Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation

BACKGROUND

Subcutaneous implantable cardioverter-defibrillator (S-ICD) is an effective alternative to transvenous implantable cardioverter-defibrillator. General anesthesia (GA) is considered the standard sedation approach because of the pain caused by the manipulation of subcutaneous tissue with S-ICD implantation. However, GA carries several limitations, including additional risk of adverse events, prolonged in-room times, and increased costs.

OBJECTIVE

The purpose of this study was to define the effectiveness and safety of tumescent local anesthesia (TLA) in comparison to GA in patients undergoing S-ICD implantation.

METHODS

We performed a prospective, nonrandomized, controlled, multicenter study of patients referred for S-ICD implantation between 2019 and 2020. Patients were allocated to either TLA or GA on the basis of patient's preferences and/or anesthesia service availability. TLA was prepared using lidocaine, epinephrine, sodium bicarbonate, and sodium chloride. All patients provided written informed consent, and the institutional review board at each site provided approval for the study.

RESULTS

Sixty patients underwent successful S-ICD implantation from July 2019 to November 2020. Thirty patients (50%) received TLA, and the rest GA. There were no differences between groups with regard to baseline characteristics. In-room and procedural times were significantly shorter with TLA (107.6 minutes vs 186 minutes; P < .0001 and 53.2 minutes vs 153.7 minutes; P < .0001, respectively). Pain was reported less frequently by patients who received TLA. The use of opioids was significantly reduced in patients who received TLA (23% vs 62%; P = .002).

CONCLUSION

TLA is an effective and safe alternative to GA in S-ICD implantation. The use of TLA is associated with shorter in-room and procedural times, less postprocedural pain, and reduced usage of opioids and acetaminophen for analgesia.

Subfascial Breast Augmentation with Crossed Fascial Sling, Under Tumescent Anaesthesia With or Without Sedation and Lower Periareolar Access

The tumescent technique is very effective for subfascial breast implant surgery. A total amount volume of 330 cc (120/160 cc for each breast) ensures a clean and bloodless field, leading to less postoperative bruising and prolonged local anaesthesia effects. The surgical procedure can be performed with or without associated sedation. Lower periareolar anaesthesia allows for good and painless infiltration of the surgical field, up to the prepectoralis plane. A smooth, vertical dissection reached the pectoralis fascia, which was smoothly opened, leaving the gland adhesions in place. Subfascial pocket dissection was performed, and the implant was then inserted. The fascial sling, consisting of 2 strips of approximately 4/5 cm × 2 cm each, was prepared superiorly and crossed for inferior fixation. One hundred patients were included over 18 months, and all surgeries were performed under tumescent anaesthesia with general sedation. Overall, we did not need to convert from local anaesthesia in general. No complications were observed, and good cosmetic results were achieved. The follow-up periods lasted for 6 months or, in a few cases, for 1 year.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 .

Tumescent technique versus electrocautery mastectomy: A randomized controlled trial

BACKGROUND

Breast cancer is the most common cancer in Danish women. In 2016 about 1450 (31%) Danish breast cancer patients had a mastectomy. The aim was to compare the frequency of postoperative complications in two methods of surgery, electrocautery dissection and tumescent technique, when performing a mastectomy.

METHODS

Open randomized controlled trial of all consecutive primary breast cancer or DCIS female patients who underwent either a simple mastectomy or a modified radical mastectomy in Vejle Hospital, from January 2012 to October 2017. Primary outcomes were seroma production, bleeding, infection and necrosis. Secondary outcomes were duration of surgery and delay of adjuvant treatment caused by complications. Categorical outcome variables were compared between randomization groups using chi-square of Fisher exact test and continuous outcome variables by using Wilcoxon rank test. All analyses were performed at a 5% two-sided significance level.

RESULTS

357 patients met the inclusion criteria. 14 had bilateral mastectomy, i.e. 371 breasts. The two randomization groups consisted of 105 patients/107 breasts operated by tumescent technique and 98 patients/102 breasts operated by electrocautery technique. Tumescent technique produced more seroma though not significant (p = 0.631) (mean 605 vs. 630 ml). Bleeding in the tumescent group was 10.3% vs. 5.9% in the electrocautery group (p = 0.245). Infection (5.9% vs. 7.5% p = 0.645) and necrosis (4.9% vs. 4.7% p = 0.938) was uncommon with no difference between the intervention groups. Infection was most common cause of delay of adjuvant treatment; 3.9% in the electrocautery technique group. No significant difference in duration of surgery (p = 0.392).

CONCLUSION

Both techniques are equally safe for simple and modified radical mastectomy.