Reducing the need for intubation in plastic surgery

Many plastic surgery procedures that have traditionally been performed under general endotracheal anesthesia may safely be undertaken using a ketamine-based intravenous sedation technique. General endotracheal anesthesia has many drawbacks, including lack of patient acceptance. Ketamine-based intravenous sedation technique includes the following steps: 1. The patient is placed in a dissociated state using sedative and narcotic agents accompanied by a subanesthetic dose (0.5 mg/kg) of ketamine. 2. A dilute local anesthetic solution (0.25% lidocaine with 1:2,000,000 epinephrine) is infiltrated into the involved tissues to provide anesthesia and hemostasis. 3. The patient is maintained in a tranquil state throughout the procedure by periodic titration of additional doses of sedative and narcotic agents. Advantages of the technique include reducing the need for intubation and its associated hazards, dramatically decreased blood loss due to use of dilute epinephrine solution, reduced recovery time, ability of patients to respond to commands during surgery, avoidance of positioning injuries and increased rapport between patient, surgeon and anesthetist. Disadvantages include respiratory depression and potential for hypoxia. Dissociative intravenous sedation combined with dilute local anesthetic provides a useful addition to the anesthetist's armamentarium.