The use of conscious sedation for outpatient dermatologic surgical procedures.

BACKGROUND: Dermatologic surgery has undergone increasing levels of sophistication over the past few decades. Commensurate with this demand, an established anesthesia technique called conscious sedation has been employed. OBJECTIVES: Methods for performing office-based conscious sedation are described. Recommendations are made regarding prerequisites for conscious sedation in an office setting, patient selection, complications management, and postoperative discharge requirements. CONCLUSION: The goals of anesthesia are to provide for patient safety and comfort, to increase patient acceptance of the procedure, and to enhance the surgeon's efficiency and satisfaction.

The combined use of propofol and fentanyl for outpatient intravenous conscious sedation.

BACKGROUND: Intravenous conscious sedation is currently being widely utilized for outpatient surgery including dermatologic surgery. Even though this type of anesthesia is typically administered by a trained, licensed anesthetist, it is important for dermatologists who either intend to or are currently utilizing this type of anesthesia to be familiar with some of the methods and agents that are commonly employed. OBJECTIVE: Propofol and fentanyl are two anesthetic agents that are in prevalent use for skin and soft tissue surgery of brief or limited duration. With the goal of familiarizing dermatologic surgeons with this form of anesthesia, a study was conducted to evaluate the safety and effectiveness of the combination of propofol and fentanyl when used for conscious sedation in an outpatient dermatology center. METHODS: Twenty patients, ages 25-65 years, who required conscious sedation were enrolled. Each patient received a standard dosage of fentanyl and propofol, as determined on a kilogram basis. Sedation time, total procedure time, recovery time, and total propofol dose, along with side effects, were determined. RESULTS: The mean onset to sedation was 52.5 seconds, the mean procedure time was 40 minutes 37 seconds, and the mean interval to recovery was 3 minutes 43 seconds, with a mean total dose of propofol of 5.83 mg/kg. Minimal side effects occurred. CONCLUSION: Propofol when used in conjunction with fentanyl appears to be a safe, quick, and effective method of providing conscious sedation.

Effect of DETOX as an adjuvant for melanoma vaccine.

The identification of effective adjuvants is critical for tumor vaccine development. Towards this end, we examined whether the immunogenicity of a melanoma vaccine could be potentiated by DETOX, an adjuvant consisting of monophosphoryl lipid A (MPL) and purified mycobacterial cell-wall skeleton (CWS). Nineteen patients with resected stage III melanoma were immunized with a polyvalent melanoma antigen vaccine (40 micrograms) admixed with DETOX, q3 wks x 4. Seven patients received vaccine + low-dose DETOX (10 micrograms MPL + 100 micrograms CWS) and 12 received vaccine + high-dose DETOX (20 micrograms MPL + 200 micrograms CWS). A non-randomized control group of 35 patients was treated similarly with 40 micrograms vaccine + alum. One week after the fourth vaccine immunization, melanoma antibodies were increased over baseline in 7/7 (100%) patients treated with vaccine + low-dose DETOX, 8/12 (67%) patients treated with vaccine + high-dose DETOX, and in 4/19 (21%) of vaccine + alum patients. For the entire DETOX group, the antibody response rate was 15/19 (79%) compared 4/19 (21%) in the alum group (p < 0.001). In contrast, a strong delayed-type hypersensitivity (DTH) response (> or = 15 mm increase in DTH response over baseline) was induced in 50% of the entire DETOX group versus in 47% of the alum group. Median disease-free (DF) survival for the entire DETOX group was 17.8 months compared with 32.1 months in the alum group (p < 0.05). In conclusion, DETOX markedly potentiated antibody but had little effect on DTH responses to melanoma vaccine immunization. It did not appear to improve disease-free survival in comparison to alum in this non-randomized study.

Improved survival of patients with melanoma with an antibody response to immunization to a polyvalent melanoma vaccine.

BACKGROUND: Melanoma vaccine treatment appears to slow the progression of melanoma in some patients, particularly in patients in whom it stimulates cellular antimelanoma immune responses. The relationship of vaccine-induced antibody responses to clinical outcome is less clear. The purpose of this study was to investigate the clinical relevance of antibody responses to melanoma vaccine immunization. METHODS: Eighty-two evaluable patients with surgically resected American Joint Committee on Cancer Stage III malignant melanoma were immunized to a partially purified, polyvalent, melanoma antigen vaccine. Antimelanoma antibodies were measured by immunoprecipitation and sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis before vaccine treatment and 1 week after the fourth immunization. RESULTS: Vaccine treatment induced or augmented antibody responses to melanoma in 32 (39%) of the patients. The antibodies were directed to one or more antigens of 38-43, 75, 110, 150 and/or 210 kDs, which previously have been shown to be expressed preferentially in cultured human melanoma cells. The median disease free survival of patients with a vaccine-induced antibody response to one or more of these antigens was 5.4 years compared with 1.4 years for nonresponders (P = 0.06), and 5-year overall survival was 71% compared with 44%, respectively (P = < 0.01). As determined by Cox multivariate analysis, the difference in overall survival was independent of disease severity or of immunologic competence as evaluated by ability to be sensitized to dinitrochlorobenzene. The difference in survival between antibody responders and nonresponders improved with time. CONCLUSIONS: The antibody response to vaccine treatment is an immune marker of vaccine activity that appears to be predictive of a later reduction in the recurrence of melanoma and is unrelated to the vaccine's ability to induce cellular immune responses. This finding suggests that vaccine treatment may be effective in slowing the progression of melanoma in some patients and that the protective effect is mediated partly by vaccine-induced antimelanoma antibodies.