Surgical Care

MAC stands for “Monitored Anesthesia Care.” This term is often used to distinguish from “Moderate Sedation” (previously known as “Conscious Sedation”). While MAC may include giving sedative medications often used for Moderate Sedation, the term MAC denotes that a qualified Anesthesia Provider is involved, focused exclusively on continuous monitoring of the patient, and that the provider is ready to manage any airway/oxygenation issues (breathing problems) or hemodynamic/physiologic issues (such as high or low blood pressure or abnormal heart rhythms). Certified Registered Nurse Anesthetists (CRNA’s) are advanced practice providers who are highly trained to provide MAC services.

By contrast, Moderate Sedation typically involves a medical doctor (MD) takin on a dual role of performing a procedure and supervising a nurse giving the intravenous sedative medications.

Because the additional clinician giving sedative medications with MAC is dedicated to the patient’s sedation and related safety aspects and is highly trained to handle complication that might arise, a different medication, called propofol, can be used with MAC.

With moderate sedation, fentanyl and midazolam (Versed) are the typical medications used. With MAC, propofol is often the primary medication given and is often the only medication needed.

• Dedicated Anesthesia Provider focused on patient safety during sedation.
• Allows the gastroenterologist/endoscopist doctor to focus on the procedural aspects of each case.
• Allows for more flexibility in scheduling patients, which ultimately translates to more efficient and effective scheduling options for patients.
• Overall higher level of patient satisfaction than Moderate Sedation.
• Propofol medication can be used, with the below advantages:
  – Less nausea/vomiting side effects
  – Quicker onset and offset, allowing patients to recover and feel better faster after their procedure
  – Less prone to the “hang-over” feeling or prolonged fatigue symptoms common to other sedative medications
  – Considered a safe medication, when properly administered and monitored by a qualified Anesthesia Provider
  – Can be adjusted (titrated) to achieve the desired sedation level individualized for each patient, from those who only want to be lightly asleep to those who wish to be more deeply asleep throughout their procedure
  – More able to sedate adequately to accomplish procedures that are of longer duration.

All patients undergoing endoscopy at WhidbeyHealth will be given MAC sedation.  A select few patients elect to have procedures without any sedation.  Please note that it is advisable to discuss the option of an unsedated procedure with a provider prior to your procedure, if interested.

We generally recommend being prepared with an escort to take you home afterwards, even if you anticipate having the procedure without sedative medications. Please note that an IV (intravenous access line) will need to be inserted even if no sedation is elected, for patient safety. Unsedated upper endoscopies (EGD) are generally not advised. Colonoscopies can be performed on unsedated patients, but the patient can expect to experience discomfort and/or pain at times.

Patients can expect to receive as many as four (4) bills for their outpatient endoscopy procedure:

1. Anesthesia Associates NW – fee for the services provided by the Anesthesia Provider who sedated you and cared for your during the procedure. Please direct all billing questions to (503) 594-1774.
2. WhidbeyHealth Surgeon – professional fee from the physician who performed the procedure. A second charge may appear on the same statement, for the histology processing of any tissue specimens taken. Please direct all questions to (360) 678-7656 ext. 4097.
3. WhidbeyHealth Medical Center – facility fee from the Ambulatory Surgery Center to cover supplies, medications, equipment, and staffing. Please direct all questions to (360) 678-7656 ext. 4097.
4. Northwest Pathology – fee from the specially trained pathologist for interpretation/reading of the slides made from any tissue samples during your procedure. Please direct questions to (360) 201-1676.

Anesthesia Associates NW is in-network for most insurance that is accepted at WhidbeyHealth Medical Center.  That means that a contracted rate has been negotiated with your carrier to provide professional sedation services.  Your carrier will determine if you have any financial responsibility (co-payment, co-insurance, or deductible) based on your specific plan and benefits.  As noted in more detail below, some insurance plans do not consider sedation medically necessary and may deny coverage.

To contain costs, some insurance carriers deny coverage for MAC saying it is not “medically necessary,” making it difficult to get authorization or pre-authorization for MAC.  For those patients for whom we expect insurance may not cover anesthesia services, an Advanced Beneficiary Notice (ABN) is offered whereby we have worked closely with Anesthesia Associates NW to offer a deeply discounted rate of $200 for colonoscopy, $200 for esophagogastroduodenoscopy (EGD), and $300 for combined EGD and colonoscopy for the sedation services.

Please note that an ABN is used when a service (in this case, MAC) is not covered.  If a patient is insured, they must use their insurance plan, subject to any deductible, coinsurance, or copayment.  Unfortunately, a patient CANNOT elect to not use their insurance in the situation where the ABN offer is lower than the contracted rate with the insurance carrier, or when the patient is not truly “self-pay.”  We too appreciate the complexity of insurance policies; however, we are obligated to follow the agreed upon terms based on complex contract negotiations with insurance carriers.

If you have questions regarding your specific insurance plan coverage benefits, please contact your insurance carrier directly or your employer’s human resource department.  Our own Billing Department can also help answer your questions.  Direct questions to (360) 678-7656, ext. 4413.

Although you are expected to be fairly alert after your procedure and upon discharge, studies have still shown impaired driving afterwards. Thus, if you receive any amount of sedative medications, you must have a trusted adult escort to whom we can hand you off after the procedure to drive you home. You may not take a taxi or Uber/Lyft-type service home afterwards, unless you are also in that vehicle with a trusted adult previously known to you. To avoid any “driving while impaired” type violations, it is recommended that you not operate a vehicle until the next day, after a good night’s sleep. Failure to follow these instructions, may result in cancellation of your procedure or dismissal from the medical practice.

Like driving, it is recommended that you get a good night’s rest after the procedure, and you should be able to return to work the following day, if you received sedation. talk to your providers if you have special concerns based on the nature of your work.

There are several types of colon preps and your provider will prescribe the preparatory regimen that is best for you. Your provider’s office will instruct you about your bowel cleanse and diet restrictions and when to stop eating and drinking altogether. It is important for you to carefully follow these instructions so that you procedure can take place as scheduled. Cases are cancelled and rescheduled if the bowel cleanse is not complete.

You should feel pretty good after a procedure and be able to eat shortly thereafter, whether at your home or out at a restaurant. As always, it is important to listen to your body and determine how bloated or crampy you feel afterwards. The team caring for you can help answer this for you following the procedure once the details of your case are better known.

Please be sure to speak to us in advance if you are pregnant.  There are special risks of doing an endoscopy procedure or giving sedation to a pregnant patient that must be carefully considered.  Women will be required to provide date of last menstruation, have a pregnancy test at our center, or sign a waiver prior to their procedure, indicating no current/known pregnancy.

If you are breastfeeding, we also encourage you to discuss your breastfeeding plans with your GI provider in advance of a procedure, so you can plan accordingly. Propofol is excreted in breast milk with maximum concentrations for 4-5 hours after administration. The effect of small doses on infants is unknown. According to the American Society for Gastrointestinal Endoscopy (ASGE) 2012 “Guidelines for endoscopy in pregnant and lactating women,” no interruption of breastfeeding is recommended. Some anesthesia providers may err on the side of caution and recommend withholding breastfeeding for up to 24 hours regardless.

Fentanyl is excreted in breast milk, but the concentrations are too low to be significant and fall to undetectable levels by 10 hours. The American Academy of Pediatrics considers fentanyl to be compatible with breastfeeding.

Midazolam is excreted in breast milk. The American Academy of Pediatrics considers the effects on nursing infants to be unknown. Based on limited data, it is advised to withhold nursing for 4 hours after administration.

When withholding nursing, pumping, and discarding is recommended, and parents are advised to plan ahead. Patients are also encouraged to speak to their child’s healthcare provider(s) or pediatricians with any additional concerns.