Functional Endoscopic Sinus Surgery: A Comparative Study of Monitored Anaesthesia Care and General Anaesthesia.

Background: Functional endoscopic sinus surgery is associated with a high rate of success for symptomatic improvement in patients. This operation can be done under general or local anesthesia. In this study we have tried to compare the efficacy of monitored anesthetic care with general anesthesia for Functional endoscopic sinus surgery. Methods: 20 patients each above the age of 18 years, were selected for Monitored anesthesia care (MAC) and for general anesthesia (GA). For MAC, 150mg Tab Ranitidine at BT/6AM, Tab Perinorm 10mg at BT /6AM, Tab Diazepam 5mg at BT /6AM was given as pre medication schedule. Inj Pentacozine 30mg + Inj Promethazine 25mg I/M was given 30–45 mins before the patient was shifted to OT. On the table Inj. Midazolam 1-3 mg was given which has 3–4 Ramsey sedation score .Inj Fantanyl 1mcg/kg weight was given for break-through pain. The GA technique used was Inj. Fantanyl 1 mcg/ kg weight + Inj Midazolam 1-2 mg; Inj Propofol 2mg/kg, Sch 2mg/kg was given, intubated by intermittent positive pressure ventilation (IPPV). Vecuronium 0.1mg/kg + Isoflurane 0.6–1% + N2O 2l/mt +o2 1l/mt was given followed by neostigmine 2.5mg+Glycopyrrolate 0.4mg. Results: There was a 15% increase in heart rate within 12 minutes of sedation in MAC and 20% in GA. The percentage of variation after 15 minutes remained at 15% in case of GA but it reduced to 5% in MAC and remained steady at this rate. 10% of the patients started to respond almost immediately after surgery in the MAC category and 100% of them were conscious within 90mins of surgery, while under general anesthesia, only 80% of them attained consciousness after 120 minutes. It took about 120 minutes for all patients under MAC for ambulation while it took more than 150 minutes for the patients under GA for ambulation. No patient under MAC had any side effects while 60% of the patient under GA ha nausea, vomiting or both. Conclusion: With no complications of extubation and mechanical ventilation, having faster recovery time, with hardly any post operative nausea and vomiting, Monitored anesthetic care is a better choice of anesthesia compared to general anesthesia for elective surgeries like Functional Endoscopic Sinus surgery.

Unanticipated hospital admissions for patients undergoing day surgery for cataract under monitored anesthesia care: a single center study

BACKGROUND: The incidence of unanticipated hospital admissions (UHA) for patients undergoing day surgery for cataract is not being reported in Korea. We investigate the incidence and causes of UHA, and the incidence of intraoperative adverse events for patients undergoing cataract surgery. METHODS: Electric medical charts of patients who underwent cataract surgery under monitored anesthesia care (MAC) in day surgery units from Nov 2011 to Jul 2012 were being reviewed. RESULTS: 1,374 cataract surgeries were performed in 942 patients. UHA was shown in six (0.4%) patients, who underwent cataract surgery only under MAC. Posterior capsular ruptures (three cases) and intraocular lens dislocation (one case) involved surgery-related UHAs, while severe postoperative nausea and vomiting (one case) led to anesthesia-related UHAs. Acute cerebral infarction (one case) was one cause of UHA. The incidences of intraoperative hypotension (mean arterial pressure [MBP] 120% of initial MBP) were 24.4% and 7.7% respectively. Of patients with hypertension, about 3% required treatments. Bradycardia (heart rate 100 beats/min) were observed in 29.7% and 4.1% respectively. But, no cases required treatments. The incidences of oxygen desaturation (oxygen saturation with pulse oximetry < 90%) and respiratory depression (respiration rate < 10 frequencies/min) were 0.3% and 1.8% respectively. CONCLUSIONS: The incidences of UHA and intraoperative adverse events were low for patients undergoing cataract surgery under MAC in our day surgery unit. A large-scaled multicenter study is necessary to find risk factors of UHA.

Consideration on Application of Modified Monitored Anesthetic Care in Plastic Surgery

PURPOSE: Many patients have fear for surgery owing to the injection of lidocaine and the possible pain in the course of the operation. To resolve such a problem the cases to do plastic surgery with monitored anesthetic care are increasing, in which something like sedatives is injected into vein without endotracheal intubation and under voluntary respiration, but the usage is now under the controversy. METHODS: There were 25 patients who had surgery with local anesthesia, and another 25 patients who had surgery with monitored anesthetic care which belongs to ASA class 1 and 2 from January to April, 2009. Their anesthesia records were collected and surveys were given before and after the surgery and the surgery staff recorded OAA/S during the surgery. The postoperative surveys included the awakening during the surgery, pain, anxiety, and the degree of patient's satisfaction through visual analogue scale to identify the difference between the two methods. RESULTS: The OAA/S results according to time lapse show that it is possible to lead a fast effective sedation and recovery with monitored anesthetic care, and monitored anesthetic care enhances both surgeon's convenience level and patient's satisfaction level, and reduces awakening, pain, and anxiety, compared to local anesthesia. CONCLUSION: The current paper shows about the plastic surgery, particularly the outpatient surgery, when monitored anesthetic care method is applied, it could gain a fast sedation and recovery or an effective sedation of patients. The method also has some affirmative effects in regard with surgeon's convenience and the patients' satisfaction degree and the reduction of their awakening, pain, and anxiety. With careful and adequate watch on the measures about vital signs like electrocardiogram, the degree of oxygen saturation, and blood pressure, it could clinically be very useful.

Monitored Anesthetic Care of Percutaneous Mitral Balloon Valvuloplasty for Severe Mitral Stenosis during Pregnancy: A case report / 대한마취과학회지

A woman presented severe mitral stenosis at 34 weeks' gestation. She did not respond to medical therapy, and underwent successful percutaneous mitral balloon valvuloplasty with monitored anesthetic care. The remainder of her pregnancy was uncomplicated, and she delivered a healthy infant at 38 weeks' gestation. We proved monitored anesthetic care is available method in percutaneous mitral balloon valvuloplasty for severe mitral stenosis during pregnancy.

The Effect of Combined Fentanyl and Ketamine Administration in the Monitored Anesthetic Care of Ambulatory Strabismus Surgery / 대한마취과학회지

BACKGROUND: Monitored anesthetic care can provide patient safety and optimal surgical conditions. However, propofol and fentanyl decrease the hypoxic ventilatory response and heart rate. Ketamine has less respiratory depression and blocks bradycardia. Furthermore, ketamine can reduce the amount of opioid use but it delays discharge in the outpatient anesthesia. Therefore, this study retrospectively examined the effects of combined fentanyl and ketamine administered during monitored anesthetic care on the use of opioids, cardiorespiratory side effects, and patient discharge. METHODS: The anesthetic room, the recovery room and day surgery center records of ambulatory strabismus surgery with monitored anesthetic care was reviewed by anesthesiologists from Oct. 2004 to July 2005. The patients were classified as those receiving either fentanyl (F group: n = 32) or fentanyl and ketamine (FK group: n = 19) with a propofol infusion. The fentanyl dose used, the need for airway support, anticholinergics and naloxone were compared. The stay in the recovery room and the day surgery center was also examined. RESULTS: The FK group used significantly less fentanyl than the F group (P < 0.05). Although airway support was needed, there was less anticholinergics and naloxone used in the FK group, but this difference was not significant. The stay in recovery room and the day surgery center were similar. CONCLUSIONS: Co-administered ketamine reduces the amount of fentanyl-needed, but it does not reduce the need for airway support and anticholinergics. In addition, co-administered ketamine does not affect the number of days in the recovery room and day surgery center.

Monitored Anesthetic Care (MAC) Using Ketamine, Midazolam and a Target-Controlled Propofol Infusion for Minor Surgery / 대한마취과학회지

BACKGROUND: There are many kinds of anesthetic methods. One of them, monitored anesthetic care (MAC) is a useful tool for minor surgery. Whether MAC can be substituted for conventional anesthesia in minor surgery was investigated. METHODS: Sixty-five patients were studied. Midazolam was given intravenously as a premedication, and then, target-controlled infusion (TCI) using propofol was started and ketamine 25 mg was given intravenously before a painful stimuli. The initial target concentration of propofol was 2.5 microgram/ml. During the procedure, we adjusted the target concentration of propofol according to clinical signs and sometimes added 25 mg of ketamine intravenously. For 10 minutes after starting the propofol infusion, blood pressure, heart rate, SpO2 and respiratory rate were recorded. During recovery, we monitored the predicted concentrations of propofol at eye opening and orientation recovery, the time from stopping the propofol infusion and intraoperative complications. In addition, we checked the patient's satisfaction with the anesthesia. RESULTS: The average consumption of ketamine and propofol were 0.68 +/- 0.43 mg/kg and 9.0 +/- 2.1 mg/kg/hr, respectively. The time to eye opening and recovery of orientation were 9.5 +/- 5.5 min and 10.2 +/- 5.3 min, respectively. The predicted plasma concentrations at eye opening and orientation recovery were 0.98 +/- 0.34 microgram/ml and 0.93 +/- 0.28 microgram/ml, respectively. Most patients (87.7%) were satisfied with the anesthetic method. However during the procedure, airway obstruction was the most frequent (21.5%) comlication. CONCLUSIONS: MAC is a useful and excellent anesthetic method, but corresponding anesthesiologists must attend closely and monitor respiratory complications.

Monitored Anesthetic Care (MAC) Using Propofol, Ketamine, Fentanyl, and Ketorolac (PKFK) for Minor Surgery / 대한마취과학회지

BACKGROUND: Even when patients agree that anesthesia is indispensable for a safe and comfortable operation, they are reluctant to experience the side effects of conventional general and regional anesthesia. We investigated whether monitored anesthetic care (MAC) using propofol, ketamine, fentanyl, and ketolorac can be substituted for conventional anesthesia in minor surgery. METHODS: One hundred forty six healthy adult patients who received minor surgery were studied. All were fasted, premedicated, and monitored according to conventional general anesthesia. Fentanyl 2 microgram/kg, propofol 1 mg/kg, ketamine 0.2 mg/kg, and ketorolac 30 mg were given intravenously and propofol was maintained at 3 4 mg/kg/h. Before local anesthetics infiltration at the incision site, ketamine 5 mg and propofol 20 mg were added intravenously. During the procedure, fentanyl 25 microgram plus propofol 20 mg were added whenever involuntary movements appeared. We observed vital signs, complications, time to eye opening to verbal command, time to regain orientation, satisfaction with anesthesia, postoperative pain scores, and analgesic consumption. RESULTS: Blood pressure and heart rate were reduced at the beginning of anesthesia, but were not clinically significant. Intraoperatively, respiratory depression (40.4%), SpO2 < 90% (25.3%) were observed, but no patients needed tracheal intubation. Postoperatively, dizziness (29.5%), pain (20.5%), and nausea (15.8%), were observed. The time to eye opening and to regaining of orientation were 57.3+/-119.4 sec, and 8.0+/-4.7 min respectively. Satisfaction with anesthesia was remarkable; surgeon (76.7%), patients (91.8%). Postoperative pain scores were low; 59.6% of patients did not need analgesics for the first 24 h. CONCLSIONS: If careful monitoring and instantaneous management for respiratory depression by anesthesiologist is provided, MAC using PKFK is an excellent and readily applicable method for minor surgery.