Cosmetic Procedures and Office Based Sedation


Surgery for the face

Rest of the body

Botox injections

Cheek lift

Chemical peel

Chin surgery

Dermabrasion

Eyebrow/forehead rejuvenation (Brow lift)

Eyelid surgery (Blepharoplasty)

Face-lift

Facial contouring

Facial fillers

Laser hair removal

Laser resurfacing

Neck lift and neck liposuction

Otoplasty (Alterations of the ears)

Rhinoplasty (Alterations of the nose)

Skin problems (Blemishes, spider veins, scar revisions, tattoo removal)

Wrinkle treatment

Abdomen reduction (Tummy tuck)

Arm lift

Body liposuction

Breast augmentation

Breast lift

Breast reduction

Buttock lift (Belt lipectomy)

Circumferential body lift

Inner thigh lift

Laser hair removal





Choice of Anesthesia Technique and Anticipated Adverse Events



Monitored Anesthesia Care


The majority of the aforementioned procedures can be performed with monitored anesthesia care (MAC). Although the ASA recently revised the definitions of sedation and anesthesia, the term monitored anesthesia care continues to be used [18]. Of note, the ASA statement mandates exhaled end-tidal carbon dioxide (EtCO2) monitoring during both moderate and deep sedation with effect from July 2011. Even though it is of questionable utility in some situations, failure to adhere is a problem in case of litigation [19, 20]. It has been recently demonstrated that majority of patients thought to be receiving moderate sedation are frequently under general anesthesia and even deep general anesthesia [21]. Sedation related adverse events are in fact more frequent in patients receiving MAC [22, 23]. The majority of the adverse events are airway related. The importance of appropriate preparation in terms of drugs and equipment cannot be overstated [24].

The use of airway adjuncts like nasal airway is described in the chapter on airway management for gastrointestinal endoscopic procedures. Some of these techniques reduce the incidence of hypoxemia and its associated complications. In fact, such a management is demonstrated to improve the safety and increase the efficiency in many endoscopic procedures [25, 26] including obese patients.

The choice of drugs and their administration are no different than in any other care setting. Pk/Pd variability is a major concern. Propofol is best administered as a regulated bolus (titrated to the effect) followed by an infusion. Although addition of opioid decreases the propofol requirement, the practice also increases the Pk/Pd variability.

Patients with a history of sleep apnea pose additional challenges. If the airway is not accessible (for example surgeries involving face), these patients are best intubated, even for short procedures. Disturbance of the surgical field (with face surgery) and rapid desaturation in the event of apnea can be eliminated by a secure airway. Intubation difficulties present in this subset of patients create additional problems in an emergency and are best avoided. A STOP-BANG questionnaire might be suitable as a screening tool, both in self-reported and observer evaluated model [27].

Morbidly obese patients have slightly different pharmacokinetics and dosing of both propofol and opioids should take this into consideration [2830]. However, no system can predict the behavior of these drugs with accuracy. As a result, factors such as the patient’s clinical condition, comorbidity, and the response of various physiological variables to anesthetic drugs should dictate the dosing of intravenous anesthetic agents, rather than any calculated or actual body weight.

Newer sedatives like dexmedetomidine can be employed for some of the office based cosmetic procedures. Absence of significant respiratory depression is a major advantage. Similarly, ketamine is a good choice in selected patients and has additional benefits in decreasing the incidence of respiratory depression. It is popular as “ketofol,” a mixture of ketamine and propofol for an infusion. However, such a mixture is not Food and Drug Administration (FDA) approved. Moreover, the stability of the mixture and its effect on the pharmacokinetics is unknown.

Remimazolam is likely to overcome many of the drawbacks of both propofol and midazolam. It combines the properties of two unique and established drugs in anesthesia, namely midazolam and remiefentanil. It produces hypnosis by binding to GABA receptors (like midazolam) and has organ-independent metabolism (like remifentanil). It is likely to be the sedative/hypnotic of the future, as evidence by the published studies [31, 32]. It has potential to be used as a sedative for procedural sedation. Unlike many rapidly acting intravenous sedatives presently available, the propensity to cause apnea is very low. Availability of a specific antagonist (flumazenil) is a major safety benefit [33].


Tumescent Anesthesia


Tumescent anesthesia is the practice of injecting a very dilute solution of local anesthetic reconstituted with epinephrine and sodium bicarbonate into a tissue, until it becomes firm and tense (tumescent) [34]. Although the practice started with liposuction, it is presently used across vascular surgery, breast surgery, plastic surgery and ENT procedures. Even though it can be used as a sole anesthetic technique, it is used with MAC in the office based setting. Addition of epinephrine reduces the blood loss and addition of bicarbonate reduces pain associated with local anesthetic injection. Tumescent lidocaine is absorbed very slowly from subcutaneous tissues, thereby producing lower, and more delayed, peak blood levels compared to other routes, along with prolonged postoperative analgesia.

Doses of up to 40 mg/Kg have been injected safety along with MAC [35], although the recommended safe dose is 35 mg/Kg. In this study involving ten patients, lidocaine was injected in two segments after an interval of time. Eight hundred-milligram lidocaine (40 mL 2 % lidocaine), 125 mL 5 % sodium bicarbonate, and 5 mL 1:1000 epinephrine were added into each bag of 3-L normal saline solution as 1 set of tumescent anesthesia solution. For infiltration volumes greater than 3 sets (9510 mL), the additional infiltration solution was made without sodium bicarbonate (8 mL 2 % lidocaine and 1 mL 1:1000 epinephrine in each bottle of 500 mL saline solution). The infusion rate was set at a speed around 160 mL/min. Patients also received MAC with propofol and remifentanil. Serum levels of lidocaine were measured every 4 h during the first 24 h after the second infiltration. The peak lidocaine levels [2.18 (0.63) μg/mL] occurred after 12–20 h [16.4 (2.27) h]. Moreover, there was no significant correlation between dose per kilogram body weight or total dose of lidocaine infiltrated and its peak levels or time.

Although this study demonstrates the safety of tumescent anesthesia, there are always factors like hepatic dysfunction, low cardiac output states, high cardiac output states, reduced plasma proteins and concomitant use of beta-blockers and calcium antagonists that can increase the risk of toxicity [36].


General Anesthesia


The issues with general anesthesia are no different than those encountered during many similar procedures performed in a hospital based setting. The need for early and uncomplicated discharge necessitates more reliance on total intravenous anesthesia. Use of short acting opioids with fixed context sensitive half-life like remifentanil can archive many of the objectives of an office based service. However, preparedness for any unanticipated adverse events including laryngospasm, malignant hyperthermia and failed intubation is essential. Use of video laryngoscopes for intubation and intravenous infusion pumps to deliver anesthesia is common and does not need any further discussion.


Regional Anesthesia


In relation to cosmetic surgery, few procedures are amenable for sole regional anesthesia. The regional blockade is typically used in conjunction with other methods [37]. For example, as a supplement to field block and MAC in an abdominoplasty, bilateral posterior intercostal nerve block is used safely. It requires injecting from T-5 or T-6 through T-12, using 3 mL/block of a local anesthetic mixture of lidocaine 0.5 %/bupivacaine 0.125 %/with epinephrine 1:200,000 [38]. However, most anesthesia providers will be averse to the idea of a bilateral intercostal nerve block for the fear of bilateral pneumothorax. Moreover, the safety and efficacy of such a technique has not been demonstrated in a scientific study.

Most of the nerve blocks are performed by the surgeons for facial and rhinological procedures. With the increase in ultrasound regional anesthesia has made a resurgence.


Specific Procedure Related Complications



Liposuction


Hypoxia during or after surgeries involving liposuction can be caused by fat embolism [3941]. Fat embolism is primarily a mechanical blockage of the vascular lumen by circulating fat globules. It typically presents with symptoms referable to the respiratory system. However, fat globules can also block the circulation to the central nervous system, retina, and skin. With regards to its occurrence during liposuction, most of the reported evidence is in the form of case reports. As it is an uncommon complication, a certain degree of suspicion is necessary. The clinical signs and symptoms can manifest even 2–3 days after the procedure. The obvious other diagnoses that need to be considered are pulmonary infection, pulmonary embolism and aspiration of gastric contents. The classic fat embolism syndrome is defined by the presence of two of three clinical findings including petechial rash, pulmonary distress, and mental disturbances within the first 48 h after the inciting event. Common signs include hypoxia, fever, tachycardia, and tachypnea with bilateral radiographic changes and urinary changes. The presentation is very similar to acute respiratory distress syndrome and the condition carries a high mortality of approximately 10–15 % [42, 43]. The treatment is largely supportive.

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Aug 26, 2017 | Posted by in Uncategorized | Comments Off on Cosmetic Procedures and Office Based Sedation

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