TUMESCENT ANESTHESIA: Best Practice Protocols

Elizabeth Milligan RN, RPhSMacon, GA

NO DISCLOSURES

Emersion and Knowledge•Dr. Jeffrey Klein’s book

Tumescent Technique•Hands-on Tumescent Training•Familiarity with ultrasound (For

Endovenous procedure)

BEST OF THE BEST

PROPER TRAINING and PROTOCOLS•Safety •Clinical pharmacokinetics and pharmacology•Technique•Adverse events•Empathy

Safety• Safer Sharps, Neutral Zone• Avoid IV infusion• Prevent Mixing and Dosage Errors• Standard Formula:

1gm Lidocaine + 1mg Epi 100ml

10mEqNa+Bicarb10ml

0.9% Physiologic Saline 1000ml

1gm/1110ml = 0.09%

Safety - MixingTowel = Do

NOT DisturbStandard

Formulas Posted

Clean workspace,

Blunt Tip needles

Safety - Dosage

http://tumescent.org/wp-content/uploads/Anesth-Analg-2016-Klein.pdf

FDA Lidocaine Labeling: 7mg/kg out-of-the bottle commercial • Based on 1948 Obstetric Epidural

Data• FDA Has No Data on Subcutaneous

Infiltration

Safety - Dosage

http://tumescent.org/wp-content/uploads/Anesth-Analg-2016-Klein.pdf

Dr Klein:• Maximum safe dosage TLA 28 mg/kg (non-lipo

cases)• Peak Plasma lidocaine level with TLA = 12

hours • Added liposuction reduces peak plasma

lidocaine levels by approx. 10 -30%• Peak Plasma lidocaine concentration should

NOT exceed 5 ųg/ml

Safety -Drug Interactions• Nurse Counseling• Drug Interactions• Bleeding Risk• Lidocaine Metabolism

• Prescribing• Antibiotic• Benzodiazepine – Lorazepam vs

Diazepam• Clonidine

Protocols- NO VARIATION

•Clear Staff Roles•Clear Physician Written Order• TEAM commitment to safe Dosage • Surgical Time out • Continued monitoring

Protocols- NO VARIATION• Forms and Record keeping• Calculating Dosage

and Limitations based on weight• Document volume

and dosage administered

Protocols- NO VARIATION• Forms and Record keeping• Labeling• Keep bottles used for

mixing until next day

• Vasovagal Syncope• Failure of physiologic mechanisms responsible or

maintain both blood pressure and cerebral blood flow – Dr Klein• Need response protocol• Preventive measures for syncope• Know ahead of time if patient is prone to fainting• Patient should NOT watch - Keep head bed down• Eat before appointment

Adverse Events – Vasovagal Syncope

•Develop Emergency Response Protocols

Adverse Events – Anaphylaxis

• Sign: decreased respiration, decreased pulse rate, decreased blood pressure, decreased O2 sat, difficult to arouse.• Action:• Flumazenil 0.2 mg IV push for 15 seconds every minute for 1-5

doses• Repeat that sequence in 20 min if needed

Adverse Events – Lorazepam Toxicity

• Signs: drowsiness, lightheadedness, nausea, vomiting, nervousness, apprehension, euphoria, confusion, dizziness, blurred/double vision, tremors

•  Action: • ER visit to have plasma level checked and possibly

stay overnight for observation (5 ųg/ml threshold) • Beware of mimic

Adverse Events – Lidocaine Toxicity

Adverse Events – Advanced Lidocaine Toxicity

• Signs: Dysrhythmia or seizures • Action: • Call 911. • Start O2• Alert EMS of the following medication recommendations:• Bretylium (for dysrhythmia)• Midazolam (for seizures): 5-7mg bolus, then 1-2 mg until

controlled. • Let EMS know not to use Diazepam

Adverse Events – Slow Lidocaine Absorption

• Signs: Toxicity occurring about 12 hrs after tumescent administration, usually after waking up from a nap. • Usually it will resolve in about 1-2 hoursAction: • Drink water• Sit slightly reclined (like watching tv)• Breathe in a paper bag • Staff call patient every 30 minutes • If occurs after 12 hours and /or the symptoms worsen /are

severe - go to the ER or call 911

 

•Mimicking behaviors of Lidocaine Toxicity• Benzodiazepine toxicity • Self-medicating (sedation drug, narcotic, alcohol)Action (if mild):• Monitor patient (or call every hour if patient at home)

until symptoms improve• Drink fluids• Relax• IF worsens, or severe, ER examination

Adverse Events – Beware of the Mimic

OUTSIDE THE BOX• Allergy to Lidocaine

• Drug challenge with allergist• Prilocaine (citanest)• Preservative Free Solution

• Histamine Reaction • Pre-treat with anti-histamine and H2 blocker• Preservative Free Solution

• Epinephrine Sensitivity • Slow infusion, avoid IV injection• Education• Preservative Free Solution• Epinephrine is responsible for the profound vasoconstriction and

consequent hemostasis essential to the tumescent technique – Dr Klein

Histamine Reaction Initial Picture

7 days post-

procedure

6 weeks post-

procedure

Action• No suture strips used• Oral Anti-histamine and

H2 blocker• Allergist drug challenge• Prilocaine, preservative

free solution, for subsequent procedures

OUTSIDE THE BOX• Liver Disease • Lidocaine metabolized in liver, • Rate of metabolism dependent on rate of blood flow to the

liver• Conditions that may cause compromised metabolism :

• Shock, Congestive heart failure, Beta-blockers, Cirrhosis

• Kidney Disease• Lidocaine clearance normal• Use caution regarding fluid overload

Empathy• Anxiety heightens pain• Anxiolysis• Verbal Anesthesia•Warm solution•Music• Relaxation APP• Target less tender sites for initial numbing• Patience and Gentleness

Prevention of complication is key:•Training•Witten Policy and procedure•Accurate record keeping•Written orders for TLA •Double check dosage calculations•Properly trained staff

Klein, Jeffrey A. (2000). Tumescent Technique , Tumescent Anesthesia & Microcannular Liposuction. St. Louis, Missouri: Mosby, Inc.

Klein, Jeffrey A. (2016). Tumescent Drug Delivery: Lidocaine and Beyond. [Power Point Slides]. Retrieved from: http://tumescent.org/TLA-AAD-2016.pdf

Klein, Jeffrey A. Collection of Articles: http://tumescent.org/tumescent-anesthesia-articles/

Klein, Jeffrey A. & Jeske, Daniel R. (2016). Estimated Maximal Safe Dosages of Tumescent Lidocaine. International Anesthesia Research Society. DOI: 10.1213/ANE.0000000000001119. www.anesthesia-analgesia.org May 2016 • Volume 122 • Number 5. Retrieved from http://tumescent.org/wp-content/uploads/Anesth-Analg-2016-Klein.pdf

Klein, Jeffrey A. (1990). Tumescent Technique for Regional Anesthesia Permits Lidocaine Doses of 35 mg/kg for Liposuction. J. Dermatol Surg Oncol 1990; 16:248-263. Retrieved from http://tumescent.org/tumescent-technique-for-regional-anesthesia-permits-lidocaine-doses-of-35-mgkg-for-liposuction/

References

THANK YOU!

elizabeth@veinspecialists.com