Essentials of Aesthetic Surgery

72
Part II Anesthesia

• Inability to visualize uvula
• Narrow or high-arched palate
MANAGEMENT OF DIFFICULT AIRWAY
(Fig. 5-3)
Tonsil
Uvula
Tongue
Soft palate
Hard palate
Soft palate
Hard palate
Tongue
Class I
Tonsil
Uvula
Tongue
Soft palate
Hard palate
Class II
Class III
Soft palate
Hard palate
Tongue
Class IV
The Mallampati score. ( Complete visualization of the soft palate; complete
visualization of the uvula; visualization of only the base of the uvula; soft palate is
not visible at all.)

view
•
• When used alone it has poor to moderate discriminative power.
• Combination of tests (adding thyromental distance) adds incremental diagnostic
value.
• ASA Practice Guidelines suggest preoperative assessment of mutiple airway features
to improve predictive value of external examination.
NOTE:

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Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
POSITIONING
31
COMPLICATIONS ASSOCIATED WITH SUBOPTIMAL PATIENT POSITIONING
ulcers and
32,33

vasoconstrictors, and massive intraoperative blood loss
• Initially focal tenderness (<24 hours) proceeds to hair loss (few days) and is usually
complete by 1 month.
• Hair regrowth begins at 3 months (most cases).
• Case reports of permanent hair loss exist.
• For longer procedures, gel doughnut headrests and periodic repositioning can be
employed.
31-35
• Mechanisms include:





• ASA closed claims studies
34 as frequent
liability claim in anesthesia practice.
•


31
sex,
(morbid obesity or very thin),
especially in lithotomy or lateral decubitus positions35
can occur with use of warm blankets, forced-air warming devices, and

• Recommended temperature limit for blanket warmers is
• Forced-air warmers MUST be used with the manufacturer’s blanket that disperses
warm air over a wide surface area.
• Fluid warmers can cause injury by tubing being in contact with patient’s skin.
33,36
• 33
• ASA closed claims database cited 41 claims settled after 1990.36
• About 50% of these were associated with general anesthesia.

• 50% resulted in $12,000 median payment.
• Incidence is decreasing over time as proportion of eye injuries in database.
•

74
Part II Anesthesia




cause corneal ischemia.
33,36,37
• Relatively low incidence, but high debilitation
• Mostly described in spine surgery (prone position), cardiac surgery, and head and
neck surgery

• One case report with prone position and protective goggles placed in addition to
foam headrest, possibly compression-induced injury
38
PATIENT SSOCIATED CHARACTERISTICS THAT CAN LEAD TO POSITIONING
INJURIES
Joint restrictions or cervical spine instability (rheumatoid arthritis, ankylosing
spondylitis)

Contractures associated with chronic debilitating disease
Fragile skin conditions of the elderly, steroid use, or autoimmune diseases
Extremes of weight, especially if prone position is needed
MANAGEMENT OF COMPLICATIONS RELATED TO POSITIONING
are most common and enigmatic.
Provide full disclosure and consistent information to patients.
Avoid speculation.
Documentation, including preexisting conditions, risk factors, limitations in positioning

Appropriate consultations, early and liberally

compartment syndrome)
Involvement of risk management team
Appropriate follow-up
PERIOPERATIVE HYPOTHERMIA
Box SUMMARY OF HYPOTHERMIA PREVENTION
• Prewarm patients for 1 hour in the preoperative area.
• Keep the OR an ambient temperature at 22.8° C.
• Monitor core temperature (esophageal or nasopharyngeal).
• Employ active warming methods.
• Employ passive covering of the exposed body surface area.
• Minimize exposure and repositioning, and resume active warming ASAP.
•
• Manage postanesthetic shivering aggressively with continuation of active-warming
devices and pharmacologic intervention.

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Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
Associated with various surgical complications and deleterious physiologic
derangements39,41

Normothermia averages around


Mild intraoperative hypothermia range is 34°-36° C.
Plastic surgery procedures that carry a include:
• Tumescent liposuction, especially high-volume
• Abdominoplasty
• Flap transfers

• Body contouring after massive weight loss
COMPLICATIONS
Infection
Delayed wound healing and/or dehiscence
Seroma39
Hematoma
Coagulation disorder of decreased platelet function and impaired clot formation41
Postanesthetic shivering as a source of deleterious discomfort, increased length of stay,
and cost
CONTRIBUTING FACTORS
Preoperative areas with low ambient temperatures
Patient fasting that reduces metabolism

general)
Cool intraoperative OR environments
Body surface exposure
Incisional heat loss from evaporation and radiation

could include:
• Increased age
• Thin body habitus
• Preexisting metabolic disorders, including diabetes-related autonomic dysfunction
and neuropathies
ACTIVE WARMING MANEUVERS41
Inadvertent hypothermia has been reported in 50%-90% of surgical patients if not
preempted by active warming measures.
Raising ambient temperature of OR to 22.8° C (73° F) is standard.
Use of forced-air heating (e.g., Bair Hugger [Arizant Healthcare, Inc.]) has become the
standard of care.
Use of special heating blankets and mattresses, either circulating warm water or
polymer-based resistive heating

76
Part II Anesthesia

heat

Radiant heating devices
Investigational research methods include amino acids infusion that provokes
thermogenesis.
PASSIVE WARMING MANEUVERS
Insulating patient with standard or heated blankets and drapes
Can only conserve, not produce, heat
Reduces cutaneous heat loss

NOTE:



PACU RECOVERY AND RETURN TO NORMOTHERMIA
Hypothermia on arrival to PACU may take up to to correct.
Postanesthetic shivering (PAS) related to volatile anesthetics occurs in of
patients.
• Related to duration of surgery and nadir of temperature
• More common in younger patients (<60 years of age)
• Aggravates pain
• Increases HR, BP, release of catecholamines, oxygen consumption (200%-400%),
myocardial oxygen demand—can be deleterious with preexisting cardiac disease
• Requires aggressive active warming measures

accompanied by other warming measures.
POSTOPERATIVE NAUSEA AND VOMITING AND POSTDISCHARGE
NAUSEA AND VOMITING
Topics of
One of the of anesthesia

Nausea incidence reported to be from
Vomiting incidence reported at
Continuation or presentation of symptoms after discharge (PDNV) is 17% nausea, 8%
vomiting.
CAUTION:

77
Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
UNDERSTANDING MECHANISM OF EMESIS AFFECTS MANAGEMENT
located in lateral reticular formation of brainstem

ventricle

•




Prophylaxis or therapies target blocking one or more of these receptors.
AREAS OF ATTENTION AND FOCUS


Female
1
Nonsmoker
1
History of PONV
1
Postoperative opioids
1
Sum =
0 . . . 4
100%
80%
60%
40%
20%
0%
0
1
2
3
4
Number of risk factors
P
O
N
V

r
i
s
k
PDNV risk factors.
Risk Factors for PONV in Adults
Evidence

Positive overall
Female sex (B1)
History of PONV or motion sickness (B1)
Nonsmoking (B1)
Younger age (B1)
General versus regional anesthesia (A1)
Use of volatile anesthetics and nitrous oxide (A1)
Postoperative opioids (A1)
Duration of anesthesia (B1)
Type of surgery (cholecystectomy, laparoscopic,
gynecological) (B1)

ASA physical status (B1)
Menstrual cycle (B1)

Muscle relaxant antagonists (A2)
Disproven or of limited clinical
relevance
BMI (B1)
Anxiety (B1)
Nasogastric tube (A1)
Supplemental oxygen (A1)
Perioperative fasting (A2)
Migraine (B1)
Body mass index; motion sickness; postoperative nausea and vomiting.

78
Part II Anesthesia

to reduce or mitigate baseline risk factors.
Employ prophylaxis, pharmacologic and otherwise, based on latest evidence-based
45

with surgeon with regard to opioid and opioid-
sparing analgesia, as well as availability of PO antiemetic agents.
RISK STRATIFICATION TOOLS

45
•



ANESTHETIC ELATED RISKS
General versus regional anesthesia
Volatile anesthetics, in a dose-dependent manner
Nitrous oxide
Postoperative opioids, in dose-dependent manner
Duration of surgery
Type of surgery
STRATEGIES TO REDUCE BASELINE RISK
allowing intake of clear liquids up to 3-4 hours before surgery
Use of techniques when indicated
Preferential use of (TIVA) to avoid volatile agents
by:
• Aggressive use of multimodal nonopioid analgesia

• Use of postoperative continuous infusion pain management techniques where
applicable
with combination or multimodal therapy based on risk

COMBINATION ANTIEMETIC THERAPY
Preferable to single drug





Current literature has recommendations for doses and timing of some drugs.45
Reserve at least one drug for PACU rescue administration.

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Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
Most Commonly Used Drugs (class/receptor)


Ondansetron (5-HT3 receptor antagonist)

Dexamethasone (corticosteroid)
Decadron IV
Haloperidol (butyrophenone/DA antagonist)

Meclizine (antihistamine/H-1 antagonist)
Antivert PO
Transdermal scopolamine (anticholinergic)
TransDerm Scop
Aprepitant (NK-1 antagonist)
Emend PO
Promethazine (phenothiazine/DA antagonist)
Phenergan IV, deep IM, or PO
NONPHARMACOLOGIC THERAPY
P6-accupressure or accupoint electrostimulation uses acupuncture principles

of median nerve.
8,45
PACU RESCUE THERAPY
If prophylaxis WAS NOT given, can give any or combinations of:
• Ondansetron 1.0 mg IV (dose is lower than the prophylactic dose)
• Dexamethasone 2-4 mg IV
• Droperidol 0.625 mg IV or haloperidol 0.5-2.0 mg
• Promethazine 2.5-12.5 mg IV/IM


If prophylaxis WAS given:
• Use drug in from those received as prophylaxis.
NOTE:

by clinical trials) can be given.
CAUTION:
MALIGNANT HYPERTHERMIA
Pharmacogenetic disorder triggered by:

• Succinylcholine

Causes from sarcoplasmic reticulum
Can present after induction, intraoperatively, or in PACU
Postoperative presentation reported to be low (1.9% of cases)49
Patients have inherited MH-susceptible mutation exposed to one or both types of
triggering agents.

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Part II Anesthesia
SIGNS

• Rigidity, with generalized muscle contraction (masseter, truncal, extremities) or
whole body
• Hypermetabolic chain reaction
• Tachycardia
• Increasing EtCO2
• Increased temperature (can be late sign)
• Hyperkalemia with ECG changes, dysrhythmias
• Acidosis
• Myoglobinuria
• Cardiac arrest
• Death
•

MANAGEMENT
Multiple tasks need to be executed quickly and concurrently.

Halt/abort procedure, if able.


• Expert consultation is available 24/7/365.
• They will stay on the line to guide and support crisis management.
Get MH cart or code cart and
• Recommend stock of 36 vials (20 mg each) OR equivalent dose (3 vials)
of new preparation Ryanodex (250 mg each)

• Hyperventilate 3-4× normal with 100% O2

anesthesia circuit to accelerate reduction in concentration of anesthetic gas.
• DO NOT take time to change machine.
• Switch to TIVA (nontriggering anesthetic).
•
preparations (Dantrium, Revonto)
• Mix each 20 mg vial of powder with 60 ml sterile nonbacteriostatic H2O.
• Need several people to help
• Dose 2.5 mg/kg in repeated doses as clinically indicated up to 10 mg/kg.
• Each 20 mg dantrolene has 3 g mannitol.
preparation (Ryanodex)
nonbacteriostatic sterile H2O/250 mg vial of powder
suspension.
•
• 1 vial Ryanodex = 12.5 vials of traditional preparation dantrolene
• Dose 2.5 mg/kg in repeated doses as clinically indicated up to 10 mg/kg
• Each vial has 125 mg mannitol (less than traditional preparation)
• Little experience with this preparation has been reported

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Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
ADDITIONAL MANAGEMENT

Place Foley catheter.
Treat metabolic/electrolyte derangement(s).
Provide hemodynamic support.

Consider future testing by muscle biopsy or molecular genetics.
Report incidence to North American Malignant Hyperthermia Registry (
).
NOTE:

Additional resources available at Malignant Hyperthermia Association of the United
States ( )

PHASES OF RECOVERY
Phase I: Immediate acute care
Phase II: Convalescent or predischarge

• Preferable and common in ambulatory setting
• Expedited clinical pathway supported by appropriate anesthetic pharmacologic
management with short-acting agents
• Bypass of phase I: OR direct to phase II under direction of anesthesiologist
• Must meet phase I criteria upon leaving OR
Combined phase 1 and 2
• Many ASCs physically merge both phases into a single unit.
• “One stop shopping” where one nurse manages entire recovery process

• Provides continuity of care

Phase III: Postdischarge continued recovery
• Can last for several days
• Continues until patient reverts to baseline preoperative status

UNPLANNED ADMISSION
By accreditation criteria, all facilities performing aesthetic surgery must have plans in
place for transfer to higher level of care.
Reported national averages are .
Precipitated by medical conditions (cardiopulmonary, respiratory, neurologic, MH)
Precipitated for surgical conditions (bleeding or postsurgical sequelae)
Calls for preestablished transport protocols with a service or EMS
Calls for preestablished agreement with receiving hospitals
Surgeon, anesthesiologist, and/or CRNA or RN can accompany patients for continuity of
care and facilitate transfer.

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Part II Anesthesia
TOP TAKEAWAYS

Regulatory agencies establish minimum standards of care in aesthetic surgery
environments.

ASA Standards for Basic Anesthetic Monitoring10 (last amended 2011) must be
met.


experience in this highly specialized, consumer-driven patient population

In diabetics, obtain by blood draw as preadmission testing (PAT) or by point of
care testing on day of surgery


renarcotization and recurrent respiratory depression.

Inadvertent hypothermia has been reported in 50%-90% of surgical patients if
not preempted by active warming measures
REFERENCES

Surgery. Berlin Heidelberg: Springer, 2013.

in Cosmetic Surgery. New York: Cambridge University Press, 2007.
3. Crowder CM, Palanca BJ, Evers AS. Mechanisms of anesthesia and consciousness. In Barash PG,

Wilkins, 2013.
4. Gertler R, Joshi GP. General anesthesia. In Twersky RS, Phillip BK, eds. Handbook of Ambulatory
Anesthesia, ed 2. New York: Springer Science, 2008.
5. Raeder J, ed. Clinical Ambulatory Anesthesia. New York: Cambridge University Press, 2010.
6. Blakely KR, Klein KW, White PF, et al. A total intravenous anesthetic technique for outpatient
facial laser resurfacing. Anesth Analg 87:827, 1998.

in Cosmetic Surgery. New York: Cambridge University Press, 2007.

Cosmetic Surgery. New York: Cambridge University Press, 2007.

40:371, 2013.
10. ASA standards for basic anesthetic monitoring. Available at
11. ASC NSQIP Surgical Risk Calculator. Available at

Cosmetic Surgery. New York: Cambridge University Press, 2007.
13. Ogunnaike B. Anesthesia. In Janis JE, ed. Essentials of Plastic Surgery, ed 2. New York: Thieme,
2014.
14. Committee on Standards and Practice Parameters, et al. Practice Advisory for Preanesthetic
Evaluation. An updated report by the American Society of Anesthesiologists Taskforce on
Preanesthesia Evaluation. Anesthesiology 116:522, 2012.
15. Mathis MR, Naughton NN, Shanks AM, et al. Patient selection for day case-eligible surgery.
Anesthesiology 119:1310, 2013.
16. Choosing wisely: an initiative of the ABIM Foundation. Available at

83
Chapter 5 Basics of Anesthesia for the Aesthetic Surgery Patient
http://
.

(NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical

19. Sankar A, Johnson SR, Beattie WS, et al. Reliability of the American Society of Anesthesiologists
physical status scale in clinical practice. Br J Anaesth 113:424, 2014.

Anaesth 92:71, 2004.
21. American Society for Anesthesiologists Committee. Practice guidelines for preoperative fasting
and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application
to healthy patients undergoing elective procedures: an updated report by the American Soci-
ety for Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology
114:495, 2011.
22. Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for
prediction of cardiac risk after surgery. Circulation 124:381, 2011.

of Anesthesiology III patients undergoing peripheral revascularization based on functional
capacity. J Vasc Surg 47:766, 2008.

status for predicting 30-day mortality. Anesth Analg 121:110, 2015.
25. ASA position on monitored anesthesia care. Available at www. asahq.org.

analgesia. Available at

Wilkins, 2013.
28. Distinguishing monitored anesthesia care (“MAC”) from moderate sedation/analgesia (con-
scious sedation). Available at

view and correlation with laryngoscopic view. Niger J Clin Pract 13:417, 2010.
-



2009.
32. Dominguez E, Eslinger MR, McCord SV. Postoperative (pressure) alopecia: report of a case after
elective cosmetic surgery. Anesth Analg 89:1062, 1999.

Plastic Surgery. New York: Thieme Publishers, 2009.
34. Cheney FW, Domino KB, Kaplan RA, et al. Nerve injury associated with anesthesia: a closed
claim analysis. Anesthesiology 90:1062, 1999.
-
thotomy positions. Anesthesiology 93:938, 2000.

highlights from the anesthesia closed claims project data request service. ASA Monitor 78:28,
2014.
37. Kara-Junior N, Espindola RF, Valverde FJ , et al. Ocular risk management in patients undergoing
anesthesia: an analysis of 309,4431 surgeries. Clinics 70:541, 2015.

84
Part II Anesthesia
38. Roth S, Tung A, Ksiazek,S. Visual loss in a prone-positioned spine surgery patient with the head
on a foam headrest and goggles covering the eyes: an old complication with a new mechanism.
Anesth Analg 104:1185, 2007.

body contouring. Plast Reconstr Surg 130:443, 2012.

eds. Patient Safety in Plastic Surgery. New York: Thieme Publishers, 2009.
41. Constantine RS, Kenkle M, Hein RE, et al. The impact of perioperative hypothermia on plastic
surgery outcomes: a multivariate logistic regression of 1062 cases. Aesthet Surg J 35:81, 2015.
-
charge nausea and vomiting in ambulatory surgery. Anesthesiol Clin 28:225, 2010.
43. Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment and preven-
tion. Anesthesiology 77:162, 1992.
44. Öbrink E, Jildenstål P, Oddby E, et al. Post-operative nausea and vomiting: update on predicting
the probability and ways to minimize its occurrence, with focus on ambulatory surgery. Int J
Surg 15:100, 2015.
45. Gan TJ, Diemunsch P, Habib AS, et al; Society for Ambulatory Anesthesia. Consensus guidelines
for management of postoperative nausea and vomiting. Anesth Analg 118:85, 2014.

Plastic Surgery. New York: Thieme Publishers, 2009.
47. Kim TW, Rosenberg H, Nami N. Current concepts in the understanding of malignant hyper-
thermia. Anesthesiology News, Feb 2014. Available at
.
48. MHAUS. Managing an MH crisis. Available at .

cases from the North American Malignant Hyperthermia Registry. Anesthesiology 109:825,
2008.

eds. Handbook of Ambulatory Anesthesia. New York: Springer Science and Business Media,
2008.

Anesthesia. New York: Springer Science and Business Media, 2008.
52. Chung F, Mezei G. Factors contributing to a prolonged stay after ambulatory surgery. Anesth
Analg 89:1352, 1999.

updated report by the American Society of Anesthesiologists Task Force on Postanesthetic
Care. Anesthesiology 188:1, 2013.
RESOURCES
American Society of Anesthesiologists (ASA). Available at
American Society of Regional Anesthesia and Pain Medicine (ASRA). Available at
Anesthesia Patient Safety Foundation (APSF). Available at

Malignant Hyperthermia Association of the United States (MHAUS). Available at
Regional Anesthesia and Pain Medicine (RAPM). Available at
Society of Ambulatory Anesthesia (SAMBA). Available at

85
Anesthesia is an important consideration in any aesthetic procedure. Close communication
between the anesthesiologist, surgeon, and patient are paramount to a safe and successful

decrease complications.
CARDIOVASCULAR DISEASES
HYPERTENSION
Continue preexisting beta-blocker on day of surgery (DOS).
Hold diuretics on DOS.
Hold ACE inhibitors (lisinopril, ramipril, benazepril, captopril) and angiotensin-receptor
blockers (ARBs) (candesartan, losartan, valsartan, irbesartan) on DOS because of
exaggerated hypotension with induction of general anesthesia.
CORONARY ARTERY DISEASE
CAUTION:
If history of angioplasty or stents: How many, when implanted, type, need for ongoing
antiplatelet therapy or anticoagulation? Consult with cardiology or
primary care physician (PCP).
Cardiomyopathy
Valvular disease
(determine mild, moderate, severe).
Dysrhythmias6-8
• Note any cardiac implantable electronic device (CIED) such as pacemaker or

NOTE:

CONGESTIVE HEART FAILURE
Consider only stable, well-compensated chronic CHF for low-risk procedures.
CEREBROVASCULAR DISEASE





Deborah Stahl Lowery

86
Part II Anesthesia
PERIPHERAL VASCULAR DISEASE
(elective surgery) should have device checked within
(elective surgery) should have device checked within
If monopolar electrocautery is necessary, consider doing these cases in hospital setting.
PULMONARY DISEASES
PULMONARY HYPERTENSION
Patients with severe pulmonary hypertension are high risk and

ASTHMA
Prevalence in United States is 8.2%
Closed claim analysis indicates incidence of intraoperative bronchospasm or
laryngospasm is as low as 2%, but 90% of these type claims were for severe brain injury
or death.
Preexisting, well-controlled asthma has been associated with low increased risk of
bronchospasm (1.7%).10


CHRONIC OBSTRUCTIVE PULMONARY DISEASE
for increased morbidity and mortality and
unplanned intubations
Most frequent risk factors for postoperative complications include atelectasis,
pneumonia, respiratory failure, and COPD exacerbation.3
• Choose a facility that allows extended PACU stay or 23-hour observation.
Highest risk for hypoxia and hypoventilation is in the
SMOKING


Smoking cessation before surgery may not improve patient outcome and
may actually cause because of increased
secretions and increased airway reactivity.

recommends
POSTOPERATIVE PULMONARY COMPLICATIONS S
Rate across all types of surgery is according to recent systematic review.
More prevalent in patients with known underlying disease
include:
• Atelectasis
• Infection, bronchitis, or pneumonia
• Respiratory failure that could result in reintubation or continued mechanical
ventilation

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Chapter 6 Perioperative Anesthesia Considerations for the Aesthetic Surgery Patient
• Exacerbation of preexisting chronic conditions
• Bronchospasm

• Poor functional status
• Poor general health status



• Smoking
• Obesity

is single, most important factor.




• Residual neuromuscular blockade
PPCs are associated with increased mortality, increased length of stay, and increased
cost of care.

BACKGROUND
Rising incidence in United States
ratio
Clinical correlation with

Remains in up to of patients
Episodic airway obstruction results in sleep disruption/disorder and daytime
hypersomnolence.
Apnea
Hypopnea
seconds
Physiologic derangement includes:
• Oxygen desaturation/hypoxia
• Hypercarbia
• Acidosis
• Polycythemia
is the standard diagnostic test—determines apnea-hypopnea index
or severe.
PREOPERATIVE ASSESSMENT
American Society of Anesthesiologists (ASA) strongly recommends anesthesiologists
and surgeons work together to develop protocols to evaluate patients before
to aid in patient selection, preparation, and management.

17 (Fig. 6-1)

88
Part II Anesthesia
1. Do you Snore loudly? Yes/No
2. Do you feel Tired, fatigued, or sleep during the daytime? Yes/No
3. Has anyone Observed you stop breathing during your sleep? Yes/No
4. Have you been or are you now being treated for high blood Pressure? Yes/No
5. Is your Body Mass Index greater than 35 kg/m 2? Yes/No
6. Are you over 50 years of Age? Yes/No
7. Is your Neck circumference greater than 40 cm? Yes/No
8. Gender (male)? Yes/No
STOP-BANG questionnaire used for screening patients to determine the risk of OSA.
Fewer than three questions positive = low risk of OSA; three or more questions positive = high risk


FOR AMBULATORY SURGERY

Patient with known OSA
Patient with presumptive
diagnosis of OSA
Optimized comorbid
conditions AND able to use
CPAP after discharge
Patients with
nonoptimized comorbid
conditions
Optimized comorbid
conditions AND
postoperative pain can be
managed predominantly by
using nonopioid analgesic
techniques
Proceed with ambulatory
surgery
Not suitable for ambulatory

diagnosis and treatment
Proceed with ambulatory
surgery
Preoperative evaluation and decision-making algorithm for ambulatory aesthetic surgery.
GENERAL MANAGEMENT
Minimal/judicious use of narcotics
Use of multimodal analgesia adjuncts such as acetaminophen, gabapentin, NSAIDs or

Use of local anesthesia; peripheral, neuraxial, and other nerve blocks; home-going
continuous infusion devices
Full reversal of neuromuscular blockade
Extubation at emergence level of fully awake
Sedation level exceeding should incorporate use of ventilation monitoring
using capnography or other automated method. This is now an ASA standard of care.18

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Chapter 6 Perioperative Anesthesia Considerations for the Aesthetic Surgery Patient
PACU care consists of:

• Avoidance of supine position; elevate head of bed to semiupright or lateral
• Continued monitoring, including SPO2, until discharge
• Use of patient’s own CPAP or other devices
consists of:

especially with use of postoperative pain medications

during the day, using nonsupine position
DIABETES
Increasingly present in ambulatory aesthetic patient population
is not uncommon residual disease in patients having
or secondary to preexisting
obesity.
Recommendations by American Diabetes Association (ADA) and American Association
of Clinical Endocrinologists (AACE) only target hospitalized patients, critically ill, and
those undergoing major surgical stress—not always helpful for ambulatory settings.
Consider using patient’s PCP or endocrinologist for management in outpatient setting.
Preanesthesia evaluation or preoperative clinic can also provide guidance with patient
selection criteria and management.
Ideally, glycemic control should be optimized before elective aesthetic surgery.
correlates with decreased infectious complications.
• Current recommendation is to hold oral and noninsulin injectables the day of surgery
until normal food intake is resumed.
HYPERGLYCEMIA ON DAY OF SURGERY

• Preexisting inadequate or poor glycemic control
• Inappropriate discontinuation of preoperative therapy
• Stress response

• Severe dehydration
• Ketoacidosis
• Hyperosmolar nonketotic state
May be acceptable to proceed if blood glucose elevated DOS but
evidenced by:

• Preprandial blood glucoses levels 70-130 mg/dl
• Postprandial blood glucose levels <180 mg/dl
Considerations include:
• Coexisting comorbidities
• Degree of end-organ impairment or autonomic dysfunction
• Potential complications of delayed wound healing and wound infection
• Duration of surgery: Higher levels may be acceptable in shorter procedures.
• Invasiveness of procedure
• Type of anesthetic technique: Symptoms of blood glucose aberrations can be
masked under general anesthesia or deep sedation.
• Expected time to resume oral intake and antidiabetic medications

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Part II Anesthesia
NOTE:
TIP: Maintain preoperative blood glucose levels, rather than preoperatively
acutely “normalizing” them.
ADJUNCTS AND CONSIDERATIONS
Aggressive postoperative nausea and vomiting (PONV) prophylaxis and avoidance of
emetogenic factors promote early resumption of adequate PO intake (see Chapter 5).
Dexamethasone dose of 4 mg IV is acceptable and provides reasonable PONV
prophylaxis

If perioperative insulin is given, discharge criteria should promote observation until
likelihood of postoperative hypoglycemia has passed.
Discharge instructions should include plan for resuming antidiabetic therapy based
on postoperative course, ability to consume adequate oral intake, and ability to self-
monitor blood glucose levels.
OBESITY
Recent statistics (2015) indicate that adult obesity in United States is approaching
21,22
BMI
Severity of Obesity Based on BMI


25.0-29.9
Overweight
30.0-34.9
Obese class I
35.0-39.9
Obese class II
40.0-49.9
Obese class III

Supermorbid obesity
Body mass index.
How big is too big for safe practice in ambulatory procedures requiring anesthesia?
• The literature is
A 2103 study using National Surgical Quality Improvement Program (NSQIP) data found
overweight and obesity to be independent risk factors for early perioperative morbidity
and mortality.
23
The Society for Ambulatory Anesthesia (SAMBA) Committee on Practice Guidelines
performed systematic literature review (2013) in an unsuccessful

24

• Hypoxemia requiring supplemental oxygen
• Need for airway maneuvers

• Treatment for PONV

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Chapter 6 Perioperative Anesthesia Considerations for the Aesthetic Surgery Patient
Based on bariatric surgery literature, morbidly obese patients may be candidates for


2) did present a higher risk; therefore these
patients need thorough evaluation, optimization, and consideration before acceptance
for elective ambulatory procedures.

2
based
Patients with BMI 40-50 kg/m2 require careful preoperative assessments for OSA,
hypoventilation syndromes, pulmonary hypertension, uncontrolled hypertension and
cardiac manifestations, and diabetic control before deemed suitable for ambulatory
facilities.
NOTE:
24
HERBAL SUPPLEMENTS
25
26

Unregulated by FDA

Various reports indicate regular
Most patients do not reveal use to health care providers.4
26,27
• Drug-drug interactions
• Bleeding
• Hypertension
• Increased heart rate
• Sedation



• Echinacea



• Ephedra
• Feverfew
• Garlic
• Ginger
• Ginkgo
• Ginseng
• Kava kava
• St. John’s wort
• Valerian root
TIP: Ephedra is used commonly by young, overweight females.
TIP: Garlic, ginger, ginkgo, and ginseng (the four Gs) are some of the most popular
supplements.

92
Part II Anesthesia
25 which can

• Regional anesthesia placed for postoperative analgesia
• Surgical homeostasis
• Postoperative complications such as hematoma
Prudent approach promotes careful preoperative patient inquiry to determine
consumption.




• 2- to 3-week period before elective procedure is cited most often.
1,13,28
TOP TAKEAWAYS

Continue preexisting beta-blocker on day of surgery (DOS).

Patients with severe pulmonary hypertension are high risk and





American Society of Anesthesiologists (ASA) strongly recommends
anesthesiologists and surgeons work together to develop protocols to evaluate
patients before to aid in patient selection, preparation, and
management.

Patient and caregiver education to promote vigilance regarding signs of OSA,
especially with use of postoperative pain medications

Dexamethasone dose of 4 mg IV is acceptable and provides reasonable PONV
prophylaxis

REFERENCES

in Cosmetic Surgery. New York: Cambridge University Press, 2007.
2. Raeder J, ed. Clinical Ambulatory Anesthesia. New York: Cambridge University Press, 2010.

40:371, 2013.

Cosmetic Surgery. New York: Cambridge University Press, 2007.
http://


Patient Safety in Plastic Surgery. New York: Thieme Publishers, 2009.
7. American Society of Anesthesiologists. Practice advisory for the perioperative management of
patients with cardiac implantable electronic devices: pacemakers and implantable cardioverter-

93
Chapter 6 Perioperative Anesthesia Considerations for the Aesthetic Surgery Patient

perioperative management of patients with cardiac implantable electronic devices. Anesthe-
siology 114:247, 2011.
8. Crossley GH, Poole JE, Rozner MA, et al. The Heart Rhythm Society (HRS)/American Society
of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management

and patient management this document was developed as a joint project with the American
Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association
(AHA), and the Society of Thoracic Surgeons (STS). Heart Rhythm 8:1114, 2011.
9. Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and broncho-
spasm. Br J Anaesth 103(Suppl 1):i57, 2009.
10. Cereda M, Neligan PJ. Managing the risk of perioperative pulmonary complications. In Young


intubation: analysis of a national database. Am Surg 81:820, 2015.
12. Snyder CW, Patel RD, Roberson EP, et al. Unplanned intubation after surgery: risk factors,


Surgery. Berlin Heidelberg: Springer, 2013.
14. Smentana GW. Evaluation of preoperative pulmonary risk. Available at
15. Stephan PJ, Mercier D, Coleman J, et al. Obstructive sleep apnea: implications for the plastic
surgeon and ambulatory surgery centers. Plast Reconstr Surg 125:652, 2009.
16. American Society of Anesthesiologists Task Force on Perioperative Management of Patients
with Obstructive Sleep Apnea. Practice guidelines for the perioperative management of pa-
tients with obstructive sleep apnea: an updated report by the American Society of Anesthe-
siologists Task Force on Perioperative Management of patients with obstructive sleep apnea.
Anesthesiology 120:268, 2014.
17. Joshi GP, Saravanan PA, Gan TJ, et al. Society of Ambulatory Anesthesia consensus statement of
preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory
surgery. Anesth Analg 115:1060, 2012.
18. ASA standards for basic anesthetic monitoring. Available at

R, eds. Patient Safety in Plastic Surgery. New York: Thieme Publishers, 2009.
20. Joshi GP, Chung F, Vann MA, et al. Society for Ambulatory Anesthesia consensus statement on
perioperative blood glucose management in diabetic patients undergoing ambulatory surgery.
Anesth Anal 111:1378, 2010.

2015. Available at

States, 2011-2014. NCHS Data Brief No. 219, 2015.
23. Mathis MR, Naughton NN, Shanks AM, et al. Patient selection for day case-eligible surgery.
Anesthesiology 199:1310, 2013.
24. Joshi GP, Ahmad S, Riad W, et al. Selection of obese patients undergoing ambulatory surgery:
a systematic review of the literature. Anesth Analg 117:1082, 2013.
-
ments. Best Pract Res Clin Anesthesiol 28:183, 2014.

94
Part II Anesthesia
26. Broughton G, Crosby MA, Coleman J, et al. Use of herbal supplements and vitamins in plastic
surgery: a practical review. Plast Reconstr Surg 119:48e, 2007.
27. Jalili J, Askeroglu U, Alleyne B, et al. Herbal products that may contribute to hypertension. Plast
Reconstr Surg 131:168, 2013.
28. Gertler R, Joshi GP. General anesthesia. In Twersky RS, Phillip BK, eds. Handbook of Ambulatory
Anesthesia, ed 2. New York: Springer Science, 2008.
RESOURCES
American Society of Anesthesiologists (ASA). Available at
American Society of Regional Anesthesia and Pain Medicine (ASRA). Available at
Anesthesia Patient Safety Foundation (APSF). Available at
Regional Anesthesia and Pain Medicine (RAPM). Available at
Society of Ambulatory Anesthesia (SAMBA). Available at

95
ANESTHESIA FOR FACIAL PLASTIC SURGICAL PROCEDURES
1,2
Patient factors
• Usually middle-aged or older
• May have increased burden of comorbidities, especially preexisting hypertension
• Can have cardiac conditions for which they take antiplatelet, antithrombotic, or
anticoagulant medication
• Any disruption/resumption in blood thinners should be coordinated with primary
care physician or consultant.
• Require increased attention to positioning and padding with range of motion
limitations, including cervical spine

• Consider Foley catheter
• DVT mechanical prophylaxis with sequential compression devices
• Intermittent position checks to assess extremity and pressure point support and
padding
Multiple anesthetic techniques used successfully
• IV sedation of varying levels
• Total intravenous anesthesia (TIVA) (see Chapter 5)
• Balanced technique with inhalational anesthesia

ANESTHETIC GOALS
Achieve optimal hemodynamic control.
is most common complication of procedure.

hematoma.
3
Appreciate anxiolysis, antiemesis, and analgesia treatments as components of
hemodynamic control.
Preemptively manage changes in surgical stimuli that result in hemodynamic aberration
(awareness of procedural components and their sequence).
Be aware of placement, timing, and tolerance of compression head dressings.
Achieve smooth emergence and extubation that prevents coughing and bucking.
PREOPERATIVE MANAGEMENT1,4
Continue any home anxiolytic medications.
Add preoperative anxiolysis with midazolam 1-2 mg IV titrated up to 0.7 mg/kg.

96
Part II Anesthesia
Continue any home antihypertensive medications (except diuretics, angiotensin-
converting enzymes [ACE-inhibitors], and angiotensin-receptor blockers [ARBs]).
Determine baseline BP and, if known, typical ranges.
Consider use of 0.1-0.2 mg PO or 0.1-0.2 mg/d transdermal patch placed
preoperatively.
Optimize preoperative PO multimodal analgesia (celcoxib, acetaminophen,
gabapentin).
Optimize preoperative antiemesis prophylaxis (aprepitant [Emend], scopolamine
patch), especially if history of PONV/PDNV.
INTRAOPERATIVE MANAGEMENT
Ensure smooth IV induction with propofol.
Continue (with addition of promethazine, decadron,
ondansetron, and/or haloperidol), as determined by Apfel score.
Continue regimen (ketamine, IV
acetaminophen).
Provide redosing preemptively for head repositioning or
injection stimulation.
Maintain during resection.
Generous surgical use of and
Bolus with shorter-acting synthetic opioids (fentanyl, sufentanil, alfentanil) to blunt:

• Periods of intermittent stimulation during local anesthesia injection
• Airway stimulation caused by changes in head positioning

postoperative nausea and vomiting (PONV).
Before closing, to facilitate surgical assessment of
oozing.
(maintenance amounts) to prevent facial edema

• No appreciable third space losses occur.
until all dressings and wraps are securely in place.
Surgeon or assistant can hold pressure to site during extubation.
ASAP to minimize postprocedural edema.
is critical to prevent coughing or bucking that causes increased
venous return and increased BP leading to hematoma.
Use
Use PRN to quickly control increases in BP.
Timely management of any anxiety, hypertension, pain, or nausea in PACU

in formation of hematoma.2

to minimize subcutaneous bleeding and hematoma formation.
AIRWAY MANAGEMENT
with controlled ventilation
• Provides maximal control of airway during head position changes
• Minimizes motion that can occur with spontaneous respiration

97
Chapter 7

• Decrease FiO2 to lowest level that supports adequate oxygenation.
• Secure ET tube in a way to maximize surgeon’s dynamic maneuverability.

(inform patient of potential gum irritation, soreness, or bleeding).
• Some surgeons prefer to leave ET tube unsecured for ability to move from side to
side throughout procedure.
TIP: If unsecured, mark the ET tube with an indelible marker at centimeter markings
for the teeth or lip so that its position can be continually checked for initial placement
depth!
• Consider preformed ET tube (oral or nasal RAE).
• Bioocclusive dressing can secure ET tube to chin to minimize tape.
• Determine level of maintenance muscle relaxation desired by surgeon to prevent
unwanted facial laxity.

• Prevents facial distortion, which is less desirable for this reason
• Assess anticipated head manipulation to prevent airway irritation or dislodgement
intraoperatively.
• Good alternative (if no contraindications) in isolated browlift, blepharoplasty, or
eyelid procedures because of maintenance of neutral head positioning.
• Facilitates smooth emergence because patients less likely to cough or buck
with spontaneous ventilation
EYE PROTECTION

CAUTION:

4

• Remember to remove before emergence to avoid unpleasant patient experience

FACIAL LASER RESURFACING
Use of CO2
intraoperatively and immediately after procedure.
Successful use of room air/natural airway/spontaneous ventilation techniques using
TIVA have been described.
• Need for cardiorespiratory depressants is prevented by using nonopioid analgesics
in conjunction with local anesthetic nerve blocks.

freed.
• Drawbacks
6
and antiemetics (32%).

98
Part II Anesthesia
Balanced technique or TIVA with use of an endotracheal tube1,5 confers ability to:
• Treat drug-induced respiratory depression with controlled ventilation



2 to lowest level that supports adequate oxygenation
2
time-out
ET tube may need repositioning to allow surgeon to work around it, possibly unsecured.
Eye protection with corneal protectors and saline-soaked gauzes pads are needed.
PACU needs can include:
• Supplemental narcotic analgesia
• Chilled air to face
• Application of ointment

RHINOPLASTY
Well-suited for general anesthesia with controlled airway
Alternative method is moderate-deep sedation with natural airway, although providing
supplemental oxygen is more challenging.
Position and secure ET tube over the mandible. Use of tube extenders, armored tube, or
oral RAE tube facilitates surgical exposure and maneuverability and prevents crimping
or compression.

Caution is needed with osteotomies and bleeding that passively migrates to stomach
causing increased incidence of PONV, risk of aspiration, and airway irritation.
TIP:
Use of throat packing dampened with saline solution can decrease blood migration but
can cause mucosal irritation and postprocedure sore throat.
CAUTION:


dressings are in place.

• Being awake enough to prevent aspiration or laryngospasm, especially because
mask application with positive pressure can cause injury to fresh repair
• Being smooth enough to prevent coughing and bucking that increase bleeding

ANESTHESIA FOR BREAST AND ABDOMINAL PROCEDURES
BREAST AUGMENTATION1
Patients tend to be younger (most <40 years of age).
Younger age, female sex, use of volatile agents and opioids increase Apfel PONV score;
thus

99
Chapter 7
Submuscular dissection and placement lends itself to postoperative deep muscular pain
and spasm.
Use of multimodal analgesia can include initial doses of acetaminophen, gabapentin,
celecoxib or other NSAID.
• Can add diazepam (Valium) or carisoprodol (Soma) to regimen to aid pectoralis
relaxation
8
Position changes intraoperatively are dynamic and frequent to observe implant location
and symmetry.





CAUTION:
Coordinate timing of emergence to account for dressings, bra, elastic bandages, and if
they were placed while patient was sitting or supine.
Although general anesthesia is the mainstay for this procedure, successful use of
regional techniques for sole anesthetics or postoperative pain supplements are well
described, including epidural or thoracic paravertebral blocks.
9,10
Postoperative pain management can be augmented by local anesthesia continuous
infusion pumps (On-Q, Kimberly-Clark), intercostal nerve blocks, paravertebral blocks,

Recommend continuation of multimodal analgesia regimen after discharge.
BREAST REDUCTION AND MASTOPEXY
Dynamic positioning is similar to that of augmentation.

ABDOMINOPLASTY1,11,12
Characterized as “moderate” surgical risk procedure
Promotes thorough preoperative assessment to aid in patient and facility selection


• Increased risk can include and

10
• Apply sequential compression devices (SCDs) in preoperative area, ensure they are
operational before anesthetic induction. (Add to checklist!)


risk assessment (Caprini RAM) (see Chapter 11).
• Provide preoperative information on signs of DVT/PE, need for early ambulation.
Warming measures include preoperative prewarming, adequate OR room temperature,

warmers.
TIP:
before patient arrives in OR.

100
Part II Anesthesia
Preoperative multimodal analgesia can include initial doses of acetaminophen,
gabapentin, and/or celecoxib.
Preoperative

(see Chapter 5).
Keeping patient anesthetized through transition from OR table to car, maintaining

Goal is smooth emergence with avoidance of increased abdominal pressure caused by
coughing and bucking.
Provide early, aggressive pain management with adequate opioid supplementation as
needed in PACU.
Consider continuing multimodal analgesia regimen after discharge, often with the
addition of a muscle relaxant, e.g., cyclobenzaprine (Flexaril).
ANESTHESIA FOR BODY CONTOURING AFTER MASSIVE WEIGHT

hours promotes procedural staging.
with thermoregulation challenges
including prone

• May need to change sites intraoperatively
• May need to use lower extremity, external jugular sites, or even central venous
access

Need for extended postoperative care beyond typical PACU length of stay


• Residual hypertension, diabetes mellitus, obstructive sleep apnea

• Risk of aspiration, especially with gastric banding
• Preexisting cardiac disease and/or pulmonary hypertension
• Decreased pulmonary reserves with quicker desaturation

• Predisposition to infection
• Thromboembolic risk
PHARMACOLOGIC CHALLENGES14
Pharmacokinetics and pharmacodynamics can be altered as both fat and lean body

Dosing based on can result in
Dosing based on can result in
If patient is TBW can be used.
POSITIONING CHALLENGES
May be dynamic and creative—atypical to achieve favorable surgical access

Consider allowing awake patient positioning pretest to assess for stress, compression,
stretching, pinching.

101
Chapter 7

breaks.
Preplan for position changes.

• Need for cart to table and back





to relieve weight compressing/restricting chest wall and
to optimize ventilation
to prevent brachial plexus compression or stretching, dislocation of
glenohumeral joint
• Arm boards with adequate padding

• Cervical spine kept neutral position while turning and positioning
• Prone headrest with appropriate cut-outs for eyes, nose, and ET tube or
manufactured mirrored support device (ProneView, Mizuho OSI)

• Perform and document periodic (every 15 minutes) ocular checks.
can help to decrease intraocular
pressure.
• Check nipples, breast, abdomen, and male genitalia for compression.

• Excess weight on chest while supine can be uncomfortable for awake patients,
limiting preoxygenation.



• Heels padded
INTRAOPERATIVE CONCERNS

associated with increased seroma formation, increased blood loss, and higher need for
transfusion.
• Thermoregulation: Use prewarming in preoperative area.
• Increase room temperature (target of 21.1° C).

for IV and irrigation.
• Remember to cover areas during lengthy position changes.
• Continue active warming into PACU.
Foley catheter
Antibiotics: Don’t forget to redose for longer-duration surgery.
DVT/VTE prophylaxis is imperative.
POSTOPERATIVE CONCERNS
Anticipate longer PACU stay.

duration of procedure(s)

102
Part II Anesthesia
Need for supplemental oxygen may be prolonged.
Extended full American Society of Anesthesiologists (ASA) monitoring with addition of
nasal cannula end-tidal carbon dioxide monitor
Continuous positive airway pressure/bilevel positive airway pressure (CPAP/biPAP)
(patients to bring their own if preexisting OSA)
Incentive spirometry (continue at home)
ANESTHESIA FOR LIPOSUCTION
Considered procedure
Anticipate proposed length of procedure and plan for:
• Positioning challenges or dynamics
• Thermoregulation mechanisms and challenges


• Concomitant procedures, especially those that would include additional lidocaine or

CAUTION:

POTENTIAL SERIOUS COMPLICATIONS

Fluid overload/pulmonary edema
Thermal injury
Pulmonary embolus
Fat embolus
Hypothermia
Dilutional coagulopathy
Metabolic/electrolyte derangement
Viscus or vascular perforation
FLUID MANAGEMENT
Good communication between surgeon, anesthesiologist, and circulator is critical to

Noninvasive hemodynamic monitoring ± urinary catheter is needed to assess volume
status.
For
For Rate 0.25 ml

aspirate.)


With aspirate <5 liters, third-space losses should be minimized by application of
compression garments.

imbalance, need for hemoglobin assessment, attention to volume status (including use
of urinary catheter), and postoperative overnight observation.

103
Chapter 7
THROMBOEMBOLIC PROPHYLAXIS

hypercoagulable state


Use of sequential pneumatic compression devices (SCDs) with general anesthesia (place


MAINTENANCE OF CORE TEMPERATURE
Use active-warming devices.
Cover exposed surface areas.
Increase OR ambient temperature.


Minimize evaporative losses from large areas of wet skin.
Continue active warming in PACU to provide additional comfort.
ANALGESIA1
Supplemental narcotics may be needed because of “feathering techniques” that may

• Becomes apparent at emergence or early PACU
Early narcotic rescue with fentanyl IV in 25 µg increments is helpful.
LIDOCAINE
An amino-amide structure

90% undergoes hepatic metabolism, 10% is excreted unchanged in urine.
Relative short duration of action (10-30 minutes)
is
is


without epinephrine, not to exceed
with epinephrine, not to exceed

19






24





is accepted limit (ASPS Practice advisory).

104
Part II Anesthesia


when necessary.
TIP: Consider omitting lidocaine when general or regional anesthesia is used.
Peak (subtoxic) plasma concentrations can be delayed and have been reported typically
as 6-14 hours (up to 23 hours)22,23 depending on:

• Patient characteristics

• Unequal volume of distribution in subcutaneous tissue
23
SIGNS AND SYMPTOMS OF LIDOCAINE TOXICITY
Dose dependent
Typically present initially (awake patient) with
Proceeds to as plasma levels increase
Continuum is obscured by general anesthesia.
Pretreatment with benzodiazepines can aid by increasing the seizure threshold but also
diminishes patient’s ability to report early symptoms.
Plasma levels are nontoxic.
Plasma levels of are more subjective and (awake patient).
• Perioral numbness and/or facial tingling
• Restlessness, confusion, or lethargy
• Metallic taste
• Vertigo
• Slurred speech
• Tinnitus
Plasma levels of symptoms are increasingly objective and
• Delirium
• Seizures
• Coma
Plasma levels proceed to cardiac manifestations.
• Hypotension
• A-V block, idioventricular rhythms
• Asystole, cardiac arrest, cardiovascular collapse
• See the following section.

MANAGEMENT

• Airway management
• Circulatory support


(ASC)

105
Chapter 7
Supportive care
• 100% FiO2
• Support or secure airway.

• Seizure suppression with IV benzodiazepines (diazepam or midazolam)
• If no benzodiazepine available, can use small doses of propofol (caution: cardiac
depression)

• Correction of acidosis with hyperventilation (avoid sodium bicarbonate as per

EMS AND TRANSFER PROTOCOLS
Proceed to nearest facility with

For Consider IV fat
emulsion,
INTRALIPID
Recommended dosing for 70 kg patient (lean body mass)
• Bolus 1.5 ml/kg (about 100 ml)
• Infusion rate 0.25 ml/kg/min (about 18 ml/min)

• Repeat bolus x 2 every 3-5 minutes circulation is restored.
• Can double infusion rate to support circulation
• Maximal upper dosing limit varies in literature; has been reported to be 8-10 ml/kg.
TOP TAKEAWAYS

Patients should take their home medications the morning of surgery to maintain
steady-state levels.

Risk factors for PONV include females, nonsmokers, past history of PONV,
history of motion sickness, young age, migraine history.

Good communication between surgeon, anesthesiologist, and circulator is



promote hypercoagulable state
Other than procedures performed using local and mild oral tranquilization,
surgery should be carried out in an accredited facility.
REFERENCES

in Cosmetic Surgery. New York: Cambridge University Press, 2007.

lift patient: lesson learned from 1089 consecutive face lifts. Plast Reconstr Surg 135:723, 2015.

Patient Safety in Plastic Surgery. New York: Thieme Publishers, 2009.
4. Sawyer W, Burwick K, Jaworski J, et al. Corneal injury secondary to accidental Surgilube expo-
sure. Arch Ophthalmol 129:1229, 2011.

106
Part II Anesthesia
5. Raeder J, ed. Clinical Ambulatory Anesthesia. New York: Cambridge University Press, 2010.
6. Blakely KR, Klein KW, White PF, et al. A total intravenous anesthetic technique for outpatient
facial laser resurfacing. Anesth Analg 87:827, 1998.

in Cosmetic Surgery. New York: Cambridge University Press, 2007.
8. Unger JG, Thornwell HP III, Decherd ME. Breast augmentation. In Janis JE, ed. Essentials of Plastic
Surgery. New York: Thieme Publishers, 2014.

in Cosmetic Surgery. New York: Cambridge University Press, 2007.
10. Tahiri Y, Tran DQ, Bouteaud J, et al. General anesthesia versus thoracic paraverterbral block for
breast surgery: a meta-analysis. J Plast Reconstr Aesthet Surg 64:1261, 2011.
11. Buck DW, Mustoe TA. An evidence-based approach to abdominoplasty. Plast Reconstr Surg
126:2189, 2010.

Thieme Publishers, 2014.
13. Hoschander A, Strauch B, et al. Risk and safety considerations in body contouring after massive
weight loss. Available at tutorial accessed 10/01/2014.
www.
tutorial accessed 10/01/2014.

procedures in previously morbidly obese patients. Anestesia en México 21:186, 2009.
16. Ellsworth WA, Basu CB, Iverson RE. Perioperative considerations for patient safety during cos-
metic surgery-preventing complications. Can J Plast Surg 17:9, 2009.

body contouring. Plast Reconstr Surg 130:443, 2012.

Cosmetic Surgery. New York: Cambridge University Press, 2007.

Thieme, 2014.

Surg 64:985, 2011.
21. American Society of Plastic Surgeons. Practice advisory on liposuction: executive summary.
Available at
-
-
ers, 2009.

Forensic Sci Int 178:e11, 2014.
24. Klein JA. The tumescent technique for liposuction surgery. AM J Cosmetic Surg 4:1124, 1987.
-
temic toxicity. Reg Anesth Pain Med 35:152, 2010.

RESOURCES
American Society of Anesthesiologists (ASA). Available at
American Society of Regional Anesthesia and Pain Medicine (ASRA). Available at
Anesthesia Patient Safety Foundation (APSF). Available at

Regional Anesthesia and Pain Medicine (RAPM). Available at
Society of Ambulatory Anesthesia (SAMBA). Available at

107
UNDERSTANDING MULTIMODAL PAIN MANAGEMENT
“Prescription drug overdose is an epidemic in the United States. All too often, in far too
many communities, ”1
of patients experience acute pain after surgery.
of U.S. patients report surgical pain rated 7 or higher (scale of 1-10).
of patients are concerned about postoperative pain.2
OPIOID EPIDEMIC
U.S. Surgeon General declares epidemic of addiction—public health
crisis3
United States contains 4.6% of the world’s total population, but consumes two thirds of
the world opioid supply.
12.5 million people, or 4.7% of the American population, aberrantly used prescription
opioids in 2015.4
1% of the U.S. population is addicted to opioids.
28,647 people died in the United States due to prescription opioid overdose
Prescription opioid use disorder is estimated to cost the American economy $53.4
billion per year.
Resurgence of heroin
• Cheaper
• Inappropriate weaning strategies from prescription opioids

opioids.5
Prescription opioid overdose responsible for
6
Rate of prescription opioid use disorder increased by 167%7
• Rates continued to rise
PRESCRIBING PATTERNS AND DEATHS
In patients with opioid prescriptions that overdose, the mortality rate increases with
escalating dose.8
Increases in opioid prescription rates have not resulted in improvement in patient
disability or health outcome.9
STATISTICS
Accidental deaths per year in United States10:
• #1: Drug poisoning

108
Part II Anesthesia
• #2: Automobile accidents
United States—5.4% of high school seniors aberrantly used prescription
opioids within the last year
11

Canada—20.6% of grade 12 high school students aberrantly used opioid
medication in the last year
12

• 44 Americans die every day of a prescription overdose.13





DIVERSION
Illicitly obtained prescription opioids are often obtained from friends or family.
Street availability of prescription opioids increased
40% of Medicaid patients with opioid prescriptions had indicators of aberrant use
or diversion14

Surgeons responsible for 9.8% of the total opioid prescriptions in the United States15
Rates of opioid prescriptions to opioid naive patients after minor surgery increased
between 2004 -2012.16


of opioids.
Simple education interventions for patients to explain how to safely store and dispose


opioid storage and disposal
PROPER STORAGE AND DISPOSAL
Opioids should be stored in a locked cabinet.
All unused medication should be returned to the pharmacy or destroyed once post-
operative pain has resolved.
SURGERY AND ADDICTION

persistent postoperative opioid use.17
Many patients continue to receive opioids chronically after initially receiving them for
postoperative pain control.
Patients taking opioids chronically prior to surgery have an increased chance of still
taking them 1 year later when compared with controls.

109
Chapter 8 Multimodal Analgesia for the Aesthetic Surgery Patient
OPIOIDS AND SURGERY
A 2016 study of elective hand surgery patients showed 13% were still taking opioids 90
days after surgery.18
Another study found that 3.1% were still taking opioids at 90 days after major surgery.19
Total knee arthroplasty: 1.4% chance of still taking opioids one year after surgery20
• Odds ratio of 5:1 when compared to nonoperated controls

have a 44% increased likelihood of chronic use at 1 year compared with controls.
21
CAUTION:
even in opioid naive
patients.
RISK FACTORS FOR OPIOID ABUSE
History of substance use disorder
Comorbid psychological health conditions (i.e., anxiety, depression)
Male sex

LEFTOVERS AND DISPOSAL
Elective hand surgery study (2012): 95% received opioids with average 30 doses22
19 doses left over after acute pain resolution
Urology: 92% received no instructions on how to dispose of leftover opioids after
surgery23
• 67% had leftover opioids
• 91% of the patients with leftovers went on to keep them in an unlocked medicine
cabinet
24
Oral surgery and pediatric surgery: similar to above
Thoracic and gynecological surgery: 83% had leftover opioid medication

SENIOR AUTHOR TIP: Since most people with prescription opioid use disorder
get them from friends and family, it is reasonable to conclude that our postoperative

opioids.
RECOMMENDATIONS FOR SURGEONS
Consider the risk that an individual patient may develop persistent opioid use and
proceed to an opioid use disorder.
Consider the risk that medications prescribed postoperatively may end up diverted to
nonmedical use and causing direct public health harm.
Identify risk factors:
• Psychiatric illness
• History of either aberrant substance use or diagnosed substance use disorder
• Communicate to the patient in a nonjudgmental way so that they can exercise
caution in taking prescribed medications.

110
Part II Anesthesia
Patients with an established or suspected substance use disorder should be referred to
an addiction specialist preoperatively if possible.25
Elective surgery in patients with established substance use disorders should not be
performed until follow-up for substance use has been arranged.

Prescriptions should be limited to 20 doses of low potency, immediate release opioids
unless circumstances clearly dictate otherwise.26,27
SENIOR AUTHOR TIP: We can make a major contribution by curbing opioid diversion
in the perioperative period. We can partner with our anesthesia/pain colleagues to
and prevent postoperative aberrant opioid use.
CAUTION:



PROPER PAIN MANAGEMENT
Multiple organizations have urged a shift toward nonopioid options for pain management.
JCAHO27:


1
CDC28:

”
2
ASA29:
•

3
IMPACT OF INADEQUATE PAIN MANAGEMENT

Associated with poor surgical outcomes



Postsurgical pain intensity was associated with delayed wound healing.
APPROACH TO PAIN MANAGEMENT
Common pain management protocols are opioid based.


Aren’t customized to patients or surgical procedures
OPIOID ELATED ADVERSE EVENTS
Primary component of most postoperative multimodal pain management strategies

111
Chapter 8 Multimodal Analgesia for the Aesthetic Surgery Patient
Associated with unwanted and severe adverse events
• Nausea and vomiting
• Pruritus
• Sedation and cognitive impairment
• Urinary depression
• Sleep disturbances
• Respiratory depression
ANALGESIC OPTIONS FOR MULTIMODAL ANALGESIA
Regional analgesic techniques

• Field blocks (TAP block)
• Peripheral nerve and plexus blocks
• Neuraxial blocks
IV lidocaine infusion
Acetaminophen
NSAIDs

Dexamethasone
Ketamine
Gabapentin/pregabalin
Opioids (as rescue)
BENEFITS
Improve postsurgical pain control
Permit use of lower analgesic doses
Reduce dependence on opioids for postsurgical pain management
Combines a variety of analgesic medication and techniques with nonpharmacological
interventions34
• Uses drugs with complimentary mechanisms of action
• Targets multiple sites of the nociceptive pathway
• Allows for lower doses of medications and potentially provides greater pain relief


Avoid “shotgun” approach

Emphasis on function NOT pain scores
ACETAMINOPHEN, NSAIDS, AND NHIBITORS COMBINATION

inhibitors
All analgesics resulted in lower 24-hour morphine requirement (6-10 mg).

NSAIDs associated with more bleeding
•

selective inhibitors at equipotent doses

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Part II Anesthesia

blood loss

PERIOPERATIVE DEXAMETHASONE AND PAIN
Systematic review of published literature that involved 45 studies, involving 5796
patients

• Reduced pain scores at 2 hours and 24 hours postoperatively
• Reduced opioid requirements
• Reduced need for rescue analgesia for intolerable pain

• Allowed shorter PACU stay
No increase in infection or delayed wound healing
No dose response with regards opioid sparing
GABAPENTIN/PREGABALIN FOR POSTOPERATIVE PAIN
Reduces postoperative pain and opioid requirements
Studies have small sample size and short duration of follow-up
Sedation, dizziness may delay discharge home


INTRAVENOUS KETAMINE
Systematic review placebo-controlled, RCTs (n = 47) IV ketamine (bolus or infusion)


studies
Reduced pain scores
Reduced PONV only when pain scores decreased


INFILTRATION OF LOCAL ANESTHETICS
TIMING
Timing of the block (preincision versus postincision) does not appear to be clinically

Nerve blocks improve postoperative analgesia.

SURGICAL SITE INFILTRATION: BEST CLINICAL PRACTICE
Use a 22-gauge, 1½-inch needle.
Use a fanning technique (“moving needle technique”).
Needle is inserted approximately 0.5-1 cm into the tissue plane and local anesthetic
solution is injected while slowly withdrawing the needle (reduces the risk of
intravascular injection).

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Chapter 8 Multimodal Analgesia for the Aesthetic Surgery Patient
1 cm
1
2
3
Fascia
Dermis
Muscle
Peritoneum
Subcutaneous tissue
Insert needle 0.5-1 cm into tissue plane
Use continuous fanning motion while
withdrawing needle
Inject while slowly withdrawing needle

solution.
MULTIMODAL ANALGESIA REGIMEN
SENIOR AUTHOR TIP: The following is my own perioperative multimodal analgesia
regimen for many patients (aesthetic and reconstructive), though it is tailored and

example only.

• 300 mg gabapentin (Neurontin) by mouth


• 1000 mg acetaminophen by mouth liquid (2 hours prior to surgery time)

• 300 mg gabapentin by mouth (2 hours prior to surgery time)

• 400 mg celecoxib by mouth (20 minutes prior to surgery time)

gastroduodenal ulcer history, renal and hepatic function)
• 40 mg aprepitant (Emend), one tablet by mouth, 2 hours before surgery*

postoperative)

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Part II Anesthesia
NOTE ON NSAIDS
Use varies depending on individual patient risks
• Bleeding complications
• Cardiovascular morbidity
• Actual or recent gastroduodenal ulcer history
• Aspirin-sensitive asthma
• Renal function
• Hepatic function
INTRAOPERATIVE

• Or liposomal bupivacaine, if available
Ketorolac IV (30 mg)
• Or IV acetaminophen or IV ibuprofen
Dexamethasone IV (8 mg)


DAY OF SURGERY
by mouth (12 hours after the morning dose)
tablet by mouth (every 6 hours, repeat 3 times)
One tablet by mouth every 4 hours as needed for pain
One tablet by mouth 2 times a day as needed for
constipation
One dissolvable tablet every 8 hours as needed for nausea
POD 1 AND AFTER
by mouth, 3 times a day for 14 days
tablet by mouth every 6 hours for 14 days (with no other
APAP-containing meds!)
One tablet by mouth every 4 hours as needed for pain
One tablet by mouth 2 times a day as needed for
constipation for 7 days
One dissolvable tablet every 8 hours as needed for
nausea
GABAPENTINOIDS

Reduce both pain and opioid requirements
Can improve perioperative sleep and anxiety
< 65 years old:
• Gabapentin 300 mg by mouth 3 times a day for 7 days

• Gabapentin 300 mg by mouth 2 times a day for 7 days

ALTERNATIVES
If allergic to celecoxib or insurance won’t cover, can use meloxicam 15 mg by mouth 2
times a day

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Chapter 8 Multimodal Analgesia for the Aesthetic Surgery Patient
If cannot take celecoxib or meloxicam, use either ibuprofen 400 mg by mouth every
6 hours or naprosyn 440 mg by mouth every 12 hours.
• Do not use if patient with history of peptic ulcer disease. Do not take both, only one
or other.
TOP TAKEAWAYS

We are in an opioid epidemic. Doctors/surgeons play a role.

Be judicious in your opioid prescribing habits and be aware of overprescribing
habits and diversion.


REFERENCES
1. US Centers for Disease Control and Prevention. Press release. Opioid painkiller prescribing
varies widely among states. July 1, 2014. Available at


survey suggest postoperative pain continues to be undermanaged. Anesth Analg 97:534, 2003.

complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician
11:S63, 2008.
4. Center for Behavioral Health Statistics and Quality. (2016). 2015 national survey on drug use
and health. Substance Abuse and Mental Health Services Administration, Rockville, MD.
5. Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: a public
health approach to an epidemic of addiction. Annu Rev Public Health 36:559, 2015.
-
ache Rep. May, 2016. Available from

States. N Engl J Med 372:241, 2015.
8. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and
opioid overdose-related deaths. JAMA 305:1315, 2011.

lack of improvement in disability metrics among users. Reg Anesth Pain Med 39:6, 2014.

[cited 2016 Nov 16]; Available from

use, 1975-2015. National Institute on Drug Abuse at the National Institutes of Health, 2016.
12. Brands B, Paglia-Boak A, Sproule BA, et al. Nonmedical use of opioid analgesics among Ontario
students. Can Fam Physician Med Fam Can 56:256, 2010.
13. Centers for Disease Control and Prevention. Prescription drug overdose data. Available at http://


Americans with Medicaid, 2010. J Health Care Poor Underserved 26:182, 2015.

U.S., 2007–2012. Am J Prev Med 49:409, 2015.
16. Wunsch H, Wijeysundera DN, Passarella MA, et al. Opioids prescribed after low-risk surgical
procedures in the United States, 2004-2012. JAMA 315:1654, 2016.

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following common hand surgery procedures. J Hand Surg 41:947, 2016.
19. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major
surgery: population based cohort study. BMJ 348:g1251, 2014.

opioid-naive patients in the postoperative period. JAMA Intern Med 176:1286, 2016.
-
tive cohort study. Arch Intern Med 172:425, 2012.
22. Rodgers J, Cunningham K, Fitzgerald K, et al. Opioid consumption following outpatient upper
extremity surgery. J Hand Surg 37:645, 2012.

postoperative pain medication delivery, consumption and disposal in urological practice. J Urol
185:551, 2011.


25. Thorson D, Biewen P, Bonte B, et al. Acute pain assessment and opioid prescribing protocol. Inst
Clin Syst Improv 2014 [cited 2016 Nov 16]; Available from


orthopedic procedures. Phys Sportsmed 42:100, 2014.


28. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain
relievers—United States, 1999-2010. MMWR Morb Mortal Wkly Rep 62:537, 2013.
29. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guide-
lines for acute pain management in the perioperative setting: an updated report. Anesthesiol-
ogy 116:248, 2012.

of surgical pain in the United States: highlights of the inaugural Surgical Pain Congress. Am
Surg 80:219, 2014.
31. Dasta J, Ramamoorthy S, Patou G, et al. Bupivacaine liposome injectable suspension compared
with bupivacaine HCl for the reduction of opioid burden in the postsurgical setting. Curr Med
Res Opin 28:1609, 2012.

2015.
33. Golembiewski J, Dasta J. Evolving role of local anesthetics in managing postsurgical analgesia.
Clin Ther 37:1354, 2015.
34. Manworren RC. Multimodal pain management and the future of a personalized medicine ap-
proach to pain. AORN J 101:308, 2015.
35. Adam F, Menigaux C, Sessler DI, et al. A single preoperative dose of gabapentin (800 milligrams)
does not augment postoperative analgesia in patients given interscalene brachial plexus blocks
for arthroscopic shoulder surgery. Anesth Analg 103:1278, 2006.
36. Paech MJ, Goy R, Chua S et al. A randomized, placebo-controlled trial of preoperative oral pre-
gabalin for postoperative pain relief after minor gynecological surgery. Anesth Analg 105:1449,
2007.
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anatomical-based approach. Plast Recon Surg Glob Open 4:e1181, 2016.

PART III
Safety
PATIENT
SAFETY
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(Trang không có chữ)

119


Hippocrates

Two decades ago of surgical procedures were performed on an outpatient basis.
Today of all surgeries are performed in an outpatient setting.2

surgical facilities.
These studies have shown low and extremely low
of approximately 2-6
The two largest plastic surgery societies in the United States, the American Society of
Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS),
have recognized the importance of establishing a culture of safety and have accordingly

surgical facilities.
7
divided this topic into four broad categories:
1. Administrative
2. Clinical aspects

4. Management of postoperative issues, in particular postoperative pain and
postoperative nausea and vomiting (PONV)
ADMINISTRATIVE ISSUES


Practitioners must obtain and maintain adequate training

should limit their practice to the scope of the certifying board.
Develop a system of quality of care with continual evaluation
focused on improving patient care/safety. This includes the maintenance of the
physical plant, operating room/recovery room equipment, personnel evaluations and
coursework, and development and implementation of protocols and procedures.
Accreditation and maintenance of surgical facility standards



Vernon Leroy Young

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Part III Safety
Protocols for management of emergency situations. This includes transfer protocols
to a higher level of care (i.e., hospitals), generally, where the surgeon has admitting
privileges and ideally privileges to perform the same procedures that are performed in

Informed consent process
Maintenance of complete medical records
Guidelines for patient discharge
System for reporting of adverse events
CORE PRINCIPLES
These core principles have been approved by the American College of Surgeons,

involving any level of anesthesia above local anesthesia procedures.
8


Depth of Sedation statement dated October 13, 1999, excluding local anesthesia or
minimal sedation.
Physicians should select patients by criteria, including the ASA

in the preoperative evaluation of the patient.

facilities accredited by the Joint Commission on Accreditation of Healthcare
Organizations, the Accreditation Association for Ambulatory Health Care, the
American Association for Accreditation of Ambulatory Surgery Facilities, the
American Osteopathic Association, or a state-recognized entity such as the Institute


privileges at a nearby hospital, or have a transfer agreement with another physician
who has admitting privileges at a nearby hospital, or maintain an emergency
transfer agreement with a nearby hospital.
States should follow the guidelines outlined by the Federation of
State Medical Boards regarding informed consent.
States should consider legally privileged adverse incident
reporting requirements as recommended by the Federation of State Medical Boards
and accompanied by periodic peer review and a program of Continuous Quality
Improvement.


Board of Medical Specialties, the American Osteopathic Association, or a board
with equivalent standards approved by the state medical board within 5 years of