r e v c o l o m b a n e s t e s i o l . 2 0 1 5;4 3(1):95100
Revista Colombiana de AnestesiologaColombian Journal of Anesthesiology
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iquid handling, lidocaine and epinephrine iniposuction. The properly form
orge Enrique Bayter Marin
D, Anesthesiologist and Intensivist, Medical Director Clnica El Pinar, Bucaramanga, Colombia. Anesthesia for Plastic Surgeryoordinating Committee, Sociedad Colombiana de Antesiologa y Reanimacin (S.C.A.R.E.), Sociedad Colombiana de Anestesiologa yeanimacin (S.C.A.R.E.)
a r t i c l e i n f o
rticle history:
eceived 28 April 2014
ccepted 13 September 2014
eywords:
ipectomy
ulmonary edema
nesthetics, local
oxicity
urgery, plastic
a b s t r a c t
Introduction: Fluid mismanagement in liposuction leads to pulmonary edema in a previ-
ously healthy individual. Pulmonary edema is considered the third cause of death in plastic
surgery after PTE and lidocaine toxicity. The most important risk factor leading to this out-
come is inadequate knowledge of fluid management and poor communication between the
surgeon and the anaesthetist.
Objectives: To review the causes leading up to pulmonary edema in liposuction and the valid
options for correct fluid management.
Methods: Non-systematic review of the literature in PubMed and Medline.
Results and conclusions: Correct fluid management in liposuction is based on a close commu-
nication between the surgeon and the anaesthetist in order to keep track of the total amount
of subcutaneous fluid infiltration plus fluids delivered intravenously, always bearing in mind
that infiltration fluids go to the central circulation.
2014 Sociedad Colombiana de Anestesiologa y Reanimacin. Published by Elsevier
Espaa, S.L.U. All rights reserved.
Manejo de lquidos, lidocana y epinefrina en liposuccin. La formacorrecta
alabras clave:
ipiectoma
r e s u m e n
Introduccin: El mal manejo de lquidos en liposuccin, conlleva a edema pulmonar en un
paciente previamente sano. El edema pulmonar se considera la tercera causa de muerte en
dema Pulmonar
nestsicos locales
oxicidad
iruga plstica
ciruga plstica despus del TEP y la Intoxicacin por lidocana. El principal factor de riesgo
que conlleva a este desenlace es el desconocimiento en el manejo de lquidos y la mala
comunicacin entre el cirujano y el anestesilogo.
Objetivos: Revisar las causas que llevan a edema pulmonar en liposuccin y las opciones
validas de manejo correcto de lquidos.
Please cite this article as: Marin JEB. Manejo de lquidos, lidocana y epinefrina en liposuccin. La forma correcta. Rev Colomb Anestesiol.015;43:95100.
E-mail address: [email protected]/ 2014 Sociedad Colombiana de Anestesiologa y Reanimacin. Published by Elsevier Espaa, S.L.U. All rights reserved.
dx.doi.org/10.1016/j.rcae.2014.10.003http://www.revcolanest.com.cohttp://crossmark.crossref.org/dialog/?doi=10.1016/j.rcae.2014.10.003&domain=pdfmailto:[email protected]
96 r e v c o l o m b a n e s t e s i o l . 2 0 1 5;4 3(1):95100
Mtodos: Se realiz una revisin de la literatura no sistemtica en las bases de datos PubMed
y Medline.
Resultados y conclusiones: El correcto manejo de lquidos en liposuccin se basa en una
estrecha comunicacin entre el cirujano y el anestesilogo para sumar los lquidos infil-
trados a nivel subcutneo y los colocados por va venosa, siempre teniendo en cuenta que
los lquidos de la infiltracin pasan a la circulacin central.
2014 Sociedad Colombiana de Anestesiologa y Reanimacin. Publicado por Elsevier
Espaa, S.L.U. Todos los derechos reservados.
Introduction
Liposuction is the most common cosmetic surgery proce-dure performed in the United States1 and also in Colombia.Advances in the techniques for infiltration, designed to allowplacement of epinephrine in a solution, thus reducing bleed-ing during lipoaspiration, have enabled removal in largevolumes during liposuction. This induces significant changesin fluid behaviour inside the compartment, with the risk ofpulmonary oedema and heart failure.2
Added to the invention by Klein in 1987 of a tumescentsolution that included 5001000 mg of lidocaine plus 1 mg ofepinephrine for every 1000 cc of NSS3 (Fig. 1) and which iswidely used today for subcutaneous infiltration, the risk oflidocaine toxicity is a reality and the second cause of deathin plastic surgery according to the American Society of PlasticSurgeons (ASPS).
The biggest problem with these new infiltration tech-niques, in particular the super wet and the tumescenttechniques is associated with the large infiltration volumes,at infiltration/aspiration ratios ranging from 1:1 in the superwet technique up to 23:1 in the tumescent technique.4 Thismeans that in a 3-litre liposuction, subcutaneous fluid infiltra-tion may amount to 39 litres, and this fluid volume requiresspecial consideration from the point of view of anaesthesia.
Methods
Non-systematic review of the literature using the PubMed andMedline databases, introducing key words in English like FluidManagement, Liposuction, pulmonary oedema, larger infiltra-tion, Aspiration volumes. All the articles were read and otherarticles of the selected references regarding the topic werealso queried. Overall, 151 references were selected using thismethodology.
Review
The use of large infiltration volumes in the tumescent solu-tions increases the difficulty of anaesthetic management inliposuction significantly. The risk of hypervolemia, pulmonaryoedema, epinephrine-related cardiovascular effects, and lido-caine toxicity is always present.5
The purpose of using infiltration solutions with 1 mg ofepinephrine in 1000 cc of Hartmans or NSS is to reduce bleed-ing into the lipoaspirate down to less than 5% of the extracted
volume.6 This results in the ability to perform large-volumeliposuction, with the ensuing complications. Some studiesconducted by Burk and Vasconez7 have shown the use of upto 10 mg of epinephrine at concentrations of 1:1,000,000 inhealthy patients, with no deleterious effects from toxicity suchas tachycardia and hypertension, although these megadosesmay lead to fatal consequences in patients with underlyingcardiac disease in whom no workup has been done.
The second problem, when Klein solutions are used, is theinfiltration of high doses of lidocaine (5001000 mg of 1% lido-caine for every 1000 cc of NSS). There are multiple studies inthe world literature conducted in plastic surgery patients thatshow that very high doses of lidocaine (up to 3555 mg/kg)could be safe8,9 considering that the infiltration is applied toscarcely vascularized adipose tissue and, moreover, consid-ering the additional vasoconstriction derived from the useof epinephrine in the dilution. These studies have shown amargin of safety in thousands of liposuction procedures per-formed, with no risk of toxic levels despite the high doses ofinfiltrated lidocaine.
As far as anaesthesia is concerned, the FDA only acceptsmaximum doses of 710 mg/kg. The ASPS has reported thatlidocaine toxicity may be an important cause of death inplastic surgery and might account for some intra- and post-operative deaths resulting from cardiac arrest in conditionsof normal oxygen saturation. However, this is very difficultto demonstrate because of the difficulty in measuring post-mortem serum levels, something that is usually done late ornot done at all. It is worth noting that the use of high lidocainedoses has enabled dermatologists and surgeons to performliposuction in their offices using local anaesthesia without thesupport of an anaesthetist, with the sole purpose of lower-ing the costs associated with the use of the operating roomand the support of the anaesthetist. For this reason, our rec-ommendation, when large quantities of lidocaine are used forinfiltration, is that an anaesthetist must be present in the roomand must be prepared to manage lidocaine toxicity-relatedcardiac arrest. Additionally, 20% lipids must be available inthe room as the only effective measure to revert cardiac arrestwhile waiting for resuscitation. Fig. 2, shows the protocol forthe management of local anaesthetic toxicity-related cardiacarrest, endorsed by the American Society of Regional Anaes-thesia and the American Society of Plastic Surgeons, andpublished in www.lipidrescue.org together with the suppor-ting literature.
The third issue relates to the large volumes of infiltratedfluids and volume overloading: in a 4-litre liposuction, subcu-taneous fluid infiltration may be as high as 12 litres.
http://www.lipidrescue.org/
r e v c o l o m b a n e s t e s i o l . 2 0 1 5;4 3(1):95100 97
Collagen (Triglycerides)
Adipose tissue
Water
Kleins solution
1000 CC NSS+
500-1000 MG lidocaine+
1 MG epinephrine+
10 cc Hco3Na
Blood
Fig. 1 Kleins solution composition and advantages for bleeding in liposuction.S
tmrdvtWuu
FtP
ource: Authors.
In 1998, the University of Texas Southwestern Medical Cen-re defined that a large-volume liposuction is the removal of
ore than 4000 cc of fat, while a small-volume liposuction cor-esponds to the removal of less than 4000 cc. The same studyetermined that the volume of fluids delivered is equal to theolume of infiltration fluids given by the plastic surgeon plushe volume of intravenous fluids given by the anaestheti
