Conscious sedation is a method that combines the use of local anesthesia and intravenous sedation. It is defined as a depressed level of consciousness to the point that the patient is in a state of relaxation, but maintains respiratory drive and the ability to protect the airway. The patient is also capable of purposefully responding to physical and verbal stimulation.
This is in contrast to deep sedation, in which the patient is unable to respond to verbal stimuli, will only respond to painful stimulation with withdrawal and has potential compromise of airway protection and respiratory drive. As opposed to monitored anesthesia care (MAC), in which an anesthesiologist or nurse anesthetist are required, conscious sedation can be performed by a nurse under the supervision of the operating surgeon.
Conscious sedation is rapidly gaining acceptance and popularity among plastic surgeons. It has been utilized for numerous years by other specialties, and now with the growth in office-based procedures and surgicenters, there has been a corresponding increase in the role of conscious sedation. Presently, nearly all aesthetic procedures can be performed using a local anesthetic combined with some form of intravenous sedation. These include breast augmentation, breast reduction, mastopexy, abdominoplasty, rhytidectomy, rhinoplasty, blepharoplasty and liposuction.
You will find numerous benefits to the use of conscious sedation instead of general anesthesia or deep sedation. First, the complications associated directly with the administration of a general anesthetic are avoided. These are not negligible, and include adverse cardiopulmonary effects, airway injury and positional nerve injuries.
Such complications happen in roughly 1-2% of aesthetic procedures performed under general anesthesia. The incidence of postoperative nausea and vomiting, which account for most unintended admissions after outpatient surgery, is much much less than that associated with general anesthesia.
The risk of developing deep vein thrombosis (DVT) as a result of blood pooling in the lower extremities during general anesthesia is significantly reduced because of the continued contraction of leg muscles and also the spontaneous shifting of the patient during the procedure. As a result of the relatively big dose of an amnestic medication that is utilized, most patients have no memory of the procedure, no recollection of experiencing pain, and numerous select to undergo conscious sedation at subsequent procedures. Simply because it may be performed safely without the presence of an anesthesiologist, there is a considerable saving in price to the patient.
Conscious sedation is not suited to all patients. Furthermore, the use of conscious sedation demands a surgeon who can "multi-task," focusing on the operation as well as on the vital signs and level of arousal of the patient. The reality that the patient is conscious and can shift position or move freely, necessitates that the surgeon be ready to stop working at any moment. Nevertheless, numerous patients are well-suited for conscious sedation.
Prior to using conscious sedation for the first time, the surgeon should familiarize herself with the medications she will probably be using, as well as their side effects and reversal agents. She should also be familiar with ACLS protocol, airway management and have readily available resuscitation equipment. Immediate access to an anesthesiologist in case of emergency is strongly recommended.
Proper patient selection is an important preoperative decision. Those with moderate to substantial cardiopulmonary disease are poor candidates. Patients should meet the criteria of the American Society of Anesthesiologists status I or II. This means that candidates for conscious sedation should be healthy or have only a mild systemic disease that results in no functional limitation (e.g., obesity, diabetes, hypertension and extremes of age). All other patients ought to obtain monitored anesthesia care by an anesthesiologist or general anesthesia.
Individuals with anxiety disorders and extreme fear of the operating room might not be suited for conscious sedation. Prior to the procedure, patients may benefit from premedication with intravenous diazepam (Valium), administered in increments of 5-10 mg. The dose administered generally ranges from 10 to 50 mg, with the goal being adequate preoperative subjective relaxation of the patient with the desired endpoint being of slurred speech.
Oral diazepam is also an choice; nevertheless, it has to be given nearly an hour prior to the procedure in order to be effective. A second medication that should be administered preoperatively is an antiemetic. Ondansetron (Zofran), given as a single 4 mg intravenous injection is used routinely at our institution. Recently, we have discovered that clonidine (0.1-0.3 mg PO) given 30 minutes prior to the procedure isn't only effective in lowering blood pressure during surgery, it also contributes considerably to patient relaxation during the process. It does, nevertheless, cause post-procedure orthostatic hypotension.
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