Commentary on: Total Intravenous Anesthesia With Dexmedetomidine for Hemodynamic Stability and Enhanced Recovery in Facial Aesthetic Surgery

See the Original Article here.

Anesthesia for facial rejuvenation surgery has many inherent challenges, including balancing the risk of hematoma formation, avoiding postoperative nausea and vomiting, adequate analgesia, and facilitating early discharge.¹ Intraoperative blood pressure control may require antihypertensive medications. Facelift, or rhytidectomy, may be performed under general anesthesia with either a laryngeal mask airway (LMA) or endotracheal tube, or under deep sedation with monitored anesthesia care (MAC). The retrospective review by Moore et al, “Total Intravenous Anesthesia with Dexmedetomidine for Hemodynamic Stability and Enhanced Recovery in Facial Aesthetic Surgery,” sought to make the case that dexmedetomidine meets the criteria for an ideal anesthetic agent within a total intravenous anesthesia (TIVA) protocol.² The article describes TIVA, often administered using propofol and ketamine, as the preferred anesthetic for facial rejuvenation surgery, with inhalational agents reserved for those who cannot tolerate TIVA. The authors reviewed 784 patients who had facial rejuvenation which included facelift and other facial plastic surgeries.

General anesthesia is defined by the American Society of Anesthesiologists as “a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilator function is often impaired.” ³ General anesthesia may be performed with intravenous agents only, TIVA, or with the use of inhalational agents with ventilation via an endotracheal tube or an LMA. An LMA does not provide airway protection, and aspiration may occur in the setting of gastroesophageal reflux, patients with morbid obesity, or delayed gastric emptying. The benefits of TIVA with propofol, over inhaled anesthesia, is that propofol is a known antiemetic and its use as part of TIVA may reduce the incidence of postoperative nausea and vomiting.⁴ Both LMA and endotracheal intubation provide a means of ventilating the patient. The patient may breathe spontaneously, or with the assistance of a ventilator. MAC differs from conscious sedation in the person administering and monitoring the patient. MAC is only administered by trained anesthesia personnel, capable of transitioning to general anesthesia should the patient lose their airway reflexes as the sedation deepens. Anesthesia personnel are responsible for administration of anesthetic agents, hemodynamic stability, and airway management. Conscious sedation may be supervised by the proceduralist.

Dexmedetomidine is an α-2-adrenergic receptor agonist that is often used as part of a MAC and can be an adjunct to a TIVA to reduce anesthetic and analgesic requirements under general anesthesia. There are many benefits to giving dexmedetomidine as an adjunct for anesthesia, as it has analgesic properties and is not associated with significant respiratory depression. Dexmedetomidine may also be used as the main anesthetic in high doses in a general anesthetic, particularly in airway cases where preservation of respiration is desired.⁵ Moore et al highlighted the desirable properties of dexmedetomidine in predictable blood pressure reduction combined with opioid and anxiolytic sparing when used as part of a TIVA.² The description of TIVA in this paper is very confusing. Moore et al define TIVA as “general anesthesia via deep sedation”; those are two separate terms. TIVA refers to a type of general anesthesia, and deep sedation is more of a type of analgesia where patients can be aroused, independent ventilatory function may be impaired, and cardiovascular function is usually maintained. What they refer to as a “TIVA,” appears to be a description of deep sedation with MAC, which is “a specific anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure.” ³ MAC is indicated when the need for sedation is deeper than that needed for moderate sedation. The statement by Moore et al that 43 cases required conversion from TIVA to general endotracheal anesthesia is confusing because TIVA is a form of general anesthesia. It would be more accurate to say that 43 cases were converted from deep sedation under MAC to TIVA, requiring endotracheal intubation. Clarification of these terms is important for communication as the differences are significant in terms of control of the airway. It is also not clear whether the conversion to a general anesthetic utilized an LMA or endotracheal intubation. The use of dexmedetomidine in the paper is described as the ideal anesthetic agent with no comparison data referenced. It would have been helpful to see data on hemodynamics and side effects in the anesthetics administered in the years prior to the use of dexmedetomidine. This paper does make excellent points about the benefits of dexmedetomidine as an integral part of the overall anesthetic, as an adjunct to propofol, and the potential reduction of intra- and postoperative adverse events.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

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