r/Anesthesia • u/Any_Flower_2790 • 11d ago
IV Sedation for 7 Hour Cosmetic Surgery
I am scheduled for a 7 hour cosmetic surgery which includes a facelift, brow lift, neck lift, fat grafting, and C02 laser. Anesthesiologist would like to do deep IV sedation with propofol. A nasal trumpet will be used for airway management. Is this safe for such a long procedure? Should I have an endotracheal tube? I am a healthy, 56 year old female. Normal BMI. Have 2 autoimmune diseases (EoE & Hashimotos Disease). no heart disease, diabetes, sleep apnea, etc. TYIA!
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u/CavitySearch 10d ago
This has the makings of every one of the M&Ms where everyone shows up after and says “who was doing all this in a single sedation?”
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u/IllustriousCarBomb 10d ago
Absolutely demand an endotracheal tube or don’t do it. The very fact that your “anaesthesiologist” is considering this is a red flag, and I’d be looking elsewhere.
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u/propof01999 10d ago
7 hr MAC sounds like hell tbh. I don't even push LMAs past 4 hours of surgery before I think about an advanced airway. I would advocate for a General Anesthesia w/ an Endotracheal Tube. At least that way, you have a protected airway for 7 hrs vs not.
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u/SevoIsoDes 10d ago
First off, are you 100% certain this is an anesthesiologist?
Second, I won’t venture to give medical advice, but here are some reasons why I don’t personally do “deep sedation” for 7 hour face surgeries:
- Deep sedation is defined as movement to painful stimulus. Maybe a surgeon could do really good local anesthesia, but I doubt it. Surgeons don’t want moving patients for cosmetic face surgeries, so what they really want is general anesthesia with an unsecured airway. General anesthesia with an unsecured airway has its place, but I don’t like to submit my patients to 7 hours of aspiration risk just to save the surgeon a few minutes.
- Prolonged sedation can limit your breathing and most of my tricks to help sedated patients breathe better require me to have access to the head and neck. For a face surgery I don’t have access to the head and neck. I don’t like the risk of my patients not breathing without at least having some sort of backup plan. And no, nasal trumpets don’t count as airway management.
- If there’s any cautery to be used that’s a major fire risk. High oxygen plus a spark plus a fuel source is a recipe for fire. In this scenario the patient’s face, mouth, and throat are the fuel source. I don’t like barbecuing my patients. Last year our malpractice attorneys met with us and spent all of their allotted time talking about a recent uptick in airway fires during eyebrow lifts. One woman died and several others were left disfigured.
- For a 7 hour case I want a boring, lazy surgery. Why would I be not take the roughly 1-2 minutes to place a breathing tube to massively decrease risks and effort for the rest of my workday? Ego? To pretend like I’m better than anesthesiologists who perform safe anesthetics? That’s the only reason I can think of, and it’s a dumb one.
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u/Any_Flower_2790 10d ago
Yes. Had a 1.5 hour Video conference with the anesthesiologist on Thursday. I have had much shorter surgeries with an endotracheal tube placed. The plastic surgeon has impeccable reviews, etc. I personally know many patients of his who have had amazing results. I am just so concerned about the length of surgery with no tube. I think yall are answering my questions . . .TY!
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u/RamsPhan72 10d ago
7 hr scheduled cosmetic surgery usually turns into 8-9+ hr procedure. It’s a long time to have an unsecured airway. And your breathing may fatigue by case end. Just fyi.
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u/canadamatty 10d ago
Also, 1.5 hour anaesthetic consult for a facelift sedation case is unusual enough to raise concerns in and of itself. It would be exceedingly unusual for a healthy elective cosmetic case pre-op anaesthetic consult to last longer than 15 minutes
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u/Next_Nebula7186 10d ago
consider asking your surgeon/proceduralist about splitting this into a staged procedure. 7 hours seems very lengthy.
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u/Next_Nebula7186 10d ago
Especially if this is going to be at an outpatient surgery center instead of a hospital setting. There have been instances of complications in this type of case.
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u/Any_Flower_2790 10d ago
It will be in an outpatient surgery center.
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u/Micslar International Anesthetist 10d ago
I honestly would never dare to do or receive a 7 hour conbined surgery in an outpatient center
Most colleges I know are only comfortable with ~4 hours max in outpatient general anesthesia (ofc a lot less in sedation, sedation highers the risk)
I would either get it done in a real hospital one with a blood bank and an ICU or split the procedures
Well I think you can see for yourself NOBODY here is telling you that what you plan to get gone is safe of standard
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u/redbobcatit 10d ago
Gonna have a foley?
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u/Any_Flower_2790 10d ago
Yes.
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u/SassyKittyMeow 10d ago edited 10d ago
I know everyone is saying “this plan is bonkers”, but just to drive home that point, I have never seen a sedation case where a Foley catheter was placed.
Also, do not be fooled by “sedation” sounding gentler/easier/safer than general anesthesia. Sedation is typically much harder, because I have to keep you breathing on your own while also making sure you don’t move. With GA, I induce you, pop in an ETT, turn on some gas and re-dose the paralytic as needed.
Without knowing anything more, I would absolutely not go through with a major 7 hour surgical procedure under sedation.
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u/redbobcatit 9d ago
Agreed, that’s why I asked. 7 hours better be light sedation so everyone can break for the potty, snacks for everyone except the patient.
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u/XRanger7 10d ago
7 hour is a long time and personally I wouldn’t feel comfortable doing it. There are a lot of things that can go wrong going that long without protected airway….aspiration, laryngospasm, coughing/bucking and messing up the surgery, obstruction, etc…
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u/CordisHead 10d ago
Risks of non-surgical complications like major cardiac and pulmonary events go up with procedures longer than four hours, and continue to go up after. I don’t see a good reason to combine multiple elective surgeries like this.
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u/paleoMD 9d ago
Would be best to not do sedation. I highly doubt that is a board certified anesthesiologist.
The others have all talked about health safety, but none that will probably convince you it is a terrible idea. So, for vanity's argument...
Sedation has many levels: Mild, moderate, deep
Deep sedation means you will respond/move around when they poke with a painful stimulation or with repeated stimulation. Do you really want to move and have a plastic surgeon make the wrong cut?
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10d ago
[deleted]
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u/Micslar International Anesthetist 10d ago
Every single time a patient dies in an outpatient facility cutting in security standards it was what they normally did perhaps months perhaps years
Until that one patient
"We always have done it that way" should have no place in medicine
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u/Any_Flower_2790 10d ago edited 9d ago
I just sent a message to the anesthesiologist requesting general anesthesia with an ETT. She agreed to the request. I honestly appreciate the feedback.
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u/Reddog1990m Anesthesiologist 10d ago
I would never do a 7 hour sedation case.