Plastic & Reconstructive Surgery

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

A role for the anesthesiologist in elective cosmetic surgery?

As an anesthesiologist currently providing propofol infusions for Dr. Nicanor Isse’s office based cosmetic surgical patients, I congratulate Yoon, et. al. (1) on their recent article but have several points of concern.

Dr. Charles A. Vinnik, who generously shared his working knowledge of ketamine(2) with me in 1992, created a twenty year legacy of teaching surgeons to administer their own diazepam ketamine anesthesia sans the presence of an anesthesiologist or CRNA. The respiratory safety of intravenous diazepam is unquestionably greater than for either midazolam or propofol.

While a recent publication stated that propofol and ketamine, when administered by a non-anesthesiologist, can provide satisfactory sedation(3), it is also important to note that another recent publication confirmed the superior value of the bispectral index (BIS) monitor (Aspect Medical Systems, Inc., Newton, MA) to any pharmacodynamic or pharmacokinetic modeling to predict the enormous individual patient variation in response to a given propofol dosing regimen(4). Yoon, et. Al. report using a 0.8 mg/kg loading dose of propofol in a relatively young (average age 35) patient population.

Your readers are well advised to take note that this level of propofol as a bolus is much more likely to lead to depression of both respiratory and cardiovascular systems in the 50-70 year old facelift patient population.

I do not administer any loading bolus of propofol in my approach. Measuring the propofol response with the BIS has enabled the majority of my patients to maintain SpO2 > 95% on room air! The routine administration of 5 liters of oxygen per minute obscures the validity of the authors’ conclusion that the loading dose of propofol was devoid of a significant decrease in oxygen saturation.

The routine use of midazolam premedication is another area of concern. Despite it’s use in the Friedberg article cited by the author’s(5), I abandoned midazolam in June ‘97, three months prior to the Level I study by Oxorn showing a three fold and statistically significant increase in patients requesting pain medication in recovery in those who received 2 mg IV midazolam premedication compared with those who did not(6). In lieu of midazolam, I began using 200 mcg of oral clonidine 30-60 minutes preoperatively in December ‘98 and published my results(7). Good preoperative sedation was achieved without postoperative ‘hangover’ or other serious side effects. I am disturbed ratio of operative time to time to discharge reported by Yoon, et. Al. They report an average 65 minute operative time with an average 45 minute recovery time. The Friedberg article they cite shows an average 150 minute operative time with an average <60 minute time to discharge(5). This article was during the era of midazolam premedication and prior to the era of routine BIS monitoring in December ‘97. The important distinction between Yoon, et. Al. and Friedberg was that an anesthesiologist (BLF) was involved titrating both the midazolam as well as the propofol in the latter article!

Timeliness of patient preparation is always an issue for efficient use of any surgical facility, be it an office, surgicenter or hospital setting. During the same 6 minutes Yoon, et. Al. report giving the midazolam and loading dose of propofol, I am able to safely induce hypnosis with propofol to a BIS = 70-75 (eliminating the hallucinations[8]) and give a 50 mg dissociative dose of ketamine to prepare my patients for a pain free injection of local anesthetic. Measuring the propofol with the BIS makes ketamine a predictable agent. Blocking the NMDA receptors with ketamine sets the stage for true preemptive analgesia.

Postoperative nausea and vomiting (PONV) is the number one anesthesia outcome patients most desire to avoid(9). Yoon, et. Al. report a 1 of 45 or 2.2% PONV rate compared to Friedberg’s 7 of 1264 or 0.6% rate(5). While 2.2% is surely a great improvement over the usual 8-35% PONV rate cited in the anesthesia literature, it is a nearly 4 fold greater than the Friedberg article cited.

As a result of incorporating the BIS monitor into my practice in addition to the clonidine premedication, propofol consumption has decreased from an average 3 -20 ml bottles per hour to 2(7). In addition to significantly reducing the cost of the propofol, BIS monitoring to a level of 60-70 intraoperatively enabled me to recently discharge, awake and alert, a patient 30 minutes after a 9.5 hour surgery for another plastic surgeon that included 3 hours of liposuction (garments applied immediately) followed by 6 hours of facial surgery. Clearly measuring the patient’s response to propofol is better than guessing.

In summary, my published experience suggests replacing the midazolam premedication with clonidine and measuring the propofol response with a BIS monitor will result in better ratios of surgery time to time to discharge as well as increasing the patient’s level of satisfaction. As I have no contractual arrangements for service, my practice is only as secure as the quality of my last anesthetic. My patients report nearly universal satisfaction with my propofol ketamine approach. Elective cosmetic surgery is about increasing our patients’ level of happiness. Lost in Yoon, et. Al. is the value of the happiness patients report from the gradual propofol induction. I respectfully suggest that, despite the success of Yoon, et. Al., there may still be a useful role for the anesthesiologist armed with propofol and a BIS monitor in the suite where elective cosmetic surgery is performed.

Yours for better outcomes,

Barry L. Friedberg, MD