Anesthesia management for Mega liposuction Dr Abhijit Nair Dr K Sriprakash Consultant Anesthesiologist, Axon Anesthesia Associates, Care Hospital, Hyderabad.
Definition:
A cosmetic surgery done to remove
fat from deposits under the skin using
a cannula with a powerful suction
It is also called as lipoplasty
or fat moulding
Goals of liposuctionTo remove target fat thereby leaving
desired body contour between suctional
and non suctional areas
Achieved by selecting the patients
carefully and using proper method to
avoid contour irregularity
To monitor the patient in a monitored
area by trained personnel to avoid
post operative complications
Patient’s perspective:Sense of confidence
Marital reasons ( pre, post )
Reduction in requirement of
anti hypertensives
Reduction in doses of OHAs/ Insulin
But ends up spending on garments !
History of liposuction:First suction liposuction done by
French Surgeon Charles Dujarier
in 1920
Patient was a famous model
from Paris
Died due to gangrene
Liposuction went into oblivion
for several decades thereafter
Techniques of liposuction:
Dry technique, ( EBL : 20-45% of aspirated volume )
Wet technique, ( EBL : 4-30% of aspirated volume )
Super wet technique, ( EBL : 1% of aspirated volume )
Tumescent technique, ( EBL : 1% of aspirated volume)
Varieties:
Ultrasound assisted
Power assisted
Laser assisted
Laser lipolysis
VASERVASER liposuction ( Vibration amplification of sound energy at resonance )
The procedure:
Not a benign procedure
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
Pulmonary embolism in 23.1% cases of deaths
Clinical Anesthesia. Barash, 6th Edition. Page 854.
Mega liposuction / Large volume liposuction
Variable definition
When more than 5 liters of total volume is removed from the patient
Most of the complications associated with mega liposuction
are related to fluid shifts and fluid balance, hence the procedure is
described as total volume removed from the patient, including fat,
wetting solution, and blood
There is no distinct boundary line that defines the limits of safe
surgery
When liposuction crosses into the domain of excessive surgical
trauma, it changes from a benign cosmetic procedure into a
potentially lethal process
There is no antidote for a toxic dose of surgical trauma
Safe approach:Prevention of excessive trauma,
Use common sense,
Respect the patient’s co morbidities
5 pillars of safety:
1)To have a trained Surgeon,
2)To have a trained Anesthesiologist,
3)To have a decent set up,
4)Trained ICU/ operation room staff,
5)To select the patient properly.
Patient selection:
Patient’s characteristics:
Unrealistic expectations
Co morbidities
Pharmacotherapy
Previous failures
Skin contour irregularities,
asymmetries, skin laxities,
redundancies to be noted/ drawn
Priming in advance for
secondary/ touch up procedures
Cost of procedure:
Indeed costly
Quality of liposuction more important than cost
Discount advertisements – misguides the patient
Patient should enquire about the expertise/ experience of surgeon,
place of surgery, set up etc
Choosing liposuction based on price may turn out to be expensive if
surgery is not up to the mark
Undesirable outcomes:
1)Incomplete liposuction,
2)Excessive liposuction-
disfigurement,
3)Irregular/ uneven depression,
4)Bad scars
In the US, more than 341,000 liposuction procedures were performed in 2008
Indian data ? But very popular
Still, information in textbooks ?!
PAC:Detailed history
Highlight co morbidities, OSA, PAH
Note ongoing medications
( NSAIDs,steroids,garlic,anti platelets
to be stopped )
Vitals, Airway, BMI
Relevant investigations
2D ECHO
Pre operative instructions
( Fasting, medications to be
stopped/ to be taken )
Outline the procedure
To inform in advance discomfort
due to garments, ooze etc
DVT prophylaxis?
Anesthesia managementGA with CV Vs Regional
GA preferred over Regional
for Mega liposuction
Review the patient
Balanced Anesthesia
Use short acting agents
Benzodiazepines, Opioids,
NDMR, Inhalational
VIMA Vs TIVA
Premedication:
Anti emetics, PPI/ H2 blockers
Antibiotic
Tranexamic acid / Ethamsylate
/ Haemocoagulase
Use warm fluids
Warming blankets
Sequential compression device
Airway:
Intra operative monitoring:Heart rate, Electrocardiogram ( lead II, V5)
Blood pressure ( Non invasive/ arterial if adequate sized cuff is not available)
Spo2
End tidal CO2
Temperature ( nasopharyngeal/ axillary/ oral, OT)
Input/ output
Charting every 5 minutes
Hemodynamic changes: Increase in:
Cardiac index
Heart rate
Mean PAP
Stroke volume index
RVSWI
Decrease in:
MAP
SVRI
During surgery , constant communication
between the Surgeon & the Anesthesiologist very important
• Input , output , quality of aspirate etc to be discussed
• NIBP during vigorous suctioning !?
• NTG, Labetalol, Metoprolol, Narcotics , Inhalational boluses during new area suctioning
Charting:Quantity of wetting solution used,
Amount of lignocaine used
( should not exceed >35-55 mg/kg)
The epinephrine in the solution :( 50 ug/kg )
decreases systemic absorption of large amount of subcutaneous injection,
Oliguria, Tachycardia
Fat & saline aspirate,
Blood loss,
Urine output
Fluid management:Controversial practice
Consider mega liposuction as burns ? PARKLAND’S formula
Insensible losses can’t be predicted
3rd spacing?
Colloids Vs Crystalloids!
Formulas?
Blood loss?
Post op hemodilution!
Goals of IVF:To replace pre operative deficit
To provide maintenance fluid
To avoid pre renal AKI
To correct insensible losses
Blood transfusion if justified
The formulas:0.25 ml of IVF for 1 ml aspirated over 4L i.e. 25% of lipo aspirate + maintenance
[ 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. ]
0.25 ml of IVF for each ml over 5L i.e. 25% of lipo aspirate ( no maintenance )
[ 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.}
RESIDUAL VOLUME THEORY:RESIDUAL VOLUME= TOTAL FLUID( Intravenous
fluids + wetting solution + local anesthetic) –
( TOTAL SALINE IN ASPIRATE, not blood + URINE)
Residual volume/ Patient’s pre op weight = 90- 120 ml/ kg
If < 90 ml/kg, volume resuscitation warranted
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.
Pitman GH, Aker JS, Tripp ZD. Tumescent liposuction. A surgeon’s perspective. Clin Plast Surg 1996;23:633-4.
Liposuction: Anaesthesia challenges. Jayshree Sood et all. IJA 2011;55:220-7.
Example:Total fluid = 4L IVF + 4L wetting solution + 50 ml lignocaine = 8050 ml
Total output = 1200 ml saline + 800 ml urine = 2000 ml
Residual volume = 8050 – 2000 = 6050 ml
Pre op Weight of patient = 100 kg
6050/100 = 60.5 ml/kg
Hypovolaemia, needs IVF
Intra operative fluid volume ratio:
[Volume of IVF + volume of infiltration] ÷ Aspirate volume
If ratio is more, patient is overhydrated
Ratio is used to compare different types of fluid resuscitation strategies
Important Anesthesia considerations:Padding of pressure points, in prone
( axilla, wrist, elbow, eyes, genitals,
brachial plexus, occiput)
Avoid unnecessary traction
Lubricate eyes
Prophylaxis for deep vein thrombosis
Use of epinephrine: intra operative oliguria?
Thermoregulation:Cold wetting solutions, IVF
Prolonged duration
GA
OT
Complications:
Coagulopathy
Oliguria
Arrythmias
Electrolyte imbalance
Complications:Rare
Frustrating for Surgeon, Patient, attenders
Minor complications: unpredictable
Major: Avoidable ( REMEMBER 5 PILLARS )
Minor complications:
Prolonged swelling,
contour related complications,
Scarring,
delayed healing,
blistering,
seromas,
hyperchromia
Major complications:PTE,
Deep vein thrombosis,
pulmonary edema due to fluid overload,
penetrating injuries,
skin/ soft tissue necrosis,
shock,
fat embolism,
local anesthesia systemic toxicity ( LAST )
excessive bleeding leading to blood transfusion
Bloody lipo aspirate?Terminate the surgery
Reevaluate the technique, enquire
about constituents of infiltration
Use more wetting solution with
epinephrine for haemostatic effect
Causes of excessive intra operative bleed:
Use of anti platelets
Use of NSAIDs, steroids
On garlic, garlic pearls, herbal medication etc.
Male gender
Smokers
Diabetics ( small vessel insufficiency)
Hypothyroids
Compressive garments:Decreases bleeding
Decreases swelling
Decreases third spacing of fluid
Tranexamic Acid :An anti fibrinolytic agent that competitively inhibits activation of plasminogen to plasmin which is responsible for degradation of fibrin, which causes hemorrhage
A preoperative dose of 10 mg/kg of tranexamic acid in a infusion over 15-20 minutes !
Trials are awaited to prove the benefit in large volume liposuction
Post operative care:TPR, BP, Pain monitoring, input/ uotput charting
IV fluids
Analgesia: short acting opioids ( Fentanyl infusion), Tramadol, PCM
Avoid NSAIDs on the day of surgery
Epidural ( If tummy tuck/ abdominoplasty is done)
TAP block
VIT C, Multivitamin preparations
Sequential compression device/ Low molecular weight heparin/ mobilisation/ Antiemetics
Blood transfusion +/-
Serratiopeptidase/ Trypsin : Chymotrypsin preparation
Delayed anemia after mega LPS:
Post operative inflammatory response leading to blunting of erythropoeitic response
Diminished availability of Iron
Panniculitis in liposuction systemic inflammatory response
Hemodilution due to fluids
Management:
Blood transfusion
IV Fe
Erythropoeitin
Further investigation
Age: 55yrs; BMI: 38; 14.5 liters removed
Reduced 12 kg
Delayed healing - 4weeks
Pre-op
Post-op3 months
Post op bleeding & hypothyroidism:
Decrease in plasma factor VII concentration
Increased aPTT
Acquired von Willebrand disease ( due to decreased
factor VII coagulant activity , decreased vWF
activity)
Decreased platelet adhesiveness, due to acquired
vWF disease
Prolonged t1/2 of factor II, VII, X
Hypothyroid patients posted for surgery manifest Euthyroid Sick Syndrome due to stress
The total T3 decreases 30 minutes after induction, it remains low for 24 hours
They also have decreased FT3 & FT4 levels perioperatively
THANK YOU
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