1. Dr. Kelly Mayson, Vancouver Coastal Health

2.  Select from the list the principle anesthesia technique used  The technique employed may be found on the anesthesia record  General Anesthesia takes precedence over all other forms of anesthesia  If the patient is given a regional/spinal or epidural and MAC, MAC anesthesia would take precedence (???)

3.  MAC = monitored anesthesia care.  It means that an anesthesiologists or nurse anesthetists ( US only) is in the room monitoring the patients vital signs. The anesthetists may be giving some sedation or just giving verbal anesthesia (reassurance) and is there to treat any problems with BP and HR, or deal with any complications of local anesthesia which is typically administered by the surgeon  MAC often implies the anesthetist is giving sedation +/- analgesics agents

4.  American Society of Anesthesiology—prefers the terminology, sedation and analgesia to describe a state of consciousness that allows patient to tolerate unpleasant procedures while maintaining adequate cardio- respiratory function and the ability to respond to verbal command and/or tactile stimulation.

5.  ANA ( American Nurse Anesthetist) definition= patient under conscious sedation has a depressed level of consciousness, but retains the ability to independently and continuously maintain a patent airway and respond appropriately to physical stimulation and / or verbal command.

6.  JCAHO definition= drug induced depression during which pt responds purposefully to verbal commands, either alone or with light tactile stimulation. No intervention are required to maintain patent airway, spontaneously ventilation adequate, CVS function maintained.  JCAHO stands for Joint Commission on the Accrediation of Healthcare Organization

7.  Levels of sedation are a continuum  1) Minimal sedation and anxiolysis--- can be done by nurse or MD ( non anesthesia and anesthesia rarely)  2) Moderate sedation—also can be done by nurse or MD ( non anesthesia and anesthesia) ◦ Radiological procedures, gastroscopy, colonoscopy  3) Deep sedation/analgesia—patient cannot be easily aroused, pts may require assistance in ventilation—should only be done by anesthesia  4) General anesthesia—only done by anesthesia

8. Sedation Score--Ramsay Score Description 0 None- patient maintains wakefulness 1 Mild - occasionally drowsy, easy to arouse 2 Moderate – frequently drowsy, easy to arouse 3Severe – somnolent, difficult to arouse S Sleeping

9.  SCR will likely be able to determine level 1— minimial sedation, however they will not be easily be able to tell the difference between moderate and deep sedation based on reviewing the chart.  I DON’T THINK THAT IT IS RELEVANT unless one is dealing with level 3 sedation—DEEP SEDATION, and then one should chart it as a combined technique a regional anesthetic technique is used.

10.  Most patients that have a spinal or epidural (with the exception) of obstetrical anesthesia will receive a dose of midazolom or fentanyl prior to placement of the block  depending on the patient and the length of the procedure the patient may receive further sedation with boluses of midazolom, or may receive an infusion of low dose remifentanyl or low dose propofol to make them amnesiac to their OR experience

11.  for many orthopedic procedures patient do not what to hear the sounds of drills and saws  the patient are maintaining their own airways, breathing spontaneously, and are typically rousable (i.e. like “take a deep breath” if they are hypoventilating). ◦ As they become more sedated they may obstruct and require a jaw thrust, and typically the sedation is decreased

12.  MAC—should be only tracked when the patient is receiving no local anesthesia administered by anesthesia, but instead local anesthesia administered by the surgeon.  Any local anesthesia that is administered by the anesthesiologist ( spinal, epidural, regional block—US guided nerve block etc), should be considered the PRIMARY ANESTHETIC

13.  The focus should be the primary anesthetic technique which is the spinal or epidural, it will be VERY DIFFICULT for an SCR to determine the degree of sedation from reviewing an anesthetic record. Unless the patient is deeply sedated, and one is giving sedation that it getting close to the level of general anesthetic this should not trump the regional technique and instead should be tracked as a combined technique. This is what we should be doing as a custom field throughout BC.

14.  They haven’t given us much  When asked for the rationale for the change in “importance”, they said they were unable to answer general questions  you can submit a de-identified anesthesia note and they will be happy to assist you

16.  A patient is brought into the OR for a hip #  the patient is given a spinal  the patient is also given 25 of ketamine at the start of the procedure  45 minutes into the case, the patient is given 1 mg of midazolam  what is the principle anesthesia technique?  (both spinal and sedation are noted on the OR record)

17.  45 year old for THR—given 3 mg midazolom and Fentany 50 ug. Spinal inserted. Propofol infusion started at 40 ug/kg/min  20 minutes later, propofol 60 mg given, Fent 100 ug, LMA inserted, and propofol infusion increased to 100 ug/kg/min  Priniciple anesthetic technique??