Monitored anesthesia care is not synonymous with low risk

Monitored anesthesia care can lead operating room (OR) personnel, both perioperative nurses and anesthesia providers, into a sense of complacency. It is not general anesthesia, so there is no stress surrounding intubation and extubation and the patient is in control of his/her own respirations. When used properly, narcotics and sedative drugs sedate and relieve pain, but should not lead to respiratory compromise. As a result, circumstances should be under control when competent staff are present. However, because unanticipated events do happen even under the most benign-appearing occurrences, there must be a sense of vigilance by everyone in the OR as this case study relates.