Office-Based Outpatient Plastic Surgery Utilizing Total Intravenous Anesthesia

Office-Based Outpatient Plastic Surgery Utilizing Total Intravenous Anesthesia Colin Failey, MD, Jaime Aburto, MD, Hector Garza de la Portilla, MD, Jorge Francisco Romero, MD, Leo Lapuerta, MD, FACS, Alfonso Barrera, MD, FACS

Research Office-Based Outpatient Plastic Surgery Utilizing Total Intravenous Anesthesia Colin Failey, MD; Jaime Aburto, MD; Hector Garza de la Portilla, MD; Jorge Francisco Romero, MD; Leo Lapuerta, MD, FACS; and Alfonso Barrera, MD, FACS Aesthetic Surgery Journal 33(2) 270 274 2013 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www.sagepub.com/ journalspermissions.nav DOI: 10.1177/1090820X12472694 www.aestheticsurgeryjournal.com Abstract Background: Office-based plastic surgery procedures continue to increase in popularity and a range of anesthetic techniques can be utilized, from light conscious sedation to general anesthesia requiring intubation. Total intravenous anesthesia (TIVA) is well suited for the office environment because it allows for moderate to deep sedation without the need for intubation. Objective: The authors review plastic surgery procedures performed in an outpatient office-based operating room under TIVA to assess patient outcomes and complications. Methods: A retrospective chart review was conducted of patients who underwent surgical procedures performed by 2 senior surgeons at American Association for Accreditation of Ambulatory Surgery Facilities certified outpatient operating rooms between 2003 and 2011. TIVA was always administered by a board-certified anesthesiologist because it required the use of propofol. Conscious sedation with midazolam and fentanyl was always administered by the plastic surgeon. Patient outcomes and complications were analyzed to assess the safety of TIVA in an office operating room. Results: A total of 2611 procedures were performed on 2006 patients. No deaths, cardiac events, or transfers to the hospital occurred in any patients, regardless of the type of sedation utilized. Six hundred forty-two patients were given TIVA, which included propofol and/or ketamine, in addition to midazolam and fentanyl. The remaining 1364 patients received conscious sedation. There was 1 documented case (0.05%; 1/2006) of deep vein thrombosis/pulmonary embolism in a patient who had an implant exchange under TIVA; this patient was taking oral contraceptive pills at the time of surgery. Conclusions: Office-based surgery is an attractive option for many patients. This review suggests that a variety of procedures can be performed in a safe manner under TIVA. Although patient selection for outpatient surgery is paramount, TIVA offsets the risks of general anesthesia and is associated with minimal postoperative complications. Level of Evidence: 4 Keywords anesthesia, office-based, outpatient surgery, TIVA, sedation, intravenous, research Accepted for publication October 24, 2012. Office-based procedures in plastic surgery have steadily increased over the past decade, and according to the American Society for Aesthetic Plastic Surgery s 2011 National Cosmetic Surgery Data Bank Statistics, 60% of all cosmetic procedures were performed in an office setting. By comparison, only 18% of cosmetic procedures were performed in the hospital. 1 Such dramatic disparity has been driven, in large part, by increased consumer demand for same-day procedures that avoid the hassle and cost of being admitted to the hospital. Based on these data, a strong argument can be made for allocating resources to optimize the office-based surgery experience. Our evolving role as plastic surgeons is to provide a safe, comfortable office environment in which patients can expect to undergo a Dr Failey is Chief Resident at The Methodist Hospital Plastic Surgery Program in Houston, Texas. Dr Aburto is a Surgical Resident at Boonshoft School of Medicine, Wright State University, Dayton, Ohio. Dr de la Portilla is a physician in training at the Universidad Autonoma de Tamaulipas, Facultad de Medicina de Tampico, Tampico, Mexico. Dr Romero is a physician in training at the Universidad Autonoma del Estado de Puebla Puebla, Mexico. Dr Lapuerta is a plastic surgeon in private practice in Pearland, Texas. Dr Barrera is Clinical Assistant Professor of Plastic Surgery at Baylor College of Medicine, Houston, Texas. Corresponding Author: Dr Alfonso Barrera, 915 Gessner #825, Houston, TX 77024, USA. Email: abarrera@lookinggood.com

Failey et al 271 wide array of procedures without concern for increased complications from sedation or surgery. To this end, several articles have been published in the plastic surgery literature that describe approaches to office-based anesthesia and surgery. Hoefflin et al 2 submitted their series of 23 260 patients who underwent a variety of cosmetic procedures in the office, all while intubated under general anesthesia. They reported no significant complications related to general anesthesia over the 18-year study period. Byrd et al 3 reviewed their office experience with 5316 patients. This study did not specify the type of anesthesia that was utilized for each procedure, but the authors advocated the use of an anesthesiologist or certified nurse anesthetist. An important nuance of their practice involved admitting many of their postoperative patients for at least 1 night to a nearby hotel that was staffed by a registered nurse. Bitar et al 4 examined the outcomes of 3615 patients who had undergone 4778 total procedures performed under intravenous (IV) sedation with propofol administered by a certified nurse anesthetist. Their focus was aimed at describing their anesthesia protocol and examining anesthesia-related complications. They reported excellent outcomes, with only 2 patients requiring postoperative admission to the hospital for reasons related to the anesthesia. A principal problem in comparing these studies to others like them is that the anesthetics used are often unspecified or are referred to globally as monitored anesthesia care or conscious sedation. These ambiguous terms can encompass a number of methodologies. Monitored anesthesia care, for example, does not imply a certain level of sedation; rather, it refers to any anesthesia given to a patient under the supervision of an anesthesiologist. 5 To avoid confusion, we focused our protocol on total IV anesthesia (TIVA), which eliminates paralytics and gases and utilizes intravenous agents exclusively for patient sedation. To evaluate TIVA s safety and efficacy, we analyzed a group of patients who all received TIVA while undergoing a major cosmetic procedure namely, abdominoplasty. Abdominoplasty is one of the most challenging procedures to perform in the office because of the time involved, the extent of tissue resection and rectus plication, and the necessity for high-quality anesthesia. Mustoe et al 6 and Kryger et al 7 have published extensively on the topic and have shown that abdominoplasty can be performed under conscious sedation with midazolam and fentanyl if adequate amounts of tumescent and local anesthesia are used. They preferred to control the sedation themselves during the procedure by directing a nurse to administer midazolam and fentanyl as necessary. Unlike our study, their cases were performed in a hospital-based operating room, and the patients had the option of being admitted overnight for observation. We sought to analyze our anesthetic-related complications to determine whether TIVA could be safely administered in an office-based operating room. Total IV anesthesia was used at the discretion of the senior surgeons and was not used on every patient. For this reason, those patients undergoing abdominoplasty were selected for a subset analysis because they all received TIVA irrespective of the surgeon performing the case. Methods A retrospective chart review was performed on all patients who underwent surgery from 2003 to 2011 at American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) certified operating rooms in 2 plastic surgery offices. During this interval, 2006 consecutive patients underwent 2611 procedures. Of these, 1364 patients (68%) had procedures that were performed under conscious sedation, defined as anesthesia with midazolam and fentanyl. The remaining 642 patients (32%) received TIVA, defined as deep sedation with propofol and varying amounts of ketamine, midazolam, and fentanyl. No patients received general anesthesia with inhalants or muscle paralytics, as this would have required endotracheal intubation. This cohort of 2006 patients was analyzed for significant intra- and postoperative complications that could be related to the anesthetic regimen. Criteria for major complications included emergent intubation during a case, postoperative transfer to a hospital, cardiac events, deep vein thrombosis (DVT), pulmonary embolism (PE), and death. Total IV anesthesia was always administered by an anesthesiologist because it involved the use of propofol. Conscious sedation was always administered by the plastic surgeon. Conscious sedation patients were not directly compared with those patients who received TIVA because only 1 major complication was discovered among the 2006 patients. During the study period, 145 patients underwent abdominoplasty, and all 145 cases were performed under TIVA. Total IV anesthesia was administered by a board-certified anesthesiologist in all cases. Patient characteristics were examined to determine the type of patient(s) being selected to undergo abdominoplasty and concurrent procedures in an officebased operating room. Complications occurring acutely ( 7 days) and long term (>7 days) were compiled to assess the outcomes of our anesthetic and operative techniques. No patients in this abdominoplasty group were excluded from the analysis. TIVA Technique Patients were brought into the office on the morning of the procedure. They were seen preoperatively by the surgeon and the anesthesiologist. Once in the operating room, the patients were given a combination of midazolam, fentanyl, propofol, and ketamine as deemed appropriate by the anesthesiologist. Propofol was typically administered via an infusion pump. When the patient was sufficiently sedated, a nasal cannula was placed for oxygen and the eyes were taped closed for protection. A nasal cannula was not used if the procedure required electrocautery on or around the face. A Foley catheter was inserted if the

272 Aesthetic Surgery Journal 33(2) anticipated case length was >3 hours. The patient was then prepped and draped for the procedure. Total IV anesthesia kept the patient comfortably sedated while the surgeon injected local and/or tumescent anesthetic into the operative field to create a dense field block. A typical abdominoplasty patient received a standard tumescent solution with lidocaine that was infused into the subcutaneous tissues of the abdomen and allowed to sit for 15 minutes. During this time, the proposed incision lines were injected with 0.25% Marcaine (Hospira, Inc, Lake Forest, Illinois) to a maximum of 2 to 3 mg/kg. The procedure was then performed, typically without further disruption to the patient or surgeon. Postoperatively, the patient was placed on a stretcher and brought to the recovery area, where the vitals were monitored for 5 minutes until stable. Following the acute phase, vitals were taken every 15 minutes until discharge. All patients received antiemetics in the form of ondansetron and/or promethazine prior to the completion of the case. Patients were discharged from the office when their pain was under control and they could tolerate liquids. Results During the study period, 2006 patients underwent 2611 procedures at 2 office-based AAAASF-certified operating rooms. A diverse number of procedures were performed, as detailed in Figure 1. Many (68%) of these cases were done under conscious sedation using IV midazolam and fentanyl. Of those cases, 32% were done under TIVA, which included a combination of midazolam, fentanyl, propofol, and ketamine. Propofol was used in 100% of TIVA cases, whereas ketamine was used primarily as an adjunct at the discretion of the anesthesiologist. Complications related to the administration of conscious sedation and TIVA were reviewed. There were no deaths, no cardiac events, no emergent intubations, and no postoperative transfers to the hospital, and all patients were discharged on the day of surgery. There was 1 documented case (0.05%) of DVT/PE, which occurred in a patient who underwent an implant exchange while on oral contraceptive pills. One hundred forty-five of the 2006 patients underwent an abdominoplasty. Multiple concomitant procedures were done at the time of abdominoplasty (Figure 2). Patient characteristics are described in Table 1. Most patients were female (n = 141) and the average age was 40 years. The mean body mass index (kg/m 2 ) in this cohort was 26.3. Twenty-three (16%) patients were smokers. All 145 abdominoplasty patients received TIVA with propofol. Ninety patients (62%) received ketamine as an adjunct. About half (n = 75; 52%) of patients were American Society of Anesthesiologists (ASA) class I, with no medical problems. The other patients (n = 70; 48%) patients were ASA class II, indicating that they had 1 medical condition that was under control. The mean operative time was 241 minutes (4 hours). The mean follow-up time for this group was 248 days (8 months). Figure 1. Distribution of all 2611 procedures performed from 2003 to 2011. Table 1. Abdominoplasty Patient and Operative Characteristics No. of patients 145 Female:male 141:4 Age, y, mean (range) 40.3 (19-68) BMI, mean (range) 25.7 (18-43) Smokers, No. 23 TIVA, No. 145 Adjunct ketamine, No. 90 ASA class I, No. 75 ASA class II, No. 70 OR time, h, mean (range) 4.0 (1.5-7.6) Follow-up, mo, mean (range) 8.1 (0-64) Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; OR, operating room; TIVA, total intravenous anesthesia. Acute and long-term complications were compiled for this abdominoplasty group (Table 2). Major acute events included 6 patients (4%) with prolonged postoperative nausea/vomiting and 2 patients (1.4%) with postoperative hematoma. One of those 2 patients developed a hematoma in the postanesthesia care unit and was taken back to the operating room immediately for evacuation and hemostasis. That patient was able to be discharged on the same day. The other patient had a small hematoma that was drained several weeks postoperatively. Long-term complications included 19 patients (13%) with seroma, 5 patients (3.4%) with wound breakdown, and 2 patients (1.4%) with suture granulomas and draining sinus tracts. There were no documented DVT or PE cases in this abdominoplasty group.

Failey et al 273 Table 2. Abdominoplasty Complications Acute ( 7 d) No. (%) Long Term (>7 d) No. (%) Nausea/vomiting 6 (4.0) Seroma 19 (13.0) Hematoma 2 (1.4) Wound dehiscence 5 (3.4) Urine retention 1 (0.7) Suture granuloma 2 (1.4) Hematuria 1 (0.7) Figure 2. Distribution of cases performed in conjunction with abdominoplasty Discussion The data reviewed in this study suggest that the use of TIVA in an office-based operating room can be safe and effective for the aesthetic patient, especially if he or she is undergoing a higher-risk, more intricate procedure such as an abdominoplasty. The 1 patient who suffered a postoperative DVT/PE in our cohort underwent implant exchange under TIVA, but she was also taking oral contraception at the time of the surgery. This event highlights the importance of screening for oral contraceptive use, as it confers a 3- to 6-fold increase in the risk for DVT/PE regardless of the anesthetic regimen. Likewise, hormone replacement therapy taken by women in menopause can result in a 2- to 4-fold increase in risk. 8 With this information in mind, we now ask patients to stop taking hormone supplementation for 2 weeks pre- and postoperatively. The incidence of DVT and PE in our cohort of 2006 patients was 0.05%, and the incidence in our group of 145 abdominoplasty patients was 0%. These numbers compare favorably to previously published data. Most et al 9 reviewed the literature to estimate the rates of thromboembolism in plastic surgery procedures and found that the incidence of DVT ranged from 0.35% to 1.3%, and the range for PE was 0.005% to 1.1%. In comparison, orthopedic procedures for fractured hips had PE rates as high as 4% to 7%. Abdominoplasty is still associated with the highest rate of DVT and PE among common plastic surgery procedures, and those rates have been shown to double when abdominoplasty is combined with other procedures. 10 Grazer and Goldwyn 11 initially established an incidence of 1.1% for DVT and 0.8% for PE for abdominoplasty, based on a survey in 1978 that collected responses from plastic surgeons throughout the United States. Data published within the past decade suggest that this original estimate was high or that strides have been made toward curtailing the problem. Matarasso et al 12 conducted a survey on abdominoplasty in 2006 and found that the incidence was 0.4% for DVT and 0.2% for PE. Alderman et al 13 corroborated these findings with an analysis of the CosmetAssure and TOPS databases from 2003 to 2007. They found that the combined incidence of DVT and PE was 0.1% to 0.3% for abdominoplasty alone and 0.27% to 0.4% for abdominoplasty performed with additional cosmetic procedures. Proper TIVA implementation requires a collaborative effort between the surgeon and anesthesiologist because efficacious TIVA is 2-pronged: midazolam, fentanyl, propofol, and ketamine establish adequate anesthesia and amnesia, whereas a dense field block limits noxious stimuli to the patient, preventing the use of escalating doses of sedatives. In our view, it was the combination of these 2 modalities that kept our patients safe and free from airway emergencies. In our study, airway issues were resolved with oral airways or nasal trumpets, and no patients required emergent intubation. Furthermore, no patients required postoperative admission to the hospital for any reason, including anesthetic complications. We think it is important to work with anesthesiologists who have experience with TIVA in an office-based operating room. As Blake and Douglas 14 suggest, in their article that debunks a number of myths about office-based anesthesia, part of the dilemma in achieving excellent outcomes is finding anesthesiologists who are comfortable with deep sedation techniques that do not rely on intubation. The 2 senior surgeons in this study have developed their own methods for implementing TIVA in their respective offices. One senior surgeon (A.B.) prefers to administer conscious sedation with midazolam and fentanyl for patients undergoing procedures above the clavicle and TIVA for patients having procedures below the clavicle. He will direct a nurse to administer the conscious sedation medications, but he brings in an anesthesiologist for all TIVA cases. The other senior surgeon (L.L.) prefers TIVA for almost all cases, irrespective of body region, and an anesthesiologist is always brought in for drug administration. Anecdotally, both surgeons have noticed that limiting the use of fentanyl to 50 mcg or less during a case appears to significantly decrease the rate of postoperative nausea and vomiting. Our study was limited because it was retrospective in nature and relied on chart documentation alone to assess patient outcomes. Another challenge was to arrive at an accurate incidence for DVT and PE, given that it already

274 Aesthetic Surgery Journal 33(2) occurs at a very low percentage among patients undergoing plastic surgery. Comparatively, the incidence for DVT/ PE of 0.05% that was generated from our 2006 patients was still lower than most published results that used similar methods of data collection to calculate a rate. Conclusions Our review demonstrates that TIVA can be used safely and reliably in the office setting for a wide array of aesthetic procedures. In particular, the use of TIVA and local anesthetics during longer, complex cases such as an abdominoplasty can spare the patient additional risks of general anesthesia and endotracheal intubation. In the future, we would like to compare our office-based surgical population with those patients who underwent the same procedures in the hospital under general anesthesia, as it is our impression that we have had increased success with TIVA administered in a certified office-based operating room. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, or publication of this article. References 1. American Society for Aesthetic Plastic Surgery. National Cosmetic Surgery Data Bank Statistics. 2011. http://www.surgery.org/sites/default/files/asaps-2011-stats.pdf 2. Hoefflin SM, Bornstein J, Gordon M. General anesthesia in an office-based plastic surgical facility: a report on more than 23,000 consecutive office-based procedures under general anesthesia with no significant anesthetic complications. Plast Reconstr Surg. 2001;107(1):243-251. 3. Byrd SH, Barton FE, Orenstein HH, et al. Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases. Plast Reconstr Surg. 2003;112(2):636-641. 4. Bitar G, Mullis W, Jacobs W, et al. Safety and efficacy of office-based surgery with monitored anesthesia care/ sedation in 4778 consecutive plastic surgery procedures. Plast Reconstr Surg. 2003;111(1):150-156. 5. American Society of Anesthesiologists. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. Quality Management and Departmental Administration. http://www.asahq. org/~/media/formembers/documents/standardsguidelinesstmts/continuumofdepthofsedation.ashx 6. Mustoe TA, Kim P, Schierle CF. Outpatient abdominoplasty under conscious sedation. Aesthetic Surg J. 2007;27(4):442-449. 7. Kryger ZB, Fine NA, Mustoe TA. The outcome of abdominoplasty performed under conscious sedation: six-year experience in 153 consecutive cases. Plast Reconstr Surg. 2004;113(6):1807-1817. 8. Seruya M, Baker SB. MOC-PS(SM) CME article: venous thromboembolism prophylaxis in plastic surgery patients. Plast Reconstr Surg. 2008;122(3)(suppl):1-9. 9. Most D, Kozlow J, Heller J, Shermak MA. Thromboembolism in plastic surgery. Plast Reconstr Surg. 2005;115(2) (suppl):20-30. 10. Hatef DA, Trussler AP, Kenkel JM. Procedural risk for venous thromboembolism in abdominal contouring surgery: a systematic review of the literature. Plast Reconstr Surg. 2010;125(1):352-362. 11. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey with emphasis on complications. Plast Reconstr Surg. 1977;59(4):513-517. 12. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg. 2006;117(6):1797-1808. 13. Alderman AK, Collins ED, Streu R, et al. Benchmarking outcomes in plastic surgery: national complication rates for abdominoplasty and breast augmentation. Plast Reconstr Surg. 2009;124(6):2127-2133. 14. Blake Douglas R. Office-based anesthesia: dispelling common myths. Aesthetic Surg J. 2008;28(5):564-570.