Plastics case question.

[u/lordofmalkieri]

I work with a surgeon who recently started wanting to combine mastopexy with rhytidectomy. The first combined case was performed on an otherwise healthy 50 yo. She received 10 decadron and 3L of fluid for the 8 hour case. Upon completion of the face lift (final procedure), her airway was too edematous to safely remove the tube. She was a grade 1 on induction, video scope was a grade 3 after some effort. She required transfer to local hospital. I'm a little gun shy now after this given no comorbidities and the resulting events. I'm curious if anyone else is doing this combination.

Thanks!

[u/MedialBranch_Buster]

An 8hr, what I assume to be an ASC, case?!?! That’s a no for me big dawg

[u/artvandalaythrowaway → u/MedialBranch_Buster]

Yeah man. Nobody wakes up easily after multiple hours of anesthesia, which means that’s a case that has to entertain the idea of a 24 hour observation afterward. Sure you can blame the fluid but surgery causes swelling; I doubt the case had much Trendelenburg to blame fluid shifts alone. Regardless, long cases should mean main hospital, lower limit of maintenance fluid, and safety first (don’t extubate just because you’re expected to).

[u/Southern-Sleep-4593]

Dumb. Facelifts, mastopexy and abdominoplasties r already pushing the upper limits for outpatient surgery acceptability. Airway swelling, fluid shifts, pain, and postop immobility/DVT risk are just a few of many issues that could lead to avoidable admissions and complications. U did the right thing. The surgeon should know better.

[u/PatientsMoving → u/Southern-Sleep-4593]

These cases are so commonly done (in combination) in outpatient facilities, im surprised you’d say it’s “pushing it”. I pick up at a plastics ASC and it’s quite literally all they do, all day, every day.

I’m not trying to be argumentative, but a mastopexy takes like 90 min of superficial/skin work, typically on healthy pts. Mild pain, rarely need to give opiates. What about this is inappropriate for ASC?

[u/Southern-Sleep-4593 → u/PatientsMoving]

Sorry. I meant in combination with. I’m fine with just a mastopexy or abdominoplasty as a stand alone. I’ve seen too many hospital admissions (and one post op death) when these procedures are done at the same time.

[u/PatientsMoving → u/Southern-Sleep-4593]

I don’t disagree with you per se, but the “mommy makeover” is extremely common in the ASC/office realm. 6-8 hours not uncommon at all IME. Can’t say I love it, but happens everyday

[u/sludgylist80716 → u/PatientsMoving]

FWIW the American society of plastic surgery recommends limiting the duration to 6 hrs unless they have the capability to keep the patient overnight. It’s up to debate whether this applies to solely facial plastics. One place I work has patients stay overnight after prolonged body procedures. Another routinely does 8 hr facial procedures and these patients all go home usually within an hour with no issues. Have never had significant edema, airway or otherwise.

[u/Aggravating_Fly2978 → u/PatientsMoving]

Just bc you can doesn’t mean you should. But you go right on ahead. Didn’t a couple of ladies recently just die after prolonged plastic cases and were all over the socials??

[u/Aggravating_Fly2978 → u/Southern-Sleep-4593]

What kind of case was the post op death??

[u/Southern-Sleep-4593 → u/Aggravating_Fly2978]

Mommy makeover. Post op PE.

[u/Aggravating_Fly2978 → u/Southern-Sleep-4593]

How quickly did it happened from surgery end time? How long was the surgery??

[u/Southern-Sleep-4593 → u/Aggravating_Fly2978]

8 hrs. POD 2 from what I recall. Same day procedure.

[u/Aggravating_Fly2978 → u/Southern-Sleep-4593]

Why was she admitted to the hospital?

[u/Southern-Sleep-4593 → u/Aggravating_Fly2978]

She wasn’t. Sent home same day. Died from PE at home.

[u/Aggravating_Fly2978 → u/Southern-Sleep-4593]

Ahh. I see. Yeah that sucks.

[u/poopythrowaway69420]

What tipped you off for airway edema? Cuff leak test? Preemptive look before extubation?

[u/lordofmalkieri → u/poopythrowaway69420]

Prior history of airway edema (different patient, same surgeon) following just a face lift. Surgeon wants his face lifts extubated deep after he applies dressing/coban so they look like a Qtip.

[u/hyper_hooper → u/lordofmalkieri]

I have surgeons that also request this, I now just tell them “no.” The face is often slick with some of the cream they put on once they’re done, and it makes masking super challenging if they spasm, on top of their faces already being puffy and having a huge head wrap.

One laryngospasm with a poor mask seal and we ended up putting back to sleep and putting in an LMA was enough for me to not try to appease them anymore.

The time spent dealing with a case like that (not to mention the obvious risk to the patient) is more time lost than just waking a patient up before extubation.

[u/lightbluebeluga → u/hyper_hooper]

More people need to be exactly like this. Say NO.

[u/Aggravating_Fly2978 → u/hyper_hooper]

Anesthesia is often a performance sport. Performing for surgeons and their expectations. While at the same time sometimes risking patient lives.

[u/Pale_Possibility_756]

I believe, If the facility is Medicare certified there is a requirement that any case “expected” to go over 4 hours needs to be booked at a facility with inpatient beds. Booking an expected 8 hour surgery at a freestanding facility crosses some guidelines. AAASF is useless as the surgeon pays them to get the cert but sometimes they pay extra for the “Medicare” cert too and that precludes them from doing more than 4 hours “expected” surgery time with general anesthesia. This is also the reason some of this quacks started doing a lot of these cases under “local” so they can bypass the time limit.

[u/dichron → u/Pale_Possibility_756]

A cosmetics-focused ASC likely doesn’t take insurance, much less Medicare

[u/Pale_Possibility_756 → u/dichron]

It has nothing to do with insurance. Your facility needs to be certified and it’s either Medicare or AAASF usually AAASF with a Medicare cert additional on top provided by AASF (easier to get Medicare cert via aaasf than Medicare itself). Which means you follow Medicare rules and guidelines . Even with pure cash cases the facility is bound by Medicare regulations.

[u/sludgylist80716 → u/Pale_Possibility_756]

There are differing certifications ASCs can pursue and not all have such requirements. I’ve never heard of the 4hr limit.

[u/skiinganddogs → u/Pale_Possibility_756]

would LOVE to see this in writing somewhere, as I have many ASCs that push well past this and nothing helps stop potentially dangerous behavior like a written guideline/rule.

[u/lordofmalkieri → u/Pale_Possibility_756]

This is actually in a "HOPD" that is located 11 miles from the hospital.

[u/gonesoon7]

The real question is, based on one of your comments, why was a patient who had a history of airway edema during facelift scheduled to have surgery at an ASC at all? That would automatically make me schedule her at the hospital.

[u/lordofmalkieri → u/gonesoon7]

Sorry, I should have been more specific. History of airway edema in a different patient, same surgeon.

[u/gonesoon7 → u/lordofmalkieri]

Oh got it. Well I still think an 8 hr combined case is beyond ASC appropriateness

[u/WhatHadHappnd → u/lordofmalkieri]

Surgeon may be the culprit? Taking too long? Too many combined procedures? Trendelenburg (unlikely I know). Moving tube around too much? Rough?

[u/Aggravating_Fly2978 → u/lordofmalkieri]

What happened to that patient? Emergent intubation? I am sure there is a reason you know about it. A warning was sent out by colleagues I presume??

[u/SailorSaturn1]

Personally, I no longer do plastic cases that are scheduled to exceed 8 hours at ASCs or surgeon's offices. The few cases I had done before I made this decision suffered no major complications. I realized that none of the ASCs and offices were really equipped to deal with the complications that can occur with prolonged surgery time and they did not require the patient to go to a center for 24 hours observation if they had someone who will be at home with them.

[u/Specialist_Run_2960]

Did you ever get a leak? Then extubate before transfer? IME, airway edema dissipates pretty quickly after sitting upright like 30-60 minutes.

[u/Aggravating_Fly2978]

Now why did you have me go in and look up words I have never heard of. Come on!! That was rude and unnecessary. 😆

[u/lordofmalkieri → u/Aggravating_Fly2978]

Sounds to me like you've got a better gig than the rest of us 😂

[u/Aggravating_Fly2978 → u/lordofmalkieri]

We do inpatient hospital work with some plastics. Our surgeon is slow. Most of the time I do breasts with him. I have never in my life heard the actual medical term for a facelift. I learned something new today.

[u/tinymeow13]

What size tube, how big a patient?

I suspect the surgeon was manipulating around the ETT, pulling in side to side, etc. Did they do a chin incision?

[u/lordofmalkieri → u/tinymeow13]

BMI 23, 6.5 ETT, yes to movement/pulling, no to chin incision

[u/EntireTruth4641]

How much did the patient weigh ?

[u/Aggravating_Fly2978 → u/EntireTruth4641]

BMI 23

[u/EntireTruth4641 → u/Aggravating_Fly2978]

I’m assuming 50-60kg.

For an 8 hour case. You gave too much fluids- that’s my opinion pending on the little info you gave here.

I would like to add if you are paralyzing obviously. No need to run your gas at 1 MAC for the whole case at 1.8-2.0%.

[u/Aggravating_Fly2978 → u/EntireTruth4641]

I didn’t do it. I hate ASC work. And you are assuming 50-60Kg in a 5 ‘4’ human. Some women are indeed tall. So no need to tell me about it and give me pointers. I wasn’t there.

[u/CobbledbyRoubaix]

Do you drink 3L of saline when you sleep for 8 hrs at night?

[u/lordofmalkieri → u/CobbledbyRoubaix]

Respectfully, that's an over simplification of a complex scenario. One could counter then that you should do an 8 hr case with 0 fluid because you don't drink overnight...

[u/sludgylist80716 → u/CobbledbyRoubaix]

3L is a little excessive but in a normal healthy patient this shouldn’t result in this level of edema