Departemen Anestesiologi dan Terapi Intensif

Semester:6

JUDUL MODUL: ANESTESI LUAR KAMAR

OPERASI/NORA

JUDULTOPIK: PERIOPERATIF NORA

dr. Anisa fadhila Farid, Sp.An-TI

LOCALLY ROOTED,
ugm.ac.id
GLOBALLY RESPECTED
Tujuan Pembelajaran:

Mampu menjelaskan mengenai perioperatif anestesi luar kamar

operasi/Non Operating Room Anesthesia (NORA)
OUTLINES
 MONITORED ANESTHESIA CARE (MAC)
 CANDIDACY FOR MAC PROCEDURES
 CONTRAINDICATIONS
 MINIMAL REQUIREMENTS FOR ANESTHESIA IN NORA LOCATIONS
 PRE-OPERATIVE
 MONITORING
 COMMON MAC TECHNIQUES
 COMMONLY USED PHARMACOLOGIC AGENTS
 ADJUVANT MEDICATIONS DURING MAC
 COMPLICATIONS
 RECOVERY AND DISCHARGE CRITERIA AFTER MAC
MONITORED ANESTHESIA CARE

• Monitored anesthesia care (MAC) does not describe the

continuum of depth of sedation
• 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.
• MAC includes all aspects of anesthesia care: a preprocedure
evaluation, intraprocedure care, and postprocedure anesthesia
management.

Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
CANDIDACY FOR MAC PROCEDURES

 Indications for MAC include the nature of the procedure, the

patient’s clinical condition, or the potential need to convert to a
general or regional anesthetic.
 Procedures performed under sedation depend primarily on the
patient’s cooperation and motivation, as well as on the nature of
the procedure being performed.
 Mild to moderate sedation can actually disinhibit a patient’s
response to painful stimulation; therefore, if adequate local or
regional anesthesia is unavailable for a patient who must
undergo a very painful procedure, sedation may not be
implemented successfully. Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
CONTRAINDICATIONS
• MAC carries no absolute contraindications,
• It may be unsuitable for the following patients and under the
following conditions:
 Pediatric patients
 Patients without full mental capacity
 Intoxicated patients
 Patients with a condition that inhibits them from lying still for
the period of time needed for the procedure
 Language barrier between the patient and the provider
Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
Con’t
 Psychotic or uncooperative patients
 Medically unstable patients,
 A patient with a suspected or known difficult airway
 Excessively long procedures
 Procedures performed in an uncomfortable position. (eg, prone,
lithotomy, kidney rest, and kneeling positions)
 Procedures in which a large volume blood loss or
cardiorespiratory instability is expected
 Procedures in which even minor movement could be hazardous
to the patient.
Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
MINIMAL REQUIREMENTS
FOR ANESTHESIA IN NORA LOCATIONS

Butterworth J.F., Mackey D.C., Wasnick J.D., 2022. Ambulatory and Non-Operating
Room Anesthesia, Morgan and Mikhail’s Clinical Anesthesiology 7 th Edition, p1512-1538
PRE-OPERATIVE
 Fasting Guidelines It is recommended that the same NPO (non
per os) guidelines for general anesthesia be followed in MAC cases
 Preprocedure Evaluation of the patient is crucial in determining
the risk factors related to the patient’s condition and also to
anesthesia.
 Focused history (major illnesses, medication allergies,
 NPO status, and previous anesthesia complications),
 Physical examination (mainly cardiovascular, respiratory, and
airway) are important
 Relevant laboratory studies and other investigations
Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
MONITORING

 Standards for intraoperative monitoring of cases performed

under MAC should be identical to those performed under
general or regional anesthesia. These standards would
naturally extend to providing NORA as well.
 Monitoring Depth of Sedation during Monitored Anesthesia
Care:
o Observer’s Assessment of Alertness/Sedation Scale
(OAA/S)
o The Bispectral Index Scale (BIS)  BIS readings of 60-80
are targeted during MAC
Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
Levels of Sedation and Analgesia

Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
COMMON MAC TECHNIQUES
• INTERMITTENT BOLUS TECHNIQUE

• CONTINUOUS INFUSION TECHNIQUE

• TARGET CONTROLLED INFUSIONS

A TCI device is a computerized infusion pump in which the selected drug is
administered according to its known therapeutic window, the patient response, and the
predicted (via computer modeling) drug concentration.

• CLOSED LOOP SEDATION TECHNIQUES

A closed-loop technique is an automated way to administer sedation guided by
patient’s hypnotic state (as measured by BIS monitoring or patient responsiveness to
commands). Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
COMMONLY USED
PHARMACOLOGIC AGENTS
An ideal sedative should have the following properties:
o Easy titration
o Potent sedative and amnestic action with analgesic properties
o Rapid onset with predictable pharmacodynamics and pharmacokinetics
o Rapid recovery with no residual effect
o High safety profile with cardiorespiratory stability
o Painless injection
o Unfortunately, this sedative has yet to be discovered, although the
o commonly used sedatives posses some but not all of these properties.

Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
1. PROPOFOL

• Propofol require special attention because of the potential for rapid, profound
changes in sedative and anesthetic depth, and the lack of antagonist medications.
• Propofol has the advantages of rapid onset and short recovery time, easy titration,
and antiemetic action.
• Disadvantages:
 inhibit hypoxic ventilatory drive, depress the normal response to hypercarbia,
apnea
 inhibit airway protective reflexes.
 hypotensive
 induce pain on injection
 propofol infusion syndrome
Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
2. BENZODIAZEPINES
• Midazolam can be administered orally, intranasally, intramuscularly, or intravenously (bolus IV
dose or continuous IV infusion)
• Incremental doses of 0.5-1 mg of IV midazolam are usually given every 2-3 minutes to reach
the desired level of sedation.
• The oral dose:
- 5-15 mg for adults
- 0.5-0.75 mg/kg for pediatric patients.
• Midazolam continuous infusion : 1-2 μg/kg/ minute
• Midazolam has no analgesic properties, so it is generally used in combination with opioids
during MACcases.
• Advantages : less respiratory depression than other sedatives at the desired levels of sedation;
has a reliable anxiolytic and amnestic action; prevents nausea and vomiting; and elevates the
seizure threshold
Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
3. OPIOIDS
MORPHINE
• Morphine has a delayed onset and prolonged duration of analgesia. These two properties may
render morphine a poor choice for MAC.

MEPERIDINE
• Meperidine 50-100 mg IV together with diazepam were commonly used agents in procedure
sedation in the early days of gastrointestinal (GI) endoscopies.
• Meperidine has an atropine-like action, inducing tachycardia, which can confuse the picture during
sedation because it might be interpreted as patient discomfort.

FENTANYL
• Fentanyl is one of the most commonly used analgesics in MAC cases
• boluses : 0.5-1 μg/kg
• continuous infusion : 0.01-0.05 μg/kg/minute
Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
Con’t

• Remifentanil is usually given in a bolus dose of 0.5-1 μg/kg, a

dose that can be repeated, and the continuous infusion rate is
usually 0.05-0.1 μg kg-1 minute
• The usual bolus dose of alfentanil is 5-10 μg/kg, which can be
repeated in 1.5-μg/kg increments. The infusion rate for
alfentanil sedation is usually 0.25-1.0 μg/kg/minute
• Sufentanil can be given as a bolus (0.1-0.5 μg/kg) or infusion
(0.005-0.01 μg/kg/minute) during MAC.

Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
4. KETAMINE

• Ketamine is a phencyclidine derivative that produces profound

analgesia, amnesia and sedation, and bronchodilatation
• The IV induction dose of ketamine is 2 mg/kg; below this dose (0.2-0.8
mg/kg), ketamine has a sedative and analgesic effect. After a single IV
dose of ketamine, its onset of action is within 30-60 seconds, and its
peak effect occurs in 1 minute, with a 15-minute duration of action.
• The use of ketamine was limited because of the high incidence of
emergence phenomena (10-20%):
- postoperative disorientation,
- sensory and perceptual illusions,
- and vivid dreams
Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
5. NEWER SEDATIVES

Dexmedetomidine
• Dexmedetomidine is a highly selective α 2-adrenergic agonist with sedative and
analgesic properties
• Dexmedetomidine is used as a continuous infusion at a rate of 0.2-1 μg kg -1 hour-1
with or without an initial loading dose of 0.5-1 μg/kg over 10-20 minutes

Fospropofol
• Fospropofol is a water-soluble prodrug of propofol.
• The recommended fospropofol dose is 4.9-6.5 mg/kg IV bolus for individuals who
weigh between 60 and 90 kg followed by supplemental doses of 0.25 of the initial
dose administered no more frequently than every 4 minutes as needed to achieve
the desired level of sedation. Patients weighing <60 kg are dosed as if they weighed
60 kg, and those weighing >90 kg are dosed as if they weighed 90 kg
Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
ADJUVANT MEDICATIONS
DURING MAC
ANTIEMETICS AND ANTINAUSEA MEDICATIONS
• Commonly used medications for the prevention and treatment of
post-procedure nausea and vomiting are dopamine antagonists,
histamine antagonists, serotonin antagonists, anticholinergics,
neurokinin antagonists, and dexamethasone.

ANALGESICS
• Multimodal analgesic plans have been recommended; in addition to
the use of local anesthetics, these may include the combination of
acetaminophen, nonsteroidal anti-inflammatory medications, and
opioids if and when needed. Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
COMPLICATIONS

Butterworth J.F., Mackey D.C., Wasnick J.D., 2022. Ambulatory and Non-Operating
Room Anesthesia, Morgan and Mikhail’s Clinical Anesthesiology 7 th Edition, p1512-1538
RECOVERY AND
DISCHARGE CRITERIA AFTER MAC
• Anesthetics used during MAC should permit rapid recovery. At
the same time, each patient care facility should develop
recovery and discharge criteria that are suitable for its specific
patients and procedures.
• Recovery and discharge criteria for MAC should be no
different from those for general or regional anesthesia.

Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care and Non-Operating Room
Anesthesia, Longnecker’s Anesthesiology 3 rd Edition, p1172-1186
Con’t

Butterworth J.F., Mackey D.C., Wasnick J.D., 2022. Ambulatory and Non-Operating
Room Anesthesia, Morgan and Mikhail’s Clinical Anesthesiology 7 th Edition, p1512-1538
Con’t

Butterworth J.F., Mackey D.C., Wasnick J.D., 2022. Ambulatory and Non-Operating
Room Anesthesia, Morgan and Mikhail’s Clinical Anesthesiology 7 th Edition, p1512-1538
REFERENSI

• Riad I.A., Abdelmalak B., 2018. Monitored Anesthesia Care

and Non-Operating Room Anesthesia, Longnecker’s
Anesthesiology 3rd Edition, p1172-1186
• Butterworth J.F., Mackey D.C., Wasnick J.D., 2022.
Ambulatory and Non-Operating Room Anesthesia, Morgan
and Mikhail’s Clinical Anesthesiology 7th Edition, p1512-1538
 Terima kasih

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