A novel sedative called a sublingual 30 microgram sufentanil pill has been developed for awake cosmetic surgery such rhytidectomy or facelifts. Cosmetic surgery, including abdominoplasty, may be done under local anesthetic alone. If an extra opioid is administered for surgical pain, patients may be vulnerable to unmonitored residual opioid effects after being sent home, such as respiratory depression, postoperative nausea vomiting (PONV), aspiration, and even death. Tablets containing sufentanil seem to have comparable hazards. Recently published article discusses Opioid-free anaesthesia.
There are no medical grounds for elective cosmetic surgery, thus the anesthetic risk calculation must be done differently. While the minor risk of malignant hyperthermia (MH) associated with succinylcholine (SCH) and general inhalation anesthesia (GIA) is tolerable for medically necessary individuals, it is difficult to justify in the cosmetic group. An anesthesia machine is required for GIA, and closed-circuit anesthesia may minimize the need of closed-system method. In the case of an MH episode, cardiac resuscitation exercises and stocking dantrolene must be carried out.
One distinctive aspect of cosmetic surgery is the use of lidocaine solutions containing epinephrine by surgeons to induce local anesthesia, mainly for the purpose of vasoconstriction. For liposuction, tumescent anesthesia with lidocaine dosages of 35–55 mg/kg is safe to use. Nevertheless, doctors are trained to believe that vasoconstriction equates to sufficient analgesia, which might result in overmedication or improper medication to quell the doctor's displeasure when the patient moves. The surgeon usually requests stronger sedation when a patient moves while under intravenous (IV) sedation in order to correct the movement. More local anesthesia is often recommended by the anesthesiologist.
Under propofol sedation, this frustrating scenario may be resolved by using a free-standing bispectral (BISTM) index monitor with secondary electromyogram (EMG) trending. Early arousal, which comes before pain and stops arousal and subsequent pain, is signaled by EMG spikes. While patient movement without an EMG spike characterizes spinal cord-generated movement and does not expose patients to awareness, managing a case with an EMG response eliminates most changes in HR or BP. 98%–99% of patient movement is eliminated with sufficient local anesthesia.
IV propofol hypnotic dosages prevent ketamine hallucinations, and over 6,000 patients with commercial insurance have received opioid-free propofol sedation followed by 50 mg of ketamine over a 26-year period. Without requiring a specialized aftercare provider, the majority of patients were sent home an hour following surgery.
EMG trends due to BIS facilitates the success of opioid-free anaesthesia. Only the patient's hypnotic state, which is 15–30 seconds behind actual time, is disclosed by BIS readings. Real-time EMG activity demonstrates the beginnings of cerebral cortical arousal.
REFERENCES -
Friedberg, Barry L.. Opioid-free anaesthesia (OFA) for elective cosmetic surgery: A role of processed EEG monitoring. Indian Journal of Anaesthesia 67(9):p 767-769, September 2023. | DOI: 10.4103/ija.ija_786_23.
1. Seify H Awake plastic surgery procedures: The use of a sufentanil sublingual tablet to improve patient experience. Aesthet Surg J Open Forum 2022;27:4.
2. Klein JA The tumescent technique for regional anaesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16:248–63.