Propofol-Ketamine Technique: Dissociative Anesthesia for Office Surgery (A 5-Year Review of 1264 Cases)

Propofol-ketamine technique is a room air, spontaneous ventilation (RASV), intravenous dissociative anesthetic technique which simulates the operating conditions of general anesthesia without the increased equipment requirements or costs. A total of 2059 procedures were performed on 1264 patients by 38 different surgeons. There were no hospital admissions for postoperative nausea and vomiting (PONV) or uncontrolled pain. All patients were pleased with their anesthetic and no hallucinations were reported. Cost:benefit analysis is presented as well as discussion of dissociative anesthesia being exempt from current California law (AB595).     

Resurfacing of Pitted Facial Acne Scars with a Long-Pulsed Er:YAG Laser

BACKGROUND: Conventional short-pulsed Er:YAG lasers show less effective hemostasis and weak photothermal damage on papillary dermis. Recently, newer long-pulsed Er:YAG laser systems has been developed. OBJECTIVE: To evaluate the clinical and histologic effects of long-pulsed Er:YAG laser resurfacing for pitted facial acne scars. METHODS: Thirty-five patients with pitted facial acne scars were treated with a long-pulsed Er:YAG laser. All patients had Fitzpatrick skin phototypes III-V. A pulsed Er:YAG laser with a 5 mm handpiece at a setting of 7.0-7.5 J/cm2 with a 10-msec pulse duration was used. The laser was fired at 5 Hz, with four to five passes. In 28 patients, the results of laser treatment were evaluated for the degree of clinical improvement, duration of erythema, pigmentary change, and any adverse events at 2 weeks, 1 month, and 3 months. In seven patients, skin biopsy specimens were obtained at the following intervals: immediately, 1 week, 2 weeks, 4 weeks, and 8 weeks postoperatively for histologic examination. RESULTS: The results of long-pulsed Er:YAG laser resurfacing for pitted facial acne scars were excellent in 10 patients (36%), good in 16 patients (57%), and fair in 2 patients (7%). Erythema occurred in all patients after laser treatment and lasted longer than 3 months in 15 patients (54%). Postinflammatory hyperpigmentation occurred in 8 patients (29%). But the pigmentation faded or disappeared within 3 months. One patient (4%) experienced mild hypopigmentation. Pruritic symptoms that required medical intervention occurred in 16 patients (57%). Mild to moderate postoperative acne flare-up occurred in 8 patients (29%). No other adverse effects such as scarring, bacterial infection, or contact dermatitis were observed. CONCLUSION: In conclusion, resurfacing with a long-pulsed Er:YAG laser is a safe and very effective treatment modality for pitted facial acne scars.     

Combination Surgical Lifting with Ablative Laser Skin Resurfacing of Facial Skin: A Retrospective Analysis

BACKGROUND: Cutaneous aging is manifested by rhytides, dyschromias, and skin laxity. Ablative laser skin resurfacing can effectively improve many signs of skin aging; however, the photoaged patient with facial laxity often requires a surgical lifting procedure in order to obtain optimal results. Concerns with delayed or impaired wound healing has led to reluctance to perform both procedures simultaneously. OBJECTIVE: To report the clinical results and side effect profiles after concomitant surgical facial lifting procedures and ablative carbon dioxide or erbium:YAG laser resurfacing in a series of patients. METHODS: A retrospective analysis and chart review was performed in 34 consecutive patients who underwent combination CO(2) or erbium:YAG laser skin resurfacing and surgical lifting procedures, including S-lift rhytidectomy, blepharoplasty, and brow lift. Side effects and complication rates were tabulated. RESULTS: The side effect profile of the combined surgical-laser procedures was similar to that reported after a laser-only procedure. The most common side effect was transient hyperpigmentation which occurred in 20.6% of treated patients. None of the patients experienced delayed reepithelialization, skin necrosis, or prolonged healing times. CONCLUSIONS: Concurrent laser skin resurfacing and surgical lifting of facial skin maximizes aesthetic results without increased incidence of adverse effects. Patients benefit from the consolidation of anesthesia and convalescent times as well as enhanced global clinical outcomes.     

Laser Resurfacing of the Neck with the Erbium:YAG Laser

Background.  Laser resurfacing of the face is widely used to correct the effects of photoaging. The neck also develops a similar degree of photoaging, but is not usually treated because a higher incidence of adverse effects can occur with laser treatment.
Objective.  To present a new method for treating photoaged skin of the neck with an erbium:yttrium aluminum garnet (Er:YAG) laser.
Methods.  Twenty patients underwent Er:YAG laser resurfacing of the neck with one of two methods. Method 1 consisted of using the Er:YAG with a 5-mm diameter collimated beam at a fluence of 8.7 J/cm² followed by a second pass using a 0.2 mm diameter non-collimated spot at 1.7 J in a defocused mode with spot sizes ranging from about 5 to 10 mm in diameter (fluences from 2–9 J/cm²). Method 2 consisted of treating the entire neck with a single pass of the Er:YAG laser with a 4 mm diameter non-collimated spot at 1.7 J (fluence of 13.5 J/cm²). A second pass at identical settings was made on the upper half of the neck with a more defocused pass using a 6–10 mm diameter spot (fluence of 2–6 J/cm²) on the lower half of the neck. Patients were evaluated by two nontreating physicians as to overall satisfaction and improvement in skin texture and color.
Results.  Overall, 51% of patients were satisfied with their results. Skin texture improved an average of 39%. Method 1 produced a 28% improvement, Method 2 a 48% improvement. Skin color improved an average of 37%. Method 1 produced a 28% improvement, Method 2 a 45% improvement.
Conclusion.  Photoaged skin of the neck can be effectively treated with the Er:Yag laser with minimal adverse effects.     

Resurfacing of Pitted Facial Acne Scars Using Er:YAG Laser with Ablation and Coagulation Mode

Although the conventional, short-pulsed erbium: yttrium-aluminum-garnet (Er:YAG) laser provides substantial clinical improvement for pitted, facial acne scars, it shows less effective hemostasis and limited residual thermal effect in the dermis. Recently, dual-mode Er:YAG laser systems with both ablation and coagulation modes have been developed. The purpose of this study was to evaluate the clinical and histologic effects of resurfacing pitted, facial acne scars with a dual-mode Er:YAG laser. Twenty patients with pitted facial acne scars underwent laser resurfacing using a computerized-scanning, dual-mode Er:YAG laser. All patients had Fitzpatrick skin types ranging III–V. Initially, the epidermis was removed in two passes using the ablative settings. This step was followed by two passes in a mixed ablation and coagulation mode, to produce further ablation and controlled, residual thermal damage. A final pass in a ablation mode was used to remove necrotic tissue. Laser overlapping was approximately 30%. The results of laser treatment were evaluated for the degree of clinical improvement, duration of erythema, pigmentary change, and any adverse events at two weeks, one month, and three months. In two patients, skin biopsies were obtained at the following intervals: immediately and two weeks postoperatively for histologic examination. There was a 75% average clinical improvement observed in pitted, facial acne scars after laser treatment. Complete wound healing occurred between six and eight days. On histologic examination, complete re-epithelialization was observed at two weeks. Erythema occurred in all patients after laser treatment and lasted longer than three months in 10 patients (50%). Post-inflammatory hyperpigmentation occurred in 12 patients (60%) two to four weeks after laser treatment and lasted longer than three months in one patient (5%). One patient (5%) experienced mild hypopigmention. Mild to moderate, postoperative acne flare-up occurred in seven patients (35%). No other adverse effects were observed. In conclusion, resurfacing with a dual-mode Er:YAG laser is a safe and effective treatment modality for pitted, facial acne scars.     

The Emerging Role of Laser Resurfacing in Combination with Traditional Aesthetic Facial Plastic Surgery

Traditional aesthetic plastic surgery procedures (facelift, browlift, blepharoplasty, etc.) can make dramatic improvement in the facial appearance by removing excess skin and fat and tightening and repositioning the soft tissues of the face, but make no improvement in the quality of the skin. Laser resurfacing is the safest, most predictable method for improving facial wrinkles and actinic damage. This paper discusses the combination of these techniques in pursuit of optimal rejuvenation of the face.     

保留自主呼吸非插管单孔胸腔镜手术的临床应用

目的探讨保留自主呼吸非插管单孔胸腔镜治疗胸部疾病的可行性及安全性。方法回顾性分析2018-01—2018-10间应用非气管插管保留自主呼吸麻醉下单孔胸腔镜手术治疗的24例胸部疾病患者的临床资料。结果 24例患者在非气管插管保留自主呼吸麻醉下应用单孔胸腔镜行手术治疗,无中转紧急插管或增加辅助切口。其中,自发性气胸20例,肺结核球1例,肺炎性假瘤2例,胸腺瘤1例。手术时间25～60 min,平均35.5 min。失血量10～50 mL,平均20.2 mL。胸腔闭式引流管引流时间1～4 d,平均2.5 d。术后随访5～12个月,无复发及其他并发症。结论非气管插管保留自主呼吸麻醉下单孔胸腔镜手术治疗胸部疾病,简单易行,安全可靠。     

Minimally Ablative Erbium:YAG Laser Resurfacing of Facial Atrophic Acne Scars in Asian Skin: A Pilot Study

BACKGROUND Atrophic scars are dermal depressions caused by collagen damage most commonly occurring after inflammatory acne vulgaris. There are little published data regarding the effectiveness and safety of minimally invasive lasers in the treatment of atrophic acne scars in darker skin types.
OBJECTIVE The purpose was to evaluate the efficacy and safety of a low-fluence 2,940-nm erbium:YAG laser in the treatment of atrophic acne scars in Asian patients.
MATERIALS AND METHODS Nine patients aged 19 to 45 years with mild to moderate atrophic facial scars and Skin Types IV and V were treated with topical anesthesia and one to two passes with an erbium:YAG laser two times at 1-month intervals. Treatment parameters were 6-mm spot size, fluence of 400 mJ, pulse duration of 300 μs, and repetition rate of 2 Hz.
RESULTS At 2 months after the last treatment, mild to moderate clinical improvement was noted in all patients compared to baseline. Treatment was well tolerated. Side effects consisted of posttreatment erythema, peeling, and crusting, which resolved within 1 to 2 weeks. There was no postinflammatory hyper- or hypopigmentation, blistering, or hypertrophic scarring.
CONCLUSION Low-fluence erbium:YAG facial resurfacing was effective and safe in patients with mild to moderately severe atrophic acne scarring.     

Resurfacing of Facial Angiofibromas in Tuberous Sclerosis Patients Using CO2 Laser with Flashscanner

BACKGROUND: Angiofibromas are a common presentation of tuberous sclerosis. They cause considerable cosmetic and hygienic morbidity for patients. Treatments of angiofibromas have included curettage, cryosurgery, chemical peel, dermabrasion, shave excision, and 13-cis retinoic acid. Results from these modalities in many cases were not satisfactory from a cosmetic standpoint. Copper vapor, argon, pulsed dye, and CO2 lasers have been used with success in isolated cases. OBJECTIVE: The purpose of this study was to evaluate the efficacy of CO2 laser resurfacing with flashscanner in the treatment of facial angiofibromas. METHODS: Two patients with angiofibromas on the face were treated with a CO2 laser with flashscanner. The cheek and nose were treated in one patient, and entire face was done in the other. RESULTS: Both patients showed remarkable cosmetic improvements without scarring. Mild hyperpigmentation was found in both patients, which disappeared in 1 month with the application of topical agents. Facial erythema persisted about 2 months in both patients. CONCLUSION: A CO2 laser equipped with flashscanner causes less residual thermal damage than conventional CO2 lasers and enables controlled depth vaporization for more precise and regular removal of angiofibromas. In whole-face resurfacing, more cosmetically acceptable results are possible because localized treatment leaves marginal prominences. Laser resurfacing is an effective alternative in the treatment of multiple protuberant angiofibromas even though we cannot permanently clear these lesions due to their nature.     

Clonidine Premedication Decreases Propofol Consumption During Bispectral Index (BIS) Monitored Propofol-Ketamine Technique for Office-Based Surgery

BACKGROUND: Propofol-ketamine anesthesia is a room air, spontaneous ventilation (RASV), dissociative intravenous (IV) sedation technique reported to have a near-zero postoperative nausea and vomiting (PONV) rate. Clonidine premedication has been reported to control blood pressure intra- and postoperatively, as well as to reduce the requirements for hypnotic agents. The bispectral index (BIS) monitor is a reproducible, objective, observer independent, quantitative measurement of the hypnotic state. OBJECTIVE: This study was designed to compare the propofol consumption rate during BIS monitored propofol-ketamine anesthesia for office-based, elective female facial rhytidectomy in patients with and without clonidine premedication. METHODS: Six patients receiving clonidine (200 microg oral premedication administered 30-60 minutes prior to induction of anesthesia were compared with a recent, historical control group of six patients who received no premedication. A BIS of 60-70 was chosen as the standard of comparison for light hypnotic state. A dilute propofol solution was used to gradually titrate anesthesia to a BIS of 60-70 prior to the administration of ketamine. RESULTS: A statistically significant reduction in propofol consumption was observed in the clonidine premedicated female elective rhytidectomy patients compared with those not receiving the clonidine. Other than modestly increased requirements for IV fluids, there were no adverse effects observed with clonidine premedication.     

The Influence of Ventilation Mode (Spontaneous Ventilation,IPPV and PEEP) on Cardiopulmonary Parameters in Sevoflurane Anaesthetized Dogs

The purpose of this study was to investigate the cardiopulmonary influences of sevoflurane in oxygen at two anaesthetic concentrations (1.5 and 2 MAC) during spontaneous and controlled ventilation in dogs. After premedication with fentanyl–droperidol (5 μg/kg and 0.25 mg/kg intramuscularly) and induction with propofol (6 mg/kg intravenously) six dogs were anaesthetized for 3 h. Three types of ventilation were compared: spontaneous ventilation (SpV), intermittent positive pressure ventilation (IPPV), and positive end expiratory pressure ventilation (PEEP, 5 cm H₂O). Heart rate, haemoglobin oxygen saturation, arterial blood pressures, right atrial and pulmonary arterial pressures, pulmonary capillary wedge pressure and cardiac output were measured. End tidal CO₂%, inspiratory oxygen fraction, respiration rate and tidal volume were recorded using a multi‐gas analyser and a respirometer. Acid–base and blood gas analyses were performed. Cardiac index, stroke volume, stroke index, systemic and pulmonary vascular resistance, left and right ventricular stroke work index were calculated. Increasing the MAC value during sevoflurane anaesthesia with spontaneous ventilation induced a marked cardiopulmonary depression; on the other hand, heart rate increased significantly, but the increases were not clinically relevant. The influences of artificial respiration on cardiopulmonary parameters during 1.5 MAC sevoflurane anaesthesia were minimal. In contrast, PEEP ventilation during 2 MAC concentration had more pronounced negative influences, especially on right cardiac parameters. In conclusion, at 1.5 MAC, a surgical anaesthesia level, sevoflurane can be used safely in healthy dogs during spontaneous and controlled ventilation (IPPV and PEEP of 5 cm H₂O).