Outpatient Surgery Magazine

Administering Safe Cosmetic Anesthesia

The sticking point for many elective cosmetic surgery patients is the post-surgical experience of nausea and vomiting, the uncomfortable byproduct of an otherwise positive surgical outcome. Here are 10 quick ideas that could help minimize the complications and increase the satisfaction of the cosmetic surgery anesthesia administered at your facility.

The patient always comes first. Yes, the No. 1 issue for cosmetic surgery patients is PONV. In general, 80 percent of elective cosmetic surgery patients tend to be non-smoking females (about one-third of whom have positive histories for previous PONV and/or motion sickness) having procedures of two or more hours in duration. By Apfel and others' definition, this is a high-risk group of patients who deserve preemptive strategies to minimize or eliminate the risk of PONV.

Emetogenic versus non-emetogenic anesthesia. It would appear intuitively obvious that it is far better to avoid a problem than try to prevent it. Readers of Outpatient Surgery Magazine are well aware of this author's bias in favor of the non-emetogenic, BIS-monitored propofol ketamine monitored anesthesia care. Avoiding both inhalational agents and opioids essentially eliminates the causes of PONV. In these high-risk patients, only 13 of 2,680 experienced PONV over a 10-year period without any anti-emetic strategy. Even the few patients who did experience PONV stated they preferred PK MAC to anesthetics they've had in prior surgeries and would have it again.

Ketamine is no longer an unpredictable drug. Over the past decade, much of the stigma surrounding the unpredictable reputation of ketamine has begun to diminish. Using the BIS to medicate patients' propofol gradually to a level of 70 to 75 makes ketamine very predictable.

The brain can't respond to stimuli it doesn't receive. Giving a 50 mg dissociative dose of ketamine two to three minutes before injecting local anesthesia sets the stage for predictable preemptive analgesia. Preventing the brain from receiving the noxious signals from the injection of local analgesia is what the dissociative effect is all about. Post-operative pain management is essentially minimized. In fact, 1,000mg oral acetaminophen will often be adequate. Sometimes the "big blue pain pill" (Tylenol PM) is more advantageous for patients with anxiety that exceeds of physical pain.

Decrease endogenous adrenalin. Pre-operative anxiety is very common in any surgical patient. We've traditionally treated it with anti-anxiety drugs like benzodiazepines, namely midazolam (Versed), diazepam (Valium) and lorazepam (Ativan). But none of these agents does anything for the underlying cause of elevated adrenalin that accompanies the anxious patient. Oral clonidine 0.2mg (for patients between 95 and 175 pounds) given 30 to 60 minutes pre-operatively is very effective for decreasing the catecholamine level of the patients.

Benefits of lowered adrenalin. De facto tranquilization. Easier induction. Lowered drug maintenance requirements, especially for BIS-monitored propofol. Patients with less anxiety have less pain on emergence. Lastly, post-operative shivering is diminished. All of these benefits can be had for about 12 cents (generic).

BIS-monitored PK MAC isn't universally applicable. Surgeons who don't take their own post-op patient calls have difficulty appreciating the value of the decrease in phone traffic for PONV and pain management issues. The tradeoff between accepting the periodic need to re-inject more local compared to the functional ease of having an inhalation anesthetic given to the patient isn't worthwhile to them. Some surgeons and OR nurses have difficulty accepting the need to speak civilly in the OR. Angry, hostile exchanges have no place in an OR using BIS-monitored PK MAC. The anesthesiologist can't control the emotional maturity of the other people in the OR.

Multi-modal therapy with emetogenic anesthesia. If you can't avoid giving a general anesthetic, several suggestions have emerged to attempt to cope with this contingency. Bicitra 30cc PO will neutralize the stomach contents without the risk of particulate antacids. Metoclopramide (Reglan) will help to empty the stomach contents into the duodenum. The combination of dexamethasone, ondansetron (Zofran or other 5-HT3 agent of choice) and droperidol had been fairly successful in eliminating PONV in the facility, but less effective for postdischarge PONV. Many institutions no longer stock droperidol because of the FDA black box warning. The use of nitrous oxide is believed by many to increase the incidence of PONV.

Other modalities. Stimulation of the P-6 acupressure point with elasticized wristbands may also be useful, especially for patients prone to motion sickness. They fit around the patient's wrist just like a sweatband with a pressure knob sewn inside. The plastic knob sewn inside of the wristband exerts pressure and stimulates the P6 (or Nei-Kuan) acupressure point. It has been proven that pressure on this point relieves nausea and vomiting. The return of the scopolamine patch has its advocates, too. Unfortunately, some patients will experience hallucinations. Extrapyramidal reactions like torticolis have caused many to become less enthusiastic about using phenothiazines like chlorpromazine (Compazine).

Words from the sage. Charles E. Laurito, MD, founder and president of the Society for Office Based Anesthesia said it best: "For the anesthetic itself, overall experiences indicate that the least amount of anesthetic that can be used is the best dose. Local and monitored anesthesia care are preferable to regional. Regional techniques are preferable to general anesthesia."

Dr. Friedberg (drfriedberg@doctorfriedberg.com) is the author of the upcoming textbook Anesthesia in Cosmetic Surgery, Minimally Invasive Anesthesia for Minimally Invasive Surgery.