The difference between the safety of GA vs Twilight Sedation

[sheonlylooks25]

I found this excellent explanation from a plastic surgeon. Bit worrying as Korea Plastic Surgeons seem to use Twilight Sedation a lot.
"When I’m discussing plastic surgery with a new patient, I often find that they are more frightened of anesthesia than of the surgery itself. Everyone has heard a story about someone dying under anesthesia or waking up in the middle of an operation unable to move or talk. The tragic Joan Rivers incident has created an even greater fear (more about that later.) Very frightening tales, indeed, but despite the fact that everything in the operating room has some potential risk, the likelihood of something going quite so wrong is way overstated.
In any case, the widely quoted ratio of one death per 250,000 general anesthetics is not all that satisfying to a patient about to undergo surgery. It’s like the airline industry fact that the chance of dying in a commercial plane crash is a lot less than dying in a freeway accident…a reassuring fact to some degree, but when there’s a lot of turbulence during a flight, it won’t stop passengers from saying their prayers.

The number is also misleading…one death per 250,000 procedures includes patients who are very frail or ill from serious diseases, and includes major heart surgery, major cancer surgery, brain surgery, and transplantation surgery. People undergoing elective cosmetic surgery are generally quite healthy…a huge difference.
I’d like to clarify a few things about anesthesia, a science and discipline absolutely necessary to a proper, safe surgery and outcome. Sadly, many surgeons have no concept of what happens on the other side of the ether screen (a term for the supporting bar that holds the surgical drapes forming a barrier between the head of the patient and the sterile operative field. The surgeon is in charge on one side, but the anesthetist rules the roost on the other side.)
During my internship at Stanford, I rotated though the Anesthesiology service for a spell, and what I learned there has helped me to understand the importance of the need for teamwork between the surgeon and the anesthesia provider, whether an
Anesthesiologist,who is an MD, or an anesthetist, who is a CRNA (Certified Registered Nurse Anesthetist).

On the face of it, most patients would say that they’d prefer having an MD taking care of such a vital aspect of their safety. In truth, most of the surgical procedures done in the United States are quite well handled by CRNA’s. In the case of the most serious operations on hospitalized patients, MD Anesthesiologists generally prevail, although CRNA’s are frequently part of the team. But for the day-to-day surgical procedures, especially at outpatient surgicenters, CRNA’s are most commonly the choice. The most important choice for the surgeon to make is that whomever is providing the anesthesia services be well trained, experienced, capable, and can work well with the surgeon for the type of surgery planned.

Most operations I perform include local anesthetic injections, regardless of whether the patient is awake or sedated. This is done for two reasons. First, numbing the area I’m working on eliminates any perception of pain, and reduces the amount of either the intravenous medications or the general anesthetic agents (gasses) to a minimal, “keep-comfy” level, so there is a faster recovery from the anesthesia. Second, a small amount of dilute epinephrine (adrenaline) in the local solution reduces the bleeding substantially and speeds up the procedure nicely, thus reducing the anesthesia and operating time and expense.

Even with the local numbing, most operations I do are under general anesthesia…that is, the patient is totally asleep. Some patients and surprisingly, some surgeons feel that a “twilight” sleep is the safest form of anesthesia. This may hold true for brief procedures like colonoscopies, but for any procedure that takes longer than an hour or so, general anesthesia is safer. Let me explain why…
Twilight sleep, or intravenous sedation, involves medication given by an intravenous drip, usually Propofol and/or other drugs, that sedate and block out most pain and awareness. The patient will breathe on his or her own, without assistance or external control. (Propofol, by the way, despite its association with the tragic death of Michael Jackson, is extremely safe and is used in almost every modern operating room in the world. Michael’s death is directly related to the ill-advised use of it without proper monitoring…just to help him sleep.)

Sounds good so far. The problem: if enough intravenous sedation (“twilight sleep”) is given to make the patient comfortable and somnolent for an operation that may take more than an hour or so, the patient may not breathe deeply enough to provide enough oxygen to the heart and brain, which can lead to respiratory arrest and cardiac arrest. Unfortunately this has happened in several high-profile cases. If the patient is given less medication, he or she might be uncomfortable, and despite the lack of pain sensation, might be unable to lie quietly for a prolonged period of time without fidgeting around, which makes the operation much more difficult. But if the airway is controlled completely by a tube connected to a ventilator, (general anesthesia) one can be assured that the patient is 100% oxygenated at all times.

So, what actually happens?
After the patient is put to sleep by intravenous drugs, an airway of some type will be utilized to make sure that oxygen and some anesthetic gases are delivered to the lungs. The most common and safest airway is an endotracheal tube, a soft plastic tube about 1/2 inch in diameter, inserted into the windpipe through the mouth. A doughnut-like balloon cuff on the inserted end of the tube is then gently inflated to create a seal between the tube and the walls of the trachea. This creates a barrier to prevent any fluids from getting round the tube into the lungs, and prevents the escape of gases into the environment.

Once the airway is secured with the tube in place and connected to the anesthesia machine, it’s simply not possible for a patient to have a respiratory arrest. The ventilator guarantees that the blood circulating in the body is 100% oxygenated at all times, supplying the vital organs all the oxygen they need. Various monitors are used to make certain of that, and that the heart is pumping away in a steady and rhythmic fashion, that the blood pressure is properly maintained, and that the patient’s fear of waking up during surgery simply cannot occur. The tube is removed before the patient wakes up, so that its presence is not even a dim memory. These are all very sophisticated techniques and use equally sophisticated monitors, but the most sophisticated equipment is the watchful eye of the anesthesia provider himself (or herself) maintaining a close eye over the entire proceedings.
Regarding the untimely death of Joan Rivers, I don’t know exactly what happened there, but I believe if she’d been given a proper general anesthesia, she’d be alive and making us all laugh today. With time, the facts will emerge. But if it was a respiratory arrest as described, which then led to the cardiac arrest and her death, I’m convinced that it just couldn’t have happened with a tube in her airway. We all miss her and her naughty wit very much."

 

[jenna56]

The only thing I've gotten with twilight is wisdom teeth removal. Other procedures I had (rhinoplasty and a removal of a large birth defect on my scalp) were under GA. I would not feel comfortable getting them under twilight yet it seems that surgeons in Korea use twilight all the time. Can you tell them you need GA? I for some reason have an extremely stubborn body. My body will fight the anesthesia/sedation the entire time. I don't get loopy from medication or anything. I'm really, really not sensitive to it and I'm worried I will wake up. I hear all these stories of people waking up in Korea and it is one of my biggest fears. So do you guys think I could tell them I need GA because I have issues with sedation and they would do it? It's definitely more taxing on the body but I feel it is worth it. x Jenna