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Transcript
TUMESCENT ANESTHESIA: Best Practice Protocols
Elizabeth Milligan RN, RPhS
Macon, 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 - Mixing
Standard
Formulas
Posted
Towel = Do
NOT Disturb
Clean
workspace,
Blunt Tip
needles
Safety - Dosage
FDA Lidocaine Labeling: 7mg/kg outof-the bottle commercial
• Based on 1948 Obstetric Epidural Data
• FDA Has No Data on Subcutaneous Infiltration
http://tumescent.org/wp-content/uploads/Anesth-Analg-2016-Klein.pdf
Safety - Dosage
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
http://tumescent.org/wp-content/uploads/Anesth-Analg-2016-Klein.pdf
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
Adverse Events – Vasovagal Syncope
• 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 – Anaphylaxis
• Develop Emergency Response Protocols
Adverse Events – Lorazepam Toxicity
• 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 – Lidocaine 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 – 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 hours
Action:
•
•
•
•
•
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
Adverse Events – Beware of the Mimic
• 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
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
Action
• No suture strips used
• Oral Anti-histamine and H2
blocker
• Allergist drug challenge
• Prilocaine, preservative free
solution, for subsequent
procedures
Initial
Picture
7 days postprocedure
6 weeks postprocedure
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
References
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-Analg2016-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/tumescenttechnique-for-regional-anesthesia-permits-lidocaine-doses-of-35-mgkg-for-liposuction/
THANK YOU!
[email protected]