Ambulatory plastic surgery procedures and neuroaxial anaesthesia.[3]
1. Introduction
Outpatient and short-stay plastic surgery procedures have increased recently up to 457% [1] due to lower prices, global availability of plastic surgeons, better and safer anaesthetic techniques. This exponential growth has been increased by greater information in the media, most notably by means of the enlightenment shown in the internet. Every day more complex patients force anaesthesiologists to develop better techniques using multimodal approaches before, during and after anaesthesia. Nowadays it is possible to perform ambulatory plastic surgery procedures in people with medical conditions that in the past were rejected; myocardial ischemia, arrhythmias, hypertension, coagulation disorders, lung diseases, diabetes, etcetera. Improved safety and efficacy in all anaesthesia procedures for plastic surgery is mandatory; surgeons, patients, relatives and media have their own concerns regarding anaesthesia patient safety.
Local anaesthesia, plexus nerve blocks and neuroaxial techniques have been reported with excellent results, as well as patient comfort and acceptance. Spinal, epidural or combined spinal-epidural procedures are quite safe and have attained widespread use for patients undergoing ambulatory surgery below the Th3-Th4 spinal level. Spinal anaesthesia for outpatient and short-stay plastic surgery cases have been well accepted by surgeons and patients due to its rapid onset and offset, easy administration, minimal expenses, and almost no side effects or complications. Ambulatory procedures as liposuction, buttocks implants and calf implants, and many more are done properly under spinal anaesthesia. Longer surgeries like abdominoplasty, lower body lift, or combined surgeries involving upper and lower body segments are also done safely under subarachnoid or epidural anaesthesia.[2,3,4] Small gauge pencil point needles have acceptable rates of 0 to 3 % of postdural puncture headache (PDPH); the most fearful side effect of spinal anaesthesia. There are several choices of local anaesthetics (LAs) available for spinal anaesthesia for ambulatory and short-stay patients, including ropivacaine, levobupivacaine, racemic bupivacaine, prilocaine, mepivacaine, articaine, procaine and chloroprocaine. Although controversial, lidocaine is no longer recommended to be used for spinal anaesthesia. Intraspinal adjuvant drugs like clonidine, dexmedetomidine, morphine, sufentanyl and fentanyl enhance quality and duration of spinal blocks.
Deep venous thrombosis and pulmonary embolism remains the greatest cause of morbidity and mortality in plastic surgery.[5,6,7] Spinal anaesthesia decreases these complications as it facilitates early ambulation. Postoperative pain can be managed with preoperative preemptive analgesia techniques, plus adjuvant drugs injected into the spinal space.
For the purposes of this review we define outpatient surgery cases as those who are discharged the same day of the procedure, and short-stay patients those who remain in the surgical unit or hospital for 24 hours after surgery. This chapter reviews the indications, contraindications, advantages, disadvantages and drugs used for spinal anaesthesia in ambulatory and short-stay plastic surgery procedures.
2. Subarachnoid anaesthesia techniques
There are three ways to perform spinal anaesthesia; single injection, combined spinal-epidural, and continuous subarachnoid anaesthesia with small gauge spinal catheters.
Spinal anesthesia is done following anatomical landmarks. The introduction of ultrasound in regional anesthesia is an advanced technique that is now used in difficult cases where anatomy cannot be identified properly, or when a difficult block is anticipated as in morbidly obese or patients with severe anatomic alterations.
3. Indications of spinal anaesthesia
There are two groups of patients who desire plastic surgery procedures: a) Those who undergo surgery for purely aesthetic reasons to look better and b) Those who do it for work, social or professional demands. These are patients with special wishes and needs that most of the times border on perfection, therefore they have poor tolerability for errors or side effects. Complications from anaesthesia are not tolerable, even small or insignificant side effects are not accepted. These patient characteristics demand a careful anaesthesiologist, a cautious anaesthetic plan with some management alternatives ready to be use in order to stay away from mistakes and complications.
Typically spinal anaesthesia is used for surgical procedures below dermatome Th10, involving the abdomen, pelvis, perineum, and lower extremities. Outpatient and short-stay plastic surgery procedures localized up to dermatome Th3-Th4 can be safely done under lumbar spinal anaesthesia, tilting the surgery table in Trendelemburg or reverse Trendelemburg position until the desired surgical level is reached. For example, you can use lumbar subarachnoid block for breast surgery and chest/back liposuction, or abdominoplasty combined with breast surgery.[16,17]
Tables 1 and 2 show our recommendations for outpatient and short-stay cosmetic surgery procedures that can be done under spinal anaesthesia, including surgeries up to Th3-Th4 dermatomes. In some circumstances it is convenient to use combined epidural-intrathecal anaesthesia to ensure sufficient anaesthetic duration, as discussed previously.
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Liposuction | L, PPX | C, F | L, PPX | C, F | L, PPX | C, F, S |
Liposculpture | L, PPX | C, F | L, PPX | C, F | L, PPX | C, F, S |
Buttock Implants/fat grafting | L,PPX | C | L, PPX | C | L, PPX | C, F, S |
Calf Implants | L, PPX | C | L, PPX | C | L, PPX | C, F, S |
Breast and liposuction | PPX | C, F | L, PPX | C, F | L, PPX | C, F. S |
Breast only | Not recomended | Not recomended | L, PPX | Not recomended | Not recomended | Not recomended |
Perineal procedures | L, PPX | C, F | L, PPX | C, F | Not recomended | Not recomended |
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Abdominoplasty (Simple, extended or circular) | PPX | C, F, S, or M | PPX | C, F. M | PPX | C, F, S, or M |
Abdominoplasty with breast surgery | PPX | C, F, S, or M | PPX | C, F, M | PPX | C, F, S, or M |
Lower body lift | PPX | C, F, S, or M | PPX | C, F, M | PPX | C, F, S, or M |
Breast pexia | Not recommended | Not recommended | L, PPX | C, F | Not recommended | Not recommended |
4. Contraindications for spinal anaesthesia
Contraindications are divided into absolute and relative, as shown in table 3. Contraindications for spinal anaesthesia have been changed over time due to advanced equipment such small gauge pencil point spinal needles, small gauge Quincke type spinal needles, special tip designs spinal needles, recent LAs and adjuvants drugs. Patients who wish to fly few days after their surgery should not receive spinal anaesthesia because of the pressure changes in aircraft cabins may facilitate cerebrospinal fluid (CSF) leak through the duramater hole. In addition to these general contraindications, there are few situations where it is not advisable to use spinal anaesthesia in these patients. For example; patients who live far away from where they are operated and are not able or willing to return to this facility, should not receive spinal anaesthesia because the small risk of PDPH. This situation implies that they have to be treated by colleagues at their city of origin and could facilitate unnecessary medical legal problems. With plastic surgeons that require longer surgical times it is better to avoid spinal anaesthesia or advice the patients that they may need general anaesthesia near the end of the procedure.
Absolute | ||
• Patient rejection • Severe coagulation disorders • Infection at cutaneous injection site • Hypovolemia or hemodynamic inestability • Increased intracranial pressure |
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Relative | ||
• Sepsis • Preexisting diseases of the central nervous system |
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○ Multiple sclerosis ○ Spina bifida ○ Cancer ○ Hydrocephalus derived |
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• Anticoagulation • Thrombocytopenia and thrombasthenia • Severe anatomical deformities • Preload dependent conditions |
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○ Aortic stenosis ○ Obstructive hyperthrophic cardiomiopathy |
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• Air travel in the immediate post anaesthetic period |
5. Advantages and complications of spinal anaesthesia
Subarachnoid anaesthesia is an easy procedure that provides a deep and fast surgical block through the injection of small dose of LA into the lumbar spinal space.[18,19] Even though lumbar volume of CSF is the main determinant of the effects produced by intrathecal injection of LA solutions, duration and spread of spinal anaesthesia can be easily manipulated with type/dose of LAs, baricity of the solution, as well as the addition of preservative free adjuvant drugs like opioids and/or alpha2-adrenergic agonists.[19,20] Although some aspects of this technique are controversial, nowadays it is known to be safer than epidural anaesthesia,[21] with many advantages over other anaesthetic procedures, fewer side effects and uncommon severe complications.
Nerve damage is the most feared side effect of spinal anaesthesia. It can be secondary to local neurotoxicity of LAs or adjuvant drugs, direct needle damage, haematoma or spinal infection. Cauda equina syndrome and transitory neurological symptoms (TNS) due to posterior nerve roots irritation at their entry to the spinal cord [26] are the most neurological controversial side effects. Several mechanisms have been proposed to explain them. Local neurotoxicity after spinal injection of any LA is an issue of concern raised after the first published data by Schneider.[27] Follow up of patients who received uncomplicated spinal anaesthesia had shown that some developed pain in the buttocks and/or lower extremities after an initial full recovery from spinal anaesthesia. This painful condition that occurs in the immediate postoperative period is known as TNS, and last up to 5 days. Numerous articles have been published showing that subarachnoid LAs are not free of neurotoxicity; all of them are neurotoxic when injected inside the spinal space, having a different grade of toxicity.[27,28,29,30] Takenami et al [26] found in rats that supraclinical concentration of lidocaine initially is limited to the posterior roots at their entry to the spinal cord. Zong et al found that spinal ropivacaine 0.75-1.0% induced neurotoxicity after repeated injections in rats; infiltration of inflammatory cells, vacuolation of myelin sheaths and axons, abnormal morphology of neurons and apoptosis in the spinal cord, mainly in posterior roots and the adjacent posterior white matter.[31]
In summary, spinal lidocaine is the most neurotoxic LA, followed in descending order of toxicity by bupivacaine, levobupivacaine, ropivacaine, articaine, chloroprocaine and procaine.
As reviewed in the previous paragraphs, severe complications secondary to spinal anaesthesia are extremely rare and therefore difficult to study. Auroy et al [25] in their prospective study conducted in France with 756 anaesthesiologists found that the incidence of deleterious events after regional anaesthesia were rare; they found only 98 incidents in 103,730 cases. There were 40,640 cases of spinal anaesthesia with cardiac arrest in 26 of whom 6 died, (6.4 ± 1.2./ 10,000 patients) which was significant (
6. Drugs for spinal anaesthesia
There are two groups of drugs used for spinal anaesthesia; LAs and adjuvant drugs. The latter are used to enhance the performance of spinal anaesthesia and or to lower doses of LAs and their corresponding side effects. They can be injected through a spinal needle or multiple doses through a spinal catheter.
Systemic toxicity of LAs is not an issue in subarachnoid anaesthesia, since the dosages used are very small compared with the epidural doses. However, due to the increasing use of combined neuroaxial anaesthesia (subarachnoid-epidural) and injections of higher doses of lidocaine during liposuction, abdominoplasty or neck and face lift, it is important to bear in mind the possibility of systemic toxicity manifested by seizures, coma, arrhythmias, or heart failure.
The choice of the spinal LA is determined taking into account the type and duration of plastic surgery procedures, patient health condition, facilities where the operation is performed, the experience of the anaesthesiologist, dexterity of surgeons, and availability of drugs. Also, it is important where the patient lives, or if he/she are tourist patients from a remote place.
The anaesthetic profile of each intrathecal drug is the most important parameter that should be considered when planning subarachnoid anaesthesia.
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Procaine | Lidocaine | Fentanyl |
2-cloroprocaine | Articaine | Sufentanyl |
Tetracaine | Bupivacaine | Morphine |
Levobupivacaine | Clonidine | |
Ropivacaine | Dexmedetomidine | |
Mepivacaine | ||
Prilocaine | ||
Etidocaine |
The amino-amide pipecoloxylidides (PPX) family of LAs incorporate four drugs: racemic bupivacaine, mepivacaine, ropivacaine and levobupivacaine. All of them are used in spinal anaesthesia for ambulatory cases, in particular bupivacaine. Changes in the total dose and/or adding some adjuvant drugs has been a growing field in this line of research/clinical practice. Ropivacaine and levobupivacaine have not been approved all over the world for intrathecal use, however, multiple reports and the fact that they are made preservatives free make them safe when injected inside the spinal space.[43,44,45]
In the following paragraphs we briefly review some LAs used in spinal anaesthesia for outpatient and short-stay cases in various surgical procedures, and analyze their results to use them in ambulatory and brief-stay plastic surgery patients. We describe the amide class of LAs first, followed by the ester type.
Although spinal lidocaine use is controversial, some authors still use it for short procedures. A dose of 40 mg is sufficient and compared with 7.5 mg of bupivacaine.[19] A dose of 15 mg of lidocaine plus 15 µg of sufentanyl produces excellent anaesthesia and recovery time better than 50 mg of lidocaine alone, however 50% develops pruritus.[47] Frey et al compared in healthy volunteers [48] 100 mg of lidocaine, bupivacaine 15 mg and 15 mg of tetracaine-the three hyperbaric-and found that lidocaine has the best recovery profile, although there were patient dependent variables between the three studied LAs, with some subjects recovering quickly among those treated with bupivacaine or tetracaine. No major differences were found between 80 mg of either spinal isobaric lidocaine 2% or spinal isobaric mepivacaine 2% for ambulatory arthroscopic surgery. Neither group had TNS.[49] Prilocaine, mepivacaine, articaine, bupivacaine, ropivacaine, and procaine at low doses have been suggested as alternatives to spinal lidocaine.
Although intrathecal levobupivacaine is safe, there have been reported cases of cauda equina syndrome and TNS. Twenty mg of isobaric levobupivacaine produce less TNS than 80 mg of isobaric lidocaine (0.33% versus 26.6%,
Doses from 4 up to 30 mg of isobaric or hyperbaric 0.75 or 1% ropivacaine can be safely used for ambulatory or short-stay plastic surgery procedures.
When choosing a LA for subarachnoid anaesthesia it is important to keep in mind that hyperbaric forms have a wider intrathecal diffusion compared to isobaric solutions, and therefore they are useful for higher dermatomes surgical procedures. The isobaric LAs are better for pelvic and lower extremity surgeries. Epinephrine is no longer recommended since it lengthens recovery time. It is always wise to consider that operating time is longer than the surgeon's estimate, as there are many timeouts prolonging the surgery. Furthermore, sometimes the original cosmetic surgical plans are modified during surgery, thereby prolonging the surgical procedure.[3] Tables 5 and 6 shows LAs and adjuvants mixtures according to the expected operating times. Note that this includes surgeries less than an hour long, which is uncommon (review of scars, liposuction of small areas, perineal). For these ultra short cases the combination of procaine+clonidine+fentanyl is excellent, without the ghost of TNS. Low doses of PPX local anaesthetics are good, but usually last longer and in a very busy facility, could prolong discharge. Doses 5 to 8 mg of ropivacaine, bupivacaine or levobupivacaine provide up to 150 minutes of intrathecal anaesthesia. This is sufficient time for most outpatient procedures in cosmetic surgery. Prolongation of the action of the LAs by adding clonidine is dose related; 150 to 300 µg can prolong spinal anaesthesia up to 4-5 hours. Drowsiness, bradycardia and hypotension are more frequent with the higher doses, but easy to treat.
In our Plastic Surgery Center the most used spinal LA for ambulatory and short-stay patients are hyperbaric bupivacaine 0.5% and 0.75%, hyperbaric ropivacaine 0.75%, and hyperbaric levobupivacaine 0.5%. We avoid the use of intrathecal lidocaine. For brief ambulatory cases we prefer to use low dose of any PPX family LA, plus clonidine 30 to 50 µg. If the ambulatory procedure is over two hours it is advisable to use regular doses of LAs, and add clonidine in doses from 75 up to 150 µg. We do not recommend spinal opioids in ambulatory cases given the likelihood of pruritus and urinary retention. For short-stay long procedures we use hyperbaric bupivacaine 15 to 25 mg, hyperbaric ropivacaine 15 to 30 mg, or hyperbaric levobupivacaine 15 up to 25 mg. Most of our short-stay patients also receive spinal clonidine 150 to 300 µg, with or without fentanyl 12.5 to 25 µg, or sufentanyl 10 µg. Morphine (100 to 200 µg) is seldom used, even in short-stay patients.
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Liposucction with buttocks fat grafting | 10 a 22.5 | 7.5 – 18 | 7.5 – 15 | 50 -100 |
Liposculpture | 10 a 22.5 | 7.5 – 18 | 7.5 – 15 | 50 - 100 |
Buttocks implants | 15 | 10 | 10 | 100 |
Calf implants | 15 | 10 | 10 | 100 |
Breast implants combined with body liposuctionº | 22.5 | 18 | 18 | No |
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Up to one hour | Lidocaine + clonidine Lidocaine + fentanyl Articaine + fentanyl Chloroprocaine + fentanyl or clonidine Small doses of PPX + fentanyl or clonidine |
One to two hours | PPX + clonidine or fentanyl |
Two to four hours | PPX + clonidine or fentanyl PPX + clonidine + fentanyl |
More than 4 hours | PPX + clonidine + fentanyl PPX + clonidine + morphine |
7. Adjuvant drugs
Adjuvant drugs for spinal anaesthesia in outpatients and short-stay cases are a usual routine in our daily practice in order to decrease the dose of LAs, facilitate a faster recovery and effective postoperative analgesia. There are numerous receptors which modulate spinal pain response, however, there are only a few drugs for subarachnoid use acting as adjuvants. Adrenaline was the most widely used adjuvant in spinal anaesthesia before the use of neuroaxial opioids. Its use has been questioned because 100-300 µg added to LAs did not prolong spinal anaesthesia, but delays recovery. There are some intrathecal adjuvants that have not been approved to be used in spinal anaesthesia like midazolam, ketamine and neostigmine. They may also improve the quality of block and prolong analgesia. Intrathecal magnesium sulphate mainly potentiates the analgesic action of intrathecal opioids, without significant side effects. A positive impact on spinal analgesia has also been suggested for intrathecal calcium channel blockers, and nonsteroidal anti-inflammatory drugs. Alpha2 agonists and opioids are the most used spinal adjuvants drugs.
The optimal dose of spinal clonidine remains unknown. In our current practice, for short ambulatory procedures we use clonidine 30 to 50 µg added to LA without negative impact on home discharge criteria. For short-stay plastic surgery we use from 75 up to 300 µg of clonidine as adjuvant for any PPX family local anaesthetics.
It has been shown that intravenous dexmedetomidine and clonidine significantly prolong bupivacaine spinal anaesthesia, with good sedation effect and hemodynamic stability. In 2003 Rhee et al [99] published the first clinical article with intravenous clonidine to prolong spinal anaesthesia; iv. clonidine 3µg/ kg-1 during 10 min immediately after the subarachnoid block or at 50 min after spinal anaesthesia, prolonged significantly duration of motor and sensory block for approximately one hour. In 2007 we found that dexmedetomidine i.v. also improves bupivacaine spinal anaesthesia.[100] In our research we use an i.v. infusion of 1 μg/Kg dexmedetomidine given in 20 min, followed by 0.5 μg/kg/h dexmedetomidine drip until end of surgery. A comparative group was treated with clonidine 4 μg/kg, given in 20 min i.v. infusion started 20 min after the spinal block, and followed by a 0.9% saline drip until the end of surgery. Sensory block duration was longer in both groups, 208±43.5 and 225±58.8 min respectively,
8. Criteria for home discharge
Outpatient plastic surgery patients managed with spinal anaesthesia must meet established home discharge criteria. The goal of these criteria is to discharge patients safely and avoid hospital readmissions due to complications. Pain, nausea, vomiting, and urinary retention are common examples. It is not entirely necessary to fulfill 100% of these home discharge standards, but patients should be warned about the gradual disappearance of spinal anaesthesia side effects, and facilitate easy communication with the surgical unit, the surgeon and anaesthesiologist. These patients require postanaesthetic and appropriate postoperative orders, transportation, and occasional professional company. It is vital that each unit defines its own ambulatory surgery discharge criteria, according to the characteristics and specific needs of their patients.[3,4] Table 7 shows the most common discharge criteria.
Hemodynamic stability | Vital signs return to pre-anaesthetic values is mandatory |
Full alertnesss | Patient awake, well oriented. Spinal anaesthesia promotes alertness which facilitates optimal conditions for early home discharge |
Permeable digestive tract | Tolerance to solid or liquid intake without nausea or vomiting |
Without or mild pain | Controlled postoperative pain (VAS <2/10) with oral analgesics. Spinal anaesthesia with adjuvants provides an extended period of analgesia, it does facilitate early home discharge and reduce analgesics needs.It is desirable to prescribe a combination of opioid and non-opioid analgesics for expected postoperative pain and patient profile. |
Spontaneous bladder voiding | This is a controversial requirement. Some centers consider it as mandatory to prevent readmissions for distended bladder. In our practice we do not consider this requirement as essential and the patient knows the remote possibility of urinating difficulties. We avoid the use of intrathecal opioids to reduce this risk. |
Ability to walk | Complete regression of motor block is convenient. The patient may try to walk when perianal sensitivity has been recovered, and is able to flex and extend the foot. In some cases it is feasible to discharge without 100% motor recovery. |
Headache | While classical PDPH occurs after 2 to 5 days after spinal anaesthesia, there are patients that may develop it in the immediate postoperative period. It is wise to investigate PDPH symptoms with the patient seated or in a standing position. |
Others | No surgical bleeding, guaranteed companionship during recovery, transportation and accommodation, do not drive. Keep an established secure communication such as telephone, FAX, e-mail. |
9. Conclusions
Outpatient and short-stay plastic surgery cases have grown exponentially worldwide. Anaesthesiologists need to provide a safe anaesthesia to these patients who are often subjected to prolonged surgeries with risks that are higher than expected. Nowadays most cosmetic operations can be done in outpatient and short-stay facilities thanks to advances in anaesthesia. Although most anesthesiologists use general anesthesia for these procedures, regional anesthesia techniques have demonstrated certain advantages such as better pain control, attenuation of the surgical stress response, preserves perioperative immune function, better preservation of oxygenation and lung residual functional capacity, improved visceral vascular flow, less bleeding, early recovery of postoperative ileum, and reduced venous thrombotic disease and pulmonary embolism.
Spinal anaesthesia is a simple technique, with a small volume of drugs producing profound anaesthesia and analgesia, and is devoid of systemic pharmacologic side effects. There are many choices of LAs for outpatient and short-stay spinal anaesthesia; for ultra short procedures the best choice are procaine, articaine or lidocaine. For intermediate duration procedures small doses of intermediate duration LAs, or even lidocaine can be used. For longer procedures bupivacaine, levobupivacaine, and ropivacaine are excellent agents. Addition of adjuvant drugs to LAs enhance subarachnoid anaesthesia with better recovery according with expected surgical time, low incidence of side effects or complications, and longer postoperative analgesia. Clonidine and dexmedetomidine accelerate the onset and prolong the duration of spinal anaesthesia and analgesia.
Severe complications after spinal anesthesia are exceedingly rare; cardiac arrest, meningitis, intracranial subdural hematoma, spinal epidural hematoma, TNS and cauda equina syndrome. Patients should be informed in detail regarding the incidence, severity, and outcome of these complications.
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