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The Secret of Gritflowness - October 2020 - Subscribe to Outpatient Surgery Magazine

Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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6 8 • O U T P A T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 2 0 T he use of deep monitored anesthe- sia care (MAC) during outpatient surgeries continues to increase, and for good reason. MAC eliminates the need for general anesthesia and is associ- ated with decreased opioid use, reduced postoperative delirium and sore throat, and less pulmonary and cardiac physio- logic disruption. From a facility perspec- tive, you're accommodating patient safety and comfort with practical needs like effi- cient OR use and faster recoveries — and their associated cost savings. Finding the perfect balance MAC is a continuum from no sedation to depression of consciousness that can progress to general anesthesia and the need for ventilation support (Fig. 1 on opposite page). Propofol is the main drug of choice for MAC because of its favorable pharmacodynamic and pharmacokinetic profiles. Propofol is "fast on" and "fast off"— useful characteristics in maintaining patient comfort and breathing, and efficient patient throughput. Local and regional anesthetics are also often part of the MAC anesthetic mix. This synergis- tic effect between sedation and analgesia is hard to predict when a combination of medications are co- infused, so an increase in respiratory depression and delayed cognitive function recovery can occur. Administering deep MAC is like walking a tight rope. Anesthesia providers must ideally maintain spontaneous breathing while preventing the need for ventilation support. Deep MAC is a great tool when properly administered, but it can be one of the most challenging anesthetics to deliver because each patient can respond differently. Geriatric and certain ethnic populations (Asian Americans, for example) show a decreased thresh- old to anesthesia due to body composition and function. In general, patients may quickly transition from one level of sedation to another. As a result, anesthesia providers must be able to respond to all depths of anesthesia and have quick access to nec- essary equipment and supplies when the depth of sedation exceeds expectations. As outpatient procedures continue to expand, so do the types of patient populations who undergo them. An increasing number of patients who are eld- erly, obese and who have a history of obstructive sleep apnea are now operated on in ambulatory ORs. For these patients, MAC can help minimize the respi- ratory and cardiac instability associated with a gener- al anesthetic. However, these same patients are at increased risk of upper airway complications during anesthesia administration, including upper airway obstruction due to reduced muscle tone. In fact, most MAC-related complications result from respira- tory events, which occur more often in obese, sleep apneic and elderly populations. The most common sedation malpractice claim associated with MAC is inadequate oxygenation/ven- tilation with more than 80% of claims of this nature the result of brain damage or death, according to the American Society of Anesthesiologists' closed claims Managing MAC Administering this form of anesthesia demands mixing art and science. Anesthesia Alert Roxanne McMurray, DNP, APRN, CRNA POTENTIAL PROBLEM During deep MAC, the upper airway can become obstructed when the patient's tongue drops into the pharyngeal cavity. Roxanne McMurray, DNP, APRN, CRNA

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