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Office-based anesthesia: dispelling common myths

Aesthetic Surgery Journal Office-Based Anesthesia: Dispelling Common Myths
Aesthetic Surgery Journal The online version of this article can be found at: can be found at:
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Office-Based Anesthesia: Dispelling Common Myths Douglas R. Blake, MD
Background: Running parallel with—and perhaps driven by—the huge increase in demand for cosmetic sur-gery, office-based anesthesia (OBA) is the fastest growing segment of anesthesia practice. Despite this, only2% of anesthesiology residencies provide exposure to OBA, and many practicing anesthesiologists are notconvinced that OBA techniques provide safe, reliable, and effective anesthesia care.
Objective: To examine OBA techniques and safety records while addressing some of the commonly heldbeliefs among anesthesiologists regarding OBA.
Methods: A review of 4800 patients undergoing 5264 cosmetic surgical procedures performed between 1997and 2007 at Dudley Street Operatory (licensed in Rhode Island as a Physician Office Setting Providing SurgicalTreatment and certified by the American Association for Accreditation of Ambulatory Surgery Facilities) wasconducted. The primary anesthetic technique was deep sedation with a propofol ketamine infusion, combinedwith local anesthetic injection. Intercostal nerve blocks were performed before surgery in patients who hadbreast surgery and/or abdominoplasty. Endotracheal or laryngeal mask airway techniques were not used, norwere paralyzing agents, anesthetic gases, or vapors.
Results: There were 16 unanticipated postoperative admissions in 10 years, all but 3 from surgical complica-tions (hematoma, infection, and pneumothorax during dissection for breast implants). One patient had an acutereaction to a small volume of local anesthetic injected into the nasal septum, one patient with a history of panicattacks had an acute anxiety attack manifested as chest pain, and one patient refused discharge from the oper-atory to home after a face lift, despite meeting postanesthesia care unit discharge criteria, and was admittedovernight to the hospital. There were no hospital admissions because of pain, nausea, or excessive sedation.
Conclusions: In experienced hands, OBA techniques deliver an anesthetic for office-based cosmetic surgerysuperior to the usual general anesthesia performed in hospitals and ambulatory surgical centers. These tech-niques are safe, do not require expensive equipment other than an infusion pump and vital signs monitor,avoid sore throats and nausea, provide postoperative analgesia, and are well received by patients and sur-geons. OBA presents an opportunity for anesthesiologists and aesthetic surgeons to partner for greater patientsatisfaction. (Aesthetic Surg J 2008;28:564–570.) As the next step in off-site (ie, out of hospital oper- typical residency. A recent survey2found that only 16% ating room) anesthesia care, office-based anesthe- of academic anesthesiology programs provide OBA serv- sia (OBA) is the fastest growing segment of ices in the community, and only 2% expose their resi- anesthesia practice. This phenomenon has paralleled dents to these services. No wonder, then, that many and was certainly driven by the huge increase in anesthesiologists in private practice respond to the demand for cosmetic surgery over the last 10 years.
request for anesthesia services in the office operatory Current estimates of 10 million procedures per year per- with refusal, reluctance, or a demand for an operating formed out of hospitals and ambulatory surgical centers facility equipped and staffed identically to the familiar (ASCs) should command the attention of anesthesiolo- hospital/ASC operating room suite. However, anesthesi- gists, whether in academia or clinical practice.1 Despite ologists that work in offices rather than hospitals have the demand for anesthesiology expertise in this area, accepted the challenge of finding new ways to provide however, almost no training in OBA is available in the adequate anesthesia/sedation for a wide variety of surgi-cal procedures (especially cosmetic) without the use ofinvasive airway devices, paralysis, anesthetic vapors, or Dr. Blake is Assistant Clinical Professor of Surgery gases. In doing so, they offer distinct advantages to their (Anesthesiology), Warren Alpert Medical School, BrownUniversity, Providence, RI.
patients and surgical colleagues with an anesthetic expe- 564 • Volume 28 • Number 5 • September/October 2008 Aesthetic Surgery Journal Table 1. Cosmetic surgical procedures performed in 4800 patients at Dudley Street Operatory between 1997 and 2007
Mammaplasty (augmentation, mastopexy, implant exchange, revision, etc) Abdomino-mammaplasty (combined procedure) Facial rejuvenation (rhytidectomy, brow lift, blepharoplasty, liposculpture, etc) Lipoplasty (primary procedure) Lipoplasty (additional procedure) Soft tissue reconstruction: Face (Mohs', scar revision, lesion excision) Soft tissue reconstruction: Body (brachioplasty, scar revision, etc) Total no. of procedures rience superior to that resulting from typical hospital/ fentanyl, or ketamine were given as indicated (patient ASC general anesthesia.
movement, local anesthetic injection). Most patientsreceived prophylactic antiemetics—combinations of dex- amethasone, metaclopramide, droperidol, ondansetron, Between 1997 and 2007, 5264 cosmetic surgical proce- and dolasetron. Intraoperative blood pressure was con- dures were performed on 4800 patients at the Dudley trolled when necessary with labetalol, metoprolol, propra- Street Operatory, which is licensed in the state of Rhode nolol, and hydralazine. Oxygen supplementation was Island and certified by the American Association for provided with nasal prongs when feasible; a standard Accreditation of Ambulatory Surgery Facilities (AAAASF) Levin stomach tube threaded through a nasal trumpet or for office-based surgery under local anesthesia and deep oral airway and securely attached to a source of oxygen sedation (Table 1).
was used in facial surgery. The flow rate was no greater The anesthetic technique used was local anesthesia than necessary to maintain adequate saturation.
with propofol ketamine (PK) infusion. For rhinoplasty Total operating room time was frequently 6 to 7.5 and rhytidectomy, surgeons selected and injected local hours for extensive body contouring and facial rejuvena- anesthesia directly into the surgical field (usually lido- tion surgeries. All patients were cooperative and ade- caine and/or bupivicaine with epinephrine 1:100- quately awake after bandaging to assist themselves into 200,000). For abdominoplasty, bilateral posterior a recovery lounge chair. Recovery in the postanesthesia intercostal nerve blocks (ICNB) from T-5 or T-6 through care unit (PACU) continued until the patient was awake, T-12 were performed, using 3 mL/block of a local alert, and sufficiently stable to leave in a wheelchair anesthetic mixture of lidocaine 0.5%/bupivicaine accompanied by a responsible adult; no minimum time 0.125%/epinephrine 1:200,000. Similarly, breast surgery of stay was established. No parenteral narcotics were was performed after bilateral anterior intercostal nerve administered in the PACU; pain was treated as needed blocks from T-3 through T-10. For both abdominoplasty with oxycodone and acetaminophen, 1 to 2 tablets and breast augmentation, additional local anesthetic before discharge.
mixture was diluted with Ringer's lactate and injected asa "field block." The total dose of local anesthetic mix- ture was 100 mL for either abdominoplasty or breast All patients save for 16 had uneventful surgical and augmentation, and 120 to 150 mL when these proce- anesthetic courses. Of those 16 unanticipated hospital dures were combined. Lipoplasty was performed with admissions, 3 patients were admitted for antibiotic treat- the tumescent technique using no more than 6 L of ment of surgical infections and 5 had hematomas or Klein's solution.
bleeding that required intervention. Five patients had After appropriate monitoring, an infusion of propofol pneumothorax; in 4 of these patients, this was immedi- 10 mg/mL plus ketamine 1 mg/mL was begun at a rate of ately apparent during surgical dissection of the chest 50 ␮g/kg/min, following an anxiolytic dose of midazolam wall musculature for breast augmentation, and in 1 2 mg (Versed; Roche Laboratories, Nutley, NJ) and fen- patient this was diagnosed 24 hours postoperatively. One tanyl 25 to 50 ␮m. Bolus administration of PK and keta- patient had an acute reaction, manifested by hypoten- mine 20 to 30 mg was given just before local anesthetic sion, apnea, and bradycardia, to a small volume of local injection so that the patient remained calm and unaware.
anesthetic (lidocaine with epinephrine) injected into the The basal rate of 50 ␮g/kg/min was rarely exceeded; sup- nasal septum during rhinoplasty. Rescue endotracheal plemental boluses of PK and small doses of midazolam, intubation and resuscitation was immediately per- Office-Based Anesthesia: Dispelling Common Myths 28 • Number 5 • September/October 2008 • 565 formed, and the patient was transferred to the hospital al12 reported on adverse incidents in offices and ASCs in where recovery was quick; the patient left the hospital Florida during 2000 to 2002, claiming a tenfold greater the next day without sequelae. One patient with a histo- risk of injury or death if the medical procedure was per- ry of panic attacks complained of chest pain in PACU formed in an office rather than an ASC, leading to a and was admitted to rule out myocardial ischemia; the series of restrictions on office-based surgery in Florida.
episode was later attributed by the patient to "anxiety." The problems with this study were: (1) no actual num- One patient who was expected to go home with a care- ber of cases was used, but rather an estimate of 140,000; taker after a face lift insisted instead on admission to a and (2) an analysis of the adverse incidents revealed that hospital, which was arranged. No patients were admit- of the 182 office "incidents" 17 were deaths, of which ted for treatment of pain, nausea/vomiting, or excessive only 15 patients underwent surgery, and only 5 of these sedation. Nausea of any magnitude was rare (⬍1%) and surgeries were performed in accredited facilities, 3 of vomiting even rarer (⬍0.5%).
which did not use an anesthesiologist. The authors stat-ed "this suggests that their (anesthesiologists) presence may be a factor in more favorable outcomes." A follow- To develop a plan for anesthesia care in the office-based up study in 2006 by Clayman and Seagle13 reported on surgical facility, the anesthesiologist should consider all more than 600,000 office-based operations in Florida available sources of information. As previously noted, from 2000 to 2006; there were 46 deaths, 20 related to training in OBA techniques during residency is rare.
plastic surgery. Nine were delayed deaths, of which 7 However, review articles specific to OBA3 and directed to were caused by thromboembolism. Of the 11 deaths particular techniques useful for cosmetic surgery (PK occurring in the OBPSF, the causes were anaphylaxis, and propofol dexmetatomidine infusion)4,5 are available, bronchospasm, fat embolism (1 each); oversedation with and the recent publication of the first textbook6 devoted inadequate monitoring or illicit drug use interaction (6 to anesthesia for cosmetic surgery is a welcome addi- cases); 2 causes of death were unknown. The authors tion. Yet it appears that even in an environment of evi- concluded that the location in which the procedures dence-based medicine, the experience and eyewitness were performed was not as much a contributing factor accounts of office-based anesthesiologists are valuable; as the regulators had suggested. To these data, I add the notably, such experience often may challenge the con- experience reported at DSO of 16 unanticipated admis- ventional wisdom of anesthesiology training and hospi- sions in 4800 patients over 10 years, an incidence of tal practice. What follows is a discussion of commonly 0.3% without a death.
held beliefs among anesthesiologists proven to be invalid OBA is not unsafe if it is performed in an accredited by those experienced in OBA.
facility by board-certified specialists who are creden-tialed for the same procedures in a hospital, and who Myth: Office-Based Anesthesia is Unsafe
wisely select patients appropriate for office-based care.
Although office-based surgery has been called the "wild, In 1999, the American Society of Anesthesiologists wild west" of health care,7 numerous studies attest to (ASA) House of Delegates adopted "Guidelines for OBA" the safety of surgery and anesthesia performed in and a related "Statement on Qualifications of Anesthesia accredited facilities by specialists practicing within their Care Providers in the Office-Based Setting," which made area of credentialed expertise. In 1997, Morello et al8 clear that ASA standards applicable to care in hospitals reviewed 400,000 cases (over 5 years) performed by sur- and ASCs also applied to OBA.
geons certified by the American Board of Plastic Surgeryin 250 facilities accredited by the AAAASF. There was a Myth: Monitored Anesthesia Care Means "Awake"
0.47% complication rate, which is comparable to free- standing or hospital-based ASCs. In 2001, Hoefflin et al9 To state the obvious, monitored anesthesia care (MAC) is reported 23,000 cases performed under general anesthe- the only kind of care anesthesiologists provide. MAC is a sia in an office-based plastic surgical facility (OBPSF) specific anesthesia service, not a description of a level of without significant anesthetic complications. However, it consciousness or sedation. MAC often includes the should be noted that the 5% incidence of sore throat administration of medications that cause the loss of and postoperative nausea and vomiting (PONV) as a appreciation for noxious stimuli in a continuum of consequence of general anesthesia is unacceptably high degrees of sedation. However, if protective reflexes are for ideal OBA. Bitar et al10 in 2003 reported 4778 consec- lost for an extended period of time (especially airway utive healthy patients undergoing plastic surgery in an reflexes), the line blurs between MAC, deep sedation, OBPSF under sedation and local anesthesia with 2 anes- and general anesthesia. The level of sedation may vary thetic complications: hypothermia with massive (10 L) during a single case, and from case to case. Infusion tumescent lipoplasty and PONV after abdominoplasty.
techniques using propofol, ketamine, and other adju- Also in 2003, Byrd et al11 reported a similar low compli- vants are clearly different from "conscious sedation" and cation rate (0.7%), and no deaths in 5316 consecutive their use should be restricted to qualified anesthesia per- patients undergoing both general and sedation anesthe- sonnel. Skill in achieving variable levels of sedation with sia in an OBPSF. It was therefore shocking when Vila et infusion anesthesia, essential to success in OBA, is not 566 • Volume 28 • Number 5 • September/October 2008 Aesthetic Surgery Journal easily attained in anesthesia residency because of the without an airway." In reply, I would remind them that universal availability of anesthesia machines and inva- all mammals do, in fact, have a natural airway. The OBA sive airway devices in hospitals and ASCs; "put the concept of the natural airway is that it is not "out of con- patient to sleep" means "put in a tube and turn on the trol." Because of its anatomy and physiology, the airway in most patients works well even with patients under The ideal anesthetic for OBA has several essential fea- deep sedation, prone or lateral, and without invasive air- tures. It should be short-acting and fast-emerging way devices (endotracheal tubes/ laryngeal mask air- (SAFE), its delivery not dependent on an anesthesia ways [LMAs]). Intubation of the trachea is not machine and scavenging system, associated with pleas- mandatory to avoid aspiration or improve oxygenation, ant recovery rather than PONV, applicable and effective nor are LMAs needed except in the rare case of soft tis- for a wide variety of surgeries, and economical. In sue upper airway obstruction that cannot be remedied Friedberg's words,4 "The ideal anesthetic technique by simpler means (2 LMA insertions in 4800 patients at would be one that is simple and safe and gives the illu- DSO). Eliminating tracheal intubation—except, of sion of general anesthesia, ie, the patient neither feels course, in an emergency rescue situation—avoids the fol- nor hears the surgery." lowing problems: certain malignant hyperthermia trig- Perhaps it is unfamiliarity with the advantages of gers, difficult intubations, sore throats, accidental infusion anesthesia combined with local anesthesia in disconnects of components of the breathing system,17 the office setting that causes surgeons to conclude that anesthesia depth necessary to maintain the endotracheal "intravenous sedation is now suboptimal for most longer tube, increased risk of aspiration during intubation and and complex surgical procedures under most circum- extubation, postextubation coughing and laryngospasm stances"9 and "general endotracheal anesthesia provides leading to ecchymosis in fresh incisions, and increased superior conditions for the surgeon, patient, and anes- incidence of PONV associated with general anesthesia.
thesiologist,"15 despite 1 in 20 patients suffering PONV Spontaneous ventilation with room air is frequently and sore throat in the reported study. Likewise, there is adequate to maintain oxygenation during sedation.
little to recommend "conscious sedation" as described Although brief periods of oxygen desaturation are toler- by Kryger et al16 in office-based abdominoplasty, in ated without negative consequences in healthy patients, which patients first received up to 50 mg of diazepam hypoxemia and cerebral ischemia may rapidly cause cat- followed by incremental doses of midazolam and fen- astrophic problems. At DSO, oxygen supplementation of tanyl, administered by a nurse with "no specialized inspired air is administered whenever needed, and the anesthesia training" in response to the surgeon's "own need is always anticipated. Nasal prongs are used when- assessment of arousal to verbal stimulation." The experi- ever possible, sometimes aided with oropharyngeal or ence of DSO is that patients want to be asleep, and sur- nasopharyngeal airways (OPA/NPA.) Creative solutions geons want their patients to be asleep, but do not want to airway patency and oxygen supplementation are them to have significant pain, sedation, or postoperative needed for facial surgery.
nausea. They want only qualified anesthesia care Two inexpensive and effective solutions during rhino- providers involved in the administration of anesthesia.
plasty and rhytidectomy are presented (Figures 1 and 2).
For OBA, anesthesiologists must "think outside the A 16 Fr. Levin stomach tube threaded through a Berman box"—in this case, the anesthesia machine—and be able OPA or a No. 7 NPA is attached with a universal adaptor to tell the patient preoperatively, "You won't be getting to an oxygen source. The secure connection should be at conventional general anesthesia: no breathing tubes, a distance from the operative field, not covered by paralyzing drugs, or vapors or gases to breathe. You'll drapes, and available for inspection at any time. The receive intravenous sedation continuously, and after that flow of oxygen is the only factor necessary to maintain begins, you'll get local anesthesia injections to numb the adequate saturation and may be interrupted during elec- surgical field. You won't feel or be aware of those injec- tions, and it is extremely unlikely that you'll remember End-tidal carbon dioxide (ET CO ) monitoring equip- anything at all—certainly nothing unpleasant. The anes- ment is available, but expensive, for spontaneous breath- thesiologist will be with you the entire time, and the lev- ing in an open system if nasal prongs are used; however, el of sedation can be adjusted at any minute to ensure mouth breathing defeats this capability. Commercial that you'll receive just the right amount: not too much devices to measure ET CO in the above described appli- and not too little. After surgery, in recovery, you should cations are not available. Adequacy of ventilation during have very little discomfort, and the chances of any stom- MAC by visual and clinical assessment meets the ASA ach upset are very remote." The ability of the anesthesi- ologist to deliver on these promises to the patient is the An important caveat is offered: spontaneous ventila- standard by which OBA should be judged.
tion is the essential requirement for the success of thissedation technique. Narcotics are the supplemental Myth: Airways Need "Control"
drugs most likely to suppress ventilation, and should Some anesthesiologists derisively refer to the deep seda- therefore be used sparingly if at all. An additional bene- tion technique described above as "general anesthesia fit to limiting narcotics is the reduced risk of PONV.
Office-Based Anesthesia: Dispelling Common Myths 28 • Number 5 • September/October 2008 • 567 ered simultaneously. Once the likelihood of poor emer-gence from anesthesia has been eliminated the advan-tages of ketamine are apparent. The dissociative effectprovides analgesia (particularly for skin [ie, injection oflocal anesthetic]), while maintaining respiratory drive; itblocks the N-methyl D-aspartate receptors in the centralnervous system which may produce preemptive analge-sia. Ketamine is not associated with PONV, has an excel-lent safety profile, and is inexpensive. As used at DSO,50 mg ketamine are added to 50 mL propofol; the PKinfusion is started at 50 ␮g/kg/min and runs continu-ously until an estimated 10 minutes of surgery remains.
Patients are informed preoperatively that they will awak-en in the operating room when the surgery is almostdone. After bandaging, all but a few patients have beenable to stand with assistance and sit in a recovery chair;the occurrence of excitation or hallucinations has notbeen observed in our 10 years of experience. In fact,anesthesiologists see emergence excitation frequentlyafter general anesthesia in hospitals and ASCs, but notas a feature of PK deep sedation for OBA. Anotheradvantage of adding ketamine to the propofol for infu- Figure 1. During a rhinoplasty procedure, a 16 Fr. Levin stomach tube
threaded through a Berman oropharyngeal airway or a No. 7
sion is the reduction, by approximately 50% (20 vs 40 nasopharyngeal airway is attached with a universal adaptor to an oxy- mL/hr), in propofol use for the typical case.19 Myth: Intercostal Nerve Blocks Are Difficult,
Dangerous, and Poorly Tolerated
The intercostal nerves enervate the skin and musculature
of the chest and abdominal wall; a diagram of the der-
matomal distribution of the intercostal nerves clarifies
that blocking these nerves can provide anesthesia from
the infraclavicular region to the pubis, making intercostal
nerve blocks (ICNB) attractive for mammaplasty/
abdominoplasty (Figure 3). No central neuraxial block-
ade (ie, epidural or spinal) is produced, and the tech-
nique of (ICNB) can be mastered rapidly. The reluctance
to apply this regional anesthesia is based on fears of
causing pneumothorax and/or local anesthetic toxicity.
The likelihood of producing pneumothorax when the
block is properly done±contacting the rib with the nee-
dle first, then walking the needle off the inferior edge,
Figure 2. During a rhytidectomy procedure, a nasopharyngeal air-
way/Levin is used.
advancing only 2 to 3 mm to aspirate, and then inject-ing±is minimal. The literature is very vague about the Myth: Ketamine is a Poor Drug for Office-Based
incidence of pneumothorax, but suggests that radi- ographic evidence without signs or symptoms is "well Ketamine is an anesthetic with multiple advantages that below 1%."20 In almost 2800 cases involving ICNB for has a reputation for negative side effects, particularly breast and/or abdominal wall surgery at DSO, most emergence hallucinations. Delirium and excitation were patients received bilateral blocks of 7 to 8 intercostal frequent reactions when ketamine was introduced to nerves per side without evidence of pneumothorax. Of practice in the early 1970s as a complete intravenous the 5 cases of pneumothorax during breast surgery, 4 anesthetic agent and used without other hypnotics or were apparent during dissection, and 1 was diagnosed sedatives. Friedberg18 has long been an advocate of by symptoms and radiograph 24 hours postoperatively using ketamine as an adjuvant to propofol sedation for (cause undetermined, but presumed similar to the oth- cosmetic surgery, stressing the crucial need to first pro- vide hypnosis with another drug before administering With regard to local anesthetic toxicity concerns, ketamine as a dissociative anesthetic. The experience of there is a difference between "rapid absorption" and DSO patients demonstrates that the delirium-sparing "toxic levels." Moore et al21 demonstrated in almost 800 effect is present when propofol and ketamine are deliv- patients that blood levels of bupivicaine were highest 568 • Volume 28 • Number 5 • September/October 2008 Aesthetic Surgery Journal Figure 5. Extensive abdominoplasty with intercostal nerve block and
propofol ketamine sedation.
following bilateral ICNB compared with epidural block,yet toxicity did not occur. Rothstein et al22 measuredbupivicaine levels in children and adolescents followingICNB with bupivicaine 2, 3, and 4 mg/kg and found thatdespite supramaximal recommended doses, no cardio- Figure 3. Dermatomal enervation of intercostal nerves.
vascular or central nervous system toxicity wasobserved. Johnson et al23 demonstrated the risk-reduc-ing effect of adding epinephrine 1:200,000 to the localfor ICNB. The DSO data also support the lack of toxicitywhen performing bilateral ICNB with 100 to 150 mL lido-caine 0.5%/bupivicaine 0.125%/epinephrine 1:200,000.
Because there is no need to seek paresthesias, patients can be sedated with PK after positioning andbefore block; patient acceptance has not been a problem(Figure 4). Because the anesthesia also provides relax-ation of the abdominal musculature, operating condi-tions for abdominoplasty are excellent (Figure 5). Theduration of analgesia is 6 to 12 hours, allowing early andcomfortable discharge from the PACU without parenteralnarcotics, even after extensive truncal modification.
There is nothing proprietary about the formulas or algo-rithms for the anesthesia techniques used at DSO, sum-marized as follows: "SAFE" (short-acting, fastemergence); "TIVA" (total intravenous anesthesia);"PAKI" (propofol and ketamine infusion); "LOPA" (lowopioid, prophylactic antiemetics); "SVOS" (spontaneousventilation, oxygen supplementation); and "ICNB." Inmy opinion, they deliver, in experienced hands, an anes-thetic for office-based cosmetic surgery superior to theusual general anesthesia performed in hospitals andASCs. These techniques are safe, do not require expen-sive equipment (other than an infusion pump and vitalsigns monitor), avoid sore throats and nausea, providepostoperative analgesia, and are well received bypatients and surgeons.
For aesthetic surgeons who want patients to have the best possible experience, anesthetic care that is "better Figure 4. Intercostal nerve block position for posterior blocks.
than in the hospital" is an asset. Aesthetic surgeons, there- Office-Based Anesthesia: Dispelling Common Myths 28 • Number 5 • September/October 2008 • 569 fore, have a real stake in the promotion and practice of 16. Kryger ZB, Fine NA, Mustoe TA. The outcome of abdominoplasty per- OBA. I would recommend welcoming anesthesia residents, formed under conscious sedation: six-year experience in 153 consecu- tive cases. Plast Reconstr Surg 2004;113:1807–1817.
under appropriate supervision, into their operatories and 17. Rose G, Eichhorn J. Wrap delays detection of disconnect. Anesthesia encourage the publication of data regarding the types of Patient Safety Foundation Newsletter (Accessed 8/8/2008 at procedures and anesthetic techniques performed.24 It is imperative, too, that the ASA take measures to provide res- ident training in OBA, understanding that an extensive 18. Friedberg BL. The dissociative effect and preemptive analgesia. In Friedberg BL, ed. Anesthesia and Cosmetic Surgery. New York: skill set is necessary to be successful at OBA. ◗ Cambridge University Press; 2007:39–46.
19. Friedberg BL. Propofol in office-based plastic surgery. Semin Plast Surg 20. New York School of Regional Anesthesia Web site. (Accessed 8/8/2008 I would like to thank my surgical colleagues at DSO (Drs. Lee Edstrom, Patrick K. Sullivan, and Richard J. Zienowicz), who are 21. Moore DC, Mather LE, Bridenbaugh PO, Bridenbaugh LD, Balfour RI, all members of the Department of Plastic Surgery of the Warren Lysons DF, et al. Arterial and venous plasma levels of bupivacaine fol- Alpert Medical School at Brown University. Grateful thanks are lowing epidural and intercostal nerve blocks. Anesthesiology also extended to Barbara Tomasetti, RN, Nurse Manager of DSO and to her wonderful staff. 22. Rothstein P, Arthur GR, Feldman JS, Kopf GS, Covino BG. Bupivacaine for intercostal nerve blocks in children: blood concentrations and phar- macokinetics. Anesth Analg 1986;65:625–632.
23. Johnson M, Mickler T, Arthur R, Rosenberg S, Wilson R, Covino B.
The author has no financial interest in and receives no compensa- Bupivacaine with and without epinephrine for intercostal nerve blocks.
tion from manufacturers of products mentioned in this article. 24. R-Labajo AD. Office-based surgery and anesthesia. Curr Opin 1. Cohen SA. How the ‘Wild West' will be won. Ambulatory Anesthesia Accepted for publication July 24, 2008.
Reprint requests: Douglas Blake, MD, 591 Eddy St., Providence, RI 02903. 2. Dillon J. Want an office based practice? Residency won't train you.
E-mail: dblake139@cox.net. Anesthesiology News 2007;33:04 www.anesthesiologynews.com Copyright 2008 by The American Society for Aesthetic Plastic Surgery, Inc.
3. Hausman LM. Advances in office-based anesthesia. Curr Opin 4. Friedberg BL. Propofol ketamine anesthesia for cosmetic surgery in the office suite. Int Anesthesiol Clin 2003;41:39–50.
5. O'Daniel GT, Shanahan PT. Dexmetatomidine: a new alpha-agonist anesthetic for facial rejuvenation surgery. Aesthetic Surg J 6. Friedberg BL. Anesthesia in Cosmetic Surgery. New York: Cambridge University Press; 2007.
7. Quattrone MS. Is the physician office the wild, wild west of health care? J Ambul Care Manage 2000;23:64–73.
8. Morello DC, Colon GA, Fredericks S, Iverson RE, Singer R. Patient safe- ty in accredited office surgical facilities. Plast Reconstr Surg 9. Hoefflin SM, Bornstein JB, Gordon M. General anesthesia in an office- based surgical facility: a report on more than 23,000 consecutive office- based procedures under general anesthesia with no significant anesthetic complications. Plast Reconstr Surg 2001;107:243–251.
10. Bitar G, Mullis W, Jacobs W, Matthews D, Beasley M, Smith K, et al.
Safety and efficacy of office-based surgery with monitored anesthesia care. Plast Reconstr Surg 2003;111:150–156.
11. Byrd HS, Barton FE, Orenstein HH, Rohrich RJ, Burns AJ, Hobar PC, et al. Safety and efficacy in an accredited outpatient plastic surgery facili- ty: a review of 5316 consecutive cases. Plast Reconstr Surg 12. Vila H Jr, Soto R, Cantor AB, Mackey D. Comparative outcomes analy- sis of procedures performed in physician offices and ambulatory sur- gery centers. Arch Surg 2003;138:991–995.
13. Clayman MA, Seagle BM. Office surgery safety: the myths and truths behind the Florida moratoria—six years of Florida data. Plast Reconstr 14. Lalwani K. Demographics and trends in nonoperating room anesthesia.
Curr Opin Anesthesiol 2006;19:430–435.
15. Waddle J. Discussion of "General anesthesia in an office-based surgical facility: a report on more than 23,000 consecutive office-based proce- dures under general anesthesia with no significant anesthetic complica- tions." Plast Reconstr Surg 2001;107:252–257.
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What are 'good' depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis Eiko I. Fried1, PhD; Sacha Epskamp2; Randolph M. Nesse, MD3; Francis Tuerlinckx1, PhD; Denny 1Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium; 2Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands;

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COMMITTEE ON SOCIAL POLICY OF THE JOGORKU KENESH OF THE KYRGYZ REPUBLIC Special report on the results of monitoring and evaluation of implementation of the Law of the Kyrgyz Republic «On Preventing and Combating Trafficking in Persons» COMMITTEE ON SOCIAL POLICY OF THE JOGORKU KENESH OF THE KYRGYZ REPUBLIC