MAC with no sedation?

[B-Bone]

Here's one for you: Yesterday I had a patient for a flex sig under sedation. Pt had eaten a full breakfast 6 hrs before. I said gotta wait until NPO 8 hours. GI doc says nevermind, I'll do it without sedation. Great! I'm not involved, no meds are going to be given, have at it. This still requires an OR nurse to be in there to monitor the patient. OR nursing director comes to me saying his nurses cannot monitor patients in the OR because they are apparently not ACLS trained (union issue, I guess?). He asks me to have a CRNA monitor the patient with me medically directing, in order to get the case done. GI doc still has a number of scopes to do and we can easily move patient to the end of the schedule where he will be >8 hr NPO. I tell the nursing director I won't subject the pt to an anesthesia charge to not provide any anesthesia, especially since the GI doc and the patient have decided that no sedation is OK and the wait time is 2 hrs. OR director keeps hassling me, so I gather the GI doc and the patient in the room and tell them our options:

1-go back now, receive no sedation, get a bill from me that his insurance may or may not pay
2-go back in 2 hrs and receive the scheduled sedation
3-reschedule with or without sedation

Everybody thinks the first option is ridiculous and we go with option 2. Anybody ever do monitoring with no anesthesia (not talking about vented, plug-and-play ICU patients)? Anyway, it sounded stupid to me so I didn't do it.

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[DrZzZz]

Here's one for you: Yesterday I had a patient for a flex sig under sedation. Pt had eaten a full breakfast 6 hrs before. I said gotta wait until NPO 8 hours. GI doc says nevermind, I'll do it without sedation. Great! I'm not involved, no meds are going to be given, have at it. This still requires an OR nurse to be in there to monitor the patient. OR nursing director comes to me saying his nurses cannot monitor patients in the OR because they are apparently not ACLS trained (union issue, I guess?). He asks me to have a CRNA monitor the patient with me medically directing, in order to get the case done. GI doc still has a number of scopes to do and we can easily move patient to the end of the schedule where he will be >8 hr NPO. I tell the nursing director I won't subject the pt to an anesthesia charge to not provide any anesthesia, especially since the GI doc and the patient have decided that no sedation is OK and the wait time is 2 hrs. OR director keeps hassling me, so I gather the GI doc and the patient in the room and tell them our options:

1-go back now, receive no sedation, get a bill from me that his insurance may or may not pay
2-go back in 2 hrs and receive the scheduled sedation
3-reschedule with or without sedation

Everybody thinks the first option is ridiculous and we go with option 2. Anybody ever do monitoring with no anesthesia (not talking about vented, plug-and-play ICU patients)? Anyway, it sounded stupid to me so I didn't do it.

Had a sort of similar case recently. Patient had some minor procedure that had previously been done in the office with just some valium. Apparently had issues with insurance paying, supposedly because it was done in the office. So, they now come to the OR for the procedure due to this issue and didn't want anything from us, but hospital policy requires an anesthetist in the OR for monitoring regardless. Patient understood that they were going to get a bill from us even though we were only monitoring vitals. They accepted this and that's what we did.

 

[deleted684261]

It's a mac if ur there even with no sedation....bill accordingly

 

[dhb]

6h fasting is plenty enough

 

[vector2]

6h fasting is plenty enough

I stick to NPO guidelines 99.99% of the time...but I would go ahead with a flex sig at 6hrs given its lateral position and no airway instrumentation, assuming pt didnt have severe GERD, gastroparesis, questionable airway etc.

 

[nimbus]

I’ve done a few no sedation MAC cases at patient request. Mostly for cataracts but also on occasion for lipomas and trigger fingers.

 

[AdmiralChz]

Yeah, I’ve had some pretty sickly decompensated severe AS types I’ve given zip for a cataract... why that individual needs a cataract removed is sort of another battle altogether.

 

[dhb]

I stick to NPO guidelines 99.99% of the time

ASA fasting guidelines​
Ingested material	Minimum fasta
Clear liquidsb	2 hours
Breast milk	4 hours
Infant formula	6 hours
Non-human milk	6 hours
Light mealc	6 hours

 

[Arch Guillotti]

ASA fasting guidelines​
Ingested material	Minimum fasta
Clear liquidsb	2 hours
Breast milk	4 hours
Infant formula	6 hours
Non-human milk	6 hours
Light mealc	6 hours

What constitutes a “light meal” can be debated ad nauseum though, and what if any effect reglan, bicitra, pepcid have.

 

[Gaseous Clay]

Where I am, a full breakfast means chicken biscuits, bacon with extra grease, sweet tea, and coffee loaded up with cream. Going by the guidelines is the right thing to do. If it was a piece of toast and plain coffee, then 6 hours is plenty.

We allow local only cases here (usually a super sick cysto or simple hand ortho stuff). If my presence is at all requested, then it is MAC whether I give anything or not.

 

[Mikkel]

I jump at the opportunity to do MAC with no sedation.

But if you did give some sedation, the patient would have been fine.

 

[deleted171991]

I've had situations where the surgeon requested anesthesia monitoring for a local case, or cases when I chose not to give anything (e.g. cataracts). It's called Monitored Anesthesia Care (and not Monitored Anesthesia Sedation) for a reason.

Me sitting in the OR, not managing the airway = MAC.
Me sitting in the OR, managing the airway = GA (from a billing standpoint).

Neither of them requires analgesia, sedation, hypnosis or amnesia, or me giving any medications.

 

[deleted9493]

MAC as defined by CMS is monitoring by an anesthesia provider capable providing whatever is required to safely and successfully complete the procedure/study.

We commonly will take care of teens with question of an anomalous coronary artery or kids with history of Kawasaki's disease who need CT coronaries with contrast to screen for aneurysm. Our involvement in these cases is most often just to titrate beta blocker to goal HR for the study. Prior to our department getting involved, the referring cardiologist had been writing for a single dose of propranolol and the study may or may not have been definitive, as a result. Worst yet were kids (without a prescription) showing up for these studies with nobody willing to prescribe a beta blocker for a patient they don't have an established relationship with...understandably so.

 

[coffeebythelake]

As others have said, pt is being billed for our presence monitoring the patient, irrespective of whether sedatives were given.

 

[dhb]

reglan, bicitra, pepcid

That'll give you nauseum

 

[TraumaLlamaMD]

That'll give you nauseum

sweat tea

This too.

 

[Planktonmd]

The issue is: If you are sitting in the OR giving nothing and the patient starts having pain or discomfort will you then decide to give sedatives violating your own NPO guidelines?

 

[UscGhost]

The issue is: If you are sitting in the OR giving nothing and the patient starts having pain or discomfort will you then decide to give sedatives violating your own NPO guidelines?

Yup. This is exactly the issue.