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Anesthesia management for Mega liposuction.


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Anesthesia management for Mega liposuction.

  1. 1. Anesthesia management for Mega liposuction<br />Dr AbhijitNair<br /> Dr K Sriprakash<br /> Consultant Anesthesiologist, <br />Axon Anesthesia Associates, <br />Care Hospital, <br />Hyderabad.<br />
  2. 2. Definition:<br />A cosmetic surgery done to remove<br /> fat from deposits under the skin using<br />a cannula with a powerful suction <br />It is also called as lipoplasty<br />or fat moulding<br />
  3. 3. Goals of liposuction<br />To remove target fat thereby leaving<br /> desired body contour between suctional<br /> and non suctional areas<br />Achieved by selecting the patients<br /> carefully and using proper method to<br /> avoid contour irregularity <br />To monitor the patient in a monitored<br /> area by trained personnel to avoid<br /> post operative complications <br />
  4. 4. Patient’s perspective:<br />Sense of confidence<br />Marital reasons ( pre, post )<br />Reduction in requirement of <br /> anti hypertensives<br />Reduction in doses of OHAs/ Insulin<br />But ends up spending on garments !<br />
  5. 5. History of liposuction:<br />First suction liposuction done by <br /> French Surgeon Charles Dujarier<br /> in 1920<br />Patient was a famous model <br /> from Paris<br />Died due to gangrene<br />Liposuction went into oblivion <br /> for several decades thereafter<br />
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  7. 7. Techniques of liposuction:<br />Dry technique, ( EBL : 20-45% of aspirated volume )<br />Wet technique, ( EBL : 4-30% of aspirated volume )<br />Super wet technique, ( EBL : 1% of aspirated volume )<br />Tumescent technique, ( EBL : 1% of aspirated volume)<br />
  8. 8. Varieties:<br />Ultrasound assisted<br />Power assisted<br />Laser assisted<br />Laser lipolysis<br />
  9. 9. VASER<br />VASER liposuction ( Vibration amplification of sound energy at resonance )<br />
  10. 10. The procedure:<br />Not a benign procedure<br />In 2000, a census survey of 1200 members of ASAPS ( American Society of Aesthetic Plastic Surgeons ) revealed an overall mortality rate of 19.1/100,000 liposuction<br />Pulmonary embolism in 23.1% cases of deaths<br />Clinical Anesthesia. Barash, 6th Edition. Page 854.<br />
  11. 11. Mega liposuction / Large volume liposuction<br />Variable definition<br />When more than 5 liters of total volume is removed from the patient<br /> Most of the complications associated with mega liposuction<br /> are related to fluid shifts and fluid balance, hence the procedure is<br /> described as total volume removed from the patient, including fat, <br /> wetting solution, and blood<br />
  12. 12. There is no distinct boundary line that defines the limits of safe <br /> surgery<br />When liposuction crosses into the domain of excessive surgical <br /> trauma, it changes from a benign cosmetic procedure into a <br /> potentially lethal process<br />There is no antidote for a toxic dose of surgical trauma<br />
  13. 13. Safe approach:<br />Prevention of excessive trauma,<br />Use common sense,<br />Respect the patient’s co morbidities<br />
  14. 14. 5 pillars of safety:<br />1)To have a trained Surgeon,<br />2)To have a trained Anesthesiologist,<br />3)To have a decent set up,<br />4)Trained ICU/ operation room staff,<br />5)To select the patient properly.<br />
  15. 15. Patient selection:<br /> Patient’s characteristics:<br />Unrealistic expectations<br />Co morbidities<br />Pharmacotherapy<br />Previous failures<br />
  16. 16. Skin contour irregularities, <br /> asymmetries, skin laxities, <br /> redundancies to be noted/ drawn<br />Priming in advance for <br /> secondary/ touch up procedures <br />
  17. 17. Cost of procedure:<br />Indeed costly<br />Quality of liposuction more important than cost<br />Discount advertisements – misguides the patient<br />Patient should enquire about the expertise/ experience of surgeon, <br /> place of surgery, set up etc<br />Choosing liposuction based on price may turn out to be expensive if <br /> surgery is not up to the mark<br />
  18. 18. Undesirable outcomes:<br />1)Incomplete liposuction,<br />2)Excessive liposuction-<br /> disfigurement,<br />3)Irregular/ uneven depression,<br />4)Bad scars<br />
  19. 19. In the US, more than 341,000 liposuction procedures were performed in 2008<br />Indian data ? But very popular<br />Still, information in textbooks ?!<br />
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  21. 21. PAC:<br />Detailed history<br />Highlight co morbidities, OSA, PAH<br />Note ongoing medications <br /> ( NSAIDs,steroids,garlic,anti platelets<br /> to be stopped ) <br />Vitals, Airway, BMI<br />Relevant investigations<br />2D ECHO<br />
  22. 22. Pre operative instructions<br /> ( Fasting, medications to be <br /> stopped/ to be taken )<br />Outline the procedure<br />To inform in advance discomfort <br /> due to garments, ooze etc<br />DVT prophylaxis?<br />
  23. 23. Anesthesia management<br />GA with CV Vs Regional<br />GA preferred over Regional <br /> for Mega liposuction<br />Review the patient<br />Balanced Anesthesia<br />Use short acting agents<br />Benzodiazepines, Opioids, <br /> NDMR, Inhalational<br />VIMA Vs TIVA<br />
  24. 24. Premedication:<br />Anti emetics, PPI/ H2 blockers<br />Antibiotic<br />Tranexamic acid / Ethamsylate<br /> / Haemocoagulase<br />Use warm fluids<br />Warming blankets<br />Sequential compression device<br />
  25. 25. Airway:<br />
  26. 26.
  27. 27. Intra operative monitoring:<br />Heart rate, Electrocardiogram ( lead II, V5)<br />Blood pressure ( Non invasive/ arterial if adequate sized cuff is not available)<br />Spo2<br />End tidal CO2<br />Temperature ( nasopharyngeal/ axillary/ oral, OT)<br />Input/ output<br />Charting every 5 minutes <br />
  28. 28. Hemodynamic changes:<br /> Increase in:<br />Cardiac index<br />Heart rate<br />Mean PAP<br />Stroke volume index<br />RVSWI<br /> Decrease in:<br />MAP<br />SVRI<br />
  29. 29. During surgery , constant communication <br /> between the Surgeon & the Anesthesiologist very important<br /> • Input , output , quality of aspirate etc to be discussed<br /> • NIBP during vigorous suctioning !?<br /> • NTG, Labetalol, Metoprolol, Narcotics , Inhalational boluses during new area suctioning<br />
  30. 30. Charting:<br />Quantity of wetting solution used, <br />Amount of lignocaine used<br /> ( should not exceed >35-55 mg/kg)<br /> The epinephrine in the solution :( 50 ug/kg )<br /> decreases systemic absorption of large amount of subcutaneous injection, <br />Oliguria, Tachycardia<br />Fat & saline aspirate,<br />Blood loss,<br />Urine output<br />
  31. 31. Fluid management:<br />Controversial practice<br />Consider mega liposuction as burns ? PARKLAND’S formula<br />Insensible losses can’t be predicted<br />3rd spacing?<br />Colloids Vs Crystalloids!<br />Formulas?<br />Blood loss?<br />Post op hemodilution!<br />
  32. 32. Goals of IVF:<br />To replace pre operative deficit<br />To provide maintenance fluid<br />To avoid pre renal AKI<br />To correct insensible losses<br />Blood transfusion if justified<br />
  33. 33. The formulas:<br />0.25 ml of IVF for 1 ml aspirated over 4L i.e. 25% of lipo aspirate + maintenance<br /> [ SAFETY CONSIDERATIONS & FLUID RESUSCITAION IN LIPOSUCTION: AN ANALYSIS OF 53 PATIENTS.  Trott, Suzanne A.; Beran, Samuel J.; Rohrich, Rod J.; Kenkel, Jeffrey M.; Adams, William P. Jr.; Klein, Kevin W. Plastic & Reconstructive Surgery. 102(6):2220-2229, November 1998. ]<br />0.25 ml of IVF for each ml over 5L i.e. 25% of lipo aspirate ( no maintenance )<br /> [ Fluid resuscitation in liposuction: A retrospective review of 89 consecutive patients. Rohrich, Rod J.; Leedy, Jason E.; Swamy, Ravi; Brown, Spencer A.; Coleman, Jayne. Plastic & Reconstructive Surgery. 117(2):431-435, February 2006.}<br />
  34. 34. RESIDUAL VOLUME THEORY:<br />RESIDUAL VOLUME= TOTAL FLUID( Intravenous<br /> fluids + wetting solution + local anesthetic) –<br /> ( TOTAL SALINE IN ASPIRATE, not blood + URINE)<br /> Residual volume/ Patient’s pre op weight = 90- 120 ml/ kg<br /> If < 90 ml/kg, volume resuscitation warranted<br />Sommer B. Advantages and disadvantages of TLA. In: Hanke CW, Sommer B, Sattler G, editors. Tumescent local anaesthesia. New York: Springer; 2001. p. 47-51.<br /> Pitman GH, Aker JS, Tripp ZD. Tumescent liposuction. A surgeon’s perspective. ClinPlastSurg 1996;23:633-4.<br /> Liposuction: Anaesthesia challenges. JayshreeSood et all. IJA 2011;55:220-7.<br />
  35. 35. Example:<br />Total fluid = 4L IVF + 4L wetting solution + 50 ml lignocaine = 8050 ml<br />Total output = 1200 ml saline + 800 ml urine = 2000 ml<br />Residual volume = 8050 – 2000 = 6050 ml<br />Pre op Weight of patient = 100 kg<br />6050/100 = 60.5 ml/kg<br />Hypovolaemia, needs IVF <br />
  36. 36. Intra operative fluid volume ratio:<br />[Volume of IVF + volume of infiltration] ÷ Aspirate volume<br />If ratio is more, patient is overhydrated<br />Ratio is used to compare different types of fluid resuscitation strategies<br />
  37. 37.
  38. 38. Important Anesthesia considerations:<br />Padding of pressure points, in prone<br /> ( axilla, wrist, elbow, eyes, genitals,<br /> brachial plexus, occiput)<br />Avoid unnecessary traction<br />Lubricate eyes<br />Prophylaxis for deep vein thrombosis<br />Use of epinephrine: intra operative oliguria?<br />
  39. 39. Thermoregulation:<br />Cold wetting solutions, IVF<br />Prolonged duration<br />GA<br />OT<br /> Complications:<br />Coagulopathy<br />Oliguria<br />Arrythmias<br />Electrolyte imbalance<br />
  40. 40. Complications:<br />Rare<br />Frustrating for Surgeon, Patient, attenders<br />Minor complications: unpredictable<br />Major: Avoidable ( REMEMBER 5 PILLARS )<br />
  41. 41. Minor complications:<br />Prolonged swelling, <br />contour related complications,<br />Scarring, <br />delayed healing, <br />blistering, <br />seromas, <br />hyperchromia<br />
  42. 42. Major complications:<br />PTE, <br />Deep vein thrombosis, <br /> pulmonary edema due to fluid overload,<br /> penetrating injuries, <br />skin/ soft tissue necrosis, <br />shock, <br />fat embolism, <br />local anesthesia systemic toxicity ( LAST ) <br />excessive bleeding leading to blood transfusion <br />
  43. 43. Bloody lipo aspirate?<br />Terminate the surgery<br />Reevaluate the technique, enquire <br /> about constituents of infiltration<br />Use more wetting solution with <br /> epinephrine for haemostatic effect <br />
  44. 44. Causes of excessive intra operative bleed:<br />Use of anti platelets<br />Use of NSAIDs, steroids<br />On garlic, garlic pearls, herbal medication etc.<br />Male gender<br />Smokers<br />Diabetics ( small vessel insufficiency)<br />Hypothyroids<br />
  45. 45. Compressive garments:<br />Decreases bleeding<br />Decreases swelling<br />Decreases third spacing of fluid<br />
  46. 46. Tranexamic Acid :<br />An anti fibrinolytic agent that competitively inhibits activation of plasminogen to plasmin which is responsible for degradation of fibrin, which causes hemorrhage<br />A preoperative dose of 10 mg/kg of tranexamic acid in a infusion over 15-20 minutes !<br />Trials are awaited to prove the benefit in large volume liposuction <br />
  47. 47. Post operative care:<br />TPR, BP, Pain monitoring, input/ uotput charting<br />IV fluids<br />Analgesia: short acting opioids ( Fentanyl infusion), Tramadol, PCM<br /> Avoid NSAIDs on the day of surgery <br /> Epidural ( If tummy tuck/ abdominoplasty is done)<br /> TAP block<br />VIT C, Multivitamin preparations<br />
  48. 48. Sequential compression device/ Low molecular weight heparin/ mobilisation/ Antiemetics<br />Blood transfusion +/-<br />Serratiopeptidase/ Trypsin : Chymotrypsin preparation<br />
  49. 49. Delayed anemia after mega LPS:<br />Post operative inflammatory response leading to blunting of erythropoeitic response<br />Diminished availability of Iron<br />Panniculitis in liposuction  systemic inflammatory response<br />Hemodilution due to fluids<br />
  50. 50. Management:<br />Blood transfusion<br />IV Fe<br />Erythropoeitin<br />Further investigation<br />
  51. 51. Age: 55yrs; BMI: 38; 14.5 liters removedReduced 12 kgDelayed healing - 4weeks<br />Post-op<br />Pre-op<br />3 months<br />
  52. 52. Post op bleeding & hypothyroidism:<br />Decrease in plasma factor VII concentration<br /> Increased aPTT<br /> Acquired von Willebrand disease ( due to decreased <br /> factor VII coagulant activity , decreased vWF<br /> activity)<br /> Decreased platelet adhesiveness, due to acquired <br />vWF disease<br /> Prolonged t1/2 of factor II, VII, X<br />
  53. 53. Hypothyroid patients posted for surgery manifest Euthyroid Sick Syndrome due to stress<br />The total T3 decreases 30 minutes after induction, it remains low for 24 hours<br />They also have decreased FT3 & FT4 levels perioperatively<br />
  54. 54.
  55. 55. THANK YOU<br />