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database. The American Association of Nurse Anesthetists Foundation's closed claims data- base also reports that respiratory events are the greatest cause of adverse anesthesia outcomes, with MAC identified as a contributing factor to those claims. As the United States general population continues to grow older and obesity becomes more prevalent, the risk for upper air- way complications during anes- thesia in these patient groups increases as well. When adminis- tering deep MAC, anesthesia providers must be ready to inter- vene if upper airway obstruction occurs to prevent further morbidi- ty or mortality. Managing the risks Administering deep MAC requires vigilance and careful titration of anesthetic to maintain a sponta- neous breathing airway and prevent apnea. Apnea can be attributed to over-sedation, central or obstructive sleep apnea, or a combination of both. Treating apnea depends on the etiology. To detect and assess apnea in real-time, anesthesia providers observe the patient's respiratory effort and chest movement, look for humidification in the oxygen mask or listen to breath sounds with a precordial stethoscope while assessing ventilation by monitor- ing ETCO 2 waveforms and respiratory rates. Pulse oximetry is also useful for monitoring oxygenation, but is a delayed response in detecting apnea leading to hypoxemia. If the apneic episode is detected early enough, the decline in pulse oximetry can be addressed and minimized. For apnea caused by over-sedation or nonob- structive central sleep apnea, positive pressure ven- tilation support maintains oxygen saturations. Obstructive sleep apnea due to upper airway obstruction is treated with airway management tools that open pharyngeal tissue to promote breathing. This is a needed area of improvement as current oral airway devices are not always long enough to stent open the airway. Anesthesia providers sometimes implement workarounds, such as the use of longer, pliable nasal airways via the oral cavity, which may contribute to other issues. Manual chin lift and jaw thrust maneuvers may also be required to maintain a patent airway. This can lead to post-procedure lingering jaw pain and bruising. These positions occupy providers' hands, often throughout the duration of the procedure. In addition, they require close, prolonged patient- provider contact — a challenge during the COVID- 19 era when providers are seeking to reduce poten- tial exposure. Clear benefits Deep MAC is an extremely effective method of sedation when skilled anesthesia providers armed with the right medications and tools perform it on the right patients. These factors, along with strong clinical judgement and vigilant monitoring, improve post-op patient comfort, avoid the need for general anesthesia and contribute to faster and safer recov- eries. OSM Dr. McMurray (rmcmurra@umn.edu) is an educator in the anesthesia program at the University of Minnesota in Minneapolis. O C T O B E R 2 0 2 0 • O U T P A T I E N T S U R G E R Y . N E T • 6 9 TRENDING UPWARD The use of deep monitored anesthesia care continues to increase in outpatient ORs. Roxanne McMurray, DNP, APRN, CRNA