liponurse

By overly aggressive, do you mean too much aspirate, or just recklessness (bowel perforation, etc)? When Tumescent Local Anesthesia is limited to 45mg/kg (and in concentrations of 700-900 mg per liter of fluid), as specified by Dr. Jeffrey Klein, inventor of Tumescent Liposuction in 1985, it is impossible to remove more than about 3.5 liters of fat. I certainly have not said anything to imply that high volume liposuction should be done after an RN injects Tumescent Local Anesthesia. I'm not sure how I made your point jwk. Just because a surgeon chooses not to spend the time administering his own Tumescent Local Anesthesia does not make him overly aggressive or unsafe. It is unfortunate that you have worked with surgeons that were overly aggressive. The procedure is safe. A trained RN can safely inject. Just as a trained surgeon can safely perform liposuction. I have worked with both for over 25 years, and NO complications... but complications can happen with any procedure, even when done safely. So should nurses stop doing all procedures to prevent possible complications? I think the solution for any nurse is to be well trained in his/her specialty, and avoid working with overly aggressive or reckless surgeons.

I guess one could wonder why a nurse would want to do any nursing procedure that she/he routinely does...... I actually started my career as a pediatric nurse and remember someone asking me how I do things to crying, frightened children. It was a good question and my answer was "if I could do something in a way that their anxiety, fear and pain was as minimal as possible, it was worth it." The are many surgeons out there that do not have the patience to inject tumescent local anesthetic, yet tumescent liposuction is the gold standard due to its low complication rate. I think most nurses are patient and kind by nature and are perfect for slowly and gently injecting tumescent local anesthesia. It can be done fairly quickly but some patients have stinging which can be dramatically minimized by reducing the speed of infiltration. If nurses can assist surgeons so that true tumescent anesthesia (aka no IV sedation or GA) is utilized even more than it already is, then patients will benefit. The risk of deep vein thrombosis, pulmonary embolism, pulmonary edema and respiratory depression is negligible. This translates to increased patient safety. The surgeon diagrams the targeted area and writes the order for the precise concentration of tumescent local anesthetic. The nurse (and surgeon) must have the skill and knowledge to determine how much volume of local anesthetic is needed to adequately "tumesce" the diagramed area. Calculations are done to convert the anticipated volume of fluid needed to lido mg and to assure the case can be done in under 45mg/kg. This takes place before infiltration is begun. If at any point (preferably early) it appears more volume will be needed, the surgeon is notified so he/she can order necessary dose or area adjustments. The surgeon may not be physically injecting the fluid, but it should be done exactly as he/she wants it to be. I enjoy creating a comfortable positive and SAFE experience for patients and helping training other nurses and physicians to do the same. That is why I do it and why I love it.

I am well trained, very proficient and practicing within the scope of my license. I am covered by malpractice insurance. Using jwk's rationale, why would a nurse ever do anything where a mistake could happen if it would be career ending? One could say that physicians should do every nursing procedure! Obviously, any nurse who injects tumescent local anesthetic needs to first be sure she/he is practicing within the scope of her/his license (as every state is different) and receive thorough training. That is what any good nurse does, regardless of the procedure. The surgeon I work for is far from lazy but there are many surgeons out there that do not have the patience to inject tumescent local anesthetic, yet tumescent liposuction is the gold standard due to its low complication rate. Sure - it can be done badly - that is why physicians and nurses have an ethical duty to be trained and knowledgeable before "practicing" on patients. If nurses can assist surgeons so that true tumescent anesthesia is utilized even more than it already is, then patients will benefit. True tumescent anesthesia is done slowly (30 minutes to 2 hours, depending upon number of areas and patient sensitivity) and gently on awake healthy patients. There is no need for IV sedation in most cases. The risk of deep vein thrombosis, pulmonary embolism, pulmonary edema and respiratory depression is negligible. Translates to increased patient safety. I've done thousands of cases. I doubt anyone does it better, or has more knowledge - yet I am "only" a nurse. I do my best to share that knowledge when training surgeons and nurses. I have queried several of the nurses I have trained over the years, and they have done thousands of cases of their own, and state there have been no complications. I enjoy creating a comfortable positive and SAFE experience for patients and helping others to do the same. That is why I do it.

You absolutely would not want to add IV and tumescent local anesthesia lidocaine together to total the maximum of "55mg/kg". The absorption is completely different. Tumescent Lidocaine is absorbed slowly due to the dilute nature and epinephrine which vasoconstricts and holds it in the tissue, releasing it slowly into the blood stream. The peak blood level is about 10-14 hours later. IV lidocaine goes straight to the blood stream. I don't know what the combined effect is.... Also although Jeffrey A. Klein, MD, the inventor of tumescent local anesthesia, at one time stated the maximum was 55 mg/kg, he changed it to 45 mg/kg following further studies. Additionally, one must look at other medications the patient takes as those that inhibit metabolism via the P450 substrate 3A pathway will greatly reduce and slow lidocaine metabolism, leading to a higher blood level and risk of toxicity. Example - a patient taking an SSRI such as Zoloft may not have more than 30-35 mg/kg without increased risk of toxicity. Other risky meds include many anti-fungals, and antibiotics such as erythromycin and cipro. See tumescent.org for further info

Additional and extensive info on infiltration can be found at the following link, although use of spinal needles are now minimized in favor of the use of multi-lumened blunt tipped 16g or 16g infiltration (Monty) cannulas. Chapter 26: Tumescent Infiltration Technique - Liposuction 1

I am an RN practicing in California and have been injecting, or "infiltrating" tumescent local anesthetic (aka very dilute, large volume, local anesthetic) for almost 25 years. In California, nurses may perform standardized procedures with adequate training, on going evaluation, supervision, and a physician's order. Scope of Practice varies state by state. Since the time I began infiltrating local anesthetic at the office based surgery center where I work, we have employed and trained about 15 nurses to perform this task. Best guess estimate is that we have infiltrated well over 10,000 patients, with not one (repeat not one) complication. We were each trained slowly and carefully, and closely observed and supervised until completely competent. I personally have been infiltrating since before most anesthesiologist had even heard of it. Over the last 20 years, I have also assisting in training over 800 physicians and nurses from all over the world. This is a procedure that requires training and skill, but with adequate training, a careful and cautious disposition, and proper instrumentation, it is not difficult to refrain from puncturing bowels or lungs! The anesthetic is infused in the subcutaneous fat, above the muscle. It is very tactile. I can most certainly feel the difference between fat and muscle, and the awake patient immediately will inform you if you even touch their muscle. That is part of what makes tumescent liposuction so much safer than liposuction under general anesthesia, where one may not realize the bowel has been punctured until the patient becomes ill. Tumescent local anesthetic is slowly and gently infused into an awake patient who can constantly provide feedback regarding their level of comfort. Please know that I would not recommend that any individual, regardless of license, inject tumescent local anesthetic without adequate training, not just on injection technique, but also on dosaging, medication interactions and medication error prevention. Please see tumescent.org for further info.