Chapter 69. Monitored Anesthesia Care and Anesthesia Outside the Operating Room

1. Many patients who are scheduled for monitored anesthesia care (MAC) are considered high risk for general anesthesia, and MAC is mistakenly presumed to be safer than general anesthesia.

2. MAC does not describe the continuum of depth of sedation; rather, it describes a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.

3. Many patients who are considered for minimally invasive procedures out of the operating room (OR) are considered high risk for traditional surgical procedures.

4. For deep sedation/MAC, proper choice of sedatives and their dosing can optimize patient safety, recovery, and discharge times.

5. The same monitoring and equipment, preprocedure evaluation, NPO (nothing by mouth) status, and recovery room standards used in the OR apply to remote locations.

6. The length and type of procedure, airway considerations, and remoteness of the location should all be considered when choosing the anesthetic technique.

7. Patient safety should supersede any other considerations in remote location anesthesia.

8. Open communication between the anesthesiologist and the proceduralist is key to safety and favorable outcomes.

9. Propofol sedation is classified as deep sedation in many circumstances. It may result in significant changes in airway anatomy and cardiopulmonary physiology. Therefore, propofol should be administered only by clinicians qualified to rescue patients from any level of sedation, including general anesthesia.

10. Involvement of the anesthesiologists in institutional sedation policy and in planning and developing remote anesthesia locations is essential.

Recent advances in medical practices such as imaging and minimally invasive diagnostic and therapeutic procedures have led to an exponential growth in the need for anesthesia services outside of the operating room (OR); so-called remote anesthesia. Each area presents unique challenges for the anesthesia care team (eg, the patient population served, the nature of the location, the procedures performed). The trend of expanding the range of procedures outside of the OR will continue, and the demand for anesthesia services in these locations will grow. For these reasons, anesthesia care teams must become involved in the care of patients and in the details of the procedural area into which they are called to provide their services. This includes ensuring that the same standards and codes that govern the OR and the recovery of patients from anesthesia are present in these remote locations before administration of an anesthetic.1

A variety of anesthetics have been successfully used for these procedures. A very commonly used technique is monitored anesthesia care (MAC). This chapter reviews the concept, definitions, and details of the MAC technique; the common procedures performed out of the OR, which often require the expertise of trained anesthesia personnel; and the specific challenges faced by the anesthesia care team in remote areas. Because these issues have been of great interest to anesthesia providers in general and anesthesiologists in particular, the American Society of Anesthesiologists (ASA) has issued many relevant and useful position statements and practice guidelines related to MAC and remote anesthesia care; this ...