7. Procedure-Specific Anesthesia Guidelines for the Aesthetic Surgery Patient
Deborah Stahl Lowery
ANESTHESIA FOR FACIAL PLASTIC SURGICAL PROCEDURES (RHYTIDECTOMY, NECKLIFT, ETC.) 1,2
■ Patient factors
• Usually middle-aged or older
• May have increased burden of comorbidities, especially preexisting hypertension
• Can have cardiac conditions for which they take antiplatelet, antithrombotic, or anticoagulant medication
• Any disruption/resumption in blood thinners should be coordinated with primary care physician or consultant.
• Require increased attention to positioning and padding with range of motion limitations, including cervical spine
■ Often part of multiprocedure combination with duration >4 hours
• Consider Foley catheter
• DVT mechanical prophylaxis with sequential compression devices
• Intermittent position checks to assess extremity and pressure point support and padding
■ Multiple anesthetic techniques used successfully
• IV sedation of varying levels
• Total intravenous anesthesia (TIVA) (see Chapter 5)
• Balanced technique with inhalational anesthesia
■ Choice of anesthetic type frequently influenced by surgical preference
ANESTHETIC GOALS2,3
■ Achieve optimal hemodynamic control.
• Hematoma is most common complication of procedure.
• Preoperative systolic BP >150 mm Hg has been identified as risk factor for hematoma.3
■ Appreciate anxiolysis, antiemesis, and analgesia treatments as components of hemodynamic control.
■ Preemptively manage changes in surgical stimuli that result in hemodynamic aberration (awareness of procedural components and their sequence).
■ Be aware of placement, timing, and tolerance of compression head dressings.
■ Achieve smooth emergence and extubation that prevents coughing and bucking.
PREOPERATIVE MANAGEMENT1,4
■ Continue any home anxiolytic medications.
■ Add preoperative anxiolysis with midazolam 1–2 mg IV titrated up to 0.7 mg/kg.
■ Continue any home antihypertensive medications (except diuretics, angiotensinconverting enzymes [ACE-inhibitors], and angiotensin-receptor blockers [ARBs]).
■ Determine baseline BP and, if known, typical ranges.
■ Consider use of clonidine: 0.1–0.2 mg PO or 0.1–0.2 mg/d transdermal patch placed preoperatively.
■ Optimize preoperative PO multimodal analgesia (celcoxib, acetaminophen, gabapentin).
■ Optimize preoperative antiemesis prophylaxis (aprepitant [Emend], scopolamine patch), especially if history of PONV/PDNV.
INTRAOPERATIVE MANAGEMENT
■ Ensure smooth IV induction with propofol.
■ Continue prophylactic antiemesis regimen (with addition of promethazine, decadron, ondansetron, and/or haloperidol), as determined by Apfel score.
■ Continue opioid-sparing multimodal analgesia regimen (ketamine, IV acetaminophen).
■ Provide neuromuscular blockade redosing preemptively for head repositioning or injection stimulation.
■ Maintain low normotension or modest hypotension during resection.
■ Generous surgical use of local anesthetic infiltration and nerve blocks
■ Bolus with shorter-acting synthetic opioids (fentanyl, sufentanil, alfentanil) to blunt:
• Hemodynamic effects of laryngoscopy
• Periods of intermittent stimulation during local anesthesia injection
• Airway stimulation caused by changes in head positioning
■ Total narcotic use is typically minimal and therefore lessens untoward side effects like postoperative nausea and vomiting (PONV).
■ Before closing, allow BP return to baseline range to facilitate surgical assessment of oozing.
■ Judicious use of IV fluids (maintenance amounts) to prevent facial edema
• Estimated blood loss (EBL) is minimal.
• No appreciable third space losses occur.
■ Delay emergence until all dressings and wraps are securely in place.
■ Surgeon or assistant can hold pressure to site during extubation.
■ Elevate head of bed at least 30 degrees ASAP to minimize postprocedural edema.
■ Smooth extubation is critical to prevent coughing or bucking that causes increased venous return and increased BP leading to hematoma.
■ Use lidocaine IV PRN to depress airway reflexes.
■ Use esmolol IV PRN to quickly control increases in BP.
■ Timely management of any anxiety, hypertension, pain, or nausea in PACU
■ In one study, hypertension in the PACU was found to be a statistically significant factor in formation of hematoma.2
■ Rhytidectomy is unique in that these components that affect BP need to be strictly controlled to minimize subcutaneous bleeding and hematoma formation.
AIRWAY MANAGEMENT1,5
■ Endotracheal intubation with controlled ventilation
• Provides maximal control of airway during head position changes
• Minimizes motion that can occur with spontaneous respiration
• Provides closed system for oxygen delivery minimizing fire risk with electrocautery
• Decrease FiO2 to lowest level that supports adequate oxygenation.
• Secure ET tube in a way to maximize surgeon’s dynamic maneuverability.
• Avoid tape by securing ET tube to incisors or canine teeth with suture or floss (inform patient of potential gum irritation, soreness, or bleeding).
• Some surgeons prefer to leave ET tube unsecured for ability to move from side to side throughout procedure.
TIP: If unsecured, mark the ET tube with an indelible marker at centimeter markings for the teeth or lip so that its position can be continually checked for initial placement depth!
• Consider preformed ET tube (oral or nasal RAE).
• Bioocclusive dressing can secure ET tube to chin to minimize tape.
• Determine level of maintenance muscle relaxation desired by surgeon to prevent unwanted facial laxity.
■ Supraglottic device (laryngeal mask airway [LMA], I-gel)
• Prevents facial distortion, which is less desirable for this reason
• Assess anticipated head manipulation to prevent airway irritation or dislodgement intraoperatively.
• Good alternative (if no contraindications) in isolated browlift, blepharoplasty, or eyelid procedures because of maintenance of neutral head positioning.
• Facilitates smooth emergence because patients less likely to cough or buck
■ Natural airway with spontaneous ventilation
EYE PROTECTION
■ Sterile ophthalmic ointment (Lacri-Lube) ONLY
CAUTION: DO NOT confuse Lacri-Lube with Surgilube, which, if applied to the cornea, can cause severe ocular damage through probable toxic effects of chlorhexidine gluconate.4
■ Corneal protectors
• Remember to remove before emergence to avoid unpleasant patient experience and difficulty with removal when awake.
FACIAL LASER RESURFACING1,6,7
■ Use of CO2 laser is painful and usually requires significant analgesia both intraoperatively and immediately after procedure.
■ Successful use of room air/natural airway/spontaneous ventilation techniques using TIVA have been described.
• Need for cardiorespiratory depressants is prevented by using nonopioid analgesics in conjunction with local anesthetic nerve blocks.
• Supplemental oxygen and assisted ventilation are avoided, and surgical field is freed.
• Drawbacks6 include eventual need for predischarge rescue opioid analgesics (>70%) and antiemetics (32%).
■ Balanced technique or TIVA with use of an endotracheal tube1,5 confers ability to:
• Treat drug-induced respiratory depression with controlled ventilation
• Minimize combustion/fire risk by:
► Using closed-circuit oxygen delivery
► Using laser-resistant ET tube
► Decreasing FiO2 to lowest level that supports adequate oxygenation
► Communicating the level of O2 to the surgeon before laser use in a specific laser time-out
■ ET tube may need repositioning to allow surgeon to work around it, possibly unsecured.
■ Eye protection with corneal protectors and saline-soaked gauzes pads are needed.
■ PACU needs can include:
• Supplemental narcotic analgesia
• Chilled air to face
• Application of ointment
• Humidified face tent
RHINOPLASTY
■ Well-suited for general anesthesia with controlled airway
■ Alternative method is moderate-deep sedation with natural airway, although providing supplemental oxygen is more challenging.
■ Position and secure ET tube over the mandible. Use of tube extenders, armored tube, or oral RAE tube facilitates surgical exposure and maneuverability and prevents crimping or compression.
■ Supraglottic devices (LMA, I-gel) have also been used successfully.
■ Caution is needed with osteotomies and bleeding that passively migrates to stomach causing increased incidence of PONV, risk of aspiration, and airway irritation.
TIP: If LMA is used, consider the type that allows gastric suctioning.
■ Use of throat packing dampened with saline solution can decrease blood migration but can cause mucosal irritation and postprocedure sore throat.
CAUTION: Use vigilance to make sure throat packing is removed at the end of the procedure! (Add to checklist.)
■ Patients should be kept anesthetized until splints are contoured and stiffened and dressings are in place.
■ Emergence entails:
• Being awake enough to prevent aspiration or laryngospasm, especially because mask application with positive pressure can cause injury to fresh repair
• Being smooth enough to prevent coughing and bucking that increase bleeding
► Postoperative pain is usually minimal because of local infiltration by surgeon.
ANESTHESIA FOR BREAST AND ABDOMINAL PROCEDURES
BREAST AUGMENTATION1
■ Patients tend to be younger (most <40 years of age).
■ Younger age, female sex, use of volatile agents and opioids increase Apfel PONV score; thus PONV prophylaxis is often indicated.
■ Submuscular dissection and placement lends itself to postoperative deep muscular pain and spasm.
■ Use of multimodal analgesia can include initial doses of acetaminophen, gabapentin, celecoxib or other NSAID.
• Can add diazepam (Valium) or carisoprodol (Soma) to regimen to aid pectoralis relaxation8
■ Position changes intraoperatively are dynamic and frequent to observe implant location and symmetry.
• All positioning should take into account:
► Pressure point padding
► Angle of arm abduction (≤90 degrees)
► Method of securing that allows safe transition between supine and sitting
► Testing the bed to sitting position before prep and drape
CAUTION: Hemodynamic and vascular changes can occur with position changes.
■ Coordinate timing of emergence to account for dressings, bra, elastic bandages, and if they were placed while patient was sitting or supine.
■ Although general anesthesia is the mainstay for this procedure, successful use of regional techniques for sole anesthetics or postoperative pain supplements are well described, including epidural or thoracic paravertebral blocks.9,10
■ Postoperative pain management can be augmented by local anesthesia continuous infusion pumps (On-Q, Kimberly-Clark), intercostal nerve blocks, paravertebral blocks, and/or incisional local anesthetic infiltration, including liposomal bupivacaine.
■ Recommend continuation of multimodal analgesia regimen after discharge.
BREAST REDUCTION AND MASTOPEXY
■ Dynamic positioning is similar to that of augmentation.
■ EBL and resulting fluid balance correlate with amount of tissue resection and duration.
ABDOMINOPLASTY1,11,12
■ Characterized as “moderate” surgical risk procedure
■ Promotes thorough preoperative assessment to aid in patient and facility selection
■ Concerning preoperative surgical factors are active smoking and increased HbA1C >7.4.
■ Carries increased risk of thromboembolism
• Increased risk can include general anesthesia and operative times >140 minutes. 10
• Apply sequential compression devices (SCDs) in preoperative area, ensure they are operational before anesthetic induction. (Add to checklist!)
• Promotes attention to adequate hydration and fluid balance
• Consider pharmacologic prophylaxis with LMW-heparin enoxaparin (Lovenox) as per risk assessment (Caprini RAM) (see Chapter 11).
• Provide preoperative information on signs of DVT/PE, need for early ambulation.
■ Warming measures include preoperative prewarming, adequate OR room temperature, active warming devices (Bair Hugger, Arizant Healthcare, Inc.), head covers, IV fluid warmers.
TIP: Preparation for procedure MUST INCLUDE testing of OR table for flexion function before patient arrives in OR.
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