Evidence-Based Patient Safety Advisory: Patient Assessment and Prevention of Pulmonary Side Effects in Surgery. Part 2—Patient and Procedural Risk Factors:

Pneumothorax as a Complication of Liposuction

Background

Pneumothorax is a rare complication of liposuction resulting from injury to the lung parenchyma.

Objectives

This study aimed to determine the incidence of pneumothorax complicating liposuction, describe an archetypal presentation, identify risk factors, and propose options for risk reduction.

Methods

In a retrospective chart review, liposuction procedures performed over a 16-year period by 8 surgeons in 1 practice were screened for pneumothorax. Cases featuring pneumothorax were analyzed to ascertain risk factors, presentation, and pathogenesis.

Results

Among the 16,215 liposuction procedures performed during the study period, 7 pneumothoraxes were identified (0.0432%). Six (85.7%) were female. Three (42.9%) had previous liposuction. Six cases (85.7%) included liposuction of the axillary region. All cases featured depression of intra/postoperative oxygen saturations as the initial sign. Three (42.9%) were identified intraoperatively. All patients were transferred to a hospital for imaging. Five (71.4%) underwent chest tube placement. Two (28.6%) were treated with observation alone. Pneumothoraxes were left-sided in 4 cases (57.1%), and right-sided in 3 cases (42.9%). In early cases, 1.5-mm infiltration cannulas were used; in 2016 cannula size was changed to 3-4 mm for infiltration and 4-5 mm for liposuction.

Conclusions

Possible risk factors for pneumothorax include liposuction of the axilla, use of flexible infiltration cannulas, and scarring from previous liposuction. We recommend including pneumothorax as a potential complication during informed consent, performing infiltration with a stiff >3.5-mm cannula, minimizing positive-pressure ventilation, emphasized awareness of cannula tip location in all patients but particularly in patients with previous liposuction or scar tissue, and increased caution when operating in the axillary area.

Level of Evidence: 4

Evidence-Based Strategies to Reduce Postoperative Complications in Plastic Surgery

Reconstructive plastic surgery is vital in assisting patients with reintegration into society after events such as tumor extirpation, trauma, or infection have left them with a deficit of normal tissue. Apart from performing a technically sound operation, the plastic surgeon must stack the odds in the favor of the patient by optimizing them before and after surgery. The surgeon must look beyond the wound, at the entire patient, and apply fundamental principles of patient optimization. This article reviews the evidence behind the principles of patient optimization that are commonly used in reconstructive surgery patients.

Venous Thromboembolism following Elective Aesthetic Plastic Surgery: A Longitudinal Prospective Study in 1254 Patients

Background. Venous thromboembolism (VTE) is a disorder with short-term mortality and long-term morbidity. Healthy patients submitted to elective aesthetic plastic surgeries (EAPS) have risk factors to develop VTE not well established yet. The objective of this study was to examine the incidence and risk factors for VTE in these patients. Methods. Longitudinal, prospective (minimum follow-up of 3 months), observational study. Comprehensive information on patient characteristics and surgeries performed was obtained. Preoperative, intraoperative, and postoperative risk factors were analyzed for their association with VTE. Results. A total of 1254 patients were included in the study. Postoperative VTE occurred in 17 (1,35%) of patients. VTE was more frequent in patients more than 40 years old (82.3%). Smoking, patients with 2 or 3 pregnancies, and hormone replacement therapy, and oral contraceptives use presents higher levels of VTE. In this study we have not found any correlation between liposuction, augmentation mammoplasty, mastopexy, and rhinoplasty as an isolated risk factor for VTE. Conclusions. The incidence of VTE in patients undergoing EAPS was 1.35%. Patients with more than 40 years of age, tobacco users, patients with 2 or more pregnancies, and hormone replacement therapy or oral contraceptives use presents higher levels of VTE.

Evidence based development of bedside clinical drug rules for surgical patients

BACKGROUND

Surgical adverse events constitute a considerable problem. More than half of in-hospital adverse events are related to a surgical procedure. Medication related events are frequent and partly preventable. Due to the complexity and multidisciplinary nature of the surgical process, patients are at risk for drug related problems. Consistent drug management throughout the process is needed.

OBJECTIVE

The aim of this study was to develop an evidence-based bedside tool for drug management decisions during the pre- and postoperative phase of the surgical pathway.

SETTING

Tool development study performed in an academic medical centre in the Netherlands involving an expert panel consisting of a surgeon, a clinical pharmacist and a pharmacologist, all experienced in quality improvement.

METHOD

Relevant medication related problems and critical pharmacotherapeutic decision steps in the surgical process were identified and prioritised by a team of experts. The final selection comprised undesirable effects or unintended outcomes related to surgery (e.g. pain, infection) and comorbidity related hazards (e.g. diabetes, cardiovascular diseases). To guide patient management, a list of bedside surgical drug rules was developed using international evidence-based guidelines.

MAIN OUTCOME MEASURE

55 bedside drug rules on 6 drug categories, specifically important for surgical practice, were developed: pain, respiration, infection, diabetes, cardiovascular diseases and anticoagulation.

RESULTS

A total of 29 evidence-based guidelines were used to develop the Bedside Surgical Drug Rules tool. This tool consist of practical tables covering management regarding (1) the most commonly used drug categories during surgery, (2) comorbidities that require dosing adjustments and, (3) contra-indicated drugs in the perioperative period.

CONCLUSION

An evidence-based approach provides a practical basis for the development of a bedside tool to alert and assist the care providers in their drug management decisions along the surgical pathway.

Asystole in young athletic women during breast augmentation: a report of three cases

Reported herein are three cases of spontaneous bradycardia progressing to asystole during routine breast augmentation in healthy, adult female patients with a history of endurance training and resting bradycardia (heart rate <60 beats per minute). The incidence of this phenomenon is minimally reported and virtually unexplained in literature. Our goal is to alert the plastic surgery community of the possibility of these events occurring without warning in athletic patients, attempt to explain these findings, and provide a plan of action to minimize morbidity and mortality in these patients. The most severe case was that of a 38-year-old female who became severely bradycardic progressing to asystole during routine breast augmentation. She had no history of any medical problems, but did have a resting heart rate of <60. Glycopyrrolate, an antimuscarinic agent, was given and chest compressions started. After 10-20 s of chest compressions the patient's normal sinus rhythm resumed. Two other cases are also reported, although these patients responded to antimuscarinic agents without requiring chest compressions. Both were endurance athletes with a resting heart rate of <60. Bradycardia caused by a vagal response during surgery is not uncommon and routinely treated successfully with administration of atropine-like agents. Bradycardia progressing to frank asystole is rare and has not been reported in young, otherwise healthy, aesthetic surgery patients. This report should serve to alert the plastic surgeon to the possibility of this situation occurring and how to treat it successfully, especially in the outpatient or office-based surgery setting. Level of Evidence V This journal requires that authors assign a level of evidence to each article.

Rhinoplasty

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty.

SUMMARY

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.