2 Anesthesia for Liposuction and Abdominoplasty 2

Chapter 2 Anesthesia for Liposuction and Abdominoplasty 2 Gary Dean Bennett 2.1 tered,thepersonneltobeinvolvedinthecareandmon- Introduction itoring of the patient, the postoperative pain manage- ment, and the discharge criteria used. Therefore, it is Since the development of the first outpatient surgical incumbent on the surgeon to understand current stan- program in 1966 and the first freestanding surgical dards of anesthesia practice. If the surgeon chooses to centers in 1969, the number of surgeries performed assume the role of the anesthesiologist, then he or she outside of the hospital setting has dramatically in- must adhere to the same standards that are applied to creased. An estimated 70% of all elective surgery is per- the anesthesiologist. While the morbidity and mortali- formed in an outpatient setting [1], and more than 50% ty of anesthesia has decreased [9, 10], risk awareness of of aesthetic plastic surgeons perform most of their pro- anesthesia and surgery must not be relaxed. ceduresinanofficesetting[2]. The popularity of surgeries performed outside of 2.1.1 the hospital setting is a consequence of multiple fac- The Surgical Facility tors.Clearly,economicconsiderationsplayamajorrole intheshifttoambulatorysurgery.Becauseofgreater The surgeon is largely responsible for deciding in efficiency, these outpatient surgical units have greater which facility the procedure is to be performed. Surgi- cost-effectiveness [3]. Advances in monitoring capabil- cal facilities may be divided into five main categories: ities and the adoption of monitoring standards of the 1. Hospital-based inpatient American Society of Anesthesiologists (ASA) are cred- 2. Hospital-associated ambulatory surgical unit ited for a reduction of perioperative morbidity and 3. Freestanding surgical center with short-stay mortality [4]. Advances in pharmacology have resulted accommodation in a greater diversity of anesthetic agents with rapid on- 4. Freestanding surgical centers without short-stay set, shorter duration of action and reduced morbidity accommodation [5]. The advent of minimally invasive procedures has 5. Office based operating rooms. further reduced the need for hospital-based surgeries. Regulatory agencies such as the American Association Each of these choices has distinct advantages and dis- of Accreditation of Ambulatory Surgery (AAAASF) and advantages. While convenient and economical, office the Accreditation Association for Ambulatory Health based surgery is associated with three times the mor- Care (AAAHC) have helped establish minimum stan- tality of surgeries performed at other types of facilities dards of care for surgical locations where anesthesia is [11]. Ultimately, patient safety should be the para- administered. Ambulatory anesthesia has even become mount factor in the final decision. Patients with a risk a formal subspecialty of anesthesia with the establish- of ASA III undergoing major liposuction or large abdo- ment of the Society of Ambulatory Anesthesia (SAM- minoplasty should preferentially be treated at hospital- BA) in 1984. An evaluation of 1.1 million outpatients based or hospital-associated surgical units rather than revealed that the mortality rate after ambulatory anes- office-based operating rooms [12–14]. thesiawas1.5per100,000cases[6].Nodeathsoccurred If the intended surgical procedure requires general in 319,000 patients who were monitored in accordance anesthesia or enough sedative-analgesic medication to with ASA standards [7, 8]. increase the probability of loss of the patient’s life pre- As a consequence of the shift away from hospital- serving protective reflexes (LPPRs), then, according to based surgery, the surgeon has adopted a more impor- the law in some states, the surgical facility must be ac- tant role in the medical decision making process with credited by one of the regulatory agencies (AAAASF or respect to anesthesia. Frequently, the surgeon decides AAAHC) [15, 16]. on the location of surgery, the extent of the preopera- Regardless of which type of facility is selected or the tive evaluation, the type of anesthesia to be adminis- type of anesthesia planned, the operating room must 30 2 Anesthesia for Liposuction and Abdominoplasty be equipped with the type of monitors required to ful- ative anesthesia preparation of the patient as an after- fill the monitoring standards established by the ASA thought must be resisted. Even if an anesthesiologist or [17], as well as proper resuscitative equipment and re- CRNA is to be involved later, the surgeon bears respon- suscitative medications [18, 19]. The facility must be sibility for the initial evaluation and preparation of the staffed by individuals with the training and expertise patient. Thorough preoperative evaluation and prepa- required to assist in the care of the patient [19, 20]. ration by the surgeon increases the patient’s confi- Emergency protocols must be established and re- dence, reduces costly and inconvenient last minute de- hearsed [21]. Optimally, the surgical facility must have lays, and reduces overall perioperative risk to the pa- ready access to a laboratory in the event a stat laborato- tient [30]. If possible, the preoperative evaluation ry analysis is required. Finally, a transfer agreement should be performed with the assistance of a spouse, with a hospital must be established in the event that an parent or significant other so that elements of the unplanned admission is required [18, 19]. health history or recent symptoms may be more readily recalled. A comprehensive preoperative evaluation form is a 2.1.2 useful tool with which to begin the initial assessment. Personnel Information contained in the history alone may deter- One of the most critical elements of successful surgical mine the diagnosis of the medical condition in nearly outcomes is the personnel assisting the surgeon. Quali- 90% of patients [31]. While a variety of forms are avail- fied and experienced assistants may serve as valuable able in the literature, a checklist format to facilitate the resources potentially reducing morbidity and improv- patient’s recall is probably the most effective [32]. Re- ing efficiency of the operating room [22, 23]. With an gardless of which format is selected, information re- office-based operating room the surgeon is responsible garding all prior medical conditions, prior surgeries for selecting the operating room personnel. and types of anesthetics, current and prior medica- An anesthesiologist or a Certified Nurse Anesthetist tions, adverse outcomes to previous anesthetics or oth- (CRNA) may administer anesthesia. The surgeon may er medications, eating disorders, prior use of antiobesi- prefer to perform the surgery using exclusively local ty medication, and use of dietary supplements, which anesthesia without parenteral sedation, especially in could contain ephedra, should be disclosed by the pa- limited liposuctions with the tumescent technique [24]. tient. However, many surgeons add parenteral sedative or an- A family history of unexpected or early health con- algesic medications with the local anesthetic. If the sur- ditions such as heart disease, or unexpected reactions, geon chooses to administer parenteral sedative-analge- such as malignant hyperthermia, to anesthetics or oth- sic medications, then another designated, licensed, er medications should not be overlooked. Finally, a preferably experienced individual should monitor the completereviewofsystemsisvitaltoidentifyingundi- patient throughout the perioperative period [25]. Use agnosed, untreated, or unstable medical conditions of unlicensed, untrained personnel to administer par- that could increase the risk of surgery or anesthesia. enteral sedative analgesic medication and monitor pa- Last minute revelations of previously undisclosed tients may increase the risk to the patient. It is also not symptoms, such as chest pain, should be avoided. acceptable for the nurse monitoring the patient to dou- Indiscriminately ordered or routinely obtained pre- ble as a circulating nurse [26]. Evidence suggests that operative laboratory testing is now considered to have anesthesia related deaths more than double if the sur- limited value in the perioperative prediction of mor- geon also administers the anesthesia [27]. Regardless of bidity and mortality [33–37]. In fact, one study showed who delivers the anesthesia, the surgeon should prefer- no difference in morbidity in healthy patients without ably maintain current Advanced Cardiac Life Support preoperative screening tests versus a control group certification (ACLS) and all personnel assisting in the with the standard preoperative tests [38]. Multiple in- operating room and recovery areas must maintain Ba- vestigations have confirmed that the preoperative his- sic Life Support Certification [28]. At least one ACLS tory and physical examination is superior to laboratory certified health provider must remain in the facility un- til the patient has been discharged [29]. Table 2.1. Guidelines for preoperative testing in healthy patients (ASA 1–11). (Adapted from Roizen et al. [305]) 2.1.3 Age Test Preoperative Evaluation 12–40a CBC The time and energy devoted to the preoperative prep- 40–60 CBC, EKG aration of the surgical patient should be commensurate Greater than 60 CBC, BUN, glucose, ECG, CXR with the efforts expended on the evaluation and prepa- a Pregnancy test for potentially childbearing females is sug- ration for anesthesia. The temptation to leave preoper- gested 2.1 Introduction 31 Table 2.2. Common indications

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