[ ] OFFICE BASED ANESTHES

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[ ] OFFICE BASED ANESTHES

  1. 1. OFFICE BASED ANESTHESIAOFFICE BASED ANESTHESIA LIPOSUCTIONLIPOSUCTION Tony Garcia, M.D.Tony Garcia, M.D. January 2009January 2009
  2. 2. August 2001August 2001 Volume 65Number 8Volume 65Number 8 Update on Office-Based Anesthesia: Caveats on the ProfessionalUpdate on Office-Based Anesthesia: Caveats on the Professional Finger-PointingFinger-Pointing Rebecca S.Rebecca S. TwerskyTwersky, M.D., Chair, M.D., Chair Committee on Ambulatory Surgical Care and Task Force on Office-Committee on Ambulatory Surgical Care and Task Force on Office- Based AnesthesiaBased Anesthesia  Dermatology vs. Plastic SurgeryDermatology vs. Plastic Surgery  Data for incidence of complicationsData for incidence of complications  Types of complicationsTypes of complications  DeathsDeaths  TechniqueTechnique
  3. 3. Reported complicationsReported complications  Prospective analysis of complications in 2000 involving FloridaProspective analysis of complications in 2000 involving Florida medical officesmedical offices  7 Deaths: 1- anaphylaxis, 6 – gen. anes.7 Deaths: 1- anaphylaxis, 6 – gen. anes.  3 deaths had abdominoplasty/ liposuction3 deaths had abdominoplasty/ liposuction  2 deaths were due to PE’s 2 days later2 deaths were due to PE’s 2 days later  1 death occurred night after discharge1 death occurred night after discharge  1 death occurred several days after tonsillectomy1 death occurred several days after tonsillectomy  Claims database from 1995 – 97 accounted for 2/257Claims database from 1995 – 97 accounted for 2/257 complicationscomplications
  4. 4. Reported ComplicationsReported Complications  Society of plastic surgeons published study of procedures: noSociety of plastic surgeons published study of procedures: no deaths in 23,000 in 2001deaths in 23,000 in 2001  Plast Reconstr Surg. 2001 Apr 15;107(5):1285-91;Plast Reconstr Surg. 2001 Apr 15;107(5):1285-91; Of the nearly 45,000 total entries in the database, 292 wereOf the nearly 45,000 total entries in the database, 292 were claims for adverse events related to lipoplasty or liposuctionclaims for adverse events related to lipoplasty or liposuction 20.9 percent were office-based claims20.9 percent were office-based claims Seven fatalities (three women and four men) were noted;Seven fatalities (three women and four men) were noted; cause of death is not recorded in this type of databasecause of death is not recorded in this type of database
  5. 5. Complications continuedComplications continued  Census surveyCensus survey  Plast Reconstr Surg. 2000 Jan;105(1):436-46; discussion 447-8Plast Reconstr Surg. 2000 Jan;105(1):436-46; discussion 447-8 Responding aesthetic plastic surgeons (917 of 1200) reportedResponding aesthetic plastic surgeons (917 of 1200) reported 95 uniquely authenticated fatalities in 496,245 lipoplasties95 uniquely authenticated fatalities in 496,245 lipoplasties 1 in 5224, or 19.1 per 100,0001 in 5224, or 19.1 per 100,000 Pulmonary thromboembolism occurred 23 %Pulmonary thromboembolism occurred 23 %
  6. 6. Liposuction RisksLiposuction Risks  PEPE  Lidocaine toxicityLidocaine toxicity  HypothermiaHypothermia  Fluid imbalanceFluid imbalance  InfectionsInfections  Visceral perforationsVisceral perforations  SeromaSeroma  Nerve compressionNerve compression  EdemaEdema  Skin necrosisSkin necrosis
  7. 7. DeathsDeaths RB Rao, SF Ely, RS Hoffman - New England Journal of Medicine, 1999 - content.nejm.org
  8. 8. CasesCases Patient 1Patient 1 33 yr old man previous history appendectomy33 yr old man previous history appendectomy Tumescent liposuction of abdomen and flanksTumescent liposuction of abdomen and flanks Gen. Anes.Gen. Anes. Chemistries normalChemistries normal 2.5 hrs into case he underwent bradycardia and hypotension2.5 hrs into case he underwent bradycardia and hypotension Asystole followedAsystole followed Post mortem: 250 peritoneal fluid, no overload of fluid, fat emboliPost mortem: 250 peritoneal fluid, no overload of fluid, fat emboli negneg
  9. 9. CasesCases Patient 2Patient 2 40 yr old woman PMH asthma40 yr old woman PMH asthma MAC for tumescent liposuction of flanks and back in prone pos.MAC for tumescent liposuction of flanks and back in prone pos. Sats 97%; 2.3 hrs into surgery she turned supineSats 97%; 2.3 hrs into surgery she turned supine Wide complex infranodal bradycardia followed by asystoleWide complex infranodal bradycardia followed by asystole Post mortem: no abnormalities consistent with asthmaPost mortem: no abnormalities consistent with asthma
  10. 10. CasesCases Patient 3Patient 3 33 yr old woman psychiatric disorder33 yr old woman psychiatric disorder Meds: Lithium, Nortryptiline, buspirone, clonazepam, sertraline, trazadone,Meds: Lithium, Nortryptiline, buspirone, clonazepam, sertraline, trazadone, carisoprodolcarisoprodol Hg 12Hg 12 MACMAC Bilateral mammoplasty and tumescent liposuction of thorac, arms, back,Bilateral mammoplasty and tumescent liposuction of thorac, arms, back, abdomen, thighs, buttock, kneesabdomen, thighs, buttock, knees EBL 700 cc; HospitalizedEBL 700 cc; Hospitalized Found to have Hg 5.8; Transfused 2 u PRBC, hydrationFound to have Hg 5.8; Transfused 2 u PRBC, hydration Inhouse for 2 days: received lasixInhouse for 2 days: received lasix Discharged: 2 hrs post DC had dyspnea and syncopeDischarged: 2 hrs post DC had dyspnea and syncope V fibV fib Found to have: normal chemistry, CXR: pulm. Edema; Echo: NL, CardiacFound to have: normal chemistry, CXR: pulm. Edema; Echo: NL, Cardiac enzymes were NLenzymes were NL Persistent anoxic coma & pronounced dead 72 hrs laterPersistent anoxic coma & pronounced dead 72 hrs later
  11. 11. CasesCases Patient 4Patient 4 54 yr old woman54 yr old woman Gen. Anes.Gen. Anes. Tumescent liposuction back, flanks, abdomen, thighsTumescent liposuction back, flanks, abdomen, thighs 18 hrs post op on standing became lightheaded and18 hrs post op on standing became lightheaded and unresponsiveunresponsive PEAPEA Post mortem: DVTPost mortem: DVT
  12. 12. LiposuctionLiposuction  Tumescent technique: 1990’sTumescent technique: 1990’s – MACMAC – Local solutionLocal solution 1 L NS1 L NS 500 – 1000 mg lidocaine500 – 1000 mg lidocaine 0.25 – 1 mg epinephrine0.25 – 1 mg epinephrine 12.5 mmol bicarbonate12.5 mmol bicarbonate
  13. 13. TechniqueTechnique  Removal of subQ fat with local performed by dermatologist orRemoval of subQ fat with local performed by dermatologist or surgeonsurgeon  Common anatomic site: abdomen, thighs, buttocks, maleCommon anatomic site: abdomen, thighs, buttocks, male breasts, arms, medial thigh, female breastbreasts, arms, medial thigh, female breast  Patient factors: Hg, PLT, Coags, ChemistryPatient factors: Hg, PLT, Coags, Chemistry  Lidocaine 35 – 45 mg/kg; max 55 mg/kgLidocaine 35 – 45 mg/kg; max 55 mg/kg  Epinephrine 0.25 – 1.5 mg/L; max 50 mcg/kgEpinephrine 0.25 – 1.5 mg/L; max 50 mcg/kg  Recommended volume of fat removed < 5000 ccRecommended volume of fat removed < 5000 cc  Plasma lidocaine levels have been elevated for 16 to 23 hrs.Plasma lidocaine levels have been elevated for 16 to 23 hrs. Indian J Dermatol Venereol Leprol. 2008 Jan;74 Suppl:S54-60Indian J Dermatol Venereol Leprol. 2008 Jan;74 Suppl:S54-60
  14. 14. LidocaineLidocaine Suppress myocardial automaticitySuppress myocardial automaticity Therapeutic plasma concentration 2 to 5 mg/L; > 5 TOXICTherapeutic plasma concentration 2 to 5 mg/L; > 5 TOXIC Some vasodilationSome vasodilation 5 to 9 mg/L5 to 9 mg/L paresthesias, somnolence, siezuresparesthesias, somnolence, siezures >10 mg/L CV collapse>10 mg/L CV collapse Goldfrank LR, Flomenbaum NE, Lewin NA, Weisman RS, HowlandGoldfrank LR, Flomenbaum NE, Lewin NA, Weisman RS, Howland MA, Hoffman RS, eds. Goldfrank’s toxicologic emergencies. 5MA, Hoffman RS, eds. Goldfrank’s toxicologic emergencies. 5thth ed. Norwalk, Cnn.: Apleton & Lange, 1994:717-9ed. Norwalk, Cnn.: Apleton & Lange, 1994:717-9
  15. 15. Clinical careClinical care

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