Death During Monitored Anesthesia Care

  • Kevin D. Marcus
  • Jonathan L. Benumof


Out of the operating room surgical procedures are generally a large part of any typical anesthesia practice. While some of these off-site procedures may not be perceived to be as invasive or complex as their operating room counterparts, these procedures nevertheless present a unique challenge to the anesthesiologist. Often, these out of the OR locations have different equipment and resources that, if unrecognized, can leave an anesthesiologist underprepared in an emergency. This chapter presents an unfortunate case of loss of life after an out of the OR gastroenterology procedure where monitored anesthesia care (MAC) was employed. Topics explored include the definition of MAC and a review of the ASA guidelines on standard monitors and levels of sedation, as well as a review of the use of propofol for MAC anesthesia. This chapter also examines the advantages of having an anesthesia machine available to anesthesiologists in off-site locations, as well as a brief review of the use of exhaled carbon dioxide to confirm endotracheal tube placement during cardiac arrest.


Endoscopic retrograde cholangiopancreatography (ERCP) MAC anesthesia Depth of anesthesia Moderate sedation Deep sedation Conscious sedation ASA standard monitors Ventilation monitoring Oxygenation monitoring Capnometry Capnography Anesthesia in remote locations Anesthesia closed claims Propofol sedation Colorimetric CO2 detection End-tidal CO2 Cardiac arrest Return of spontaneous circulation (ROSC) 


  1. 1.
    American Society of Anesthesiologists. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. Last amended October 15, 2014.Google Scholar
  2. 2.
    American Society of Anesthesiologists. Position on monitored anesthesia care. Last amended October 16, 2013.Google Scholar
  3. 3.
    American Society of Anesthesiologists. Distinguishing monitored anesthesia care (“MAC”) from moderate sedation/analgesia (conscious sedation). Last amended October 21, 2009 and reaffirmed on October 16, 2013.Google Scholar
  4. 4.
    American Society of Anesthesiologists. Standards for basic anesthetic monitoring. Last amended October 20, 2010, with an effective date of July 1, 2011.Google Scholar
  5. 5.
    American Society of Anesthesiologists. Statement on respiratory monitoring during endoscopic procedures. Last amended October 15, 2014.Google Scholar
  6. 6.
    Metzner J, Domino KB. Risks of anesthesia care in remote locations. Anesth Patient Saf Found Newsl. 2011. 26(1).Google Scholar
  7. 7.
    Diprivan ® [package insert]. Wilmington: Zeneca Pharmaceuticals; 1999.Google Scholar
  8. 8.
    American Society of Anesthesiologists. Statement on non-operating room anesthetizing locations. Last amended October 16, 2013.Google Scholar
  9. 9.
    American Society of Anesthesiology. Practice guidelines for management of the difficult airway: an updated report by the ASA task force on management of the difficult airway. Anesthesiology. 2013;18(2).Google Scholar
  10. 10.
    Field JM, et al. American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:640–56.CrossRefGoogle Scholar
  11. 11.
    Hayden SR, et al. Colorimetric end-tidal CO2 detector for verification of endotracheal tube placement in out-of-hospital cardiac arrest. Acad Emerg Med. 1995;2(6):499–502.CrossRefGoogle Scholar
  12. 12.
    MacLeod BA, et al. Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection. Ann Emerg Med. 1991;20(3):267–70.CrossRefGoogle Scholar
  13. 13.
    Barash PG, et al. Clinical anesthesia. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2009.Google Scholar
  14. 14.
    Garnett AR, et al. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. JAMA. 1987;257(4):512–5.CrossRefGoogle Scholar
  15. 15.
    Sanders AB, et al. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation: a prognostic Indicator for survival. JAMA. 1989;262(10):1347–51.CrossRefGoogle Scholar
  16. 16.
    Falk JL, et al. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation. N Engl J Med. 1988;318:607–11.CrossRefGoogle Scholar
  17. 17.
    Benumof JL, editor. Anesthesia for thoracic surgery. 2nd ed: Elsevier Health Sciences; 1995.Google Scholar
  18. 18.
    Fogel EL, Sherman S. ERCP for gallstone pancreatitis. N Engl J Med. 2014;370:150–7.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Kevin D. Marcus
    • 1
  • Jonathan L. Benumof
    • 2
  1. 1.Department of AnesthesiologyMission Hospital – Mission ViejoMission ViejoUSA
  2. 2.Department of AnesthesiologyUniversity of California, UCSD Medical Center, UCSD School of MedicineSan DiegoUSA

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