5. Basics of Anesthesia for the Aesthetic Surgery Patient
General Principles
Anesthesia for patients undergoing purely elective aesthetic procedures presents specific challenges that encompass:
Patient selection
Surgical venue selection (ambulatory surgery centers, offices, hospital)
Choice of anesthetic technique(s)
Personnel requirements
Postoperative care and pain management
Discharge criteria
Patient satisfaction
Requires high level of understanding, communication, and cooperation between surgeon and anesthesia provider to ensure optimal surgical outcome and patient experience
Regulatory agencies establish minimum standards of care in aesthetic surgery environments.
Accreditation Association for Ambulatory Health Care (AAAHC)
The Joint Commission (TJC), formerly Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
Regulations may vary with regard to state and type of facility.
Professional societies provide consensus statements, guidelines, recommendations, practice parameters, and advisories for evidence-based best practices for ambulatory surgery centers (ASC) and office-based practices.
American Society of Anesthesiologists (ASA)
Society for Ambulatory Anesthesia (SAMBA)
American Society of Regional Anesthesia and Pain Medicine (ASRA)
American College of Cardiology and American Heart Association (ACC/AHA)
American College of Surgeons (ACS)
American Society of Plastic Surgeons (ASPS)
American Society for Aesthetic Plastic Surgery (ASAPS)
Anesthetic Goals
Anxiolysis
Amnesia
Analgesia
Sedation
Unconsciousness or hypnosis
Immobility, including muscle relaxation or paralysis
Quiet, nondistracting operating milieu, if patient awake
Attenuation of autonomic responses to noxious stimuli
Preservation of vital functions
Objectives of Anesthesia in the Aesthetic Patient
Safe implementation of chosen technique
Fast-track characteristics with rapid onset and emergence
Predictable and reliable methodology
Prevention of undesirable side effects
Confidence in ability to meet accepted discharge criteria
Patient satisfaction commensurate with entirely elective, often self-funded, procedures
Techniques
General Anesthesia
“Balanced” technique incorporates multiple classes of IV drugs (sedative-hypnotics, narcotics, muscle relaxants), along with the volatile/inhalational agents (desflurane, sevoflurane, less commonly isoflurane and nitrous oxide).
Volatile agents
Easier titration of depth, faster emergence, and early recovery
Lesser risk of intraoperative awareness
Simple administration
Typically less expensive maintenance agent
Total Intravenous Anesthesia (TIVA)
Component therapy involving sedative-hypnotic infusion (propofol, ketamine, dexmedetomidine)
Additional drugs such as midazolam, choice of narcotic, or muscle relaxant supplemented either by IV bolus or infusion
Aided by liberal surgical use of local anesthetic block or infiltration
Reduced incidence of postoperative nausea and vomiting (PONV)
High degree of patient satisfaction
More complex administration
Increased cost
Avoids gas delivery systems and therefore need for scavenging equipment
Avoids malignant hyperthermia (MH) triggers (see Malignant Hyperthermia section later in the chapter)
Various well-described “recipes” for TIVA 5 , 6 , 8 commonly include:
Propofol: Sedation/hypnosis
Midazolam: Anxiolysis and amnesia
Ketamine: Dissociation and analgesia
Opioids (fentanyl, alfentanil, remifentanil): Analgesia
Rocuronium: Muscle relaxation
Dexmedetomidine: Anxiolysis, sedation, analgesia, decreased adrenergic output
Acetaminophen: Nonopioid analgesic
Ketorolac: NSAID
Frequently accompanied by use of “depth of anesthesia” or “level of consciousness” monitoring
Employs algorithm-driven surface EEG to calculate an “index” number that correlates with hypnotic level
Bispectral Index (BIS; Medtronic) commonly used in the United States
Airway can be natural or controlled (endotracheal tube or supraglottic airway), with either mechanical or spontaneous ventilation.
Regional Anesthesia
Neuraxial (spinal or epidural)
Nerve blocks: Plexus, peripheral, paravertebral, intercostal, specific nerve branch, transversus abdominal plane (TAP), truncal, or other
IV sedation, at multiple and varying levels
Local infiltration
Selection determined by
Type, extent, and duration of surgery
Patient or surgeon preference
Anesthesiologist experience
Patient’s underlying medical status and/or any pertinent psychological aspects
Can be isolated anesthetic technique or involve combinations listed previously
Important Considerations with Administration of Anesthetics
Standard of care for nonhospital locations should be equivalent to those of hospitals.
ASA Standards for Basic Anesthetic Monitoring 10 (last amended 2011) must be met.
Emergency protocols must be established, documented, and rehearsed.
Transfer agreement with nearby/associated hospital for unplanned admission must be established.
Preoperative risk assessment and evaluation are required, including laboratory tests and specialty consultation as needed. 11
Selection of anesthesia type with appropriate monitoring
Selection of appropriate model of provider(s)
Anesthesiologist, alone or as part of anesthesia care team, with certified registered nurse anesthetist (CRNA) or, in some states, an anesthesia assistant (AA)
CRNA supervised by surgeon
Surgeon supervising RN whose sole responsibility is administration of ordered medication(s) and monitoring patient
Appropriate education, training, and certification of staff involved in all phases of patient care
Duration and complexity of procedure(s), especially if multiple procedures will be performed simultaneously or concurrently
Preoperative medications and postoperative pain control plans
Discharge criteria and postoperative follow-up
Preoperative Screening, Evaluation, and Patient Selection
Goals
Identify and optimize comorbid conditions.
Assess suitability for ASC or office.
Align anesthetic needs and resources with proposed procedure and patient needs.
Minimize perioperative risk.
Reduce delays and cancellation.
Assess ability for safe and timely discharge.
Provide education and reassurance to patients to build confidence.
Tools
Checklist-format patient questionnaire
Primary care physician/practitioner evaluation
Subspecialty consultations as needed
Old anesthesia records
In-person or phone interview with anesthesiologist or nurse
Video chat, Skype, or telemedicine
Timing
Process guided by
Patient demographics
Patients’ clinical conditions
Invasiveness of procedure
Nature of the health care system
Can be done day of surgery (DOS) if low severity of disease and procedure of low-medium surgical invasiveness, otherwise in advance
Things Anesthesiologists Like To Know Or Review
Up-to-date history and physical examination
Pertinent active medical conditions
Current medications and therapies in place
Status of optimization of current problems
Pertinent subspecialty consultation
Pertinent diagnostic studies of record
Pertinent psychosocial conditions
Surgical findings and operative plan
History of difficult intubation
History of PONV or postdischarge nausea and vomiting (PDNV) (discussed later in the chapter)
History of other anesthetic complications like delayed emergence, unanticipated admission, or prolonged postanesthesia care unit (PACU) stay
Personal or familial history suggestive of malignant hyperthermia
Intangibles, nuances, or needs that may affect patient’s satisfaction or experience in this highly specialized, consumer-driven patient population
Identifying Risk Factors
Red flags of unsuitability for general anesthesia in an ASC or office 2 , 5 , 9 , 12
Unstable angina
Myocardial injury within 3–6 months
Severe cardiomyopathy
Uncompensated heart failure
Aortic stenosis (moderate to severe) or symptomatic mitral stenosis
Uncontrolled or poorly controlled hypertension
High-grade arrhythmias
Implantable cardiac devices (pacer-dependent or defibrillator)
Recent stroke within 3 months
End-stage renal disease (ESRD)/dialysis
Severe liver disease
Awaiting major organ transplant
Sickle cell anemia
Symptomatic or active multiple sclerosis
Myasthenia gravis
Severe chronic obstructive pulmonary disease (COPD)
Abnormal/difficult airway
Severe obstructive sleep apnea (OSA)
Morbid obesity
Psychiatric status unstable, dementia
Acute substance intoxication
Poor functional status <4 metabolic equivalents (METs) (discussed later in the chapter)
Mathis et al 15 (2013) suggested seven independent risk factors associated with increased 72-hour morbidity and mortality in ambulatory surgery:
Overweight BMI
Obese BMI
COPD
History of transient ischemic attack/stroke
Hypertension
Previous cardiac surgical intervention
Prolonged operative time
Preoperative Testing
The culture shift is to NO routine testing.
Tests should be for indication only, as per current medical conditions or per procedure.
Avoid baseline laboratory studies when:
Patient is healthy
Patient has less than significant systemic disease (ASA I or II)
Blood loss expected to be minimal
Procedure is designated low risk
Testing guidelines available from ASA, SAMBA, ACC/AHA
Pregnancy (Hcg) Test
Positive pregnancy tests have been reported in 0.3%–1.3% of premenopausal menstruating females, which led to postponement, cancellation, or changes in management of 100% of the cases. 14
Routine testing of all females within childbearing years remains controversial.
Evidence-based medicine is inadequate or unsupportive with regards to anesthetic exposure and teratogenic effects or other harmful effects, e.g., spontaneous abortion, stimulation of contractions, or premature birth.
ASA provides no consensus on routine testing versus based on clinical menstrual history.
Recommends “offering” rather than “requiring” hCG testing
Affords “individual physicians and hospitals the opportunity to set their own practices and policies” according to ASA Choosing Wisely initiative 16
Many institutions perform routine point of care (POC) urine hCG on day of surgery.
Some institutions perform rapid qualitative serum hCG testing should urine results be equivocal or contested by patient.
Hemoglobin / Hematocrit (Hgb /Hct) and Complete Blood Cell Count (CBC)
Significant blood loss anticipated (>500 ml)
Patients with liver disease
Extremes of age
Preexisting anemia
Hematologic disorders
Factor deficiencies
Chemistries
High-grade dysrhythmia, pacemaker, cardiac implantable electronic device (CIED), e.g., defibrillator
H/O heart failure
Diabetes
Chronic renal insufficiency (CRI) or ESRD
Hepatic disease
Poorly controlled hypertension
Malabsorption/malnutrition (note history of eating disorder or bariatric surgery)
Blood Glucose
In diabetics, obtain by blood draw as preadmission testing (PAT) or by point of care testing on day of surgery
HbA1C is helpful in perioperative glucose interpretation and management
Coagulation Studies (PT, PTT, INR)
Bleeding disorders
Liver disease
Factor deficiencies
Chemotherapy
Electrocardiogram (ECG)
Box 5-1% When to Obtain a Preoperative Electrocardiogram
Patient with known CAD or risk factors
Patient for high risk (>1%) surgery
Patient with known arrhythmias (helpful to have a baseline)
Patient with known peripheral or cerebral vascular disease
Patient with significant structural heart disease
Patient with signs or symptoms of active cardiac conditions, e.g., chest pain, diaphoresis, shortness of breath (SOB), dyspnea on exertion (DOE)
Patient with DM requiring insulin or end-organ damage
Patient with renal insufficiency
Based on cardiac risk
Not indicated for asymptomatic patients undergoing low-risk surgery, regardless of age (ACC/AHA 2014)
Moderate-risk cosmetic procedures (abdominoplasty, large-volume liposuction, or body contouring after massive weight loss) with at least one clinical risk factor supports obtaining baseline or current/updated ECG.
ECGs valid for 6 months, if patient clinically stable
Revised Cardiac Risk Index (RCRI) clinical risk factors:
Coronary artery disease (CAD) with H/O myocardial infarction, coronary artery bypass graft (CABG) bypass, percutaneous coronary intervention (PCI), intracoronary stents
Cerebral vascular disease, with H/O stroke or transient ischemic events
Heart failure
Diabetes, requiring insulin, poorly controlled, or with end-organ damage
Renal insufficiency, serum creatinine >2.0 mg/dl or ESRD
RCRI stratifies risk of major cardiac complications.
No risk factors: 0.4%
One risk factor: 1.0%
Two risk factors: 2.4%
Three or more risk factors: 5.4%
Risk interpreted as:
Patients with <1.0% are low risk and need no further testing.
Patients with ≥1.0% are a greater risk and should be evaluated for optimization or further workup before elective surgery.
High-risk indicators that should command attention and dissuade from elective surgery in anything but a hospital setting, or not at all, are:
Recent MI
Unstable angina
Uncompensated heart failure
High-grade arrhythmias
Hemodynamically significant valvular disease, e.g., aortic stenosis
Additional considerations used as risk factors
Morbid obesity
Poorly controlled hypertension
High-grade arrhythmia, pacemaker, or implanted defibrillators
H/O significant peripheral arterial disease
Chest Radiograph
Not many indications in the elective aesthetic surgery patients
Active symptomatic pulmonary disease
Advanced Cardiovascular Testing
Stress test, ECG, carotid duplex, vascular studies guided by subspecialty consultation
Asa Physical Status Classification (ASA PS)
Used as a global descriptor of a patient’s clinical state based on history, physical examination, and laboratory data
Most widely used and accepted method of describing preoperative health status
Gross predictor of overall risk; does not assess surgical risk per se 9
Robust predictor of postoperative morbidity and mortality
Validated by and incorporated in current risk assessment models 18
Other applications include allocation of resources and anesthesia reimbursement. 19
Limitations include subjectivity and interrater inconsistency. 18
Recently updated by ASA 2014
Definitions remain unchanged, but clinical examples reflect liberalization with some stable chronic severe diseases, e.g., ESRD with hemodialysis, moving from class IV to class III
Patients frequently present for aesthetic surgery with multiple medical problems that represent an ASA III status.
ASA III patients are a widely disparate group with huge variations in pathophysiology.
Note:
The presence of stable, optimized preexisting diseases consistent with an ASA III status is NOT a contraindication for elective surgery
NPO Fasting Guidelines and Prevention of Pulmonary aspiration
Fasting
Ingested Material | Minimum Fasting Period (hours) |
Clear liquids | 2 |
Dairy, nonclear juices | 6 |
Light meal (toast and clear liquid) | 6 |
Heavy meal (fried, fatty foods; meat) | ≥8 |
Guidelines are limited to healthy patients undergoing elective procedures.
Modification based on clinical indicators may be needed.
Modification may be needed if difficult airway is anticipated.
Patients need to be informed (verbal, written) and status verified on day of surgery.
Following the guidelines does not guarantee sufficient gastric emptying.
Note:
Allowing black coffee and plain tea as “clear liquid” intake per guidelines for healthy patients without aspiration concerns can have added benefit of preventing caffeine withdrawal headaches
Acid Aspiration Prophylaxis and Considerations
Pulmonary aspiration: Aspiration of gastric contents occurring after the induction of general anesthesia, during a procedure, or in the immediate period after surgery
ASA and SAMBA recommend NO ROUTINE administration of preoperative acid aspiration prophylaxis medications.
Clinical indications for use of medications, AS WELL AS EXTENDING OR MODIFYING NPO GUIDELINES, incorporate comorbidities that affect or delay gastric emptying:
Obesity
Pregnancy
Diabetes
Gastroesophageal reflux disease (GERD)
Hiatal hernia
After bariatric surgery (especially laparotomy band)
Ileus or bowel obstruction
Emergency surgery (e.g., return to OR for hematoma or wound dehiscence after PO intake in PACU)
Preoperative prophylactic medications include:
Gastrointestinal stimulants (metoclopramide)
Gastric acid blockers
H2-receptor antagonists (cimetidine, ranitidine, famotidine)
Proton pump inhibitors (omeprazole, lansoprazole)
Antacid, nonparticulate (sodium citrate)
Antiemetics (ondansetron, prochlorperazine) used alone or in combination
Functional Status and Metabolic Equivalents (METS)
Functional Status Or Functional Capacity
Derived by estimating patient’s abilities to perform various tasks and activities of daily living (ADLs)
Expressed in METs
1 MET = 3.5 ml O2 uptake/kg/min (resting oxygen uptake in sitting position)
Adjunct to assess cardiac risk
Although not a formal component of the ASAPS classification, it is part of the routine anesthetic preoperative evaluation described as:
<4 METs; = 4 METs; <4 METs
Used as an indicator on Gupta Myocardial Infarction and Cardiac Arrest (MICA) Perioperative Cardiac Risk Calculator 22
Used as an indicator on ASC National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator 11
Has been suggested as a useful adjunct in assessing ASA class II-IV patients and an independent predictor of outcome and mortality 23
Patient descriptors:
Totally independent
Partially dependent
Totally dependent
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