|
|
|
 |
|
| 1. |
What is anesthesia? |
| |
|
Oliver Wendel Holmes coined the
term "anesthesia" in the mid-1800s to describe the state
of etherization as the absence of sensation. We now know that the
state of anesthesia is composed of the elements of hypnosis (sleep)
and analgesia (pain relief). |
| |
|
|
| 2. |
Who will be giving my anesthesia? |
| |
|
In an office-based
setting, it could be the surgeon's secretary (at the surgeon's direction),
a registered nurse with technical training in anesthesia, or an
anesthesiologist (an MD specializing in the medical practice of
anesthesiology). |
| |
|
|
| 3. |
Why is office-based anesthesia
different from the hospital or surgicenter? |
| |
|
Office-based anesthesia has given
rise to the demand for S.A.F.E. (short acting, fast emerging) anesthesia.
This need is greater in the office setting than in either a hospital
or a surgicenter since it is paramount that patients in an office-based
setting recover quickly-pain and nausea free-in order to free up
the operating room, which often also serves as the admitting, surgery,
and recovery room. Patients awaiting a procedure, or the physician
scheduled to conduct a patient consult, can be delayed if the surgical
patient is unable to emerge quickly from the anesthetic. |
| |
|
|
 |
| 4. |
Is office-based anesthesia
new? |
| |
|
No. Crawford
Long, DDS, was giving ether to his office patients in Louisiana
in 1842 and Ralph Waters, MD, practiced anesthesia from his Downtown
Clinic in Sioux City, Iowa in 1919. Privacy issues as well as the
considerable economic advantages are had by patients choosing office
based surgery. Efficiencies in time accrue to the surgeon as well.
Patients must always balance the advantages and take care that the
facility has the ability to handle common emergencies which may
occur during surgical procedures. Supplemental oxygen, positive
pressure devices (i.e. Ambu bag) and a suction device to clear the
airway are minimal standards insisted upon by medical liability
carriers.
According to the American Society of Anesthesiologists' (ASA - www.asahq.org)
publication on guidelines for a safe office anesthesia practice,
an anesthesia machine is not necessary when non-triggering (i.e.
no inhalational agents like isoflurane, desflurane or sevoflurane)
anesthesia is used. States like Florida and California led the nation
in requiring office certification by either AAAASF, AAAHC or HCFA
(now CMS) agencies. Certification assures that a crash cart and
defibrillator are present as well as policies and procedures to
handle the day to day activities as well as emergencies. Certification
per se does not assure sound medical judgment is being practiced. |
| |
|
|
|
| 5. |
What is PK? |
| |
|
The "P" stands for propofol
(Diprivan, AstraZeneca)
and the 'K' stands for ketamine (Ketalar,
ParkeDavis). The combination "PK" stands for an anesthetic
technique pioneered by Barry L. Friedberg, MD designed to maximize
patient safety in the office-based setting. |
| |
|
|
| 6. |
Am I asleep or awake with PK
technique? |
| |
|
PK technique creates the illusion
of general anesthesia, with the minimal trespass of sedation. Patients
neither hear nor feel their surgery, yet remain at the lightest
level of anesthesia short of awake. |
| |
|
|
|
| 7. |
What are my anesthesia options? |
| |
|
Cosmetic surgery differs from non-cosmetic
surgery in that it involves only the superficial tissues. The choice
of anesthesia options will depend on the preference of the patient,
surgeon and anesthesia provider.
Depending on the patient and the surgeon (e.g. a motivated patient
and cooperative surgeon) all cosmetic procedures can be performed
entirely awake with local anesthesia only.
Most patients prefer to have some alteration of their level of consciousness
from wide-awake. According to the American Society of Anesthesiologists
(ASA - www.asahq.org)
definition of anesthesia, there is a continuum of the depth of sedation
from minimal (anxiolysis) to moderate (conscious) to deep (unconscious)
to general anesthesia. |
| |
|
|
|
| 8. |
Is PK technique sedation or
general anesthesia? |
| |
|
According to the ASA, PK would
fall between moderate and deep sedation, depending on whether or
not airway intervention is required. The principle shortcoming of
the ASA definition of PK is the failure to account for the ability
to quantitate (measure) the level of hypnosis from either propofol
or methohexital -- the two most popular intravenous agents. The
Bispectral Index® (BIS®) monitor (Aspect Medical System,
Inc., Newton, MA - www.aspectms.com)
is a validated measure of the patient's level of hypnosis. There
are no units to the index but 98-100 is an awake value, whereas
0 represents an isoelectric (no electrical activity) value. Hypnosis
compatible with general anesthesia is at a BIS® level between
40 to 60 on a scale of 0 to 100. Hypnosis compatible with sedation
can be seen at BIS® levels between 60 and 80 on a scale of 0
to 100. |
| |
|
|
|
| 9. |
How do you know how much medication
to give me? |
| |
|
The ASA definiton of anesthesia
goes on to state: "Because sedation is a continuum, it is not
always possible to predict how a each patient will respond."
The abililty to measure (i.e. the BIS®) is superior to
trying to predict an individual's response to medication. Typically,
the propofol is given as a slow, continuous, intravenous infusion
to achieve and maintain a BIS® level between 60-70 on a scale
of 0 to 100. The added bonus of the slow induction is that patients
do not experience the intense sensation of being 'put out.' Many
have commented that the 'going to sleep' part was the best.
|
| |
|
|
|
| 10. |
I had a hard time waking up
from my last anesthetic. How soon will I wake up after my surgery? |
| |
|
Propofol is a very short acting
drug, which makes it ideal for use in Office-based anesthesia. Being
able to measure the patient's brain response to the propofol with
a BIS® monitor greatly increases the accuracy of propofol dosing.
Because no benzodiazpeines (Valium, Versed, Ativan, Dalmane) are
used with PK technique, patients emerge from propofol hypnosis within
3 to 5 minutes of the propofol infusion being turned off at the
end of surgery. Often patients are able to go home, clear headed,
within 20 to 30 minutes after their surgery is concluded, with their
surgeon's approval. |
| |
|
|
|
| 11. |
Why is PK technique different
from other anesthesia options? |
| |
|
There is no other anesthetic technique that so often leaves patients
with a sense of happiness and well being as does Dr. Friedberg's
PK technique. Elective cosmetic surgery is about increasing one's
sense of personal happiness which matches very well with the happiness
experienced from PK technique. Patients have been quite enthusiastic
in their response to PK, especially those with less than happy
previous anesthetic experiences.
The use of opioids (narcotic medications like morphine, Demerol,
fentanyl) are a common practice for pain relief in anesthesia.
Opioids are associated with a 15-40 percent incidence of postoperative
nausea and vomiting (PONV). By providing non-opioid analgesia
(pain relief), PK technique has essentially eliminated PONV from
patient recovery.
|
| |
|
|
|
| 12. |
Will I have a sore throat after
my anesthesia? |
| |
|
The sore throat after anesthesia
is often associated with endotracheal (inside the windpipe) breathing
tubes. PK technique does not utilize endotracheal tubes for airway
management, so it is very rare for patients to experience a sore
throat after PK technique. |
| |
|
|
| 13. |
I threw up after my last anesthetic.
What can you do to keep this from happening to me again? |
| |
|
Non-narcotic pain relief from ketamine
and adequate local anesthesia with PK technique has essentially
eliminated PONV. Even by using two anti-nausea medications, techniques
that use opioids report an 8 percent PONV rate. By contrast, PK
has less than a 0.5 percent PONV without the use of any anti-nausea
medications. Also, anti-nausea medications can have unpleasant side
effects of their own. |
| |
|
|
|
| 14. |
For what kind of surgery can
I have PK anesthesia? |
| |
|
All cosmetic procedures from abdominoplasty
(tummy tuck), liposuction, breast augmentation, to facelift and
other facial enhancement procedures, can be performed with PK. Other
procedures where PK is appropriate include hernia repairs, lower
abdominal (Gyn) laparoscopy, joint arthroscopy, and lithotripsy.
It is important for patients to be aware of this non-opioid alternative
and ask their surgeon and anesthesiologist if they can have it for
their surgery |
| |
|
|
|
| 15. |
I heard that ketamine is a
street drug or an animal tranquilizer? Why are you using this drug? |
| |
|
Safety. Ketamine (Ketalar,
ParkeDavis) was introduced in 1964 as a complete intravenous
anesthetic agent for humans. We have since learned that ketamine
is better suited as an addition (adjuvant) to rather than a 'stand
alone' anesthetic in humans above the age of ten. The safety profile
of ketamine is the reason it is also used in veterinary anesthesia.
There have been no deaths reported from clinical doses of ketamine
which is not the case for the opioids (i.e. morphine, Demerol, fentanyl).
One cannot equate the clinically controlled use of ketamine from
the media reports of deaths from uncontrolled doses of questionable
purity.
Ketamine had fallen into disfavor among anesthesiologists for the
same reason it is being abused on the street; i.e. its hallucinogenic
potential. Many websites exist to describe ketamine for street use.
This is not one. Titrating the propofol to a BIS® range between
70-75 prevents hallucinations from ketamine, making the agent predictable.
This accounts for the growing resurgence in the clinical use of
ketamine by anesthesiologists who insist on predictablility, as
well as safety, from the agents they employ. |
| |
|
|
| 16. |
What is Preoperative Patient
Protocol? |
| |
|
In general, Preoperative Patient
Protocol is the standard "nothing by mouth after midnight".
This is not an unreasonable starting place for patient instruction.
Long experience with room air, spontaneous ventilation, office
based anesthesia has led to several modifications of this old
instruction.
- Patients taking anti-hypertensives, anti-depressants,
beta blockers, asthma medications or oral hypoglycemic agents
should maintain their usual morning dosage with enough water
to comfortably get their medications down. Asthmatics should
bring their inhalers with them to surgery.
- Patients who regularly consume caffeinated
beverages who experience headache without the usual morning
caffeine dose are encouraged to have their usual morning dose
of caffeine WITHOUT any dairy product. Nondairy creamers are
acceptable if needed.
- Patients who are very hungry upon awakening
may have toast and jam and/or apple juice if so desired.
- Patients who are scheduled for afternoon surgery
may have a light breakfast not closer than four hours prior
to their surgery. Again "light" means NO DAIRY PRODUCTS
(i.e. milk, cream, butter, yogurt, or cheese)
|
| |
|
|
| 17. |
How can I obtain an Anesthesia
Consent Form? |
| |
|
Please click the link below to visit the Consent
Form section.
Anesthesia Consent Form>>
|
| |
|
|
|
|
