Choosing the Right Anesthesia for
Your Patient
Fred E. Shapiro, DO
Assistant Professor of Anesthesia
Department of Anesthesia,
Critical Care, and Pain Medicine
Kenneth Hughes, M.D.
Aesthetic Fellow
Division of Plastic and
Reconstructive Surgery
Beth Israel Deaconess Medical Center
Harvard Medical School
Patient Workup and Risk
Stratification
Risks, benefits and alternatives to the
administration of sedative and analgesic
drugs to establish the level of sedation
required
 Assess risks and comorbidities
 Anesthesia professionals should be available
for morbidly obese patients, pregnant
patients, and patients with severe systemic
disease, obstructive sleep apnea, or delayed
gastric emptying

Intraoperative Monitoring
Pharmacology of sedative/analgesic
drugs, pharmacological antagonists to
these drugs, and vasoactive
drugs/antiarrhythmics
 Benefits/risks of supplemental oxygen
 Recognition of adequacy of ventilatory
function and proficiency in advanced
airway management
 Monitoring of physiologic variables,
including blood pressure, respiratory
rate, and oxygen saturation

The Continuum of Sedation
Moderate Sedation
 Deep Sedation
 General Anesthesia
 Following Definitions from
“Continuum of Depth of Sedation –
Definition of General Anesthesia and
Levels of Sedation/Analgesia”
(Approved by ASA House of Delegates
amended October 21, 2009)

Moderate Sedation
Drug-induced depression of
consciousness during which patients
respond purposefully to verbal
commands
 No interventions are required to
maintain a patent airway
 Spontaneous ventilation is adequate

Deep Sedation
Drug-induced depression of
consciousness during which patients
cannot be easily aroused but respond
purposefully following repeated or
painful stimulation
 Patients may require assistance in
maintaining a patent airway
 Spontaneous ventilation may be
inadequate

General Anesthesia
Drug-induced loss of consciousness
during which patients are not
arousable, even by painful stimulation
 The ability to independently maintain
ventilatory function is often impaired
 Often require assistance in maintaining
a patent airway
 Cardiovascular function may be
impaired

Fast-track anesthesia and monitored
anesthesia care (MAC)
Fast-track anesthesia involves moving
patients through the OR, PACU, and
discharge in a relatively short time
 Short-acting anesthetics and improved
pain control are key
 Local anesthetic with intravenous
sedation has become increasingly
popular in the office-based plastic
surgery community

MAC
Monitored Anesthesia Care (MAC)
 MAC is "a specific anesthesia service
in which an anesthesiologist has been
requested to participate in the care of a
patient undergoing a diagnostic or
therapeutic procedure"

Five Components of Anesthesia
1. Anxiolysis
 2. Amnesia
 3. Sedation
 4. Analgesia
 5. Avoidance of side effects (i.e.,
headache, nausea, vomiting, dizziness,
drowsiness, and pain)
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Seeking the Ideal Anesthetic
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Rapid onset
Rapid recovery
Easily controlled depth of sedation
Minimal respiratory effect
Cardiovascular stability
Minimal active metabolic byproducts
Local Anesthesia
Infiltration within wound or via block
or topical
 Local anesthetic should reduce
perioperative opioid
 Allows patients to remain alert and
maintain GI function
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Local Anesthetic Specifics
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Local anesthetics of choice in ambulatory
anesthesia include lidocaine, bupivacaine, and
ropivacaine
Lidocaine has a relatively short duration of action
Bupivacaine has longer duration of action but a
small therapeutic window
--- It is associated with profound cardiovascular
and central nervous system effects
Ropivacaine has a greater safety profile with
respect to cardiovascular and CNS toxicity
Midazolam
Midazolam is a rapid, short-acting
benzodiazepine that causes profound
anxiolysis, amnesia, and sedation
 Commonly used as for premedication
 Minimal cardiovascular depressant
effects in doses used for sedation
 Increasing age reduces requirements
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Ketamine
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Causes amnesia and profound analgesia
Minimal respiratory effect
Stimulates the sympathetic nervous system and
can balance the negative cardiovascular effects of
propofol
Avoid in patients with hypertension, coronary
artery disease, congestive heart failure, and
increased intracranial pressure
High incidence of psychomimetic effects such as
restlessness, agitation, and hallucinations
Inhaled Anesthetics
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Desflurane and sevoflurane are well
tolerated and achieve a rapid anesthesia and
permit rapid emergence
Propofol, sevoflurane, and desflurane are
similar in recovery endpoints such as home
readiness and actual time for discharge
From Fredman B, et al. AQ9 Sevoflurane for
outpatient anesthesia: A comparison with
propofol. Anesth Analg. 1995;81:823–828.
AND Raeder J, et al. Recovery
characteristics of sevoflurane- or propofolbased anaesthesia for day-care surgery. Acta
Anaesthesiol Scand. 1997;41:988–994.
Propofol
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Most widely used intravenous agent for
ambulatory anesthesia and sedation
Easy to administer, rapid onset, short
duration of action, and low incidence of
postoperative nausea and vomiting
Adverse effects include hypotension and
decreased myocardial contractility
Common office-based settings include
gastroenterology, ophthalmology, and
plastic surgery
Opioids
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Can cause respiratory depression
Other side effects include nausea, vomiting,
and pruritus
Fentanyl is the most commonly used opioid
Fast onset (3 to 5 minutes) and its duration
is 45 to 60 minutes
Remifentanil
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Half-life is 3 to 5 minutes
Advantage of short duration is its ability to
provide analgesia intraoperatively without
postoperative sedation or drowsiness
Metabolized by plasma esterase, ideal for
patients with kidney or liver disease
Disadvantage of its short duration :
--- local anesthetic or NSAID must be
used for postoperative pain control
Nonopioid Analgesics
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Reduce pain by decreasing the synthesis of
prostaglandins
Decrease the requirement for opioids and
concomitant incidence of nausea, vomiting, and
pruritus
Ketorolac (Toradol) is a commonly used
perioperative NSAID
Avoid in those with kidney problems, GI problems,
and bleeding issues
α2 Agonists
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Includes clonidine and dexmedetomidine
α2 Agonists act in the CNS by decreasing
sympathetic nervous system outflow and
have sedative, anxiolytic, and analgesic
effects
Their use decreases the requirement of other
anesthetics
They help to maintain cardiovascular and
respiratory stability
Dexmedetomidine
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Generally well tolerated
Particularly safe with respect to respiratory
function
Very useful for patients undergoing aesthetic
facial surgery
--- Allows patient to breathe room air
spontaneously without use of supplemental
oxygen, avoids the issue of combustion
Decreases pain medications used postoperatively
What makes an ideal agent?
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To date, no single agent has all these
properties
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Combinations of local anesthetics,
midazolam, ketamine, inhaled anesthetics,
propofol, opioids, NSAIDS, and α2 agonists
can achieve the desired effect
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Benefits include synergy and decreased
potential for side effects
POSTOPERATIVE NAUSEA AND
VOMITING (PONV)
To a large extent, unplanned hospital
admission results from uncontrolled pain,
nausea, and vomiting
 Higher risk patients include females,
middle-aged patients, nonsmokers, patients
with history of motion sickness or PONV
 Various treatment options could include
--- low dose dexamethasone
--- transdermal scopolamine
--- serotonin antagonists
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Choosing the Right Anesthesia
for Your Patient
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Thank You