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those of the AAAASF, namely, level: local only, level II,
individual practice and practitioner is multifaceted. Sev-
intravenous (sedation), and level III (general anesthesia).
eral studies have found that the friendliness and courtesy
of the staff were top predictors of patient satisfaction.5 The Additionally, surgical societies may have consensus
statements and practice standards that are changing and
rendering of anesthetic care must be cognizant of the con-
are prudent to regard. Some practices may have outside
sumerism of plastic surgery and be sensitive of delivering
or independent peer review as a gauge of practice qual-
their care with a practice philosophy suited to the surgical
ity. Alternatively, the surgeon who is part of a hospital
practice. Care is often beyond expectations as patients and
staff is subject to peer review from that avenue. Postpro-
their idiosyncratic requests are willingly accommodated.
cedure care and patient satisfaction are vital to a surgical
In this chapter, some of the speci¬c particulars of general
practice. In association with the surgical practice, check
anesthetic care are provided as they relate to individual
anesthetic parameters of patient care and satisfaction as
procedures. There are also some methods of care that cater
well.
to the consumerism milieu.
General Inhalation Anesthesia for Cosmetic Surgery 157


Screen one™s surgeons as carefully as one would one™s
Table 13-1. Selection list of patients undergoing
anesthesia colleagues. Verify their licenses and credentials.
general anesthesia criteria that suggest a patient
Check their references and run a query via the AMA data may be unsuitable for a procedure in the of¬ce suite
bank or the National Practitioner data bank. What is the
1. Unstable angina
surgeon™s rate of infection? How many “redos” or “touch-
2. History of myocardial injury within three to six
ups” does the practice do? months
What is the admission rate to the acute care center or 3. Severe cardiomyopathy
4. Uncontrolled hypertension
hospital postprocedure? In how many litigious encounters
5. End stage renal disease on dialysis
is your surgeon involved? Do not hesitate to “credential”
6. Sickle-cell anemia
them within your practice much as one do one™s own staff 7. Patient on major organ transplant list
and reciprocally provide the same information to your 8. Active multiple sclerosis
9. Severe chronic obstructive pulmonary disease
surgeon. Encourage one™s staff to keep all of your practice
(COPD)
credentialing ¬les up to date. If one is in a state that has
10. Abnormal airway (dif¬cult intubation and mask
no local or state guidelines, then it is incumbent on one ventilation9
to develop them. The of¬ce-based guidelines approved by 11. Malignant hyperthermia
12. Acute illegal substance abuse
the American Society of Anesthesiologists (ASA)6 are an
13. Morbid obesity: body mass index10
excellent template for the development of one™s own inter- 14. Dementia
nal guidelines. 15. Psychological instability: rage/anger problems
16. Myasthenia gravis
17. Recent CVA within three months
18. Obstructive sleep apnea11
PATIENT SELECTION FOR THE COSMETIC
19. Patients with implanted electrical devices (i.e.,
SURGICAL SUITE
AICD)
An invaluable service that can be monitored by the anes-
thesia group is appropriate patient selection for the facility.
Desai™s group screens every patient well in advance of the
calls and the tracking of postoperative information can be
date of the procedure. The screening process begins as
utilized to maintain a very high standard of practice and a
soon as the patient is scheduled. Testing is procedure and
very high standard of patient satisfaction.
history speci¬c. Algorithms may be developed and imple-
mented to make the ¬‚ow of the preanesthesia interviews
and laboratory screening succinct.
GENERAL ANESTHETIC CONCERNS FOR
Desai™s screening criteria are constantly updated and
STANDARD AESTHETIC PROCEDURES
revised as the literature and experience warrants. Pre-
existing medical conditions can be predictors of adverse In the fast-paced, ef¬ciency driven environment, it
events in the ambulatory setting.7’10 The American Col- behooves one to employ the best use of time to ensure
lege of Cardiology and the American Heart Association patient satisfaction and safety in a mode that is also cost
have updated guidelines for Perioperative Cardiovascular conscious. An ideal general anesthetic technique should
Evaluation for Noncardiac Surgery11 that are useful for provide smooth and rapid induction, optimal operating
appropriate patient evaluation and selection. The British conditions, and a rapid recovery with minimal or no side
Journal of Anaesthesia also has an excellent review that effects. One would like to tailor the anesthetic technique
helps one judge perioperative cardiac risk.12 to promote fast-tracking.
Many surgeons™ practices track patients with postoper- Several comparisons have been done to facilitate the
ative follow-up calls. selection of the inhalation agents des¬‚urane, iso¬‚urane,
or sevo¬‚urane.13’17 Although one may have varied results
Satisfaction with the anesthesia services may not always
be a part of this interview. Therefore, the anesthesia prac- with each agent and each anesthesiologist, the differences
tice should also follow up to ensure a high level of patient in time can be minor. The use of a Bispectral Index
satisfaction, speci¬cally with their anesthesia care. These (BIS) monitor correlates increasing sedation and loss of
158 Meena Desai


consciousness. BIS can facilitate the titration of the anes- important to ensure they are maximally optimized for
thetic to ensure a rapid emergence.19’24 Studies in the past elective surgery. These procedures are often four or more
however, have not been clear on the impact of the monitor hours and may have a signi¬cant impact on the patient. A
on real cost saving,25 nor is it proven to reduce the risk thorough review of all herbal and other medications also
of awareness.26 Recent studies show cost savings range should be noted, as many may impact on clotting, and
between 21“39% with BIS monitoring.27,28 N.B. The B- care should be taken to stop all herbals for at least two
Aware trial29 also recently demonstrated a statistically sig- weeks (see Chapter 14 and Appendix A). Premedication
ni¬cant 82% reduction in intraoperative awareness under with clonidine is useful for sedation as well as for helping
anesthesia, whereas the SAFE2 Trial30 recently demon- with hemodynamic control.
strated a similarly signi¬cant 77% reduction in intraoper-
ative awareness under anesthesia.
Intraoperative considerations
The ongoing discussion of the use of nitrous oxide in
The endotracheal tube is inserted and secured in a few
the balanced inhalational anesthetic technique has propo-
different ways. The surgeon must work around the tube
nents and antagonists.17,31 In Desai™s experience deliver-
and the anesthesiologist must be able to see that it is stable
ing the “Rolls Royce” of care, the use of nitrous oxide has
and connected during the case. Each surgeon will have a
been eliminated as it may increase the incidence of PONV
preferred method of securing the tube and one must adapt
in some patients. The choice of opioids has also been
to it. Endotracheal tubes, either oral or oral RAE r , may be
studied.32,33 The short-acting remifentanil (Ultiva r ) ver-
secured with sterile bio-occlusive dressing onto the chin or
sus fentanyl should be reviewed within any given practice.
tied to the canine or front teeth with wire or dental ¬‚oss.
Remifentanil is clearly more costly. Its very short-acting
Some anesthesiologists prefer to use a laryngeal mask air-
pro¬le may not leave the homebound postsurgical patient
way (LMA) to deliver inhalational anesthesia. In any case,
with adequate analgesia. Additionally, it has been shown
it is important not to distort the face when securing any
to have a higher frequency of hypotension in equivalent
airway device. Doing so is a powerful subliminal message
doses. Inasmuch as many cosmetic surgical procedures
of the anesthesiologist™s indifference to the surgeon™s task!
involve postoperative pain, Desai preferentially adminis-
Indifference is anathema to cooperation.
ters fentanyl. Fentanyl allows for a comfortable patient and
The eyes will be protected with gel or eye shields during
facilitates timely discharge. Changes in clinical practice
the case. The control of blood pressure during the pro-
that are geared toward well-titrated, short-acting agents
cedure is key. Maintain the pressure 20“30% lower than
can substantially affect how a patient feels and can shorten
baseline during the resection and then bring it back up
the time to discharge.34
close to baseline prior to closing. Restoring normotension
allows the surgeon to observe additional oozing prior to
Rhytidectomy or Facelift closing when the patient reaches their normotensive range.
The purpose of the facelift is to decrease skin wrinkling and Keep ¬‚uid load to a minimum as bleeding is min-
rejuvenate the appearance of the face with the removal of imal. There are no appreciable third-space losses with
excess skin and the suspension of facial fascia and tissues. rhytidectomy. Administer maintenance ¬‚uid only, as
Most patients seeking rhytidectomy are over the age excess ¬‚uid administration can contribute signi¬cantly to
of forty-¬ve. This is a procedure for which the anesthetic facial edema. Some surgeons will request dexamethasone
technique has a great deal of variation. Much of it is depen- to help minimize edema. Doses from 4“10 mg have been
dent on the choice of anesthesia by the surgeon as well as safely used.
the skills of the surgeon with that choice of anesthesia. The
concepts to consider in general anesthesia and facelifts fol-
Emergence considerations
low.
Extubate the patient without coughing and bucking as
both acts increase venous return and bleeding. Most sur-
Preoperative considerations geons want complete dressings applied on or before awak-
These patients are often elderly and require proper screen- ening. Many will hold pressure to minimize postextuba-
ing. A thorough examination of comorbid conditions is tion bleeding. The head dressing is circumferential of the
General Inhalation Anesthesia for Cosmetic Surgery 159


face and neck. One needs to make sure the dressing is not younger age groups, all ages of patients may present them-
too constricting around the neck. Elevate the head as soon selves (see Chapter 15).
as it is feasible as it helps with postprocedure swelling. The preoperative interview is the ideal time to address
postprocedure pain-management strategy and expecta-
Postprocedure considerations tions. The nature of pain post“breast implantation should
As local anesthetic is used for facelifts, there is not much be discussed. The quality of the pain is that of pressure
postoperative pain in the immediate recovery area. PONV and heaviness. As a weight has been added to their chest
is a great concern, and a multimodal regimen plan may and many will have a ¬rm circumferential pressure dress-
have better outcomes. Some surgeons prefer to observe ing, this sensation, of pressure and heaviness, is acutely
the patient in recovery for a period of time in excess of experienced with each breath. The expectation should be
that required for discharge according to Aldrete scores. that pain is to be expected, however, it should be tolerable.
The stretching of skin in a very short time period is often
Browlift felt as a deep ache in the shoulders and back. Submus-
This procedure serves to lift “excess” skin over the eye as cular dissection and implant placement will also involve
aging and gravity pull the eye and eyebrow down from the postprocedure deep muscular pain. Submuscular implant
supraorbital rim. placement produces spasm as well as pain. Postoperative
This procedure also is used to remove excess skin and oral diazepam can be very helpful in relieving pain sec-
wrinkling on the brow. There are a few common types ondary to spasm.
of browlifts that are incisional. There is the full coronal
Intraoperative considerations
incisional browlift and the side oblique incisional browlift.
One of the key factors for a good surgical result is to
The incisions are within the hairline for the full coronal
have total control of the bleeding and oozing in the breast
lift, and the undermining of tissues is done under direct
pocket. Blood in the pocket is known to increase the inci-
visualization. The oblique incisional lift places the incision
dence of capsule contracture and breast immobility. The
at the start of the hairline oblique to the brow. There is
placement of the implants also requires position changes
some blood loss with the scalp incision and dissection
intraprocedurally from supine to sitting.
as control is gained after incision. There is not the same
Airway circuits and IV lines of suf¬cient length should
concern over the use of muscle relaxants for browlift as
enable a smooth and timely transition from supine to sit-
applies to rhytidectomy. One may elect to intubate and
ting during the procedure.
paralyze the patient. Considerations about coughing on
The position of the arms is at the discretion of the sur-
extubation and increase in blood pressure are similar to
geon. Whether the arm placement is at the patient™s side or
those for rhytidectomy. Often pressure is applied to the
out on arm boards, check pressure points and abduction
dressings upon extubation.
angles. Also, ensure the arms will transition safely from
Endoscopic browlift supine to sitting as placement of implants is con¬rmed.
The browlift procedure lends itself well to the endoscopic Consider the effects of position as pertains to vascular tone
approach. The approach involves three to ¬ve minimal and blood pressure and be prepared to treat accordingly
incisions and is dissected endoscopically. The repair and as one may change supine to sitting positions frequently.
suspension may be held together with installed screw hard- Awareness of serious surgical complications would encom-
ware in the frontal mid-scalp well within the hairline. This pass pneumothorax and uncontrolled bleeding from the
approach may involve a longer operative time as com- thoracic vessels. A plan for transfer and admission to an
pared to the incisional lift but does leave less scarring for acute-care facility should be in place in the event that com-
the patient. plications cannot be de¬nitively addressed in the of¬ce
surgical suite setting.
Breast Augmentation
Preoperative considerations Emergence considerations
Breast augmentation is an extremely popular procedure. As in much of plastic and cosmetic surgery, the prefer-
Although many of the patients are in the forty-and- ence of the surgeon is key. Many will want all dressings
160 Meena Desai


on prior to extubation. Dressings will involve wound cov- ¬‚ow to the ¬‚ap. The effects of the nitropaste are usually
ering as well as bras and elastic bands or bandages that subclinical. However, attention must be paid to the poten-
are positioned to mold the placement of the implant in tial effects on the patient™s vital signs.
the pocket. If the surgeon would prefer all dressings in
Liposuction
place, one must maintain an adequate level of anesthesia
that keeps the patient still as they are sat up. The ideal Contouring lipoplasty is a very common plastic surgery
awakening would involve extubation without coughing as procedure. This procedure is not a weight-loss procedure
increases in venous pressures may increase the chance of but is a body-contouring procedure. Almost any area of
bleeding and oozing in the pocket. the body is amenable to liposculpture. The most common
method to perform liposuction is the tumescent tech-
nique. This technique involves the instillation of saline
Postprocedure considerations
mixed with a dilute solution of lidocaine (0.05“0.1%) and
Pain management solutions may include continuous infu-
epinephrine (1:1,000,000) into the areas of lipoplasty (see
sion pumps (i.e., On-Q, r or others) and intercostal and
Chapter 8).
incisional blocks.
The lidocaine in the mixture is a method of analge-
sia, and the epinephrine component is to aid hemostasis.
Endoscopic breast implants
The tumescent technique takes advantage of the tissue-
Most breast implants are still placed using the traditional
binding capacity of lidocaine with this dilute concentra-
inframammary approach. Alternative approaches are used
tion, where there is the slow uptake of lidocaine into the
by some surgeons as a marketing tool in their practices.
bloodstream with serum level peaking as late as 10“14
For example, the larger incision of the inframammary
hours after the infusion. The surgeon keeps a precise tally
approach is excellent for silicone implants. As often as
of the infusion amount of each tumesced site, and spe-
not, the peri-areaolar approach is used for in¬‚atable saline
ci¬c attention is given to tumescent input and aspirate
implants.
output.
Endoscopic breast implants allow for a smaller inci-
The most common method of suction is the use of a
sion and dissection under direct endoscopic view. The
power suction canister. The suction cannulae vary in the
approaches may be either transaxillary or transumbilical
number and placement of the suction ports and have a
for the placement of breast implants. The anesthetic con-
varied diameter depending on the effect desired. Fibrous
cerns remain similar to the other various approaches of
areas of the body are dif¬cult to suction and also are less
breast implant placement.
conducive to the even spread of the tumescent ¬‚uid. These
dif¬cult ¬brous areas may be suctioned using an ultra-
Mastopexy sonic suction that will “liquefy” the fat before the area
Mastopexy may be performed alone or in conjunction with is resuctioned with the standard liposuction machine to
augmentation. Reduction mammoplasty will have similar remove the lique¬ed fat. The ultrasonic liposuction adds
position change concerns as breast size, shape, and contour another element of complexity (viz., timing its use) as
are manipulated. there is an association of seroma formation with increased
time usage. Additionally, heat injury is a concern with this
Intraoperative considerations technology, and particular care must be taken to watch
The duration of the case is directly related to the extent and protect the skin.
of the mastopexy and its repair. As cosmetic surgery is Much has been discussed in the plastic surgical litera-
assessed with appearance, each incision is painstakingly ture over the amount of liposuction volume. The consen-
closed by hand. Blood loss and ¬‚uid-balance concerns in sus would lead the prudent plastic and cosmetic surgeon to
reduction mammoplasty are dependent on the extent of suction volumes less than 5,000 cc of aspirate. The removal
the resection, the amount of tissue, and the extent of the of larger volumes may require overnight stays and addi-
¬‚aps in question. Some surgeons may apply nitropaste tional postprocedure monitoring of ¬‚uid balance, blood
0.5“1.0 inch to the nipple areola complex to increase blood loss, and pain management.
General Inhalation Anesthesia for Cosmetic Surgery 161


Preoperative concerns sure points. The anesthesiologist must also ensure that all
monitoring cables and intravenous tubing will allow for
Liposuction is a potentially serious surgery and is of a
ease of movement during repositioning. The anesthesi-
moderately invasive nature.
ologist must prepare ahead with padding and position-
The mortality rate is 19 in 1,000, where the most com-
mon cause of death is from thromboembolism.35 ing devices because they are often managing much of the
“moves” on their own. It is most helpful to have all the
Thromboembolic concerns need to be addressed to
devices handy as one also has to be careful with the instru-
minimize risk. Particular attention should be paid to
mented airway. Attention to the patient™s temperature is in
herbal and other medications that may elevate this risk
order because hypothermia is a real risk.36 The patient has
(see Chapter 14 and Appendix A). Oral contraceptives
many exposed areas to the loss of convective heat. The
(and smoking) will increase this risk, and these issues must
in¬ltration of tumescent ¬‚uid produces losses of body
be discussed by the practice with the patient. Preoperative
heat. Often the skin is wet because the surgeon checks
education should include discussions on early ambulation
for evenness of liposculpture. There is additional heat loss
and exercises to ward against venous pooling. The char-
through evaporation. Methods to increase patient temper-
acter of liposuction pain is often that of incisions, and
ature need to involve Bair r huggers and keeping OR tem-
patients may experience some interior orthostatic symp-
peratures higher than normal. The procedure concludes
toms (described as “burning”) in the ¬rst twelve to twenty-
with feathering the edges of the fat deposit that involves
four hours. The discomfort after twenty-four hours will be
the suction cannula, providing a transition between the
that of a deep ache that is accentuated when the muscles
suctioned and residual fat to provide a natural contour.
under the suctioned fat are being used. The patient may
This feathering will trespass into less anesthetized areas
continue to ooze ¬‚uid from the ¬rst twenty-four hours.
because the tumescent solution will not have been infused
The patient should have immediate home help for that
there. There is often transient pain at the end of proce-
time.
dure. This is best addressed with short-acting hypnotics
Intraoperative concerns to manage hyperdynamic changes, which will resolve sud-
denly at the end of the procedure. The liposuction gar-
The most immediate anesthetic concern is the ¬‚uid man-
ment is a snug elastic garment applied immediately at the
agement of this patient, along with adequate analgesia.
Much of the tumescent ¬‚uid is absorbed by the patient,36 end of the procedure to control ¬‚uid sequestration. The
compression of the potential “third space” created by the
even though it appears that much is aspirated out with
suction of the fat is largely eliminated by the use of com-
the fat. With the use of epinephrine, the blood loss is
limited.37,38 One can observe the amount of hemoglobin pression garments. Failure to appreciate this issue has led
some anesthesia providers to administer overzealous ¬‚uid
staining or “redness” of the aspirate. Using the “wet” tech-
replacement. Inappropriate ¬‚uid management can lead to
nique of liposuction, one can keep the ¬‚uid requirements
to a minimum, “maintenance only”37 level. Amounts of dilutional anemia, dilution of platelets, and other clotting
factors, sometimes with fatal outcomes. The garment is
liposuction greater than 4,000 cc should be replaced with
worn for several weeks to smooth the skin and promote
0.25 ml intravenous crystalloid per ml of aspirate removed
over 4,000.38 Other intraoperative complications must retraction to the newly sculpted areas.
be considered in the diagnostic differential if dif¬culties
Postprocedure considerations
arise. These complications include viscus perforation, pul-
monary edema, vascular perforation, fat embolism, local Despite the use of lidocaine tumescent, there can be pain
anesthetic toxicity, and hypothermia.37 Positioning and in the “feathered” areas. One must ensure that the patient
repositioning the patient from side-to-side and supine- is comfortable as they are assessed in PACU. Our practice
to-prone is frequently done as one infuses the tumescent utilizes nalbuphine (Nubain r ) in doses of 5“10 mg IVP in
solution to all the sites. The surgeon allows it to work and PACU. In doses exceeding 10 mg, there is often an increased
then repositions for suctioning. This is an intraoperative element of sedation that will delay discharge. Warming the
challenge as one must be careful to position safely and patient with a Bair r hugger in the PACU is also very useful
continuously be aware of body alignment and all pres- after liposuction.
162 Meena Desai


Rhinoplasty cough, which will increase bleeding, and yet must be
awake to guard against aspiration. In addition, because
Rhinoplasty is a common procedure that involves con-
one cannot exert proper mask pressure with a “new nose”
touring the nose. Repairs can be simple or quite involved,
without potentially injuring the repair, the patient must
as many aspects may need to be manipulated to achieve
be awake at extubation to eliminate the propensity for
the desired result.
laryngospasm.
Intraoperative concerns
Postprocedure concerns
Rhinoplasty is a procedure well suited to general anesthe-
The patient is generally comfortable because local has been
sia with an instrumented airway. The endotracheal tube is
used during the procedure. Nausea and vomiting may be
positioned over the mandible and the oral RAE r tube with
a problem and will need to be addressed.
its curve may be quite helpful in its pro¬le. An armored
or ¬‚exible style LMA will also do well for administering
Abdominoplasty
inhalation anesthesia. The tube may be easily taped to
the patient™s chin to keep it out of the surgeon™s ¬eld of This is a procedure that is designed to remove excess
vision. The ¬‚exible tube™s advantage is the additional bal- skin and skin laxity and to remove fat with the abdom-
lotment of the esophagus, reducing the amount of blood inal skin ¬‚ap. Liposuction does not address the issue of
that can drip down into the stomach. Blood in the stomach excess skin, and abdominoplasty is the de¬nitive proce-
is a well-recognized cause of PONV following rhinoplasty. dure to solve this problem. Most abdominoplasty patients
Insertion of the ¬‚exible LMA is facilitated by lubricating are past child-bearing age and many are moderately over-
an uncuffed #5 endotracheal tube and using it as a stylet weight. The number of men undergoing this procedure
is also steadily increasing.39 The procedure is moderately
to stiffen the outer tube.
Extensive repair with osteotomies may involve bleeding, invasive, and patients will need a thorough workup pre-
which may compromise the airway and put the patient operatively. The procedure is extraperitoneal and often
at a higher risk for aspiration. The use of an endotra- accompanied by liposuction.
cheal tube with throat packing may help in controlling Liposuction may be done to the hips and ¬‚anks. Aggres-
how much blood goes down the esophagus and into the sive liposuction of the ¬‚ap is to be avoided because it com-
stomach. Attention must be paid to see that the throat promises the blood supply to the ¬‚ap and increases the
packs are removed. Unfortunately, even when dampened chance of ¬‚ap necrosis.
with saline, the throat packs are still very abrasive to the
Preoperative considerations
esophageal mucosa. Since the patient will likely have a sore
throat complaint from the endotracheal tube, they may Abdominoplasty patients are particularly at increased risk
have dif¬culty understanding why swallowing is painful for thromboembolic events. Teaching must be done to
as well. Limiting the cuff in¬‚ation of the LMA to the least advise patients of this particular risk, to inform them of
effective amount will lower the incidence of sore throat their postoperative role in the recognition of the symp-
complaints compared with the endotracheal tube throat toms of this complication, and to instruct them in their
pack combination. Cosmetic surgery patients will com- role in decreasing the incidence of this complication. Many
plain if the IV insertion hurt. They will not fail to complain patients also describe muscular back pain, back muscle
about a sore throat. “Rolls Royce” anesthesia care means spasm, and tightness in the ¬rst twenty-four hours. These
eliminating any and all avoidable patient complaints. discomforts can be best addressed with local heat, ice ther-
apy, and comfortable positioning.
Emergence concerns
Intraoperative concerns
The application of the surgical splint and dressing at the
completion of the rhinoplasty is an art and varies with Abdominoplasties can be performed with general anesthe-
every surgeon. Awaken the patient after the dressing is sia, oral endotracheal intubation, and muscle paralysis.
in place and the splint has stiffened and contoured. The After the imbrication of the rectus muscle sheath Mus-
awakening is a challenge because the patient should not cle paralysis is not required for suf¬cient conditions to
General Inhalation Anesthesia for Cosmetic Surgery 163


imbricate the rectus muscle sheath. Less is more is com- lated with water-soaked drapes and gauze. Water-soaked
pleted, the patient will be positioned in a ¬‚ex position with gauze should be applied to the endothracheal tube and
the back up and the knees bent. The back is raised and the placed over the eyes. Critical attention must be paid to
patient is ¬‚exed at approximately 30“40 degrees. This ¬‚ex- ensure the laser beam does not come into contact with
ion allows the abdominal ¬‚ap to be closed under tension. the endotracheal tube. The endotracheal tube provides the
The patient is kept in this position throughout the remain- least leakage of oxygen to the areas and is therefore the best
der of the procedure and in the PACU. Drains are usually option versus another airway device choice. One must also
placed and removed in seven to ten days. If pain-infusion keep the inspired oxygen concentration to a minimum in
systems are to be used, they are placed and primed at this case of airway ¬re.
time.40
Postprocedure concerns
Emergence concerns
Adequate analgesia is key after this procedure. When ade-
Because the sutures are closed under tension, one should quate intraoperative analgesia was supplied for laser facial
try and extubate without coughing. Coughing can increase resurfacing, only 12 percent of patients required postop-
intra-abdominal pressure, which can impact on the repair. erative analgesia and the PONV rate was zero.41 In com-
parison, when intraoperative analgesia was inadequate,
Postprocedure concerns
70 percent of patients required postoperative analgesia
The greatest immediate concern is to ensure the patient is and the PONV rate was 35 percent!42 The patient often
comfortable with tolerable pain. Adequate opioid analge- remarks that the face feels like it is on ¬re. Occlusive oint-
sia intraoperatively is key. ment applied topically shields the face and does allevi-
Many practices are now utilizing local pain-infusion ate some pain. Cool compresses and cold-water-soaked
pumps that will deliver local anesthetic to the site over gauze also aid in decreasing the pain. Narcotic analgesia
a number of days. Home instructions need to stress the given intraoperatively may need to be supplemented in the
necessity of moving about after surgery and the impor- PACU.
tance of leg and feet exercises that can be done to deter
venous pooling.
Blepharoplasty
Blepharoplasty and cosmetic eye surgery is performed to
Laser Facial Resurfacing
improve the appearance of the eye. The patient usually
Laser facial resurfacing serves to reduce ¬ne-line wrin-
wishes to alter excess skin wrinkling and puf¬ness due to
kles and to even out skin coloration. It can also be useful
excess fat deposition. General anesthesia is provided at the
to lessen facial scarring owing to previous injury. This is
request of the patient or surgeon. Most often these cases
particularly applicable to acne scarring. The laser seeks
are done with IV sedation; however, some patients may
to damage a skin layer that with healing will come in
not be able to tolerate four quadrant blephroplasty or may
with stronger connective tissue and “tighten” the face.
wish to have general anesthesia.
The insult generated by the laser is similar in quality to a
second-degree burn. The procedure itself is quite painful
Emergence concerns
and does require adequate analgesia. The duration of the
procedure may change from ¬fteen to forty-¬ve minutes The most critical time is that of emergence and extubation.
depending on the area to be covered and the number of One must attempt to ensure that the patient is extubated
passes to be made. without coughing and bucking. Patients are less likely to
cough or buck on an LMA compared to an endotracheal
Intraoperative concerns tube because any increase in venous and arterial pressure
Protect the eyes with shield protectors during the pro- is deleterious to the surgical result and may lead to uncon-
cedure. A major concern is that of ¬re in and around trolled bleeding. Keeping the head elevated at least 30
the patient. Precaution should be taken to use a laser- degrees will aid in reducing the venous pressure impacting
resistant endotracheal tube. The patients should be insu- on the surgical site.
164 Meena Desai


PRACTICAL CONSIDERATION
OF CLINICAL ISSUES

Fast Tracking and Discharge Criteria
The length of postoperative stay among ambulatory surgi-
cal patients is mainly determined by the type of surgery and
adverse events such as excessive pain, PONV, dizziness,
drowsiness, and unexpected cardiovascular events.43 An
approach that incorporates concepts to avoid pitfalls and
increase the feasibility of fast tracking is well reviewed.44,45
One should utilize a modi¬ed Aldrete score for bypass-
ing the intensive PACU and also develop and use Post-
Figure 13-1. Abdominoplasty patient shown at the conclusion of
anesthesia Discharge Scoring System (PADS) criteria for
the procedure with pain pump.
determining home readiness.46 New ideas in ambulatory
postprocedure care also allow for oral ¬‚uids in selected
patients but not as routine for all discharge protocols. The
safely discharged home. Dosing greater than 10 mg does
issue of voiding before discharge can also be individual-
often lead to unwanted side effects, such as drowsiness,
ized, as it may not be necessary in those patients at low
that may delay discharge. For pain score values 8 or greater,
risk for urinary retention.47
dose with up to two incremental doses of 25 ug of fentanyl
intravenously in the PACU.
Pain medication in recovery Many surgeons are also employing continuous infusion
Oftentimes the general surgical cosmetic suite has one OR pain-management techniques that involve local anesthetic
and one acute recovery bay. The nursing staff, though qual- pumps. These pumps may be patient-controlled as well
i¬ed, is limited, and the ef¬cient ¬‚ow of patients is depen- as continuous infusion via indwelling soaker catheters.
dent on minimal to no delays in the discharge area. The They are most commonly used for abdominal surgeries
greatest concerns of patients in the PACU relate to pain and breast surgeries (see Figures 13-1, 13-2, and 13-3).
management48,49 and PONV issues. The catheters are placed prior to closing, and the initial
dosing of local anesthetic is delivered prior to awakening.
Pain management They are typically kept in place for three to ¬ve days and
then removed at a postprocedure of¬ce visit. Many sur-
Excepting rhytidectomies, most cosmetic surgical proce-
geons may also place local anesthesia on incision sites to
dures involve some postprocedure pain. The adequate dos-
ing of an analgesic intraoperatively may be the key to
prompt discharge in the PACU. The patient that awak-
ens with a tolerable comfort level will fare better ful¬lling
the discharge and home-readiness protocols of the cen-
ter. Desai™s practice largely uses intraoperative fentanyl
because it provides cost-effective analgesia and allows for
timely discharge with comfort. The patient may resume
oral medications at home as soon as they begin to feel
pain. Rescue analgesia is primarily done after the patient
is assessed and a pain score value is determined. For
pain score values 7 or less, treatment with nalbuphine is
instituted in rapid incremental doses of 5, 7.5, or 10 mg.
Nalbuphine, a mixed agonist/antagonist opioid, has a good
analgesic pro¬le and a respiratory ceiling. The patient is Figure 13-2. Additional view of pain pump for abdominoplasty
still monitored after the intravenous dose before being patient.
General Inhalation Anesthesia for Cosmetic Surgery 165


consumerism, one must attend to all aspects of the surgi-
cal experience by considering all patients as a PONV risk.
Many patients will consider paying out of pocket for the
avoidance of this complication.53
A simpli¬ed PONV risk score includes the female gen-
der, history of motion sickness or PONV, nonsmoker,
and the use of postoperative opioids as being predictive
of risk.54,55 Although high-dose opioids are implicated in
increasing nausea, it has been shown that usual opioid
doses used in the course of outpatient surgery do not pro-
mote an increased incidence of PONV.56
The use of reversal agents are also implicated in increas-
ing the incidence of PONV; however, their use is guided by
clinical necessity.57,58 Consider the guidelines or consensus
statements regarding PONV.51 A multimodal approach
may be a successful regime.59,60 The timing of antiemetic
dosing has been shown to affect its ef¬cacy. It appears
that 5-HT3 blockers, such as ondansteron, may be best
administered immediately before the end of surgery for
the greatest ef¬cacy.61,62 The use of a second dose of a
5-HT3 blocker has been shown to have a diminished ef¬-
cacy as a rescue drug.52,62
Prophylactic intravenous administration of dexametha-
sone immediately after induction rather than at the end
of anesthesia was most effective in preventing PONV.63 A
single prophylactic dose of dexamethasone has not been
Figure 13-3. Close-up view of pain pump for abdominoplasty
patient. shown to have any clinically relevant toxicity in otherwise
healthy patients. The combination of dexamethasone and
a 5-HT3 receptor antagonist may be a more ef¬cacious
decrease postoperative discomfort. Others may also use
combination that either one administered alone.64,65
intercostals or other local ¬eld blocks. Many plastic and
The use of a multidrug regime can reduce the nausea
cosmetic surgeons are averse to using nonsteroidal anti-
and vomiting propensity of an inhalational general anes-
in¬‚ammatory medications (NSAIDs) because they do not
thetic. Mandatory po ¬‚uid intake is unnecessary as a dis-
wish to do anything that may increase the risk of bleed-
charge criterion.66 Patients also need to be counseled as
ing. Intravenous ketorolac (Toradol, r ) has an increased
to how to deal with the car ride home, especially if they
bleeding and oozing pro¬le that has made cosmetic sur-
have a propensity toward motion sickness. They should
geons less amenable to its use. The recent controversies of
be advised to recline the chair, close their eyes, and sit
the COX-2 inhibitors have led many patients and plastic
quietly. Additionally, they should be told to avoid sudden
surgeons away from their use.
movements, which can increase the incidence of motion
sickness.
PONV

The other main concern for patients is nausea and vomit-
MALIGNANT HYPERTHERMIA (MH) PROTOCOL
ing after the procedure. For many in this satin-gloved ser-
vice, even the feeling of nausea is distasteful. Many recent In Desai™s practice, extreme diligence is used obtaining in-
analyses have developed a model for predicting high- and depth patient history as soon as the case is booked. The
low-risk anesthesia groups for PONV.50,51 At this level of collection of patient anesthetic history often precedes the
166 Meena Desai


procedure by two weeks. Under no circumstances should a
Table 13-2. Risk factors for deep venous
patient with a personal or a family history of MH undergo
thrombosis and pulmonary embolism68
a triggering anesthetic in an of¬ce-based setting.
The level of staf¬ng, materials, and testing required in 1. Virchow™s triad (stasis, hypercoaguability, vascular
injury)
case of an attack of malignant hyperthermia would not be
2. Immobilization (e.g., from surgery or a fracture)
adequate in most of¬ce locations. One keeps an of¬ce loca- 3. Malignancy
tion that performs triggering anesthetics equipped with 4. Thrombophlebitis
5. Pregnancy, and for six to twelve weeks postpartum
dantrolene, iced ¬‚uids, bicarbonate, mannitol, insulin,
6. Extremity trauma
and so forth as advised by the many societies (i.e., JACHO,
7. Hormone replacement therapy or oral
MHAUS, AAAASF, and AAAHC) to ensure the initiation contraceptives
of timely treatment. Guidelines and policies are available 8. Smoking
9. Obesity (body mass index >30)
on the MHAUS web site.67 One should routinely have prac-
10. Recent myocardial infarction or cerebrovascular
tice drills for how to deal with this as well as other emer-
accident
gencies in the of¬ce cosmetic suite setting. Preparedness 11. Previous history of deep vein thrombosis
(pulmonary embolism)
may be lifesaving.
12. History of radiation therapy (especially pelvic)
13. Antiphospholipid antibody syndrome
14. Homocystinemia
THROMBOEMBOLISM
15. Polycythemia
16. Other hypercoaguable states
Thromboembolism is a dreaded complication of surgery.
a. Abnormal protein C or S
Deep venous thrombosis and pulmonary embolus can
b. Factor V Leiden
cause signi¬cant morbidity and even death. Certain guide- c. Abnormal factors XIII, IX, X
lines have been published that can signi¬cantly reduce the
incidence of this complication.68 The plastic and cosmetic
surgeon walks a ¬ne line between postoperative bleeding
ing oral contraception or undergoing hormone replace-
and thromboembolism. Abdominoplasty has one of the
ment therapy. Although general anesthesia for less than
highest rates of deep venous thrombosis and pulmonary
thirty minutes does not cause signi¬cant venous pool-
embolus in plastic surgery.69
ing, a linear increase in the risk of deep venous throm-
Recent investigations into deaths in Florida have shown
bosis occurs with general anesthesia times of greater than
a signi¬cant association of pulmonary embolus as cause of
one hour.71 High-risk patients are those who have addi-
death. Thromboembolic risk increases when abdomino-
tional risk factors from the moderate-risk group such as
plasty is combined with other aesthetic procedures.70 The
malignancy, immobilization, obesity, and hypercoagulable
association of pulmonary embolus and abdominoplasty
states.
may be related to the reduction of ease of super¬cial
venous drainage from the pelvis and legs. Adding suction-
Recommendations according to risk strati¬cation
assisted lipectomy to abdominoplasty does not increase the
risk of deep venous thrombosis or pulmonary embolus.70 Position the patient comfortably on
LOW-RISK PATIENTS.

the operating table with slight knee ¬‚exion and a pillow to
The American Society of Plastic Surgery has formulated
enhance popliteal venous return. Avoid external pressure
a task force on Deep Venous Thrombosis Prophylaxis
and has established some guidelines.68 It is recommended on the legs or constricting garments.
that patients be strati¬ed according to their risk of deep
venous thrombosis and pulmonary embolus. The low-risk Observe the same comfortable
MODERATE-RISK PATIENTS.

group represents patients who have known risk factors, positioning and the use of intermittent pneumatic com-
require surgical procedures of thirty minutes or less, and pression garments worn before, during, and after general
are under the age of forty (see Table 13-2). A moderate risk anesthesia until the patient is fully awake. If possible, these
exists for patients who are greater than forty years of age, patients should stop taking risky medications at least one
require procedures longer than thirty minutes, or are tak- week before surgery, although it is unclear in the literature
General Inhalation Anesthesia for Cosmetic Surgery 167


if the risk for deep venous thrombosis and pulmonary indicate that the least amount of anesthetic that can be
embolus normalizes within this time.68 used is the best dose. Local and monitored anesthesia care
(MAC) is preferable to regional. Regional techniques are
preferable to general anesthesia.”74
Observe the same measures as the
HIGH-RISK PATIENTS.

lower-risk categories plus a preoperative consultation
from hematology. Consider low-molecular-weight hep-
CONCLUSION
arin two hours before surgery and until the patient
is ambulatory. Prophylactic anticoagulation, however, is The challenge of the of¬ce-based, cosmetic surgery suite
considered optional in procedures with a high risk for remains as anesthetic agents and techniques continue to
hematoma. The majority of aesthetic procedures fall into evolve. The satisfaction of the patient and the work atmo-
this category. sphere continue to provide positive reinforcement as anes-
Intermittent pneumatic compression devices (IPCD) thesiologists continue to address the challenges in this
are mechanical devices that increase the pulsatile ¬‚ow specialized setting.
in the veins by preventing stagnation and enhancing
endogenous ¬brinolytic activity. However, there is no
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PART III OTHER CONSIDERATIONS FOR ANESTHESIA IN COSMETIC SURGERY




14 Preanesthetic Assessment of the Cosmetic
Surgery Patient
Norman Levin, M.D.


INTRODUCTION
PAST MEDICAL HISTORY
Hypertension
Cardiac Disease
Diabetes Mellitus
Herbal Supplements
PAST ANESTHETIC HISTORY
Malignant Hyperthermia (MH)
PREGNANCY
PHYSICAL EXAMINATION
PREOPERATIVE TESTS
Preoperative Tests Should Not Be Routinely Ordered
Electrocardiogram (EKG)
Laboratory Tests
Chest Radiographs
PREOPERATIVE PREPARATION
Anxiety
Prevention of Postoperative Nausea and Vomiting (PONV)
Prevention of Aspiration Pneumonitis
SUMMARY




The preanesthetic evaluation of the surgical patient is
INTRODUCTION
the ¬rst duty of an anesthesiologist to a patient. Klafta
Over the past two decades, outpatient cosmetic surgical and Rozien identi¬ed six interrelated goals of the pre-
procedures have grown at an exponential rate, progress- anesthetic evaluation.1 The ¬rst is to assess health and
ing from simple procedures in a physician™s of¬ce surgi- ensure physical readiness for anesthesia-requiring proce-
cal suite to a broad spectrum of procedures in of¬ces and dures. The second is to devise a mutually agreeable anes-
freestanding ambulatory surgery centers in addition to the thetic plan and to educate the patient about it. The third
hospital setting. This number continues to grow as more is to reduce the psychological and physiological conse-
of¬ce surgery suites and ambulatory surgical centers con- quences of anxiety. The fourth is to plan postoperative care
tinue to open. This rapid growth in ambulatory surgery and pain therapy. The ¬fth is to coordinate patient care in
would not have been possible without the changing role a way that decreases total cost and improves outcomes.
of the anesthesiologist and the development of better and The sixth is to obtain informed consent for anesthesia
shorter acting anesthetic medications. (Table 14-1).




171
172 Norman Levin


physical examinations, and medical and laboratory tests,
Table 14-1. Six preanesthetic goals
in addition to the patient™s interview.
Because of the importance of the preanesthetic assess-
1. Assess health and physical readiness for surgery
2. Devise an anesthetic plan and inform patient thereof ment, this chapter reviews many of the aspects involved in
3. Reduce anxiety the anesthetic management of the patient undergoing cos-
4. Plan postoperative care and pain management
metic surgery. Many cosmetic surgeons utilize the services
5. Coordinate patient care
of other medical specialties, such as internal medicine, for
6. Obtain informed consent for anesthesia
the medical workup and the appropriate laboratory tests.
In addition to the internist giving clearance for surgery, it
must be emphasized that the anesthesiologist is ultimately
The preanesthetic evaluation provides one of the most responsible for the pre- and postoperative management of
formidable challenges for anesthesiologists and represents that patient.
a focused assessment to address issues relevant to the safe
administration of anesthesia. The preanesthetic evalua- PAST MEDICAL HISTORY
tion gives the anesthesiologist the opportunity to meet,
Obtain information concerning the patient™s past medical
comfort, and allay any anxiety that the patient might have
history. Although the ASA patient-physical-status classi-
concerning the surgical procedure. The preanesthetic eval-
¬cation is widely accepted, it is only a gross predictor of
uation is also an opportunity to assess the health of the
the overall outcome and not a predictor of anesthetic risk
patient, to educate the patient concerning anesthesia, and
(Table 14-2). In the past, the majority of patients undergo-
to obtain pertinent information concerning the patient™s
ing cosmetic surgery were healthy individuals (ASA phys-
medical history and an informed consent.
ical status 1 or 2). However, over the years, the number
In the past, only “healthy” patients were acceptable can-
of patients with various severe medical problems (ASA
didates for ambulatory (or of¬ce-based) surgery. However,
physical status 3) has increased, and these patients have
in cosmetic surgery over the years, the number of patients
undergone outpatient cosmetic surgery with safety. This
with more severe medical problems has increased through
has been possible because of newer and better medications
the utilization of different anesthetic techniques. The pre-
for medical conditions, in addition to faster-acting anes-
anesthetic assessment of the cosmetic patient is of utmost
thetic agents and the improvement of anesthesia monitor-
importance and should not be different than that of any
ing equipment. Natof concluded that ASA physical status
patient undergoing other types of surgical procedures in
3 patients, whose systemic diseases were well controlled
any setting, whether it be in ambulatory surgical centers,
preoperatively, were at no higher risk for postoperative
of¬ce surgical suites, or hospital surgical suites. However,
complications than ASA 1 or 2 patients.2 Many cosmetic
with the continued growth of ambulatory surgery centers
patients come to surgery with numerous medical condi-
and of¬ce-based surgical procedures, this has placed the
tions, but only the most common ones are discussed in
anesthesiologist in a position of being the most involved
this chapter.
in the direct medical care of the patient.
Previously unacceptable, high-risk patients, many of
whom comprise cosmetic patients, are now being done in
Table 14-2. ASA patient physical status
outpatient surgical centers. As a result, a new role has been
created for the anesthesiologist. That is why the preanes- ASA 1 A normal healthy patient
ASA 2 A patient with a mild systemic disease
thetic assessment is very important and most bene¬cial in
ASA 3 A patient with a severe systemic disease that
identifying medical problems, previous anesthetic prob-
limits activity
lems, family history of anesthetic problems, medications ASA 4 A patient with severe systemic disease that is
and/or herbal supplements patients might be taking, and a constant threat to life
ASA 5 A moribund patient who is not expected to
the hour at which food or liquids were taken.
survive without the operation
During the preanesthesia evaluation, information
ASA 6 A declared brain-dead patient whose organs
should be reviewed from multiple sources, including the are being removed for donor purposes
patient™s medical records, other physician evaluations and
Preanesthetic Assessment of the Cosmetic Surgery Patient 173


Hypertension tainly on any patient with hypertension in the periop-
A large number of patients undergoing cosmetic surgery erative period. If there are no strong contraindications,
have a history of hypertension and are on blood pressure atenolol, metoprolol, or labetolol could be considered in
medications. These patients should continue their medi- such a patient.8,9 Patients at risk of cardiovascular morbid-
cations until and including the day of surgery. Diuretics ity are increasingly receiving perioperative beta-blocker
should not be taken before surgery to limit the possibility therapy.10 For those patients in whom beta-blockers might
of intraoperative enuresis. be contraindicated (i.e., asthmatics), hydralazine or a
At what level of blood pressure in hypertensive patients nitrate should be considered. Patients will tolerate pres-
would it be acceptable to proceed with surgery? According sure elevator but not heart rate elevation. It is mandatory
to Dix, there is little evidence to support canceling surgery to avoid tachycardia.
in patients who present for surgery with systolic blood
Cardiac Disease
pressures between 140 and 179 mm Hg and diastolic blood
pressures between 90 and 109 mm Hg.3 Many older patients coming for cosmetic surgery have an
Patients with systolic blood pressures between 180 and 210 abnormal cardiac history and are under good control with
mm Hg are three times more likely to suffer postoperative pharmacological management. There are many commonly
myocardial ischemia than those with a preoperative blood seen dysrhythmias such as sinus tachycardia, sinus brady-
pressure of 120 mm Hg.4 cardia, and ventricular and atrial premature beats.
There are some patients who come to the operating Bradycardia is frequently seen in patients who might be
room without a history of hypertension, yet the anesthe- athletically active or on medications accounting for their
siologist ¬nds hypertension to be present. Anxiety con- slow heart rate. In other patients, tachycardia might be a
cerning the procedure can cause the blood pressure to new problem needing further study and treatment prior
be elevated. Some of these patients could have a cardiac to surgery.
abnormality. Approximately 10% of the general popula- Alternatively, tachycardia might be due only to anxi-
tion has an increased incidence of altered left-ventricular ety with the release of endogenous catecholamines. Seda-
structure and function when mildly stressed.5 tives or cardiac medications might be necessary to control
An increase in blood pressure can also occur when the dysrhythmia prior to commencing with the surgical
epinephrine is injected by the surgeon for surgical hemostasis. procedure. As previously mentioned, most cosmetic sur-
An elevated blood pressure can occur in patients under- geons use epinephrine for hemostasis, and this can
going general anesthesia, especially during the induction cause the dysrhythmia to become more exaggerated and
of anesthesia and intubation with an endotracheal tube. severe.
Compared with direct laryngoscopy, a lower incidence of Patients with a history of myocardial infarction (MI)
hypertension in hypertensive patients can be achieved dur- should not have a cosmetic surgery for at least six months
ing laryngeal intubation when utilizing a lightwand device following the occurrence. Multiple studies have demon-
or a laryngeal mask airway (LMA) Fastrack„.6 There is an strated an increased incidence of reinfarction if the MI
was within six months of surgery.11’13 Patients with unsta-
increasing recognition that systolic blood pressure is as
important or more important than diastolic blood pres- ble acute coronary syndromes, such as unstable angina or
sure in elderly patients. Older patients with systolic hyper- decompensated congestive heart failure of ischemic origin,
tension are at increased risk for stroke and cardiac events.7 are at high risk of developing further decompensation,
Control the patient™s blood pressure during the preanes- myocardial necrosis, and death during the perioperative
thesia period or immediately prior to the induction of period. Patients with unstable acute coronary syndromes
anesthesia or before the injection of epinephrine by the should not be considered for cosmetic (or any) surgery,
unless absolutely necessary.14
surgeon.
Beta-blockers are used as the ¬rst line of antihy- Based on observations of the surgery on thousands of
pertensive drugs for the treatment of hypertension. patients, the author notes that neither increasing age nor
Beta-blockade in the perioperative period decreases peri- the presence of stable preexisting disease has any effect
operative cardiac morbidity and mortality. There are many on the incidence of postoperative complications in the
cases in which beta-blocker use can be justi¬ed, but cer- surgical outpatient setting.
174 Norman Levin


Diabetes Mellitus of over-the-counter herbal medications during the peri-
operative period is an area of both enormous consumer
There are many patients coming for cosmetic surgery with
enthusiasm and physician concern.15 Several studies have
a history of diabetes mellitus. Diabetes mellitus (DM) is
suggested that patients undergoing surgery appear to use
the most commonly encountered endocrinopathy and is
herbal medications signi¬cantly more frequently than the
a progressive disease of glucose dysregulation. This carbo-
general population.16,17 Many cosmetic surgical patients
hydrate intolerance frequently results in signi¬cant acute
have not only a concern for their appearance but also
and long-term systemic sequelae. The goal of the anesthe-
a great concern for their health. As a result, they often
siologist is to maintain the patient in a physiological state
take herbal medications to improve their physical well-
to mimic normal metabolism.
being. Kaye and colleagues reported that nearly a third of
Avoid hypoglycemia. Administer exogenous glucose, if
the patients in an ambulatory surgical setting admitted to
necessary. Prevent excessive hyperglycemia, ketoacido-
using herbal medications, and over 70% of those patients
sis, and electrolyte disturbances. Administer exogenous
failed to disclose their herbal medicine use during their
insulin when needed. The well-controlled, diet-treated
routine preoperative assessment.17
patient with NIDDM (non“insulin-dependent diabetes
The danger to patients is that morbidity and mortality
mellitus) does not require any type of special treatment.
with herbal medications may be more likely in the peri-
Patients on oral hypoglycemic drugs should continue
operative period because of the polypharmacy and phys-
their medication until the evening before surgery. Patients
iologic alterations that occur during that time.18 Adverse
with well-controlled insulin-dependent diabetes mellitus
reactions that may be caused by supplements include pro-
(IDDM) may not need any adjustment in their usual
longed bleeding, interference with anesthesia, cardiovas-
subcutaneous insulin dosage. In all diabetic patients, an
cular disturbances, and interactions with pharmaceuticals
Accu-chek r or some other method of blood sugar deter-
(Table 14-3). Also, it may be extremely dif¬cult to dif-
mination should be performed during the immediate
ferentiate cause and effect related to surgery versus the
preoperative evaluation, and insulin medication, where
use of herbal medications when dealing with postopera-
appropriate, should be administered.
tive complications such as myocardial infarction, stroke,
Most IDDM patients check their blood sugars on a reg-
coagulation disorders, prolonged effects of anesthetics,
ular basis. Many internists like to control their patient™s
and interference with medications necessary for patient
insulin dosage for surgery and suggest an amount of
care.
insulin to be taken on the day of surgery. If the patient™s
The ¬ve most popular herbal products in the United
physician does not recommend an insulin regimen, the
States are (1) Gingko Biloba, (2) St. John™s Wort, (3)
anesthesiologist should suggest one. A commonly used
Ginseng, (4) Garlic, and (5) Echinacea. Gingko Biloba can
approach is to reduce the intermediate preparation of
inhibit platelet function, causing intraoperative bleeding
insulin by one fourth (25%) to one half (50%) the usual
(see Chapter 12 for the particular risk with neuraxial
daily dosage the morning of surgery. If regular insulin
blockade). St. John™s Wort has multiple drug interactions
is part of the morning schedule, the intermediate-acting
and is contraindicated with MAOIs and SSRIs. Ginseng
insulin dose may be increased by 0.5 unit for each unit of
can interact with cardiac and hypoglycemic agents.
regular insulin.
Garlic can inhibit platelet function, causing increased
When a patient receives insulin and is not eating, an intra-
bleeding. Echinacea can cause immunosuppression and
venous of glucose solution should be started in the preoper-
a potential for hepatotoxicity.19,20 Ephedra (ma huang)
ative period to minimize the chance of hypoglycemia during
is contained in many supplements. Ephedra is danger-
or after surgery.
ous because it indirectly causes release of endogenous
Herbal Supplements catecholamines. Increased catecholamines contribute to
perioperative instability with hypertension, tachycardia,
Obtain information during the preanesthesia evaluation
dysrhythmia, and potentially myocardial infarction.
about the use of herbal medications that are often found
Anesthesiologists must inquire speci¬cally as to the use
in herbal dietary supplements, diet pills, muscle builders,
of herbal medications from their patients.
and so-called power drinks (see Appendix A). The use
Preanesthetic Assessment of the Cosmetic Surgery Patient 175



Table 14-3. Supplements contraindicated in the perioperative period

Supplement Common Use(s) Adverse Effects

Echinacea Simulates immune system, used in Can cause hepatotoxicity, may
common cold and bronchitis decrease effectiveness of
corticosteroids
Ephedra CNS stimulant, diet aid, bronchodilator, Death, tachycardia, hypertension,
(ma huang) nasal decongestant myocardial infarction
Garlic Blood pressure and lipid lowering, Affects platelet aggregation, avoid
antithrombotic, antiviral with anticoagulants
Ginger Antispasmodic, antiemetic Can prolong bleeding time,
contraindicated with anticoagulants
Ginkgo Biloba Enhances blood ¬‚ow, alleviates vertigo Can increase bleeding time,
and tinnitus contraindicated in patients on
anticoagulants
Ginseng Improves physical and cognitive May interact with cardiac and
enhancer, antioxidant hypoglycemic medication,
contraindicated with anticoagulants
Goldenseal Anti-in¬‚ammatory, diuretic May worsen edema and hypertension
Kava kava Anxiolytic, sedative, analgesic May potentiate barbiturates,
antidepressants, and general
anesthesia
Licorice Gastric and duodenal ulcers and May cause hypertension,
bronchitis hypokalemia, and edema
Melatonin Insomnia, jet lag May potentiate barbiturates and
general anesthetics
St. John™s Wort Antidepressant Multiple drug interactions,
contraindicated with MAOIs and
SSRIs




When asked about medications for medical reasons, many the preoperative evaluation, the anesthesiologist should
patients feel that herbals are completely safe and do not con- obtain from the patient or a family member information
sider them to be drugs. concerning previous anesthetic problems. This is espe-
The ASA recommends that supplements producing cially important for those patients who have experienced
adverse effects be avoided for at least two weeks prior to or are susceptible to MH. In those individuals, prepara-
surgery and one week after surgery. tions for safe administration of anesthesia are necessary
to avoid a catastrophic outcome. A treatment plan for
PAST ANESTHETIC HISTORY MH should be available in every anesthetizing location.
MH-triggering agents (i.e., halothane, en¬‚urane, iso¬‚u-
A review of the patient™s past anesthetic and surgical his-
rane, des¬‚urane, sevo¬‚urane, and succinylcholine) should
tory is important. The review can make the anesthesiol-
not be used on patients susceptible to MH or their undi-
ogist aware of prior anesthetic problems and/or compli-
agnosed relatives.
cations that the patient or a family member might have
All facilities, including ambulatory surgery centers and
experienced. This will enable the physician to develop a
of¬ces, where MH-triggering anesthetics are administered
better anesthetic plan for the care, comfort, and safety of
should stock dantrolene sodium for injection.
the patient.
With the avoidance of the MH-triggering agents, pre-
Malignant Hyperthermia (MH) anesthesia treatment with dantrolene is not recommended
Although extremely rare, malignant hyperthermia is for most MH-susceptible patients. Neither propofol nor
a potentially fatal complication of anesthesia. During ketanine are triggering agents.
176 Norman Levin


tive to determine which patient might present as a dif¬cult
PREGNANCY
intubation.
Occasionally patients who are not aware of being preg-
The failure of the anesthesiologist to monitor and main-
nant are scheduled for cosmetic surgery. Mandatory
tain a patent airway, when involved with the patient
pregnancy testing on all females during their reproductive
undergoing cosmetic surgery, is one of the most common
years (between ages twelve and ¬fty years) is a controversial
causes of anesthesia-related morbidity and mortality (see
issue. Spontaneous abortion and teratogenic effects may
Chapter 18).
occur during the ¬rst trimester of pregnancy.21
Keeping the airway patent and protected is an important
Teratogenic effects of anesthetics are probably minimal to
function of the anesthesiologist. Mallampati suggested
nonexistent and have never been conclusively demonstrated
that the size of the base of the tongue is an important fac-
in humans.
tor in determining the degree of dif¬culty of direct laryn-
The drugs that were of most concern included nitrous
goscopy.24 A relatively simple grading system that involves
oxide and the benzodiazepines.22,23 In animal studies,
the preoperative ability to visualize the faucial pillars, soft
nitrous oxide, if not combined with a halogenated (sympa-
palate, and base of uvula was designed as a means of pre-
tholytic) agent, may cause vasoconstriction of the uterine
dicting the degree of dif¬culty in laryngeal exposure. Khan
vessels with a decrease in uterine blood ¬‚ow. No adverse
modi¬ed Mallampati™s classi¬cation utilizing the upper-
effect of nitrous oxide has been demonstrated in human
lip bite test as an acceptable option for predicting dif¬cult
pregnancy. The maintenance of uterine perfusion and
intubation as a simple, single test.25
maternal oxygenation to preserve fetal oxygenation are
the keys to any anesthetic during pregnancy, with the
avoidance of maternal hypoxia and hypotension being PREOPERATIVE TESTS
essential.
Preoperative Tests Should Not Be Routinely
If, during the presurgical workup, a positive pregnancy
Ordered
test occurs, delay the surgery until after the delivery. Delay
The ASA Task Force on Preanesthesia Evaluation con-
may avoid any suspicion of anesthetic involvement causing
cluded that routine preoperative tests do not make an
either the spontaneous abortion or fetal abnormalities that
important contribution to the process of preoperative
might occur.
assessment and management of the patient by the anes-
thesiologist.27 It is the patient™s underlying condition and
PHYSICAL EXAMINATION
the likelihood that the results will affect the anesthetic
plan that should guide the choice of preprocedure labo-
One of the major responsibilities of the anesthesiologist is
ratory tests, chest x-ray, and EKG. Preoperative tests may
to physically evaluate the cosmetic surgical patient imme-
be ordered on a selective basis for optimizing periopera-
diately before surgery concerning the risk of anesthesia and
tive management. Most cosmetic surgical patients come
of the procedure to be performed. At a minimum, a focused
to surgery having had a workup by an internist or other
preanesthetic physical examination should include an
physician giving medical clearance for the surgery. Often
assessment of the airway, lungs, and heart with documen-
a request is made to the anesthesiologist for speci¬c tests
tation of the vital signs.
or studies. The ASA Task Force on Preanesthesia Evalua-
The importance of the preanesthesia airway examina-
tion concluded that there should not be rules for ordering
tion of the cosmetic surgical patient cannot be under-
preoperative tests but only for selected clinical situations.26
stated. It is not important whether the proposed anesthetic
Depending on the patient™s clinical situation, the following
administered to the patient is local with intravenous seda-
studies might act as a guide in preoperative testing.
tion, total intravenous anesthesia (TIVA), or general anes-
thesia. The unexpected need for airway support, whether
Electrocardiogram (EKG)
by endotracheal intubation, LMA, or other means, should
be evaluated in advance for the possibility of being a dif¬- Patients with a known history of cardiovascular disease
cult airway. If an emergency arises and the need for endo- should have an EKG. The ASA Task Force feels that age alone
tracheal intubation should become necessary, it is impera- is not an indication for an EKG. However, many others feel
Preanesthetic Assessment of the Cosmetic Surgery Patient 177


that having a baseline EKG for patients over forty years of requesting postoperative analgesia in a group that received
age might be bene¬cial. preoperative midazolam compared to a group that did
not.29a
Laboratory Tests
Prevention of Postoperative Nausea and
For active healthy patients, laboratory tests might not be
Vomiting (PONV)
necessary for males below ¬fty years of age. For females in
As part of the preoperative evaluation, it is important to
this age range, only hemoglobin (or hematocrit) should be
identify patients in whom PONV occurred following a
necessary. Patients with chronic diseases (e.g., hyperten-
previous surgical procedure or are at a high risk for devel-
sion, diabetes) should have the appropriate additional lab-
oping such a complication. PONV is often a limiting factor
oratory studies (e.g., electrolytes, glucose) as indicated for
in the early discharge of ambulatory surgery patients, in
a medical condition. Also, patients with an unexplained
addition to being a leading cause of unanticipated hospital
hemoglobin less than 10 gm · dl’1 should undergo fur-
admission.30,31
ther evaluation prior to elective cosmetic surgery. Testing
Typically, the administration of opioids, as part of a
should rule out other diseases (e.g., liver disease, anemia,
preanesthetic regimen or during the course of an anes-
bleeding, and other hematological disorders) that could
thetic, is known to increase the incidence of PONV. Gen-
in¬‚uence perioperative mortality and morbidity.
eral anesthesia carries a higher risk of PONV than regional
anesthesia, major conduction anesthesia (subarachnoid
Chest Radiographs
or epidural block), intravenous anesthesia, or monitored
Unless the patient has clinically acute pulmonary symp-
anesthesia care. Perhaps the most controversial aspect of
toms, routine chest x-rays are not necessary.
general anesthesia is the independent risk associated with
the administration of nitrous oxide.
PREOPERATIVE PREPARATION
Many patients prefer the avoidance of PONV than the
avoidance of postoperative pain.32
Anxiety
The preoperative assessment and communication with Not all patients should receive PONV prophylaxis.
the patient is essential in obtaining information. Many However, patients at small risk for PONV are unlikely to
presurgical patients are very anxious in spite of a tele- bene¬t from prophylaxis and would be put at unneces-
phone conversation with the anesthesiologist the night sary risk from the potential side effects of antiemetics.
before surgery.27 However, Levin has found that a call Thus, prophylaxis should be reserved for those patients at
to the patient the night before surgery has the effect moderate to high risk for PONV. Individuals with four
of allaying anxiety and decreasing the need for preop- primary risk factors for PONV were reported by Apfel et
al.33 as patients receiving balanced inhalation anesthesia:
erative sedative medications. In the past, it has been
shown that the preoperative visit by the anesthesiologist is female sex, nonsmoking status, history of PONV, and opi-
more effective than preoperative barbiturate medication in oid use. The incidence of PONV with the presence of
reducing perioperative anxiety.28 A signi¬cant amount of none, one, two, three, or all four of these risk factors was
anxiety is present at least six days prior to surgery in unpre- approximately 10%, 20%, 40%, 60%, and 80%, respec-
pared patients.29 High levels of anxiety are often associ- tively. Reduce the risk of PONV whenever clinically practi-
ated with other adverse outcomes, such as an increased cal. Patients receiving general anesthesia had an elevenfold
incidence of emesis. Frequently, cosmetic surgical patients increase in risk for PONV compared with those receiving
regional anesthesia.34
who need anxiolytics are not given preoperative medi-
cations because of concern for prolonged recovery and Propofol, administered for the induction and main-
discharge from the facility. However, midazolam, with a tenance of anesthesia, effectively reduced early PONV
incidence.35 Oxygen supplementation restricted to the
relatively short half-life and the lack of signi¬cant side
intraoperative period also halved the risk of PONV.36
effects produces excellent amnesic and anxiolytic proper-
Hydration can also reduce the incidence of PONV.37
ties without any delay in discharge from the facility (see
Chapter 7). Oxorn found a threefold incidence of patients Avoiding nitrous oxide and volatile inhaled anesthetics
178 Norman Levin


and minimizing intraoperative and postoperative opioid from anesthesia. The optimal dose of dolasetron appears
use reduced the incidence of PONV.33,38’43 Scuderi et al.44 to be 12.5 mg and the timing of administration for prophy-
tested the ef¬cacy of a multimodal approach to reducing laxis appears to be less important than for ondansetron.
PONV. Their multimodal approach consisted of preop- For droperidol, the optimal dose is 0.625“1.25 mg and
erative anxiolysis, aggressive hydration, oxygen, prophy- mostly effective when given at the end of surgery. Droperi-
lactic antiemetics (droperidol and dexamethasone at the dol in doses of either 0.625 mg or 1.25 mg compares favor-
induction with ondansetron at the end of surgery), total ably with ondansetron 4 mg in outpatients. In fact, the
IV anesthesia with propofol and remifentanil, and ketoro- higher dose of droperidol (i.e., 1.25 mg) is more effective
than ondansetron in preventing nausea.53
lac. No nitrous oxide or neuromuscular blockade was used.
Patients who received multimodal therapy had a 98% com- In December 2001, the FDA issued a “black box” warning
plete response rate, compared with a 76% response rate for droperidol in response to patient deaths associated with
among patients receiving antiemetic monotherapy and a cardiac rhythm abnormalities.
59% response rate among those receiving routine anes- Metoclopramide stimulates gastric emptying and is
thetic plus saline placebo. administered at the end of surgery. Metoclopramide™s use-
The introduction of serotonin antagonists (speci¬- fulness is uncertain except in patients where gastric stasis
cally the 5-HT3 subgroup) in the early 1990s offered is an issue. Prochlorperazine (Compazine r ) is as effective
considerable promise for the management of PONV. as ondansetron but can cause extrapyramidal symptoms.
Ondansetron, dolasetron, and granisetron are the drugs Transdermal scopolamine (Transderm-Scop r ) has an
approved for PONV prophylaxis. Prophylactic adminis- onset of action of four hours. Thus, it should be applied
tration of this class of medication has been shown to far enough in advance to ensure it has time to start
decrease the incidence of PONV in various patient pop- working, but it can cause visual disturbances and dry
ulations. Comparisons of ondansetron and dolasetron mouth. The various side effects caused by some of these
for PONV prophylaxis suggest that there are no clini- medications “ sedation, dysphoria, cardiac effects, and

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