MAC cases

[Bougie]

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As a new CA1, one thing I seem to struggle with the most, oddly enough, are straightforeward MAC cases on ASA 1s or 2s (ie Hickman catheters). I've done the fentanyl/midazolam, propofol gtt, Precedex scenarios. I can't quite seem to find that fine line between good sedation (no squirming or asking questions) and apnea (loss of style points for having to jaw thrust and bag for a few seconds). What styles and setups do you guys find effective?

 

[Laryngospasm]

As a new CA1, one thing I seem to struggle with the most, oddly enough, are straightforeward MAC cases on ASA 1s or 2s (ie Hickman catheters). I've done the fentanyl/midazolam, propofol gtt, Precedex scenarios. I can't quite seem to find that fine line between good sedation (no squirming or asking questions) and apnea (loss of style points for having to jaw thrust and bag for a few seconds). What styles and setups do you guys find effective?

A little secret is that MACs can be some of the biggest pains in the a** of anything.

 

[cchoukal]

I agree; I find these much more stressful than a straight GA where they're out cold. Three things I've found helpful:

1) limiting my propofol drips to 30 or so mcg/kg/min. Deeper seems to encourage more delirium so when the patients occasionally wake-up during the case (which seems to be inevitable), they'd be out of their freaking mind and difficult to redirect. At 30, they redirect easier.

2) mixing a little ketamine with my propofol (like 1 mg/mL) and run at the propofol rate. Seems to chill them out a bit.

3) warning them in advance they might wake up and talking with them very calmly when they do wake up.

 

[BIS]

Remifentanyl has worked really well for me in recent MAC cases especially eyeballs.

 

[mick2003]

As a new CA1, one thing I seem to struggle with the most, oddly enough, are straightforeward MAC cases on ASA 1s or 2s (ie Hickman catheters). I've done the fentanyl/midazolam, propofol gtt, Precedex scenarios. I can't quite seem to find that fine line between good sedation (no squirming or asking questions) and apnea (loss of style points for having to jaw thrust and bag for a few seconds). What styles and setups do you guys find effective?

In a true MAC, the surgeon should be providing all of the analgesia - don't forget to remind them of that.

Oftentimes, I think we do GANA's (GA, no airway) and, because of a good anesthesiologist, we let the surgeon think they can do more under sedation than is really possible (FYI: these can then be billed as GA). As you get more senior, you should feel more comfortable speaking up and, if need be, telling the surgeon that you're converting to general.

Mick

 

[bubalus]

Things I like for a MAC:

Remifentanil 50-150 mcg bolus to stun the patient and have surgeon inject local. Great for small cases where the local is the primary anesthetic. With bigger boluses of remi, the patient can go apneic and you may have to bag for a minute. Smaller boluses will stun them, but they'll open their eyes and take a breath when you tell them to and tap their shoulder.

Propofol with 10 mcg/ml remifentanil. Run at 20-50 mcg/kg/min based on the propofol. Titrate up or down to effect.

A little midaz and fentanyl can also work quite well.

 

[VolatileAgent]

yeah, i agree. a lot of things we call MAC are really tubeless GA. the only true MAC case, as an example, is something like a cataract surgery where you maybe squirt in a little propofol and/or alfentanil during the especially painful parts (i.e. when the retrobulbar block is placed by the opthamologist).