IV Sedation vs General Anesthesia

By Ricardo L Rodriguez, MD 2009

Should I use IV sedation or General Anesthesia for my cosmetic surgery procedure?

General Anesthesia is different from IV sedation and the differences have a major impact in the recovery from surgery, as well as the risk level of surgery. I will explain some of the differences between the two and why you should think about it seriously before making your choice of anesthesia. The principal difference is that under General Anesthesia the anesthesia provider controls your breathing with an endotracheal tube (inside your windpipe) , whereas under IV sedation you are breathing on your own. Each type of anesthesia has its uses, and a lot depends on how the anesthesia provider and surgeon work together.

“ General Anesthesia is different from IV sedation and the differences have a major impact in the recovery from surgery, as well as the risk level of surgery”

Will I be able to feel anything while under anesthesia?

People assume that being “totally under” using General Anesthesia guarantees you won’t feel anything, whereas you may feel something under IV sedation. This is not so. Under a general anesthetic, a patient may feel pain or be conscious enough to remember comments, but cannot respond because of the breathing tube. Under IV sedation, there are levels of sedation the patient goes thru before becoming fully conscious. Because the patient is able to breathe and move on her own with IV sedation, both the surgeon and anesthesiologist are aware of discomfort way before the patient becomes conscious of it. They can then respond appropriately by giving more local anesthetic or increasing the level of sedation.

Because sedation cannot accomplish total analgesia, or pain relief, the use of IV sedation forces the surgeon to be more skilled with local anesthesia to numb the area around the operative site. Local anesthesia is provided by localized injections to the particular area where surgery is being performed—face, breast, body, or buttocks.

Several years ago I would choose General Anesthesia for a body lift because the area to be operated was too large and I was concerned about the toxicity of local anesthetics. This is no longer true. The effectiveness of dilute concentrations of local anesthetics in large volumes of fluid (tumescent anesthesia) has dramatically expanded the areas that can be covered under local anesthetics. The body lift procedure is now done routinely under IV sedation in my AAAASF accredited facility in Baltimore, Maryland.

The overall experience of pain depends on the original pain stimulus, as well as the experience of pain in the immediate aftermath of the painful stimuli. Under a General Anesthetic, one rarely takes the time to do a local anesthetic block of the surgical field, since the anesthesiologist is taking care of the pain issue. Unfortunately, once the General Anesthetic is over, narcotics are needed at the end of the procedure to blunt the pain.

Narcotics have their own set of problems, including nausea, depressing respiration, constipation, etc. Thus, after General Anesthesia patients often experience one or more of these symptoms .

IV Sedation with pain pump following surgery

Using IV sedation one blocks the pain nerve fibers before doing surgery, and the block lasts 12-18 hours, which helps decrease the total experience of pain. The need for narcotics is dramatically reduced, especially when combined with use of a pain pump. Pain pumps are installed during the procedure and allow a reservoir of local anesthesia to be slowly injected into the operated area over the next 2-3 days. I use pain pain pumps routinely with breast augmentations, tummy tucks, and body lifts. Patients have a much faster recovery with pain pumps and experience much less nausea.

Which type of anesthesia is safer?

If the procedure is less than 4 hours, it really depends on which technique the anesthesia provider and surgeon are most comfortable with. Most anesthesia providers feel more comfortable with General Anesthesia because they have total control of the airway. An anesthesia provider experienced with IV sedation can routinely keep the airway secure, but it takes constant attention. IV sedation is technically harder. He needs a surgeon proficient with local anesthetic techniques. Thus, in these shorter cases, I defer the decision to the anesthesia provider.

Cases longer than 4 hours are a different story. The risk of complications of General Anesthesia increase proportionately with time. After 4 hours the risk of anesthesia itself becomes a factor independent of the surgeon. Complications to the lungs and blood clots increase to a point both the surgeon and patient must weigh risks and benefits carefully. In contrast, the record of safety for IV sedation in long cases is well documented. Once the tumescent anesthesia has set, the patient can be at a more superficial level of sedation for the duration of the case.

What is the difference in recovery?

“ IV sedation has less side effects such as nausea, less risk of blood clots and lung complications, and patients recover much quicker.”

After a long period of IV sedation , patients are able to come out of anesthesia rapidly. With General Anesthesia, patients emerge slowly from General anesthesia after a long period of anesthesia. This has implications. When I previously performed body lifts in the hospital under General Anesthesia patients stayed in the recovery room for hours before their vital signs were stable enough, and we often had to admit them overnight because of nausea. In contrast, a patient who has had an 8 hour body lift in our out patient surgical facility is conversational after 30-45 minutes, and able to stand up with assistance in 60-90 minutes.

Summary of General Anesthesia vs. IV sedation with local

Above all, both surgeon and anesthesia provider should feel comfortable with the anesthesia plan. If the surgery is going to be long, you, as a patient, should weigh carefully the risks and benefits of prolonged general anesthesia. If you choose IV sedation, it is crucial both surgeon and anesthesia providers are very familiar with the technique.

Given experience with both General Anesthesia at a state-of-the-art hospital and IV sedation in an out-patient surgical clinic environment, I have drawn several conclusions. IV sedation has less side effects such as nausea, less risk of blood clots and lung complications, and patients recover much quicker.

Ricardo L Rodriguez, MD
Board Certified Plastic Surgeon
20 years experience