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airway. Cardiovascular, respiratory, and neurologic evalu-
Regional Anesthesia for Cosmetic Surgery 133



Table 12-3. Conditions associated with increased Table 12-5. Conditions associated with increased
risk of neuraxial anesthesia risk for ambulatory surgery

Condition Risk Condition Risk

Perioperative MHa
Increased intracranial Brain stem herniation Malignant hyperthermia
pressure reaction
Signi¬cant coagulopathy Spinal or epidural Obstructive sleep apnea, Postoperative airway
hematoma obesity obstruction
Uncorrected hypovolemia Shock, cardiovascular Oxygen desaturation
collapse Unstable systemic disease Exacerbation of symptoms
Infection overlying needle Neuraxial infection Absence of reliable Insuf¬cient assistance for
puncture site caregiver patient after discharge
Systemic sepsis Neuraxial infection Surgery involving Intravascular volume
Signi¬cant aortic stenosis Cardiovascular collapse signi¬cant blood loss depletion and ¬‚uid
Unstable neurologic disease Neurologic de¬cit shifts
Local anesthetic allergy Allergic reaction Surgery associated with Potential for hospital
prolonged recovery admission
Surgery associated with Potential for hospital
severe postoperative admission for analgesia
course as well as the potential side effects and risks of the
pain
anesthetic technique(s) contemplated.
Local anesthetic allergy Allergic reaction
Patients having cosmetic surgery are a unique subset. a MH = malignant hyperthermia
They often have numerous questions, seek more infor-
mation than the general surgical population, and have
extremely high standards and expectations.
Special Consideration: Coagulation Abnormalities
As discussed, the patient™s underlying medical conditions
Table 12-4. Conditions associated with increased
risk of peripheral nerve blocks factor into the decision regarding the suitability of regional
anesthesia. Altered coagulation is one such condition that
Condition Risk
deserves special mention as it increases the risk of neuraxial
Infection overlying needle Perineural infection hematoma following spinal or epidural anesthesia. Coagu-
puncture site
lopathy may result from an intrinsic defect in the patient™s
Blood loss ± transfusion
Signi¬cant coagulopathy
coagulation system, from prescribed anticoagulant medi-
Hematoma ± nerve
cation, or from nonpresciption drug use like garlic, ginger,
compression
Uncorrected hypovolemia Shock, cardiovascular or ginko biloba (see Table 14-3 in Chapter 14).
collapse
Patients with an intrinsic bleeding diathesis such as
Perineural tumor Tumor seeding and
hemophilia or thrombocytopenia represent a subset of
spread
Blood loss ± transfusion
Perineural vascular patients with altered coagulation. Preoperative assessment
Hematoma ± nerve
malformation includes a focused bleeding history and physical examina-
compression
tion. Appropriate laboratory evaluation depends on the
Unstable neurologic Neurologic de¬cit
underlying disorder, and perioperative management usu-
disease
Previous thoracic surgery Obliteration of ally occurs in conjunction with a hematologist. Individ-
paravertebral space by
uals with moderate and severe disease would rarely be
scar tissue
considered for ambulatory cosmetic surgery because of
Pneumothorax from
the increased surgical and anesthetic risk. Patients with
paravertebral block
Infection within chest Paravertebral or neuraxial mild disease having low-risk surgical procedures may
cavity (i.e., empyema) infection from
be suitable. However, these patients require a thorough
paravertebral block
evaluation of their coagulation system and coordination
Local anesthetic allergy Allergic reaction
with their hematologist prior to being considered for
134 Holly Evans and Susan M. Steele


neuraxial anesthesia. The risk of neuraxial hematoma tion is as described previously. The American Society
increases as coagulation parameters fall out of the range of Regional Anesthesia guidelines for the perioperative
of normal. The risk-to-bene¬t ratio must be considered in management of anticoagulation therapy for patients hav-
the context of this population of patients who are having ing spinal or epidural anesthesia are summarized in
Table 12-6.9
entirely elective procedures.
Patients with altered coagulation as a result of antico- Guidelines regarding the use of peripheral nerve blocks
agulants used for thromboprophylaxis represent another for patients with altered coagulation due to an intrin-
subset of anticoagulated patients. Preoperative evalua- sic bleeding diathesis or the use of thromboprophylactic




Table 12-6. American Society of Regional Anesthesia and Pain Medicine recommendations
regarding neuraxial anesthesia in the patient receiving thromboprophylaxis

Thromboprophylactic agent Recommendation

No contraindication with NSAIDsa
Antiplatelet Medication
Discontinue ticlopidine 14 d in advance
Discontinue clopidogrel 7 d in advance
Discontinue GP IIb/IIIab inhibitors 8“48 h in advance
Unfractionated Heparin (Subcutaneous) No contraindication
Consider delaying heparin until after block if technical
dif¬culty anticipated
Unfractionated Heparin (Intravenous) Heparinize 1 h after neuraxial technique
Remove catheter 2“4 h after last heparin dose
No mandatory delay if traumatic
Low Molecular Weight Heparin Twice daily dosing:
LMWHc 24 h after surgery, regardless of technique
Remove neuraxial catheter 2 h before ¬rst LMWHc
dose
Single daily dosing (as per the following European
guidelines):
Neuraxial technique 10“12 h after LMWHc
Next dose at least 4 h after needle or catheter
placement
Catheters removed 10“12 h after LMWHc and 4 h
prior to next dose
Postpone LMWHc 24 h if traumatic
Document normal INRd after discontinuation (prior to
Warfarin
neuraxial technique)
Remove catheter when INRd ¤ 1.5 (initiation of
therapy)
Thrombolytics No data on safety interval for performance of
neuraxial technique or catheter removal
Follow ¬brinogen level
Herbal Therapy No evidence for mandatory discontinuation prior to
neuraxial technique
Be aware of potential drug interactions
Adapted from Horlocker TT, Wedel DJ, Benzon HP, et al.: Regional anesthesia in the anticoagulated patient:
De¬ning the risks (the second ASRA consensus conference on neuraxial anesthesia and anticoagulation). Regional
Anesthesia & Pain Medicine 28;172,2003.9
a NSAIDs = nonsteroidal anti-in¬‚ammatory drugs
b GP IIb/IIIa = glycoprotein IIb/IIIa inhibitors
c LMWH = low molecular weight heparin
d INR = international normalized ratio
Regional Anesthesia for Cosmetic Surgery 135


agents are extrapolated from those described previously.9 Ketamine affords an alternate option for analgesia with a
lower incidence of opioid-related side effects such as nau-
Adherence to these guidelines should be more stringent
sea, vomiting, respiratory depression, and pruritus. The
for peripheral nerve blocks performed near noncompress-
dysphoria associated with ketamine may limit the use of
ible vessels (i.e., intercostal or sciatic nerve block) and for
this agent; however, the concurrent use of midazolam can
those where hematoma formation could result in signi¬-
minimize side effects.11 The alpha2 agonist, clonidine, also
cant injury to nerves or other surrounding structures (i.e.,
paravertebral or lumbar plexus block).10 offers analgesia with minimal opioid-related side effects,
though this agent may cause hypotension and bradycardia
MONITORING AND SEDATION as well as prolonged postoperative sedation. Nonpharma-
cologic anxiolysis is generated from verbal reassurance or
Monitoring
music.12 The importance of this cannot be overempha-
Intravenous access, supplemental oxygen, and appropri-
sized.
ate monitors are imperative to the safe practice of regional
anesthesia. Nerve blocks can produce signi¬cant physi-
ologic changes (see Table 12-2). Furthermore, multisys-
Intraoperative Sedation
temic side effects may result from the intravascular absorp-
Intraoperative sedation should enhance patient comfort
tion of large volumes of local anesthetic. Consequently,
yet have minimal postoperative effects allowing for timely
monitoring with pulse oximetry, noninvasive blood pres-
patient recovery. Sedation can be continued intraoper-
sure, and electrocardiogram are required both during
atively using incremental doses of the agents described
block placement and intraoperatively.
herein. Alternatively, an infusion of a short-acting, eas-
Sedation for Block Placement ily titratable agent can be used (see Table 12-7). Target-
Sedation may be required during block placement. In this controlled infusion devices may be used to minimize drug
setting, the goal is to relieve apprehension and pain as dose and associated side effects and have also been used to
provide patient-controlled sedation.13
well as to maintain a communicative patient able to con-
vey information about potential adverse effects of regional The pharmacokinetics of propofol make it well suited
anesthesia. For example, description of paresthesias allows for sedation by continuous infusion. It has a rapid onset,
needle redirection and prevention of intraneural injection is easily titratable, and is associated with prompt awaken-
of local anesthetic. And communication about tinnitus ing upon discontinuation of the infusion. The use of pro-
and metallic taste allows discontinuation of injection of pofol has also been effective in reducing the incidence of
postoperative nausea and vomiting.14 The ultrashort-
local anesthetic and prevention of more serious symptoms
related to local anesthetic toxicity. acting potent opioid remifentanil is designed for contin-
Intravenous agents are typically used for their titrata- uous infusion and provides sedation as well as additional
bility (see Table 12-7). Benzodiazepines provide anxiolysis analgesia. Servin et al. compared sedation with an infus-
ion of remifentanil (0.1 ug · kg’1 · min’1 IV) or propofol
and anterograde amnesia. They raise the seizure threshold,
(50 ug · kg’1 · min’1 IV) in patients who received regional
which is advantageous when large doses of local anesthetic
anesthesia for their surgical procedure.15 Servin et al. fou-
are used. The benzodiazepine midazolam is frequently
used owing to its rapid onset, relatively short half-life, and nd that remifentanil provided greater analgesia, less amne-
lack of active metabolites. Analgesia and additional seda- sia, and a higher incidence of respiratory depression and
postoperative nausea and vomiting (PONV).15 Dexmede-
tion result from supplementation with opioid analgesics.
The potent, short-acting agent fentanyl is frequently emp- tomidine is a short-acting alpha2 agonist suitable for
loyed for this purpose. Benzodiazepines and opioids can continuous infusion. It provides improved postopera-
both be reversed with speci¬c antagonists, and this further tive analgesia and has opioid-sparing effects compared
enhances their safe application for perioperative sedation. to propofol. However, it has a slower onset of action, a
The half-life of reversal agents is sometimes shorter then longer duration of action after discontinuation of infusion,
the drugs being reversal. Dependence on reversal agents and a greater incidence of postoperative hypotension and
sedation.16
provides, the illusion of safety.
136 Holly Evans and Susan M. Steele



Table 12-7. Selected intravenous agents used for sedation

Mechanism Speci¬c agents
Class of agent of action Systemic effects Adverse effects and dose

Bind to GABAa
Benzo- Sedation Hypotension Midazolam
diazepines A receptor Anxiolysis Respiratory depression Incremental doses of
Facilitate central Anterograde amnesia Prolonged sedation in 20“30 ug/kg IV up
to 0.1 mg · kg’1
nervous system Anticonvulsant some patients
inhibition of Skeletal muscle relaxation
Paradoxical excitement in
GABAa some patients
Opioids Opioid receptor Sedation Nausea, vomiting Fentanyl:
(i.e., mu, kappa, Analgesia Pruritus Incremental doses of
0.5“1.5 ug · kg’1 IV
delta) agonists No amnesia Respiratory depression
Decrease Urinary retention Alfentanil:
5“10 ug · kg’1 IV
neurotransmitter Constipation
release Muscle rigidity Remifentanil:
0.025“0.2 ug · kg’1
Bradycardia
b receptor Emergence deliriumc 0.15“0.5 mg · kg’1
Ketamine NMDA Dissociative state
Psychosisc
antagonist May Sedation
Hallucinationsc
also interact with Analgesia
opioid receptors Amnesia Increases salivary
Pharyngeal and laryngeal secretions
re¬‚exes maintained near Nystagmus
Increases ICPd and IOPe
normal
Sympathomimetic effects
Bronchodilation
Clonidine1“2 ug · kg’1
Alpha2 Sympathetic alpha2 Sedation Hypotension
Agonists receptor agonists Analgesia Bradycardia IV or 0.2 mg po
Decrease Minimal respiratory Prolonged sedation Dexmedetomidine
Bolus: 0.4“1 ug · kg’1
(clonidine >
neurotransmitter depression
release dexmetetomidine) IV over 10“20 min
Infusion: 0.2“0.7 ug ·
kg’1 · hr’1 IV
25“100 ug · kg’1 ·
Propofol Presumed via Sedation Pain on intravenous
min’1 IV
interaction with Amnesia injection
GABAa receptor Antipruritic Hypotension
Anticonvulsant Respiratory depression,
Antiemetic apnea
Spontaneous excitatory
movements
Supports growth of
microorganisms
a GABA = Gamma-amino-butyric acid
b NMDA = N-methyl-D-aspartate
c Editor™s note: This information is correct only when ketamine is given as a sole IV agent. Friedberg BL : Hypnotic doses of propofol

block ketamine induced hallucinations. Plast Reconstr Surg 91:196,1993. ”BLF
d ICP = Intracranial pressure
e IOP = Intraocular pressure
Regional Anesthesia for Cosmetic Surgery 137



Table 12-8. Potential advantages of spinal Table 12-9. Selected potential adverse effects
of spinal anesthesia1,9,27,64,77“83
anesthesia for cosmetic surgery1,3,7

Ease of performance Self-limiting Back pain
Dense anesthesia Urinary retention
Minimal additional sedation required Transient neurologic symptoms
Prompt return of awake state Postdural puncture headache
Low incidence of PONVa Rare but serious Epidural abscess
Reduced physiologic stress response Spinal or epidural hematoma
Reduced thromboembolic complications Meningitis
Low incidence of local anesthetic toxicity Cauda equina syndrome
Cost savings Isolated nerve injury
Total spinal anesthesia
a PONV = postoperative nausea and vomiting Bradycardia and cardiac arrest



SPINAL ANESTHESIA
Lidocaine and mepivacaine both have a rapid onset and
short to intermediate duration of action.18,19 Lidocaine
Indications and advantages
has been associated with transient neurologic symptoms,
Spinal anesthesia provides rapid onset, bilateral surgical
which has signi¬cantly curtailed its use, particularly in the
anesthesia for cosmetic procedures of the abdomen and
outpatient population.20,26 In addition, there is some evi-
lower extremities. Potential advantages are outlined in
dence that this complication may also occur with mepiva-
Table 12-8.
caine.27 Procaine is another short-acting agent. However,
its use has been limited by frequent block failure.28
Equipment
A preparation of chloroprocaine without the preserva-
Two classes of spinal needles are available. Cutting nee-
tive methylparaben or the antioxidant bisul¬te has recently
dles, such as the Quincke or Greene, have a beveled distal
been used for spinal anesthesia.29,34 In a crossover study of
tip with an end ori¬ce. Pencil-point needles, such as the
volunteers, intrathecal chloroprocaine (40 mg) was com-
Whitacre or Sprotte, have a blunt distal tip and an ori-
pared to lidocaine (40 mg).29 Investigators found that
¬ce on the side of the distal needle shaft. Pencil-point
both provided adequate anesthesia. However, the chloro-
needles provide an enhanced tactile feel as the needle is
procaine group had faster resolution of sensory block by
advanced through the various tissues. Spinal needles in
twenty-three minutes as well as earlier time to ambula-
current use have an inner stylet that prevents plugging of
tion and voiding by thirty minutes. Transient neurologic
the needle with skin or fat and subsequent deposition into
symptoms occurred in 87.5% in the lidocaine group and
the epidural or subarachnoid space. Both classes of nee-
none in the chloroprocaine group. In a study of simi-
dles are available in a range of diameters and lengths. The
lar design, spinal anesthesia with chloroprocaine (40 mg)
gauge describes the outer diameter of the needle. A larger
was compared to low-dose bupivacaine (7.5 mg).35 Both
gauge represents a smaller diameter needle (i.e., a 29 ga
agents had a similar peak block height and time to peak
needle has a smaller diameter than a 22 ga needle). The
block; however, complete regression of sensory and motor
use of pencil-point and small-gauge needles is associated
block, ambulation and voiding occurred over one hour
with a lower incidence of postdural puncture headache
(PDPH).17 Small gauge needles can be more technically later in the bupivacaine group. Despite the bene¬cial
pro¬le described, the addition of epinephrine to hyper-
dif¬cult to use as they are more prone to de¬‚ection and
baric chloroprocaine has been associated with transient
often have slower return of cerebrospinal ¬‚uid.
neurologic symptoms and nonspeci¬c, transient, ¬‚u-like
symptoms.30 Transient neurologic symptoms are rare with
Local anesthetics and adjuvants
bupivacaine and levobupivacaine.36 These agents have a
The selection of local anesthetic for spinal anesthesia is
based on the desired block onset, duration, and spread, as long duration of action, which can potentially delay recov-
ery and discharge of ambulatory patients.37 A reduction
well as the drug™s side-effect pro¬le.
138 Holly Evans and Susan M. Steele


in dose has been used in an attempt to shorten the dura- anesthesia for cosmetic surgery as it has a rapid onset and
short duration of action.44,46,48 Hydrophilic opioids, such
tion of action; however, this can potentially lead to block
failure.37 Intrathecal ropivacaine also has a long duration as morphine (0.1“0.3 mg), have a longer duration of effect
of action.38“42 However, some studies have shown earlier and more extensive rostral spread within the neuraxis. As a
recovery of sensory and motor function when compared to result, intrathecal morphine can provide prolonged post-
bupivacaine, which may be advantageous to outpatients.42 operative analgesia to inpatients.
The naturally occurring lumbar lordosis and thoracic The risk of delayed respiratory depression contraindicates
kyphosis affect the spread of both hypo- and hyperbaric the use of intrathecal morphine for outpatients.
solutions. A hyperbaric solution injected into a lumbar The alpha2 agonist clonidine increases the quality and
interspace (near the peak of the lumbar lordosis) gravi- duration of sensory and motor block when administered
intrathecally.34 Side effects such as hypotension, brady-
tates cephalad to the thoracic kyphosis and caudally to the
sacral nerve roots in a patient in the supine position (Fig. cardia, and sedation are common with intrathecal doses
12-1). A mid-thoracic block may also result from a hypo- between 75 and 225 ug, and this may limit the use of
this agent in outpatients.49 A number of investigators have
baric solution if the patient remains sitting for several
minutes after injection. Unilateral spinal anesthesia can be studied a lower dose of intrathecal clonidine (15 ug) and
achieved with either hypo- or hyperbaric solutions admin- have shown enhanced block quality with limited systemic
side effects.34,50
istered to patients in the lateral decubitus position.
The effect of spinal local anesthetics can be impacted Vasoconstrictors such as epinephrine (0.2“0.3 mg) and
by the addition of adjuvant medications. Intrathecally phenylephrine (2“5 mg) can increase the density and dura-
tion of lidocaine spinal block.51,56 Prolonged motor block
administered opioids are commonly used adjuvants that
act by binding to opiate receptors in the spinal cord.43 and urinary retention may limit more widespread use of
They enhance the quality of spinal anesthesia and increase these agents. In addition, phenylephrine has been associ-
the duration of sensory anesthesia. As a result, the dose of ated with the development of transient neurologic symp-
toms.54,56
spinal local anesthetic can be reduced, facilitating recov-
ery and outpatient discharge. Ben-David et al. illustrated
Adverse effects
this in a population of patients who received 5 mg hyper-
baric spinal bupivacaine.44 The incidence of inadequate If spinal anesthesia is planned for outpatient cosmetic
block was 24% in the group who received bupivacaine surgery, appropriate patient selection based on a thor-
alone, whereas there were no failed blocks in the group ough preoperative assessment and meticulous technique
who received 10 ug intrathecal fentanyl with bupivacaine. can signi¬cantly minimize the risk. Nevertheless, potential
Pruritus is a known side effect of intrathecal opioids and risks do exist (see Table 12-9). Patients must be informed
is usually mild and self-limiting.45 The highly lipophilic about these risks and should be provided with appropriate
agent fentanyl (10“25 ug) is well suited for ambulatory contact information in the event that problems arise.
Back pain is estimated to occur in 11% of surgical
patients twenty-four to thirty-six hours after spinal anes-
thesia.57 (Any additional discomfort, beyond the surgical,
in the cosmetic surgical patient may be cause for com-
plaint. Therefore, the possibility of back pain must be dis-
closed to adjust the patient™s expectations as well as to
obtain an informed consent.) Back pain may result from
needle trauma, from intrinsic effects of the local anesthetic,
Figure 12-1. Distribution of hyperbaric local anesthetic solution
or from ligamentous strain. Urinary retention is related to
in the intrathecal space after injection at L3“4 (at the apex of the
inhibition of detrusor muscle activity from S3 nerve root
lumbar lordosis) in a patient turned immediately supine. Note
higher concentrations in midthoracic and sacral regions as the block. Risk factors include male gender, age greater than
local anesthetic solution runs “down hill.” Reproduced with per-
sixty years, surgery duration greater than 120 minutes, and
mission from Neuraxial Blocks by Stevens RA, in Regional Anes-
systemic analgesia.58,59
thesia and Analgesia, edited by Brown DL; WB Saunders; 1996.
Regional Anesthesia for Cosmetic Surgery 139


Transient neurologic symptoms involve pain or dyses-
Table 12-10. Selected potential adverse effects
thesia in the legs or buttocks that occurs within twenty-
of epidural anesthesia1,64,73,77,82,105,106
four hours of spinal anesthesia.60,61 Risk factors include
the use of lidocaine, possibly mepivacaine, ambulatory Self-limiting Back pain
Urinary retention
surgery, and the lithotomy position. Treatment is symp-
Postdural puncture headache
tomatic and spontaneous recovery typically occurs within Rare but serious Local anesthetic toxicity
days. Total spinal anesthesia
Cardiac arrest
A postdural puncture headache (PDPH) is a fronto-
Isolated nerve injury
occipital headache that occurs in a sitting or standing
Cauda equina syndrome
position and is immediately improved upon assuming a Epidural abscess
supine position.62 The incidence is greater with cutting Meningitis
Epidural hematoma
and large bore spinal needles, a transversely directed nee-
Retained catheter
dle bevel, young age, and female sex.63,64 Treatment is ini-
tially conservative with ¬‚uid hydration, analgesics, and
possibly caffeine.65 An epidural blood patch can be con-
sidered, although spontaneous resolution generally occurs EPIDURAL ANESTHESIA
in one to two weeks.
Indications and advantages
Serious neurologic injury related to spinal anesthesia
Epidural anesthesia achieves bilateral surgical anesthesia
is extremely rare.66,69 Nonetheless, any new neurologic
with similar advantages to spinal anesthesia (Table 12-10).
de¬cit should be promptly assessed in the event that a
In addition, epidurals provide the option for extended
potentially reversible etiology exists. An epidural abscess
postoperative analgesia for patients admitted to hospital.
presents with progressive sensory or motor de¬cits, bowel
Thoracic epidurals have applications for cosmetic pro-
or bladder dysfunction, fever, or back pain.70,72 A neu-
cedures involving the breast and thorax, whereas thora-
raxial hematoma may present similarly.70 Magnetic reso-
columbar epidurals are more suited to abdominal, lower
nance imaging can establish the diagnosis of either condi-
extremity, and buttock surgery.
tion. Following diagnosis, immediate surgical evacuation
of the abscess or hematoma may be required. Subsequently,
Equipment
abscesses are also managed with antiobiotics.73 Menin-
In order to facilitate catheter placement, epidural needles
gitis is suspected if the patient presents with headache,
have a curved distal tip (i.e., Tuohy or Hustead) and a larger
fever, nuchal rigidity, or a new neurological de¬cit.73,75
diameter (i.e., 16“18 ga) than spinal needles. Multiori¬ced,
Cerebrospinal ¬‚uid analysis can yield the diagnosis, and
polyamide epidural catheters have a closed end and three
systemic antibiotic therapy is begun early. Cauda equina
ori¬ces at the distal tip. This design enhances even distri-
syndrome presents with pain in the lower back or legs,
bution of local anesthetic. The loss-of-resistance syringe
lower extremity sensorimotor de¬cit, and bowel or blad-
is a 3 or 5 ml size and is made of glass or plastic.
der dysfunction.70,75 Risk factors include the use of 5%
hyperbaric lidocaine and continuous spinal anesthesia
Local anesthetics and adjuvants
with microcatheters. Emergent investigation and treat-
ment are necessary. The diagnosis and management of The selection of local anesthetic for epidural anesthesia is
other neurologic complications (i.e., isolated nerve injury) based on the desired block onset and duration as well as
can be greatly facilitated with the assistance of a consultant the drug™s side-effect pro¬le. The mass of the local anes-
neurologist. thetic administered also affects onset time and duration
Total spinal anesthesia results from excessive cepha- as well as depth of anesthesia and the extent of cranio-
caudal spread.77,79 In addition, the volume of injectate
lad spread of the spinal block. Apnea, bradycardia,
profound hypotension, and cardiac arrest can result.76 affects the extent of the block.79 Other factors such as preg-
nancy and age may also be important.80,82 When dosed
Prompt recognition and initiation of supportive therapy
is crucial. with concentrated local anesthetic, the epidural catheter
140 Holly Evans and Susan M. Steele


(i.e., fentanyl 5 ug · ml’1 ) and dilute ropivacaine, lev-
provides surgical anesthesia. Chloroprocaine has a fast
onset and short duration of action.83,85 A number of stud- oubupivacaine, or bupivacaine (i.e., 0.1“0.2%) is used to
ies have investigated the use of epidural chloroprocaine for provide sensory anesthesia with minimal opioid- or local-
ambulatory surgical procedures and have found onset of anesthetic“related side effects. For example, this combi-
maximal block in 16 minutes, a time to ambulation of 78 nation minimizes the motor block and hypotension that
minutes, and outpatient discharge as soon as 130 minutes result from higher concentrations of local anesthetic and
after completion of surgery.83,85 This agent has historically reduces the pruritus typically seen with larger doses of
been associated with back pain following epidural admin- neuraxial opioids.
istration of large and repeated doses.86,87 In addition, there
Adverse effects
are reports of persistent neurologic de¬cits and adhesive
Epidural anesthesia shares many of the potential side
arachnoiditis following accidental intrathecal administra-
tion.88 Preservatives and antioxidants in older prepara- effects and complications described for spinal anesthesia
(see Table 12-9).
tions were likely causal. Recent data supporting the safe
Back pain occurs in up to 31% at twenty-four to thirty-
intrathecal use of preservative-free chloroprocaine may
six hours after surgery and is more common than with
lead to more frequent epidural use of this agent.
spinal anesthesia (i.e., > 11%). Urinary retention can occur
Lidocaine and mepivacaine both have a rapid onset and
short to intermediate duration of action.89 Bupivacaine, as discussed previously. PDPH can result from uninten-
tional dural puncture with an epidural needle. Presenta-
levobupivacaine, and ropivacaine have a long onset and
tion and treatment have been previously outlined.
duration. These agents would not be suitable for ambula-
Epidural anesthesia is associated with the risk of sys-
tory procedures; however, they are effective in providing
temic local anesthetic toxicity. This may result from sys-
extended postoperative analgesia for patients admitted to
temic absorption of a large volume of local anesthetic
hospital. When a bolus dose of concentrated long-acting
administered epidurally or from inadvertent intravascu-
local anesthetic is administered epidurally, ropivacaine is
lar injection. Prompt recognition of the symptoms of
selected preferentially in order to minimize the risk of
cardiovascular toxicity associated with bupivacaine.90 In local anesthetic toxicity is required in order to initiate
timely treatment (see Table 12-11). Total spinal block and
addition, ropivacaine provides a greater separation of sen-
sory and motor block.
Adjuvant medications can be used to enhance epidural
anesthesia. Epidural opioids can improve block quality,
Table 12-11. Signs and symptoms of local
though they may be associated with postoperative nau- anesthetic toxicity
sea and vomiting, pruritus, or urinary retention. Short-
1. Disorientation, restlessness
acting agents such as fentanyl are preferentially chosen for
2. Tremor
ambulatory patients. Long-acting epidural morphine is
3. Metallic taste
reserved for inpatients because of the risk of delayed res- 4. Perioral paresthesias
5. Tinnitus
piratory depression. Clonidine (100“200 ug epidurally)
6. Auditory hallucinations
enhances the duration of epidural anesthesia.91 However,
7. Muscle spasms
side effects such as hypotension, bradycardia, and seda- 8. Tonic/clonic seizures
tion may impede safe outpatient recovery and discharge.92 9. Coma
Vasoconstrictors such as epinephrine (2.5“5 ug · ml’1 ) 10. Respiratory arrest
11. Cardiac arrest, ventricular ¬brillation
can enhance the quality of the block, prolong the duration
12. Death
of short-acting local anesthetics, and decrease the risk of
local anesthetic toxicity.93 Bicarbonate (0.1 mEq · ml’1 ) Editor™s note: Signs 1“6 may be seen only in patients
receiving regional anesthesia with minimal or no addi-
increases speed of onset of chloroprocaine, lidocaine, and tional sedation. In particular, seizure threshold will be
mepivacaine.94,96 elevated in patients receiving either benzodiazepine or
propofol. A-V dissociation and hypotension may precede
A continuous epidural can be used to provide postop-
#11, cardiac arrest. ”BLF
erative analgesia.97 The combination of low-dose opioid
Regional Anesthesia for Cosmetic Surgery 141


subsequent cardiac arrest can occur following acciden- of each rib to the inferior aspect of the transverse process
tal intrathecal injection of a large volume of local anes- above.
thetic intended for the epidural space. This was described The endothoracic fascia exists within the paraverte-
in the context of spinal anesthesia along with isolated nerve bral space between the parietal pleura and the superior
costotransverse ligament.102 This deep thoracic fascia is
injury, cauda equina syndrome, epidural abscess, menin-
gitis, and epidural hematoma. Finally, catheter shearing attached anteriorly to the periosteum of the sternum and
with retention of catheter fragments in vivo has been the perichondrium of the costal cartilages (see Fig. 12-3).
reported.98,99 To minimize this risk, avoid withdrawing Posteriorly, it fuses with the periosteum of the verte-
the catheter through the epidural needle. bral bodies and is continuous with the prevertebral fascia
(see Fig. 12-4). The endothoracic fascia divides the par-
avertebral space into an anterior extrapleural paravertebral
PERIPHERAL NERVE BLOCKS
compartment and a posterior subendothoracic paraver-
tebral compartment.103 The anterior section contains
Paravertebral Nerve Blocks
the sympathetic trunk and loose connective tissue called
Anatomy
the subserous fascia. The posterior segment contains the
The thoracic paravertebral space is a wedge-shaped space
present on either side of the vertebral column100,101 (see sympathetic rami communicantes, the spinal/intercostal
nerves with their associated dorsal ramus, and the seg-
Fig. 12-2). It is bound anterolaterally by the parietal
mental spinal blood vessels. The spinal nerves are in fact
pleura and medially by the posterolateral aspect of the
groups of small nerve rootlets surrounded by fatty tissue.
vertebral body, the intervertebral disks, the interverte-
There is no encompassing fascial sheath, which enhances
bral foramina, and its contents. The superior costotrans-
the nerve™s susceptibility to local anesthetic blockade in
verse ligaments represent the posterior boundary of the
this location.
space. These ligaments extend from the superior aspect




Figure 12-2. Transverse section at level of intervertebral foramen. Reproduced with permission from Eason MJ and Wyatt R, in Anaes-
thesia 34:638,1979.108
142 Holly Evans and Susan M. Steele




Figure 12-3. Paravertebral saggital section of the thorax portraying the extent of the endothoracic fascia. Reproduced with permission
from Karmakar MK, in Regional Anesthesia & Pain Medicine 25(3):325“7;2000.110



Each thoracic paravertebral space communicates with intervertebral foramen and pass through the paraverte-
adjacent spaces superiorly and inferiorly across the heads bral space. Unilateral or bilateral segmental block can be
and necks of the ribs. This communication occurs pre- performed. Long-acting local anesthetics provide intraop-
dominantly in the anterior extrapleural compartment, erative anesthesia and up to twenty-three hours of postop-
erative analgesia.104 Thoracic paravertebral blocks are use-
whereas the posterior subendothoracic compartment is
more segmental. The thoracic paravertebral space is con- ful for cosmetic surgical procedures of the breast and/or
tinuous with the intercostal space laterally and the epidural chest wall (see Chapter 10). Thoracolumbar paravertebral
space medially via the intervertebral foramen101 (see Fig. nerve blocks are suitable for lower abdominal surgery such
12-5). Communication with the contralateral paraverte- as abdominoplasty (Table 12-12).
bral space can occur either through the epidural space or Klein et al. studied the ef¬cacy of thoracic paraverte-
the prevertebral space.102 bral nerve blocks for breast augmentation or reconstruc-
The thoracic paravertebral space is limited caudally by tion. They randomized sixty patients to T1-7 paraverte-
the origin of the psoas muscle. Nevertheless, the endotho- bral blocks with bupivacaine or general anesthesia. The
racic fascia continues below the diaphragm as the fas- group that received the nerve blocks had decreased opi-
oid requirements in the postanesthesia care unit (0.8 ±
cia transversalis, and continuity between the thoracic and
2.0 mg vs 3.6 ± 4.0 mg of morphine equivalent; p =
lumbar paravertebral spaces occurs via the medial and lat-
eral arcuate ligaments.103 0.001), lower verbal analog pain scores for the ¬rst seventy-
two hours postoperatively (p < 0.05), and reduced nausea
scores at twenty-four hours (p = 0.04) compared to the
Indications and advantages
general anesthesia group. Similar bene¬cial effects were
Paravertebral nerve block involves injection of local anes-
noted in comparable studies involving breast surgery and
thetic close to the spinal nerves as they emerge from the
Regional Anesthesia for Cosmetic Surgery 143




Figure 12-4. Anatomy of the thoracic paravertebral space. Reproduced with permission from Karmakar MK, in Anesthesiology 95(3):
771“80,2001.109




lower abdominal procedures.105 Table 12-13 summarizes horizontally in the lumbar spine. As a result, the palpable
these advantages. lumbar spinous process is usually in line with the trans-
verse processes of the same vertebra. The most prominent
spinous process in the neck corresponds to C7, the lower
Technique
border of the scapula is T7, and the intercristal line marks
An intravenous is placed, monitors are attached, and resus-
L4. The skin is cleaned with disinfectant and subcutaneous
citation equipment is made available. Light sedation may
in¬ltration of local anesthetic is given at all needle entry
be provided. The patient can be placed lateral decubitus or
sites.
prone, though identi¬cation of landmarks is greatly facil-
A number of ways to identify the paravertebral space
itated in the sitting position.
have been described. The paravertebral space can be
The neck is ¬‚exed forward, the back is rounded, and
located when a change in resistance (or “pop”) is felt as
the shoulders are maximally relaxed. Levels to be blocked
a Tuohy needle passes through the costotransverse lig-
are chosen based on the nature of the surgical procedure
ament106 (Fig. 12-7). A 10 cm, 22 ga Tuohy needle is
(Table 12-14). The superior aspect of the spinous pro-
attached to extension tubing and a 20 ml syringe contain-
cess is identi¬ed and a mark is placed 2.5 cm lateral to
ing local anesthetic. The needle is inserted perpendicular
it (Fig. 12-6). Because of the extreme angulation of the
to the skin 2.5 cm lateral to the midpoint of the supe-
thoracic spinous processes, this mark overlies the trans-
rior border of the spinous process. The needle is advanced
verse process of the vertebra below. For example, the T5
to contact the transverse process and the depth is noted.
spinous process is at the same horizontal level as the T6
The transverse processes in the high thoracic spine (T1,2)
transverse process. The spinous processes project more
144 Holly Evans and Susan M. Steele



Table 12-13. Potential advantages of
paravertebral blocks2,4,5

Dense, long-lasting analgesia
Profound segmental sympathectomy
Reduced postoperative opioid requirements
Reduced PONVa
Low incidence of hemodynamic perturbations
Early postoperative ambulation
Low incidence of urinary retention
Decreased hospital length of stay
a PONV = postoperative nausea and vomitting




ciated 1 cm past the depth of the transverse process as the
superior costotransverse ligament is penetrated. A cau-
Figure 12-5. The paravertebral space is contiguous with the inter- tious approach is warranted because bone contacted deep
costal and epidural spaces. Thus, local anesthetic may spread
to the transverse process may represent the rib. The nee-
laterally to the intercostal space, cephalad and caudad in the
dle should not be advanced deep to the rib because of the
paravertebral space, and medially to the epidural space. Repro-
duced with permission from Continuous Thoracic Paravertebral risk of pleural puncture and pneumothorax. In the lum-
Block by Chan VWS and Ferrante FM, in Postoperative Pain
bar area, the technique is slightly modi¬ed. After locating
Management, edited by Ferrante FM and VadeBoncoeur TR;
Churchhill-Livingstone; 1993. the transverse process, the needle is advanced only 0.5 cm
deeper because the transverse processes are much thinner.
and the low lumbar spine (L4,5) are deeper than those In addition, no loss of resistance is appreciated because of
in the midthoracic spine (T5“10); precise depth depends the absence of the costotransverse ligament.
on patient size. The needle tip is withdrawn to the subcu- An alternate localization technique involves the use of
loss of resistance to air or saline.101 The loss of resistance
taneous tissue and subsequently redirected caudal to the
transverse process. Recall that in the thoracolumbar spine, upon entering the paravertebral space is more subtle and
nerve roots exit below their associated transverse process. subjective compared to that observed upon entering the
epidural space.107
The needle is advanced and a change in resistance is appre-



Table 12-12. Paravertebral blocks for cosmetic surgery: application and suitability

Surgical Procedure Paravertebral Block Level Supplemental Anesthesia
T2“6 ± T1, T7
Breast (augmentation, Super¬cial cervical plexus
reduction, mastopexy) Unilateral or bilateral Medial and lateral
according to surgical pectoral nerve blocks for
procedure analgesia during pectoral
dissection
Truncal liposuction According to location of
surgery
± T7,8 depending on
Abdominoplasty T9,10,11,12,L1 Bilateral
cephalad extent of
undermining
Truncal scar revision According to location of
surgery
Regional Anesthesia for Cosmetic Surgery 145



Table 12-14. Selected potential adverse effects of
paravertebral blocks and their incidence4,114

Adverse Effect

Self-limiting Failed block
Vascular puncture
Injection-site hematoma
Pain at injection site
Epidural spread
Postdural puncture headache
Brachial plexus block
Horner™s syndrome
Rare but serious Pneumothorax
Pulmonary hemorrhage
Local anesthetic toxicity
Nerve injury
Intrathecal injection, total spinal
anesthesia
Septic complications
Figure 12-6. Super¬cial skin markings for left breast surgery.
Reproduced with permission from Greengrass R and Steele S,
in Techniques in Regional Anesthesia & Pain Management 2(1):
8“12, January 1998.
Others have used nerve stimulation to identify the spinal
nerve roots in the paravertebral space. A 21 or 22 ga short-
bevel insulated stimulating needle is advanced to contact contrast dye within one or two spinal segments; this is
transverse process. The needle is subsequently redirected thought to occur when the needle is in the posterior com-
partment.109
while connected to a nerve stimulator providing a current
output greater than 1.5 mA. Paraspinal muscle contraction Some advocate a technique whereby after contact with
occurs initially as the needle passes through these muscles. the transverse process, the needle is redirected superior to
it108,109 (Fig. 12-7). Using this approach, it is possible to
On further needle advancement, intercostal or abdomi-
nal muscle contractions are observed depending on the inadvertently contact rib ¬rst and walk off superiorly into
dermatomal level of the block. The stimulating current is the pleura and lung. In addition, this technique blocks the
decreased to 0.5“0.6 mA while appropriate muscle con- nerve root and dermatomal segment above the transverse
traction is maintained. Isolated posterior spinal muscle process contacted. The authors prefer redirecting the nee-
dle caudad to the transverse process.110 If rib is contacted
contraction is not accepted as this may represent either
direct muscle stimulation or stimulation of the posterior ¬rst, caudal redirection will bring the needle into contact
ramus of the spinal nerve root after it diverges from the with the transverse process at a shallower depth. Conse-
spinal nerve. An additional option involves pressure mea- quently, more accurate estimation of the depth of the par-
surement to con¬rm paravertebral needle placement.108 avertebral space is made and the risk of pneumothorax is
When the needle tip is in the erector spinae muscle, mea- minimized.
sured pressure is higher during inspiration than expira- When the needle is properly sited, an assistant aspirates
tion. Within the paravertebral space, there is a sudden the syringe for blood, cerebrospinal ¬‚uid, and air. If air
lowering of pressures and a pressure inversion occurs. is detected, it is likely that penetration of the pleura and
Expiratory becomes higher than inspiratory pressure. lung has occurred. The needle should be removed and
A further method to identify the paravertebral space patient stability ensured. Similar steps are taken if blood
involves the injection of contrast material. Contrast may or cerebrospinal ¬‚uid is detected. When the paraverte-
distribute linearly as it spreads superiorly and inferiorly; bral space is correctly identi¬ed, there is no resistance to
this is presumed to occur within the anterior compart- injection of local anesthetic. Smaller volumes of local anes-
ment. Alternatively, there may be cloud-like dispersal of thetic (3“5 ml per level) are used for thoracic paravertebral
146 Holly Evans and Susan M. Steele




Figure 12-7. Needle “walked off” transverse process into paravertebral space. Reproduced with permission from Greengrass R and
Steele S, in Techniques in Regional Anesthesia & Pain Management 2(1),8“12, January 1998.




blocks, whereas larger volumes (5“7 ml per level) are used posterior subendothoracic paravertebral compartment of
in the lumbar area. Doses may need to be reduced when the thoracic paravertebral space. As discussed previously,
multiple and/or bilateral levels are blocked. Patients will the pattern of spread of contrast dye may help with
often experience a pressure paresthesia upon injection of this differentiation. Adequate block will result follow-
local anesthetic. Block adequacy is evaluated in a number ing multilevel injection into either compartment; how-
of ways. Sensory anesthesia and motor block are sought ever, more extensive craniocaudad spread occurs when
in the appropriate dermatomes. For example, successful the needle is in the anterior compartment (mean 4.5
upper thoracic paravertebral block is associated with loss dermatomal levels) compared to when it exists in the
posterior compartment (mean 2.3 dermatomal levels).111
of sensation over the breast and upper chest wall. In addi-
tion, motor block of the intercostal muscles occurs and These results re¬‚ect more complete cephalocaudad conti-
can be con¬rmed by inspection and palpation of limited nuity between anterior segments. Consequently, it is here
hemithorax expansion. Vasodilation and warmth in the that a single-level injection of a larger volume of local
corresponding distribution provides evidence of a suc- anesthetic or placement of a continuous catheter should
cessful sympathetic block. occur.
Using the majority of the techniques described, it is dif- Continuous paravertebral block can provide extended
¬cult to determine whether the needle tip exists in the postoperative analgesia. This technique can be used both
in patients admitted to hospital as well as outpatients.110
anterior extrapleural paravertebral compartment or the
Regional Anesthesia for Cosmetic Surgery 147


A large-bore Tuohy needle is ¬rst used to identify the par-
Table 12-15. Comparison between paravertebral
avertebral space. Subsequently, a ¬‚exible catheter with a
and intercostal nerve blocks
single distal ori¬ce is threaded 1“2 cm into the space.
Paravertebral nerve Intercostal nerve blocks
blocks
Equipment
Segmental sensory and Segmental sensory and
The equipment required depends on the technique used motor block motor block
to identify the paravertebral space. As described previ- Posterior ramus blocked Posterior ramus not
reliably blocked
ously, commonly used equipment consists of a 10 cm
Sympathetic block Sympathetic chain not
22 ga Tuohy needle with wings and centimeter gradations.
reliably blocked
This is attached to extension tubing and a 20 ml syringe Some LA spread to Minimal LA spread to
containing local anesthetic. If loss of resistance is utilized, adjacent levels adjacent levels
Continuous catheter can Continuous catheter
a loss of resistance syringe is also needed. When a nerve-
provide multilevel usually provides only
stimulation technique is used, a 10 cm 21“22 ga insulated
analgesia single-level analgesia
short-bevel needle and a nerve stimulator are required. Risk of pneumothorax Risk of pneumothorax
Risk of vascular puncture Risk of vascular puncture
And when pressure measurement is undertaken, a three-
Risk of epidural spread, Lower risk of epidural
way stopcock, pressure tubing, and a pressure transducer
dural puncture spread, dural puncture
are employed. A sterile skin marker and ruler should also Less systemic LA Signi¬cant LA systemic
be included. absorption absorption


Local anesthetics and adjuvants
The local anesthetic agent selected is based on the desired
onset and duration of the nerve block. Block onset occurs from cephalad extension of injected local anesthetic. The
within ten minutes and surgical anesthesia within forty features of Horner™s syndrome include ptosis, miosis, and
minutes following injection of short-acting local anes- anhydrosis and result from block of the sympathetic stel-
thetic.112 Analgesia lasts up to twenty-three hours when late ganglion.
long-acting local anesthetic is used.106 Epinephrine is fre- Pleural puncture following paravertebral block is rare.
quently added to enhance block quality and limit sys- Pneumothorax results infrequently and is suspected if a
temic toxicity. The proximity of the paravertebral space pleural “pop” is felt during needle advancement, if air
to the intercostal space raises concern about signi¬cant is aspirated into the syringe attached to the block nee-
systemic absorption of local anesthetic following paraver- dle, or if the patient develops an irritating cough or a
tebral block. However, plasma local anesthetic levels have sharp pain in chest or shoulder. Resulting pneumothoraces
been below toxic range when standard doses are used.113 are often small enough to warrant conservative manage-
ment.100 However, when a chest tube is indicated and hos-
In addition, systemic absorption is similar when a single-
level injection of 20 ml is given at T3-4 compared to when pital admission is required, this signi¬cantly impacts the
injections of 4 ml each are given over ¬ve levels between patient™s postoperative recovery. A case report describes
T2 and T6 (total 20 ml).113 pulmonary hemorrhage as a complication following
paravertebral block in a patient who had previous thoracic
surgery.115 In addition, this patient population may have
Adverse effects
The adverse effects of paravertebral blocks are summa- pleural scarring affecting paravertebral anatomy, and this
rized in Table 12-15. Vascular puncture, injection site can increase the risk of pneumothorax. Local anesthetic
hematoma, and pain at the site of needle puncture are toxicity (Table 12-11) can result from the use of large vol-
usually mild, self-limiting, and respond to symptomatic umes of local anesthetic or from accidental intravascular
treatment. Epidural spread may be due to excessively injection. Precalculation of the maximum allowable dose
medial needle placement. A more extensive block than of local anesthetic and meticulous aspiration technique to
expected may result and hypotension may occur.114 detect intravascular needle location should minimize this
Brachial plexus block or Horner™s syndrome may result risk. Nerve injury is rare, though a case report describes
148 Holly Evans and Susan M. Steele


a patient who developed chronic segmental thoracic pain passes posteriorly to supply the skin and muscle in the
following paravertebral nerve block. Intrathecal injection, paravertebral area. These branches are more reliably anes-
dural puncture, and postdural puncture headache may thetized with paravertebral than intercostal nerve blocks.
result from overly medial needle placement or from pen- The intercostal nerve also gives rise to lateral and anterior
etration of a dural cuff that extends into the paraverte- cutaneous branches.
bral space.116 Signi¬cant resuscitation may be required
depending on the dose of local anesthetic injected intrathe- Indications and advantages
cally and the resulting symptoms. An intercostal nerve block is indicated for analgesia follow-
ing breast or chest-wall procedures and is predominantly
Intercostal Nerve Blocks
used when paravertebral or epidural blocks are not indi-
Anatomy
cated. The differences between paravertebral and inter-
The intercostal space is continuous with the lateral aspect
costal blocks are outlined in Table 12-15.
of the paravertebral space. Upon exiting the paraverte-
bral space, the spinal nerve becomes the intercostal nerve.
Technique
Medial to the angle of the rib, the intercostal nerve is found
between the pleura and the fascia of the internal intercostal An intravenous is placed, monitors are attached, and
muscle. The angle of the rib is located 6 to 8 cm from mid- resuscitation equipment is made available. Light sedation
line. At this point, the intercostal nerve continues its course may be provided. The patient is typically placed prone,
between the internal and the innermost intercostal mus- although the lateral decubitus, sitting, or supine positions
cles. The nerve lies in close proximity to the segmental can also be used. In the prone position, a pillow is placed
intercostal vessels, but its relation to the subcostal groove under the upper abdomen to promote thoracic spine ¬‚ex-
is variable.117 Each intercostal nerve has four branches ion and to widen the intercostal spaces. The patient™s arms
(Fig. 12-8). The gray ramus communicans passes anteri- hang over the edge of the bed to displace the scapulae
orly to the sympathetic ganglion, and the posterior ramus laterally (see Fig. 12-8).




Figure 12-8. Longitudinal section to show direction of needle: (a) above, (b) below: transverse process or rib. Reproduced with permis-
sion from Eason MJ and Wyatt R, in Anaesthesia 34(7):638“42,1979.108
Regional Anesthesia for Cosmetic Surgery 149




Figure 12-9. (A) Intercostal nerve block: patient positioning. (B) The index ¬nger displaces the skin up over the rib. The needle is
inserted at the tip of the ¬nger and rests on the rib. The needle is walked off the lower rib edge and inserted 3 to 5 mm. (C) An
intercostal nerve and its branches. Reproduced with permission from Nerve Blocks by Wedel DJ, in Anesthesia, 5th edition, edited by
Miller RD; Churchhill-Livingstone; 2000.

A paraspinal line is drawn 5 to 9 cm lateral to the midline After negative aspiration for blood, 3“5 ml of local anes-
where the posterior angulation of the ribs is most easily thetic is injected and the nerve block is repeated at each of
palpable. In order to avoid the scapula, the line diverges the desired levels. The most caudal rib to be anesthetized is
medially in the upper thoracic segments. This location is blocked ¬rst. Subsequent nerve blocks gradually proceed
chosen for the nerve block as it is proximal to the diver- in a cephalad direction.
gence of the lateral cutaneous branch. The inferior border
of each rib is marked along the length of the paraspinal Equipment
line. The appropriate levels to be blocked are identi¬ed A 3“4 cm 22 ga short bevel needle and a 10 ml syringe are
according to the surgical procedure. The skin is cleaned required.
with disinfectant and sterile drapes are placed. The anes-
thesiologist stands to the patient™s side. A subcutaneous Local anesthetics and adjuvants
skin wheal is placed at the mark representing the inferior There may be signi¬cant systemic absorption of local anes-
border of the angle of the rib at each level to be blocked. thetic following intercostal nerve block. Therefore, the
The left hand is used to move the skin wheal so that it over- dose of local anesthetic used should be carefully calculated.
lies the rib. The right hand holds a 3“4 cm 22 ga short bevel Ropivacaine offers long-acting anesthesia with an accept-
needle attached to a 10 ml syringe and advances it onto the able safely pro¬le. Epinephrine can be added to further
rib (Fig. 12-9). The left hand grasps the needle while the reduce the risk of toxicity.
right hand holds the syringe. The needle is subsequently
walked in a caudal direction past the inferior border of the Adverse effects
rib and advanced 3“5 mm past the depth at which the rib Pneumothorax is rare (0.42%), despite the close proxim-
ity of the lung and pleura.118 The risk of local anesthetic
was contacted. A subtle change in resistance if often felt as
the needle passes through the internal intercostal muscle. toxicity is related to the large volumes of local anesthetic
150 Holly Evans and Susan M. Steele


used to obtain an adequate block and to the signi¬cant discharge. Forty-six patients had less than 400 ml urine
systemic absorption that occurs in this highly vascular and were discharged home without voiding. They were
area. instructed to return to hospital if they had not voided
within eight hours; however, all were able to void sponta-
neously. Twenty-three patients had urine volume greater
RECOVERY AND DISCHARGE than 400 ml. Most (97.7%) voided spontaneously during
the subsequent sixty minutes in which they were detained
Recovery
in hospital; however, three patients required catheteriza-
Patients require a period of monitoring postoperatively
tion. The quanti¬cation of urine volume with bladder
because both surgery and anesthesia can be associated
ultrasound and a de¬ned protocol certainly led to their
with signi¬cant physiologic changes. Standard monitors
success and excellent results. The use of this protocol in
such as pulse oximeter, noninvasive blood pressure, and
cosmetic surgical patients who have received regional anes-
electrocardiogram are used. In addition, the vigilance of a
thesia remains unexplored.
nurse with resuscitation skills is of critical importance. A
Finally, all patients should receive appropriate contact
physician with advanced cardiac life-support skills should
numbers should complications arise following discharge,
be immediately available.
and contingency plans should be in place for those patients
A plan is required for analgesia as block resolution
who do not meet discharge criteria and who require admis-
occurs. This transition is managed in the postanesthesia
sion to an inpatient facility.
care unit following spinal or epidural anesthesia. For both
groups, multimodal analgesia is ideal. This involves the
used of regular, scheduled doses of acetaminophen and SUMMARY
nonsteroidal anti-in¬‚ammatory medication in addition
Regional anesthesia has broad application for cosmetic
to oral opioid tablets.
surgical procedures. Neuraxial techniques provide rapid-
onset, dense anesthesia with minimal postoperative seda-
Discharge tion, nausea, and vomiting. Spinal anesthesia, in partic-
Many cosmetic surgical procedures are performed on an ular, has been tailored for day-case procedures by the
ambulatory basis. Traditional outpatient discharge criteria use of low doses of local anesthetics, short-acting agents,
include adequate analgesia; absence of side effects such as dose-sparing adjuvants such as opioids, and small-gauge,
nausea, vomiting, and sedation; as well as the ability to pencil-point needles. As a result, side effects have been
ambulate, void, and tolerate ¬‚uid intake. minimized and there is timely recovery of motor strength
Recent literature has challenged the requirements to as well as ability to ambulate and to void.
drink and void prior to discharge.119,120 In a randomized Paravertebral nerve blocks uniquely offer dense
trial, Jin et al. documented the feasibility of discharging intraoperative anesthesia and prolonged postoperative
patients prior to ¬‚uid intake.119 They found no differ- analgesia with rare side effects. This technique is surpris-
ence in the incidence of postoperative nausea and vomit- ingly underutilized given its bene¬ts. With appropriately
ing when they compared a group of patients who drank selected patients, surgical procedures, and nerve block
prior to discharge versus a group who did not drink. techniques, regional anesthesia can facilitate successful
Patients with a history of urinary retention, men, those cosmetic surgery and result in positive patient outcome
who have had spinal anesthesia, and those who have had with high patient satisfaction.
anal, urogenital, and hernia surgery are known to be at
high risk of postoperative urinary retention. Mulroy and
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13 General Inhalation Anesthesia for Cosmetic Surgery
Meena Desai, M.D.



INTRODUCTION
PATIENT SELECTION FOR THE COSMETIC SURGICAL SUITE
GENERAL ANESTHETIC CONCERNS FOR STANDARD AESTHETIC
PROCEDURES
Rhytidectomy or Facelift
Preoperative considerations
Intraoperative considerations
Emergence considerations
Postprocedure considerations
Browlift
Endoscopic browlift
Breast Augmentation
Preoperative considerations
Intraoperative considerations
Emergence considerations
Postprocedure considerations
Endoscopic breast implants
Mastopexy
Intraoperative considerations
Liposuction
Preoperative concerns
Intraoperative concerns
Postprocedure considerations
Rhinoplasty
Intraoperative concerns
Emergence concerns
Postprocedure concerns
Abdominoplasty
Preoperative considerations
Intraoperative concerns
Emergence concerns
Postprocedure concerns
Laser Facial Resurfacing
Intraoperative concerns
Postprocedure concerns




155
156 Meena Desai


Blepharoplasty
Emergence concerns
PRACTICAL CONSIDERATION OF CLINICAL ISSUES
Fast Tracking and Discharge Criteria
Pain medication in recovery
Pain management
PONV
MALIGNANT HYPERTHERMIA (MH) PROTOCOL
THROMBOEMBOLISM
Recommendations according to risk strati¬cation
Low-risk patients
Moderate-risk patients
High-risk patients
CONCLUSION




INTRODUCTION
Many patients respond to the branding of names in rela-
tionship to the care that is rendered. Hospital-based care
The ultimate in consumer-driven medical care is the
may be analogized as the “Cadillac,” whereas the plastic
business of cosmetic surgery. These are purely elective
surgical care that is provided in an ASC or of¬ce-based
procedures performed for the convenience and wishes of
cosmetic surgical suite may be analogized as the “Rolls
the buyer patient and at the convenience of the patient.
Royce.” Attempts are made to preempt postoperative nau-
Traditional ideology of surgical care is maximized as
sea and vomiting (PONV) instead of addressing it after it
service is optimized. The maximization of service should
occurs. Comforters are provided for blankets, linens have
never, however, compromise the prevailing medical,
lace, neck pillows have aromatherapy, heat, and so forth.
surgical, or anesthetic standard of care. Meeting the
This is the “spa” surgical experience.
standard of care is the minimum requirement of the
Keeping abreast of the cosmetic surgery literature pro-
cosmetic surgical practice.
vides some assurance that one is collaborating with a sur-
Much has been written regarding the safety of general
anesthesia in the of¬ce.1’4 One should have a structure and geon that also has the highest regard for the standard of
care. This may vary from state to state. Florida, for exam-
plan for the administration of care that adheres to known
ple, currently has modeled its of¬ce regulations around
standards. The care offered to entice the consumer to an

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