Plastic & Reconstructive Surgery

Robert M. Goldwyn, M.D.
Editor in Chief
Plastic & Reconstructive Surgery

A role for the anesthesiologist in elective cosmetic surgery

Kudos to Marcus, et. al. (1) recent publication of a Level I study on postoperative nausea and vomiting (PONV) . There are several distressing elements of the article, beginning with the title ‘Prevention of Emesis...’ By reducing their PONV incidence from 30 to 13%, they did not prevent its occurrence.

There is a very serious typo on pg. 2490, line 5 in ‘Results.’ The average dose of fentanyl reads 167 ‘mg’ instead of 167 ‘mcg’ or ‘ug’ as in micrograms. Surgeons attempting to emulate their example would more likely have non-breathing patients!

Most distressing to me was the statement “Whether alternative sedation regimens, such as propofol infusion or the dissociative technique based on ketamine, have more optimal outcomes remains to be determined.” (my italics) A recent publication by Yoon, et. Al. (2) published a 2.2% PONV rate with a low dose propofol, no opioids and no prophylactic onandsetron! Certainly the authors could be excused for being unaware of this work as it appeared on these pages only 3 months ago. An Index Medicus literature search on either ‘ketamine’ or ‘dissociative technique’ would have pulled the Level IIIa Friedberg paper (3) in Aesthetic Plastic Surgery. There are three subsequent letters (4,5,6) citing this paper in both the surgical and anesthesia literature. A PONV rate of 0.7% (7 of 1,264 patients) was reported in a high risk group of predominantly middle aged females using a propofol infusion, a dissociative dose of ketamine and avoiding routine emetogenic opioids. A recent ASA publication (7)states : “The literature suggests that, when administered by non-anesthesiologists that propofol and ketamine can provide moderate sedation.” This appears to validate the safety of Vinnik’s approach (8) that Marcus et. Al. also cite and in whose path they follow.

Later in the same article (7), the recommendations state: “Even if moderate sedation is intended, patients receiving either propofol or methohexital by any route should receive care consistent with that required for deep sedation. Accordingly, practitioners administering these drugs should be qualified to rescue (my italics) from any level of sedation, including general anesthesia.” This is why I was unable to comply with Dr. Vinnik’s request to defend a surgeon who performed a tracheotomy on a ketamine receiving patient who had laryngospasm intraoperatively.

The patient who presents with a history of previous PONV (as one third of my patients do) is telling us that they are opioid sensitive and must be given a non-opioid approach, like propofol ketamine (PK), to best approximate a zero PONV rate. In my ten year, 2,680 patient experience (now 13 emesis or 0.05% PONV), PK technique without anti-emetic prophylaxis seems to demonstrate a ‘more optimal outcome’ than Marcus et. Al. I again (9) respectfully suggest that, despite the statistical success of Marcus, et. Al. in reducing PONV, there may be a useful place for the evolved anesthesiologist in elective cosmetic surgery.

Yours for better outcomes,

Barry L. Friedberg, MD