Local Anesthetics in Liposuction: Considerations for New Practice Advisory Guidelines to Improve Patient Safety

[Liposuctions in the ambulatory setting]

BACKGROUND

 Liposuctions are among the most frequently performed operations in plastic surgery worldwide. They are offered as inpatient as well as outpatient procedures. In the outpatient setting, tumescent anaesthesia is used in various forms. There is ambiguity about the amount of lipoaspirate that can be removed safely in an outpatient setting, and also about the monitoring of parameters and the duration of postoperative care.

MATERIAL AND METHODS

 A systematic literature review was conducted with the help of the MEDLINE data base of the U. S. National Library of Medicine (NLM) and the bibliographic search engine Google Scholar (https://scholar.google.com) of Google LLC. The key words "Liposuction Anesthesia" and "Liposuction Guidelines" were used. All items resulting from the search were checked for thematic concordance and further analysed by their level of evidence, significance and availability.

RESULTS

 After the literature review, a total of 197 items were identified for further analysis. The analysis of the international and German literature yielded a systematic overview of recommendations.

CONCLUSIONS

 Tumescence anaesthesia in an outpatient setting has various advantages, e. g. cost reduction for provider and patient as well as avoidance of the risk profile of general anaesthesia. Also patients can change their position autonomously, which can be beneficial for surgery. However, there are limitations in terms of the lipoaspirate volume that can be removed safely. With increasing lipoaspirate volumes, more local anaesthetic is needed, which also increases the postoperative monitoring time. In the authors view, tumescent anaesthesia should only be used for small-volume and localised liposuctions. Liposuction in general anaesthesia offers more advantages, especially with increasing lipoaspirate volumes.

Safety of Postoperative Opioid Alternatives in Plastic Surgery: A Systematic Review

With the growing opioid epidemic, plastic surgeons are being encouraged to transition away from reliance on postoperative opioids. However, many plastic surgeons hesitate to use nonopioid analgesics such as nonsteroidal antiinflammatory drugs and local anesthetic blocks because of concerns about their safety, particularly bleeding. The goal of this systematic review is to assess the validity of risks associated with nonopioid analgesic alternatives. A comprehensive literature search of the PubMed and MEDLINE databases was conducted regarding the safety of opioid alternatives in plastic surgery. Inclusion and exclusion criteria yielded 34 relevant articles. A systematic review was performed because of the variation between study indications, interventions, and complications. Thirty-four articles were reviewed that analyzed the safety of ibuprofen, ketorolac, celecoxib, intravenous acetaminophen, ketamine, gabapentin, liposomal bupivacaine, and local and continuous nerve blocks after plastic surgery procedures. There were no articles that showed statistically significant bleeding associated with ibuprofen, celecoxib, or ketorolac. Similarly, acetaminophen administered intravenously, ketamine, gabapentin, and liposomal bupivacaine did not have any significant increased risk of adverse events. Nerve and infusion blocks have a low risk of pneumothorax. Limitations of this study include small sample sizes, different dosing and control groups, and more than one medication being studied. Larger studies of nonopioid analgesics would therefore be valuable and may strengthen the conclusions of this review. As a preliminary investigation, this review showed that several opioid alternatives have a potential role in postoperative analgesia. Plastic surgeons have the responsibility to lead the reduction of postoperative opioid use by further developing multimodal analgesia.

Trends in medical disputes involving anesthesia during July 2009-June 2018: an analysis of the Korean Society of Anesthesiologists database

Background

To identify trends in injuries and substandard care associated with anesthesia, we analyzed the Korean Society of Anesthesiologists database for anesthesia-related case files from July 2009 to June 2018.

Methods

Case characteristics, injuries, and outcomes were compared between the first part (July 2009–June 2014, n = 105) and the second part (July 2014–June 2018, n = 92) of the analyzed time period.

Results

Overall, 132 cases resulted in death. The proportion of fatal cases for sedation was similar to general anesthesia (66.2% vs. 76.3%). The proportion of cases with permanent injury or death decreased significantly in the second part of the period compared with the first part (76.1% vs. 93.3%, P = 0.002). With a growing trend in the proportion of sedation cases, a similar number of sedation and general anesthesia cases were referred during the overall period (77 and 76 cases, respectively). Propofol-based regimens remained the dominant sedation method (89.7% in the first part vs. 78.9% in the second part). The most common adverse event in cases of permanent injury or death was identified as being respiratory in origin (98/182, 53.8%). Permanent injuries or deaths were related to local anesthetic systemic toxicity (LAST) and beach-chair positioning for shoulder surgery, in 8 and 5 cases, respectively.

Conclusions

Despite the decreasing trend in injury severity with time, several characteristic injury profiles were identified: lack of vigilance in propofol-based sedation, neurological injuries related to the beach-chair position, and LAST occurring during tumescent anesthesia or brachial plexus block.

Tumescent anaesthesia: its applications and well tolerated use in the out-of-operating room setting

PURPOSE OF REVIEW

Tumescent anaesthesia is a method of administering dilute local anaesthetic into the subcutaneous tissue. Many anaesthesiologists are unfamiliar with the technique, its applications and potential risks.

RECENT FINDINGS

The maximum safe dose of lidocaine with epinephrine in tumescent anaesthesia for liposuction is probably between 35 and 55 mg/kg. Without liposuction, the maximum dose of lidocaine with epinephrine should be no more than 28 mg/kg. After tumescent infiltration for liposuction, serum lidocaine concentrations peak between 12 and 16 h after injection. When tumescent lidocaine without epinephrine is used for endovenous laser therapy, peak serum lidocaine concentrations are observed much earlier, between 1 and 2 h after injection. Slow administration of more dilute concentrations of local anaesthetic decreases the risk of local anaesthetic systemic toxicity.

SUMMARY

Although appealing because of its ability to provide prolonged analgesia, high doses of local anaesthetic are frequently administered using the tumescent technique, and absorption of local anaesthetic from the subcutaneous tissue is variable. When caring for patients having procedures in which tumescent anaesthesia is used, the risk of local anaesthetic toxicity should be acknowledged and lipid emulsion should be available for prompt treatment if needed.

1000 Consecutive Cases of Laser-Assisted Liposuction Utilizing the 1440 nm Wavelength Nd:YAG Laser: Assessing the Safety and Efficacy

BACKGROUND

Liposuction remains one of the most popular aesthetic surgery procedures performed today, and it has undergone continuous refinements over the past four decades. Advancements in anesthesia, improvements in instrumentation, better understanding of fluid dynamics and the addition of energy to liposuction have led to better outcomes with improved safety and efficacy.

OBJECTIVES

The purpose of this study is to review 1000 consecutive laser-assisted liposuction (LAL) cases utilizing the 1440 nm wavelength. Emphasis was placed on complication rates and the need for revision procedures.

METHODS

The charts of 611 patients who underwent 1000 consecutive LAL operations were reviewed. All cases were performed either under general anesthesia or under local with sedation, and the cases were performed alone or in conjunction with other procedures. All patients went to presurgical testing and had preoperative laboratory and additional clearance by a specialist when indicated. Before and after medical photographs were obtained of all patients. All operations were done in an accredited office-based operating room. Demographic information, tumescent volume, aspirate volume, surgical time, complications and other data were reviewed.

RESULTS

There were one minor complication and no major complications such as burns, hospitalizations or mortalities. One patient developed a small hematoma, which was likely caused by the patient self-aspirating edema fluid during the immediate post-op period. The hematoma resolved with non-surgical management. The average laser energy applied was 15,756 J with an average total aspirate volume of 1256 cc. Fourteen anatomic areas were treated with LAL, and 59 operations were combination cases.

CONCLUSION

Energy-assisted liposuction using the 1440 nm wavelength has been shown in this series to have a very low complication rate when performed alone or in combination with other aesthetic operations under local and general anesthesia.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

On Beyond Lidocaine: Reconsidering Local Anesthetics in Tumescent Liposuction-A Critical Review

The use of tumescent solution in liposuction is now considered standard of care; however, much debate still exists regarding its ideal components, especially surrounding the inclusion of local anesthetics. This article reviews the discussion regarding the use of local anesthetics in tumescent liposuction and how it may evolve in the future. The need for local anesthetic additives in tumescent liposuction has been questioned, and the use of longer-acting agents discouraged; however, increasing number of reports in recent years have described the increasingly widespread use of tumescent anesthesia where a wetting solution is infiltrated to achieve anesthesia in an operative field for procedures other than liposuction. More high-level evidence, such as randomized controlled clinical trials, will be required; however, it should be possible to develop a useful standardized algorithm that can guide surgeons to optimize patient safety as well as patient experience.