Monitored Anesthesia Care Protocol for Neck Dissection
For patients undergoing neck dissection, monitored anesthesia care (MAC) should include continuous presence of an anesthesia provider, standard monitoring (ECG, SpO2, NIBP, capnography), and individualized sedation with propofol titrated to clinical response, while maintaining spontaneous ventilation and verbal responsiveness when possible.
Personnel and Monitoring Requirements
- An appropriately trained and experienced anesthesia provider must be present continuously throughout the procedure to ensure patient safety 1
- Standard monitoring must include ECG, pulse oximetry (SpO2), non-invasive blood pressure (NIBP), and capnography 1
- Monitoring should begin before sedation is initiated and continue throughout the procedure and recovery 1
- Capnography is essential whenever there is loss or likelihood of loss of normal response to verbal contact 1
- Alarm limits should be set to patient-specific values and audible alarms enabled 1
Sedation Protocol
- For initiation of MAC sedation, either slow infusion or slow injection method should be used while closely monitoring cardiorespiratory function 2
- With infusion method: Start propofol at 100-150 mcg/kg/min (6-9 mg/kg/h) for 3-5 minutes and titrate to desired clinical effect 2
- With slow injection method: Administer approximately 0.5 mg/kg over 3-5 minutes and titrate to clinical response 2
- For maintenance of sedation, a variable rate infusion method is preferable over intermittent bolus dosing 2
- Maintenance rates typically range from 25-75 mcg/kg/min (1.5-4.5 mg/kg/h) during the first 10-15 minutes, then decrease to 25-50 mcg/kg/min and adjust to clinical response 2
- In elderly, debilitated, or ASA-PS III/IV patients, reduce dosage to approximately 80% of usual adult dosage 2
Special Considerations for Neck Dissection
- Due to the proximity to the airway and risk of complications, continuous monitoring of respiratory function is critical 1
- Consider supplementing propofol with dexmedetomidine for its analgesic properties, "cooperative sedation," and reduced risk of respiratory depression 3
- Ensure the surgical field is adequately prepared with local anesthesia by the surgeon to minimize pain and patient movement 4
- Position the patient to optimize airway access in case emergency intervention is needed 1
- Be prepared for potential conversion to general anesthesia if complications arise 1
Fire Safety Precautions
- Neck dissection involves proximity to the airway and potential use of ignition sources (electrocautery), creating fire risk 1
- Surgical drapes should be configured to prevent oxygen from accumulating under drapes or flowing into the surgical site 1
- Ensure sponges are moistened when used near an ignition source, particularly when near the airway 1
- Notify the surgeon whenever an ignition source is in proximity to an oxygen-enriched atmosphere 1
Management of Common Complications
- Bradycardia and hypotension: Monitor closely and adjust infusion rates accordingly; have vasopressors readily available 3
- Respiratory depression: Maintain spontaneous ventilation when possible; capnography helps early detection of hypoventilation 1, 3
- Airway obstruction: Position patient appropriately; have airway equipment immediately available 1
- Bleeding: Ensure adequate IV access and have blood products available if significant blood loss is anticipated 5
Documentation Requirements
- Maintain an accurate record of all monitoring data, including heart rate, blood pressure, SpO2, and ETCO2 at least every 5 minutes 1
- Document all medications administered, including timing and dosages 1
- Record any complications and interventions performed 1
- Electronic anesthetic record systems are recommended when available 1