Interesting article. Do not stop reading.
Rev. Col. Anest. vol.36 no.3 Bogotá July / Sept. 2008
Tuesday, February 22, 2011
Anesthesia "based on the surgeon or the patient? Javier H. Eslava-Schmalbach, MD, MSc, PhD
Anesthesiology since its inception has progressively performing more complex surgical techniques, so that the spectrum of possibilities has expanded since the completion of surgery that initially aimed to improve the patient's life expectancy, until today the completion of surgeries are done to correct problems of self-esteem or having to do with improving self-image, rather than functionality in other organs or tissues that are repaired. Thus currently operating as suitable techniques for patients with morbid obesity, although not classified clearly as such, just overweight; for patients is an expeditious manner to lose weight, have the financial capacity to do so, and there are surgeons and equipment available to do so in any price range.
In either case, whether or not medically indicated surgery, surgeons and anesthesiologists need to interact in interdisciplinary management of these patients. Additionally, in some cases, surgeons in an attitude that goes beyond the interaction between specialists, the anesthesiologist must be involved, the conducting anesthetic techniques or procedures that are cheaper or that reduce blood loss, although in some cases may be accompanied by greater morbidity. This is the case of regional techniques for high mammaplasty (high thoracic epidural or subarachnoid) and controlled hypotension techniques in cosmetic surgery. Although these techniques have been described in literature, in trained hands, and patients referred, sometimes it is clear that beyond a medical indication or anesthesia, is more relevant to the lower total cost of the procedure, and increased economic benefit Finally, the greater the potential morbidity patient.
With situations like these ethical conflicts are obvious. In the specific case of breast augmentation surgery, the anesthesiologist require the performance of a technique with the only argument that is cheaper, it transcends the limits of ethics. Although this technique has been described 1 , the benefit of its widespread use is questionable because it ignores the incidence and magnitude of adverse events related to it. Generally, these adverse events are not published.
same happens with controlled hypotension in performing cosmetic surgery. There are descriptions in which is mentioned use long
2-5, to facilitate the implementation of such procedures with a lower incidence of bleeding in the operative field. This is a condition that benefits the surgeon and the patient if the global bleeding and / or surgical time are lower. In this regard some of these studies contradict those benefits
6 7 . Now, assuming that controlled hypotension is beneficial, its use can not be generalized to all patients. Is not the same hypotensive technique in young subjects than in older and even more so if associated comorbidities (hypertension, hypothyroidism, coronary artery disease). If the benefit hypotensive technique is less than the risk of intraoperative complications, prima net benefit to the patient. In this case the little bleeding in the operative field becomes a secondary problem that can be handled in other ways. The complications have been associated with this technique range from the likely increase in pressure areas to the central organ hypoperfusion such as heart, brain or kidney
8,9,10.
Sometimes in the interests of patient safety will have to choose a technique that is not going to be the surgeon's taste. Additionally, in the case of cosmetic surgery, there are clearly cases of elective surgeries indicated in patients with high potential risks of perioperative morbidity. For example, outpatient surgery tummy tuck on a 71 year old woman with a history of hypertension and hypothyroidism. In this case, the need for surgery is defined by the patient's ability to pay, not the real indication for surgery. Many studies support the potentially underlying psychiatric problems in patients with obesity and cosmetic surgery and should be studied and / or resolved before surgery 11 - 16
with the social pressure is becoming increasingly important, in our field. Other highlights an ethical conflict, to make a procedure in a patient who is not clearly indicated or is contraindicated by the need to resolve the request of a patient who somehow manages to have the ability to pay to support the request. The boundary between ethically contraindicated medically indicated and can only be resolved on the critical and ethical sense of the surgeons involved in these procedures. Obviously, if for no ethical surgeon generates conflict by requiring specific anesthetic technique, riskier but cheaper, or to schedule an outpatient procedure that should be hospitalized in order to save one day of hospitalization, much less will generate conflict when operating a patient with a high probability of underlying psychiatric problems or high risk of complications, but has adequate capacity to pay. Anesthesiologists have the option to act as doctors, always putting the medical and ethical criteria prior to gloss over this type of situation. Today, in Colombia and abroad, job opportunities allow us to be more demanding in the way we interact with surgeons and institutions, thus putting himself in an ethical sense the actions of our life, what is likely to make you feel better and more gratified with our work. course and as it happens everywhere, some people will feel more gratified with the remuneration, without deciding whether the proceedings are adjacent or not an ethical conflict. Improve the interaction between the surgeon and the anesthesiologist will conclude the proceedings in these scenarios where appropriate resolve ethical conflicts. A board, previous surgical and preoperative assessment and allow anestésca discuss these potential conflicts, improve the performance of surgeons and anesthesiologists and give items to enhance patient safety, objectives which ultimately must focus our attention on daily tasks of anesthesiology. 
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