Anasthesia and analgesics in aesthetic procedure

Anaesthesic and Analgesics in Aesthetic Procedure Prof. Dr. Andrew Charles Gomez MBBS, FAMM (Mal), LRCP MRCS (Edin), LRCP + S (Glas), FRCS (Edin), FRCS. GS. (Glas), FICS (USA), FICCS (UK), Consultant Surgeon

Anaesthetic and Analgesics in Aesthetic Procedure Introduction • The first successful demonstration of general anaesthesia was at Massachusetts General Hospital, Boston, USA on 16th October 1846 when Morton, a local dentist administered ether to Edward Gilbert Abbott so that John Collins Warren could operate upon a vascular tumour on the patient’s neck.

• Queen Victoria accepted chloroform from Dr John Snow during the birth of Prince Leopold in April 1853 thereby leading to the extensive use of anaesthesia for general surgery and to relieve labour pain.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure Patient safety and welfare is of primary importance 1. Patient’s condition must be optimum before surgery 2. Patient should be given a full understanding of what is going to happen.

3. Co-ordinate the team during surgery 4. It is a collective responsibility of the team to protect the patient from harm 5. Safety of the patient during recovery from anaesthesia.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Types of Anaesthesia

Anaesthesia can either be general or local.

The triad of general anaesthesia are 1. Unconsciousness; 2. Pain relief; and 3. Muscle relaxation.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Management of airway

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Positioning of tongue and jaw Laryngeal mask airway (LMA) Endotracheal intubation Cricothyroidotomy Tracheostomy Venturi Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Complications 1.

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Accidental intubation of the oesophagus Accidental intubation of the main bronchus Aspiration of vomitus Disconnection or blockage of the tube Delayed tracheal stenosis.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Recovery from anaesthesia 1.

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Maintain patency of airway Check for use of anaesthetic agent Prevent hypoxia or hypercarbia Hypocarbia from hyperventilation Persistent neuromuscular blockage Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure Day or ambulatory surgery Of late and in our practice, day or ambulatory surgery is becoming more prevalent.

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These are now being used more and more commonly even for major operations Pre-operative assessment of social, medical and surgical needs is important Anaesthesia needs to be modified for rapid recovery Breakthrough pain must be prevented with appropriate and regular postoperative anagelsia Chaperone must be available to take the patient home.

Breakthrough pain must be explained to the patient and proper management should be advised.

Patient must be discharged with proper instructions in case of emergency.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure Main drugs used for local anaesthesia

Adrenaline • enhances the effects of local anaesthesia; • prolongs its effects; • allows larger doses to be used Contraindication – cannot be used near end arteries like eye and tip of fingers.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure Types of anaesthesia 1. Local anaesthesia suitable for daycare but cannot be used in an infection 2. Regional block – very useful in emergencies when the patient is not starved. Gives very good post-operative pain relief 3. Spinal and epidural anaesthesia – only to be used when an anaesthetist is available. Under full sterile conditions and allows post-operative pain relief.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure Common local anaesthetic techniques 1.

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Brachial plexus block Field block Regional block Beir block  only safe in upper limb;  prilocaine is best – bupivacaine must not be used.  cuff must not be deflated for 20 minutes to prevent systemic toxicity.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure Spinal anaesthesia • Spinal anaesthesia is very useful in awake patients for some form of surgery in the pelvis or lower limb.

• Hyperbaric solution of bupivacaine is injected as a single shot into the CSF to rapidly produce an intense blockage within 5 minutes.

• Important - as sympathetic blockage may occur resulting in hypotension, the patient should be pre-loaded with IV fluid.

• Spinal anaesthesia is usually used for surgery below T-10 level.

• One of the most common complications of this anaesthesia is severe postoperative headache due to CSF fluid leakage through the dural perforation.

This is now prevented by the use of Touby needle which does not cut but splits the dura.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure Epidural anaesthesia

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Slower onset of action compare to spinal.

Blood clot in surgery is minimal.

Allows top up and is ideal for post-operative pain.

Epidural containing of opioids needs careful monitoring for 24 hours.

Epidural anaesthesia is safer than spinal anaesthesia.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure Analgesia • Post-operative analgesia is very important for patient’s relief of pain.

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Prefrontal lobe – emotions Precentral gyrus Postcentral gyrus Thalamus RAS Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Post-operative pain relief

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Requires an expert team approach Opiates should be used A combination analgesics gives best results Pain levels must be measured regularly – The human being has 8 levels of pain Anagelsic is best given before breakthrough pain.

7. The dose of anagelsic must be adequate.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

4 steps of pain relief

The 4 steps of pain relief as recommended by WHO are 1. Simple anagelsics and NSAID 2. Codein phosphate and tramadol 3. Morphine - Pedethine has been removed due to its addiction and tolerance.

4. Gabapentin, an anti-convulsant acting on the NA pump is now being used for neurogelsic pain.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure Techniques for post-operative pain relief 1. Regular intramuscular injections – may get pain breakthrough 2. Local anaesthetic block is best 3. Indwelling epidural – gives good pain control but may cause respiratory depression 4. Continuous infusion – it reduces oscillation in pain relief but risks overdose.

5. Patient-controlled analgesia – pain relief titrated to patient’s needs Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Effective post-operative pain control

1. Provides a sense of wellbeing to the patient 2. Helps patient breathe and prevents respiratory complications 3. Helps in the digestion of food 4. Prevents bed sores 5. Prevents muscle loss – sarcopenia due to lying in bed 6. Prevents bone loss due to immobility.

Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Chronic pain

Chronic pain is due to 1. Inadequate control of acute pain 2. Chronic stimulation of nociceptors – skin and brain 3. Dysfunction in nerves producing neuropathic pain 4. Psychogenic pain causes depression Prof. Dr. Andrew Charles Gomez

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Anaesthetic and Analgesics in Aesthetic Procedure

Management of chronic pain 1.

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Local block Transcutaneous nerve stimulators – TENS Nerve decompression Amputation Encouraging activities and anti-depressants.

Prof. Dr. Andrew Charles Gomez

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