Propofol ketamine anesthesia for cosmetic surgery in the office suite.

Abstract

Before 1968, the operating room did not exist outside the four walls of the hospital for most anesthesiologists. The first free-standing ambulatory surgicenter (ASC) was created in Phoenix, Arizona, in 1968. This initiated an era in which operating rooms were no longer confined to the hospital setting. In the mid-1980s, the Society for Ambulatory Anesthesia (SAMBA) was formed as a result of the ASC movement. In the past two decades, this society has grown, and it is estimated that more than 60% of all surgery in the United States is currently done on an outpatient basis. However, not all outpatient facilities are of equal caliber. Although office practitioners such as Ralph M. Waters, MD, operated the Downtown Clinic in Sioux City, Iowa, in 1919, the modern era of office-based anesthesia for cosmetic surgery is considered to have begun in the mid-1970s. One of the pioneers of this enterprise was Charles A. Vinnik, MD, a Las Vegas plastic surgeon. Unable to secure dedicated professional anesthesia services, Vinnik developed the “diazepam/ketamine” technique, which eliminated the hallucinatory side effects of ketamine by preceding the dissociative dose of ketamine with hypnotic doses of incremental diazepam. Diazepam/ketamine is a nontriggering technique that eliminated the need for either an anesthesia machine or dantrolene to treat the rare syndrome of malignant hyperthermia. A recent American Society of Anesthesiologists’ (ASA) publication validated the nontriggering approach for office anesthesia as safe without an anesthesia machine. While manufacturers continue to shrink the size of anesthesia machines, interoffice transport and scavenging requirements impose added burdens to the office anesthesiologist. Aside from these issues, it is difficult for me to justify any risk of malignant hyperthermia in a patient population having surgery without medical indication (i.e., elective cosmetic surgery). Vinnik’s breakthrough discovery was published in the plastic surgery literature, where it lay unnoticed and unappreciated by the anesthesia community for over a decade. In December 1991, I attended a lecture by