Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Let’s keep the February 2024 APSF Newsletter open because we are featuring another new article today. Have any of your patients undergone non-surgical cosmetic enhancements with neurotoxins, eyelash extensions, gel manicures, or permanent jewelry? Have you had to modify your anesthetic technique. Stay tuned because we are discussing the anesthesia patient safety implications of these cosmetic enhancements today.
Before we dive into the episode today, we'd like to recognize ICU Medical, a major corporate supporter of APSF. ICU Medical has generously provided unrestricted support to further our vision that "no one shall be harmed by anesthesia care". Thank you, ICU Medical - we wouldn't be able to do all that we do without you!"
Our featured article today is from the February 2024 APSF Newsletter. It is “If Looks Could Kill: Anesthetic Implications of Cosmetic Enhancements” by Melissa Byrne and Danielle Saab. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. We have one of the authors to help get the conversation started. Let’s take a listen.
[Byrne] “Hi, my name is Melissa Byrne, and I am an anesthesiologist at the University of Michigan in Ann Arbor, Michigan.”
[Bechtel] I asked Byrne what got her interested in this topic. This is what she had to say.
[Byrne] “My initial interest in this topic came after anecdotally recognizing an increasing number of patients with eyelash extensions who were presenting for surgery at our ASC. I then began to wonder how others in my institution, or perhaps those across the country, were protecting patients’ eyes during general anesthesia.
I was suspicious that patients with long eyelash extensions were at risk for corneal abrasions, but I also acknowledged the monetary costs a patient may incur. If their lashes were inadvertently removed by IT practices. As my colleague, Dr. Danielle Saab and I started researching this article, we were struck by the sheer spectrum of non-surgical cosmetic enhancements that could have implications in the perioperative environment.
I am truly glad to have the opportunity to raise awareness of these topics that I would venture most APSF readers, regardless of subspecialty, likely encounter on a regular basis.”
[Bechtel] Thank you so much to Burns for helping to kick off the show today. And now, it’s time to get into the article. We are going to be discussing non-surgical cosmetic enhancements including neurotoxins, eyelash extensions, gel manicures, and permanent jewelry which may have under recognized anesthetic patient safety considerations. Table 1 provides excellent information about cosmetic safety risks and the authors’ proposed risk mitigation strategies. This is a good resource that you can print out and share with your colleagues. Plus, you can find it in the show notes. We will review it later on the show as well.
Okay, so first up let’s talk about neurotoxins and peripheral nerve stimulator monitoring. There has been a dramatic increase in popularity of minimally invasive cosmetic procedures over the past 5 years. The American Society of Plastic Surgeons report that neuromodulator injections are the most popular minimally invasive procedure. Did you know that over 8.7 million procedures were performed in 2022 which was an increase of over 709% from 2019. This procedure involves the injections of Botulinum toxin which is a neurotoxin produced by the bacterium Clostridium botulinum, to produce flaccid muscle paralysis by blocking the release of acetylcholine at the neuromuscular junction. This is a treatment option for hyperfunctional facial lines resulting from repeated facial muscle contractions especially in the orbicularis oculi, procerus corrugator supercilia, and frontalis. The brand names include Botox cosmetic, Dysport, Xeomin, Jeuveau, and Daxxify. The popularity of these procedures likely stems from the combination of desire for personal beauty, economic feasibility, and accessibility.
If we look at the literature, there are a few case reports of difficulty monitoring as a result of neurotoxin use. There is a 2006 case report of a 35-year-old-woman who underwent elective laparoscopic surgery. Rocuronium was used for neuromuscular blockade and one hour after induction, there was no train-of-four, double-burst, or tetanic stimulation patterns observed on her forehead while forceful muscle contractions without fade were seen after stimulation of the ulnar nerve. In 2007, there was a case report of a 72-year-old-man who had an urgent exploratory laparotomy. During closure of the fascia, the surgeon stated that the patient was not relaxed, but at the same time there were 0 out of 4 twitches with a peripheral nerve stimulator at the orbicularis oculi muscles bilaterally. When the nerve stimulator was moved to the ulnar nerve, 4 out of 4 twitches were observed. Postoperative evaluation of both of these patients revealed a history of botulinum toxin injections to the upper facial muscles in the weeks prior to surgery. The case reports continue. There was a case of an urgent intra-abdominal procedure with the surgeon raising concerns about the degree of paralysis as well as the patient continuing to breath over the ventilator. Another case report revealed a 46-year-old woman who had a cesarean delivery under general anesthesia for HELLP syndrome who received succinylcholine on induction and then had 0 out of 4 twitches on peripheral stimulation of the orbicularis oculi muscle with full recovery when the ulnar nerve was monitored. Keep in mind that you may be more likely to see patients with cosmetic neurotoxin use in the aging pregnant population. Let’s look at one more report from the ICU when a patient with multi-organ failure required postoperative ventilatory support. Cisatracurium was used for neuromuscular blockade with facial nerve stimulation monitoring. There was patient-ventilator dyssynchrony with re-evaluation of the degree of paralysis at the ulnar nerve which revealed muscle contractions and inadequate paralysis. These case reports highlight important patient safety considerations for patients with cosmetic neurotoxin injections. Here are some considerations going forward:
· Routine use of the ulnar nerve stimulation for neuromuscular monitoring. We have talked about this on the podcast before and if you have a quantitative neuromuscular monitor, make sure you use it! Check out the 2023 ASA Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade.
· Obtain a complete and accurate history include the use of cosmetic procedures prior to administration of neuromuscular blockers. This is important for patients regardless of age, gender, and appearances.
The next cosmetic enhancement that we are talking about today are eyelash extensions. Have you seen a patient with eyelash extensions presenting for surgery and anesthesia care? Eyelash extensions involve the placement of semipermanent, artificial lash fibers along the base of each individual natural lash with glue to give the appearance of fuller and longer lashes. This procedure has also been increasing in popularity and is easily accessible. There may be side effects from the procedure that include dry eyes, burning sensations, lid swelling, and pain. Patients with eyelash extensions are at risk for lagophthalmos which is incomplete closure of the eye during sleep. This puts patients at risk for further complications including increased corneal exposure and dryness, bacteria collecting under the lash bed leading to infection and challenges with physical hygiene and cleaning of the eyelid which may lead to infection and blepharitis.
A well-known complication following anesthesia care is corneal injury especially for patients undergoing general anesthesia. When there is incomplete closure of the eyelids for patients under general anesthesia, there is an increased risk for corneal abrasions and exposure keratopathies. Patients with eyelash extensions who develop lagophthalmos may be at even higher risk. In addition, misdirection of the artificial eyelashes into the eye may further increase the risk for corneal injury. An important consideration is that, when possible, eyelash extensions should be removed prior to surgery. If the eyelash extensions cannot be removed, then it is important to discuss with patients the increased risk for corneal abrasions, infection, and inadvertent removal of the lashes. During the procedure, you may place a soft, oval pad across the eyelid with tape from brow to zygomatic arch in the horizonal direction as the first option, or in the vertical direction as the second option. This can help prevent direct adhesive contact to the eyelashes. Ocular lubricants may also be used, and frequent intraoperative eye checks are important to help keep patients safe especially if there is repositioning of the head or neck.
Now, it’s time to talk about keeping patients with oral and facial piercings safe during anesthesia care. This is a time where the preoperative assessment is vital. There are potential and actual hazards associated with mouth, tongue, and nose piercings including unintentional dislodgement, airway obstruction, or reactivity. You may have some of your own examples of this while providing patient care and if we look at the literature, there are case reports. One report described a missing nose stud that was found near the patient’s head but could have just as easily been dislodged into the airway. There is another case report of a tongue laceration adjacent to a tongue stud leading to oropharyngeal bleeding and the development of laryngospasm. During the preoperative history and physical exam, it is critical to identify and document any piercings and discuss the risks with the patient. Risks associated with piercings include tongue injury and laceration, infection, bleeding, dental injury, piercing dislodgement, nerve injury, aspiration, pressure necrosis injury, death. Patients may decide to replace the metal stud with a radiolucent bar to help keep the piercing hole open, but this may be even more difficult to see and locate in the event of a dislodgement. You will need to remain vigilant for patients undergoing regional or neuraxial anesthesia with piercings in place due to the risk for emergent conversion to general anesthesia which may be even more challenging if the piercings are left in place. Raise your hand if you ask your pregnant patient with a tongue piercing to remove the piercing prior to proceeding with the labor epidural or maybe it is your patient undergoing regional anesthesia for an orthopedic procedure and you ask the patient to remove their tongue piercing prior to performing the regional block.
Mark your calendars for next week when we talk about permanent jewelry and burn risks, nail polish, gel manicures, and the pulse oximeter, and improving communication and facilitating disclosure. In the meantime, check out the Fall 2013 APSF Newsletter article, Body Piercing and Electrocautery Risks, and episode #59 of this podcast for some important considerations! Plus, we are going to hear from Melissa Burns again.
If you have any questions or comments from today’s show, please email us at podcast@apsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
The Anesthesia Patient Safety Podcast released the first episode on June 30th, 2020, called Welcome to the APSF Podcast. Since then, we have released 198 episodes counting this one. We are almost at 200 episodes. We couldn’t have done it without all the amazing APSF Newsletter articles and authors and the wonderful APSF family. We are looking forward to the next 200 episodes. Thanks for listening and we hope that you continue to download, listen, and share this podcast with anyone you know who is interested in keeping patients safe during anesthesia care.
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
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