9910-1338 Marcus
Marcus JR, Tyrone JW, Few JW, Fine NA, Mustoe TA.
Optimization of conscious sedation in plastic surgery.
Plast Reconstr Surg. 1999 Oct;104(5):1338-45. PMID: 10513915
Division of Plastic and Reconstructive Surgery at Northwestern University
Medical School, Chicago, IL 60611, USA.
The administration of conscious sedation by the plastic surgeon must be safe,
efficient, and consistent. In the proper setting, with trained staff and
appropriate backup, conscious sedation can allow optimal patient satisfaction
with expedient recovery in addition to cost containment. The highly effective
local anesthesia afforded by dilute, high-volume ("tumescent") infiltration
extends the use of conscious sedation to cases previously performed under
general anesthesia or deep sedation. The purpose of this analysis was to
identify variables in conscious sedation that affect traditional outcome
parameters in ambulatory surgery, particularly the duration of recovery and
adverse events such as nausea and emesis. All perioperative and operative
records of 300 consecutive patients having plastic surgical procedures under
conscious sedation were carefully reviewed. Patients were ASA class I or II by
requisite. Conscious sedation followed a standardized administration protocol,
using incremental doses of two agents: midazolam (0.25 to 1 mg) and fentanyl
(12.5 to 50 mcg). A subset of patients received preoperative oral sedation.
Multivariate statistical analysis was conducted using SPSS 8.0 for Windows (SPSS
Inc., Chicago, Ill.). Of the 300 patients, same-day discharge was intended for
281. Eight procedure categories were defined. No anesthetic complications
occurred. As expected, recovery time was significantly correlated with the
duration and type of procedure (p < 0.001) and the total dosage of both
intraoperative sedative agents (p < 0.001). Interestingly, a negative
correlation with advancing age existed (p < 0.001), likely reflecting the
significantly higher intraoperative sedative dosing in younger patients (p <
0.001). When controlled for the effects of procedure duration and intraoperative
sedative dosing, two other variables-use of preoperative oral sedation and
postoperative nausea/emesis-significantly lengthened recovery time (p = 0.0001
for each). Fifteen unintended admissions occurred secondary to nausea, prolonged
drowsiness, or pain control needs. Conscious sedation is an effective anesthetic
choice for routine plastic surgical procedures, many of which would commonly be
performed under general anesthesia. In our experience with a carefully
structured and controlled conscious sedation protocol, the technique has proven
to be safe and effective. This analysis of outcome parameters identified two
important and potentially avoidable causes of recovery delay following conscious
sedation-oral premedication and nausea/emesis. Nausea and emesis were
particularly problematic in that they were responsible for 11 of 15 (73 percent)
unintended admissions. Preoperative sedation is valuable in certain
circumstances, and its use is not discouraged; however, its benefits must be
weighed against its unwanted effects, which can include a prolongation of
recovery.
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