Amidate and Propofol for MAC?

i think it is not a clean technique to rely on polypharmacy to reach a goal - as you now confound different half-lives etc....

would you use propofol, etomidate, versed and thiopental mixed up for an induction?

would you use dilaudid, morphine, methadone, remifentanil and sufentanil for your intra-operative pain control?

and first of all, i would be very careful using propofol/etomidate for a MAC as their use can quickly convert the case to a GA:

here is the ASA guideline on MAC -

Monitored anesthesia care may include varying levels of sedation, analgesia and anxiolysis as necessary. The provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.

I would not use that mix either for the same reasons Tenesma states. By using amidate, you extend the context sensitive half-life and you sedation is unpredictable.

Mike

and first of all, i would be very careful using propofol/etomidate for a MAC as their use can quickly convert the case to a GA:

While this is an important point, I am a bit puzzled that you would emphasize it in this discussion. The OP is a SRNA, and learning to provide MAC anesthesia care. I don't think the question was about using this mix in non-anethesia provider deep/conscious sedation cases.

The possibility for tipping the scale to a general is always present when providing this type of anesthesia. Perhaps you wanted to emphasize that this is more likely when you mix these two particular drugs. If so-then point taken.

However, don't we use polypharmacy all the time? In fact, I think that might be one of our particular strengths as anesthesia specialists-the knowledge and expertise to devise particular cocktails to suit particular needs.

And there are so many choices at our disposal, it is quite unlikely that any one provider will find them all useful. What works in my hands may not be a good technique for another. I believe it is a good attribute in an anesthesia professional to keep an open mind about these things. (Of course, there is no need to try a technique that one has misgivings about, based on one's knowledge of anesthesia, so if Tenesma and mwbeah judge this particular combination to be undesirable, that is certianly a valid opinion).

As to the original question, I have no experience with the combination of propofol and etomidate. However, the goals the OP describes for using this mix remind me of another MAC technique that has a similar profile-propofol and ketamine, preceeded by a little versed to counteract any ketamine-creepiness. Propofol ketamine is widely used in plastics and other MAC situations where fairly profound sedation is required, but there may be less than ideal access to the airway. I believe it to be a more accepted choice, that might be a suitable alternative for some cases. It is especially useful when you need its analgesia properties.

GI lab-those cases usually don't cause much pain. I too would go with straight propofol in those settings. I have found that even fentanyl and/or versed just add to recovery time, without changing procedure conditions very much.

loisane crna

Interesting how different people do things differently.

Propofol / Amidate makes no real sense to me. I personally see no advantage, unless you're just wanting to see the difference in techniques.

We do a ton of GI MAC cases. I don't particularly like propofol alone, but that's just me. I use fentanyl and versed and propofol. Some think it's overkill, but my patients are out the door in 15-30 minutes just like those who use propofol alone, so it hasn't created any problems. I have more problems using propofol alone, mainly because our GI docs think because we're there the patient should pretty much be unconscious and not moving. With no analgesic properties with propofol, I end up using more to keep them from squirming off the stretcher during the procedure. And before you think I'm a wimp, I'm more than happy to tell the doc that I can change it to a general anesthetic, but that I'll have to wake up the patient, get an anesthesia machine and check it out, and it will only delay them about 45 minutes. That usually shuts them up. With my current polypharmacy technique, they're breathing, they're still, they're fully awake quickly, and everyone is happy.

Fortunately for my department, at least for now, our hospital has a firm policy that the only providers in the hospital who get to use IV push Propofol, Ketamine, pentothal, brevital, and Amidate are the Anesthesia Department. That applies to all department - GI, ER, Radiology, the intensivists, house docs, everyone. No GI nurses pushing propofol here.:)

loisane you misunderstand my point.... this has nothing to do with non-anesthesia provider sedation.

I was trying to point out that what we often call MAC is really a GA without airway protection....

I was trying to point out that what we often call MAC is really a GA without airway protection....

I agree 1000%. I have done plenty of sedation cases that ended up being generals. As long as all the standards of care are met, I have no trouble calling them a general. Now if we could just get those pesky billing people to understand that the depth of anesthesia is determined by patient response, not the equipment used.

After all, MAC is a term for bean counters, it really doesn't have a clinically useful meaning. But we all use it to refer to anesthesia provider sedation, which I am sure is how we all understood the OP.

loisane crna

Fortunately for my department, at least for now, our hospital has a firm policy that the only providers in the hospital who get to use IV push Propofol, Ketamine, pentothal, brevital, and Amidate are the Anesthesia Department. That applies to all department - GI, ER, Radiology, the intensivists, house docs, everyone. No GI nurses pushing propofol here.:)

jwk, how does the ER fuction with these limitations? While I certainly agree with the stance of your department / hospital, I would imagine that many docs (esp ER) would not be pleased with this. Are you saying that the ER cannot give these drugs unless anesthesia is present? And if so, then how often are you guys consulted to do an anesthesia case with these drugs after traditional CS meds (versed/fent) have failed? Does anesthesia have to be in the room when persons in the unit are intubated, even if non-emergent?

Just wondering..

I saw you basically answered my question on another post, I was just wondering specifically how the ER functions around this policy. What is your response time to the ER and are you there for every intubation?

I saw you basically answered my question on another post, I was just wondering specifically how the ER functions around this policy. What is your response time to the ER and are you there for every intubation?

We are rarely called for ER intubations. I can only assume they're probably using Versed for sedation, or nothing. All I can tell you is that the policy is in place and it is followed.

as to the posting about the ER -

as an ER nurse i can tell you that the majority of pts that are in need of intubation in the ER require little to nothing for intubation or they are already dead. but they generally use versed and sux -

i agree with all the previous posts on the "cocktail" and i thank you for the input...here is the reasoning behind why (to my knowledge) it was being used and why i in turn used it...

like loisane mentioned - we cocktail much of our medicine - ketamine/propofol and excellent example... the amidate/propofol mix came about because amidate in small divided doses doesn't have the respiratory depression that propofol has it also doesn't have the significant hypotension that propofol does (of course i know that with hypovolemic patients anything will likely drop their pressure)

the patient i used it on was acutally an eye patient that told us she had a problem with hypotension - so i used a very small amt of etomidate and a very small amount of propofol - the times i have seen it used and the times i have used it have worked very well....

however - the doc didn't approve :) thanks again for the input - i appreciate it.

I agree with the above. I do very little true MAC cases in my student anesthesia practice. In reality they are almost all general anesthetics with the patient either maintaining their own airway or maintaining with the assist of a jaw lift.

I find most surgeons tend to get a little wiggy and give me the old "when are you going to put the patient to sleep" look if I do the case with the patient under true MAC.

Gives you a good appreciation for the need of airway management skills when giving propofol, if nothing else.

I had an interesting case recently. Pt was an ASA IV with intractible pain from CBD stones, and this was really a quality of life issue. We did a MAC for ERCP with much trepidation and fear d/t cardiomyopathy, poor EF, and you name it.... I pretreated with Zofran 4 mg. For sedation, I used 2mg Versed and Fentanyl and titrated Amidate in 2mg increments for the case. I did give a touch of lidocaine IV just prior to beginning the amidate. He received a total of 8mg, tolerated it well, no nausea, great sedation for procedure and maintained his own airway. I was leary, but it worked...well.