tumescent anesthesia?

smiling_ru · Mar 29, 2004

It is used mostly in plastic surgery. It involves diluting a local anesthetic (usually lidocaine and some epi) in a relatively large amount of fluid and injecting into the area to be worked on. Slow steady absorption of the diluted anesthetic helps with pain and compression of vessels help with bleeding. This is usually performed by the surgeon not the anesthesia provider.

loisane · Mar 30, 2004

All true. But there are anesthesia implications.

This technique has been implicated in some high profile cosmetic surgery complications. If you are the anesthesia provider in one of these cases, you need to aware of the impact on your patient.

Fluid balance is critical. It is easy for the amount of systemic absorption to be under appreciated, resulting in fluid overload and pulmonary edema.

Under estimating systemic absorption can also lead to local anesthetic toxicity.

Anesthesia providers who are involved in these cases make it very clear to the surgeon that when the maximum amount of fluid has been used, the procedure will stop-no ifs, ands or buts. And if the surgeon complains, that is the last time they will get anesthesia coverage from that provider.

A quality surgeon will have no problem with this. This is one of the reasons you want to be sure your cosmetic surgeon is qualified to do what he is doing. Non-specialist MDs who have attended a weekend seminar and go on to open a liposuction practice are not where you want to be-as an anesthesia provider or as a patient.

loisane crna

WntrMute2 · Mar 30, 2004

Anesthesia providers who are involved in these cases make it very clear to the surgeon that when the maximum amount of fluid has been used, the procedure will stop-no ifs, ands or buts. And if the surgeon complains, that is the last time they will get anesthesia coverage from that provider.
loisane crna

I'm assuming that the maxumum amounts of epinepnine and lidocane need to be factored in. How would you calculate the fluid limit, the drugs have pretty specific guidelines to follow or is there something different about that too?

Thanks in advance.

yoga crna · Mar 30, 2004

I'm assuming that the maxumum amounts of epinepnine and lidocane need to be factored in. How would you calculate the fluid limit, the drugs have pretty specific guidelines to follow or is there something different about that too?
Thanks in advance.

It is very difficult to calculate maximum doses of lidocaine and epinephrine. Some dermatology literature states that over 50 mg/kg of lidocaine can safely be used with tumescent anesthesia. Those doses are too high for my comfort. The reason why it is difficult to calculate doses is because it is very slowly absorbed from the fat and some of it is suctioned out. Studies pubished in the literature show that the maximum plasma levels of lidocaine peak at 6-8 hours post infiltration.

There have been a lot of deaths from tumescent liposuction, because of overdose, excessive bleeding and inadequate fluid replacement.

A Medline search on this topic is very useful.

YogaCRNA

Brenna's Dad · Mar 30, 2004

Seems like a bad technique.

loisane · Mar 30, 2004

Yoga, thanks for your input, and for answering Wntrmute. I did just enough of these cases to realize the management was trickier than it looked. But I am no longer involved with them, so I never really got to be an expert.

I figured you would be more up to speed than me ;-)

loisane crna

yoga crna · Mar 31, 2004

Tumescent liposuction is the most commonly performed plastic surgery procedure in the country and probably the world. The history of the tumescent anesthsia technique is very interesting. A dermatologist was looking for anesthetists for liposuction surgery in his office. No one (including me) wanted to do anesthesia for a dermatologist, so he developed a technique where no anesthesia provider was necessary. The administration of high volume local anesthetic to the fat to be suctioned was thus developed by Dr. Jeffrey Klein. Since then, most plastic surgeons use the technique in conjunction with general anesthesia or deep sedation, while the dermatologist stick with the Klein's technique. What I am impressed with is the fact that mostly fat is suctioned out. The old technique, pure suction, produced about a 10-15% blood loss along with the fat. We used to give autologous blood.

I agree with Loisane, liposuction is an interesting procedure, best explained to me as internal burns with a lot of third space fluid loss. Most patients do well, because they are young and healthy; others may have blood pressure and fluid issues post-op, I administer anesthesia for many liposuction cases in my practice and I have a lot of respect for the physiologic changes with the procedure. Also, they require excellent nursing care post-op, with fluid management to prevent postural hypotension.

For your interest, I testified in criminal court against an RN who administered tumescent liposuction herself and finished the liposuction when the obstetrician who was performing the procedure went to the hospital for a delivery. The patient died. The nurse was convicted and spent jail time. The surgeon was found not-guilty. Go figure.

Yoga

Pete495 · Mar 31, 2004

The Obstetrician was performing liposuction? Talk about shady.