Hi All,

I give IV sedation for plastic surgeries. The cases run close to 4 hours and some run almost 6 hours. The preop meds are usually xanex 2-4mgs or Valium 5-10mgs (O) and Demerol 50mgs and Phenergan 25mgs IM. These drugs are the surgeons choice. Most of the cases are face lifts, brow lifts, upper/lower eyes and
sometimes fat transfers. I sedate the patients with fentanyl and versed. As we know some patients require more and some less. I've given up to 26 mgs and 300mcgs for a 6hour case and a couple of times I had to use Flumazinil at the end of the case to reverse the versed to enable the patients to eventually go home.

My indication for dosing after the local injection is appearance of wakefulness, awareness, movement, talking, complaints of pain, or surgeon requests more sedation. After three hours patients get uncomfortable lying on the table. Most are older and have difficultly staying still in one position. Comfort measures of pillow under the knees and foam padding, etc. are used.

My questions are criteria for giving more sedation after the initial local, when to quit giving more sedation,
( even when the vitals are all satisfactory). When should the last dose be given? What is the max dose
of Versed? Sometimes the last part of the procedure is the most painful (laser facial resurfacing). Now they're done and the patient is too sleepy.

Your thoughts are appreciated,