Conscious sedation-as it pertains to plastic surgery, involves the administration of local anesthesia in addition to the intravenous sedation. In fact, it's the methodical use of tumescent anesthesia that ensures a smooth, relatively pain free process. Tumescence, or wetting solution as it's more appropriately termed, should be infiltrated into the surgical field. Two goals should be kept in mind: anesthesia of the sensory nerves and vasoconstriction of the blood vessels in the region. Achieving these goals demands at least 10 minutes for the wetting answer to exert its effects.
Even though there are a number of intravenous sedation regimens obtainable, an excellent choice is the combined use of midazolam (Versed) and fentany. The advantage of using this combination is that midazolam has both anxiolytic and amnestic effects, whereas fentanyl is really a potent, short-acting analgesic. The combination of fentanyl and midazolam is superior to midazolam alone in decreasing patients' subjective report of pain and anxiety. The main drawback of fentanyl is respiratory depression; nevertheless unlike other commonly utilized intravenous opiates like morphine, it does have a extremely short half life.
Midazolam, in contrast, has minimal effects on the respiratory system except in the elderly, in which lower doses should be utilized. Both of these medications have antagonists. Flumazenil (Mazicon) and naloxone (Narcan), the antagonists of midazolam and fentanyl respectively, should be readily obtainable in the operating room.
An additional technique of intravenous sedation involves the use of propofol in combination with an opiate and benzodiazepine. The reality that a deeper level of sedation can be maintained makes this technique preferable for selected patients who are very anxious. Nevertheless, the disadvantage of this combination is the higher risk of respiratory depression, and the lack of a reversal agent for propofol.
This technique necessitates a higher degree of expertise and training in anesthetic method including the capability to intubate the patient if needed. In the operating room, one nurse should be responsible for continuously monitoring patient status using pulse oximetry, blood pressure and cardiac monitoring.
This should be performed by a nurse with suitable experience and background in continuous patient monitoring; however specialized anesthesia training is generally not needed. It is important to emphasize that this nurse ought to have no other duties to perform during the procedure. The patient's oxygen saturation, blood pressure, heart rate, level of arousal and respiratory status should be monitored every 5 minutes. Changes in important signs, level of arousal and also the oxygen saturation are communicated to the surgeon. In addition, the surgeon ought to make his own assessment of arousal based on response to verbal stimulation, as well as the patient's degree of discomfort.
Based on the patient's condition, 0.5 to 2 mg of midazolam should be administered at the 5 minute intervals. In addition, fentanyl should be given in increments of 12.5 to 50 mcg. After local anesthetic is infiltrated, fentanyl administration is infrequently required, except in preparation for subsequent local anesthetic administration to a new surgical website. The total dose of fentanyl ought to rarely exceeded 200 mcg over the course of the procedure. Toward the end of the case, the quantity of sedation should be decreased to allow the patient to slowly return to a normal state of arousal and awareness.
During conscious sedation, supplemental oxygen is generally not essential. The ability of the patient to maintain an oxygen saturation over 95% with out supplemental oxygen is really a useful guideline to steer clear of oversedation. Occasional periods of deep sedation might happen, generally lasting for a few minutes at most. Brief stimulation and rarely jaw thrust may be required to maintain adequate ventilation.
The use of small incremental doses of midazolam, limited use of narcotics and efficient local anesthesia help to limit episodes of deep sedation. Nevertheless, as a safety measure, the capability to convert to general anesthesia or immediate assistance from an anesthesiologist should always be obtainable.
Foley catheters and sequential compression devices are usually not needed due to the relatively short length of procedures utilizing conscious sedation, and the fact that venous stasis is minimal due to spontaneous patient movement and leg muscle contractions. For instances involving big volume liposuction or those that are longer than a couple of hours, a Foley catheter should be utilized to monitor fluid status and to allow higher flexibility in intraoperative fluid resuscitation.
Following the process, many hospitals will permit patients to bypass the recovery room and proceed directly to the outpatient day surgery region. This saves the patient the extra costs of recovery room care. Patients are monitored postoperatively in a standard manner. Those that choose to go home the day of surgery should meet criteria for discharge. Patients who received preoperative clonidine should be monitored for orthostatic hypotension.
Inpatient stay in an observation unit is appropriate for longer cases that involve multiple procedures, as well as for older patients who live alone. Postoperative nausea and vomiting is the main factor contributing to unintentional hospital admission after outpatient surgery. It begins shortly after arrival in the recovery room and generally lasts no longer than 12-24 hours postoperatively. Numerous studies support the administration of a preoperative antiemetic.
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