Twilight (Conscious) Sedation Versus General Anaesthetic

General Anaesthetic or Twilight Sedation?

Well, this is a topic that has certainly heated up in the last few weeks. A few weeks ago we wrote about the concerns in the industry regarding the level of sedation being applied to patients undergoing procedures in private clinics, see that article here. It has now reached boiling point with the spotlight on a particular clinic where several women have been rushed to hospital following complications from the amount and type of anaesthesia they received during breast augmentation surgery.

We’d like to clear a few things up for you. There are different types of anaesthesia.

General Anaesthesia

General Anaesthesia is the deepest type of anaesthesia. Under a general anaesthetic you are unconscious and unrousable, even to severely painful stimuli. You are closely monitored to ensure your heart rate, pulse, breathing and vital signs all remain acceptable. You do not have any memory of the procedure (Total amnesia). This type of anaesthesia is used for procedures that may take longer or be more involved, or when the amount of local anaesthetic required to make the procedure painless may be toxic. General Anaesthesia is usually administered through a vein or through breathing gases through a special breathing tube inserted into your mouth. It is essentially a medically induced coma. Your muscles may be paralysed and you will lose control of reflexes. You may not be able to breath spontaneously and therefore may require a machine to breath for you. The amount, type and administration of drugs administered can vary depending on your weight, age, existing medical conditions and the amount of stimulation given during the procedure. This is controlled by an anaesthetist (or anesthesiologist for our America friends), a doctor with special training in anaesthetics.

Deep Sedation

Deep sedation (Anaesthesia without airway control) is similar to General anaesthesia. It is administered by an anaesthetist in the same way as a general anaesthetic however the dose of drugs administered is controlled to allow you to breath without the aid of the breathing tube or the need for a machine to breath for you. You are not paralysed but may be too sedated even to respond to painful stimuli. This type of sedation still requires very careful monitoring and needs to be administered in an operating theatre with facilities available for acute resuscitation and the ability to convert to a general anaesthetic if required in an emergency.

Conscious Sedation / Twilight Sedation

Conscious sedation, also known as twilight sedation, also involves the administering of a combination of medicine to help you relax. You may fall asleep but will be easily aroused or responsive to people in the room. You will still feel and respond to pain under twilight sedation and so the person performing the surgery will need to numb the area having the procedure using local anaesthetic. Local anaesthetic is a chemical that is injected into the region of the procedure to make it numb, and allows a procedure to occur without causing any stimulation that may wake you up or cause you to respond, either consciously or reflexly.

The recovery time after deep sedation or conscious sedation may be reduced compared to a general anaesthetic, but varies depending on many factors. There is a continuous spectrum of levels of sedation between conscious sedation and general anaesthesia. Depending on your reaction to painful stimuli and the amounts and combination of medicines administered, you may move from a light sedation to a deeper sedation while under the aneaesthetic. If a patient moves from a light to a deeper sedation, their airways and ventilation may be affected. It is therefore absolutely essential that an aneasthetist is present when heavy or deep sedation is administered so they may control the level of sedation, monitor your breathing and circulation and if necessary resuscitate you if there are problems. For safety reasons, sedation should never be administered by the person performing the surgery as this leaves them unable to monitor you effectively whilst performing the surgery.

The concerns raised recently (and indeed the cause of emergency situations) occurred because the clinic in question was unprepared and not equipped for the complications that can occur when a patient is given higher dosages of sedation moving them to a general anaesthetic state or when the amount of local anaesthetic administered in order to perform the procedure under sedation was too high and became toxic.

Conscious sedation is a perfectly safe and acceptable means by which a plastic surgery procedure can be performed, dependent on the particular procedure and the patient. If you are having conscious sedation at a clinic, it is extremely important to consider the following things:

  • Is the clinic equipped to deal with emergencies?
  • Will you have a designated qualified anaesthetist present throughout your procedure and are they appropriately trained to be administering your sedation and deal with any complications should they arise?
  • Is the procedure/s you are having appropriate for conscious sedation?

There are other factors to consider and Dr Gavin Sandercoe, Plastic and Cosmetic Surgeon, has had his anaesthetist explain them perfectly here on his website.

There has been a recent increase in interest from the Federal Government to introduce more specific regulations and legislations controlling what is a reasonable standard of care for procedures performed under conscious sedation.

You can’t be too careful when choosing a practitioner taking into consideration their experience and where the surgery will be performed. Private clinics are perfectly fine when they are fully equipped and run by competent, qualified and experienced surgeons, anaesthetists and staff. It is when doctors are performing the procedures in their offices and clinics without appropriate anaesthetic cover, staffing and equipment to deal with emergencies that the problems arise.

Are there any particular procedures that should be performed under General Anaesthesia or Conscious Sedation?

This is a tricky question to answer and it depends on your surgeon, anaesthetist and what your preference is. Some surgeons prefer General Anaesthesia for most plastic surgery procedures; however some will perform Breast Augmentation or boob job under Deep or Conscious Sedation, with an anaesthetist present. You need to discuss with your surgeon what the best option for you is. Some cut price clinics try to reduce the cost of surgery by allowing the surgeon to administer the conscious sedation rather than having an anaesthetist present. This is dangerous and you should avoid this type of clinic unless you do not mind putting yourself at risk in order to save money. Any lengthier or potentially tricky procedures should definitely be performed under a General Anaesthesia in a fully accredited private clinic or hospital.

From the research we’ve done, in our opinion, if the surgery you are scheduled to have may be performed with a small amount of local anaesthetic which is enough to completely numb the area, it would appear conscious or twilight sedation is ok. If you do not want to have any pain during the injection of the local anaesthetic or if larger amounts of local anaesthetic would be required that could be potentially toxic, then you would need deep sedation or a general anaesthetic. This should be administered by an anaesthetist in a facility accredited to perform general anaesthesia.

You do need to be aware that Cosmetic Surgeons in private clinics are NOT allowed to administer General Anaesthetic so their only option is to administer a Twilight Sedation or Conscious Sedation. Even when it may be in your best interest to have your procedure under a General Anaesthetic, you will not be offered that option with that surgeon at their clinic. Again, you need to ensure you have found a surgeon and clinic that is right for YOU.

We have also always encouraged our readers to be wary of cheap offers, whether it be overseas or in our own backyard. There are some quality surgeons offering very competitive prices, and we have many of them listed on our website. All of our featured surgeons and clinics have received excellent reviews and have highly qualified surgeons and staff. To find a quality Plastic or Cosmetic Surgeon or practitioner visit our directory.