MAC anesthesia versed / propofol

[ffliper27]

I have a question. For starters, I'm a fairly new RN, thus seeking some knowledge on anesthetics. I recently started a job at an eye surgery center doing PACU. When I receive pts from the OR, I see the anesthesia sheet and see the drugs used. This place pretty much uses MAC.

To my understanding, MAC is a type of conscious sedation, correct? I also understand that the predominant drug for MAC / conscious sedation is versed, because i see it on the anesthesia sheet. However, sometimes the patient is also given propofol in addition to versed. Here is where my confusion comes in.

I was under the impression that propofol is pretty much general anesthesia agent. So why is it sometimes used for MAC along with versed. Some patients get just versed, and some other get both drugs.

And one more question. I understand that versed is a benzo that "takes the edge off" and relaxes you before the procedure, and that you will be somewhat conscious during the procedur and won't remember a thing after. Does versed itself provide pain relief, because as mentioned before, when I see my pt's anesthesia sheet with only versed, I dont see any kind of opioid med for pain control.

Any clarification on these topics would be so appreciated. I am too embarrased to ask the CRNA / anesthesiologist at the clinic for fear of being considered a "stupid" new RN.

Thanks

[manusko]

If the pt is unable to protect their airway, then they have crossed to a general anesthetic. Many MACs are truly generals. There are guidelines to the definitions. I have performed many generals without an LMA or ETT. I had a TIVA with an airway and a non rebreather mask. During a MAC the patient should be able to respond to stimuli.

Never have been in the room without actually giving any meds at all. Not sure how you can bill for that and why you stand in an OR not doing anything at all.

[MaudKennedy]

In what circumstances do patients versed alone?? I mean,if it isnt a pain relief,why use it alone? I understand the fact you can t suffer from something you don t remember but...You don t take a medication to forget you were in pain,you take it to not feel it in first place.

[offlabel]

And I have to agree with Syhuggins, I do not think the PACU is a good place for a new grad.

A runny nosed 25 year old pgy 1 resident whose voice has barely changed can take out my grandma's appendix but a new grad nurse can't work in the PACU?

[offlabel]

In what circumstances do patients versed alone?? I mean,if it isnt a pain relief,why use it alone? I understand the fact you can t suffer from something you don t remember but...You don t take a medication to forget you were in pain,you take it to not feel it in first place.

As sedation for pre procedural local anesthetic infiltration. Brief periods of intense pain.

[MaudKennedy]

Thanks for answering.:)I wondered because I saw it was used alone for procedures like colonscopies and endoscopies and I wondered if it was the rule.

[traebabes]

Another good book to read along with Drains PeriAnesthesia Nursing (Which is humongous to carry so mine is on Kindle) is "PeriAnesthesia Nursing Care- A Bedside Guide for Safe Recovery". Authors are Stannard and Krenzischek. It is a soft cover, easy to carry around, and bullet points PACU essentials including all the anesthesia types, pain management, and importance information for different procedures.

[traebabes]

Please please please new RN do not be afraid to ask questions. Honestly you could ask 10 CRNA's or anesthesiologists to define General Anesthesia, MAC, TIVA, etc., and get 20 answers.

It is the "art" of medicine that different clinics, anesthesiologist etc., use different "cocktails" for their procedures.

It is not written in stone or even in policy exactly what drug equals what anesthetic method used equals what "category" if falls under.

You could work PACU 30 years and find things change, the "answers" change, and there IS NO DUMB QUESTION!

Very true-even when you ask several different anesthesiologist what "General Anesthesia" is, you also get different answers and none are wrong, it is their own philosophy and experience. You will then make your own opinions as you gain experience and just let everyones opinions roll off your back, some become a little passionate about their own opinion! Good Luck!

[twozer0, NP]

Thanks for answering.:)I wondered because I saw it was used alone for procedures like colonscopies and endoscopies and I wondered if it was the rule.

Versed has no pain relieving properties, it is purely used as an amnestic and for relaxation since its technically a benzodiazapine. Its short acting but very potent. Its used virtually on every patient, usually in the pre op setting before induction again to help relax the patient and provide amnesia. This is why most people dont realize anything during the case, they just remember "going in".

As offlabel mentioned its used for periods of brief pain, it really provides no pain relief, it just makes the person forget about the pain. Typically if the person has that much pain its going to be given with fentanyl as the midaz isnt treating the pain. We use fentanyl regularly but occationally get someone with emergence delerium and have to resedate with midaz. In severe cases, they go in the K hole.

[kvocrna]

MAC is a billing term. It means Monitored Anesthesia Care. As a CRNA, I am not standing around the room "doing nothing." I am in the room monitoring the patient. Even if I give nothing I am there for the "what ifs." In your cases, what if the 5 and dime reflex is activated and the patient goes asystolic? That is why I am there.

So, back to your original question. Versed is for anxiety, not for pain. Typically those cataracts are done with topical anesthestic drops (lidocaine or tetracaine), so they do not need pain medication. And truly, the only reason they may need Versed is because the patient may have a hard time lying flat under the drape.

Conscious sedation is for patients who receiving versed/demerol/fentanyl, etc for procedures. Nurses trained in this and credentialed by their facility can give this. Total IV anesthesia is when propofol or etomidate is given and the patient loses their ability to protect their airway, irrespective of whether airway instrumentation is used. That is billed as a general anesthetic. If an endotracheal tube or LMA is placed, those are also billed as general anesthetics.

Never be afraid to ask questions in the PACU. Talk to one of your CRNAs. Usually the CRNAs will try to mentor you and make sure you understand what is going on with the patient and the drugs that they have given.

Certainly take the advice of others here. You need to start taking notes. Write down the various drugs being used. Look them up. Find out their duration of action, side effects and reversals.

Good luck to you and your future.

From:

A Solo Practice CRNA who depends on her PACU nurses greatly!

[offlabel]

In what circumstances do patients versed alone?? I mean,if it isnt a pain relief,why use it alone? I understand the fact you can t suffer from something you don t remember but...You don t take a medication to forget you were in pain,you take it to not feel it in first place.

As an aside, versed in the elderly ( >63 or so?) is an awful drug. Post op cognitive dysfunction, disinhibition of sensorium (during the case) and delayed emergence\discharge are reasons I avoid it like the plague wit these patients.