MAC anesthesia versed / propofol

brithoover · Mar 2, 2013

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

I'm not sure what MAC is, however I used to work in dental sedation and GAs. Versed is not used for pain. We typically used ketorolac or fentanyl as pain relief. Versed (midazolam) is used for anxiety/amnesia/sedation. Propofol is used in GAs and deep sedations. Depending on the procedure and the pt, sometimes versed is enough, but we typically always bolused with propofol to keep them under.

Do not being embarrassed to ask questions. A nurse with 20 years experience could be doing this job but not know any of these things. Propofol is not used on an everyday basis in the hospital. I learned SO much just by asking my anesthesiologist tons of questions. I also enrolled myself in a PACU course. It is very important you know all about the meds they are using so you know what side effects to expect.

This is a specialty all on its own that no matter how much experience you have will be a huge learning curve!

Syhuggins · Mar 2, 2013

As a new nurse it is critical you understand the importance of using your nursing drug book. There are no stupid questions. As a PACU Nurse Manager I am concerned about the type of orientation you are receiving and the decision if any manager to hire a new grad into this speciality. Even in an outpatient surgical center setting you must have critical care experience in order to posses the understanding of how to care for the patients in this setting. Good luck in your endeavors. Read everything you can get you hands on about post anesthesia care.

Editorial Team / Admin · Mar 2, 2013

MAC stands for "monitored anesthesia care." Depending on the facility, that may mean very different things, and indeed can mean many different things within the same facility. For us, conscious sedation is just that- sedation without full loss of consciousness, and may be given by certified sedation nurses without the presence of an anesthesia provider. MAC is deeper, but the patient is able to (usually) maintain their own airway, and requires the presence of an anesthesia provider. Our conscious sedation is typically Versed and fentanyl; MAC is generally Propofol. Propofol can be used for induction of general anesthesia; however, after the patient is asleep they are generally kept that way using inhalational anesthetics, such as sevoflurane or desflurane. Our definition of MAC is generally anesthesia provider involvement, use of Propofol, no intubation with an ET tube or use of an LMA, and PACU stay required. Our conscious sedation patients do not go to PACU; they go to our post-op discharge unit.

brownbook · Mar 3, 2013

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!

meandragonbrett · Mar 3, 2013

The particular drugs used don't determine whether its a MAC or a GA. Also, being intubated or having an LMA placed doesn't determine whether the case is a MAC or GA. Is the patient able to maintain their protective reflexes?

A MAC can be anything from 2 of Midaz all the way to propofol and ketamine infusions.

PMFB-RN, RN · Mar 3, 2013

FWIW many facilities use propofol for concious sedation procedures. My hospital does and it's fantastic.

ffliper27 · Mar 4, 2013

thank you all so much for the clarifications. :-)

Roseyposey · Mar 6, 2013

I'm not sure if procedure is still considered conscious sedation when Diprivan is added into the mix - that's the line where I would be calling it MAC. I'm probably splitting hairs, and I am sure it differs by facility and state. I know in my state as an RN I can administer conscious sedation, but cannot push Diprivan.

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

Editorial Team / Admin · Mar 6, 2013

I'm not sure if procedure is still considered conscious sedation when Diprivan is added into the mix - that's the line where I would be calling it MAC. I'm probably splitting hairs, and I am sure it differs by facility and state. I know in my state as an RN I can administer conscious sedation, but cannot push Diprivan.
And I have to agree with Syhuggins, I do not think the PACU is a good place for a new grad.

Same here- must be an anesthesia provider (CRNA/MDA) to push propofol at my facility; thus, we charge for MAC anytime propofol is given because of the necessity of an anesthesia provider.

I do, however, disagree with the sentiment of PACU not being a place for new grads. As long as training is adequate, new grads can and have succeeded in PACU. I've worked with many of them, and the environment at my facility's PACU is very nurturing of new grads. That may be what makes the difference.

ckh23, BSN, RN · Mar 9, 2013

The particular drugs used don't determine whether its a MAC or a GA. Also, being intubated or having an LMA placed doesn't determine whether the case is a MAC or GA. Is the patient able to maintain their protective reflexes?
A MAC can be anything from 2 of Midaz all the way to propofol and ketamine infusions.

I would certainly hope if you are putting in an ETT or LMA in for a procedure that the patient is getting GA.

BCRNA · Aug 3, 2013

A MAC is anesthesia involvement. No drugs have to be given, it can be wide awake or almost a general. All ETTs and LMAs are generals, otherwise the patient gets upset, lol. An LMA used in a MAC is usually due to loss of airway (unintentional general). Propofol in low dosages can be "conscious sedation". I find if you give enough propofol to cause slurred speech then the patient will not remember most local injections. Versed alone might prevent a patient from remembering the pain but it is not a guarantee. It is a pet peeve of mine when non-anesthesia providers tell the patient they wont remember anything in a MAC. It can not be guaranteed and results in the patient claiming "anesthesia awareness" when it never actually occurred. Not to mention it can be interpreted as breech of contract in some examples. If you tell a person they will remember nothing, and they do then they can sue for breech of contract.