Van Noord BA, Cupp CL. Safety of Surgeon-Directed Conscious Sedation in Nasal Surgery. Arch Facial Plast Surg. 2008;10(4):282-284. doi:10.1001/archfaci.10.4.282
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Nasal surgery requires numerous, painful local anesthetic injections. Systemic sedation-analgesia is therefore administered concurrently via intravenous conscious sedation (IVCS), deep sedation (DS) with propofol, or general endotracheal anesthesia (GETA). Although DS and GETA are effective, these approaches are substantially more resource intensive than IVCS. The study by Byrd et al1 showed that outpatient plastic surgery can be safely performed; however, multiple procedures and anesthesia methods were pooled. Given the difficulty in achieving and maintaining analgesia in nasal surgery, it is not clear whether IVCS is appropriate in these procedures. Furthermore, recent reports of adverse outcomes in outpatient surgery and increased regulations2 suggest that more studies to verify safety of surgeon-directed IVCS are necessary. The current study examines the safety of IVCS limited to patients undergoing nasal surgery.
The medical records of all patients who underwent nasal surgery (rhinoplasty, septoplasty, and septorhinoplasty with or without turbinate reduction) from January 2005 to December 2006 were retrospectively reviewed. The procedures were performed by the otolaryngology department at a single academic health center. Procedures performed using DS or GETA and that had incomplete medical charts were excluded. Patients who returned for a revision procedure on a different day were classified as new patients. Medical charts were reviewed for patient demographics, intraoperative and postoperative vital signs, medication dosage, anesthetic complications, recovery time, and unplanned admissions. Statistical analysis was performed by the biostatistician at the academic health center. An institutional review board approved the study prior to implementation.
A total of 150 procedures were performed using IVCS during the time period studied. In total, 3 cases were excluded: 2 because the medical charts were incomplete and 1 because the operation was canceled (an adequate level of sedation-analgesia was unattainable in a patient with a history of opiate abuse). The procedures in this study were performed largely on young, healthy, active-duty military men (see Table 1 for demographic data and Table 2 for case parameters). Because the study took place at a military institution, most cases were performed for functional or reconstructive rather than aesthetic reasons. No major complications occurred during either the operative or perioperative period, and there were no deaths, intubations, intraoperative ventilation requirements, seizures, or arrhythmias (Table 3).
After analyzing the patient demographics, case parameters, and complications, we found that postoperative nausea prolonged recovery time (P < .001) and increased unplanned admission (P = .03). Nonadmission recovery time was not associated with age, sex, procedure performed, surgical time, or medication dosage administered.
Intraoperative antiemetic administration was inversely correlated with age (P = .02) and associated with female sex (P < .001). An increased surgical time predicted intraoperative antiemetic requirements (P = .03). An increased fentanyl citrate dosage was associated with intraoperative antiemetic administration (P = .02), whereas morphine sulfate and midazolam hydrochloride dosages were not.
Surgical time was directly proportional to the fentanyl dosage (r = 0.40; P < .001), morphine dosage (r = 0.40; P < .001), and midazolam hydrochloride dosage (r = 0.39; P < .001). Older patients required statistically significantly less fentanyl (r = −0.37; P = .001), morphine (r = −0.37; P < .001), and midazolam hydrochloride (r = −0.31; P < .001) than younger patients. An increased morphine dosage was associated with intraoperative hypertension (P = .003) and with postoperative hypertension that required treatment (P = .01). An increased midazolam hydrochloride dosage was associated with intraoperative hypertension (P = .004).
Analysis of the unscheduled admissions revealed several important points. Two patients were admitted solely secondary to emesis; neither of these patients had received an intraoperative antiemetic. In retrospect, this may have been beneficial. One patient was admitted secondary to postoperative epistaxis, which seems to have been unrelated to the sedation-analgesia method. One patient had a history of obstructive sleep apnea and was admitted as a precautionary measure after oxygen desaturation to a level of 90% to 92%; the concern was that the agents administered might cause catastrophic desaturation during the immediate postoperative period. In retrospect, this precaution was unnecessary. One patient was admitted for monitoring of postoperative tachycardia with chest pain and emesis. It is hypothesized that her symptoms were related to dehydration because her symptoms resolved after fluid administration. She underwent unremarkable revision nasal surgery the following year even though the same anesthetic technique was employed. It is our experience that patients are often admitted secondary to minor complaints when the surgery is performed late in the day or if the patient lives some distance from the hospital; however, this was not an issue in the unscheduled admissions discussed herein.
The final unscheduled admission involved a patient with a history of opiate abuse and posttraumatic stress disorder that was not elucidated until after surgery. Although the patient's surgery was uneventful, he had marked postoperative pain and anxiety that required patient-controlled analgesia, methadone hydrochloride, and zolpidem tartrate. During the evening, approximately 18 hours after surgery, he experienced an apneic episode that required bag-mask ventilation and naloxone hydrochloride administration. The patient recovered completely and was not intubated. However, this case illustrates the importance of obtaining a thorough clinical history and the potential complications from oversedation. Indeed, it has been shown that most avoidable deaths after office-based surgery result from oversedation and inadequate monitoring.3 The current case also highlights the need to have transfer and emergency protocols in place. Finally, presurgical consultation with the pain management service and/or injection of the surgical sites with bupivacaine hydrochloride at the conclusion of the procedure may have been prudent.
Several important associations were determined in this study. Nausea prolonged recovery and led to more unplanned admissions. This association has been previously observed.4 The lack of association between surgical time and unplanned admission rates differs from previous studies5 and perhaps reflects the shorter mean duration of surgical time in this study. If so, there may be a “critical” duration of surgery in which clinical judgment leads to overnight admission. Clinically, a higher fentanyl dosage, younger age, female sex, intraoperative hypertension, and a preoperative diagnosis of hypertension were all associated with nausea. The fact that younger patients had more nausea likely reflects the fact that older patients required less medication to achieve adequate sedation-analgesia. Female patients experienced more nausea than male patients, reflecting a known sex difference.6
In this study, a history of hypertension predicted intraoperative hypertension, postoperative hypertension, and postoperative emesis. Excellent preoperative control of hypertension may assist in reducing the amount of opioid given during surgery (because hypertension can be easily misconstrued as pain) and help reduce postoperative nausea. Also of note, hypotension was seen less frequently than hypertension, both intraoperatively (4% vs 24%) and postoperatively (0% vs 13%), perhaps reflecting the short duration and minimal blood loss in nasal surgery.
The many benefits of IVCS compared with DS and GETA include more efficient resource utilization, less patient risk, and less required training to administer and monitor. In addition, IVCS has a lower risk of airway or ventilation problems (compared with DS) and lower risk of DVT (compared with GETA).7 Also, a high level of patient satisfaction is evident with IVCS in aesthetic surgery.8 In this study, surgeon-directed IVCS was safe in nasal surgery, with no major airway, ventilatory, or hemodynamic complications during surgery or in the immediate postoperative period. Nausea was statistically significantly associated with prolonged recovery (P<.001) and led to more unplanned admissions (P = .03).
Correspondence: Dr Van Noord, c/o Clinical Investigation Department (KCA), Naval Medical Center San Diego, 34800 Bob Wilson Dr, Ste 5, San Diego, CA 92134-1005 (firstname.lastname@example.org).
Author Contributions: Dr Van Noord had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
Funding/Support: This study was sponsored by the Bureau of Medicine and Surgery, Navy Department, Washington, DC, Clinical Investigation Program (CIP No. S-07-045) as required by Military Health Centers rule NSHSBETHINST 6000.41B.
Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the US government.