Intravenous Anesthesia With Bispectral Index Monitoring vs Inhalational Anesthesia for Rhytidoplasty: A Randomized Clinical Trial

JAMA Facial Plast Surg. Jul-Aug 2015;17(4):239-44. doi: 10.1001/jamafacial.2015.0222.


Importance: Minor adverse effects related to anesthesia are common and worrisome to patients, including perioperative vomiting, gagging on the endotracheal tube, incisional pain, and nausea. A previously published intravenous anesthesia protocol reports extremely low rates of postoperative nausea and vomiting (<1%) and decreases in postoperative pain perception compared with rates reported following administration of inhalational anesthetics.

Objective: To evaluate and compare postoperative outcomes in patients after administration of combined propofol and ketamine hydrochloride anesthesia with bispectral index monitoring (PKA-BIS protocol) vs inhalational anesthesia (IA) during lower rhytidoplasty.

Design, setting, and participants: We performed a prospective, double-blind, randomized comparison trial of the PKA-BIS protocol and IA in 30 consecutive female patients undergoing rhytidoplasty by a single surgeon at a single outpatient surgery center from October 2013 to June 2014.

Main outcomes and measures: Outcome measures included nausea, vomiting, pain, overall feeling of well-being, time to awaken, time to discharge, and cost. Patient measures were recorded using a combination of a 40-item validated postoperative quality of recovery questionnaire (QOR-40) and visual analog scales (VASs). Results were recorded immediately after surgery and on postoperative days 1 and 7.

Results: A statistically significant reduction in emergence time (mean [SD], 29.8 [10.6] vs 46.0 [10.2] minutes; P < .001) and time to meet discharge criteria (51.4 [19.3] vs 66.1 [12.9] minutes; P = .02) was seen in patients in the PKA-BIS group. Patient-reported (subjective) postoperative nausea (3 of 15 [20%] vs 7 of 15 patients [47%]; P = .12; χ2 = 2.40), vomiting (0 vs 2 of 15 patients [13%]; P = .14; χ2 = 2.14), and confusion on the day of surgery (3 of 15 [20%] vs 6 of 14 patients [43%]; P = .18; χ2 = 1.77) were also decreased in the PKA-BIS group, but these differences did not reach significance. Differences in global recovery scores (QOR-40 scores in the postanesthesia care unit, 158.13 [22.68] vs 155.33 [18.09]; P = .71; at day 1, 166.47 [26.39] vs 166.00 [16.00]; P = .96), postoperative overall feeling of well-being (VAS scores at day 1, 6.10 vs 6.26; at day 7, 7.49 vs 8.00), and postoperative pain perception (VAS scores at day 1, 3.40 vs 3.65; at day 7, 2.26 vs 1.81) between the PKA-BIS and IA groups, respectively, did not reach significance. The costs of anesthesia administration were similar between the PKA-BIS ($10.37/h) and IA ($8.47/h to $9.87/h) groups.

Conclusions and relevance: The PKA-BIS protocol for anesthesia appears to be a comparable alternative to traditional IA in patients undergoing elective rhytidoplasty. A larger patient sample size is needed to determine whether trends toward decreased nausea, vomiting, and postoperative confusion and differences in postoperative pain perception are significant.

Trial registration: Identifier: NCT02410460.

Level of evidence: 1.

Publication types

  • Comparative Study
  • Randomized Controlled Trial

MeSH terms

  • Aged
  • Anesthesia, Inhalation / methods*
  • Anesthesia, Intravenous / methods*
  • Anesthetics, Dissociative / administration & dosage
  • Anesthetics, Inhalation
  • Anesthetics, Intravenous / administration & dosage
  • Double-Blind Method
  • Female
  • Humans
  • Ketamine / administration & dosage
  • Middle Aged
  • Monitoring, Intraoperative / methods*
  • Pain Measurement
  • Pain, Postoperative / prevention & control
  • Postoperative Nausea and Vomiting / prevention & control
  • Propofol / administration & dosage
  • Prospective Studies
  • Rhytidoplasty*
  • Surveys and Questionnaires


  • Anesthetics, Dissociative
  • Anesthetics, Inhalation
  • Anesthetics, Intravenous
  • Ketamine
  • Propofol

Associated data