Plastic Surgery lecture

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Anesthesia for Plastic and Reconstructive Surgery:

Anesthesia for Plastic and Reconstructive Surgery University of New England School of Nurse Anesthesia

General Information:

General Information Varied procedures encompassing the entire body fall under the “plastic surgery” roof Reconstructive surgery vs. cosmetic surgery Association of “plastic” with hand surgery Office based vs hospital or ambulatory center

Facial Cosmetic Surgery:

Facial Cosmetic Surgery Goal is to rejuvinate and restore facial form from the effects of aging and gravity Combined procedures are common Browlift,necklift , face lift often done together Blephoraplasty , rhino plasty complete the scheme typically at subsequent times New Dermatologic procedures can be added in , Rejuvenate injection, botox , colloid fillers

Facelifts:

Facelifts May involve 3 planes of dissection or elements of each Use of epinephrine /LA with or without bicarb and meticulous hemostasis Hematoma is most common complication Smoking diminishes flap survival, smoking cessation for 2 weeks Facial nerve injury- better to avoid paralytics

Necklift:

Necklift Involves midface to clavicle region Often combined with facelift, liposuction, platysima muscle modification Indicated for jowls, turkey neck, wrinkling of the neck Commonly combined with brow lift, blephoroplasty

Brow lift:

Brow lift Resuspension of brow and upper face, typically paired with the blephoroplasty Can be performed with endoscopic techniques Soft tissues may be fixated to the cranium or temporal fascia “muscular” bleeding is controlled with cautery

Blephoroplasty:

Blephoroplasty Rejuvination of periorbital region Eliminates tired look, or aging laxity Westernization of asian eye form Resection of skin, muscle, and fat Post op blindness- hematoma formation OCR- surgical manipulation

Anesthetic concerns:

Anesthetic concerns Consider anesthesia setting, patient history Can be done at the hospital, ambulatory center, or office OR Totally elective surgery, should only be performed on ASA I, II Choice of Mac with local or GA

Preop:

Preop Airway assessment, plan airway approach Cardiovascular assessment- htn can be disastrous to results Assess bleeding tendancy , recent asa or nsaids Appropriate preop meds, antibiotics, pain prophylaxis, steriod and nausea prophylaxis.

Intraoperative care:

Intraoperative care Anesthetic choice- GA, Mac GA either ETT or LMA, Mac can be more difficult due to concerns about O2 and fire General can be standard inhaled anesthetic or “ ketafol”dissociative anesthetic. Omit opiates, pain prophylaxis with cox2 inhibitor , clonidine, intraoperative lidocaine Avoid/ rx htn

cont:

cont Use of midazolam to prevent awareness Facial nerve monitoring Smooth emergence and antiemetic prophylaxis is important to preventing hematoma Blood loss tends to be minimal with epi infiltration and good hemostasis Fluids 2-4 ml /kg, balance requirement with avoiding a full bladder, longer cases >4 hrs may require a catheter)

cont:

cont Good positioning, gel pads, scleral shields with ointment for eye protection Diligent monitoring of LA use, consider toxicity

Rhinoplasty:

Rhinoplasty Done for aesthetic or functional reasons Often combined with septal surgery Can involve the tip, dorsal hump, septum of the nose May involve the use of implanted materials

Rhinoplasty :

Rhinoplasty Done through mucousal incisions, intercartiligagenous incisions, or the alar cartilidge for exposure of the nasal frame Procedures may be considered “open” or “closed” or a combination of the two May require intranasal or external splinting post procedure

rhinoplasty:

rhinoplasty Considered 3 rd most common cosmetic procedure Preop preparation with afrin , or cocaine soaked nasal pads Can be done with mac/local or GA, ett or LMA Throat pack in general to diminish blood collecting in oropharynx

Facial laser resurfacing:

Facial laser resurfacing A technique aimed at resurfacing the skin A controlled burn with CO2 laser which after healing leaves a smoother appearance Laser surgery has inherent hazards in the OR to include ocular hazards, fire hazards, airborne contaminants Nerve block, local, iv sedation or GA are appropriate

Facial cosmetic procedures summary :

Facial cosmetic procedures summary Very common procedures When considering hazards, GA may be best BP control is paramount Field avoidance In general require a light anesthetic, amnestics are useful Use of a flexible lma or oral rae ett makes moving the tube for surgical access easy, may need an extension

Non facial aesthetic surgery:

Non facial aesthetic surgery Reduction mammoplasty Mastopexy or breast lift Brachioplasty Abdominoplasty - standard and minimal Body lifts Liposuction Augmentation mammoplasty

Breast augmentation:

Breast augmentation Gel or saline implants Mac or general Tumescent lidocaine with epinephrine Can be subglandular or submuscular May need to seat the patient for assessment of fit placement Saline implants are filled after placement Outpatient procedure PONV common with breast procedures

Reduction mammoplasty:

Reduction mammoplasty Various approaches , typically a pedicle of breast tissue with the nipple complex is preserved. Often combined with liposuction, or procedure is entirely liposuction Covered by insurance for functional issues General anesthesia with appropriate airway management, pain control, PONV prophylaxis

Mastopexy/ breast lift:

Mastopexy / breast lift Match the volume of skin with the volume of breast tissue Reduction of “skin envelope” or implant to increase volume or combination of the two Similar to reduction In markings and skin excision, less breast tissue removed

Anesthesia considerations:

Anesthesia considerations Population for these procedures include women with ptosis from aging, obese women, or post ca treatment for reconstruction, typically to produce symmatry Positioning with arms </= to 90 degrees Blood loss can be significant with reductions Increase incidence of PONV

Cancer Treatment or Chemotherapy:

Cancer Treatment or C hemotherapy Consider chemotherapy SE, (pulmonary fibrosis, cardiomyopathy from adriamycin , renal/ liver dysfunction from methotrexate) , no bp on surgical side Check labs for SE like anemia , thrombocytopenia , leukopenia

Emergence and post op :

Emergence and post op May need to seat the patient, apply dressings or clothing in seated position on emergence Treat pain appropriately Complications may occur, hematoma formation, pneumothorax PONV

Body sculpting:

Body sculpting Massive weight loss brings excess and laxity of skin Procedures aimed at removing redundant tissue include brachioplasty , abdominoplasty,body lifts Liposuction is aimed at reducing body fat either primarily or post weight reduction

Brachioplasty:

Brachioplasty “batwing” operation, excision of tissue in axilla to elbow may be obese , preop workup considering labs, pulmonary and cardiac function aspiration prophylaxis, airway difficulty, rapid desaturaton secondary to decreased FRC Use high FiO2, large volumes for ventilation IV access may be difficult, discuss with surgeon placement,, may need neck or lower limb Positioning, consider arms may need elevation for extended duration

Quick Story………………..:

Quick Story………………..

Abdominoplasty:

Abdominoplasty Laxity of abdominal muscles, excess skin and adipose tissue Excess adipose removed with liposuction prior to abdominoplasty but part of same procedure Umbilicus to pubis is excised in standard procedure and reanastomosed with umbilicus being tunneled into new position

Anesthesia considerations:

Anesthesia considerations To reduce blood loss, Tumescent lido with epi for hemostasis is typically used with electrocautery Operating table is flexed to approximate skin edges for closure Abdominal muscles may be sutured for tightening Drains and compressive dressings are placed, require significant patient movement

Patient concerns:

Patient concerns May be post weight loss, may be obese Obesity requires particular care for cardiovascular and pulmonary management addressed in another lecture GERD prophylaxis, DVT prophylaxis, antibiotics Consider history of fen/ phen and possible pulmory htn , valvular disease Diabetis incidence is higher in obesity/gallbladder disease in post weight loss

Operative care :

Operative care GETA is recommended, RSI, fiberoptic airway Calculate lean body mass, standard maint Controlled ventilation with high fi02 and high volumes Consider epi infiltration and arrythmogenic nature of inhaled agent Treat moderate blood loss with 6-10 ml/kg Maintain flexed position Smooth emergence to avoid disruption of sutures

Settings:

Settings Consider individual patient and choose appropriate surgical setting Consider post op needs and possible required care Obese patients should be done inpatient Post weight loss or healthy patients for office or outpatient setting

Body lifts/Liposuction:

Body lifts/Liposuction Post weight loss, fine tuning Removal of residual fat, skin and tightening to eliminate folds and laxity Many patients have multiple areas, may need series of surgeries Patients need to be marked preop ,typically standing, consider this with premedication

Procedures:

Procedures Facelifts with associated procedures Breasts ( mastopexy , implants) Abdominal to include abdominoplasty to circumforal torsoplasty Lower body work, thigh lifts, buttock lifts and implants Liposuction may be used in combination with any of these

Operative conciderations:

Operative conciderations Larger surface area of dissection increase incidence post op complications Position changes intraoperatively require careful planning up front, consider airway, positioning equipment, etc One portion of the combination of procedures may dictate your choice of airway management

Liposuction:

Liposuction Most commonly performed procedure Use of tumescence, lidocaine infiltration allows anesthetic to be general or mac Soln contains 1 L of LR, 1 mg of epi , 200-500 mg of lidocaine , prewarmed Large volume procedures may need postop fluid monitoring for day or two, small volume procedures may need more IV soln for hydration

Anesthetic techniques:

Anesthetic techniques Choose appropriate technique for planned procedure, MAC vs general Regional may fit procedure, but vasodilation may increase blood loss, fat embolism Standard maintenance, continue through application of compression garments PONV prophylaxis Fluid Volume according to extent of procedure

PowerPoint Presentation:

Standard monitoring, may need foley catheter, careful temperature monitoring and heat conserving measures Frequent position changes require careful airway maintenance, padding and positioning

care:

care Postop restrictive garments may interfer with respiration Prior chf or mvp may not be candidates especially high volume lipo Tumescence may cause numbness post op Blood loss is minimized from epi added to tumescence

complications:

complications Local anesthetic toxicity Excess blood loss Volume overload Abdominal cavity perforation Peripheral nerve injury Hypothermia Fat emboli Htn Respiratory comprimise pain

Office based setting:

Office based setting Most any procedure can be performed in the office based setting, however tend to be self pay procedures as procedures covered by insurance may not be paid if done in this setting Totally elective in nature, careful screening to include ASA I and II’s only Offices may or may not have gas machines which obviously dictate the anesthetic technique Less regulated than hospitals or ambulatory centers Safety has been contraversal

Patient selection:

Patient selection Patients are screened by the surgeon and staff, cleared by the primary care physician and the anesthesia provider prior to the procedure Controlled and minor cv or pulmonary disease, diabetes in a single presentation may be considered on a case by case basis, example bp ASA I, II only

Safety Standards:

Safety Standards Both the AANA and the ASA adopted safety standards for office anesthesia in 1999 in response to a rash of patient deaths and morbidity in the office setting in the early 1990’s Standard I- Perform complete and thorough assessment Standard II- Obtain informed consent Standard III- Formulate a specific plan of care Standard IV- implement and adjust the plan of care based on patient physiologic response Standard V-Monitor the patients physiologic condition as appropriate for the type of anesthesia and specific patient needs Standard VI- Complete, accurate, and timely documentation on the patients medical record

Standards- cont:

Standards- cont Standard VII-Transfer patient care to other qualified providers in a manner that ensures continuity of care and patient safety Standard VIII- Adhere to appropriate safety precautions, as established within the institution, to minimize the risk of fire,explosion,electrical shock, and equipment malfunction. Document on the record that the anesthesia machine or equipment as been checked. Standard IX- Precautions shall be taken to minimize the risk of infection to the patient, the CRNA, and other health care providers. Standard x- Anesthesia Care shall be assessed to ensure quality and contribution to safe outcomes Standard XI- The CRNA shall respect and maintain the basic rights of others.

Accreditation:

Accreditation American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) Accreditation requires 100% compliance with standards Key elements include: Surgeons must be board eligible or board certified Director must be ABMS (American Board of Medical Specialties) certified or an anesthesiologist Surgeons must hold hospital privilidges with transfer policies intact Reviews are performed at multiple levels of anesthesia capabilities

AAAHC (American Association for Ambulatory Health Care):

AAAHC (American Association for Ambulatory Health Care) Accreditation of office practice since 1979 Assesses critical organizational structure Credentialing, policies and procedures, safety measures,, transfer protocols, etc. Allows CRNA practice as a physician supervised qualified individual

JCAHO (Joint Commission on Accreditation of Healthcare Organizations:

JCAHO (Joint Commission on Accreditation of Healthcare Organizations Approved standards for office practice in 2001 Offers 3 year accreditation

State Regulation for Office surgery and Anesthesia:

State Regulation for Office surgery and Anesthesia Through legislation efforts in the wake of office associated deaths, morbidiity Guidelines established by regulatory boards (Board of Medicine) Guidelines adopted by state Departments of Health

regulation:

regulation Extremely varied from state to state Offer regulation regarding the offices, standards for practice, practitioner credentialing, practitioner restrictions, patient restrictions, etc

Office techniques:

Office techniques All techniques are acceptable if the office is properly equipped Large focus on discharge readiness- “fast-tracking” Pain Nausea/vomiting Ambulation Techniques employ premptive analgesia, local anesthesia, nsaids , and antiemetics

Multimodal Premptive Analgesia :

Multimodal Premptive Analgesia COX-2 inhibition- cox 2 nsaids NMDA blockade-ketamine Pre incision local anesthesia

IV sedation:

IV sedation Broad spectrum of use, and level of sedation 88% of office anesthesia Short acting agents- propofol combined with local anesthetics, analgesics, sedatives Twilight sedation on escalating scale to deep IV sedation Respiratory monitioring is paramount- oxygenation and ventilation Ketamine has become analgesic/anesthetic of choice in the office setting- little or no respiratiory depression may decrease need for supplemental O2 Benzodiazepine prior to ketamine has attenuated emergence reactions

Fire Safety:

Fire Safety Fire very common in facial surgery with supplemental oxygen, loose draping, use of electrocautery New standards are being developed and fire education is increasing Oxygen source, fuel, heat for ignition are the triangle of fire Any of these increase the danger of fire Avoid O2 using ketamine, use an ETT or LMA, seal draping, avoid alcohol based prep solutions, communicate with surgeon if using cautery on patient with supplemental oxygen, limit FIO2 to less than 30%

Regional Anesthesia:

Regional Anesthesia Should be considered when possible Reduces possibility of airway problems, bronchospasm,prolonged sedation,MH,PONV,cardiac problems, respiratory depression, or drug interactions Facial techniques may utilize local/regional blocks for cutaneous procedures by plastic surgeons or dermatologists

General Anesthesia:

General Anesthesia Typically Desflurane or Sevoflurane for office setting Must maintain supplies, policies for treatment of MH TIVA is becoming acceptable for varied procedures, may eliminate the need for MH equipment and supplies if no triggering agents are kept in the department LMA may be utilized, lower incidence of sore throat than with ETT Bis monitoring may aid in anesthesia titration, rapid awakening, appropriate depth monitoring

Tumescent Anesthesia:

Tumescent Anesthesia Combination of warm IV fluid, dilute lidocaine (.05-.1%), and epinephrine (1:1,000,000) Functions to emulsify fat, provide anesthesia and hemostasis (liposuction ) Used in various other procedures for anesthesia adjunct to deep sedation Infiltration of up to 35 mg/kg to 50 mg/kg in the dilute solution may be injected. It binds to tissues and is slowly released over 18-28 hours avoiding spike in serum levels. Anesthetist should monitor and chart volume of tumescence Cautious use of IV fluids with consideration to infiltrated volume, use of a urinary catheter to monitor output

Complications:

Complications In 1999, death rate of liposuction was 19/100,000, higher than for general surgical procedures PE is most common cause of death related to lipo Venous stasis, caval compression,fat mobilization are contributing factors Pulmonary edema secondary to IV fluid overload Hemmorhage Organ perforation Convulsions secondary to lidocaine toxicity Nausea and vomiting

Lidocaine Toxicity:

Lidocaine Toxicity Rare occurance , treatment protocols should be well organized and readily available Lipid emulsion “kit” should be on crash cart, with instruction included

Systemic Toxicity: Treatment:

Systemic Toxicity: Treatment Stop injection immediately Treat Give oxygen - hyperventilate (mask or airway device) Stop cerebral excitation (Benzodiazepines -barbiturates -propofol) Correct hypotension and dysrhythmias (crystalloids -vasopressors -antidysrhythmics) Cardiopulmonary resuscitation for cardiac arrest/VF Avoid/treat aggravating factors Hypoxia and acidosis Midazolam 2 - 5mg Thiopental 50 - 150mg Propofol 50 - 100mg

Cardiovascular Toxicity: Treatment:

Cardiovascular Toxicity: Treatment Follow ACLS guidelines Substitute amiodarone for lidocaine Substitute vasopressin for epinephrine Lipid infusion Consider cardiopulmonary bypass if standard drugs fail.

Lipid Rescue:

Lipid Rescue In the event of local anesthetic-induced cardiac arrest that is unresponsive to standard therapy , in addition to standard CPR intralipid 20% should be given IV in the following dose regime: Intralipid 20% - 1.5 ml/kg given over 1 minute Follow immediately with an infusion @ 0.25 ml/kg/min Continue chest compressions (for lipid to circulate) Repeat bolus every 3-5 minutes up to 3 ml/kg total dose until circulation is restored Continue infusion until hemodynamic stability is restored (increase the rate to 0.5 ml/kg/min if BP declines A maximum total dose of 8 ml/kg is recommended www.lipidrescue.org

Nausea and Vomiting:

Nausea and Vomiting Very uncomfortable for patient, but more importantly, delays discharge Contributing factors include type of surgery, drugs used, patient history, patient characteristics, perioperative factors (like pain) Formulate a patient specific plan based on the risk factors presented Single, double, or triple prophylaxisZofran , decadron , Kytril,Anzemet,Reglan , droperidol , (black box), relief bands, queez ease

The recipe:

The recipe Oral Cox 3 inhibitor, clonidine, preop 100mg Lidocaine to 1000cc bag of IV fluid intraoperative Antibiotic, Versed, decadron prior to induction 25-50 mg of Ketamine mixed in 10 cc Propofol slowly while prepping patient, apply nasal O2 Give sufficient propofol for local infiltration, tumescence, start iv infusion 50-200 mcg/kg/min Ventilate with ambu until patient breaths spontaneously Adjust level with propofol boluses or titration of infusion Use LMA for facial procedures or positioning requirements Use LMA for airway obstruction which recurs Nausea prophylaxis 15 to 20 min prior to end of case Coordinate emergence with surgeon, transfer to wheelchair

PACU:

PACU Patient monitored Fluids, po pain med, small amount of food Instructions to family members Local accomodations for out of town patients Discharge in about an hour with instructions to return for office follow up Phone call in morning for assessment

Pacu:

Pacu Important to be available while the patient is in pacu , stay until patient is discharged home

Jameson:

Jameson C

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