Most
podiatry cases are performed utilizing Local Anesthesia
in conjunction with Monitored Anesthesia Care
(MAC). At times, a podiatrist may elect to
use General Anesthesia.
General
anesthesia is a deep state of sleep where the
patient loses consciousness and sensation and
usually requires assisted ventilation. Like general
anesthesia, MAC uses sedatives and other agents,
but the dosage is low enough that patients, remain
responsive and breathe without assistance. MAC
is often used to supplement local and regional
anesthesia, particularly during simple procedures
and minor surgery. Local anesthesia provides numbness
to a small area limited to where local anesthetic
is injected. Regional anesthesia such as epidural,
spinal, and other methods provide numbness to
much larger areas because of the nerve blocks
involved.
The
purpose of MAC is to provide the patient with
anxiety relief, amnesia, pain relief, comfort,
and safety during the procedure. MAC can be requested
for patients undergoing uncomfortable procedures
and minor surgeries which do not require general
anesthesia. MAC is usually ordered by the physician
performing for the procedure, by the primary care
physician of the patient, or requested by the
patient himself if he is unable to lie still for
the procedure. MAC is sometimes used alone for
nonpainful procedures and often to supplement
local anesthetic injections for painful ones.
During MAC, the patient is sedated and amnestic
but always remains responsive when stimulated
to do so. The patient is in a light sleep and
may or may not wake up from time to time during
the procedure even if he does not remember doing
so. The patient breathes on his own and ventilation
is not assisted as in general anesthesia. The
patient is usually awake at the end of the procedure
and can readily be discharged from the recovery
room. When undergoing a procedure with MAC, the
patient is evaluated and monitored in the same
manner as if he is having any other form of anesthesia.
Getting
Ready
Prior to the procedure, the anesthesiologist will
interview the patient about his general health.
Pertinent information will include the patient’s
current medical history, medications, allergies,
and past medical, surgical and anesthetic history.
This evaluation may be done over the phone or
the patient may come to the clinic to be examined.
Old medical records are also reviewed and lab
tests may be needed. Instructions for taking medications,
restrictions on eating and drinking prior to the
procedure are also given at this time.
What
to Expect During the Procedure
On the day of the procedure, an intravenous line
(IV) will be placed in the patient through which
medications can be given. The anesthesia care
provider (the anesthesiologist, nurse anesthetist,
or the anesthesia team consisting of both) may
give the patient a sedative prior to entering
the operating suite. Once in the operating suite,
monitors will be placed on the patient to measure
his vital signs which include blood pressure,
heart rate and rhythm, oxygenation and respiration.
Supplemental oxygen may be given if indicated.
Further sedation is then given and the procedure
begins. Anesthesia medications mainly include
sedatives for anxiety relief and amnesia, opioids
and local anesthetic for pain relief, and antiemetics
for treating nausea and vomiting. Other medications
needed to treat any existing medical condition
such as diabetes, high blood pressure, etc., may
also be given. Depending on the type of procedure
and the medical condition of the patient, the
anesthesia care provider will choose the appropriate
medication. Local anesthetics are often given
as local injections or as nerve blocks by the
podiatric surgeon. When used with local anesthesia,
numbness at the surgical site provided by the
injections is the main pain reliever.
MAC
may range from a mild sedation to a deeper sleep.
The patient may or may not wake up from time to
time during the procedure when he is stimulated.
He may or may not remember the experience but
should remain comfortable throughout the procedure.
The sedatives and opioids can make the patient
drowsy and may slow down his respiration. To ensure
the patient’s comfort and safety, the anesthesia
care provider continuously monitors the patient’s
vital signs and verbal response throughout the
procedure. Side effects from anesthetic medications
to watch for include prolonged sedation, agitation,
confusion, nausea, vomiting, and respiratory depression.
End
of Procedure and Discharge
At the completion of the procedure, the patient
should be easily arousable and is taken to the
recovery room or post anesthetic care unit (PACU).
He spends about 30 minutes or more there and continues
to be monitored by the PACU staff for residual
anesthetic effects. The patient is discharged
from the PACU when his functioning level has returned
to his pre-sedative state. If the patient were
to stay in the hospital, he is promptly discharged
to his room as long as his vital signs and mental
function remain stable. If the patient were to
go home, in addition to being stable, he has to
first drink, void, and function with little assistance
(if he were able before). Since the patient has
been given sedatives, the patient is advised not
to operate any machinery, go to work, make any
major decision, sign any legal document, nor drink
alcohol for the rest of that day. In addition,
he should have someone to assist him in getting
home and watch for any lasting sedative effect
or unexpected problem. Often times, the medical
staff will not discharge a patient home by himself
without assistance. Clear follow-up instructions
and appropriate contact phone numbers are also
given at this time.
Conclusion
MAC provides safe sedation for patients undergoing
uncomfortable procedures and minor surgeries.
Like any other form of anesthesia, the patient
should be just as carefully evaluated and monitored
before, during and after the procedure to ensure
his safety and comfort. The patient quickly recovers
from MAC and this allows for a timely discharge.
If the patient should have any question concerning
his care under MAC, he should never hesitate to
discuss them with his anesthesiologist.
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