Frequently Asked Questions

Oliver Wendel Holmes coined the term "anesthesia" in the mid-1800s to describe the state of etherization as the absence of sensation. We now know that the state of anesthesia is composed of the elements of hypnosis (sleep) and analgesia (pain relief).

In an office-based setting, it could be the surgeon's secretary (at the surgeon's direction), a registered nurse with technical training in anesthesia, or an anesthesiologist (an MD specializing in the medical practice of anesthesiology).

Office-based anesthesia has given rise to the demand for S.A.F.E. (short acting, fast emerging) anesthesia. This need is greater in the office setting than in either a hospital or a surgicenter since it is paramount that patients in an office-based setting recover quickly-pain and nausea free-in order to free up the operating room, which often also serves as the admitting, surgery, and recovery room. Patients awaiting a procedure, or the physician scheduled to conduct a patient consult, can be delayed if the surgical patient is unable to emerge quickly from the anesthetic.

No. Crawford Long, DDS, was giving ether to his office patients in Louisiana in 1842 and Ralph Waters, MD, practiced anesthesia from his Downtown Clinic in Sioux City, Iowa in 1919. Privacy issues as well as the considerable economic advantages are had by patients choosing office based surgery. Efficiencies in time accrue to the surgeon as well.

Patients must always balance the advantages and take care that the facility has the ability to handle common emergencies which may occur during surgical procedures. Supplemental oxygen, positive pressure devices (i.e. Ambu bag) and a suction device to clear the airway are minimal standards insisted upon by medical liability carriers.

According to the American Society of Anesthesiologists' (ASA - www.asahq.org) publication on guidelines for a safe office anesthesia practice, an anesthesia machine is not necessary when non-triggering (i.e. no inhalational agents like isoflurane, desflurane or sevoflurane) anesthesia is used. States like Florida and California led the nation in requiring office certification by either AAAASF, AAAHC or HCFA (now CMS) agencies. Certification assures that a crash cart and defibrillator are present as well as policies and procedures to handle the day to day activities as well as emergencies. Certification per se does not assure sound medical judgment is being practiced.

The "P" stands for propofol (Diprivan, AstraZeneca) and the 'K' stands for ketamine (Ketalar, ParkeDavis). The combination "PK" stands for an anesthetic technique pioneered by Barry L. Friedberg, MD designed to maximize patient safety in the office-based setting.

PK technique creates the illusion of general anesthesia, with the minimal trespass of sedation. Patients neither hear nor feel their surgery, yet remain at the lightest level of anesthesia short of awake.

Cosmetic surgery differs from non-cosmetic surgery in that it involves only the superficial tissues. The choice of anesthesia options will depend on the preference of the patient, surgeon and anesthesia provider.

Depending on the patient and the surgeon (e.g. a motivated patient and cooperative surgeon) all cosmetic procedures can be performed entirely awake with local anesthesia only.

Most patients prefer to have some alteration of their level of consciousness from wide-awake. According to the American Society of Anesthesiologists (ASA - www.asahq.org) definition of anesthesia, there is a continuum of the depth of sedation from minimal (anxiolysis) to moderate (conscious) to deep (unconscious) to general anesthesia.

According to the ASA, PK would fall between moderate and deep sedation, depending on whether or not airway intervention is required. The principle shortcoming of the ASA definition of PK is the failure to account for the ability to quantitate (measure) the level of hypnosis from either propofol or methohexital -- the two most popular intravenous agents. The Bispectral Index® (BIS®) monitor (Aspect Medical System, Inc., Newton, MA - www.aspectms.com) is a validated measure of the patient's level of hypnosis. There are no units to the index but 98-100 is an awake value, whereas 0 represents an isoelectric (no electrical activity) value. Hypnosis compatible with general anesthesia is at a BIS® level between 40 to 60 on a scale of 0 to 100. Hypnosis compatible with sedation can be seen at BIS® levels between 60 and 80 on a scale of 0 to 100.

The ASA definiton of anesthesia goes on to state: "Because sedation is a continuum, it is not always possible to predict how a each patient will respond." The abililty to measure (i.e. the BIS®) is superior to trying to predict an individual's response to medication. Typically, the propofol is given as a slow, continuous, intravenous infusion to achieve and maintain a BIS® level between 60-70 on a scale of 0 to 100. The added bonus of the slow induction is that patients do not experience the intense sensation of being 'put out.' Many have commented that the 'going to sleep' part was the best.

Propofol is a very short acting drug, which makes it ideal for use in Office-based anesthesia. Being able to measure the patient's brain response to the propofol with a BIS® monitor greatly increases the accuracy of propofol dosing. Because no benzodiazpeines (Valium, Versed, Ativan, Dalmane) are used with PK technique, patients emerge from propofol hypnosis within 3 to 5 minutes of the propofol infusion being turned off at the end of surgery. Often patients are able to go home, clear headed, within 20 to 30 minutes after their surgery is concluded, with their surgeon's approval.

There is no other anesthetic technique that so often leaves patients with a sense of happiness and well being as does Dr. Friedberg's PK technique. Elective cosmetic surgery is about increasing one's sense of personal happiness which matches very well with the happiness experienced from PK technique. Patients have been quite enthusiastic in their response to PK, especially those with less than happy previous anesthetic experiences.

The use of opioids (narcotic medications like morphine, Demerol, fentanyl) are a common practice for pain relief in anesthesia. Opioids are associated with a 15-40 percent incidence of postoperative nausea and vomiting (PONV). By providing non-opioid analgesia (pain relief), PK technique has essentially eliminated PONV from patient recovery.

The sore throat after anesthesia is often associated with endotracheal (inside the windpipe) breathing tubes. PK technique does not utilize endotracheal tubes for airway management, so it is very rare for patients to experience a sore throat after PK technique.

Non-narcotic pain relief from ketamine and adequate local anesthesia with PK technique has essentially eliminated PONV. Even by using two anti-nausea medications, techniques that use opioids report an 8 percent PONV rate. By contrast, PK has less than a 0.5 percent PONV without the use of any anti-nausea medications. Also, anti-nausea medications can have unpleasant side effects of their own.

All cosmetic procedures from abdominoplasty (tummy tuck), liposuction, breast augmentation, to facelift and other facial enhancement procedures, can be performed with PK. Other procedures where PK is appropriate include hernia repairs, lower abdominal (Gyn) laparoscopy, joint arthroscopy, and lithotripsy. It is important for patients to be aware of this non-opioid alternative and ask their surgeon and anesthesiologist if they can have it for their surgery

Safety. Ketamine (Ketalar, ParkeDavis) was introduced in 1964 as a complete intravenous anesthetic agent for humans. We have since learned that ketamine is better suited as an addition (adjuvant) to rather than a 'stand alone' anesthetic in humans above the age of ten. The safety profile of ketamine is the reason it is also used in veterinary anesthesia.

There have been no deaths reported from clinical doses of ketamine which is not the case for the opioids (i.e. morphine, Demerol, fentanyl). One cannot equate the clinically controlled use of ketamine from the media reports of deaths from uncontrolled doses of questionable purity.

Ketamine had fallen into disfavor among anesthesiologists for the same reason it is being abused on the street; i.e. its hallucinogenic potential. Many websites exist to describe ketamine for street use. This is not one. Titrating the propofol to a BIS® range between 70-75 prevents hallucinations from ketamine, making the agent predictable. This accounts for the growing resurgence in the clinical use of ketamine by anesthesiologists who insist on predictablility, as well as safety, from the agents they employ.

In general, Preoperative Patient Protocol is the standard "nothing by mouth after midnight". This is not an unreasonable starting place for patient instruction. Long experience with room air, spontaneous ventilation, office based anesthesia has led to several modifications of this old instruction.

1. Patients taking anti-hypertensives, anti-depressants, beta blockers, asthma medications or oral hypoglycemic agents should maintain their usual morning dosage with enough water to comfortably get their medications down. Asthmatics should bring their inhalers with them to surgery.

2. Patients who regularly consume caffeinated beverages who experience headache without the usual morning caffeine dose are encouraged to have their usual morning dose of caffeine WITHOUT any dairy product. Nondairy creamers are acceptable if needed.

3. Patients who are very hungry upon awakening may have toast and jam and/or apple juice if so desired.

4. Patients who are scheduled for afternoon surgery may have a light breakfast not closer than four hours prior to their surgery. Again "light" means NO DAIRY PRODUCTS (i.e. milk, cream, butter, yogurt, or cheese)

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If one does not believe the BIS is useful, then these cases provide
ample reason not to use it.

If you believe, as I do, the BIS gives you information you cannot
obtain by vital signs monitoring, then one finds a way to use the
device.

For facelifts, my surgeons typically start on the right side of the
face. Therefore, I put the #3 tab of the montage on the left side of
the face.

N.B. If your surgeon is concerned about the sterility of the sensor,
PREP IT, taking care not to get the liquid into the junction of the
sensor and the cable.

If your scrub nurse is overly vigorous, it is possible to disrupt
the adhesion between the skin and the sensor. Just dabbing the sensor
will do fine.

Unless the patient is to receive some sort of facial implant along
with the facelift, then sterility is not a huge issue. It is very
difficult to get an infection in the facelift patient.

If, after the first side of the facelift, you want to continue to
monitor with the BIS, several options are available:

1. Remove the sensor and turn it around so the little tab is now on
the patient's right temple area.

Re-prep is one feels the need. I do not think it is necessary,
initially or secondarily.

2. Leave the first 3 sensor leads in place and move the #3 tab up,
down or anywhere it will be far enough away from the incision not to
disturb the surgeon.

Having done this several times, I have not observed any serious
degradation in the utility of the monitoring information.

If, on the other hand, the patient has been stable and you are
comfortable with your dosing regimen, one can always simply remove the
sensor and stop using the device.

Browlifts are a more interesting situation.

If you surgeon is still doing the coronal ear to ear incision with
full flap reflection down onto the nose, you will obviously lose the
usefulness of the monitor for the time the flap is completely
elevated until it is replaced.

Many surgeons around the world have abandoned this open style of
browlift in favor of the endoscopic style browlift.

Nicanor Isse, M.D., Oscar Ramirez, M.D., and Luiz Vasconez, M.D. are
the three plastic surgeons generally credited for the development of
this type of browlift.

As fate would have it, I had the opportunity to anesthetize most of
Dr. Isse's patients, including his endo-browlifts, for the 4 years
prior to beginning to writing Anesthesia in Cosmetic Surgery in
2004. Dr. Isse also had me lecture about MIA at several of his
Endoscopic Plastic Surgery Educational Seminars (EPSES) courses as
well as give the anesthesia for the demonstration cases. He is
pictured along side of me in an article I wrote for Outpatient Surgery
Magazine in February 2004 entitled 'Minimally invasive anesthesia for
minimally invasive surgery. Although the article is a trade journal,
non-peer reviewed one, it was cited on the Karolinska Insititute web
site.

During none of Dr. Isse's endo-browlift cases did we have to
discontinue BIS monitoring.

During the few moments the skin flap is entirely elevated from the
skull, obviously, one will lose input to the sensor/BIS.

Hopefully, knowing BS monitoring was good for Dr. Isse will be
sufficient to reassure your surgeons that it will be OK for them.

I dealt with the sensor issue for the endo-browlifts in the same way
I described above for the facelift cases.

Hair transplantations have not been as big an issue as either
facelifts or endo-browlifts. I would suggest putting the patient in
the prone position to whatever level of sedation you choose for the
harvest and disconnecting the sensor before turning the patient
supine. (If one does not detach the cable, one risks inadvertently
puling it off during the turning process.) In this manner one has only
to turn the patient once. One may even lighten the patient enough to
allow them to turn themselves and then deepen the sedation. They are
unlikely to have any recall when asked post-operatively.

EMG

If you are already trending the EMG as a secondary trace, please
accept my apology for being redundant.

If you are NOT trending EMG as a secondary trace, please do so.

BIS is 15-30 seconds delayed behind real time whereas, EMG is
instantaneous.

Titrating propofol with BIS only is much like trying to drive down the
street using only your rear view mirror.

EMG spikes will greatly increase the utility of the monitor to predict
patient movement and your ability to proactively manage the propofol
as opposed to perpetually playing 'catch-up.'

Table 1-9 Errors to Avoid

1. Ketamine before propofol: NO

2. Ketamine at BIS >75: NO

3. Bolus propofol induction: NO

4. Inadequate local analgesia: NO
BIS as fianchetto for adequate propofol and lidocaine

5. Opioids instead of more lidocaine: NO

6. Ketamine instead of more lidocaine: NO

7. >200 mg total ketamine or any in last 20 min. of case: NO

8. Tracheostomize patient for laryngospasm instead of IV lidocaine: NO

9. SCH instead of lidocaine for laryngospasm: NO