A recent question to the blog:
“What is iv sedation and what is the difference between that and general sedation? Is the patient out completely and will not feel anything? I am interested in Breast augmentation but have a lot of questions.”
Some of you may have read my posts on why I like to do breast augmentation under IV sedation. I also do IV sedation for all major and combined procedures. Naturally, some patients are anxious because they don’t want to feel anything, but they are attracted to the idea of not undergoing general anesthesia. There is also some confusion as to what exactly is IV sedation. This is understandable because there are many levels of sedation. I will explain the different levels so you can make a more informed decision when discussing this with your surgeon or anesthesiologist.
In cosmetic surgery, we often refer to the three distinct choices: local, IV or General Anesthesia. However, I have outlined all of the slight variations so you can fully understand the entire spectrum of anesthesia. In general, my bias is to use as minimal sedation as possible, but ensure that the patient does not feel or remember anything. Following are examples of increasing levels of anesthesia and examples of cases that might be suitable.
1 – Local anesthesia only
This is suitable for small lumps and bumps. I have used it for small wound revisions, but you have to know very well what your level of pain tolerance or anxiety is. I am a poor judge of it myself, and once I underwent a gastroscopy under local. Wow, all I can say is I will never do that again! If you are anxious about needle sticks, you might consider going up to the next level.
2 – Minimal sedation
This usually means giving the patient some Valium or other anxiolytic agent in combination with pain medication such as Percocet by mouth. This is done a good half hour before surgery. The patient should be visibly relaxed or sleepy. In combination with a good local anesthetic, we can do eyelifts, liposuction of small areas, lip lifts, fat injections to the face, and scar revisions. Some patients bring their Ipods with them, or we supply them with ipods from our office. The combination of earphones, sedation and good local anesthesia can do some amazing things. I once did a mini tummy tuck under minimal sedation.
3 – IV Sedation- Minimal
If I decide to use IV anesthesia, I perform it with an anesthesiologist on board. He is responsible for monitoring the patient’s vital signs so I can concentrate on surgery. Minimal IV sedation is really just a step up from Minimal sedation with oral medications as discussed in option 2, except that with the IV and anesthesiologist on board I can ramp up to any level of anesthesia I need. This is great for a patient who does not know if she/he will tolerate only local anesthetics and wants to make sure she/ will be comfortable. I have done eyelifts, revision nose jobs, and fat injections to the face with this technique. It is perfect for lip lifts, where the patient is too anxious to have it done under local anesthesia, but I want her to be really coherent and able to see if she likes the level of lip lift.
4 – IV sedation Moderate, also known as Twilight anesthesia or Conscious sedation
This level of anesthesia includes amnesic drugs, which make the patient forget what happened during surgery. The patient is usually asleep, but able to breathe on his/her own. If the patient feels some pain they may moan and verbalize, or even move some. We generally will then administer more local anesthesia which will be adequate for the level of surgery we are doing. Sometimes patients may need small adjustments in head position to help them breathe better. Upon emerging from sedation patients do not remember what went on and sometimes will even ask if surgery was done. This type of sedation is great for facelifts, capsulectomies, breast reductions, mini tummy tucks, and facial implants.
5 – IV Sedation- Deep sedation
With deep sedation the patients are able to breathe on their own but need an assistive device such as a nasal airway or oral airway. We can do any kind of major plastic surgery including body lifts, combined procedures, etc., provided we use good local anesthesia. Tumescent anesthesia has been great for us in these cases. The beauty of this technique is that since the tumescent local anesthetic agents we use are long lasting, the patient can start emerging from the intravenous anesthesia well before the end of the case. It is rare that a patient will ever feel pain or remember anything during deep sedation.
6 – Total Intravenous Analgesia, also known as TIVA or General sedation, or General Anesthesia
These patients need respiratory support. We at Cosmeticsurg do not believe it is necessary to use TIVA, as we can achieve all our goals with lesser amounts of anesthesia.
Most patients are concerned about the possibility of feeling something during surgery, and so they tell me they want to be totally out during surgery. Before becoming proficient with IV sedation, the way to achieve that was with an inhalation general anesthetic. The problems of general anesthetic are well known: nausea, prolonged recovery times, sometimes needing to admit the patient overnight, and increasing risk of the anesthetic itself with increasing time of surgery. The problems of nausea and prolonged recovery are eliminated with IV sedation. More importantly, there is no increased risk with increased time of surgery.
I feel very strongly that monitored IV sedation is the way to go not only because of the increase in patient comfort, but more importantly, because it is safer.
- See me speak with two different patients, one 20 minutes after a 2-hour procedure and the other 40 minutes after a 9-hour procedure: Twilight IV Anesthesia Interview video.
- See Dr. Hobelmann, a Board Certified Anesthesiologist, talk about the difference between twilight IV anesthesia vs. general anesthesia: IV Anesthesia vs. General Anesthesia.