A Comprehensive Approach to Sedation, Analgesia and General Anesthesia

Chapter 13. A Comprehensive Approach to Sedation, Analgesia and General Anesthesia

Stephen L. Ratcliff, MD; Fred E. Shapiro, DO

INDICATIONS

More than 10 million surgical and nonsurgical cosmetic procedures were performed in the United States in 2008. Of these, 53% were performed in the office facility, 19% were performed in the hospital, and 26% were performed in a freestanding surgical center. Newer anesthetic and surgical techniques have allowed the total number of cosmetic surgeries to increase more than 162% since 1997. With the increase in environments in which anesthesia is provided, it is imperative that both the anesthesiologist and nonanesthesiologist administering anesthesia adhere to evidence-based standards and safe practices. This is done while continuing to offer patients lower costs, increased efficiency, faster recovery times, fewer infections, and a more streamlined and comfortable experience.

GENERAL ANESTHESIA

Accompanying the increase in number of aesthetic procedures being performed in office and ambulatory surgicenters is an increase in the number of patients with major medical problems and risk factors undergoing these procedures. Therefore, there is great concern to ensure patient safety, particularly as the number of healthcare providers who administer sedation in the office-based setting continues to grow.

The importance of maintaining quality and safety can be understood by examining levels of sedation on a continuum. The American Society of Anesthesiology (ASA) has outlined various guidelines and issued related statements regarding patients, policies, and personnel involved in the perioperative management of patients. Introduced in 1999 and revised in 2008, the ASA House of Delegates approved the Continuum of Depth of Sedation—Definition of General Anesthesia and Levels of Sedation/Analgesia (Table 13-1).

Table 13-1 Continuum of Depth of Sedation

For aesthetic head and neck surgery, the desired level of sedation may range from minimal sedation or moderate sedation (“conscious sedation”) to deep sedation or general anesthesia. The location of the surgery and patient characteristics often dictate the appropriate level of anesthesia. Regardless of the plan, the levels of sedation that are defined in Table 13-1 are not absolute and one must plan for an unintended deeper level of sedation. This concept of “rescue” has an impact upon the clinical training of the personnel involved in administering the anesthesia. “Rescue” of a patient implies that the practitioner must be proficient in airway management and advanced life support, and be able to correct adverse physiologic consequences of the deeper-than-intended level of sedation (eg, hypoventilation, hypoxia, hypotension) in order to return the patient to the originally intended level.

MONITORED ANESTHESIA CARE VERSUS CONSCIOUS SEDATION

It is important to clarify the difference between monitored anesthesia care (MAC) and conscious sedation.

In October 2003, the ASA position on MAC stated that MAC is a specific anesthesia service for a diagnostic or therapeutic procedure. It encompasses all aspects of pre-, intra-, and postoperative anesthesia management. The services include diagnosis and treatment of clinical problems, support of vital functions, administration of sedatives, hypnotics, analgesics as necessary for patient safety, psychological support and physical comfort, and preparation to convert to a general anesthetic when necessary.

In October 2004, the ASA issued a related statement delineating the difference between MAC and conscious sedation. In addition to the definitions previously stated, a provider’s ability to intervene to rescue a patient’s airway from any sedation-induced compromise is a prerequisite to the qualifications to provide MAC. By contrast, moderate sedation is not expected to induce depths of sedation that would impair the patients own ability to maintain the integrity of his or her airway.

MAC allows for the safe administration of a maximal depth of sedation in excess of that provided during moderate sedation. The ability to adjust the sedation level from full consciousness to general anesthesia during the course of a procedure provides maximal flexibility in matching sedation level to patient needs and procedural requirements. In situations where the procedure is more invasive, or when the patient is especially fragile, optimizing sedation level is necessary to achieve ideal procedural conditions.

Like all anesthesia services, MAC includes an array of postprocedure responsibilities, including assuring a return to full consciousness, pain relief, and management of side effects of medications administered during the procedure, as well as diagnosis and treatment of coexisting medical problems. These components of MAC are unique aspects of an anesthesia service that are not part of moderate sedation.

MAC is a service that is clearly distinct from moderate sedation because of the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure.

Box 13-1 Clinical Care Patient and Procedure Selection

• The anesthesiologist should be satisfied that the procedure to be undertaken is within the scope of practice of the healthcare practitioners and the capabilities of the facility.

• The procedure should be of a duration and degree of complexity that will permit the patient to recover and be discharged from the facility.

• Patients who, by reason of preexisting medical or other conditions, may be at undue risk for complications, should be referred to an appropriate facility for performance of the procedure and the administration of anesthesia.

THE CHOICE OF ANESTHESIA

There are 4 broad types of anesthesia employed for aesthetic head and neck procedures: local anesthesia, MAC, regional anesthesia, and general anesthesia. The technique employed may comprise 2 or more types of anesthesia and is determined by taking several factors into consideration, such as type and length of the procedure, level of sedation required, whether the procedure is in a hospital or an office-based setting, the patient’s physical and psychological status, and the qualifications of the anesthesia provider.

The ASA has published guidelines for patient and procedure selection (Box 13-1) and has emphasized the importance of proper qualifications for administering anesthesia, particularly in an office-based setting (Box 13-2). Regardless of the anesthetic technique chosen for a particular patient or procedure, the standard for patient selection, monitors, equipment, and drugs is the same. Please refer to specific chapters within the atlas for common anesthetic techniques employed for particular procedures.

PREOPERATIVE PREPARATION

Before undergoing anesthesia for aesthetic surgery of the head or neck, a complete preoperative history and physical examination should be performed and an ASA class assigned. Patients who are healthy or who have mild systemic disease (ASA 1 and 2) are generally appropriate candidates for a procedure in an office-based setting. If the patient has a higher severity of underlying medical disease (ASA 3 or 4), further direct consultation with an anesthesiologist is necessary and the decision to undergo the procedure at a hospital or surgical center can be made so that resource risks can be minimized.

Box 13-2 Statement on Qualifications of Anesthesia Providers in the Office-Based Setting (Excerpt)

The American Society of Anesthesiologists believes that specific anesthesia training for supervising operating practitioners or other licensed physicians, while important in all anesthetizing locations, is especially critical in connection with office-based surgery where normal institutional backup or emergency facilities and capacities are often not available.

Box 13-3 Anesthesia in the Office-Based Setting

The following is a partial list of specific factors that should be taken into consideration when deciding whether anesthesia in the office setting is appropriate:

• Abnormalities of major organ systems, and stability and optimization of any medical illness.

• Difficult airway, morbid obesity, and/or obstructive sleep apnea.

• Previous adverse experience with anesthesia and surgery, including malignant hyperthermia.

• Current medications and drug allergies, including latex allergy.

• Time and nature of the last oral intake.

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