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Embed code for: epinephrine concentration in tumescent fluid in liposuction
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anesthesia for liposuction
Epinephrine (Adrenaline) 1:1000000 versus 1:500000 in tumescent fluid for abdomen liposuction effect on intraoperative hemodynamics .
Ahmed Mostafa Ibrahim Abo Sakaya MD
Objectives: In this study, we aimed to determine which concentration of adrenaline is safer 1mg per liter or 2mg per liter.
Methods: 100 female patients undergoing liposuction for abdomen and flanks are divided into 2 groups Group A : Epinephrine concentration 1:1000000 (one ampoule 1 mg)\L, lidocaine 2% 20 ml and sodium bicarbonate 8.4% 5ml per liter. Group B : Epinephrine concentration 1:500000 one ampoule 1 mg per 0.5 liter with same lidocaine and bicarb.dose. HR and Mean BP are recorded at baseline and every 10 minutes up to 120 minutes.
Results: A total number of 50 patients candidate for elective liposuction abdomen were studied in each group (A vs. B). The patients were aged 18 to 60 (28.2 ± 7.9) years. Duration of anesthesia was in the range of 90 to 140 (110 ± 48) minutes). With p values less than 0.05 both HR&BP differences between Group A and Group B are statistically significant.
Conclusion: Adrenaline concentration in tumescent fluid affected significantly hemodynamics intraoperatively but 1:1000000 concentration is safer with less increase in heart rate and blood pressure.
Liposuction is more of an art than a surgical procedure. It entails a practical application of scientific knowledge with precision and craftsmanship and is a skill attained with clinical experience. It brings as much contentment and joy to the person undergoing it, as to the surgeon practising the intimidating task of delivering that eventual result.
In the United States, more than 300,000 liposuction procedures were performed in 2008(1). However, there have been reports of adverse outcomes (2-4),so the anesthesiologist should understand the pathophysiology of obesity and fluid management during liposuction and be aware of the complications. In our hospital, a variety of liposuction procedures are being conducted on a regular basis, which vary from small volume liposuction of the arms to very large volume liposuction procedures of the abdomen and thighs total of 1055 liposuction procedures have been performed at our hospital from 2013-2015 (2 years).
Liposuction types include; manual liposuction, suction assisted lipectomy (SAL), ultrasound assisted liposuction (UAL-VASER), power assisted liposuction(PAL-MICROAIRE) and laser liposuction(COOL LIPO). Another classification of liposuction techniques have been described based on the volume of infiltration or wetting solution injected, dry, wet, superwet, and tumescent technique .The main difference between these techniques is the amount of infiltration done into the tissues and the resultant blood loss as a percentage of aspirated fluid. The tumescent technique is the most common of all liposuction techniques. Jeffery Klein (a dermatologist in the US) who described the ‘tumescent technique’ of liposuction in the mid-1980s, which is associated with decreased blood loss, thus making it possible to perform liposuction as a day care procedure (4).
Klein coined the term ‘tumescent technique’. The word tumescence means ‘to swell’. In this technique, very large volumes of dilute local anesthetic along with additives like epinephrine and sodium bicarbonate, are injected into the subcutaneous tissue to expand the tissues and make them firm, swollen, and turgid, i.e., the final endpoint of strong tissue turgor. This creates a plane from where suction of fat becomes easier, with lesser blood loss (5).
In the tumescent solution, originally described by Klein, the local anesthetic is diluted in 0.9% isotonic saline (4). While isotonic saline as a solution is associated with burning sensation upon injection, lactated Ringer's solution does not cause any burning sensation on injection and also reduces the sodium load. In our hospital, lactated Ringer's solution is used for dilution of the local anesthetic.
Lignocaine is the most commonly used local anesthetic in tumescent solutions, the maximum dose of which along with adrenaline is considered to be 7 mg/kg. With the advent of tumescent anesthesia, the maximum dose of lignocaine, when delivered in a tumescent solution may be significantly larger (6-8).The recommended maximum dose of lignocaine is 55 mg/kg for most patients, with a range of 35-55 mg/kg in patients undergoing liposuction (5,9).
Vasoconstrictors reduce blood circulation in the tissues, and thus delay the absorption of local anesthetics. Adrenaline is the most commonly used vasoconstrictor, the recommended concentration in tumescent solution is 0.5-2 mg/L depending on the tissue vascularity. In the more vascular tissues, the concentration is 1 mg/L and is decreased to 0.5 mg/L in the less vascular areas of the body. The dose should not exceed 50μg/kg. If the maximum dose is anticipated to exceed, the procedure should be done in several stages (11-13).
Sodium bicarbonate is added to decrease the burning sensation associated with injection of the tumescent solution. Adding bicarbonate raises the pH of the solution, which increases the proportion of nonionized lipid soluble lignocaine, leading to a more rapid entry into the nerve cells (14,18).Epinephrine, which is used in large doses routinely during liposuction, may be responsible for tachycardia and increased cardiac index (15-17).
PATIENTS AND METHODS
100 female patients undergoing liposuction for abdomen and flanks are divided into 2 groups
Group A: Epinephrine concentration 1:1000000 (one ampoule 1 mg)\L, lidocaine 2% 20 ml and sodium bicarbonate 8.4% 5ml per liter.
Group B: Epinephrine concentration 1:500000 one ampoule 1 mg per 0.5 liter with same lidocaine and bicarb.dose.
Non invasive BP and HR are recorded every 10 minutes and results are recorded. All continuous data with normal distribution are expressed as means ± SD. Differences with probability values less than 0.05 were considered statistically significant.
Preoperative assessment and is essential since many obese patients opting for liposuction may be having other comorbidities like hypertension, diabetes mellitus, coronary artery disease, deep vein thrombosis, and obstructive sleep apnea. Liposuction is contraindicated in patients with severe cardiovascular disease, coagulation disorder, and during pregnancy.
History of all medications, and anticoagulants should be documented, as they may affect blood clotting. Most of these drugs should be stopped at least 2 weeks before surgery. Any medication that interferes with metabolism of lignocaine such as statins and calcium channel blockers should be either discontinued before liposuction, or the total dosage of lignocaine should be reduced.
Preoperative investigations include a complete blood count with quantitative platelet assessment, prothrombin time, partial thromboplastin time, liver function tests, and pregnancy test for women of childbearing age.
General anesthesia by Propofol 200 mg. Airway can be maintained with Endo Tracheal Tube. Muscle relaxation may be achieved with a nondepolarizing drug – atracurium or Cis-Atracurium. Sevoflurane 2% in oxygen100% is used as maintenance anesthetic. Analgesia is provided by fentanyl and infiltration of lignocaine in the subcutaneous tissue
Standard monitoring as oxygen saturation (SpO2), noninvasive blood pressure (NIBP), end-tidal carbon dioxide (EtCO2,), electrocardiogram (ECG), and temperature monitoring. Monitoring hourly urine output is important to indicate the fluid homeostasis in the body. Monitoring should continue in the postoperative period for large-volume liposuction. Analgesia provided by the local anesthetic in tumescent liposuction decrease the requirement of analgesics in the intraoperative and postoperative period. By adding epinephrine to lignocaine, the duration of analgesia obtained from tumescent lignocaine can be extended by many hours. Non Steroidal Anti-inflammatory Drugs (NSAIDs), paracetamol and narcotics may also be prescribed for postoperative pain relief.
A total number of 100 female patients candidate for elective liposuction abdomen were studied in each group (A vs. B). The patients were aged 18 to 60 (28.2 ± 7.9) years. Duration of anesthesia was in the range of 90 to 140 (110 ± 48) minutes). Patients were divided into 2 groups
Non invasive BP and HR are recorded every 10 minutes and results are recorded.
Heart Rate (HR)
95 ± 16
88 ± 11
92 ± 18
94 ± 17
91 ± 13
97 ± 15
85 ± 11
87 ± 16
79 ± 11
Table (1) heart rate
Figure (1) heart rate
With p values less than 0.05 HR differences between Group A and Group B are statistically significant.
Mean arterial blood pressure (BP)
102 ± 16
99 ± 12
98 ± 11
100 ± 13
102 ± 15
101 ± 11
104 ± 16
95 ± 11
Table (2) blood pressure
Figure (2) blood pressure
With p values less than 0.05 BP differences between Group A and Group B are statistically significant.
Adrenaline is the most commonly used vasoconstrictor, the recommended concentration in tumescent solution is 0.5-2 mg/L, Patients were divided into 2 groups
Non invasive BP and HR are recorded every 10 minutes up to 120 minutes and results are recorded.
Concerning intra operative rise in heart rate and blood pressure readings it were less in group (A) with less adrenaline concentration in the tumescent fluid than in group (B) where more adrenaline concentration was present, With p values less than 0.05 HR and BP differences between Group A and Group B are statistically significant.
Adrenaline concentration in tumescent fluid affected significantly hemodynamics intraoperatively as shown above 1:1000000 concentration is safer with less increase in heart rate and blood pressure
Other contributing factors in hemodynamic changes are: type and rate of liposuction, one or two suction machine used, amount of tumescent fluid, surface area of liposuction, squeezing and in which part of the body is the suction done. Other complications like severe rise in BP or arrhythmia may occur also, treated by labetalol (trandate) 5mg incremental doses.
Adrenaline concentration in tumescent 1:1000000 is safer and less toxic than Adrenaline 1:500000 which should not be used.
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