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It is very common for me to hear from by patients during their pre-operative appointment( prior to their hair transplantation procedure) say the following – “Doc, can you knock me out for the procedure?”  Though it sounds like a good idea, there are significant risks to heavy sedation.  I would like to highlight the risks and give you my perspective.

During my entire career as a physician, I have been anti-heavy (IV) sedation for most out-patient procedures.  I come from an interventional pain management background and have performed over 40,000 spinal injections.   Most of them were completed without any sedation.  Early in my career, I saw how heavy sedation, particularly when given IV created undo risks and complicated procedures

I quickly came up with a better approach – to do the injection in a way which produced minimal pain and perfect efficiency in my technique to limit how long the injections took.  My patients were amazed that they could easily get a spinal injection without IV sedation and in such a painless manner.  I had many referring physicians ask how their patients were coming back to them with glowing reviews of the procedure, despite having no sedation.

This is in direct contrast to most practices that give heavy IV sedation, prolong the procedure pre and post op monitoring, keep both the patient and the person driving the patient out of work for the day and add undo risks which IV sedation carries.

In my mind, the patient is my best monitor.  If heavily sedated, then the feedback from that patient is eliminated and bad things can happen.  In most states, the person completing the procedure can not be the one administering IV medications, which often is not the case.  Strict guidelines for storing, charting and administering IV sedation and IV pain medications are mandated, along with strict monitoring to evaluate respirations and blood pressure.  Unfortunately, many offices do not have these protocols in place.

I feel that the best approach is to provide a written prescription for sedation medications during the preoperative visit.  The prescription is then filled at a pharmacy prior to the procedure and then take then taken upon arrival.  We prefer Ativan between 1 to 3 mg since is has a medium half life of approximately 3 to 4 hours and is not metabolized by the same liver enzymes pathways as the typical anesthetics drugs – limiting adverse reactions.  This takes away the need for storing any controlled substances in the office and reduces any cardiovascular issues related to IV sedation.

The next step is to perform high quality nerve and ring blocks in the scalp to provide total and prolonged anesthesia during the procedure.  With this combination of oral sedation and effective blocks, my patients have an uneventful, painless experience.  Approximately 50% request no oral sedation even with large cases and they do well after the blocks.

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