MAC and pts with reflux

jwk · Feb 12, 2005

Hi. I'm curious to hear everyone's opinion regarding MAC and patients with GERD with moderate/good symptom relief by proton pump inhibitors and/or H2 antagonists. From a conservative standpoint, are these patients still candidates for MAC involving the use of versed, opioid, and/or propofol? I had this debate with a friend of mine, and I'd like to know what everyone here thinks. Thanks.

A true MAC doesn't involve loss of airway reflexes, so in theory, it should be OK for patients such as this. However, once you loose protective airway reflexes, you have crossed into the realm of a general anesthetic, and it becomes a much higher risk in patients with reflux.

gotosleep · Feb 12, 2005

Hi. I'm curious to hear everyone's opinion regarding MAC and patients with GERD with moderate/good symptom relief by proton pump inhibitors and/or H2 antagonists. From a conservative standpoint, are these patients still candidates for MAC involving the use of versed, opioid, and/or propofol? I had this debate with a friend of mine, and I'd like to know what everyone here thinks. Thanks.

What's the alternative? General anesthesia with ETT for everyone with reflux who needs a EGD, colonoscopy, or mole removed?

Brenna's Dad · Feb 12, 2005

I am hesitant to do a MAC case in patients with serious GERD. As I said in a recent post, I believe the majority of MAC cases are really general anesthetics. Since pharygeal reflexes are lost when the patient becomes non-responsive, I do not think a MAC is appropriate in this patient population.

deepz · Feb 12, 2005

I am hesitant to do a MAC case in patients with serious GERD. ......I do not think a MAC is appropriate in this patient population.

That's your personal feeling, BD. Fine. There are a thousand ways to skin a cat, and many thousand ways to practice anesthesia. But ideally we practice evidence-based anesthesia. IMHO Blanket statements about entire patient populations based on personal feelings and personal choice might be rather too sweeping a statement on your part. Not a flame, amigo, just my observation here.

Each and every patient presents a titration challenge. Some more than others. Years back I gave an old gentleman 1 mg of Valium IV and general anesthesia resulted. Good thing he did not have GERD! Live and learn.

If we approach each titration challenge with respect for the individual patient's specific circumstances, and with a large dose of caution, surely we can provide MACs to GERD folks with a reasonable degree of safety.

deepz

gotosleep · Feb 12, 2005

I am hesitant to do a MAC case in patients with serious GERD. As I said in a recent post I believe the majority of MAC cases are really general anesthetics. Since pharygeal reflexes are lost when the patient becomes non-responsive, I do not think a MAC is appropriate in this patient population.[/quote']
So you are a proponent of general anesthesia with ETT for someone with GERD requiring a colonoscopy?

charles-thor · Feb 12, 2005

So I suppose it primarily depends on how stimulation the procedure is and how confident you are that you will maintain airway reflexes throughout the case. I guess it really depends on whether you're doing MAC say for example a mole removal vs. wisdom teeth extraction.

Brenna's Dad · Feb 13, 2005

I'm not a proponent for ETT and a general anesthetic for Colonoscopy. However, I do feel these cases should be truly done with MAC/ conscious sedation if the patient has significant GERD. I'm not talking about the individual with a wee bit of reflux when they eat too much or after a spicy meal, but the few individuals I've seen with truly symptomatic reflux. The ones sitting up on their stretcher becaue when they lie down acid comes into their throat.

Deepz, I'm not trying to make a blanket statement, but only the point that at least in my facility, almost all patients presently to the operating room are receiving a general anesthetic throughout most of the case. If this statement is true, then yes, patients with significant GERD should either receive ETT intubation and general anesthetic, a nerve/conduction block, or a true MAC.

WntrMute2 · Feb 13, 2005

I'm not a proponent for ETT and a general anesthetic for Colonoscopy. However, I do feel these cases should be truly done with MAC/ conscious sedation if the patient has significant GERD. I'm not talking about the individual with a wee bit of reflux when they eat too much or after a spicy meal, but the few individuals I've seen with truly symptomatic reflux. The ones sitting up on their stretcher becaue when they lie down acid comes into their throat.
Deepz, I'm not trying to make a blanket statement, but only the point that at least in my facility, almost all patients presently to the operating room are receiving a general anesthetic throughout most of the case. If this statement is true, then yes, patients with significant GERD should either receive ETT intubation and general anesthetic, a nerve/conduction block, or a true MAC.

IMHO your last statement is the correct position. All those MACs that have an unconcious patient are GAs. For safety, the airway reflexs should remain intact is reflux is a potential issue. If the patient cannot tolerate the procedure then the sturgeon needs to localize better, we need to do a conduction block or insert ETT. Does this mean I never cross the line? No, frequently on cases such as breast biopsies, or foot blocks I provide a minute or so of GA while the local is injected. I think the risk/reward ratio is OK for MOST patients. The ones that can't lie flat as in your example get "squeeze my hand" anesthesia to get them through the localization. BTW, we consider as if all those MAC cases are GAs when it comes to consents and billing.