Patient Awareness - The Key to Safer Cosmetic Surgery Anesthesia
Aside from post-mastectomy reconstruction, no cosmetic surgery has a medical reason or indication. Patient deaths in cosmetic surgery are uncommon. it is the nature of cosmetic surgery that creates a media frenzy when deaths do happen. It stands to reason that, if you don't have to have a surgery, dying having it would be very unacceptable as well as attract a great deal of media attention.
General anesthesia (GA) is almost certainly the commonest form of anesthesia given for cosmetic surgery. It is expedient but fraught with avoidable risks. There are no avoidable risks for surgery that has no medical indication as is the case for cosmetic surgery. Those avoidable risks include malignant hyperthermia (i.e. recent Florida teen death), lack-of-oxygen mishaps leading to brain damage or death, blood clots to the lungs, vomiting, edema of the lungs. These risks occur because of the significant degree of trespass depressing the patient's ability to protect themselves.
Fortunately, there is a alternative anesthetic technique that creates a minimal trespass and thereby maximizes patient safety while eliminating the risks associated with GA. In 1997, Dr. Friedberg developed BIS monitored propofol ketamine technique, now trademarked as minimally invasive anesthesia(MIA)®
The BIS monitor generates a number from 0-100 generated by information collected by a forehead sensor on the patient. The lower the number, the more asleep the patient is.
Most patients desire to neither hear, feel or remember their surgery - a state associated with GA (BIS 45-60). MIA gives the identical experience of GA at BIS 60-75 with 20-30% less medication (i.e. propofol). 'Goldilocks' anesthesia becomes possible by not letting the BIS drift lower than 60 ('too much') and not letting it go higher than 75 ('too little'). BIS between 60-75 is 'just right' along with adequate local analgesia.
A fair number of anesthesiologists have embraced the concept of brain monitoring as useful to assist in the giving of anesthesia.. However, many anesthesiologists have been reluctant to adopt technology approved by the FDA in 1996.
Since the brain is what is being medicated, it stands to reason that using a device like the BIS that measures the brain response would be a far more accurate way to give patients their anesthetic drugs. Rarely has a member of the lay public failed to grasp this obvious point. Having patients request this type of monitoring may be a positive force for change.
Gradually giving propofol while following the BIS down to 75 often permits patients to continue to breathe on their own without requiring additional oxygen to be safe. Under these conditions, lack-of-oxygen mishaps have never occurred with MIA.
Once BIS reaches 75, ketamine may be given. Propofol at BIS less than 75 prevents all of the historically reported negative side effects while to sparing the patient from experiencing the pain of the local anesthetic injection that is common to all cosmetic procedures. The numerical value of the patient's brain response to propofol makes giving the ketamine a predictable, reproducible, and very safe experience.
Propofol is a powerful anti-nausea medication, so MIA patients have the lowest incidence of vomiting (0.5%), even without additional anti-nausea medications like Zofran®. Neither propofol nor ketamine are triggering drugs for malignant hyperthermia which eliminates that risk.
The Doctors' Company (TDC) is a medical malpractice insurer with a large number of plastic surgeons as insured. The Fall 2005 TDC Newsletter about deep vein thrombosis (blood clots) and pulmonary emboli (blood clots to the lungs) said:
"... the immobility associated with general anesthesia is a risk factor for thromboembolism. Newer techniques for intravenous sedation that include the use of propofol drips, often in combination with other drugs, have made it possible to perform lengthy or extensive surgeries without general anesthesia and without the loss of the patient's airway protective reflexes." reference #11
11. Friedberg BL: Propofol-ketamine technique: dissociative anesthesia for office surgery. Aesthetic Plastic Surgery Journal 1999,23;70.
Some anesthesiologists are just as reluctant to give patients ketamine as they are to utilize brain activity monitors like the BIS. Patients will likely need to ask for MIA in order to receive it.
Any anesthesia provider has more skill than necessary to provide MIA. Giving MIA is more a matter of being asked to provide it than any technical difficulty in doing it.
Create a force for change! If you knew there was a safer (simpler and better) anesthetic for cosmetic surgery, wouldn't you want to ask for it?
Barry L. Friedberg, M.D. is a Board certified anesthesiologist and has been an ardent promoter of safety in cosmetic surgery. He supports the Anesthesia Patient Safety Foundation. He has been in active practice exclusively in office-based anesthesia for cosmetic surgery since 1992. He has published 30 letters to the editor, 14 articles and 6 book chapters including 3 in "Anesthesia in Cosmetic Surgery" recently published by Cambridge University Press. Dr. Friedberg is also an Assistant Professor in Anesthesia at the University of Southern California in Los Angeles where he is volunteer faculty. He has lectured in the US and abroad. Dr. Friedberg also provides an on-site training service for those who request it.
Disclaimer: Dr. Friedberg is not employed by Aspect Medical Systems, makers of the BIS monitor. He is not a stockholder or a paid consultant. The opinions expressed herein are his professional opinion based on 11 years experience with BIS monitoring.
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