Monitored anesthesia care in adults
- Eric B Rosero, MD
Eric B Rosero, MD
- Assistant Professor of Anesthesiology and Pain Management
- UT Southwestern Medical Center at Dallas
Monitored anesthesia care (MAC) is a type of anesthesia service in which an anesthesia clinician continually monitors and supports the patient's vital functions; diagnoses and treats clinical problems that occur; administers sedative, anxiolytic, or analgesic medications if needed; and converts to general anesthesia if required. Approximately one-third of ambulatory anesthesia services for diagnostic or therapeutic procedures in the United States are provided as MAC , often in out-of-operating-room locations.
This topic will discuss preoperative evaluation for patients who will receive MAC, monitoring during MAC, and the medications and sedation techniques commonly used during MAC. Procedural sedation by non-anesthesia clinicians and the drugs and techniques used for general anesthesia are discussed separately. (See "Procedural sedation in adults outside the operating room" and "Overview of procedural sedation for gastrointestinal endoscopy" and "General anesthesia: Induction" and "General anesthesia: Maintenance and emergence".)
Sedation during procedures for which the primary anesthetic is a regional anesthesia technique, either neuraxial anesthesia or peripheral nerve block, is not considered MAC. However, the basic principles of sedation that are discussed here apply to those anesthetics as well.
A medical history and anesthesia-directed physical examination should be performed for all patients who undergo anesthesia, including those having monitored anesthesia care (MAC).
Patient medical status — The goals for preoperative evaluation are to identify underlying medical and physical conditions that may increase risk and to create an anesthetic plan that minimizes risk. In anticipation of MAC, the patient should be evaluated for conditions that increase sensitivity to sedative and analgesic medications (eg, older age; obstructive sleep apnea; advanced chronic lung disease; pulmonary hypertension; coronary, liver, or renal disease; anxiety disorders; chronic pain; use of opioids, sedatives, or recreational drugs) to allow appropriate drug dosing and administration.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Bayman EO, Dexter F, Laur JJ, Wachtel RE. National incidence of use of monitored anesthesia care. Anesth Analg 2011; 113:165.
- American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring (Approved by the ASA House of Delegates on October 21, 1986, last amended on October 20, 2010, and last affirmed on October 28, 2015). https://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/standards-for-basic-anesthetic-monitoring.pdf (Accessed on April 06, 2016).
- Checketts MR, Alladi R, Ferguson K, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2016; 71:85.
- Soto RG, Fu ES, Vila H Jr, Miguel RV. Capnography accurately detects apnea during monitored anesthesia care. Anesth Analg 2004; 99:379.
- Srinivasa V, Kodali BS. Capnometry in the spontaneously breathing patient. Curr Opin Anaesthesiol 2004; 17:517.
- Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology 2006; 104:228.
- American Society of Anesthesiologists. Position on Monitored Anesthesia Care (Approved by House of Delegates on October 25, 2005, and last amended on October 16, 2013). http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/position-on-monitored-anesthesia-care.pdf (Accessed on April 06, 2016).
- Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974; 2:656.
- Chernik DA, Gillings D, Laine H, et al. Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol 1990; 10:244.
- Liu J, Singh H, White PF. Electroencephalographic bispectral index correlates with intraoperative recall and depth of propofol-induced sedation. Anesth Analg 1997; 84:185.
- Ibrahim AE, Taraday JK, Kharasch ED. Bispectral index monitoring during sedation with sevoflurane, midazolam, and propofol. Anesthesiology 2001; 95:1151.
- Glass PS, Bloom M, Kearse L, et al. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology 1997; 86:836.
- Sandler NA, Sparks BS. The use of bispectral analysis in patients undergoing intravenous sedation for third molar extractions. J Oral Maxillofac Surg 2000; 58:364.
- von Delius S, Thies P, Rieder T, et al. Auditory evoked potentials compared with bispectral index for monitoring of midazolam and propofol sedation during colonoscopy. Am J Gastroenterol 2009; 104:318.
- Kearse LA Jr, Rosow C, Zaslavsky A, et al. Bispectral analysis of the electroencephalogram predicts conscious processing of information during propofol sedation and hypnosis. Anesthesiology 1998; 88:25.
- Yu YH, Han DS, Kim HS, et al. Efficacy of bispectral index monitoring during balanced propofol sedation for colonoscopy: a prospective, randomized controlled trial. Dig Dis Sci 2013; 58:3576.
- Chisholm CJ, Zurica J, Mironov D, et al. Comparison of electrophysiologic monitors with clinical assessment of level of sedation. Mayo Clin Proc 2006; 81:46.
- Nishiyama T. Auditory evoked potentials index versus bispectral index during propofol sedation in spinal anesthesia. J Anesth 2009; 23:26.
- Weaver CS, Hauter WH, Duncan CE, et al. An assessment of the association of bispectral index with 2 clinical sedation scales for monitoring depth of procedural sedation. Am J Emerg Med 2007; 25:918.
- https://dailymed.nlm.nih.gov (Accessed on September 20, 2016).
- Wilson E, David A, MacKenzie N, Grant IS. Sedation during spinal anaesthesia: comparison of propofol and midazolam. Br J Anaesth 1990; 64:48.
- White PF, Negus JB. Sedative infusions during local and regional anesthesia: a comparison of midazolam and propofol. J Clin Anesth 1991; 3:32.
- Wilson E, Mackenzie N, Grant IS. A comparison of propofol and midazolam by infusion to provide sedation in patients who receive spinal anaesthesia. Anaesthesia 1988; 43 Suppl:91.
- Veselis RA, Reinsel RA, Feshchenko VA, Johnson R Jr. Information loss over time defines the memory defect of propofol: a comparative response with thiopental and dexmedetomidine. Anesthesiology 2004; 101:831.
- Veselis RA, Reinsel RA, Feshchenko VA, Wroński M. The comparative amnestic effects of midazolam, propofol, thiopental, and fentanyl at equisedative concentrations. Anesthesiology 1997; 87:749.
- Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 2000; 90:963.
- Jalota L, Kalira V, George E, et al. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ 2011; 342:d1110.
- Egan TD. Remifentanil pharmacokinetics and pharmacodynamics. A preliminary appraisal. Clin Pharmacokinet 1995; 29:80.
- Byun SH, Hwang DY, Hong SW, Kim SO. Target-controlled infusion of remifentanil for conscious sedation during spinal anesthesia. Korean J Anesthesiol 2011; 61:195.
- Sá Rêgo MM, Inagaki Y, White PF. Remifentanil administration during monitored anesthesia care: are intermittent boluses an effective alternative to a continuous infusion? Anesth Analg 1999; 88:518.
- Hsu YW, Cortinez LI, Robertson KM, et al. Dexmedetomidine pharmacodynamics: part I: crossover comparison of the respiratory effects of dexmedetomidine and remifentanil in healthy volunteers. Anesthesiology 2004; 101:1066.
- Arain SR, Ebert TJ. The efficacy, side effects, and recovery characteristics of dexmedetomidine versus propofol when used for intraoperative sedation. Anesth Analg 2002; 95:461.
- Venn RM, Karol MD, Grounds RM. Pharmacokinetics of dexmedetomidine infusions for sedation of postoperative patients requiring intensive caret. Br J Anaesth 2002; 88:669.
- Shen SL, Zheng JY, Zhang J, et al. Comparison of dexmedetomidine and propofol for conscious sedation in awake craniotomy: a prospective, double-blind, randomized, and controlled clinical trial. Ann Pharmacother 2013; 47:1391.
- Alhashemi JA. Dexmedetomidine vs midazolam for monitored anaesthesia care during cataract surgery. Br J Anaesth 2006; 96:722.
- John S, Somal J, Thebo U, et al. Safety and Hemodynamic Profile of Propofol and Dexmedetomidine Anesthesia during Intra-arterial Acute Stroke Therapy. J Stroke Cerebrovasc Dis 2015; 24:2397.
- Jalowiecki P, Rudner R, Gonciarz M, et al. Sole use of dexmedetomidine has limited utility for conscious sedation during outpatient colonoscopy. Anesthesiology 2005; 103:269.
- Zeyneloglu P, Pirat A, Candan S, et al. Dexmedetomidine causes prolonged recovery when compared with midazolam/fentanyl combination in outpatient shock wave lithotripsy. Eur J Anaesthesiol 2008; 25:961.
- Darnobid JA. The pharmacology of total intravenous anesthesia. Int Anesthesiol Clin 2015; 53:13.
- Kohrs R, Durieux ME. Ketamine: teaching an old drug new tricks. Anesth Analg 1998; 87:1186.
- Loh G, Dalen D. Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department. Ann Pharmacother 2007; 41:485.
- Hession PM, Joshi GP. Sedation: not quite that simple. Anesthesiol Clin 2010; 28:281.
- Badrinath S, Avramov MN, Shadrick M, et al. The use of a ketamine-propofol combination during monitored anesthesia care. Anesth Analg 2000; 90:858.
- Cho JS, Shim JK, Na S, et al. Improved sedation with dexmedetomidine-remifentanil compared with midazolam-remifentanil during catheter ablation of atrial fibrillation: a randomized, controlled trial. Europace 2014; 16:1000.
- Brownlie GS, Baker JA, Ogg TW. Propofol: bolus or continuous infusion. A day case technique for the vaginal termination of pregnancy. Anaesthesia 1991; 46:775.
- González-Santiago JM, Martín-Noguerol E, Vinagre-Rodríguez G, et al. Intermittent boluses versus pump continuous infusion for endoscopist-directed propofol administration in colonoscopy. Rev Esp Enferm Dig 2013; 105:378.
- Grendelmeier P, Tamm M, Pflimlin E, Stolz D. Propofol sedation for flexible bronchoscopy: a randomised, noninferiority trial. Eur Respir J 2014; 43:591.
- Chiang MH, Wu SC, You CH, et al. Target-controlled infusion vs. manually controlled infusion of propofol with alfentanil for bidirectional endoscopy: a randomized controlled trial. Endoscopy 2013; 45:907.
- Moerman AT, Herregods LL, De Vos MM, et al. Manual versus target-controlled infusion remifentanil administration in spontaneously breathing patients. Anesth Analg 2009; 108:828.
- Domino KB. Trends in anesthesia litigation in the 1990's: Monitored anesthesia care claims. ASA Newsl 1997; 61:15.
- Franz R, Hartman J, Wright M. Comparison of anesthesia technique on outcomes of endovascular repair of abdominal aortic aneurysms: a five-year review of monitored anesthesia care with local anesthesia vs. general or regional anesthesia. J Cardiovasc Surg (Torino) 2011; 52:567.
- Liu J, Martinez-Wilson H, Neuman MD, et al. Outcome of Carotid Endarterectomy after Regional Anesthesia versus General Anesthesia - A Retrospective Study Using Two Independent Databases. Transl Perioper Pain Med 2014; 1:14.
- Snyder SK, Roberson CR, Cummings CC, Rajab MH. Local Anesthesia With Monitored Anesthesia Care vs General Anesthesia in Thyroidectomy: A Randomized Study. Arch Surg 2006; 141:167.
- Vu MM, Galiano RD, Souza JM, et al. A multi-institutional, propensity-score-matched comparison of post-operative outcomes between general anesthesia and monitored anesthesia care with intravenous sedation in umbilical hernia repair. Hernia 2016; 20:517.
- Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol 2009; 22:502.
- PREPROCEDURE EVALUATION
- Patient medical status
- Airway evaluation
- Appropriateness of monitored anesthesia care
- MONITORING DURING MONITORED ANESTHESIA CARE
- Standard physiologic monitors
- Monitoring depth of sedation and analgesia
- - Clinical assessment of sedation
- - Processed electroencephalography
- SUPPLEMENTAL OXYGEN
- DRUGS USED FOR SEDATION AND ANALGESIA FOR MONITORED ANESTHESIA CARE
- STRATEGY FOR MONITORED ANESTHESIA CARE
- Procedures with minimal or no pain
- Procedures with brief, initial pain
- Procedures with variable pain throughout
- DRUG ADMINISTRATION TECHNIQUES
- Bolus versus infusion
- Target-controlled infusion
- COMPLICATIONS DURING MONITORED ANESTHESIA CARE
- POST-ANESTHESIA CARE
- SUMMARY AND RECOMMENDATIONS