General Anesthesia versus Twilight Sedation

Bonnie had Dr Sauceda.  I'm going down to Dr Sauceda next month, well less than 3 weeks from now.  I'm having the LBL, small upper thigh lift, BL, and my arms done.  Come check out his group here.  Dr Sauceda

"I had twilight too.   Never General again.   I was out 13 hours, lots of work done, woke up like from a nap." 

That is absolutely an unsafe practice, and most reputable surgeons would not perform a 13 hour elective surgery, much less one under IV sedation for that length of time. Patient safety for long procedures (particularly body contouring on weight loss patients) has been a big focus of research on outcomes. It is very clear that complication rates start to increase as you go past 6-7 hours. Most of the time (in the united states at least) ,a surgeon who exclusively performs IV sedation is operating out of a non-acredited office O.R. suite, cannot get insurance coverage for general anesthesia in their office,  or does not want to invest in sophisticated and expensive equipment. While there are strong proponnents of IV sedation (usually versed/ketamine due to cost) for nearly all cosmetic cases, most anesthesiologists/CNRA's get uncomfortable with the monitioring of it for more complex and prolonged cases

IV sedation is fine for shorter cases like a breast augmentation/lift or a facelift. It is more problematic for bigger body contouring cases as the level of sedation and relaxation required essentially produce a general anesthetia without a secure airway. It requires a lot of drugs and high doses of local anesthesia to work well. As you get into prolonged cases, the dosing for this gets problematic as there is an addative effect of many anesthetics and you can get near toxic levels of local anesthetics on bigger cases, particularly when liposuction is involved.

Dude I'm so sick of you and your negative post. You are a major ___hole.

Please give links to the studies that you are referring to so that we can judge for ourselves what the results suggest.  I am extremely interested in the study that suggests that a surgeon who uses twilight sedation with epidural is not reputable. Also, the study looking at procedures beyond the 6-7 hour point, is that with IV sedation or twilight?

Cathy,

Here are a few studies...note the time frame of under 2 hours in the second study for all cases and in Dr Bitar's study of 4778 patients, the mean operation time for twilight was 111 minutes.

http://www.ncbi.nlm.nih.gov/pubmed/14578803

http://www.ncbi.nlm.nih.gov/pubmed/10513915

http://www.ncbi.nlm.nih.gov/pubmed/12496575


Here's the real kicker on all this, folks. 

Why are you asking Dr. Oliver for articles  ? 

Who is your advocate as a patient ?  Your knowledegable expert ?

Who is looking out for you as you embark upon plastic surgery ? 

Do you have to delve into the scientific literature to find out what's safe ?

Can you be assured of what ANY doctor in ANY country says about a facility that he personally owns and profits from ? 

You need a bulldog, and  an advocate that is charged with ensuring pateint safety.  Period.

A non-profit agency that goes hands-on to these facilities and inspects them physically and their records and their practices and their complications.  One that reviews all infection control reports and sorts out their causes. An agency that strikes fear into the facilities because if they are not up to par, they will not be accredited. 

Everything else is just people talking. And posting.

They are the experts, and are there to protect you, the patient

"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."

http://www.jointcommission.org/about_us/about_the_joint_comm ission_main.aspx

It's not just a pice of paper on the wall. 

And you need a bulldog in your corner.

A legal system to protect you.  Yes I said it.  I am a doctor and I say that we need trial lawyers and personal injury attorneys because that in it's own way serves it's function to protect patients.  Fear of a lawsuit changes behavior.

My point is that "do it yourself" is fine for the Home Depot, but if you seek medical care outside of the regulations and without a legal system to protect you, you may find yourself doing your "research" and getting your "facts" on internet message boards.

Thank you Dr. L for the links.

Why are you asking Dr. Oliver for articles  ? 
I asked for links to articles to support this statement he made
"That is absolutely an unsafe practice, and most reputable surgeons would not perform a 13 hour elective surgery, much less one under IV sedation for that length of time."

Who is your advocate as a patient ?  Your knowledegable expert ?
I am my own advocate who seeks out knowledegable experts to assist me in making my decisions. I do not blindly allow others to make decisions about my health care, I arm myself with as much knowledge as I can find.

Who is looking out for you as you embark upon plastic surgery ? 
Those that I have chosen to assist me in my decisions.

Do you have to delve into the scientific literature to find out what's safe ?
I delve into the scientific literature so that I am aware of all risks and benefits of my health care choices. I never try a new medication or consider a procedure without having check into the literature.

Can you be assured of what ANY doctor in ANY country says about a facility that he personally owns and profits from ? 
No, but do not doctors profit from all procedures whether they are performed in a non-profit or clinic?

You need a bulldog, and  an advocate that is charged with ensuring patient safety.  Period.
Sorry, but I work in a hospital. Joint commission accreditation is great and has resulted in higher safety standards and better practices, but it is no guarantee that you will receive better care than at an non accredited facility.

A non-profit agency that goes hands-on to these facilities and inspects them physically and their records and their practices and their complications.  One that reviews all infection control reports and sorts out their causes. An agency that strikes fear into the facilities because if they are not up to par, they will not be accredited. 

Everything else is just people talking. And posting.

They are the experts, and are there to protect you, the patient

"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."

http://www.jointcommission.org/about_us/about_the_joint_comm ission_main.aspx

It's not just a pice of paper on the wall. 

And you need a bulldog in your corner.

A legal system to protect you.  Yes I said it.  I am a doctor and I say that we need trial lawyers and personal injury attorneys because that in it's own way serves it's function to protect patients.  Fear of a lawsuit changes behavior.
I knew going out of the country for medical procedures that I would not be able to sue my doctor.

My point is that "do it yourself" is fine for the Home Depot, but if you seek medical care outside of the regulations and without a legal system to protect you, you may find yourself doing your "research" and getting your "facts" on internet message boards.
I consider this Internet message board as "one" place to research my choice of surgeon. Just as I would seek out former patients of a surgeon here in the states to hear of their satisfaction and results. This message board is a place for information and support with individuals who have similar experiences.
There are some who come on these boards and do not appear to have done much research or seem to care about finding out more about their procedures or surgeons. But, I find it insulting that you assume that we are all just basing our choices on what we find on this message board.

Thank you Dr. L for the links.
Good points and some I'd like to respond to...

Why are you asking Dr. Oliver for articles  ? 
I asked for links to articles to support this statement he made
"That is absolutely an unsafe practice, and most reputable surgeons would not perform a 13 hour elective surgery, much less one under IV sedation for that length of time."

I kind of meant that as a rhetoric question.  But my concern is simply that not all people can honestly be expected to go through the hundreds of scientific articles out there and then attend a meeting to put them in perspective, and then gain a real understanding of the topic. 

Curious as to any readers take on the references I provided re: time in surgery under twilight.

Who is your advocate as a patient ?  Your knowledegable expert ?
I am my own advocate who seeks out knowledegable experts to assist me in making my decisions. I do not blindly allow others to make decisions about my health care, I arm myself with as much knowledge as I can find.

Thats great.  My hope is we can share links and resources to your non-biased experts here on the boards.  Patients are inherently biased when it comes to their doctor (good or bad).  I am biased because of what I have seen in my practice and my review of bad outcomes via the legal system.

Who is looking out for you as you embark upon plastic surgery ? 
Those that I have chosen to assist me in my decisions.

Do you have to delve into the scientific literature to find out what's safe ?
I delve into the scientific literature so that I am aware of all risks and benefits of my health care choices. I never try a new medication or consider a procedure without having check into the literature.

Thats great. Again, more a rhetorical question but glad you have a "trust no-one" approach.
Recommend "The Wrong Right Stuff" http://www.slate.com/blogs/blogs/thewrongstuff/archive/2010/ 06/28/risky-business-james-bagian-nasa-astronaut-turned-pati ent-safety-expert-on-being-wrong.aspx

Can you be assured of what ANY doctor in ANY country says about a facility that he personally owns and profits from ? 
No, but do not doctors profit from all procedures whether they are performed in a non-profit or clinic?

Clinic ownership by the operating doctor is a huge conflict of interest in my very, very unpopular opinion.  The overhead is high and if a doctor doesn't use his center (that he equips and staffs) he loses money.  Doctors can't own pharmacies, rehab clinics, or anthing else they refer their own patients to. Surgery clinics are the exception.  Accreditation is the only way to ensure that patients are being properly selected and that standards are being met..

You need a bulldog, and  an advocate that is charged with ensuring patient safety.  Period.
Sorry, but I work in a hospital. Joint commission accreditation is great and has resulted in higher safety standards and better practices, but it is no guarantee that you will receive better care than at an non accredited facility.

It's not a guarantee (nothing in medicine is) but I agree with you that accreditation significantly raises your odds of receiving better care.  Completely disagree that non-accredited facilities are just as safe and have equal outcomes...but we will never know, will we?  They are off the radar and don't have to report anything.  Thats kind of my whole point.

A non-profit agency that goes hands-on to these facilities and inspects them physically and their records and their practices and their complications.  One that reviews all infection control reports and sorts out their causes. An agency that strikes fear into the facilities because if they are not up to par, they will not be accredited. 

Everything else is just people talking. And posting.

They are the experts, and are there to protect you, the patient

"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value."

http://www.jointcommission.org/about_us/about_the_joint_comm ission_main.aspx

It's not just a pice of paper on the wall. 

And you need a bulldog in your corner.

A legal system to protect you.  Yes I said it.  I am a doctor and I say that we need trial lawyers and personal injury attorneys because that in it's own way serves it's function to protect patients.  Fear of a lawsuit changes behavior.
I knew going out of the country for medical procedures that I would not be able to sue my doctor.

I was thinking deterrence.  I feel that patients who can seek legal proetction are, well, more protected and "go in" with a stronger hand.

My point is that "do it yourself" is fine for the Home Depot, but if you seek medical care outside of the regulations and without a legal system to protect you, you may find yourself doing your "research" and getting your "facts" on internet message boards.
I consider this Internet message board as "one" place to research my choice of surgeon. Just as I would seek out former patients of a surgeon here in the states to hear of their satisfaction and results. This message board is a place for information and support with individuals who have similar experiences.

Agreed. Lets see more informational  links.

There are some who come on these boards and do not appear to have done much research or seem to care about finding out more about their procedures or surgeons. But, I find it insulting that you assume that we are all just basing our choices on what we find on this message board.
 
I certainly don't assume that you  "are all just basing our choices on what we find on this message board."   My posts here since 2003 almost always include outside links to encourage expanded research. I hope and believe that people follow those links.

What is your deal Dr. Oliver????  You never respond to any other post on here except if it is about Dr. S. At LEAST Dr. L answers a FEW more questions. Dr. S is an amazing surgeon.

Doing twilight well is more of a challenge than general anesthesia, especially for longer procedures. 

Twilight has developed somewhat of an unfair reputation thanks to the horrible experiences that have made the rounds on TV where patients were aware of what was going on or may felt things during their surgery.

So you are saying if someone is doing twilight all the time, and have been very successful in some very long surgeries, then they must be doing it well?
I guess what irks me is when I post about Mexico, American surgeons usually say how unsafe it is.   Not this time though Dr L.   If Dr. Sauceda has done hundreds, maybe thousands, of patients, who are all very happy with results, and he uses twilight and it works.. then what's the issue?  He provides an experience that is also very very safe.   Patients have never run into trouble as we are driven back and forth by paid drivers.

Bonnie