anesthesia management for mega liposuction

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

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