Dr. Friedberg is a board-certified anesthesiologist based in Corona del Mar, Calif., where he specializes in the practice of office-based anesthesia for elective cosmetic surgery. He introduced propofol ketamine monitored anesthesia care (PK MAC) 15 years ago. Ten years ago, the BIS monitor was added to PK MAC, making it the MIA technique.
In addition to using a minimal number of medications, the simplicity of the technique facilitates room air spontaneous ventilation (RASV) and reduces equipment and instrumentation needs. The MIA technique involves only three medications and is performed with routine vital signs monitoring and a BIS monitor to measure level of consciousness. In comparison, general anesthesia typically involves administration of 12 to 15 agents, necessitates an anesthesia machine and routine supplemental oxygen, and has airway management issues as well as scavenging considerations for exhaled gases and vapors. General anesthesia also includes an increased risk of thromboembolic phenomenon secondary to pooling of blood in the pelvic veins.NO TRESPASSING Based on its differences with general anesthesia, the MIA technique has important benefits. For the surgeon, it is able to simulate the operating conditions of general inhalational anesthesia but with much greater safety because it creates a minimal physiologic trespass. In addition, the MIA technique involves no medications that are triggers for malignant hyperthermia (MH) or post-operative nausea and vomiting (PONV). In addition, RASV avoids the potential fire hazard during laser procedures that accompanies the routine use of oxygen. The MIA technique also provides preemptive analgesia that essentially eliminates the need for post-operative opioids, a well-known etiologic factor for PONV.
"Change is the most difficult thing to accomplish in the world, and the approach to cosmetic surgery anesthesia I am advocating represents a profound change in the conventional conceptualization of that task. However, I believe there is no acceptable threshold for risk of anesthesia-related complications in elective cosmetic surgery. With its superior safety profile, the MIA technique offers the best method for achieving that goal," Dr. Friedberg tells Cosmetic Surgery Times.
"The MIA technique has multiple benefits for the surgeon and anesthesia provider performing the procedure, the family members or friends who are the post-op caregivers, and especially for the patients who do not feel, hear or remember their operation and are universally happy secondary to the euphorigenic effects of propofol."
Dr. Friedberg says the MIA technique is appropriate for all cosmetic procedures because by definition all cosmetic surgery, including rhinoplasty and abdominoplasty, is minimally invasive.
NO DEEP NEED "There is no cosmetic surgery that is intra-abdominal, intra-cranial, or intra-thoracic. Since there is less involvement of the patient's critical organs and systems, these procedures require less deep anesthesia. Certainly general anesthesia can be used safely for cosmetic surgery," Dr. Friedberg says, "but that does not mean it should be used. When it comes to anesthesia safety, less trespass is better. The MIA technique represents an alternative approach to avoid putting patients at undue risk."
The MIA technique is performed using the BIS monitor, which measures the brain electroencephalogram and processes that information to provide a numerical indicator of the hypnotic component of the anesthetic state. The BIS numeric scale ranges from 0 to 100, where 100 indicates the patient is fully awake and 0 represents absent brain activity. In the MIA technique, propofol is titrated to maintain a BIS level between 60 and 75. General anesthesia, in comparison, is associated with a BIS level between 45 and 60 when patients are given systemic analgesia.