Anesthesia; Epidural w/ twilight vs. General anesthesia

I noticed that Dr. Sauceda uses epidurals with verset or a similar sedative. The surgery is a secondary concern to me do to VERY bad nausea from general anesthesia. Is it common for U.S. Surgeons to do epidurals if requested. Is there a down side to this. Any thoughts would be greatly appreciated. I'm scheduled for LBL & med. thigh (crescent cut) rated @ Apx. 7 hrs. O. R. time.

I too have an awful time with nausea & vomiting after general anesthesia, that is one of the reasons that I have chosen Dr S. I did have a surgery last year that I made them use the epidural w/ sedative vs the general, and was much happier and I had a much easier recovery. I have a friend who went to Dr S and said as much as he loved Dr S and as skilled as he was Mrs S ( the anesthesiolgist)was even more skilled. I am sold on the epidural.

Thanks for your post Were you aware of any of your surgery?Do you have to remain flat for a period of time post op. ?

I was not aware of any of it, and I did not have to lie flat after waking up. It was day surgery and I was able to leave about 2 hours sooner then I would have if I had, had general.
Like someone else said, no groggy hungover feeling which is amazing.

Bethany

I've had 3 surgeries with Dr. S and they have lasted between 7 hours for my face and 12 hours for my LBL. I have Malignant Hyperthermia so general anesthesia is something I try to avoid if at all possible. Dr. S using epidural was a great benefit for me. Mrs. S gets the cath in without even one tinge of discomfort and you sleep the entire surgery. The first time, in 2009, I did wake twice, but it's like waking from a sleep state, no pain - I asked what he was doing and he said, "finishing your arms" and then I went back to sleep. Women have epidurals everyday in this country for c/sections and they remain awake the entire time - they feel no pain.

I loved coming out of the epidural state. No hangover or grogginess. No nausea or vomiting.

As far as laying flat the entire time for you surgery - that depends on what procedure you're having. (I see you asked about laying flat during the post-op period, sorry, I thought you asked about during operation. After surgery, I was taken to the PACU and I was on a monitor and monitored by my nurse. I didn't have to remain flat during this time, when I woke up and was stable, they took me to my room.)

Just want to add that Dr. Sauceda's wife (the anesthesiologist) is Dr. Moreno.

Dr. Moreno is excellent indeed, as is her bedside manner!

Thx for all the helpful posts. I wonder why more U. S. Plastic Surgeons do not offer epidurals?

I believe its called High Risk of Spinal injury.. I personally had to have an emergency C section and did not do well with the epidural.. no offense to the fans of epidurals out there.. but I want to be out and nothing in my back thanks.. I still experienced vomiting and nausea after the epidural. I want  be put out..

Michelle

I'll share my approach, which has been in place for 10 years in my practice and was developed by an MD anesthesia team who also service several of Houston's busiest and most established plastic surgery practices (both facial and breast/body surgeons.)

First, you have to realize that one protocol or anesthesia technique is never used for all patients.  A history is taken, records reviewed, and a custom plan is developed especially for patients with prior issues with postop nausea and vomiting (PONV)

Nausea and vomiting: not acceptable, period.  Esp. amongst our facial plastic surgeons. So patients are premediated with Decadron, Zofran, and sometimes Scopolamine depending on their history.  Re-dosing is done in recovery if needed and standing orders for the chosen medications are available so nurses can treat on the spot.  Avoiding pills during he first 12 hours is important too,  so a narcotic pump, numbing medicine pump, and oral dissolving fast-acting Zofran tabs are a big help here.

Continuity of pain control:  for short cases where I want the patient to go home, we of course will use twilight or a short acting anesthetic.  Spinals are fine but spinal headache and other issues preclude me from including them in my toolbox.   Larger cases like TT and LBL, where patients are required to rest and not move much the first 24 hours are different.  What's wrong with leaving some narcotics on board after a big operation esp. if the patient will be monitored closely ?  For this reason I don't like to "switch gears" and start new or unproven pain control after surgery...rather just keep the numbing pump running, narcotics as needed, and pills when awake.

Deeper anesthesia with a slow emergence (awakening) is the best way to minimize pain in my experience.  No need for patients to awaken too quickly after bigger cases.

We monitor narcotic use during surgery, and patients *****quire more medication may be given a long acting numbing medication (ropivicaine) directly into the surgical sites to control pain.  A pain pump system (like On-Q) is also started before emergence.  because

Anxiety management Patients waking up from anesthesia after surgery who are unaware they have pain have better recoveries with less narcotic usage.  It's partially a mental trick but it works, especially when combined with Valium the night before surgery.  Anxiety before and after are a huge part of pain severity, so why not treat it as needed ?

Twilight  (a.k.a. conscious sedation) is generally used for smaller cases like colonoscopy, not suitable for longer cases.  By definition, the patient can respond to physical stimuli and still follow commands.  I think the term gets over-used.  I cant image a patient aware of what we're doing during TT and LBL !  Also,  ever since the TV show aired about patients who were aware or feeling things during their surgery, patients have been more hesitatnt about "twilight.". 

Anyway, long answers but hope it helps.

Always enjoy your replies to board, I've always read them since you have been on here. I don't think I was told  1/10 of this info by my surgeon in all of my visits. If I was anywhere in texas and knew of you I definately would have came to you for a consult if I was anywhere near texas.

Appreciate your contributions to this message board.

Bubba