March FY20

[kristenhorsman]

The March journal article is presented by Beth Medina. She chose an interesting article that focused on the implications of inspired CO2 during ophthalmic surgery under MAC. Frequently, ophthalmic procedures are performed using MAC with facial draping, leading to hypercapnia and a myriad of physiologic changes. You can learn more in the article here.

Please answer the following two questions:

1. Given the current resources in Wilmer, are we able to decrease FiCO2 to an acceptable level under MAC. Why or why not?

2. After reading about the issues mentioned in this article, can we continue to think of MAC as "just sedation". Will this article make you more vigilant during these types of procedures?

[Amy Swank CRNA]

1. During the MAC cases that i have participated in at Wilmer, the patients have not been "over-sedated", in my opinion to warrant concern about hypercapnia.
2. There is an art to the science of MAC anesthesia, I believe, and vigilance and experience cannot be overstated.

[Jessica Switzman]

We no longer do sedation Ophthalmic cases at Bayview. In my recent experience, ophthalmic blocks allow us to give minimal to no sedation.

Vigilance regarding signs and symptoms of hypercapnia, including cardiac changes, is the reason a anesthesia professional should be present.

When I did do these cases, I used Air Insufflation like the article described; it seemed to work well.

[Anne McNulty CRNA]

I feel with have fairly good resources in wilmer . I would like to have the respiratory wave on the monitor to follow. It is not on the new GE monitor setup. On page 289 of the article the respiratory wave is suggested as capnography In patients under sedation is in accurate. Mac is billing term , Sedation requires vig . Anneilance. I like this article

[Wai-Ling Lo]

1. I feel that it is important to make sure a.)the plastic drape is not sticking directly over the nostril and mouth (ask the resident to adjust the plastic drape if needed; also ask the scrub tech to elevate the plastic drape away from the face using their instrument tray is helpful too); b.) the blue drape is not covering the outlet of the circuit that insufflate air to eliminate CO2. If this is done right, it really helps to eliminate CO2 accumulation.

2. Staying vigilant is basic professional practice, it doesn't matter whether the case is MAC or GA.

[Ben Waldbaum]

Please answer the following two questions:

1. Absolutely yes. In cases like this I put a suction yankauer near the patients head. On the other side I tape the circuit and run Air at full blast. This greatly increases air circulation with no increase in fire risk.

2. It doesn't change that this is a sedation procedure. And any procedure, regardless of the modality has risk. Our job is to mitigate that risk

[Jessica Hadley]

1. I do think based on the available recommendations that we are taking the appropriate steps in Wilmer to mitigate inspired CO2 levels. I personally use the drape holder and insufflate 10 L of air under the drapes. The article also discusses use of suction under the drapes, however we are often asked to share our suction with the surgical field so I'm not sure we would be able to implement this in Wilmer.

2. MAC anesthesia does require an added level of vigilance in my opinion. I think we are progressing in how we are taking care of MAC cases since agents other than Propofol are now available eg. Precedex.

[Katya Podin]

1.When I do cases in Wilmer, I give the minimum amount of sedation as possible. Sometimes, just talking to patient and hold hand is enough sedation. I use drape holder and insuflate air under the drapes. Suction is usually shared with surgical team.
2. Vigilance should be practiced all the time, especially in MAC cases.

[khall]

1. Yes we are able to decrease FiCO2 to acceptable levels using the drape holder and air insuflation under the drapes.

2. Vigilance is necessary whether MAC or GA.

[BGardner]

1. Given the current resources in Wilmer, are we able to decrease FiCO2 to an acceptable level under MAC. Why or why not?

I find that using O2 NC along with a drape holder, and air from circuit at 10LPM under the drape FiCO2 can maintained at reasonable levels. Also checking to make sure the drape is off the face/nose/mouth pulled up and held in place by the tray along with parting the drapes and hanging them over a tube tree on the side allows for improved egress.

2. After reading about the issues mentioned in this article, can we continue to think of MAC as "just sedation". Will this article make you more vigilant during these types of procedures?

This is a good reminder but optimal patient care always includes vigilance especially when the airway is covered and turned away from the anesthesia provider. Limiting sedation to only what is necessary is always a good idea and will reduce the risk of over sedation, hypoxia and hypercapnia.

[aileenm4]

I believe all the suggested ways such as air flow under the drapes, suction under the drapes, not having the plastic tight around the face and tenting it up, are all great ways to decrease the inspired CO2,

I also agree that MAC is an art and  has the same need for meticulous care that we all do every day for very case we do

[Jules Chandler]

1. Given the current resources in Wilmer, are we able to decrease FiCO2 to an acceptable level under MAC. Why or why not?

I have been using the circuit under the drape taped to the patient's chest at 10L FGF of air and the cardboard drape support the drape off the patient's face. Most of the time it works well keeping FICO2 under 10, other times not as well and requires me to investigate under the drape. I have not experienced any instances of patient's having hypercarbia thus far.


2. After reading about the issues mentioned in this article, can we continue to think of MAC as "just sedation". Will this article make you more vigilant during these types of procedures?

In Endoscopy, sedation/MAC is charted as general with natural airway as we get them more deeply sedated for endoscopy procedures than ophthalmology procedures. Most of our cataract patient's have had some sort of endoscopy in the past and assume sedation will be the same as for their endoscopy. I am careful to set the expectation that they will be lightly sedated, however aware of what is going on and that they will hear us speaking and the sounds of the equipment. I think it is important for us to set the expectation to patients that they will be lightly sedated, if we don't set realistic expectations we get ourselves in trouble and patient's think they had "awareness during anesthesia" or their anesthesia was not done correctly.

[kels]

I agree that Wilmer is equipped to keep FiCo2 at reasonable levels. Yes High flow air, drape " bridge" and suction are helpful

100 % Vigilance is needed at all times

[Soo-Ok Kim]

1.Yes, it is possible to decrease FiO2 and I normally give 2L/min NC.

2. In my opinion, "just sedation" is misleading. It doesn't matter the modality of the anesthesia in that every case needs vigilance and meticulous attention to details.
skim

[Jocelyn Datud]

1. I haven't done ophthalmic cases in almost a year. However, with other mac cases where the face is covered by drapes, I try to be very mindful of the CO2 accumulation.

2. I believe all of us are already vigilant no matter what type of anesthetic we are giving. Every case is always different. This article is definitely a good resource.