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| 1. |
What is anesthesia? |
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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). |
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| 2. |
Who will be giving my anesthesia? |
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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). |
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| 3. |
Why is office-based anesthesia
different from the hospital or surgicenter? |
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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. |
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| 4. |
Is office-based anesthesia
new? |
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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. |
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| 5. |
What is PK? |
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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. |
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| 6. |
Am I asleep or awake with
PK technique? |
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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. |
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| 7. |
What are my anesthesia options? |
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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. |
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| 8. |
Is PK technique sedation
or general anesthesia? |
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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. |
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| 9. |
How do you know how much
medication to give me? |
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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.
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| 10. |
I had a hard time waking
up from my last anesthetic. How soon will I wake up after my surgery? |
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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. |
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| 11. |
Why is PK technique different
from other anesthesia options? |
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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.
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| 12. |
Will I have a sore throat
after my anesthesia? |
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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. |
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| 13. |
I threw up after my last
anesthetic. What can you do to keep this from happening to me
again? |
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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. |
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| 14. |
For what kind of surgery
can I have PK anesthesia? |
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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 |
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| 15. |
I heard that ketamine is
a street drug or an animal tranquilizer? Why are you using this
drug? |
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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. |
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| 16. |
What is Preoperative Patient
Protocol? |
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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)
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| 17. |
How can I obtain an Anesthesia
Consent Form? |
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Please click the link below to visit the Consent
Form section.
Anesthesia Consent Form>>
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