MAC Recipes

[pie944]

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Just curious if people have a certain combination/style that they go to for MAC cases that seems to work well? I've been shown so many variations so far that I'm still trying to figure out which style I like best. Obviously it adjusts based on the case/patient, but I was just curious about some of the starting combinations people work with. Some people where I'm at seem either very pro/anti Ketamine, so I was also curious about people's view on that? How about MAC cases that are prone, do you hesitate to go on the heavier side since obstruction/apnea might be more difficult to deal with?

pie944

 

[pgg]

MAC cases in prone fatty OSA'ers suck no matter what you use, but they actually obstruct less than when supine. (Same reason OSA gets better during pregnancy ... they don't lie flat on their backs any more.)

I'm in the 'pro' ketamine column. Since you asked for recipes, Versed & glyco followed by propofol with ketamine 1-2 mg/mL titrated to effect is what I'll usually use.

For the skinny healthy NPO chick getting a D&C I'll start heavy, usually 150 mcg/kg/min with about a 5 cc bolus up front, essentially giving her a general anesthetic. They're typically awake by the time we reach the PACU, with the vacant stoned look going away pretty quickly. For not-skinny not-healthy people getting not-D&Cs I use less.

The ketamine nystagmus freaks out some PACU nurses too, so that's a plus.

 

[BDanes]

We do a lot of MAC with local.
I tend to use Midaz and Propofol only. Just blous propofol a large subinduction dose so the surgeon can inject the local. Then I just give intermittent propofol boluses.

If it's a longer case I'll use a pump. I do not combine fent versed and propofol. I have just had too many experiences with resp depression. I don't like having to do jawlifts etc. Usually if local is given they manage fine.

I don't use ketamine much, but will from time to time. I like the drug.
If I use it I put 100mg (2ml) with 18 ml of propofol. Then I just slowly titrate. It works very well in my opinion.

 

[pie944]

I love Ketamine.

The only downside I've had with it is the secretions that leads to coughing that leads to the surgeon asking you to stop the coughing. Now whenever I use it I just give a little Glyco right before and haven't had that situation since.

Do you guys use Fentanyl or Alfentanil more frequently? Some people prefer Alfentanil because of the quicker onset, but I think if you know what is coming and can time your Fentanyl it works out just the same.