1. Anesthesia management for Mega liposuction Dr AbhijitNair Dr K Sriprakash Consultant Anesthesiologist, Axon Anesthesia Associates, Care Hospital, Hyderabad.

2. Definition: A cosmetic surgery done to remove fat from deposits under the skin using a cannula with a powerful suction It is also called as lipoplasty or fat moulding

3. Goals of liposuction To remove target fat thereby leaving desired body contour between suctional and non suctional areas Achieved by selecting the patients carefully and using proper method to avoid contour irregularity To monitor the patient in a monitored area by trained personnel to avoid post operative complications

4. Patient’s perspective: Sense of confidence Marital reasons ( pre, post ) Reduction in requirement of anti hypertensives Reduction in doses of OHAs/ Insulin But ends up spending on garments !

5. History of liposuction: First suction liposuction done by French Surgeon Charles Dujarier in 1920 Patient was a famous model from Paris Died due to gangrene Liposuction went into oblivion for several decades thereafter

7. Techniques of liposuction: Dry technique, ( EBL : 20-45% of aspirated volume ) Wet technique, ( EBL : 4-30% of aspirated volume ) Super wet technique, ( EBL : 1% of aspirated volume ) Tumescent technique, ( EBL : 1% of aspirated volume)

8. Varieties: Ultrasound assisted Power assisted Laser assisted Laser lipolysis

9. VASER VASER liposuction ( Vibration amplification of sound energy at resonance )

10. The procedure: Not a benign procedure In 2000, a census survey of 1200 members of ASAPS ( American Society of Aesthetic Plastic Surgeons ) revealed an overall mortality rate of 19.1/100,000 liposuction Pulmonary embolism in 23.1% cases of deaths Clinical Anesthesia. Barash, 6th Edition. Page 854.

11. Mega liposuction / Large volume liposuction Variable definition When more than 5 liters of total volume is removed from the patient Most of the complications associated with mega liposuction are related to fluid shifts and fluid balance, hence the procedure is described as total volume removed from the patient, including fat, wetting solution, and blood

12. There is no distinct boundary line that defines the limits of safe surgery When liposuction crosses into the domain of excessive surgical trauma, it changes from a benign cosmetic procedure into a potentially lethal process There is no antidote for a toxic dose of surgical trauma

13. Safe approach: Prevention of excessive trauma, Use common sense, Respect the patient’s co morbidities

14. 5 pillars of safety: 1)To have a trained Surgeon, 2)To have a trained Anesthesiologist, 3)To have a decent set up, 4)Trained ICU/ operation room staff, 5)To select the patient properly.

15. Patient selection: Patient’s characteristics: Unrealistic expectations Co morbidities Pharmacotherapy Previous failures

16. Skin contour irregularities, asymmetries, skin laxities, redundancies to be noted/ drawn Priming in advance for secondary/ touch up procedures

17. Cost of procedure: Indeed costly Quality of liposuction more important than cost Discount advertisements – misguides the patient Patient should enquire about the expertise/ experience of surgeon, place of surgery, set up etc Choosing liposuction based on price may turn out to be expensive if surgery is not up to the mark

18. Undesirable outcomes: 1)Incomplete liposuction, 2)Excessive liposuction- disfigurement, 3)Irregular/ uneven depression, 4)Bad scars

19. In the US, more than 341,000 liposuction procedures were performed in 2008 Indian data ? But very popular Still, information in textbooks ?!

21. PAC: Detailed history Highlight co morbidities, OSA, PAH Note ongoing medications ( NSAIDs,steroids,garlic,anti platelets to be stopped ) Vitals, Airway, BMI Relevant investigations 2D ECHO

22. Pre operative instructions ( Fasting, medications to be stopped/ to be taken ) Outline the procedure To inform in advance discomfort due to garments, ooze etc DVT prophylaxis?

23. Anesthesia management GA with CV Vs Regional GA preferred over Regional for Mega liposuction Review the patient Balanced Anesthesia Use short acting agents Benzodiazepines, Opioids, NDMR, Inhalational VIMA Vs TIVA

24. Premedication: Anti emetics, PPI/ H2 blockers Antibiotic Tranexamic acid / Ethamsylate / Haemocoagulase Use warm fluids Warming blankets Sequential compression device

25. Airway:

27. Intra operative monitoring: Heart rate, Electrocardiogram ( lead II, V5) Blood pressure ( Non invasive/ arterial if adequate sized cuff is not available) Spo2 End tidal CO2 Temperature ( nasopharyngeal/ axillary/ oral, OT) Input/ output Charting every 5 minutes

28. Hemodynamic changes: Increase in: Cardiac index Heart rate Mean PAP Stroke volume index RVSWI Decrease in: MAP SVRI

29. During surgery , constant communication between the Surgeon & the Anesthesiologist very important • Input , output , quality of aspirate etc to be discussed • NIBP during vigorous suctioning !? • NTG, Labetalol, Metoprolol, Narcotics , Inhalational boluses during new area suctioning

30. Charting: Quantity of wetting solution used, Amount of lignocaine used ( should not exceed >35-55 mg/kg) The epinephrine in the solution :( 50 ug/kg ) decreases systemic absorption of large amount of subcutaneous injection, Oliguria, Tachycardia Fat & saline aspirate, Blood loss, Urine output

31. Fluid management: Controversial practice Consider mega liposuction as burns ? PARKLAND’S formula Insensible losses can’t be predicted 3rd spacing? Colloids Vs Crystalloids! Formulas? Blood loss? Post op hemodilution!

32. Goals of IVF: To replace pre operative deficit To provide maintenance fluid To avoid pre renal AKI To correct insensible losses Blood transfusion if justified

33. The formulas: 0.25 ml of IVF for 1 ml aspirated over 4L i.e. 25% of lipo aspirate + maintenance [ SAFETY CONSIDERATIONS & FLUID RESUSCITAION IN LIPOSUCTION: AN ANALYSIS OF 53 PATIENTS. Trott, Suzanne A.; Beran, Samuel J.; Rohrich, Rod J.; Kenkel, Jeffrey M.; Adams, William P. Jr.; Klein, Kevin W. Plastic & Reconstructive Surgery. 102(6):2220-2229, November 1998. ] 0.25 ml of IVF for each ml over 5L i.e. 25% of lipo aspirate ( no maintenance ) [ Fluid resuscitation in liposuction: A retrospective review of 89 consecutive patients. Rohrich, Rod J.; Leedy, Jason E.; Swamy, Ravi; Brown, Spencer A.; Coleman, Jayne. Plastic & Reconstructive Surgery. 117(2):431-435, February 2006.}

34. RESIDUAL VOLUME THEORY: RESIDUAL VOLUME= TOTAL FLUID( Intravenous fluids + wetting solution + local anesthetic) – ( TOTAL SALINE IN ASPIRATE, not blood + URINE) Residual volume/ Patient’s pre op weight = 90- 120 ml/ kg If < 90 ml/kg, volume resuscitation warranted Sommer B. Advantages and disadvantages of TLA. In: Hanke CW, Sommer B, Sattler G, editors. Tumescent local anaesthesia. New York: Springer; 2001. p. 47-51. Pitman GH, Aker JS, Tripp ZD. Tumescent liposuction. A surgeon’s perspective. ClinPlastSurg 1996;23:633-4. Liposuction: Anaesthesia challenges. JayshreeSood et all. IJA 2011;55:220-7.

35. Example: Total fluid = 4L IVF + 4L wetting solution + 50 ml lignocaine = 8050 ml Total output = 1200 ml saline + 800 ml urine = 2000 ml Residual volume = 8050 – 2000 = 6050 ml Pre op Weight of patient = 100 kg 6050/100 = 60.5 ml/kg Hypovolaemia, needs IVF

36. Intra operative fluid volume ratio: [Volume of IVF + volume of infiltration] ÷ Aspirate volume If ratio is more, patient is overhydrated Ratio is used to compare different types of fluid resuscitation strategies

38. Important Anesthesia considerations: Padding of pressure points, in prone ( axilla, wrist, elbow, eyes, genitals, brachial plexus, occiput) Avoid unnecessary traction Lubricate eyes Prophylaxis for deep vein thrombosis Use of epinephrine: intra operative oliguria?

39. Thermoregulation: Cold wetting solutions, IVF Prolonged duration GA OT Complications: Coagulopathy Oliguria Arrythmias Electrolyte imbalance

40. Complications: Rare Frustrating for Surgeon, Patient, attenders Minor complications: unpredictable Major: Avoidable ( REMEMBER 5 PILLARS )

41. Minor complications: Prolonged swelling, contour related complications, Scarring, delayed healing, blistering, seromas, hyperchromia

42. Major complications: PTE, Deep vein thrombosis, pulmonary edema due to fluid overload, penetrating injuries, skin/ soft tissue necrosis, shock, fat embolism, local anesthesia systemic toxicity ( LAST ) excessive bleeding leading to blood transfusion

43. Bloody lipo aspirate? Terminate the surgery Reevaluate the technique, enquire about constituents of infiltration Use more wetting solution with epinephrine for haemostatic effect

44. Causes of excessive intra operative bleed: Use of anti platelets Use of NSAIDs, steroids On garlic, garlic pearls, herbal medication etc. Male gender Smokers Diabetics ( small vessel insufficiency) Hypothyroids

45. Compressive garments: Decreases bleeding Decreases swelling Decreases third spacing of fluid

46. Tranexamic Acid : An anti fibrinolytic agent that competitively inhibits activation of plasminogen to plasmin which is responsible for degradation of fibrin, which causes hemorrhage A preoperative dose of 10 mg/kg of tranexamic acid in a infusion over 15-20 minutes ! Trials are awaited to prove the benefit in large volume liposuction

47. Post operative care: TPR, BP, Pain monitoring, input/ uotput charting IV fluids Analgesia: short acting opioids ( Fentanyl infusion), Tramadol, PCM Avoid NSAIDs on the day of surgery Epidural ( If tummy tuck/ abdominoplasty is done) TAP block VIT C, Multivitamin preparations

48. Sequential compression device/ Low molecular weight heparin/ mobilisation/ Antiemetics Blood transfusion +/- Serratiopeptidase/ Trypsin : Chymotrypsin preparation

49. Delayed anemia after mega LPS: Post operative inflammatory response leading to blunting of erythropoeitic response Diminished availability of Iron Panniculitis in liposuction  systemic inflammatory response Hemodilution due to fluids

50. Management: Blood transfusion IV Fe Erythropoeitin Further investigation

51. Age: 55yrs; BMI: 38; 14.5 liters removedReduced 12 kgDelayed healing - 4weeks Post-op Pre-op 3 months

52. Post op bleeding & hypothyroidism: Decrease in plasma factor VII concentration Increased aPTT Acquired von Willebrand disease ( due to decreased factor VII coagulant activity , decreased vWF activity) Decreased platelet adhesiveness, due to acquired vWF disease Prolonged t1/2 of factor II, VII, X

53. Hypothyroid patients posted for surgery manifest Euthyroid Sick Syndrome due to stress The total T3 decreases 30 minutes after induction, it remains low for 24 hours They also have decreased FT3 & FT4 levels perioperatively

55. THANK YOU