propofol drip with poor access to the airway does not seem wise.

Ketamine should be fine also. Key is judicious titration.

 

[jennyboo]

I prefer Versed and fentanyl for these patients to any sedation with propofol as the primary drug. (I reserve propofol for the occasional 10-20mg bolus for periods of high surgical stimulus). Long lasting and so you don't have to keep re-bolusing every few minutes when these procedures -- and also graft thrombectomies under MAC -- can take a long time.

Propofol and ketamine are probably not bad either. I like this combination in endoscopy in 1cc boluses of each drug at a time (no continuous infusion) since the procedures are relatively short.

When I was a Ca1 I started out doing all MAC cases with propofol (10-50 mcg/kg/hr) and remifentanil (0.05-0.1 mcg/kg/hr) infusions, because, well, that was what everyone else was doing and it sounded cool, having never done it before. The downside of that -- combining two big respiratory and cardiovascular depressants at the same time. I find that patients get apneic, hypotensive, and bradycardic -- and some people say disinhibited from the propofol -- rather quickly and you end up having to do chin lift/jaw thrust for airway obstruction.

 

[bne_12mne]

More local.

 

[CerebralEdema]

Primary anesthetic is local with dex infusion... supplemented with a lowe dose propofol infusion (<50mcg/kg/min) and/or small fent or sufent doses. Minimal hypotension with the dex.

 

[jennyboo]

Minimal hypotension with the dex.

Interesting. The few times I've used dexmedetomidine for MAC the BP did drop a little but not beyond my tolerance -- but I tended to get calls from worried PACU nurses telling me the low BP lingered around for a while (like, SBP to.the 80s). Usually responded to fluid boluses in patients who could have fluid (not the ESRD patient).

 

[Dryacku]

I like the idea of the boluses as needed but are you worried about their pressure dropping to quickly and also possibly going apenic?

If the do go apenic for a brief period do you just mask ventilate them?

I prefer Versed and fentanyl for these patients to any sedation with propofol as the primary drug. (I reserve propofol for the occasional 10-20mg bolus for periods of high surgical stimulus). Long lasting and so you don't have to keep re-bolusing every few minutes when these procedures -- and also graft thrombectomies under MAC -- can take a long time.

Propofol and ketamine are probably not bad either. I like this combination in endoscopy in 1cc boluses of each drug at a time (no continuous infusion) since the procedures are relatively short.

When I was a Ca1 I started out doing all MAC cases with propofol (10-50 mcg/kg/hr) and remifentanil (0.05-0.1 mcg/kg/hr) infusions, because, well, that was what everyone else was doing and it sounded cool, having never done it before. The downside of that -- combining two big respiratory and cardiovascular depressants at the same time. I find that patients get apneic, hypotensive, and bradycardic -- and some people say disinhibited from the propofol -- rather quickly and you end up having to do chin lift/jaw thrust for airway obstruction.

 

[rsgillmd]

I like the idea of the boluses as needed but are you worried about their pressure dropping to quickly and also possibly going apenic?

If the do go apenic for a brief period do you just mask ventilate them?

I don't know about Jennyboo, but my main concern would be airway obstruction/apnea.

I don't know about at your place, but at mine it is awkward to access the airway under the drapes when the surgical residents are working in the neck. Just because I can provide jaw thrust or mask ventilate if needed doesn't mean I want to.

Cases like this should not be a big adventure. Whatever you do, keep it simple. Supplemental local by the surgeons and reassurance is usually your answer to patient discomfort.

 

[huktonfonix]

I prefer Versed and fentanyl for these patients to any sedation with propofol as the primary drug. (I reserve propofol for the occasional 10-20mg bolus for periods of high surgical stimulus). Long lasting and so you don't have to keep re-bolusing every few minutes when these procedures -- and also graft thrombectomies under MAC -- can take a long time.

Propofol and ketamine are probably not bad either. I like this combination in endoscopy in 1cc boluses of each drug at a time (no continuous infusion) since the procedures are relatively short.

When I was a Ca1 I started out doing all MAC cases with propofol (10-50 mcg/kg/hr) and remifentanil (0.05-0.1 mcg/kg/hr) infusions, because, well, that was what everyone else was doing and it sounded cool, having never done it before. The downside of that -- combining two big respiratory and cardiovascular depressants at the same time. I find that patients get apneic, hypotensive, and bradycardic -- and some people say disinhibited from the propofol -- rather quickly and you end up having to do chin lift/jaw thrust for airway obstruction.

Pts can get disinhibited from versed and fentanyl also. My personal favorite was the patient who became uncooperative after 0.5 mg of versed for a cataract surgery.