I appreciate the opportunity to respond to Dr. Ersek’s commentary on the communication by Chang and myself entitled “Flash Fires during Facial Surgery: Recommendations for the Safe Delivery of Oxygen” (Plast. Reconstr. Surg. 119: 1982, 2007). While Dr. Ersek has abandoned the use of supplemental oxygen when performing facial surgery under dissociative anesthesia,1 I respectfully disagree with him. It is Dr. Ersek’s practice not to use supplemental oxygen during his procedures; however, he admits to the occasional need for supplemental oxygen and offers the advice to turn off the electrocautery before turning on the oxygen. I am curious to know how he continues his operations if the patient subsequently requires continuous supplemental oxygen. Does he abandon the operation? Although there are other reports of safe conscious sedation without the use of supplemental oxygen,2 this practice depends on the agents being used. Certainly not all plastic surgeons use Valium and ketamine as Dr. Ersek does. The use of agents that may result in respiratory depression, such as opiates, benzodiazepines, or propofol, is also a common practice in outpatient surgery.3 Respiratory depression rates can be as high as 80 percent in patients sedated with fentanyl and midazolam.4 The combination of propofol and ketamine can also cause respiratory depression, particularly in elderly patients.5 The use of supplemental oxygen to maintain an oxygen saturation level greater than 90 percent is recommended by anesthesiologists who frequently use these agents.6 Furthermore, certification of outpatient surgery centers requires that supplemental oxygen be available6 in the event that it is needed. If supplemental oxygen is then needed, there must be a safe way to administer it. My coauthor and I have devised a simple solution to the potential problem created by the use of supplemental oxygen and electrocautery. While it may be true that one can get away with not using supplemental oxygen, why take the chance? In the end, I think that common sense should prevail.
Lorne Rosenfield, M.D.
Department of Plastic Surgery
University of California, San Francisco
1750 El Camino Real, Suite 405
Burlingame, Calif. 94010
1. Ersek, R. A. Dissociative anesthesia for safety’s sake: Ketamine and diazepam–-A 35-year personal experience. Plast. Reconstr. Surg.
113: 1955, 2003.
2. Hansen, K. V. An outcome study comparing intravenous sedation with midazolam/fentanyl (conscious sedation) versus propofol infusion (deep sedation) for aesthetic surgery. Plast. Reconstr. Surg.
112: 1683, 2003.
3. Bitar, G., Mullis, W., Jacobs, W., et al. Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures. Plast. Reconstr. Surg.
111: 150, 2003.
4. Miner, J. R., Heegaard, W., and Plummer, D. End-tidal carbon dioxide monitoring during procedural sedation. Acad. Emerg. Med.
9: 275, 2002.
5. Friedberg, B. L. Propofol-ketamine technique: Dissociative anesthesia for office surgery (a 5-year review of 1264 cases). Aesthetic Plast. Surg.
23: 70, 1999.
6. Friedberg, B. L. (Ed.) Anesthesia for cosmetic facial surgery. In Anesthesia for Cosmetic Surgery.
New York: Cambridge University Press, 2007.
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