Chapter 2 Anesthesia for Liposuction and Abdominoplasty 2

Gary Dean Bennett

2.1 tered,thepersonneltobeinvolvedinthecareandmon- Introduction itoring of the patient, the postoperative pain manage- ment, and the discharge criteria used. Therefore, it is Since the development of the first outpatient surgical incumbent on the surgeon to understand current stan- program in 1966 and the first freestanding surgical dards of anesthesia practice. If the surgeon chooses to centers in 1969, the number of surgeries performed assume the role of the anesthesiologist, then he or she outside of the hospital setting has dramatically in- must adhere to the same standards that are applied to creased. An estimated 70% of all elective surgery is per- the anesthesiologist. While the morbidity and mortali- formed in an outpatient setting [1], and more than 50% ty of anesthesia has decreased [9, 10], risk awareness of of aesthetic plastic surgeons perform most of their pro- anesthesia and surgery must not be relaxed. ceduresinanofficesetting[2]. The popularity of surgeries performed outside of 2.1.1 the hospital setting is a consequence of multiple fac- The Surgical Facility tors.Clearly,economicconsiderationsplayamajorrole intheshifttoambulatorysurgery.Becauseofgreater The surgeon is largely responsible for deciding in efficiency, these outpatient surgical units have greater which facility the procedure is to be performed. Surgi- cost-effectiveness [3]. Advances in monitoring capabil- cal facilities may be divided into five main categories: ities and the adoption of monitoring standards of the 1. Hospital-based inpatient American Society of Anesthesiologists (ASA) are cred- 2. Hospital-associated ambulatory surgical unit ited for a reduction of perioperative morbidity and 3. Freestanding surgical center with short-stay mortality [4]. Advances in pharmacology have resulted accommodation in a greater diversity of anesthetic agents with rapid on- 4. Freestanding surgical centers without short-stay set, shorter duration of action and reduced morbidity accommodation [5]. The advent of minimally invasive procedures has 5. Office based operating rooms. further reduced the need for hospital-based surgeries. Regulatory agencies such as the American Association Each of these choices has distinct advantages and dis- of Accreditation of Ambulatory Surgery (AAAASF) and advantages. While convenient and economical, office the Accreditation Association for Ambulatory Health based surgery is associated with three times the mor- Care (AAAHC) have helped establish minimum stan- tality of surgeries performed at other types of facilities dards of care for surgical locations where anesthesia is [11]. Ultimately, patient safety should be the para- administered. Ambulatory anesthesia has even become mount factor in the final decision. Patients with a risk a formal subspecialty of anesthesia with the establish- of ASA III undergoing major liposuction or large abdo- ment of the Society of Ambulatory Anesthesia (SAM- minoplasty should preferentially be treated at hospital- BA) in 1984. An evaluation of 1.1 million outpatients based or hospital-associated surgical units rather than revealed that the mortality rate after ambulatory anes- office-based operating rooms [12–14]. thesiawas1.5per100,000cases[6].Nodeathsoccurred If the intended surgical procedure requires general in 319,000 patients who were monitored in accordance anesthesia or enough sedative-analgesic medication to with ASA standards [7, 8]. increase the probability of loss of the patient’s life pre- As a consequence of the shift away from hospital- serving protective reflexes (LPPRs), then, according to based surgery, the surgeon has adopted a more impor- the law in some states, the surgical facility must be ac- tant role in the medical decision making process with credited by one of the regulatory agencies (AAAASF or respect to anesthesia. Frequently, the surgeon decides AAAHC) [15, 16]. on the location of surgery, the extent of the preopera- Regardless of which type of facility is selected or the tive evaluation, the type of anesthesia to be adminis- type of anesthesia planned, the operating room must 30 2 Anesthesia for Liposuction and Abdominoplasty

be equipped with the type of monitors required to ful- ative anesthesia preparation of the patient as an after- fill the monitoring standards established by the ASA thought must be resisted. Even if an anesthesiologist or [17], as well as proper resuscitative equipment and re- CRNA is to be involved later, the surgeon bears respon- suscitative medications [18, 19]. The facility must be sibility for the initial evaluation and preparation of the staffed by individuals with the training and expertise patient. Thorough preoperative evaluation and prepa- required to assist in the care of the patient [19, 20]. ration by the surgeon increases the patient’s confi- Emergency protocols must be established and re- dence, reduces costly and inconvenient last minute de- hearsed [21]. Optimally, the surgical facility must have lays, and reduces overall perioperative risk to the pa- ready access to a laboratory in the event a stat laborato- tient [30]. If possible, the preoperative evaluation ry analysis is required. Finally, a transfer agreement should be performed with the assistance of a spouse, with a hospital must be established in the event that an parent or significant other so that elements of the unplanned admission is required [18, 19]. health history or recent symptoms may be more readily recalled. A comprehensive preoperative evaluation form is a 2.1.2 useful tool with which to begin the initial assessment. Personnel Information contained in the history alone may deter- One of the most critical elements of successful surgical mine the diagnosis of the medical condition in nearly outcomes is the personnel assisting the surgeon. Quali- 90% of patients [31]. While a variety of forms are avail- fied and experienced assistants may serve as valuable able in the literature, a checklist format to facilitate the resources potentially reducing morbidity and improv- patient’s recall is probably the most effective [32]. Re- ing efficiency of the operating room [22, 23]. With an gardless of which format is selected, information re- office-based operating room the surgeon is responsible garding all prior medical conditions, prior surgeries for selecting the operating room personnel. and types of anesthetics, current and prior medica- An anesthesiologist or a Certified Nurse Anesthetist tions, adverse outcomes to previous anesthetics or oth- (CRNA) may administer anesthesia. The surgeon may er medications, eating disorders, prior use of antiobesi- prefer to perform the surgery using exclusively local ty medication, and use of dietary supplements, which anesthesia without parenteral sedation, especially in could contain ephedra, should be disclosed by the pa- limited liposuctions with the tumescent technique [24]. tient. However, many surgeons add parenteral sedative or an- A family history of unexpected or early health con- algesic medications with the local anesthetic. If the sur- ditions such as heart disease, or unexpected reactions, geon chooses to administer parenteral sedative-analge- such as malignant hyperthermia, to anesthetics or oth- sic medications, then another designated, licensed, er medications should not be overlooked. Finally, a preferably experienced individual should monitor the completereviewofsystemsisvitaltoidentifyingundi- patient throughout the perioperative period [25]. Use agnosed, untreated, or unstable medical conditions of unlicensed, untrained personnel to administer par- that could increase the risk of surgery or anesthesia. enteral sedative analgesic medication and monitor pa- Last minute revelations of previously undisclosed tients may increase the risk to the patient. It is also not symptoms, such as chest pain, should be avoided. acceptable for the nurse monitoring the patient to dou- Indiscriminately ordered or routinely obtained pre- ble as a circulating nurse [26]. Evidence suggests that operative laboratory testing is now considered to have anesthesia related deaths more than double if the sur- limited value in the perioperative prediction of mor- geon also administers the anesthesia [27]. Regardless of bidity and mortality [33–37]. In fact, one study showed who delivers the anesthesia, the surgeon should prefer- no difference in morbidity in healthy patients without ably maintain current Advanced Cardiac Life Support preoperative screening tests versus a control group certification (ACLS) and all personnel assisting in the with the standard preoperative tests [38]. Multiple in- operating room and recovery areas must maintain Ba- vestigations have confirmed that the preoperative his- sic Life Support Certification [28]. At least one ACLS tory and physical examination is superior to laboratory certified health provider must remain in the facility un- til the patient has been discharged [29]. Table 2.1. Guidelines for preoperative testing in healthy pa- tients (ASA 1–11). (Adapted from Roizen et al. [305]) 2.1.3 Age Test Preoperative Evaluation 12–40a CBC The time and energy devoted to the preoperative prep- 40–60 CBC, EKG aration of the surgical patient should be commensurate Greater than 60 CBC, BUN, glucose, ECG, CXR with the efforts expended on the evaluation and prepa- a Pregnancy test for potentially childbearing females is sug- ration for anesthesia. The temptation to leave preoper- gested 2.1 Introduction 31

Table 2.2. Common indications for additional risk specific testing. (Adapted from Roizen et al. [306]) Electrocardiogram Chest X-ray Electrolytes, glucose, Urinalysis liver function tests, BUN, creatinine History Coronary artery disease, congestive Bronchial asthma, con- Diabetes mellitus, chronic Diabetes mellitus, heart failure, prior myocardial in- gestive heart failure, renal failure, chronic liver chronic renal dis- farction, hypertension, hyperthy- chronic obstructive pul- disease, adrenal insuffi- ease, and recent roidism, hypothyroidism, obesity, monary disease, pulmo- ciency, hypothyroidism, urinary tract in- compulsive eating disorders, deep nary embolism hyperthyroidism, diuretic fection venous thrombosis, pulmonary em- use, compulsive eating bolism, smoking, chemotherapeutic disorders, diarrhea agents, chemical dependency, chron- ic liver disease Symptoms Chest pain, shortness of breath, Chest pain, shortness of Dizziness, generalized Dysuria, urgency, dizziness breath, wheezing, unex- fatigue or weakness frequency, and plained weight loss, he- bloody urination moptysis Signs Abnormal heart rate or rhythm, hy- Cyanosis, wheezes, rales, Abnormal heart rate or pertension, cyanosis, peripheral ede- rhonchi, decreased rhythm, peripheral ede- ma, wheezing, rales, rhonchi breath sounds, peripher- ma, jaundice al edema, abnormal heart rate or rhythm analysis in determining the clinical course of surgery 2.1.4 and anesthesia [39–43]. Newer guidelines for the ju- Preoperative Risk Assessment dicious use of laboratory screening are now widely accepted. Table 2.1 outlines a general approach for Theultimategoalsofestablishingapatient’slevelofrisk healthy patients not taking medications. Additional are to reduce the probability of perioperative morbidity preoperative tests may be indicated for patients with and mortality. The preoperative evaluation is the cru- prior medical conditions or risk factors for anesthesia cial component of determining the patient’s preopera- and surgery (Table 2.2). tive risk level. There is compelling evidence to suggest Consultation from other medical specialists should that the more coexisting medical conditions a patient be obtained for patients with complicated or unstable has,thegreatertheriskforperioperativemorbidityand medical conditions. Patients with ASA III risk designa- mortality [25, 44]. Identification of preoperative medi- tion should be referred to the appropriate medical spe- cal conditions helps reduce perioperative mortality. cialist prior to elective surgery [25]. The consultant’s A variety of indexing systems have been proposed to role is to determine if the patient has received optimal help stratify patients according to risk factors. One treatment and if the medical condition is stable. Addi- such classification, first proposed in 1941 [45], later tional preoperative testing may be considered neces- modified in 1961 by Dripps [46], and finally adopted by sary by the consultant. The medical consultant should the ASA in 1984 (Table 2.3) [47], has emerged as the also assist with stabilization of the medical condition in most widely accepted method of preoperative risk as- the perioperative period if indicated. If the surgeon has sessment.Numerousstudieshaveconfirmedthevalue concerns about a patient’s ability to tolerate anesthesia, of the ASA system in predicting which patients are at a a telephone discussion with an anesthesiologist or even higher risk for morbidity [48] and mortality [49–51]. a formal preoperative anesthesia consultation may be Goldman and Caldera established a multifactorial in- indicated. dex based on cardiac risk factors [52]. This index has Certain risk factors, such as previously undiagnosed repeatedly demonstrated its usefulness in predicting hypertension, cardiac arrhythmias, and bronchial perioperative mortality [53, 54]. Physicians should in- asthma may be identified by a careful physical exami- corporate one of the acceptable risk classification sys- nation. Preliminary assessment of head and neck anat- tems as an integral part of the preoperative evaluation. omy to predict possible challenges in the event endo- Multiple authors have documented the association tracheal intubation is required may serve as an early between morbidity and mortality and the type of sur- warning to the anesthesiologist or CRNA even if a gen- gery [55–58]. The consensus of these studies confirms eral anesthetic is not planned. For most ambulatory the increased risks of perioperative complications for surgeries, the anesthesiologist or CRNA evaluates the more invasive surgeries, surgeries with multiple com- patient on the morning of surgery. bined procedures, surgeries with prolonged duration, and surgeries with significant blood loss [59]. While 32 2 Anesthesia for Liposuction and Abdominoplasty

Table 2.3. The American Society of Anesthesiologists’ Physical indexofsuspicionforsilentischemiamustbemain- Status Classification tained when assessing asymptomatic patients with risk factors for heart disease, such as smoking, hyperten- ASA Class I A healthy patient without systemic medical or psychiatric illness sion, diabetes mellitus, obesity, hyperlipidemia, or family history of severe heart disease. Patients with ASA Class II Apatientwithmild,treatedandstable systemic medical or psychiatric illness known cardiac disease must be evaluated by the inter- nist or cardiologist to ensure the medical condition is ASA Class III A patient with severe systemic disease that is not considered incapacitating optimally managed. When anesthesia is planned, pa- tients with significant heart disease should preferen- ASA Class IV A patient with severe systemic, incapacitat- ing and life threatening disease not neces- tially undergo surgery at a hospital-based surgical unit sarily correctable by medication or surgery rather than a physician’s office. Most studies have consistently demonstrated that ASA Class V A patient considered moribund and not expectedtolivemorethan24h patients who have suffered previous myocardial infarc- tions have a dramatically greater risk of reinfarction and death if surgery is performed less than 6 months af- studies correlating the amount of fat aspirate during li- ter the cardiac event [67–69]. More recent studies sug- posuction or the amount of tissue removed during ab- gesting a lower rate of reinfarction [70, 71] involved pa- dominoplasty with perioperative morbidity and mor- tients who were hospitalized in the intensive care unit talityhavenotbeenperformed,itwouldnotbeunrea- with invasive hemodynamic monitoring. These studies sonable to extrapolate conclusions from the previous may not have relevance to patients undergoing elective studies and apply them to abdominoplasty and lipo- ambulatory surgery. At this time, the prudent choice suction. Liposuction surgeries with less than 1,500 ml remainstopostponeelectivesurgeriesforatleast fat aspirate are generally considered less invasive pro- 6monthsaftermyocardialinfarction. cedures, while liposuctions aspirating more than Goldman et al. established a cardiac risk index [52] 3,000 ml are considered major surgical procedures which has been useful in identifying patients with in- [19]. As blood loss exceeds 500 cc [59], or the duration termediate risk for cardiac complications in the periop- of surgery exceeds 2 h, morbidity and mortality in- erative period [53]. Patients with a score greater than crease [48, 60]. 13 should be referred to a cardiologist for preoperative evaluation. Dipyridamole thallium scanning and dobu- tamine stress echocardiography have proven useful in 2.2 predicting adverse perioperative cardiac events [72]. Anesthesia in Patients with Preexisting Disease One reliable and simple screening method to evaluate cardiac status is exercise tolerance. The ability to in- Over the past 30 years the morbidity and mortality of crease the heart rate to 85% of the age-adjusted maxi- surgeryhavesteadilydeclined[10].Onehypothesisto mal heart rate is a reliable predictor of perioperative explain this decline has been the greater recognition of cardiac morbidity [73]. preoperative risk factors and the improved periopera- Despite years of investigation, no one anesthetic tive medical management of patients with coexisting technique or medication has emerged as the preferen- diseases. Surgeons who perform outpatient surgery, es- tial method to reduce the incidence of perioperative pecially office-based surgery, and particularly those complications in patients with cardiac disease [74, 75]. surgeonswhochoosetoadministersedativeoranalge- Regardless of which anesthesia technique is selected, sic medication, must appreciate how these medical scrupulous monitoring should serve as the framework conditions may increase the risk of anesthesia in the for safe anesthetic management. Hemodynamic fluctu- surgical patient. Furthermore, the surgeon should ations must be avoided to prevent ischemic episodes in maintain a current, working understanding of the eval- the perioperative period. uation and treatment of these medical conditions. 2.2.2 2.2.1 Obesity Cardiac Disease The current prevalence of obesity in the USA is esti- Cardiac related complications, including myocardial matedtobe55%ofthepopulation[76].Itisreasonable infarction and congestive heart failure, are the leading to assume that patients undergoing major liposuction cause of perioperative mortality [62, 63]. Most patients or abdominoplasty have a greater incidence of obesity. with heart disease can be identified with a careful pre- The most widely accepted method of quantifying the operativehistoryandphysical[64].Since80%ofallep- level of obesity is the body mass index (BMI), which is isodes of myocardial ischemia are silent [65, 66], a high determined by weight (kg)/height (m)2. Patients with a 2.2 Anesthesia in Patients with Preexisting Disease 33

BMI over 30 are considered obese, while a BMI over 35 pnea,chestpain,andirregularheartrate,murmur,and indicates morbid obesity [77]. edema, some patients remain asymptomatic [91]. The risk factors associated with obesity such as dia- Patients who have developed pulmonary hyperten- betes mellitus, hypertension, heart disease, sleep ap- sion and valvular heart disease as a result of these med- nea, and occult liver disease [78] should concern clini- ications are predisposed to fatal cardiac arrhythmias, cians administering anesthesia to patients with obesity. congestive heart failure, and intractable hypotension. A thorough preoperative evaluation must rule out these Some authors advocate a cardiac evaluation with echo- occult risk factors prior to elective surgery. cardiogram and continuous wave Doppler imaging Anatomical abnormalities make airway control with color-flow examination for any patient who has challenging [79] and endotracheal intubation hazard- taken these antiobesity medications prior to surgery. ous [80]. The combination of a higher gastric volume Sustained hypotension may not respond to ephedrine, and lower pH with a higher frequency of esophageal re- a popular vasopressor. Phenylephrine is the treatment flux results in a higher risk of pulmonary aspiration of choice for hypotension in these patients [91]. [81]. Pulmonary function can be severely restricted even in an upright position [82]. However, in the supine 2.2.3 position, pulmonary function is further reduced [83]. Hypertension Pulmonaryfunctionisfurthercompromisedinthe anesthetized patient. Because of these cardiopulmo- Early studies revealed a significantly increased risk of nary abnormalities, obese patients develop hypoxemia perioperative mortality in patients with untreated hy- more quickly [84]. This respiratory impairment may pertension [92, 93]. The reduction in mortality from persist up to 4 days after surgery [85]. Even distribu- cardiovascular and cerebral vascular disease resulting tion and metabolism of medications vary significantly from proper treatment of hypertension has been widely and often unpredictably in the obese patient [86]. accepted [94–96]. Although somewhat controversial, Given the increased risk of perioperative morbidity most authors concur that preoperative stabilization of and mortality of anesthesia, morbidly obese patients hypertension reduces perioperative cardiovascular (BMI greater than 35) undergoing major surgery and complicationssuchasischemia[97–99].Patientswith anesthesia of any type should preferentially be restrict- undiagnosedorpoorlycontrolledhypertensionshould ed to a hospital based surgical facility. In general, these be identified early in the preoperative preparation pro- patients should not be considered candidates for am- cess and referred to the family physician or internist for bulatory surgery. Anesthesia delivered in the office set- evaluation and treatment. ting should be restricted to patients with a BMI less Physicians should not mistakenly attribute severe than 35. hypertension to the patient’s preoperative anxiety. Premedication with metaclopromide, a dopamine Because of the risk of rebound hypertension, antihy- receptor antagonist, increases gastric motility and low- pertension medications should be continued up to the er esophageal sphincter tone. A histamine receptor- morning of surgery [100], except for angiotensin-con- blocking agent such as ranitidine used with metaclo- verting (ACE) inhibitors, which have been associated promide the evening before and on the morning of sur- with hypotension during induction of general anesthe- gery reduces the risk of pulmonary aspiration [87]. sia [101]. Because of the increased risks of deep venous Mild to moderate perioperative hypertension may thrombosis(DVT)[88]andpulmonaryembolism(PE) be a response to inadequate general or local anesthesia [89], prophylactic measures such as lower extremity or pain control. In these cases, pain is usually accompa- pneumatic compression devices and early ambulation nied by other signs, such as the patient’s complaints, in should be used. the case of anesthesia for the conscious patient, tachy- An undetermined number of patients self-adminis- cardia, and tachypnea. If hypertension persists despite ter herbal dietary supplements. Many of these supple- additional local anesthetic or analgesic medication, ments contain ephedra alkaloids, which may predispo- then treatment of the blood pressure is indicated. Mod- se the patient to perioperative hypertension and cardi- erate to severe blood pressure elevations occurring ac arrhythmias [90]. Some herbals may result in the in- during the surgery or during recovery should be treat- creased incidence of bleeding from coumadin-like sub- ed using one or more of the antihypertensive agents stances. Antiobesity medications such as aminorex fu- available. marate, dexfenfluramine (Redux), fenfluramine (pon- Perioperative hypertension, especially if the hyper- damin) and phentermine (Ionamin, Adipex-P, Fastin, tension is accompanied by tachycardia, may be treated Oby-Cap, Obenix, Oby-trim, Zantryl) are associated with a beta-adrenergic blocking agent such as propran- with pulmonary hypertension and valvular heart dis- olol in judiciously administered, intravenous doses of ease,evenwithaslittleas2monthsofuse.Whilemost 0.5 mg at 10- to 15-min intervals. Even small doses of a patients develop symptoms such as palpitations, dys- beta-adrenergic blocking agent have been shown to re- 34 2 Anesthesia for Liposuction and Abdominoplasty

duce the incidence of cardiac ischemia [99]. Labetolol, sulin and patients with type II diabetes should not take an antihpertensive agent with combined alpha-adren- the oral hypoglycemia agents on the morning of sur- ergic and beta-adrenergic blocking properties, admin- gery. Diabetic patients should be scheduled the first isteredin5–10mgdosesevery10min,isalsoasafe case in the morning to minimize the risk of hypoglyce- and effective alternative for treating both hypertension mia during the NPO period. After the patient arrives, and tachycardia [102]. preoperative fasting glucose should be checked and Nifedipine (10 mg s.l.), a potent systemic and coro- then an infusion of 5% dextrose is generally initiated at nary arteriolar dilator, effectively reduces blood pres- 1–2ml/kg/handcontinueduntiloralfluidsaretolerat- sure, and may be administered in a conscious patient. ed in the recovery period. Usually, one-half of the pa- The effect of nifedipine may be additive if given with tient’s scheduled dose of insulin is administered after narcotics or inhalational anesthetic agents. Because ni- the intravenous dextrose is begun [112]. fedipine and lidocaine are both highly protein bound, For surgeries longer than 2 h, at least one peripheral caution must be exercised when administering nifedi- blood glucose should be measured, especially if the pa- pine after high dose lidocaine tumescent anesthesia has tient is receiving general anesthesia. Blood glucose been administered to avoid possible toxic effects of the above 200 mg/dl may be effectively managed with a lidocaine [103]. sliding scale of insulin [113]. Treatment regimens di- For severe hypertension, hydralazine, a potent vaso- rected toward tighter control of the blood sugar, such as dilator, may be useful in 2.5–5 mg doses intravenously continuous insulin infusions, do not necessarily im- at 10–15 min intervals. The effects of hydralazine may prove the perioperative outcome [114, 115]. It is imper- be delayed up to 20 min and its effects prolonged. Hy- ative that, prior to discharge, patients are able to toler- dralazine may cause tachycardia or hypotension, espe- ateoralintakewithoutnauseaandvomiting.Afinal cially if the patient is hypovolemic [104]. glucose level should be checked prior to discharge.

2.2.4 2.2.5 Diabetes Mellitus Pulmonary Disease Although patients with diabetes mellitus have a sub- Bronchial asthma, chronic bronchitis, chronic obstruc- stantially increased surgical mortality rate than non- tive pulmonary disease, obesity, history of smoking, diabetic patients [105], these complications are more and recent upper respiratory infection are the most likely to be a consequence of the end-organ disease common medical conditions which may influence pul- such as cardiovascular disease, renal disease, and al- monary function in the perioperative period. An esti- tered wound healing [106–108]. While evidence sug- mated 4.5% of the population may suffer some form of gests that tight control of blood sugar in insulin-depen- reactive airway disease [116]. If these medical condi- dent diabetics slows the progression of end-organ dis- tions are identified in the preoperative history, a thor- ease [109], tight control is associated with additional ough evaluation of the patient’s pulmonary function risks such as hypoglycemia and even death [110]. shouldensure.Aswithothermedicalconditions,a The preoperative evaluation should identify diabetic carefulhistorymayhelpseparatepatientswiththese patients with poor control as well as medical condi- medical conditions into low and high risk groups, espe- tions associated with diabetes such as cardiovascular cially since the degree of preoperative respiratory dys- disease and renal insufficiency. Diabetic patients have a pnea closely correlates with postoperative mortality greater incidence of silent myocardial ischemia [111]. [117]. Using a simple grading scale, the patients’ preop- Minimum preoperative analysis includes fasting blood erative pulmonary function can be estimated (Ta- sugar, glycosylated hemoglobin, electrolytes, BUN, cre- ble 2.4). atinine and EKG. If any doubt exists regarding the pa- Patients with level 2 dyspnea or greater should be re- tient’s medical stability, consultation should be ob- ferred to a pulmonologist for more complete evalua- tained from the diabetologist, cardiologist, or nephrol- ogistifneeded.Patientswithbrittlediabetesorwith other coexisting medical conditions should be referred Table 2.4. Grade of dyspnea while walking. (Adapted from to a hospital-based surgical unit, especially if general Boushy et al. [117]) anesthesia is contemplated. Level Clinical response The goal of perioperative management of stable type 0Nodyspnea IortypeIIdiabeticpatientsisprimarilytoavoidhypo- 1Dyspneawithfastwalkingonly glycemia. Although patients are generally NPO after 2 Dyspnea with one or two blocks walking midnight prior to surgery, a glass of clear juice may be 3 Dyspnea with mild exertion (walking around the takenupto2hpriortosurgerytoavoidhypoglycemia. house) Patients with type I diabetes should not administer in- 4Dyspneaatrest 2.2 Anesthesia in Patients with Preexisting Disease 35 tion and possibly further medical stabilization. The patients may suffer significant and sustained hypox- benefits of elective surgery in patients with level 3 and emia. As a result of the pathophysiology of OSA, pa- 4 dyspnea should be carefully weighed against the in- tients develop left and right ventricular hypertrophy creased risks. Certainly, this group of patients would [126]. Consequently, patients have a higher risk of ven- not be considered good candidates for outpatient sur- tricular dysarrhythmias and myocardial infarction gery. [127]. Since upper respiratory infection (URI) may alter Most medications used during anesthesia, including pulmonary function for up to 5 weeks [118], major sur- sedativessuchasdiazepamandmidazolam,hypnotics gery requiring general endotracheal anesthesia should such as propofol, and analgesics such as fentanyl, me- be postponed, especially if the patient suffers residual peridine and morphine, increase the risk of airway ob- systems, such as fevers, chills, coughing and sputum struction and respiratory depression in patients with production, until the patient is completely asymptom- OSA [128]. Death may occur suddenly and silently in atic. patients with inadequate monitoring [129]. A combina- While many studies confirm that patients who tion of anatomical abnormalities make airway manage- smokemorethanonetotwopacksofcigarettesdaily ment, including mask ventilation and endotracheal in- have a higher risk of perioperative respiratory compli- tubation, especially challenging in obese patients with cations than non-smokers, cessation of smoking in the OSA [130]. Perioperative monitoring, including visual immediate preoperative period may not improve pa- observation, must be especially vigilant to avoid peri- tients’ outcome. In fact, patients’ risk of perioperative operative respiratory arrest in patients with OSA. complications may actually increase if smoking is For patients with severe OSA, particularly those stopped immediately prior to surgery. A full 8 weeks with additional coexisting medical conditions such as may be required to successfully reduce perioperative cardiac or pulmonary disease, surgery performed on pulmonary risk [119]. anoutpatientbasisisnotappropriate.Forthesehigh- If the physical examination of asthmatic patients re- risk patients, monitoring should continue in the inten- veals expiratory wheezing, conventional wisdom dic- sive care unit until the patient no longer requires par- tates that potentially reversible bronchospasm should enteral analgesics. If technically feasible, regional anes- be optimally treated prior to surgery. Therapeutic thesiamaybepreferableinpatientswithsevereOSA. agents include inhaled or systemic, selective beta-ad- Postoperatively, patients with any history of OSA renergic receptor type-2 agonists (albuterol) as a sole should not be discharged if they appear lethargic or agent or in combination with anticholinergic (ipratro- somnolent [131]. pium) and locally active corticosteroid (beclomethaso- During the preoperative evaluation of the obese pa- ne dipropronate) medications [120]. Continuing the tient, a presumptive diagnosis of OSA may be made if asthmatic medications up to the time of surgery [121] the patient has a history of loud snoring, long pauses of and postoperative use of incentive spirometry [122] has breathing during sleep, as reported by the spouse, or been shown to reduce postoperative pulmonary com- daytime somnolence [132]. If OSA is suspected, pa- plications. tients should be referred for a sleep study to evaluate With regard to treated stable pulmonary disease, the severity of the condition. there are no conclusive, prospective, randomized stud- ies to indicate which anesthesia technique or medica- 2.2.7 tions would improve patient outcome. Malignant Hyperthermia Susceptibility Patients with susceptibility to malignant hyperthermia 2.2.6 (MH)canbesuccessfullymanagedonanoutpatient Obstructive Sleep Apnea basis after 4 h of postoperative monitoring [133]. Trig- According to the National Commission on Sleep Disor- geringagentsincludevolatileinhalationagentssuchas ders Research, approximately 18 million Americans halothane, enflurane, desflurane, isoflurane and sevof- suffer with obstructive sleep apnea (OSA). Unfortu- lurane.Eventraceamountsoftheseagentslingeringin nately, the majority of patients with OSA remain undi- an anesthesia machine or breathing circuit may precip- agnosed [123]. The incidence of sleep apnea increases itate an MH crisis. Succinylcholine and chlopromazine among obese patients [124]. Since the target popula- are other commonly used medications, which are tion for major liposuction and abdominoplasty in- known triggers of MH. However, many non-triggering cludes patients with morbid obesity, concern about medications may be safely used for local anesthesia, se- OSA becomes more germane. dation-analgesia, postoperative pain control, and even OSA is a result of a combination of excessive pha- general anesthesia [134]. Nevertheless, anesthesia for ryngeal adipose tissue and inadequate pharyngeal soft patients suspected of having MH susceptibility should tissue support [125]. During episodes of sleep apnea, not be performed in an office-based setting. A stan- 36 2 Anesthesia for Liposuction and Abdominoplasty

dardized protocol to manage MH (available from the [139] and the possible cytochrome inhibition of con- Malignant Hyperthermia Association of the United comitantly administered medications [140]. The maxi- States, MHAUS) and supplies of dantrolene and cold in- mum tolerable limits of local anesthetics have been re- travenous fluids should be available for all patients. defined with the development of the tumescent anes- Preferably, patients with MH susceptibility should thetic technique [141]. Lidocaine doses up to 35 mg/kg be referred to an anesthesiologist for prior consulta- were found to be safe, if administered in conjunction tion. Intravenous dantrolene [135] and iced intrave- with dilute epinephrine during liposuction [142]. With nousfluidsarestillthepreferredtreatment.MHAUS the tumescent technique, peak plasma levels occur may be contacted at 800–98MHAUS and the MH hotli- 6–24 h after administration [142, 143]. More recently, ne is 800-MH-HYPER. doses up to 55 mg/kg have been found to be within the therapeutic safety margin [144]. However, recent guide- lines by the American Academy of Cosmetic Surgery 2.3 recommend a maximum dose of 45–50 mg/kg [29]. Anesthesia for Liposuction and Abdominoplasty Since lidocaine is predominantly eliminated by he- patic metabolism, specifically, cytochrome oxidase Anesthesia may be divided into four broad categories: P450 34A, drugs that inhibit this microsomal enzyme local anesthesia, local anesthesia combined with seda- may increase the potential of lidocaine toxicity [140, tion, regional anesthesia and general anesthesia. The 145]. Table 2.6 lists some of the more common medica- ultimate decision to select the type of anesthesia de- tions,whichinhibitthecytochromeoxidasesystem. pends on the type and extent of the surgery planned, Propofol and Versed, commonly used medications for the patient’s underlying health condition and the psy- sedation and hypnosis during liposuction, are also chological disposition of the patient. For example, a known to be cytochrome P450 inhibitors. However, limited liposuction of less than 500 ml of fat from a since the duration of action of these drugs is only small area in a healthy patient, with limited anxiety, 1–4 h, the potential inhibition should not interfere could certainly be performed using strictly local anes- with lidocaine at the peak serum level 6–12 h later. Lo- thesia without sedation. As the scope of the surgery rezepam is a sedative which does not interfere with cy- broadens, or the patient’s anxiety level increases, the lo- tochrome oxidase and is preferred by some authors cal anesthesia may be supplemented with oral or par- [146]. enteral analgesic or anxiolytic medication. Table 2.6. Medications inhibiting cytochrome oxidase P450 2.3.1 3A4 (Shiffman [140]) Local Anesthesia Amiodarone Fluoxetine Nifedipine A variety of local anesthetics are available for infiltra- Atenolol Itraconazole Paroxetine tive anesthesia. The selection of the local anesthetic de- Carbamazepine Isoniazide Pentoxifylline Cimetidine Labetolol Pindolol pends on the duration of anesthesia required and the Clarithromycin Ketoconazole Propofol volume of anesthetic needed. Chloramphenicol Methadone Propranolol The traditionally accepted, pharmacological pro- Cyclosporin Methyprednisolone Quinidine filesofcommonanestheticsusedforinfiltrativeanes- Danazol Metoprolol Sertraline Dexamethasone Miconazole Tetracyline thesia for adults are summarized in Table 2.5. The max- Diltiazam Midazolam Terfenidine imum doses may vary widely depending on the type of Erythromycin Nadolol Thyroxine tissue injected [136], the rate of administration [137], Fluconazole Nefazodone Timolol the age, underlying health, and body habitus of the pa- Flurazepam Nicardipine Triazolam tient [138], the degree of competitive protein binding Verapamil

Table 2.5. Clinical pharmacology of common local anesthetics for infiltrative anesthesia. (Adapted from Covino and Wildsmith [61]) Agent Concen- Without epinephrine With epinephrine tration (%) Duration of action (min) Maximum Duration of action (min) Maximum mg/kg total mg total ml dose mg/kg total mg/kg total ml dose Lidocaine 1.0 30–60 4 300 30 120 7 500 50 Mepivacaine 1.0 45– 90 4 300 30 120 7 500 50 Etidocaine 0.5 120–180 4 300 60 180 5.5 400 80 Bupivacaine 0.25 120–240 2.5 185 75 180 3 225 90 Ropivacaine 0.2 120–360 2.7 200 8 120–360 2.7 200 80 2.3 Anesthesia for Liposuction and Abdominoplasty 37

Certainly, significant toxicity has been associated [156] is uncomfortably close to the maximum serum with high doses of lidocaine as a result of tumescent an- levels reported by Ostad et al. [140] of 3.4 and 3.6 µg/ml esthesia during liposuction [146]. The systemic toxicity following tumescent lidocaine doses of 51.3 and of local anesthetic has been directly related to the se- 76.7 mg/kg respectively. Similar near toxic levels were rum concentration by many authors [139, 142–144, reported in individual patients receiving about 35 mg/ 146–148]. Early signs of toxicity, usually occurring at kg of lidocaine by Samdal et al. [157]. Pitman [158] re- serum levels of about 3–4 µg/ml for lidocaine, include ported that toxic manifestations occurred 8 h postoper- circumoral numbness and lightheadedness, and tinni- atively after a total dose of 48.8 mg/kg which resulted tus. As the serum concentration increases toward 8 µg/ from a 12-h plasma lidocaine level of 3.7 µg/kg. Ostad et ml,tachycardia,tachypnea,confusion,disorientation, al. [140] concludes that because of the poor correlation visual disturbance, muscular twitching and cardiac de- of lidocaine doses with the plasma lidocaine levels, an pression may occur. At still higher serum levels above extrapolation of the maximum safe dose of lidocaine 8 µg/ml, unconsciousness and seizures may ensue. for liposuction cannot be determined. Given the devas- Complete cardiorespiratory arrest may occur between tating consequences of lidocaine toxicity, physicians 10 and 20 µg/ml [139, 146, 147]. However, the toxicity of must exercise extreme caution while attempting to lidocaine may not always correlate exactly with the push the acceptable safe limits to ever-higher levels of plasma level of lidocaine presumably because of the tumescent anesthesia. Physicians must consider the variable extent of protein binding in each patient and important variables affecting susceptibility of individ- the presence of active metabolites [139] and other fac- ual patients to lidocaine toxicity before “boldly going tors already discussed including the age, ethnicity, where no surgeon has gone before”, especially since health, and body habitus of the patient, and additional plasma lidocaine levels typically peak after the patient medications. is at home. Ropivacaine, a long lasting local anesthetic, has less Patients who report previous allergies to anesthetics cardiovascular toxicity than bupivacaine and may be a may present a challenge to surgeons performing lipo- safer alternative to bupivacaine if a local anesthetic of suction. Although local anesthetics of the aminoester longer duration is required [149, 150]. The cardiovas- class such as procaine are associated with allergic reac- cular toxicity of bupivacaine and etidocaine is much tions, true allergic phenomena to local anesthetics of greater than that of lidocaine [149–151]. While bupiva- theaminoamideclass,suchaslidocaine,areextremely caine toxicity has been associated with sustained ven- rare [158, 159]. Allergic reactions may occur to the pre- tricular tachycardia and sudden profound cardiovascu- servativeinthemultidosevials.Tachycardiaandgener- lar collapse [152, 153], the incidence of ventricular alized flushing may occur with rapid absorption of the dysarrhythmias has not been as widely acknowledged epinephrine contained in some standard local anes- with lidocaine or mepivacaine toxicity. In fact, ventric- thetic preparations. The development of vasovagal re- ular tachycardia of fibrillation was not observed despite actions after injections of any kind may cause hypoten- the use of supraconvulsant doses of intravenous doses sion,bradycardia,diaphoresis,pallor,nausea,andloss of lidocaine, etidocaine, or mepivacaine in the animal of consciousness. These adverse reactions may be mis- model [150]. interpreted by the patient and even the physician as al- Indeed, during administration of infiltrative lido- lergic reactions [159]. A careful history from the pa- caine anesthesia, rapid anesthetic injection into a high- tient describing the apparent reaction usually clarifies ly vascular area or accidental intravascular injection the cause. If there is still concern about the possibility leading to sudden toxic levels of anesthetics resulting in of true allergy to local anesthetic, then the patient sudden onset of seizures or even cardiac arrest or car- should be referred to an allergist for skin testing. diovascular collapse has been documented [154, 155]. Intheeventofaseizurefollowingatoxicdoseoflo- One particularly disconcerting case presented by cal anesthetic, proper airway management and main- Christie confirms the fatal consequence of a lidocaine taining oxygenation is critical. Seizure activity may be injection of 200 mg in a healthy patient [156]. Seizure aborted with intravenous diazepam (10–20 mg), mida- and death occurred following a relatively low dose of li- zolam (5–10 mg), or thiopental (100–200 mg). docaine and a serum level of only 0.4 mg/100 ml or Although the ventricular arrhythmias associated 4 µg/ml. A second patient suffered cardiac arrest with a with bupivacaine toxicity are notoriously intractable blood level of 0.58 mg/100 ml or 5 µg/ml [156]. Al- [152,153],treatmentisstillpossibleusinglargedoses though continued postmortem metabolism may artifi- of atropine, epinephrine and bretylium [161, 162]. cially reduce serum lidocaine levels, the reported se- Some studies indicate that lidocaine should not be used rum levels associated with mortality in these patients [163]. Pain associated with local anesthetic administra- were well below the 8–20 µg/ml considered necessary tionisduetothepHofthesolutionandmaybereduced to cause seizures, myocardial depression, and cardiore- by the addition of 1 mEq of sodium bicarbonate to spiratory arrest. The 4 µg/ml level reported by Christie 10 ml of anesthetic [164]. 38 2 Anesthesia for Liposuction and Abdominoplasty

EMLA (eutectic mixture of local anesthetics), a com- of general anesthesia [166]. During general anesthesia bination of lidocaine and prilocaine, may provide ef- the patient most likely loses the LPPRs. fective topical anesthesia over smaller areas such as the In actual practice, the delineation between the levels face.However,anocclusivedressingmustbeapplied, of sedation becomes challenging at best. The loss of andatleast60minisrequiredforadequateanesthesia consciousness occurs as a continuum. With each incre- [165]. Except for small, localized surgical procedures, mental change in the level of consciousness, the likeli- topical anesthetics do not have a wide application for li- hood of loss of LPPRs increases. Since the definition of posuction or abdominoplasty. conscious sedation is vague, current ASA guidelines consider the term sedation-analgesia a more relevant term than conscious sedation [25]. The term sedative- 2.3.2 analgesic medication (SAM) has been adopted by some Sedative-Analgesic Medication (SAM) facilities. Monitored anesthesia care (MAC) has been Most liposuctions are performed with a combination of generally defined as the medical management of pa- local tumescent anesthesia and supplemental sedative- tients receiving local anesthesia during surgery with or analgesic medications (SAM) administered orally without the use of supplemental medications. MAC (p.o.), intramuscularly (i.m.), or intravenously (i.v.). usually refers to services provided by the anesthesiolo- Abdominoplasties performed under local or regional gist or the Certified Registered Nurse Anesthetist anesthesia generally require SAM. The goals of admin- (CRNA). The term “local standby” is no longer used istering supplemental medications are to reduce anxi- because it mischaracterizes the purpose and activity of ety (anxiolysis), the level of consciousness (sedation), the anesthesiologist or CRNA. unanticipated pain (analgesia), and, in some cases, to Surgical procedures performed using a combination eliminate recall of the surgery (amnesia). of local anesthetic and SAM usually have a shorter re- Sedation may be defined as the reduction of the level covery time than similar procedures performed under of consciousness usually resulting from pharmacologi- regional or general anesthesia [167]. Using local anes- cal intervention. The level of sedation may be further thesia alone, without the benefit of supplemental medi- divided into three broad categories, conscious seda- cation is associated with a greater risk of cardiovascu- tion, deep sedation, and general anesthesia. The term lar and hemodynamic perturbations such as tachycar- conscious sedation has evolved to distinguish a lighter dia, arrhythmias, and hypertension particularly in pa- state of anesthesia with a higher level of mental func- tients with preexisting cardiac disease or hypertension tioning whereby the life-preserving protective reflexes [168]. Patients usually prefer sedation while undergo- are independently and continuously maintained. Fur- ing surgery with local anesthetics [169]. While the ad- thermore, the patient is able to respond appropriately dition of sedatives and analgesics during surgery using to physical and verbal stimulation [166]. local anesthesia seems to have some advantages, use of Life preserving protective reflexes (LPPRs) may be SAM during local anesthesia is certainly not free of defined as the involuntary physical and physiological risk. A study by the Federated Ambulatory Surgical As- responses that maintain the patient’s life which, if inter- sociation concluded that local anesthesia, with supple- rupted, result in inevitable and catastrophic physiolog- mental medications, was associated with more than ical consequences. The most obvious examples of twice the number of complications than with local an- LPPRs are the ability to maintain an open airway, swal- esthesia alone. Furthermore, local anesthesia with lowing, coughing, gagging, and spontaneous breath- SAM was associated with greater risks than general an- ing. Some involuntary physical movements such as esthesia [60]. Significant respiratory depression as de- head turning or attempts to assume an erect posture termined by the development of hypoxemia, hypercar- may be considered LPPRs if these reflex actions occur bia, and respiratory acidosis often occurs in patients af- in an attempt to improve airway patency such as expel- ter receiving minimal doses of medications. This respi- ling oropharyngeal contents. The myriad of homeo- ratory depression persists even in the recovery period static mechanisms to maintain blood pressure, heart [170, 171]. function and body temperature may even be consid- One explanation for the frequency of these compli- ered LPPRs. cationsisthewidevariabilityofpatients’responsesto As the level of consciousness is further depressed to these medications. Up to 20-fold differences in the dose thepointthatthepatientisnotabletorespondpur- requirements for some medications such as diazepam, posefullytoverbalcommandsorphysicalstimulation, andupto5-foldvariationsforsomenarcoticssuchas the patient enters into a state referred to as deep seda- fentanyl, have been documented in some patients [172, tion. In this state, there is a significant probability of 173]. Even small doses of fentanyl as low as 2 µg/kg, loss of LPPRs. Ultimately, as total loss of consciousness considered by many physicians as subclinical, produce occurs and the patient no longer responds to verbal respiratory depression for more than 1 h in some pa- command or painful stimuli, the patient enters a state tients [174]. Combinations of even small doses of seda- 2.3 Anesthesia for Liposuction and Abdominoplasty 39 tives, such as midazolam, and narcotics, such as fenta- during local anesthesia to decrease pain associated nyl, may act synergistically (effects greater than an ad- with local anesthetic injection or unanticipated break- ditive effect) in producing adverse side effects such as through pain. Fentanyl has the advantage of rapid onset respiratory depression and hemodynamic instability and duration of action of less than 60 min. However, [175]. The clearance of many medications may vary de- because of synergistic action with sedative agents, even pending on the amount and duration of administra- doses of 25–50 µg can result in respiratory depression tion, a phenomenon known as context-sensitive half- [183]. Other medications with sedative and hypnotic life. The net result is increased sensitivity and duration effectssuchasabarbiturate,ketamine,orpropofolare of action to medication for longer surgical cases [176]. often added. Adjunctive analgesics such as ketorolac Because of these variations and interactions, predicting may be administered for addition of analgesic activity. any given patient’s dose response is a daunting task. Pa- As long as the patient is carefully monitored, several tients appearing awake and responsive may, in an in- medications may be titrated together to achieve the ef- stant, slip into unintended levels of deep sedation with fects required for the patient characteristics and the greater potential of loss of LPPRs. Careful titration of complexity of the surgery. Fixed combinations of medi- these medications to the desired effect combined with cations are not advised [25]. vigilant monitoring are the critical elements in avoid- More potent narcotic analgesics with rapid onset of ing complications associated with the use of SAM. action and even shorter duration of action than fenta- Supplemental medication may be administered via nyl include sufenanil, alfenanil, and remifenanil and multiple routes including oral, nasal, transmucosal, may be administered using intermittent boluses or con- transcutaneous,intravenous,intramuscularandrectal. tinuousinfusionincombinationwithothersedativeor While intermittent bolus has been the traditional hypnotic agents. However, extreme caution and scru- method to administer medication, continuous infusion pulous monitoring is required when these potent nar- and patient controlled delivery result in comparable cotics are used because of the risk of respiratory arrest safety and patient satisfaction [177, 178]. [184,185].Useofthesemedicationsshouldberestrict- Benzodiazepines such as diazepam, midazolam and ed to the anesthesiologist or the CRNA. A major disad- lorezepam remain popular for sedation and anxiolysis. vantage of narcotic medication is the perioperative Patients and physicians especially appreciate the potent nausea and vomiting [186]. amnesticeffectsofthisclassofmedications,especially Many surgeons feel comfortable administering SAM midazolam. The disadvantages of diazepam include the to patients. Others prefer to use the services of an anes- higher incidence of pain on intravenous administra- thesiologist or CNRA. Prudence dictates that for pro- tion, the possibility of phlebitis [179], and the pro- longed or complicated surgeries or for patients with longed half-life of up to 20–50 h. Moreover, diazepam significant risk factors, the participation of the anes- has active metabolites which may prolong the effects of thesiologist or CRNA during MAC anesthesia is prefer- the medication even into the postoperative recovery able. Regardless of who administers the anesthetic time [180]. Midazolam, however, is more rapidly me- medications, the monitoring must have the same level tabolized, allowing for a quicker and more complete re- of vigilance. covery for outpatient surgery [180]. Because the seda- Propofol, a member of the alkylphenol family, has tive, anxiolytic and amnestic effects of midazolam are demonstrated its versatility as a supplemental sedative- more profound than other benzodiazepines and the re- hypnotic agent for local anesthesia and of regional an- covery is more rapid, patient acceptance is usually esthesia. Propofol may be used alone or in combination higher [181]. Since lorezepam is less affected by medi- with a variety of other medications. Rapid metabolism cations altering cytochrome P459 metabolism [182], it and clearance results in faster and more complete re- has been recommended as the sedative of choice of li- covery with less postoperative hangover than other posuctions which require a large dose lidocaine tumes- sedative-hypnotic medications such as midazolam and cent anesthesia [146]. The disadvantage of lorezepam is methohexital [187, 188]. The documented antiemetic the slower onset of action and the 11–22 h elimination properties of propofol yield added benefits of this med- half-life, making titration cumbersome and postopera- ication [189]. The disadvantages of propofol include tive recovery prolonged [180]. pain on intravenous injection and the lack of amnestic Generally, physicians who use SAM titrate a combi- effect [190]. However, the addition of 3 ml of 2% lido- nation of medications from different classes to tailor caine to 20 ml of propofol virtually eliminates the pain the medications to the desired level of sedation and an- on injection with no added risk. If an amnestic re- algesia for each patient. Use of pre-packaged combina- sponse is desired, a small dose of a benzodiazepine, tions of medications defeats the purpose of the selec- such as midazolam (5 mg i.v.), given in combination tive control of each medication. Typically, sedatives with propofol, provides the adequate amnesia. Rapid such as the benzodiazepines are combined with narcot- administration of propofol may be associated with sig- ic analgesics such as fentanyl, meperidine, or morphine nificant hypotension, decreased cardiac output [191], 40 2 Anesthesia for Liposuction and Abdominoplasty

and respiratory depression [192]. Continuous infusion used effectively in combination with various narcotic with propofol results in a more rapid recovery than medications. Innovar is a combination of droperidol similar infusions with midazolam [193]. Patient-con- and fentanyl. While droperidol has a minimal effect on trolled sedation with propofol has also been shown to respiratory function if used as a single agent, when be safe and effective [194]. combined with narcotic medication, a predictable Barbiturate sedative-hypnotic agents such as thio- dose-dependent respiratory depression may be antici- pental and methohexital, while older, still play a role in pated [200]. Psychomimetic reactions such as dyspho- many clinical settings. In particular, methohexital, ria or hallucinations are frequent, unpleasant side ef- with controlled boluses (10–20 mg i.v.) or limited infu- fectsofdroperidol.Benzodiazepinesornarcoticsre- sions remain a safe and effective sedative-hypnotic al- duce the incidence of these unpleasant side effects ternative with rapid recovery. However, with prolonged [201]. Extrapyramidal reactions such as dyskinesias, administration, recovery from methohexital may be torticollis, or oculogyric spasms may also occur, even delayedcomparedtopropofol[195]. with small doses of droperidol. Dimenhydrinate usual- Ketamine, a phencyclidine derivative, is a unique ly reverses these complications [202]. Hypotension agent because of its combined sedative and analgesic may occur as a consequence of droperidol’s alpha-ad- effects and the absence of cardiovascular depression in renergic blocking characteristics. One rare complica- healthypatients[196].BecausetheCNSeffectsofketa- tion of droperidol is the neurolept malignant syndrome mine results in a state similar to catatonia, the resulting (NMS) [203], a condition very similar to malignant hy- anesthesia is often described as dissociative anesthesia. perthermia, characterized by extreme temperature ele- Although gag and cough reflexes are more predictably vations and rhabdomyolysis. The treatment of NMS maintained with ketamine, emesis and pulmonary as- and malignant hyperthermia is essentially the same. piration of gastric contents is still possible [197]. Un- While droperidol has been used for years without ap- fortunately, a significant number of patients suffer dis- preciable myocardial depression [201], a surprising an- tressing postoperative psychomimetic reactions [198]. nouncement from the Federal Drug Administration While concomitant administration of benzodiazepines warned of sudden cardiac death resulting after the ad- attenuates these reactions, the postoperative psycho- ministration of standard, clinically useful doses [204]. logical sequelae limit the usefulness of ketamine for Unfortunately, this potential complication makes the most elective outpatient surgeries. routine use of this once very useful medication difficult Droperidol, a butyrophenone and a derivative of to justify given the presence of other alternative medi- haloperidol, acts as a sedative, hypnotic, and antiemet- cations. ic medication. Rather than causing global CNS depres- Butorphanol, buprenorphine, and nalbuphine are sion like barbiturates, droperidol causes more specific three synthetically derived opiates, which share the CNS changes similar to phenothiazines. For this rea- properties of being mixed agonist-antagonist at the son, the cataleptic state caused by droperidol is referred opiate receptors. These medications are sometimes to as neuroleptic anesthesia [199]. Droperidol has been preferred as supplemental analgesics during local, re-

Medication Bolusdose Averageadultdose Continuous infusion Table 2.7. Common medica- rate (µg/kg/min) tions and dosages used for sedative analgesia. These Narcotic analgesics doses may vary depending Alfentanil 5–7 µg/kg 30–50 µg 0.2–0.5 on age, gender, underlying Fentanyl 0.3–0.7 µg/kg 25–50 µg 0.01 health status, and other con- Meperidine 0.2 mg 10–20 mg i.v., 50–100 mg i.m. NA comitantly administered Morphine 0.02 mg 1–2 mg i.v., 5–10 mg i.m. NA medications. (Adapted from Remifentanil 0.5–1.0 µg/kg 10–25 µg 0.025–0.05 Philip [214], SaRego et al. Sufentanil 0.1–0.2 µg/kg 10 µg 0.001–0.002 [215], and Fragen [216]) Opiate agonist-antagonist analgesics Buprenorphene 4–6 µg/kg 0.3 mg NA Butorphanol 2–7µg/kg 0.1–0.2mg NA Nalbuphine 0.03–0.1 mg/kg 10 mg NA Sedative hypnotics Diazepam 0.05–0.1 mg/kg 5–7.5 mg NA Methohexital 0.2–0.5 mg/kg 10–20 mg 10–50 Midazolam 30–75 µg/kg 2.5–5.0 0.25–0.5 Propofol 0.2–0.5 mg/kg 10–20 mg 10–50 Thiopental 0.5–1.0 mg/kg 25–50 mg 50–100 Dissociative anesthetics Ketamine 0.2–0.5 mg/kg 10–20 mg 10 2.3 Anesthesia for Liposuction and Abdominoplasty 41 gional, or general anesthesia, because they partially re- Airway control is a key element in the management verse the analgesic and respiratory depressant effects of the patient under general anesthesia. Maintaining a of other narcotics. While these medications result in patent airway, ensuring adequate ventilation, and pre- respiratory depression at lower doses, a ceiling effect vention of aspiration of gastric contents are the goals occurs at a higher dose, thereby limiting the respirato- of successful airway management. For shorter cases, ry depression. Still, respiratory arrest is possible, espe- the airway may be supported by an oropharyngeal air- cially if these medications are combined with other way and gas mixtures delivered by an occlusive mask. medications with respiratory depressant properties For longer or more complex cases, or if additional fa- [205]. While the duration of action of butorphanol is cial surgery is planned requiring surgical field avoid- 2–3 h, nalbuphine has a duration of action of about ance, then the airway may be secured using laryngeal 3–6handbuprenorphanupto10h,makingthese mask anesthesia (LMA) or endotracheal intubation medicationslesssuitableforsurgeriesofshorterdura- [213]. tion. Table 2.7 summarizes the recommended doses for SAM. 2.3.4 Preoperative Preparation 2.3.3 Generally, medications, which may have been required General Anesthesia to stabilize the patient’s medical conditions, should be While some authors attribute the majority of complica- continued up to the time of surgery. Notable exceptions tions occurring during and after liposuction to the ad- include anticoagulant medications, monoamine oxi- ministration of systemic anesthesia [148, 206], others dase inhibitors (MAO) [217, 218], and possibly the an- consider sedation and general anesthesia safe and ap- giotensin converting enzyme (ACE) inhibitor medica- propriate alternatives in indicated cases [19, 158, 207, tions [219, 220]. It is generally accepted that MAO in- 208].Infact,Kleincorrectlyacknowledgesthatmostof hibitors, carboxazid (Marplan), deprenyl (Eldepryl), the complications attributed to midazolam and narcot- pargyline (Eutonyl), phenelzine (Nardil), tranylcypro- ic combinations occurred as a result of inadequate mine (Parnate), be discontinued 2–3 weeks prior to monitoring [148]. Although significant advances have surgery, especially for elective cases, because of the in- been made in the administration of local anesthetics teractions with narcotic medication, specifically hyper- and supplemental medications, the use of general anes- pyrexia, and certain vasopressor agents, specifically thesia may still be the anesthesia technique of choice ephedrine [217, 218]. Patients taking ACE inhibitors for many patients. General anesthesia is especially ap- (captopril, enalapril, and lisinopril) may have a greater propriate when working with patients suffering ex- risk for hypotension during general anesthesia [220]. treme anxiety, high tolerance to narcotic or sedative As previously discussed, diabetics may require a reduc- medications, or if the surgery is particularly complex. tion in dosage of their medication. However, if the risks The goals of a general anesthetic are a smooth induc- of discontinuing any of these medications outweigh the tion, a prompt recovery, and minimal side effects, such benefits of the proposed elective surgery, the patient as nausea, vomiting, or sore throat. The inhalation an- and physician may decide to postpone, modify, or can- esthetic agents, halothane, isoflurane, and enflurane, cel the proposed surgery. remain widely popular because of the safety, reliability, Previous requirements of complete preoperative fast- and convenience of use. The newer inhalation agents, ing for 10–16 h are considered unnecessary by many an- sevoflurane and desflurane, share the added benefit of esthesiologists [221, 222]. More recent investigations prompt emergence [209, 210]. Nitrous oxide, a long- have demonstrated that gastric volume may be less 2 h time favorite anesthetic inhalation agent, may be asso- after oral intake of 8 ounces of clear liquid than after ciated with postoperative nausea and vomiting [211]. more prolonged fasting [223]. Furthermore, prolonged Patients receiving nitrous oxide also have a greater risk fasting may increase the risk of hypoglycemia [224]. of perioperative hypoxemia. Many patients appreciate an 8 ounce feeding of their fa- The development of potent, short-acting sedative voritecaffeinatedelixir2hpriortosurgery.Preopera- opiates, analgesics, and muscle relaxant medications tive sedative medications may also be taken with a small has resulted in a newer medication regimen that per- amount of water or juice. Abstinence from solid food in- mits the use of intravenous agents exclusively. The gestion for 10–12 h prior to surgery is still recommend- same medications that have been discussed for SAM ed. Liquids taken prior to surgery must be clear [225], can also be used during general anesthesia as sole e.g., coffee without cream or juice without pulp. agents or in combination with the inhalation agents Healthy outpatients are no longer considered higher [212]. The anesthesiologist or CRNA should preferen- risk for gastric acid aspiration, and therefore routine tially be responsible for the administration and moni- use of antacids, histamine type-2 (H2) antagonists, or toring of a general anesthesia. gastrokinetic medications is not indicated. However, 42 2 Anesthesia for Liposuction and Abdominoplasty

patients with marked obesity, hiatal hernia, or diabetes dansetron is available in a parenteral preparation and mellitus have higher risks for aspiration. These patients as orally disintegrating tablets and oral solution. may benefit from selected prophylactic treatment Promethazine (12.5–25 mg p.o., p.r., or i.m.) and [226]. Sodium citrate, an orally administered, non-par- chlorpromazine (5–10 mg p.o., or i.m. and 25 mg p.r.) ticulate antacid, rapidly increases gastric pH. However, are two older phenothiazines which are still used by its unpleasant taste and short duration of action limits many physicians as prophylaxis, especially in combina- itsusefulnessinelectivesurgery[227].Gastricvolume tion with narcotic analgesics. Once again, sedation and and pH may be effectively reduced by H2 receptor an- extrapyramidal effects may complicate the routine pro- tagonists. Cimetidine (300 mg p.o., 1–2 h prior to sur- phylactic use of these medications [232]. gery) reduces gastric volume and pH. However, cimeti- Preoperative atropine (0.4 mg i.m.), glycopyrrolate, dine is also a potent cytochrome oxidase inhibitor and (0.2 mg i.m.), and scopolamine (0.2 mg i.m.), anticholin- may increase the risk of reactions to lidocaine during ergic agents once considered standard preoperative tumescent anesthesia [228]. Ranitidine (150–300 mg medication because of their vagolytic and antisialogic 90–120 min prior to surgery) [229] or famotidine effects, are no longer popular because of side effects (20 mg p.o. 60 min prior to surgery) are equally effec- such as dry mouth, dizziness, tachycardia, and disorien- tive but have a better safety profile than cimetidine tation [247]. Transdermal scopolamine, applied 90 min [230]. prior to surgery, effectively reduces PONV. However, the Omeprazole, which decreases gastric acid secre- incidence of dry mouth and drowsiness is high [248], tion by inhibiting the proton pump mechanism of the and toxic psychosis is a rare complication [249]. Antihis- gastric mucosa, may prove to be a safe and effective al- tamines, such as dimenhydrinate (25–50 mg p.o., i.m., ternative to the H2 receptor antagonists [230]. Metac- or i.v.) and hydroxyzine (50 mg p.o. or i.m.), may also be lopramide (10–20 mg p.o. or i.v.), a gastrokinetic used to treat and prevent PONV with few side effects ex- agent, which increases gastric motility and lower cept for possible postoperative sedation [250]. esophageal sphincter tone, may be effective in patients The selection of anesthetic agents may also play a with reduced gastric motility, such as diabetics or pa- major role in PONV. The direct antiemetic actions of tients receiving opiates. However, extrapyramidal side propofol have been clearly demonstrated [251]. Anes- effects limit the routine use of the medication [231, thetic regimens utilizing propofol, alone or in combi- 232]. nation with other medications, are associated with sig- Postoperative nausea and vomiting (PONV) re- nificantly less PONV [252]. Although still controver- mains one of the more vexing complications of anes- sial,nitrousoxideisconsideredbymanyauthorsa thesia and surgery [233]. In fact, patients dread PONV prime suspect among possible causes of PONV [211, more than any other complication, even postoperative 253, 254]. Use of opiates is also considered a culprit in pain [234]. PONV is the most common postoperative the development of PONV and the delay of discharge complication [235, 236] and the common cause of post- after outpatient surgery [186, 255–257]. Adequate fluid operative patient dissatisfaction [237]. Use of prophy- hydrationhasbeenshowntoreducePONV[258]. lactic antiemetic medication has been shown to reduce Onegoalofpreoperativepreparationistoreduce the incidence of PONV [238]. Even though many pa- patients’ anxiety. Many simple, non-pharmacological tients do not suffer PONV in the recovery period after techniques may be extremely effective in reassuring ambulatory anesthesia, more than 35% of patients de- both patients and families, starting with a relaxed, velop PONV after discharge [239]. friendly atmosphere and a professional, caring, and at- Droperidol, 0.625–1.25 mg i.v., is an extremely cost- tentive office staff. With proper preoperative prepara- effectiveantiemetic[240].However,troublesomeside tion, pharmacological interventions may not even be effects such as sedation, dysphoria, extrapyramidal re- necessary. However, a variety of oral and parenteral an- actions [241], and more recently cardiac arrest have xiolytic-sedative medications are frequently called up- been described [203]. These complications may pre- on to provide a smooth transition to the operative clude the widespread use of droperidol altogether. On- room. Diazepam (5–10 mg p.o.), given 1–2 h preoper- dansetron, a seratonin antagonist (4–8 mg i.v.), is one atively, is a very effective medication, which usually of the most effective antiemetic medications available does not prolong recovery time [259]. Parenteral diaze- withoutsedative,dysphoricorextrapyramidalsequel- pam (5–10 mg i.v. or i.m.) may also be given immedi- ae [242, 243]. The antiemetic effects of ondansetron ately preoperatively. However, because of a long elimi- may reduce PONV for up to 24 h postoperatively [244]. nation half-life of 24–48 h, and active metabolites with The effects of ondansetron may be augmented by the an elimination half-life of 50–120 h, caution must be addition of dexamethasone (4–8 mg) [245] or droperi- exercised when using diazepam, especially in shorter dol (1.25 mg i.v.) [246]. Despite its efficacy, cost re- cases, so that recovery is not delayed [260]. Pain and mains a prohibitive factor in the routine prophylactic phlebitis with i.v. or i.m. administration reduces the use of ondansetron, especially in the office setting. On- popularity of diazepam [179]. 2.3 Anesthesia for Liposuction and Abdominoplasty 43

Lorezepam (1–2 mg p.o. or s.l., 1–2 h preoperative- gave no information regarding the incidence of non-fa- ly) is also an effective choice for sedation or anxiolysis. tal PE [271]. Other reports suggest that the incidence of However, the prolonged duration of action may pro- pulmonary embolism after tumescent liposuction and long recovery time after shorter cases [261]. Midazo- abdominoplastymaybemorecommonthanreported lam (5–7.5 mg i.m., 30 min preoperatively, or 2 mg i.v. [272–275]. One study revealed that unsuspected PE minutes prior to surgery) is a more potent anxiolytic- mayactuallyoccurinupto40%ofpatientswhodevel- sedative medication with more rapid onset and shorter op DVT [276]. elimination half-life, compared to diazepam [262]. Un- Prevention of DVT and PE should be considered an fortunately, oral midazolam has unpredictable results essential component of the perioperative management. and is not considered a useful alternative for preopera- Although unfractionated heparin reduces the rate of fa- tive medication [263]. Oral narcotics, such as oxycodo- tal PE [277], many surgeons are reluctant to use this ne (5–10 mg p.o.), may help relieve the patient’s intra- prophylaxis because of concerns of perioperative hem- operative breakthrough pain during cases involving orrhage. The low molecular weight heparins, enoxapa- more limited liposuction with minimal potential peri- rin, dalteparin, ardeparin, and danaparoid, a heparino- operative sequelae. Parenteral opioids, such as mor- id, are available for prophylactic indications. Graduated phine (5–10 mg i.m., or 1–2 mg i.v.), demerol compression stockings and intermittent pneumatic (50–100 mg i.m., or 10–20 mg i.v.), fentanyl (10–20 µg lower extremity compression devices applied through- i.v.), or sufentanil (1 to 2 ug i.v.), may produce sedation out the perioperative period, until the patient has be- and euphoria and may decrease the requirements for come ambulatory, are considered very effective and safe other sedative medication. The level of anxiolysis and alternatives in the prevention of postoperative DVT and sedation is still greater with the benzodiazepines than PE [278, 279]. Even with prophylactic therapy, PE may with the opioids. Premedication with narcotics has still occur up to 30 days after surgery [280]. Physicians been shown to have minimal effects on postoperative should be suspicious of PE if patients present postoper- recovery time. However, opioid premedication may in- atively with dyspnea, chest pain, cough, hemoptysis, crease PONV [264, 265]. pleuritic pain, dizziness, syncope, tachycardia, cyano- Antihistamine medications, such as hydroxyzine sis, shortness of breath, or wheezing [268]. (50–100 mg i.m, or 50–100 mg p.o.), dimenhydrinate (50 mg p.o., i.m., or 25 mg i.v.), are still used safely in 2.3.5 combination with other premedications, especially the Perioperative Monitoring opioids, to add sedation and to reduce nausea and pru- ritis. However, the anxiolytic and amnestic effects are The adoption of a standardized perioperative monitor- notaspotentasthebenzodiazepines[266].Barbitu- ing protocol has resulted in a quantum leap in periop- rates, such as secobarbital and pentobarbital, once a erative patient safety. The standards for basic perioper- standard premedication have largely been replaced by ative monitoring were approved by the ASA in 1986 and the benzodiazepines. amended in 1995 [17]. These monitoring standards are Postoperative PE is an unpredictable and devastat- now considered applicable to all types of anesthetics, ing complication with an estimated incidence of including local with or without sedation, regional, or 0.1–5%,dependingonthetypeofsurgicalcase[267], general anesthesia, regardless of the duration or com- and a mortality rate of about 15% [267]. Risk factors plexity of the surgical procedure and regardless of for thromboembolism include prior history or family whether the surgeon or anesthesiologist is responsible historyofDVTorPE,obesity,smoking,hypertension, for the anesthesia. Vigilant and continuous monitoring use of oral contraceptives and hormone replacement and compulsive documentation facilitates early recog- therapy, and patients over 60 years of age [268]. Esti- nition of deleterious physiological events and trends, mates for the incidence of postoperative DVT vary be- which, if not recognized promptly, could lead to irre- tween 0.8% for outpatients undergoing herniorrha- versible pathological spirals, ultimately endangering a phies [269], to up to 80% for patients undergoing total patient’s life. hip replacement [267]. Estimates of fatal PE also vary During the course of any anesthetic, the patient’s ox- from 0.1% for patients undergoing general surgeries to ygenation, ventilation, circulation, and temperature up to 1–5% of patients undergoing major joint replace- should be continuously evaluated. The concentration ment [267]. While a recent national survey of physi- oftheinspiredoxygenmustbemeasuredbyanoxygen cians performing tumescent liposuction, in a total of analyzer. Assessment of the perioperative oxygenation 15,336 patients, indicated that no patient suffered DVT of the patient using pulse oximetry, now considered or PE [270], only 66 physicians who perform liposuc- mandatory in every case, has been a significant ad- tion responded out of 1,778 questionnaires sent, which vancement in monitoring. This monitor is so critical to is a mere 3.7% response rate. A review of 26,591 abdo- thesafetyofthepatientthatithasearnedthenickname minoplasties revealed 9 cases of fatal PE, or 0.03%, but “the monitor of life”. Evaluation of ventilation includes 44 2 Anesthesia for Liposuction and Abdominoplasty

observationofskincolor,chestwallmotion,andfre- 2.3.6 quent auscultation of breath sounds. During general an- Fluid Replacement esthesia with or without mechanical ventilation, a dis- connect alarm on the anesthesia circuit is crucial. Cap- Management of perioperative fluids probably generates nography, a measurement of respiratory end-tidal CO2, more controversy than any other anesthesia related is required, especially when the patient is under heavy topics. Generally, the typical, healthy, 60-kg patient re- sedation or general anesthesia. Capnography provides quires about 100 cc of water per hour to replace meta- the first alert in the event of airway obstruction, hypo- bolic, sensible, and insensible water losses. After a 12-h ventilation, or accidental anesthesia circuit disconnect, period of fasting, a 60-kg patient may be expected to even before the oxygen saturation has begun to fall. All have a 1-liter volume deficit on the morning of surgery. patients must have continuous monitoring of the elec- This deficit should be replaced over the first few hours trocardiogram (ECG), and intermittent determination of surgery. The patient’s usual maintenance fluid needs of blood pressure (BP) and heart rate (HR) at a mini- may be met with a crystalloid solution such as lactated mum of 5-min intervals. Superficial or core body tem- Ringer’s solution. perature should be monitored. Of course, all electronic Replacement fluids may be divided into crystalloid monitors must have preset alarm limits to alert physi- solutions, such as normal saline or balanced salt solu- cians prior to the development of critical changes. tion, colloids, such as fresh frozen plasma, 5% albu- While the availability of electronic monitoring min, plasma protein fraction, or hetastarch, and blood equipment has improved perioperative safety, there is products containing red blood cells, such as packed red no substitute for visual monitoring by a qualified, expe- blood cells. Generally, balanced salt solutions may be rienced practitioner, usually a CRNA or an anesthesiol- used to replace small amounts of blood loss. For every ogist. During surgeries using local with SAM, if a sur- milliliter of blood loss, 3 ml of fluid replacement is usu- geonelectsnottouseaCRNAorananesthesiologist,a ally required [282]. However, as larger volumes of separate, designated, certified individual must perform blood are lost, attempts to replace these losses with these monitoring functions [25]. Visual observation of crystalloid reduces the serum oncotic pressure, one of the patient’s position is also important in order to avoid the main forces supporting intravascular volume. Sub- untoward outcomes such as peripheral nerve or ocular sequently, crystalloid rapidly moves into the extracellu- injuries. lar space. Intravascular volume cannot be adequately Documentation of perioperative events, interven- sustained with further crystalloid infusion [283]. At tions, and observations must be contemporaneously this point, many authors suggest that a colloid solution performed and should include BP and HR every 5 min may be more effective in maintaining intravascular vol- and oximetry, capnography, ECG pattern, and temper- ume and hemodynamic stability [284, 285]. Given the ature at 15-min intervals. Intravenous fluids, medica- ongoing crystalloid-colloid controversy in the litera- tion dosages in milligrams, patient position and other ture, the most practical approach to fluid management intraoperative events must also be recorded. Docu- is a compromise. Crystalloid replacement should be mentation may alert the physician to unrecognized used for estimated blood losses (EBL) less than 500 ml, physiological trends that may require treatment. Prep- whilecolloidssuchashetastarchmaybeusedforEBLs aration for subsequent anesthetics may require infor- greater than 500 ml. One milliliter of colloid should be mation contained in the patient’s prior records, espe- used to replace 1 ml of EBL [282]. However, not all au- cially if the patient suffered an unsatisfactory outcome thors agree on the benefits of colloid resuscitation. due to the anesthetic regimen that was used. Treatment MossandGouldconcludedthatisotoniccrystalloidre- of subsequent complications by other physicians may placement, even for large EBLs, restores plasma volume require information contained in the records, such as as well as colloid replacement [286]. the types of medications used, blood loss or fluid totals. For patients with less than 1,500 ml of fat extraction Finally, compulsive documentation may help exonerate using the tumescent technique, studies have deter- a physician in many medical-legal situations. mined that postoperative serum hemoglobin remains When local anesthesia with SAM is used, monitor- essentially unchanged [287]. Therefore, intravenous ing must include an assessment of the patient’s level of fluids beyond the deficit replacement and the usual consciousness as previously described. For patients un- maintenance amounts are generally not required [19, der general anesthesia, the level of consciousness may 158, 287, 288]. As the volume of fat removed ap- be determined using the bispectral index (BIS), a mea- proaches or exceeds 3,000 cc, judicious intravenous flu- surement derived from computerized analysis of the id replacement, including colloid, may be considered, electroencephalogram. When used with patients re- depending on the patient’s hemodynamic status [19]. ceiving general anesthesia, BIS improves control of the Fluid overload with the possibility of pulmonary ede- level of consciousness, rate of emergence and recovery, ma and congestive heart failure following aggressive and cost-control of medication usage [281]. administration of infusate and intravenous crystalloid 2.3 Anesthesia for Liposuction and Abdominoplasty 45 solutions has become a legitimate concern [158, timated preoperative blood volume of the patient, and 288–292]. Using the tumescent technique during the hemodynamic stability of the patient are the prima- which subcutaneous infusion ratios are 2–3 ml for 1 ml ry concerns. The potential risks of transfusions, such as of fat aspirated, significant intravascular hemodilution infection, allergic reaction, errors in cross matching, has been observed [289]. A 5-liter tumescent infusion and blood contamination should be considered. Final- may result in a hemodilution of 10%. Plasma lidocaine ly, the patient’s personal or religious preferences may near toxic levels, combined with an increased intravas- play a pivotal role in the decision to transfuse. Cell sav- cular volume, may increase the risk of cardiogenic pul- ing devices and autologous blood transfusions may al- monary edema, even in healthy patients [139]. leviatemanyoftheseconcerns.Healthy,normovolemic While crystalloid replacement regimen may vary, patients, with hemodynamic and physiologic stability, Pitman et al. [290] advocates limiting i.v. replacement should tolerate hemoglobin levels down to 7.5 g/dl to the difference between twice the volume of total aspi- [295]. Even for large volume liposuction using the tu- rate and the sum of i.v. fluid already administered intra- mescent technique, transfusions are rarely necessary venouslyandastumescentinfusate.Thisreplacement [19].Oncethedecisiontotransfuseismade,1mlof formula presumes a ratio of infusate to aspirate of RBCs should be used to replace every 2 ml of EBL [282]. greater than 2 to 1. If the ratio is less than one, more Serial hematocrit determination, although sometimes generous replacement fluids may be required since hy- misleading in cases of fluid overload and hemodilution, povolemia may occur [291]. The determination of fluid is still considered an important diagnostic tool in the replacement is still not an exact science, by any means. perioperative period to assist with decisions regarding Because of the unpredictable fluid requirements in pa- transfusion. tients, careful monitoring is required, including possi- During abdominoplasty and large volume liposuc- ble laboratory analysis such as CBC, BUN [291]. tion monitoring the urine output using an indwelling The estimation of perioperative blood and fluid loss urinary catheter is a useful guide to the patient’s vol- during liposuction and abdominoplasty surgeries is ume status. Urinary output should be maintained at not a trivial task. Observers in the same room frequent- greater than 0.5 ml/kg per hour. However, urinary out- ly have wide discrepancies in the estimated blood loss. put is not a precise method of determining the patient’s In the case of the abdominoplasty, unrecognized blood volume status since other factors, including surgical loss occurs. Substantial amounts of blood typically stress, hypothermia, and the medications used during seep around and under the patient, unnoticed by the anesthesia are known to alter urinary output [296]. surgeon, only to be discovered later as the nurses apply Therapeutic determinations based on a decreased uri- thedressing.Becauseofsubcutaneoushematomafor- nary output must also consider other factors, since oli- mation and the difficulty of measuring the blood con- guriamaybearesultofeitherhypovolemiaorfluid tent in the aspirate, estimating the EBL during liposuc- overload and congestive heart failure. In general, use of tion may be a particularly daunting task. Fortunately, loop diuretics, such as furosemide, to accelerate uri- the development of tumescent technique has dramati- nary output, makes everyone in the room feel better, cally reduced perioperative blood loss during liposuc- but does little to elucidate the cause of the reduced uri- tion surgeries [24, 293]. nary output, and in cases of hypovolemia may worsen The blood content in the aspirate after tumescent li- the patient’s clinical situation. However, a diuretic may posuction has varied between less than 1% [288, 293] be indicated if oliguria develops in the course of large and 8% [290]. To underscore the difficulty of estimat- volume liposuction where the total infusate and intra- ing the EBL, the range of the determined blood loss in venous fluids are several liters more than the amount of one study was 0–1,002 ml or 0–41.5% of the aspirate aspirate [292]. for liposuctions removing 1,000–5,500 ml of fat [290]. Thesameintensivemonitoringandtreatmentwhich Samdal et al. [293] admitted that the mean fall of post- occurs in the operating room must be continued in the operative hemoglobin of 5.2% (±4.9%) was higher recovery room under the care of a designated, licensed, than anticipated. The author suggested that previous and experienced person for as long as is necessary to estimates of continued postoperative blood extravasa- ensure the stability and safety of the patient, regardless tion into the surgical dead space may be too low and of whether the facility is a hospital, an outpatient surgi- may be greater than the EBL identified in the aspirate. cal center, or a physician’s office. During the initial Mandel [294] concluded that unappreciated blood loss stages of recovery, the patient should not be left alone continuesforseveraldaysaftersurgery,presumably while hospital or office personnel attend to other du- duetosofttissueextravasation,andthatserialpostop- ties. Vigilant monitoring including visual observation, erative hematocrit determinations should be used, es- continuous oximetry, continuous ECG, and intermit- pecially for large volume liposuctions. tent BP and temperature determinations must be con- Thedecisiontotransfuseapatientinvolvesmultiple tinued. Because the patient is still vulnerable to airway considerations. Certainly, the EBL, health, age, and es- obstruction and respiratory arrest in the recovery peri- 46 2 Anesthesia for Liposuction and Abdominoplasty

od, continuous visual observation is still the best meth- Use of medication intended to reverse the effects of od of monitoring for this complication. Supplemental anesthesia should be used only in the event of suspect- oxygenationshouldbecontinuedduringtheinitial ed overdose of medications. Naloxone (0.1–0.2 mg i.v.), stages of recovery and continued until the patient is a pure opiate receptor antagonist, with a therapeutic able to maintain an oxygen saturation above 90% on half-life of less than 2 h, may be used to reverse the re- room air. spiratory depressant effects of narcotic medications, The most common postoperative complication is such as morphine, demerol, fentanyl, and butorphanol. nausea and vomiting. The antiemetic medications pre- Becausepotentialadverseeffectsofrapidopiaterever- viously discussed, with the same consideration of po- sal of narcotics include severe pain, seizures, pulmo- tential risks, may be used in the postoperative period. nary edema, hypertension, congestive heart failure, Because of potential cardiac complications, droperidol, and cardiac arrest [299], naloxone must be adminis- one of the most commonly used antiemetics, is now tered by careful titration. Naloxone has no effect on the considered unsafe unless the patient has no cardiac risk actions of medications, such as the benzodiazepines, factors and a recent 12-lead ECG is normal [68]. On- the barbiturates, propofol, or ketamine. dansetron (4–8 mg i.v. or s.l.) is probably the most ef- Flumazenil (0.1–0.2 mg i.v.), a specific competitive fective and safe antiemetic. However, the cost of this antagonist of the benzodiazepines, such as diazepam, medicationisoftenprohibitive,especiallyinanoffice midazolam, lorezepam, may be used to reverse exces- setting. Postoperative surgical pain may be managed sive or prolonged sedation and respiratory depression with judiciously titrated i.v. narcotic medication such resulting from these medications [300]. The effective as demerol (10–20 mg i.v. every 5–10 min), morphine half-lifeofflumazenilislhorless[301]. (1–2 mg i.v. every 5–10 min), or butorphanol The effective half-lives of many narcotics exceed the (0.1–0.2 mg i.v. every 10 min). half-life of naloxone. The benzodiazepines have effec- Following large volume liposuction, extracellular tive half-lives greater than 2 h and, in the case of diaze- fluid extravasation or third spacing may continue for pam, up to 50 h. Many active metabolites unpredictably hours postoperatively leading to the risk of hypoten- extend the putative effects of the narcotics and benzo- sion, particularly if the ratio of tumescent infusate to diazepines. A major risk associated with the use of nal- aspirate is less than one [292]. For large volume lipo- oxone and flumazenil is the recurrence of the effects of suction, blood loss may continue for 3–4 days [294]. thenarcoticorbenzodiazepineafter1–2h.Ifthepa- Crystalloid or colloid replacement may be required in tient has already been discharged to home after these the event of hemodynamic instability. effects recur, the patient may be at risk for oversedation The number of complications that occur after dis- or respiratory arrest [299, 302]. Therefore, routine use charge may be more than twice the complications oc- of reversal agents, without specific indication, prior to curring intraoperatively and during recovery com- discharge is ill advised. Patients should be monitored bined [297]. Accredited ambulatory surgical centers for at least 2 h prior to discharge if these reversal agents generally have established discharge criteria. While are administered [25]. these criteria may vary, the common goal is to ensure Physostigmine (1.25 mg i.v.), a centrally acting anti- the patient’s level of consciousness and physiological cholinesterase inhibitor, functions as a non-specific re- stability. Table 2.8 is one example of discharge criteria versal agent which may be used to counteract the agita- that may be used: tion, sedation, and psychomotor effects caused by a va- riety of sedative, analgesic, and inhalation anesthetic agents [303, 304]. Neuromuscular blocking drugs, if re- Table 2.8. Ambulatory discharge criteria. (Modified from Mecca quired during general anesthesia, are usually reversed [298]) by the anesthesiologist or CRNA prior to emergence in 1 All life-preserving protective reflexes, i.e., airway, cough, theoperatingroomwithanticholinesteraseinhibitors gag, must be returned to normal such as neostigmine or edrophonium. Occasionally, a 2 Thevitalsignsmustbestablewithoutorthostatic second dose may be required when the patient is in the changes recovery room. 3 There must be no evidence of hypoxemia 20 min after the discontinuation of supplemental oxygen In the event patients fail to regain consciousness 4 Patients must be oriented to person, place, time, and sit- duringrecovery,reversalagentsshouldbeadminis- uation (times 4) tered. If no response occurs, the patient should be eval- 5 Nausea and vomiting must be controlled and patients uated for other possible causes of unconsciousness, in- should tolerate p.o. fluids 6 There must be no evidence of postoperative hemorrhage cluding hypoglycemia, hyperglycemia, cerebral vascu- or expanding ecchymosis lar accidents, or cerebral hypoxia. If hemodynamic in- 7 Incisional pain should be reasonably controlled stability occurs in the recovery period, causes such as 8 The patient should be able to sit up without support and occult hemorrhage, hypovolemia, pulmonary edema, walk with assistance congestive heart failure, or myocardial infarction must References 47 beconsidered.Accesstolaboratoryanalysistoassist House of Delegates on October 21, 1986, and last amended with the evaluation of the patient is crucial. Unfortu- on October 13, 1993. Directory of Members, American So- nately, stat laboratory analysis is usually not available if ciety of Anesthesiologists, Park Ridge, IL, ASA, p 394 18. Guidelines for Ambulatory Surgical Facilities (1995) Last the surgery is performed in an office-based setting. amended 1988. Directory of Members, American Society The above text is meant to serve as an overview of of Anesthesiologists, Park Ridge, IL, pp 386–387 the extremely complex subject of anesthesia. It is the in- 19. American Academy of Cosmetic Surgery (1995) Guide- tent of this chapter to serve as an introduction to the lines for Liposuction, pp 2–6 20. West Group, West’s Annotated California Codes, Health physician who participates in the perioperative man- and Safety Code. 38B, Chapter 1.3, Section 1248.15 agement of patients and should not be considered a 21. Courtiss EH, Kanter MA (1990) The prevention and man- comprehensivepresentation.Thephysicianisencour- agement of medical problems during office surgery. 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