Sedation Analgesia during Office-Based Plastic Surgery Procedures: Comparison of Two Opioid Regimens

"Spin" in Plastic Surgery Randomized Controlled Trials with Statistically Nonsignificant Primary Outcomes: A Systematic Review

BACKGROUND

"Spin" refers to a manipulation of language that implies benefit for an intervention when none may exist. Randomized controlled trials (RCTs) in other fields have been demonstrated to employ spin, which can mislead clinicians to use ineffective or unsafe interventions. This study's objective was to determine the strategies, severity, and extent of spin in plastic surgery RCTs with nonsignificant primary outcomes.

METHODS

A literature search of the top 15 plastic surgery journals using MEDLINE was performed (2000 through 2020). Parallel 1:1 RCTs with a clearly identified primary outcome showing statistically nonsignificant results ( P > 0.05) were included. Screening, data extraction, and spin analysis were performed by two independent reviewers. The spin analysis was then independently assessed in duplicate by two plastic surgery residents with graduate-level training in clinical epidemiology.

RESULTS

From 3497 studies identified, 92 RCTs were included in this study. Spin strategies were identified in 78 RCTs (85%), including 64 abstracts (70%) and 77 main texts (84%). Severity of spin was rated moderate or high in 43 abstract conclusions (47%) and 42 main text conclusions (46%). The most identified spin strategy in the abstract was claiming equivalence for statistically nonsignificant results (26%); in the main text, focusing on another objective (24%).

CONCLUSIONS

This study suggests that 85% of statistically nonsignificant RCTs in plastic surgery employ spin. Readers of plastic surgery research should be aware of strategies, whether intentional or unintentional, used to manipulate language in reports of statistically nonsignificant RCTs when applying research findings to clinical practice.

Breast augmentation under local anesthesia with intercostal blocks and light sedation

INTRODUCTION

This study of breast augmentations performed under local anesthesia with intercostal blocks and light sedation describes the outcomes and evaluates benefits and complications.

METHOD

From December 2005 until August 2019, 335 women consecutively underwent bilateral breast augmentation procedures. The anesthetic protocol consisted of an initial intravenous bolus of 1 mg midazolam and 0.25 mg alfentanil preoperatively. In 2017, this was changed to 2-4 mg midazolam intramuscularly, 1 mg midazolam intravenously, and 2.5 µg sufentanil intravenously. Intercostal blocks were injected at the midaxillary line into the intercostal spaces two to seven. The operating field was infiltrated with tumescent local anesthesia. Retrospective data extraction from patients' medical charts was done, registering demographics, dosage of anesthesia, surgical characteristics, complications, and reoperation rates.

RESULTS

Two hundred and eighty-one women underwent primary augmentation and 54 had implant replacement. The most common complications included suboptimal cosmetic results, asymmetry, and healing-related problems. The overall rate of reoperation was 16.1% within an average follow-up period of 2 years, ranging from 0 to 12.5 years. The majority of the reoperations were due to cosmetic reasons. The change in anesthetic regime was associated with a significantly (p < 0.0001) decreased need for supplementary medication with no increased risk of complications.

CONCLUSION

Breast augmentations in local anesthesia with intercostal blocks and light sedation can be performed safely and can serve as an alternative to procedures in general anesthesia.

Facial Aesthetic Surgery: The Safe Use of Oral Sedation in an Office-Based Facility

BACKGROUND

The desire for efficient and safe office-based facial plastic surgery procedures has continued to rise. Oral sedation is a safe and effective method to provide anesthesia for facial aesthetic surgery.

OBJECTIVES

This study reviewed private practice anesthesia-related outcomes using oral sedation combined with local anesthesia for office-based facial aesthetic surgery procedures.

METHODS

A retrospective chart review was performed on all patients who underwent office-based facial plastic surgery procedures from July 2008 to July 2014. Patient demographic data including age, gender, body mass index (BMI), past medical history, social history, surgical history, allergies, and medications were collected. Anesthesia-related data were also collected including: American Society of Anesthesia (ASA) class, type of procedure, medications administered, and major complications related to sedation were assessed.

RESULTS

There were 199 patients (23 males and 176 females) who underwent 283 facial aesthetic surgical procedures. Mean age was 49.8 years (range, 29 to 80 years). There were 195 patients in ASA class I and 4 patients were in ASA class II. Patients underwent 44 upper blepharoplasty procedures, 35 lower blepharoplasty procedures, 5 browlifts, 43 upper blepharoplasty-browpexy, 46 facelifts, 38 neck lifts/lower facelifts, 54 fat grafting, 3 tip rhinoplasties, and 15 minor revision cases. During the study period, there were no major complications and no sedation issues.

CONCLUSIONS

Facial aesthetic surgical procedures can be performed safely and comfortably in the office-based setting under oral sedation in appropriately selected patients. LEVEL OF EVIDENCE 4: Therapeutic.

Office-based anesthesia: safety and outcomes

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Breast implant procedures under conscious sedation: a 6-year experience in 461 consecutive patients

BACKGROUND

Breast implant procedures are commonly performed using general anesthesia; however, patient apprehension, the potential for improved safety, lower costs, and faster recovery times have increased interest in the use of conscious sedation in plastic surgery. The authors examined the safety and efficacy of breast implant procedures performed under conscious sedation over a 6-year period using their standardized institutional protocol.

METHODS

Between 2002 and 2008, 461 consecutive patients underwent breast implant procedures under conscious sedation using a protocol of preoperative intravenous diazepam along with intraoperative midazolam, fentanyl, and local anesthetic. All operative and follow-up data were recorded. Augmentation mammaplasty patients were further analyzed for conscious sedation medication dosing.

RESULTS

The study population was divided into two groups (years 1 to 3 and years 4 to 6 of the study period) to analyze changes to the authors' regimen over time. In years 4 to 6, higher preoperative doses of diazepam (p = 0.01) allowed more effective local anesthesia administration, thereby reducing intraoperative fentanyl requirements (p < 0.0001). Midazolam doses and operating times did not differ significantly between groups. No patient required conversion to a deeper method of anesthesia. The overall complication rate was 4.34 percent.

CONCLUSIONS

The authors' study demonstrates the safety and efficacy of conscious sedation in breast implant procedures. Higher preoperative doses of diazepam have significantly reduced fentanyl requirements, resulting in shorter recovery times, decreased postoperative nausea/vomiting, and elimination of unintended admissions. These benefits are obtained without increasing operative times or complications. The authors conclude that conscious sedation is the preferred method of anesthesia for most patients undergoing breast implant procedures.

Probing the combined effect of flunitrazepam and lidocaine on the stability and organization of bilayer lipid membranes. A differential scanning calorimetry and dynamic light scattering study

Combined effects of flunitrazepam (FNZ) and lidocaine (LDC) were studied on the thermotropic equilibrium of dipalmitoyl phosphatidylcholine (dpPC) bilayers. This adds a thermodynamic dimension to previously reported geometric analysis in the erythrocyte model. LDC decreased the enthalpy and temperature for dpPC pre- and main-transitions (ΔHp, ΔHm, Tp, Tm) and decreased the cooperativity of the main-transition (ΔT(1/2,m)). FNZ decreased ΔHm and, at least up to 59 μM, also decreased ΔHp. In conjunction with LDC, FNZ induced a recovery of ∆T(1/2,m) control values and increased ΔHm even above the control level. The deconvolution of the main-transition peak at high LDC concentrations revealed three components possibly represented by: a self-segregated fraction of pure dpPC, a dpPC-LDC mixture and a phase with a lipid structure of intermediate stability associated with LDC self-aggregation within the lipid phase. Some LDC effects on thermodynamic parameters were reverted at proper LDC/FNZ molar ratios, suggesting that FNZ restricts the maximal availability of the LDC partitioned into the lipid phase. Thus, beyond its complexity, the lipid-LDC mixture can be rationalized as an equilibrium of coexisting phases which gains homogeneity in the presence of FNZ. This work stresses the relevance of nonspecific drug-membrane binding on LDC-FNZ pharmacological interactions and would have pharmaceutical applications in liposomal multidrug-delivery.

Anesthesia for cosmetic surgery

Increasing numbers of plastic surgery procedures are performed in diverse environments, including traditional hospital operating rooms, outpatient surgery centers, and private offices. Just as plastic surgeons develop areas of specialization to better care for their patients, anesthesiologists have specialized in outpatient plastic surgery, both cosmetic and reconstructive. The methods they utilize are similar to those for other procedures but incorporate specific techniques that aim to better relieve preoperative anxiety, induce and awaken patients more smoothly, and minimize postoperative sequelae of anesthesia such as nausea and vomiting. It is important for plastic surgeons to understand these techniques since they are the ones who are ultimately responsible for their patients' care and are frequently called on to employ anesthesiologists for their practices, surgery centers, and hospitals. The following is a review of the specific considerations that should be given to ambulatory plastic surgery patients and the techniques used to safely administer agreeable and effective anesthesia.

Anesthesia for outpatient cosmetic surgery

PURPOSE OF REVIEW

American Society of Aesthetic Plastic Surgery statistics show outpatient cosmetic procedures increased from 3 to 11 million (1997-2007), an increase of 457%, and $13 billion was spent. Exponential growth, complexity of cases and patients, and media attention to high-profile untoward events are accompanied with concerns for patient safety and development of safer anesthesia practices.

RECENT FINDINGS

Improved safety and efficacy in aesthetic facial surgery include oral sedation and local anesthesia, addition of dexmedetomidine to intravenous anesthesia, and defining the 'safest' dose of lidocaine with epinephrine. A nasopharyngeal tube can be used to deliver a concentration of oxygen commensurate with recent American Society of Anesthesiologists Task Force Practice Advisory for the prevention and management of operating room fires. Analgesia for breast surgery including instillation of bupivicaine, paravertebral block, and combination dexamethasone with nonsteroidal anti-inflammatory drugs can decrease narcotic requirement and recovery time. Risks of combined gynecologic and plastic surgical procedures are not greater than those seen with either procedure alone. A coordinated team approach for patient management is essential. Pulmonary embolism remains the greatest cause of mortality.

SUMMARY

The methods presented improve patient safety. The number of cosmetic procedures will continue to grow exponentially and evolve additional patient safety concerns. This larger population is the foundation for prospective trials to develop evidence-based anesthesia for cosmetic surgery.

Fast-track anesthetic techniques for ambulatory surgery

PURPOSE OF REVIEW

Improving perioperative efficiency and throughput has become increasingly important in facilitating the fast-track recovery process following ambulatory surgery. This review focuses on the important role played by the anesthesiologist as a perioperative physician in fast-track ambulatory surgery.

RECENT FINDINGS

A literature review of more than 200 peer-reviewed publications was used to develop evidence-based recommendations for optimizing recovery following ambulatory anesthesia. The choice of anesthetic technique should be tailored to the needs of the patient as well as the type of surgical procedure being performed in the ambulatory setting. The anesthetic decisions made by the anesthesiologist, as a key perioperative physician, are of critical importance in developing a successful fast-track ambulatory surgery program.

SUMMARY

The pivotal role played by the anesthesiologist as the key perioperative physician in facilitating the recovery process has assumed increased importance in the current outpatient fast-track recovery environment. The choice of premedication, anesthetic, analgesic and antiemetic drugs, as well as cardiovascular, hormonal and fluid therapies, can all influence the ability to fast-track outpatients after ambulatory surgery.