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Rosa Bragamele - One of the best experts on this subject based on the ideXlab platform.

  • Monitored Anesthesia Care by registered respiratory therapists during cataract surgery an update
    Ophthalmology, 2010
    Co-Authors: Peter A Zakrzewski, Alexander V Banashkevich, Tammy Friel, Rosa Bragamele
    Abstract:

    Objective To reevaluate the safety and practicality of registered respiratory therapists (RRTs) providing Monitored Anesthesia Care during cataract surgery. Design Prospective observational cohort study. Participants A total of 15440 consecutive patients undergoing phacoemulsification cataract surgery with intraocular lens insertion using topical Anesthesia ± intravenous (IV) sedation at 2 surgical centers. Methods Registered respiratory therapists, specially trained as Anesthesia assistants, provided Monitored Anesthesia Care during all stages of surgery, with an anesthesiologist immediately available for consultation as required. Main Outcome Measures The primary outcome measure was the rate of serious perioperative medical complications relating to the surgery and Anesthesia. The secondary outcome measure was the rate (total and by stage of surgery) of anesthesiologist intervention, defined as consultation by the RRT to the attending anesthesiologist for any reason irrespective of the ultimate level of patient Care rendered. Patient age and American Society of Anesthesiology (ASA) Physical Status (PS) score were also analyzed as potential predictors of the need for anesthesiologist intervention. Results There were no serious perioperative medical complications leading to death, endotracheal intubation, or postoperative hospitalization. A total of 395 cases (2.6%) required Anesthesia intervention, with 257 (1.7%) occurring preoperatively, 140 (0.91%) occurring intraoperatively, and 5 occurring (0.03%) postoperatively. Seven cases required interventions at 2 different stages of surgery. Mean patient age in the anesthesiology intervention group (73.2 years) was greater than in the non-intervention group (71.2 years) ( P = 0.0002), whereas patient age of ≥75 years correlated with a greater need for intervention (3.0%) than P = 0.001). The mean ASA PS score was higher for cases requiring anesthesiology intervention (2.6) than for those not requiring intervention (2.2) ( P P Conclusions We have demonstrated that allowing RRTs to provide Monitored Anesthesia Care during cataract surgery with an anesthesiologist available as required seems to be both safe (no serious medical complications in 15440 cases) and practical (anesthesiology intervention rate of 2.6%). Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

  • Monitored Anesthesia Care provided by registered respiratory Care practitioners during cataract surgery a report of 1957 cases
    Ophthalmology, 2005
    Co-Authors: Peter A Zakrzewski, Tammy Friel, Rosa Bragamele
    Abstract:

    Objective To evaluate the safety and feasibility of having Monitored Anesthesia Care during cataract surgery provided by registered respiratory Care practitioners (RRCPs). Design Retrospective case series. Participants One thousand nine hundred fifty-seven consecutive patients undergoing cataract surgery at one surgical center between November 2001 and October 2003. Methods Phacoemulsification cataract surgery with intraocular lens insertion was performed using topical Anesthesia, with or without IV sedatives. An RRCP, trained to function as an Anesthesia assistant, provided Monitored Anesthesia Care during all stages of surgery, with an anesthesiologist immediately available for consultation or assistance as required. Main outcome measures The number of serious medical complications resulting from the Anesthesia or surgery was measured. The rate of anesthesiologist intervention required at each stage of surgery—preoperative, intraoperative, and postoperative—was determined, along with the reasons for the interventions. Age, American Society of Anesthesiologists (ASA) risk class (a rating of preoperative physical status), and number of IV sedative agents given were analyzed as potential predictors of the need for anesthesiologist intervention. Results Among the 1957 cataract surgeries, there were no adverse medical events that resulted in death, hospitalization, or tracheal intubation. Two cases were aborted intraoperatively for medical reasons. A total of 78 cases (4.0%) required anesthesiologist intervention, with 34 (1.7%) requiring preoperative intervention, 43 (2.2%) requiring intraoperative intervention, and 3 (0.2%) requiring postoperative intervention; 4 cases required 2 separate interventions. The mean age of the intervention group (73.9 years) was statistically greater than that of the nonintervention group (71.0) ( P = 0.02). A higher ASA rating (>2) correlated with an increased need for anesthesiologist intervention in terms of the total intervention rate ( P P P = 0.053) but not with a higher intraoperative intervention rate ( P = 0.68). Conclusion With the inherent safety of cataract surgery and the relatively low need for anesthesiologist intervention, we believe it is justified to allow RRCPs, trained as Anesthesia assistants, to provide Monitored Anesthesia Care during cataract surgery so long as anesthesiologist support is directly available when required. Potential benefits include cost savings in health Care and decreased demand for anesthesiology services. To validate formally the preservation of patient safety from such a change in practice, however, a larger sample size would be required due to the inherently low rate of cataract surgery complications.

Lowell F Satler - One of the best experts on this subject based on the ideXlab platform.

  • transcatheter aortic valve replacement under Monitored Anesthesia Care versus general Anesthesia with intubation
    Cardiovascular Revascularization Medicine, 2012
    Co-Authors: Itsik Bendor, Patrick M Looser, Gabriel Maluenda, Travis C Weddington, Nicholas G Kambouris, Israel M Barbash, Camille Hauville, Petros Okubagzi, Paul J Corso, Lowell F Satler
    Abstract:

    Abstract Aims Most transcatheter aortic valve replacement (T-AVR) using the Edwards SAPIEN transcatheter heart valve (Edwards Lifesciences, Irvine, CA) is done under general Anesthesia. The present study aimed to examine the feasibility and safety of T-AVR under Monitored Anesthesia Care and aimed to compare the clinical outcome to the outcome of patients who underwent general Anesthesia. Methods The analysis included 92 consecutive patients undergoing T-AVR via the transfemoral approach guided by transesophageal echocardiography using the Edwards SAPIEN valve. The cohort was divided into two groups: I, Monitored Anesthesia Care ( n =70; 76.1%) and II, intubation ( n =22; 23.9%). Monitored Anesthesia Care was given by anesthesiologists in one of two protocol regimens: Ketamine & Propofol or Dexmedetomidine. The crossover rate to general Anesthesia and the clinical outcome of these two groups were compared. Results Baseline clinical characteristics of the two groups were similar, except for higher logistic EuroSCORE and prior stroke in the Monitored Anesthesia Care group. Surgical access of the femoral artery was performed in 15 (68.1%) from the general Anesthesia group and in 24 (34.2%) from the Monitored Anesthesia Care group, p=0.05. The median procedure duration was significantly lower in the Monitored Anesthesia Care group (91 vs. 155 min, p=0.008) and there was a trend to lower median intensive Care unit stay and hospital stay (27 vs. 72 h, p=0.07 and 5 vs. 7.5 days, p=0.06, respectively). Of the patients with Monitored Anesthesia Care, 8 (11.4%) converted to general Anesthesia. Conclusion T-AVR using the Edwards SAPIEN valve can be performed in the majority of cases with controlled Monitored Anesthesia Care, thereby avoiding the necessity of general Anesthesia and resulting in shorter procedure time and in-hospital length of stay.

Patrick M Mccarthy - One of the best experts on this subject based on the ideXlab platform.

Paul F. White - One of the best experts on this subject based on the ideXlab platform.

  • general Anesthesia versus Monitored Anesthesia Care with remifentanil for assisted reproductive technologies effect on pregnancy rate
    Journal of Clinical Anesthesia, 2002
    Co-Authors: W Wilhelm, Paul F. White, M E Hammadeh, T Georg, Rosine Fleser, A Biedler
    Abstract:

    Abstract Study Objectives: To compare the outcome of assisted reproductive technology procedures in women who undergo Monitored Anesthesia Care (MAC) with remifentanil versus general Anesthesia. Design: Retrospective data analysis. Setting: University hospital. Patients: 251 ASA physical status I and II women participating in an in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) program. Interventions: During the first phase of the study, all patients underwent general Anesthesia induction with alfentanil, propofol, and nitrous oxide, which was maintained with isoflurane or propofol infusion. In the second phase of the study, all patients received a standardized MAC technique with a remifentanil infusion; local anesthetics were not used. Measurements: The primary endpoint was pregnancy rate per transfer. The number of oocytes collected, fertilized, and cleaved was recorded, as was the number of oocytes transferred. Main Results: Patients who underwent MAC had a greater pregnancy rate with IVF (28.2 vs. 16.3%), with ICSI (32.2% vs. 18.8%), and overall (30.6% vs. 17.9%). Conclusions: Pregnancy rates in women undergoing transvaginal oocyte retrieval for assisted reproductive technologies were significantly higher with a remifentanil-based MAC technique than with a general anesthetic technique.

  • fast tracking after immersion lithotripsy general Anesthesia versus Monitored Anesthesia Care
    Anesthesia & Analgesia, 2000
    Co-Authors: Margarita Coloma, Paul F. White, Jen W Chiu, William K Tongier, Larry L Duffy, Steven C Armbruster
    Abstract:

    Both Monitored Anesthesia Care (MAC) and general Anesthesia (GA) offer advantages over epidural Anesthesia for immersion lithotripsy. We compared propofol-based MAC and desflurane-based GA techniques for outpatient lithotripsy. After receiving midazolam 2 mg IV, 100 subjects were randomly assigned to one of two anesthetic treatment groups. In the MAC group, propofol 50-100 μg kg -1 min -1 IV was titrated to maintain an observer's assessment of alertness/sedation score of 2-3 (5 = awake/alert to 1 = asleep). Remifentanil 0.05 μg kg -1 . min -1 IV supplemented with 0.125 μg/kg IV boluses, was administered for pain control. In the GA group, Anesthesia was induced with propofol 1.5 mg/kg IV and remifentanil 0.125 μg/kg IV and maintained with desflurane (2%-4% inspired) and nitrous oxide (60%). Tachypnea (respiratory rate >20 breaths/min) was treated with remifentanil 0.125 μg/kg IV boluses. In the GA group, droperidol (0.625 mg IV) was administered as a prophylactic antiemetic. Recovery times and postoperative side effects were assessed up to 24 h after the procedure. Compared with MAC, the use of GA reduced the opioid requirement and decreased movements and episodes of desaturation (<90%) during the procedure. Although the GA group took longer to return to an observer's assessment of alertness/sedation score of 5, discharge times were similar in both groups. We conclude that GA can provide better conditions for outpatient immersion lithotripsy than MAC sedation without delaying discharge.

  • the comparative effectiveness of fentanyl and its newer analogs during extracorporeal shock wave lithotripsy under Monitored Anesthesia Care
    Anesthesia & Analgesia, 2000
    Co-Authors: Zsuzsanna Gesztesi, Monica Sa M Rego, Paul F. White
    Abstract:

    M any different anesthetic techniques have been used for extracorporeal shock wave lithotripsy (ESWL). Although both general and epidural anesthetic techniques have been described (1,2), these techniques were associated with prolonged recovery times and higher than expected hospital admission rates (3). More recently, IV sedative-analgesic techniques have been described that provide for shorter recovery times (4,5). Although propofol has become the drug of choice for the maintenance of sedation (6), the comparative effects of the commonly used opioid analgesics have not been studied when administered in combination with propofol as part of a Monitored Anesthesia Care (MAC) technique. Whereas fentanyl, sufentanil, alfentanil, and remifentanil have all been used during ESWL procedures (4–8), no direct comparison of fentanyl with its newer analogs has been performed during MAC. This prospective, randomized, double-blinded study was designed to compare the clinical effectiveness of intermittent bolus injections of fentanyl with remifentanil, alfentaniln and sufentanil when administered during propofol sedation for ESWL procedures. In addition to assessing their analgesic efficacy and respiratory stability, we determined the effects of the analgesic medications on the early recovery profile.

  • remifentanil administration during Monitored Anesthesia Care are intermittent boluses an effective alternative to a continuous infusion
    Anesthesia & Analgesia, 1999
    Co-Authors: Sa Rego Mm, Y Inagaki, Paul F. White
    Abstract:

    This randomized, double-blind study was designed to evaluate the analgesic effectiveness and respiratory stability of remifentanil when administered as intermittent bolus injections, a variable-rate infusion, or a combination of a constant basal infusion supplemented with intermittent boluses during Monitored Anesthesia Care (MAC). Forty-five patients undergoing extracorporeal shock wave lithotripsy (ESWL) procedures were randomly assigned to one of the three modes of remifentanil administration. All patients received midazolam 2 mg IV, followed by a propofol infusion at 50 μg. kg - 1 . min -1 . Two minutes before administering a series of test shock waves: Group I received a remifentanil infusion of 0.1 μg. kg 1 . min -1 , and a saline bolus (5 mL); Group II received a saline infusion and a remifentanil bolus (25 μg in 5 mL); and Group III received a remifentanil infusion of 0.05 μg. kg -1 . min - 1 , and a remifentanil bolus (12.5 μg in 5 mL). The average pain intensity was scored on an 11-point scale, with 0 = no pain to 10 = severe pain. During the ESWL procedure, pain was treated by increasing the study drug infusion rate by 25%∼50% and administering 5-mL bolus injections of the study medication in Groups I (saline) and II (remifentanil 25 μg). In Group III, intermittent 5-mL boluses (remifentanil 12.5 μg) were administered as needed. Patients in Groups II and III reported lower pain scores in response to the test shocks. Significantly more remifentanil was administered in Group 1 (379 ± 207 μg) than in Group II (201 ± 136 μg). However, more interventions were required for the treatment of intraoperative pain in the intermittent bolus group (Group II). When remifentanil is administered as the analgesic component of a MAC technique, these data support the use of intermittent bolus doses (12.5-25 μg) alone or in combination with a 1 basal infusion (0.05 μg. kg - 1 . min -1 ) as alternatives to a variable-rate continuous infusion. Implications: In this study, three different modes of remifentanil administration were used during Monitored Anesthesia Care for extracorporeal shock wave lithotripsy procedures. These results suggest that using intermittent bolus injections of remifentanil (25 μg) or a continuous infusion (0.05 μg. kg -1 . min -1 ) supplemented with intermittent bolus (12.5 μg) injections may be more effective than a variable-rate infusion of remifentanil during propofol sedation.

  • What is new in Monitored Anesthesia Care
    Current Opinion in Anesthesiology, 1998
    Co-Authors: Monica M. Sa Rego, Paul F. White
    Abstract:

    The use of Monitored Anesthesia Care (MAC) techniques is increasing in popularity because recovery profiles seem to be improved compared with general and regional Anesthesia. This article describes the conceptual basis for MAC and reviews the current MAC practices.

Sang Hwan Do - One of the best experts on this subject based on the ideXlab platform.

  • dexmedetomidine is effective for Monitored Anesthesia Care in outpatients undergoing cataract surgery
    Korean Journal of Anesthesiology, 2011
    Co-Authors: Hyo Seok Na, Jungwon Hwang, In Ae Song, Hong Sik Park, Sang Hwan Do
    Abstract:

    Background: Dexmedetomidine has a sedative analgesic property without respiratory depression. This study evaluated the efficacy of dexmedetomidine as an appropriate sedative drug for Monitored Anesthesia Care (MAC) in outpatients undergoing cataract surgery on both eyes compared with combination of propofol and alfentanil. Methods : Thirty-one eligible patients were randomly divided into two groups on the first operation day. Dexmedetomidine was administered in group D at 0.6 μg/kg/h, and propofol and alfentanil was infused concomitantly in group P at a rate of 2 mg/kg/h and 20 μg/kg/h, respectively. Sedation was titrated at Ramsay sedation score 3. Iowa satisfaction with Anesthesia scale (ISAS) of the patients was evaluated postoperatively. Systolic blood pressure (SBP), heart rate (HR), respiration rate (RR), and peripheral oxygen saturation (SpO2) were recorded throughout the surgery. For the second operation, the group assignments were exchanged. Results: Postoperative ISAS was 50.3 (6.2) in group D and 42.7 (8.7) in group P, which was statistically significant (P < 0.001). SBP was significantly lower in group D compared with group P from the beginning of the operation. HR, RR, and SpO2 were comparable between the two groups. There were 8 cases (25.8%) of hypertension in group P, and 1 case (3.2%) in group D (P < 0.05). In contrast, 1 case (3.2%) of hypotension and 1 case (3.2%) of bradycardia occurred in group D. Conclusions: Compared with the combined use of propofol and alfentanil, dexmedetomidine could be used appropriately for MAC in cataract surgery with better satisfaction from the patients and a more stable cardiovascular state. (Korean J Anesthesiol 2011; 61: 453-459)

  • optimal target concentration of remifentanil during cataract surgery with Monitored Anesthesia Care
    Journal of Clinical Anesthesia, 2010
    Co-Authors: Yunmi So, Jungwon Hwang, Sang Hwan Do
    Abstract:

    Abstract Study objective To determine the effect-site target concentration (C et ) of remifentanil that provides optimal conditions for patients and operators during cataract surgery during Monitored Anesthesia Care using a target controlled infusion (TCI) of propofol and remifentanil. Design Prospective, randomized, double-blinded study. Setting Operating room and postoperative recovery area of a university-affiliated hospital. Patients 66 adult, ASA physical status I, II, and III patients undergoing cataract surgery Interventions Group I received C et of remifentanil 0.5 ng/mL; Group 2 received C et of remifentanil one ng/mL; and Group 3 received C et of remifentanil 1.5 ng/mL. After giving TCI propofol (C et ; one μg/mL) - remifentanil, an ophthalmologist administered topical Anesthesia. Measurements and main results Intraoperative hemodynamics, pain scores, sedation scores, patient satisfaction scores, and operators' satisfaction scores regarding surgical conditions were recorded. No statistical differences in heart rate or mean blood pressure were detected among the three groups during surgery. Pain scores (Group 1: 31.9 ± 17.9 vs. Group 2: 11.8 ± 7.7 and Group 3: 11.8 ± 7.7; P vs. Group 2: 5.4 ± 0.4 and Group 3: 5.5 ± 0.4; P P Conclusion C et values of remifentanil and propofol of one ng/mL and one μg/mL, respectively, appear to provide optimal conditions for patients and operators during cataract surgery using Monitored Anesthesia Care with TCI.

  • remifentanil propofol versus fentanyl propofol for Monitored Anesthesia Care during hysteroscopy
    Journal of Clinical Anesthesia, 2008
    Co-Authors: Kumsuk Park, Sang Hwan Do
    Abstract:

    Abstract Study Objective To compare the efficacy of remifentanil-propofol with that of fentanyl-propofol for Monitored Anesthesia Care during hysteroscopy. Design Prospective, randomized study. Setting Operating room and postAnesthesia Care unit of a university hospital. Patients 30 ASA physical status I and II adult patients undergoing hysteroscopic procedures. Interventions After propofol infusion, patients received a bolus of remifentanil (group R, 0.5 μ g/kg) or fentanyl (group F, 1 μ g/kg) 4 minutes before starting the procedure and then received a continuous infusion of remifentanil (group R, 0.05 μ g/kg per min) or bolus doses of fentanyl (group F, 0.5 μ g/kg). Measurements and Main Results Patients in group R had lower pain scores than patients in group F (0-0 vs 0-7, P P Conclusion Remifentanil seems to be a safe and effective analgesic adjunct for Monitored Anesthesia Care of hysteroscopic surgery.