. 4
( 13)


6. How much training and experience with this type
tion 300.29 Speci¬c Phobia of blood-injection-injury type.
of anesthetic does he/she have? (443“450) Washington, DC: American Psychiatric Associa-
7. What is the rate of successful completion of planned tion, 2000.
10. Milgrom P, Garcia RI, Ismail A, et al.: Improving Amer-
treatment with this type of anesthetic?
ica™s access to care: The national institute of dental and
8. What type of monitors will be used? (During con-
craniofacial research addresses oral health disparities. JADA
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tion, heart rate, and respirations should be continu- 11. Doyle N, Thompson L, Anderson D, et al.: The use of general
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ously monitored. Additional monitors are needed if
deep sedation or general anesthesia is planned. State 12. Newman JF, Gift HC: Regular pattern of preventative dental
regulations may mandate monitoring for different services: A measure of access. Soc Sci Med 35:997,1992.
levels. Call or click one™s state health professions 13. Dionne RA, Gordon SM, McCullagh LM, et al.: Assessing the
need for anesthesia and sedation in the general population.
JADA 129:167,1998.
9. How many drugs will be used during the procedure? 14. Yagiela JA: Of¬ce-based anesthesia in dentistry. Past, present
(When two or three drugs are used together, it and future trends. Dent Clin North Am 43:201,1999.
increases the likelihood that your sedation may 15. Gordon SM, Dionne RA, Snyder J: Dental fear and anxiety
as a barrier to accessing oral health care among patients with
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10. If there were a problem, where would I be trans- agement and one-year mortality after non-cardiac surgery.
Anesth Analg 100:4,2005.
ferred? How often do problems happen?
17. Kim YC, Lee SH, Noh GJ, et al.: Thermosoftening treatment
11. Who in the of¬ce is CPR and/or ACLS certi¬ed?
of the nasotracheal tube before intubation can reduce epis-
12. How can I reach the anesthesia provider after taxis and nasal damage. Anesth Analg 91:698,2000.
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tube for ¬beroptic orotracheal intubation: A randomized
double-blind study. Anesthesiol 98:354,2003.
19. ASDA membership survey, 2004.
20. Oral and Maxillofacial Surgery National Insurance
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1. Skidmore S: Toothsome treatments; Smile-conscious con-
Rosemont, IL: OMSNIC, 2002.
sumers are boosting the popularity”and pro¬tability”of
21. Perrott DH, Yuen JP, Anderson RV, Dodson TB: Of¬ce-
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May 8, 2005; H-1.
58 James A. Snyder

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Available at http://www.novamed-usa.com/LifeSound% propofol consumption during bispectral (BIS) index moni-
20Heart%20&%20Breath%20Monitor.html. Accessed July tored propofol-ketamine technique for of¬ce based surgery.
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24. Aspect Medical Systems: An important re¬nement in brain 36. Hall JE, Uhrich TD, Barney JA, et al.: Sedative, amnesic and
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25. Mak S, Crowley J: The utility of the Bispectral Index vs. stan- 37. Gentili M, Bernard JM, Bonnet F: Adding clonidine to lido-
dard practice anesthetic care: A meta analysis of randomized caine for intravenous regional anesthesia prevents tourni-
trials comparing drug reduction and recovery times. SAMBA quet pain. Anesth Analg 88:1327,1999.
Newsletter Park Ridge, IL: American Society of Anesthesiol- 38. Reuben SS, Steinberg RB, Klatt JL, et al.: Intravenous regional
ogists, 2002. anesthesia using lidocaine and clonidine. Anesthesiol 91:654,
26. Boodman SG: It knows when you™re awake. Washington Post, 1999.
Health Section. November 23, 2004. 39. Goyagi T, Tanaka M, Nishikawa T: Oral clonidine premedi-
27. Song D, Joshi GP, White PF: Titration of volatile anesthetics cation reduces induction dose and prolongs awakening time
using bispectral index facilitates emergence after ambulatory from propofol-nitrous oxide anesthesia. Can J Anaesth 46:
anesthesia. Anesthesiol 87:842,1997. 894,1999.
28. Moore P: Data presented at ASDA, April 2005. 40. Dalsasso M, Tresin P, Innocente F, et al.: Low-dose ketamine
29. Neumann MA, Weiskopf RB, Gong DH, et al.: Changing with clonidine and midazoalm for adult day care surgery.
from iso¬‚urane to des¬‚urane toward the end of anesthesia Eur J Anesthesiol 22:67,2005.
does not accelerate recovery in humans. Anesthesiol 88:914, 41. Wang J, Ho S, Tzeng J, et al.: The effect of timing of dex-
1998. amethasone administration on its ef¬cacy as prophylactic
30. Pavlin DJ, Rapp SE, Polissar NL, et al.: Factors affecting dis- antiemetic for nausea and vomiting. Anesth Analg 91:136,
charge time in adult outpatients. Anesth Analg 87:816,1999. 2000.
31. Dionne RA, Wirdzek PR, Fox PC, et al.: Anesthesiology sup- 42. Henzi, I, Walder B, Tramer MR: Dexamethasone for the pre-
pression of postoperative pain by the combination of a non- vention of postoperative nausea and vomiting: A quantitative
steroidal antidrug, ¬‚urbiprofen, and a long-acting local anes- systematic review. Anesth Analg 90:186,2000.
thetic, etidocaine. JADA 108:598,1985. 43. Snyder JA: Communicating with patients about OBA:
32. Jinks SL, Antognini JF, Dutton RC, et al.: Iso¬‚urane depresses SOBA™s patient assistance sheet. Am J Anesthesiol 591,
windup of C ¬ber-evoked limb withdrawal with variable 2000.
6 Propofol Ketamine (PK) in the UK, Propofol Ketamine
Beyond Cosmetic Surgery
Chris Pollock, M.B.

Conduct of the Anesthetic
Patient Outcomes
Conduct of the Anesthetic
Patient Outcomes
Conduct of the Anesthetic
Patient Outcomes

The risk of PONV is generally conceived as an attribute
of the patient with subsidiary risks attached to the context,
“Nothing can be said to be certain except death and taxes.”1 that is, the drugs and operation. However, drugs them-
selves have no executive power. Additionally, it is unusual
Had Benjamin Franklin lived two centuries later, he might
for a patient scheduled for elective surgery to enter the
have cared to add a third”anesthesia with nausea. It is
theater suite with preoperative nausea and vomiting. The
almost an expectation by both patients with health pro-
uncomfortable reality surely must be that the major risk
fessionals alike that nausea and vomiting follow general
factor for the presence or absence of PONV is the choice
anesthesia: it is the “big little problem,” it “goes with the
of the anesthesiologist. For it is, indeed, he or she who
territory.” Can anesthesiologists honestly conceive of a day
chooses which drugs and which techniques to employ and
when the emesis basin in the PACU is relegated to the
which to avoid in the perioperative management of that
museum? Perhaps not, but how far are anesthesiologists
patient. Lastly, it is the anesthesiologist™s responsibility to
moving toward that halcyon day, and exactly just how seri-
ensure that what has been prescribed for the postoperative
ous are anesthesiologists about preventing or even treat-
management is, in fact, given.
ing postoperative nausea and vomiting (PONV)? Just how
The commonest approach to the PONV problem
close are anesthesiologists to “zero tolerance” using what
is to continue giving the standard emetogenic anes-
is currently available? Just how often is the full panoply of
thetic and bolt on antiemetic drugs,2 either as pro-
the available antiemetics prescribed, and just how often are
phylaxis, as rescue medication, or as both. This may
those that are prescribed administered in a timely fashion
lessen the immediate PONV burden but does not abol-
and by an appropriate route? Just exactly how seriously are
ish it. Reliably continuing this type of strategy into the
anesthesiologists interested in eliminating PONV?

60 Chris Pollock

postoperative period on the ward or at home is proble- problem.” Early discharge and fully managed PONV is a
matic. prerequisite for the of¬ce-based practice and commercial
The other approach is to minimize or eliminate the use survival.
of drugs that are known to contribute to PONV, to reduce
the baseline, as it were. For this strategy some changes
are relatively easy to make, for example, the avoidance of
nitrous oxide (N2 O). Thus, in using an inhalational anes- Friedberg has reported a twenty-four-hour incidence of
PONV of 0.6% in elective cosmetic surgical procedures,4 a
thetic technique, adjustments can be made to compensate
for the absence of the N2 O without a major alteration in whole order below the 7% result quoted by Eberhart using
the technique itself. Nowadays, especially with the avail- a total intravenous anesthetic technique along with three
prophylactic antiemetics.5 PK is the immediate heir to
ability of des¬‚urane and sevo¬‚urane, vapors with relatively
the diazepam and ketamine technique devised by Vinnik,6
low blood gas solubility coef¬cients, the rate of emergence
from anesthesia need not necessarily be prolonged in the which retained the desirable properties of ketamine while
absence of N2 O. It is probably this ease of elimination abolishing the undesirable dysphoria. Friedberg replaced
from the anesthetic technique that has focused attention the diazepam with propofol, which has a far superior phar-
on nitrous oxide as the bete noir of PONV, but it is perhaps macokinetic pro¬le, while still maintaining the taming of
less of a key player in PONV than has been supposed.2 ketamine. PK is perhaps more usefully paraphrased as “PK
Eliminating anesthetic vapors, by contrast, requires a LA,” which emphasizes the key part that the local anesthe-
signi¬cant change in both technique and hardware. How- sia plays in providing the analgesic component.
ever, it is the use of opioids that is probably the major Ketamine is a dissociative agent with analgesic activ-
contributor to PONV. It is the minimization of their use ity, but its predominant role in PK is to minimize patient
in the whole perioperative period that is the real challenge. movement in response to the local anesthetic injections
The whole perioperative period is emphasized as there is rather than to the surgery itself. Ketamine certainly should
little to be achieved by avoiding emetogenic agents during not be viewed as an opioid replacement. Sleep doses of
the anesthetic and then relying on postoperative opioids as propofol reliably block the unpleasant hallucinogenic haz-
the main means of pain control.3 ard of ketamine.4
John Snow is widely regarded as the father of British PK was originally conceived for use in of¬ce-based elec-
anesthesia, but in his own lifetime he was more noted for tive cosmetic surgery practice, in part to reduce the capi-
his epidemiological aptitude. He traced the source of a tal and running costs of providing anesthesia. The poten-
major outbreak of cholera in London in 1854 to a well. tial for PK to substantially improve patient outcomes also
Snow famously interrupted this epidemic by the simple makes it highly relevant for hospital-based practitioners.
expedient of removing the handle from the water pump in The PK technique as described is strictly appropriate
Broad Street, Golden Square, London. Were he alive today only for noncavity surgery, with the intraoperative anal-
how might he have combined his epidemiological and his gesia being provided either by nerve conduction blockade
anesthetic interests in approaching the PONV problem? or ¬eld block (see Chapters 9 and 10). PK can, however,
Would some of the handles be removed from certain drug also be used to considerable advantage in minor gyneco-
cupboards in the anesthetic room? Perhaps. logical and urological surgery without the additional use
In the United Kingdom, almost all general anesthet- of local anesthesia. PK anesthesia has been well evaluated
ics are given within a hospital setting. There is neither for surgery in adults, but the experience in its use in pedi-
an administrative nor a ¬nancial incentive to the indi- atric practice is more limited. PK does appear to compare
vidual anesthesiologist to eliminate PONV. For a patient favorably with more standard anesthetic approaches in
operated on in a Day Surgery Unit who has “intractable” this group. Over the last ¬ve years, Pollock has had the
PONV, an overnight bed can always be found. Manag- opportunity to use PK anesthesia for a variety of surgi-
ing the PONV subsequently becomes somebody else™s prob- cal procedures, both adult and pediatric. The response by
lem. It is therefore worthwhile to look to the of¬ce-based patients, surgeons, PACU, and ward nurses has been very
practitioners for innovative ways around that “big little positive.
Propofol Ketamine (PK) in the UK, Propofol Ketamine Beyond Cosmetic Surgery 61

Pollock™s English surgeons are more accustomed to patient movement from brain-generated patient move-
operating on patients under general anesthesia rather than ment. Suppressing movement with additional propofol is
under local in¬ltration anesthesia. So it is prudent for the not as optimal a strategy as empirically injecting more
anesthesiologist to take the responsibility for the in¬ltra- local to the operative ¬eld. After completion of the surgery,
tion of local anesthetic or nerve block prior to the surgery patients may well then wake up very rapidly after discon-
and to present the surgeon with a patient “as if under tinuation of the infusion and be completely pain free. The
GA.” Although it may seem obvious, it is imperative that high concentration requirement may not be a result of
the anesthesiologist discuss with the surgeon beforehand noxious stimulation within an area uncovered by the local
exactly where the initial incision and subsequent dissec- anesthetic block.
tion is going to be to ensure the correct placement of local
anesthetic. If the local anesthetic doesn™t cover the whole
¬eld of the surgery, no amount of rhetoric about improved
postoperative outcomes is going to enamor the surgeon to
a technique that does not emulate the conditions of a more
Conduct of the Anesthetic
standard general anesthetic, namely, a relatively still oper-
ating ¬eld. The majority of the breast procedures were for tumor
In the United Kingdom and most of Europe, Target Con- management both benign and malignant. Without the BIS
trolled Infusion (TCI) pumps incorporating Diprifuser„ monitor to guide therapy, one may be hard-pressed to gain
are available to administer propofol from pre¬lled 50-ml the surgeon™s cooperation. One suppresses movement at
syringes to adults. The Diprifuser„ subsystem and soft- the expense of adding incoming noxious afferent stimula-
ware uses a readable tab on the syringe to identify the tion, which may add to postoperative pain management.
propofol concentration as either 1% or 2%. The software In the anesthetic room, a 22G cannula was placed ide-
includes pharmacokinetic parameters based on a three- ally in the nondominant antecubital fossa. Patients were
compartment model. The variables, which can be keyed then given 40 mg bolus of propofol (or titrated up to 40
in at the beginning of anesthesia, are the patient™s age mg in the elderly or frail) and transferred to the oper-
(16“100 yrs.), weight (30“150 kg), and the target blood ating theater. There, standard monitoring was attached,
oxygen via a Hudson mask at 1 L · min’1 administered,
concentration to be achieved. The pumps offer a choice
of rate of induction between 30 seconds and 10 minutes. and the patient turned into the lateral position if inter-
In these pumps, the typical default settings are 40 years, costal nerve blocks were planned (see Chapter 10). The
70 kg, and 4 ug · ml’1 . Hence, for a more elderly or physi- initial dose of propofol provides signi¬cant relief of anx-
ologically brittle patient, a lower blood concentration and iety and acts as an indicator of the likely sensitivity (or
a slower speed of induction might be chosen. Although resistance) to the drug. Propofol was then infused using
the Diprifusor„ takes care of the time-dependent aspects a Diprifusor„ infusion pump set to default values for
of the infusion, the anesthesiologist needs to adjust the age, weight, and blood concentration and a 30-seconds
desired target level of blood propofol in light of the indi- induction time. After loss of consciousness, ketamine
vidual patient response to noxious or indeed nonnoxious 50 mg was administered. Local anesthetic was adminis-
stimulation. It is analogous to adjusting the dial setting on tered either by in¬ltrating the proposed surgical area or
a plenum vaporizer for an inhalational anesthetic. Biolog- by intercostal blocks performed posteriorly at the angle
ical variability certainly rules out a “one target concentra- of the ribs from T6 to T1, with 5 ml injected at each
tion suits all” approach. The correct concentration for any level after negative aspiration for air and blood. Although
individual is empirical rather than predictable. Whereas additional patient positioning is required to perform the
the default setting of 4 ug · ml’1 propofol manages the intercostal blocks using a posterior approach,7 it allows
majority of adult patients, some will require a 10 ug · ml’1 access to T1“3. Inasmuch as the depth of the rib is great-
setting (or even higher) to prevent intraoperative move- est at the posterior angle (about 8 mm), the posterior
ment. Without a level-of-consciousness monitor, like the approach also minimizes the risk of pneumothorax in
comparison to the lateral approach.8 If the surgery was
BIS, it is impossible to differentiate spinal-cord“generated
62 Chris Pollock

likely to extend to T3 or into the axilla, a supraclavicular
Table 6-2. Procedures using PK and
block was added. The standard local anesthetic used was
intercostals blocks
a 1:1 mixture of 1% lidocaine with 1:200,000 epinephrine
and 0.25% L-bupivacaine.9 For procedures where large 1. Wide local excisions 332
2. Wide local excisions plus axillary gland 330
volumes of local anesthetic were necessary (e.g., latis-
simus dorsi ¬‚aps), the lidocaine was omitted and 0.25% 3. Mastectomy +/’Prosthesis or tissue 267
L-bupivicaine with 1:200,000 epinephrine was used on its expander +/’ axillary gland sample
4. Mastectomy with latissimus dorsi ¬‚ap 9
5. Breast reductions (25 bilateral) 32
If there was no contraindication, an NSAID was
6. Axillary clearance/sampling 27
included at some time during the procedure either as rofe- 7. Breast prosthesis insertion/replacement 149
coxib 50 mg oral preoperatively or ketorolac 10 mg intra- 8. Breast augmentation 10
9. Miscellaneous 24
operatively. With the withdrawal of rofecoxib from the
Total breast surgical procedures 1,439
market, parecoxib 40 mg or etoricoxib 90 mg PO are Pol-
lock™s current choice of agents.
For patients who would be sat up at some stage during
the operation (e.g., breast-reduction patients or patients
tively managed by the lidocaine and a transient increase
undergoing latissimus dorsi ¬‚ap [LDF] breast reconstruc-
in the propofol infusion rate. None required opioids or
tions), glycopyrrolate 0.2 mg was used at induction as an
paralyzing agents to control it.
antisialogogue to reduce the likelihood of coughing. Its
At the beginning of the anesthesia, the Diprifuser„ is
utility in patients who remained supine was less apparent,
set for a slow induction over thirty seconds. This typically
and thus was not routinely given (see Tables 6-1 and
gives rise to a loss of consciousness after thirty to sixty
6-2). Details of the patients™ age, weight, propofol usage,
seconds. Nevertheless, apnea often occurred, but its dura-
and duration of anesthetic are given in Table 6-3. All the
tion was very brief (less than ¬fteen seconds), and blood
patients were ASA 1 or 2, apart from twelve who were
oxygen saturation was well maintained by the prior use of
ASA 3.
supplemental oxygen through a Hudson mask. No patient
Ketamine 50 mg bolus was adequate for 98% of the
required ventilation on account of prolonged apnea. The
patients, the remaining 2% requiring up to 100 mg to min-
majority of airways could be maintained by careful posi-
imize movement while injecting the local anesthetic. Intra-
tioning of the head. In a few patients (26 of 1,439, or
operative coughing was a problem in twenty-four patients
1.7%), a nasopharyngeal airway had to be inserted, par-
requiring bolus doses of lidocaine 30“50 mg and increas-
ticularly in those procedures where the patient was sat
ing the propofol infusion rate to settle. In Pollock™s experi-
ence, coughing tended to occur early in the anesthetic and
Although patient movement is not uncommon with PK,
did not appear to be more common in smokers compared
its incidence and severity decreased with experience in
with nonsmokers. As previously mentioned, the adminis-
using the technique. Rarely did patient movement interfere
tration of glycopyrrolate did not have an obvious effect in
with the conduct of the surgery. Five patients required
reducing the incidence of coughing. All patients were effec-
supplemental opioids (nalbuphine or tramadol along with
two antiemetics) during the operation. Only one patient,
an LDF procedure, required conversion to a more standard
Table 6-1. Procedures using PK and local general anesthetic with a laryngeal mask, opiate, paralysis,
anesthetic in¬ltration
and ventilation.
1. Fibroadenomas 109
2. Major duct excision 123 Patient Outcomes
3. Excision male gynecomastia 10
Pneumothorax as detected by aspiration of air prior to
4. Scar revision 17
injecting the local anesthetic occurred in three patients
Total 259
(0.36% of patients, 0.06% per space injected). None of
Propofol Ketamine (PK) in the UK, Propofol Ketamine Beyond Cosmetic Surgery 63

the median dose was 6 mg, the max-
Table 6-3. Surgical procedures
imum 20 mg. All patients receiving
morphine were given ondansetron 4
Age Wt Prop T
mg and cyclizine (Marazine) 10 mg
Procedure yrs kg mg min
at the same time. Only two patients
1. Excision ¬broademona 32 63 373 19 required additional morphine
and similar (16“60) (40“109) (174“970) (8“54)
during their stay on the ward. Oral
2. Wide local excision c 58 69 601 40 codeine or tramadol was available
axillary sample (31“86) (41“117) (274“2612) (20“110)
on the ward along with paracetamol
3. Mastectomy +/’ 59 70 775 76
(acetaminophen) and an NSAID.
axillary sample +/’ (28“92) (45“130) (240“2653) (22“215)
Two-thirds of the patients were inpa-
tients and were reviewed the follow-
4. Latissimus dorsi ¬‚ap 48 77 3656 335
+/’ mastectomy ing day (a minimum of ¬fteen hours
(36“68) (61“107) (2400“5132) (180“403)
postoperatively). The incidence
of nausea (requiring treatment
with antiemetics) was 2.2% and of vomiting 0.27%. The
the patients became symptomatic and were treated expec-
majority of these episodes appeared to be in associa-
tantly. In other series, the incidence of pneumothorax
was as low as 0.073%,10 but typically they are closer tion with the use of oral codeine or tramadol post-
to 2%.11’13 operatively. This rate is approaching Friedberg™s inci-
dence of 0.6%.4 The comparable incidence of PONV in
One eighty-year-old ASA 3 patient died on the third
breast-surgery patients under general anesthesia (GA)
postoperative day from a stroke. Preoperatively she was in
and single-level paravertebral block was 33%.15 With
intermittent atrial ¬brillation (AF) and heart failure. The
paravertebral block and conscious sedation (CS), the
procedure was a mastectomy and axillary gland clearance.
PONV rate was 20%.16,17 This rate may relate to
There was one instance of awareness during the opera-
the use of opioids as part of the CS technique. The
tion (a mammotome excision of gynecomastia) in a 100 kg
twenty-four-hour PONV incidence after a GA using
male, but without intraoperative discomfort. This proba-
sevo¬‚urane, fentanyl, and prophylactic ondansetron was
bly resulted from the inappropriate reduction in the rate of
propofol infusion near the beginning of the anesthetic after
In the United Kingdom, there is no regulatory advan-
75 mg of ketamine had been administered. There were no
tage in de¬ning a procedure as “deep sedation” as opposed
reports of unpleasant dreams or feelings on questioning
to “general anesthesia” (GA). The two signi¬cant distinc-
in the PACU. Indeed, most patients experienced decid-
tions are between conscious sedation, which can be given
edly pleasant dreams, although the content was typically
by a nonanesthesiologist, and general anesthesia, which
mundane. The recall of the dream was rapidly lost soon
need be administered by a physician trained in anesthe-
after awakening. Thus, the timing of questions regarding
sia. Deep sedation is regarded as a GA. Nonetheless, deep
dreaming will be critical to the response. This may explain
sedation using PK appears to be an optimum mode of
the marked discrepancy between this and other reports of
4 management in breast surgery in (a) avoiding the fail-
an incidence of dreaming in only 1% of patients. Never-
ure rate of 9% using paravertebral block with CS,17 and
theless, the important observation is that, given the bad
(b) the PONV morbidity associated with a more standard
reputation of ketamine for emergence dysphoria, there
GA, or a CS that includes the use of opioids. An additional
were no such cases in this series. Pollock has related his
advantage is the absence of delay between completing the
patients™ dreams as being pleasant. It is probably more
blocks and commencement of surgery. Either the inclu-
accurate to state that the patients were in a rather euphoric
14 sion of lidocaine in the block or the analgesic effect of
state and that they were dreaming; the two were not nec-
the ketamine allowed satisfactory operating conditions to
essarily linked.
be achieved almost straight away after performance of the
Postoperative strong opioids were required in 21%
local anesthetic block, avoiding the twenty-four-minute
of the patients in the PACU. Using titrated morphine,
64 Chris Pollock

set up time for CS plus paravertebral block.19 The time tion of carbon dioxide is not excessive and the surgeon is
well skilled.
to complete a set unilateral intercostals blocks was typi-
Patients were given an NSAID if there was no con-
cally between 90 and 120 seconds. In using PK and inter-
traindication either as an oral premed (rofecoxib 50 mg)
costal nerve block, there is a limited increase in setup time
or at induction ( ketorolac 10 mg). For the patients who
compared to general anesthesia, but there is a substantial
did not receive an NSAID, tramadol 100 mg was given
improvement in the quality and duration of analgesia. The
at induction along with 10 mg cyclizine (Marazine) as an
outcome from this approach is a major reduction in the
antiemetic. Cervical misoprostal was applied two hours
use of perioperative opioids. This minimization of opioid
preoperatively in patients for STOP. A sedative dose of
use combined with the avoidance of vapors and nitrous
propofol (40 mg) was given in the anesthetic room, and
oxide lurches the benchmark for PONV decidedly far to
then the patient was transferred to the operating the-
the left.
ater. There standard monitoring was attached, and oxygen
Intercostal block is neither a widely utilized nor a widely
1 L · min’1 administered through a Hudson mask with gas
taught procedure in the United Kingdom. The literature
sampling for the display of expired CO2 . In these relatively
enthuses about its use in (a) open cholecystectomy where
short cases, the propofol was titrated manually instead
it reduces opioid requirement (but does not abolish it),
of by Diprifusor.„ Further increments of propofol were
(b) in rib fracture management”which rarely comes to
administered until loss of consciousness, then ketamine
the attention of the practicing anesthesiologist, and (c) in
30“50 mg was given. Further increments of propofol were
thoracic surgery, where its bene¬t is limited as the pos-
administered during the procedure to maintain loss of con-
terior branch of the intercostal nerve is better picked up
sciousness and in response to excessive movement to the
by either an epidural or paravertebral block. In addition,
surgical stimulus. It is important not to give large boli
pneumothorax is perceived as a risk better avoided than
of propofol in response to movement but to titrate it in
managed. In reality, the posterior approach to intercostal
order to avoid apneic episodes. There is often some patient
blockade is surprisingly safe”even in moderately obese
movement (adduction of legs in response to cervical dilata-
patients. Intercostal blockade (a) has a prolonged dura-
tion), but this is rarely of such severity to interfere with
tion of action, (b) is quick to perform, (c) can be used
the conduct of the procedure.
with a reasonable regard to the in¬ltration of LA onto the
The anesthetic management for the laparoscopies was
rib, acceptable to an unsedated patient, and (d) has high
similar, but with the addition of 0.5% bupivicaine in¬l-
degree of ef¬cacy. The incidence of pneumothorax is about
tration of the abdominal wall at the sites of instrumenta-
1%. The vast majority of patients is asymptomatic and can
tion. These patients were positioned with a thirty-degree
be managed expectantly.
head down tilt (see Table 6-2). All the procedures were
performed as day cases, and postoperative assessment was
limited to six hours after the procedure (see Table 6-4).

Conduct of the Anesthetic Patient Outcomes
PK anesthesia as described requires local anesthetic in¬l- Two patients (1.4%) vomited in the postoperative period,
tration or nerve block to provide the analgesic platform for one patient in the STOP group, and the other patient after
the procedure. Nonetheless, for short gynecological pro- a laparoscopy and tubal clip who had received morphine
cedures with a minimal incisional stimulus, the same tech- without antiemetic prophylaxis in the PACU. There were
nique can be successfully employed without the necessity no additional patients with signi¬cant nausea requiring
of presurgical in¬ltration with local anesthetic. In proce- medication. No patient experienced dysphoria. This low
dures such as suction termination of pregnancy (STOP), incidence of PONV in the absence of routine antiemetic
acceptable operating conditions can be achieved, along prophylaxis is encouraging in a group of procedures
with a good recovery pro¬le particularly in relation to that are regarded as being of high risk. As in the breast
PONV by using PK. Even for laparoscopic clip steriliza- procedures, the use of ketamine did not precipitate any
tion, it is feasible to use PK if the intraperitoneal insuf¬‚a- instances of unpleasant dreams or feelings.
Propofol Ketamine (PK) in the UK, Propofol Ketamine Beyond Cosmetic Surgery 65

Table 6-4. Details of minor gynecological procedures under PK anesthesia

N Age Wt Prop K T

Procedure yrs kg mg mg min

1. STOP,a
ERPC 117 24 65 187 45 10
(14“43) (40“104) (100“375) (35“50) (5“15)
2. Lapb 22 31 65 302 59 15
(18“49) (54“95) (227“480) (50“75) (10“24)
3. Hscopyc 5 49 78 234 48 12
(44“52) (72“90) (150“250) (40“50) (10“15)
4. Miscd 3 37 86 233 50 13
(27“48) (73“94) (200“350) (50) (5“20)
a STOP”suction termination of pregnancy
bLaparoscopy with and without tubal clips
c Hscopy”hysteroscopy
d Misc.”insertion of coil, balloon endometrial ablation, excision Bartholin™s cyst

In principle, any operation that could be performed can address. The avoidance of triggering agents for malig-
using local anesthesia in a fully cooperative awake child nant hyperpyrexia (MH) and the likely greatly reduced
would be a candidate for PK plus local anesthetic in the PONV are certainly in favor of PK.
more typical, uncooperative child. The chief issues are (a)
does it work in children, (b) how well is the airway main-
tained, and (c) is it worth the additional effort?
Does it work in children? Yes, but not as smoothly as Conduct of the Anesthetic
in adults. In an adult, ketamine 50 mg (less than 1 mg · All the children were admitted to the hospital ward and
kg’1 ) is usually suf¬cient to prevent signi¬cant movement most were discharged home the same evening. Those that
in response to LA in¬ltration or other moderate noxious weren™t discharged were kept overnight for domestic or
stimulus. In children, even with a dose of ketamine of 2 mg transport reasons. Children were unpremedicated but had
· kg’1 , there can often be substantial movement. Increas- topical Ametop gel applied over a vein on the dorsum of the
ing the dose above 2 mg · kg’1 compromises the speed hand or in the antecubital fossa. Anesthesia was induced
of recovery. Reduce the stimulus of the local anesthetic with increments of propofol, and then either a pediatric
injection by (a) using of a ¬ne gauge (30 ga) needle, (b) Hudson mask or nasal prongs were positioned and oxygen
1 L · min’1 administered. Ketamine 1 mg · kg’1 was given,
buffering the LA with sodium bicarbonate, and (c) inject-
increasing to 2 mg · kg’1 if there was signi¬cant move-
ing into distensible tissue planes slowly. Airway integrity?
Yes, again. As with adults, the key is to titrate the propofol ment while the local anesthetic was being in¬ltrated. The
and to eschew large boli in order to minimize the occur- surgeons routinely inject 0.5% lidocaine with epinephrine
rence of central apnea and of glossopharyngeal relaxation. into the auricle to separate the tissue planes and to improve
Active laryngeal re¬‚exes as evinced by coughing are present hemostasis. The injection is usually very stimulating and
(although not guaranteed). In the few children who devel- would require a relatively high dose of ketamine to min-
oped upper-airway obstruction, a chin lift was all that was imize movement. An additional ketamine bolus would
required to recover a patent airway. Is it worth the addi- need to be given prior to injecting the second ear twenty
tional effort? There are obviously issues around the debate minutes or so later. Additional ketamine can be avoided if
between an intubated or laryngeal masked airway versus bilateral auriculotemporal and posterior auricular blocks
the unintubated airway that only a large comparative study are performed after induction. These nerve blocks allow
66 Chris Pollock

nursing staff tended to allow chil-
Table 6-5. PK Anesthesia for pediatric procedures 3 unilateral
dren to awaken in their own time
without exogenous stimulation. A
common spontaneous complaint by
N Age Wt Prop K T
children on awakening was of dou-
Procedure yrs kg mg mg min
ble vision and a feeling of dizzi-
1. Oto 85 9.6 37 366 50 52
ness. Horizontal nystagmus was fre-
(2“15) (13“66) (100“690) (10“10) (22“100)
quently observable, but there were
2. Otherb 170 8 34 214 37 23
no incidences of vomiting in the
(1“15) (8“103) (30“802) (10“100) (5“90)
PACU. One child said he had had
a Oto”Otoplasty
an unpleasant dream. Follow up
bSee text for details of “Other”

the following day by phone to
the ward or to the home elicited
one patient with vomiting (1.2%).
both sides to be injected in quick succession under a sin- No child required oral opioids postoperatively, and all
gle dose of ketamine. Inasmuch as these blocks are less were managed on oral paracetamol (acetaminophen) and
stimulating than the intra-auricular in¬ltration, the total ibuprofen. The type of follow up was not adequate to elicit
dose of ketamine can be substantially reduced. The nerve the presence or absence of dysphoric symptoms.
blocks are performed with a 1:1 mixture of 1% lidocaine
with epinephrine and 0.25% L-bupivicaine, typically 2“
3 ml per side. The subsequent surgical in¬ltration of the
ears with 0.5% lidocaine and epinephrine evokes min- PK anesthesia was used in a further 170 children between
imal movement. In addition, bupivicaine provides pro- one and ¬fteen years of age for a variety of super¬cial
longed postoperative analgesia, minimizing the need for procedures, including (a) toe straightening surgery, (b)
postoperative, emetogenic opioids. The current Diprifu- hypospadias repair, (c) excision of skin nevi, (d) scar revi-
sor„ pumps are not suitable for use in children. Hypnosis sion, and (e) the removal of wires or screws after resolution
was maintained by incremental injections throughout the of bone fractures. These were mainly performed as day
surgery. There were eighty-¬ve children, of whom three procedures. There were no management problems during
had unilateral surgery. the anesthetic. Again, no patients required oral opioids in
Patient movement during local-anesthetic intra- the postoperative period, and there were no episodes of
auricular in¬ltration was a problem in the earlier patients, vomiting prior to discharge.
but this was largely resolved by the use of the nerve blocks,
and thus the ketamine requirements and wake-up time
became progressively less. Three children coughed during
the early stages of the anesthetic, requiring suction of the PK anesthesia is feasible in adult patients and children
oropharynx and cautious deepening with propofol. One over the age of one year having super¬cial surgery, with-
child brie¬‚y lost his upper airway, which was regained by out producing problems relating to airway management or
a chin lift under the surgical drapes. Neither supplemental respiratory depression. In all the cases where the upper air-
opioids nor conversion to a GA was required for any of way was lost, a simple chin lift was all that was required to
the cases. restore ventilation. The reliance on long-acting local anes-
thetics to provide the analgesic platform for the surgery
to take place allows the elimination (or minimization) of
Patient Outcomes opioids in the perioperative period and thus avoids signif-
Awakening time was highly variable. Some children were icant respiratory depression and unnecessary vomiting.
chatting while the bandages were being put on, but oth- The elimination of triggering agents for MH was certainly
ers took up to ¬fteen minutes to emerge. The PACU reassuring. Some wake-up times in the PACU were perhaps
Propofol Ketamine (PK) in the UK, Propofol Ketamine Beyond Cosmetic Surgery 67

longer than with conventional GA techniques, particularly 6. Vinnik CA: An intravenous dissociative technique for out-
patient plastic surgery: Tranquility in the of¬ce surgical facil-
with the very young, but this did not lead to delayed dis-
ity. Plast Reconstr Surg 67:799,1981.
charge from the hospital. 7. Kopacz DJ, Thompson GE: Intercostal blocks for thoracic
PK anesthesia plus local anesthetic in¬ltration is a seri- and abdominal surgery. Techniques in Regional Anesthesia &
Pain Management 2:25,1998.
ous contender as the technique of choice for optimum
8. Moore DC, Bush WH, Scurlock JE: Intercostal nerve block: A
patient outcomes with the low risk of PONV”in part
roentgenographic anatomic study of technique and absorp-
from the minimization of opioid use while still main- tion in humans. Anesth Analg 59:815,1980.
taining good quality postoperative analgesia. Even latis- 9. Badgwell JM, Heavner JE, Kytta J: Cardiovascular and cen-
tral nervous system effects of co-administered lidocaine and
simus dorsi ¬‚ap reconstruction of breast defects lasting
bupivicaine in piglets. Reg Anesth 16:89,1991.
six hours or more were manageable on single-shot inter-
10. Moore DC: Intercostal nerve block for postoperative somatic
costal blockade and PK, with subsequent limited postop- pain following surgery of the thorax and upper abdomen. Br
erative opioid requirement. There is minimal respiratory J Anaesth 47:284,1975.
11. Moore DC: Intercostal nerve block for postoperative somatic
depression in comparison to benzodiazepine with opiate
pain following surgery of the thorax and upper abdomen. Br
sedation.20 Success with the technique does require close J Anaesth 47:284,1975.
cooperation with the surgeon. PK anesthesia is best appre- 12. Bridenbaugh PO, DuPen SL, Moore DC, et al.: Postoperative
intercostals nerve block analgesia versus narcotic analgesia.
ciated by surgeons with whom one works regularly, rather
Anesth Analg 52:81,1973.
than on an occasional basis. To the unwary, the modest
13. Cronin KD, Davies MJ: Intercostal block for postoperative
patient movement that may occur may be misinterpreted pain relief. Anaesth Intens Care 4:25“9,1976.
as an inadequate general anesthesia. With perseverance, 14. Mortero RF, Clark LD, Tolan MM, et al.: The effects of small-
dose ketamine on propofol sedation: Respiration, postoper-
the nuances of PK can be mastered, critically altering the
ative mood, perception, cognition, and pain. Anesth Analg
“always sick after anesthesia” to the more measured “usu-
ally sick after anesthesia, but not today! Anesthesia can be 15. Kairaluoma PM, Bachmann MS, Korpinen AK, et al.:
different.” Single-injection paravertebral block before general anes-
thesia enhances analgesia after breast cancer surgery with
and without associated lymph node biopsy. Anesth Analg
16. Coveney E, Weltz CR, Greengrass R, et al.: Use of paraverte-
bral block anesthesia in the surgical management of breast
1. Franklin B: Letter to Jean Baptiste Le Roy. In Writings. 1789,
cancer. Ann Surg 227:496,1998.
vol x.
17. Weltz CR, Greengrass RA, Lyerly HK: Ambulatory surgical
2. Apfel CC, Kortilla K, Abdalla M, et al.: A factorial trial of
management of breast carcinoma using paravertebral block.
six interventions for the prevention of postoperative nausea
Ann Surg 222:19,1995.
and vomiting. N Engl J Med 350:2441,2004.
18. Jokela MR, Kangas-Saarela TA, Valanne JVI, et al.: Post-
3. White PF: Prevention of postoperative nausea and
operative nausea and vomiting after sevo¬‚urane with or
vomiting”A multimodal solution to a persistent problem.
without ondansetron compared with propofol in female
N Engl J Med 350:2511,2004.
patients undergoing breast surgery. Anesth Analg 91:1062,
4. Friedberg BL: Propofol-ketamine technique: Dissociative
anesthesia for of¬ce surgery (a 5-year review of 1,264 cases).
19. Klein SM, Bergh A, Steele SM: Thoracic paravertebral block
Aesth Plast Surg 23:70,1999.
for breast surgery. Anesth Analg 90:1402,2000.
5. Eberhart LH, Mauch M, Morin AM, et al.: Impact of a mul-
20. Avaramov MN, Smith I, White PF: Interactions between
timodal anti-emetic prophylaxis on patient satisfaction in
midazolam and remifentanil during monitored anesthesia
high risk patients for postoperative nausea and vomiting.
care. Anesthesiol 85:1283,1996.
Anaesthesia 57:1022,2002.
7 Propofol Ketamine Beyond Cosmetic Surgery:
Implications for Military Medicine and
Mass-Casualty Anesthesia
Joel W. McMasters, M.D., MAJ, MC, U.S.A.


this chapter we examine how PK anesthesia and TIVA are
ideally suited for mass-casualty anesthesia.
The terrorist attacks of September 11, 2001, forced med-
ical personnel throughout the United States to reevalu-
ate their capabilities for dealing with mass-casualty situa-
tions. This included the specialty of anesthesiology, which
had to reexamine its readiness for delivering anesthesia Why is TIVA an ideal anesthetic for military anesthesia
in a chaotic environment. Anesthesiologists know that and mass-casualty situations? TIVA is simple to deliver,
mass-casualty situations challenge health care profession- as one needs only a working intravenous line and the
als because of large numbers of patients, time constraints, appropriate drugs. TIVA is more scienti¬c because physi-
and limited resources. In settings such as this, there likely cians and researchers have a better understanding regard-
would be more patients requiring surgery and anesthesia ing the mechanisms of action of these agents. TIVA is
than there are anesthesia machines and traditional anes- safer than inhalation anesthesia because there is no risk
thetizing locations. Thus, mass-casualty situations would of malignant hyperthermia. There is also less myocar-
be better managed if physicians had anesthetic tools that dial depression with TIVA, again adding to safety. Finally,
were more versatile and portable. The anesthesia commu- TIVA is desirable in the military and mass-casualty setting
nity familiar with total intravenous anesthesia (TIVA) gave because of its small logistical footprint. Delivering general
Army anesthesiologists ideas for improving mass-casualty intravenous anesthesia does not require bulky, heavy, and
anesthesia. Avoiding the need of heavy and bulky anesthe- expensive anesthesia machines that require maintenance
sia machines, propofol-ketamine (PK) anesthesia1’3 and and signi¬cant oxygen stores. It is easy to see how the four
other combinations of intravenous agents seemed ideal for S™s of TIVA”Safe, Simple, Scienti¬c, and Small logistical
mass-casualty care. footprint”are suited for mass-casualty anesthesia in the
Army anesthesiologists have begun exploring TIVA as a 21st century (see Table 7-1).
way of delivering anesthesia on the battle¬eld of the future, The types of injuries seen in terrorist attacks will range
where large numbers of casualties could be the norm. In from minor to severe. Literally every surgical specialty

Propofol Ketamine Beyond Cosmetic Surgery 69

Table 7-1. Four “S™s” of TIVA
1. Safe
The U.S. Army had already begun a massive transforma-
2. Simple
tion project prior to September 11, 2001. However, this
3. Scienti¬c
initiative was largely focused on combat units. The rapid
4 Small logistical footprint
increase in operational tempo of U.S. military medical
units following 9/11 required military physicians to begin
their own transformation process.
The medical transformation project had to consider
would be involved in treating patients with injuries sus-
the portability or logistical footprint of medical equip-
tained in a terrorist attack. Regardless of the type of injury,
ment. The long-standing tools and techniques revolving
anesthesiologists need methods of anesthetizing many
around inhalational anesthesia were recognized as being
patients in multiple locations, without needing medical
less than ideal for mass-casualty situations. The weight
gas systems and electricity. Utilizing PK would eliminate
and cube of anesthesia machines, inhalational agents, and
the requirement of an operating room and an anesthesia
other equipment requires excessive amounts of space on
machine, allowing physicians to manage many patients in
military transport vehicles. Furthermore, electrical and
other areas, quickly and with excellent operating condi-
medical gas requirements of anesthesia machines could
tions. This approach to delivering trauma anesthesia in
be problematic in mass-casualty settings. Realizing that
dif¬cult settings is safe, simple, and a force multiplier.
TIVA had a smaller logistical footprint, it became a point
of emphasis for U.S. Army physicians.
Thus, Army anesthesiologists began a global initiative
HISTORY OF ANESTHESIA IN focusing on TIVA. Following exhaustive reviews of the
AUSTERE ENVIRONMENTS medical literature and numerous conferences with inter-
nationally recognized experts in TIVA, the Army formu-
Though anesthesia has a long history of safety, the expe-
lated a strategy for implementing TIVA on the battle-
rience of Bonnano4 in Africa in the 1990s is probably the
¬eld. In March of 2004, the Triservice Anesthesia Research
best illustration of the simplicity and safety of total intra-
Group Initiative on TIVA, or TARGIT Center (see Fig. 7-1),
venous anesthesia. Working with untrained personnel,
opened at Brooke Army Medical Center in San Anto-
Dr. Bonnano used ketamine, diazepam, glycopyrrolate,
nio, Texas. The goal of this Army, Air Force, and Navy
and local anesthesia to safely anesthetize sixty-two patients
having sixty-four different surgical procedures. The types
of procedures ranged from gastroschisis repair to Cesarean
section to amputations. The ages of the patients were
from infants to geriatric patients. Time and time again,
anesthesia allowed these procedures to be performed on
patients without arti¬cial airways. That is, no one was
intubated or had laryngeal mask airways (LMA) or anes-
thesia face masks for these surgeries. All of the patients
breathed spontaneously on room air or an air/oxygen
mixture. The untrained personnel were taught by
Dr. Bonnano to increase the drip rate of the ketamine
based on a patient™s heart rate or movement with surgi-
cal stimulation. With minimal monitoring and untrained
personnel, Dr. Bonnano oversaw these sixty-four cases.
There were no anesthetic mishaps. This TIVA technique
was safe, simple, scienti¬c, and had a small logistical
footprint. Figure 7-1. TARGIT insignia.
70 Joel W. McMasters

consortium is to improve battle¬eld anesthesia. In the 100“150 mg ketamine for patients under the age of 50.
future, the lessons learned by military physicians at the Patients over the age of 50 emerge better when limited
TARGIT Center will be passed on to our civilian colleagues. to a total of 100 mg ketamine. N.B. This means no more
Ultimately, patients will bene¬t from improvements in than a total of 100“150 mg of ketamine-containing ˜cock-
trauma anesthesia care. tail.™ Administer no ketamine in the last twenty minutes of
the case. Do not turn off the ˜cocktail™ until the initiation of
the head dressing. Otherwise, the patients tend to buck on
the endotracheal tube when their heads are ¬‚exed. They
Though the U.S. military has used TIVA on occasion, emerge very quickly, in about 5 minutes. Remember to
inhalational anesthesia has dominated anesthesia practice add the remaining of 50“100 ug fentanyl at the end of the
for years. The TARGIT Center had to demonstrate the sim- surgery. The hemodynamic stability is awesome. I can™t
plicity and clinical superiority of TIVA in a combat setting. remember the last time I had to use neosynephrine. PKR
Beginning in March of 2003, Army anesthesiologists increases the operational tempo of U.S. military medical
across Iraq delivered countless numbers of anesthetics to units.”6
a variety of patients. Although most anesthetics were con- In the six months before Grathwohl™s arrival, over 100
ducted using iso¬‚urane, TIVA was utilized on occasion. craniotomies were performed with iso¬‚urane fentanyl
The overall TIVA results were impressive. Patients did well, anesthesia administered by the same nurse anesthetist.
supplies were conserved, and ketamine was again viewed On June 2, 2005, Grathwohl7 summarized his ¬rst 100
as being the ideal anesthetic. craniotomies with PKR. The Glasgow Coma Score (GCS)
In an after-action report describing anesthesia in OIF and other neurosurgical trauma severity scores were the
2003, Dr. Mark Meeks wrote: “Our unit found the use of same between the two groups of patients. Compared to
ketamine to be extremely bene¬cial when faced with large the previous hundred craniotomies, half as many craniec-
numbers of casualties, and a limited amount of medical tomies were required with PKR versus iso¬‚urane fentanyl
supplies . . . patients did not require intubation, or any sup- anesthesia and half as many transfusions were required.
plemental oxygen. We saved our meager stocks of medical The iso¬‚urane fentanyl group had twice the postoperative
supplies, such as endotracheal tubes, anesthesia circuits, mortality rate compared with the PKR group.
and cylinders of oxygen.”5 This testimony from the ¬rst A neurosurgeon deployed to Iraq also has been
anesthesiologist to enter Iraq is the best example of the impressed with TIVA compared with inhalation anesthe-
suitability of TIVA for military and mass-casualty anes- sia. Poffenbarger9 wrote: “We have had great brain relax-
thesia. Fortunately, the use of TIVA in OIF continued. ation with TIVA. I™ve only had to shoehorn one patient.
Since August of 2004, TIVA has been extensively The wakeups have been crisper than what I am used to
utilized in Baghdad, Iraq as the anesthetic of choice and there has been no retching seen with nausea and vom-
for craniotomies. This propofol-ketamine-remifentanil iting. The patients all used to sag hemodynamically with
(PKR) technique has been used hundreds of times, expertly gas anesthesia, but none of that with your technique.”
delivered by an anesthesiologist, and has been named Certainly more will be written about TIVA in Opera-
“Cadillac anesthesia.” tion Iraqi Freedom, but these early reports are powerful
Describing his experience with TIVA for neuroanesthe- evidence that TIVA can be very effective in trauma anes-
sia, Grathwohl wrote: “My experience with PKR has been thesia settings.
nothing but positive. The setup is simple, meaning it is The TARGIT Center is now actively involved in clin-
easy to mix the drugs. Take a 100 cc 1% propofol bot- ical research with TIVA. The knowledge being gained
tle and add 100 mg ketamine and 2 mg remifentanil. The will improve the quality of anesthesia being delivered in
resulting concentrations are approximately 10 mg propo- the combat setting. Since 2003, members of the TARGIT
fol · cc’1 , 1 mg ketamine · cc’1 , & 20 ug remifentanil · Center at Brooke Army Medical Center have delivered
cc’1 . over 1,000 TIVA cases. Regimens using propofol-ketamine
“Induce with 50“100 ug fentanyl and 1“2 mg · kg’1 (PK), propofol-ketamine-fentanyl (PKF), propofol-keta-
propofol. Titrate the ˜cocktail™ about 70“100 propofol mine-sufentanil (PKS), and propofol-ketamine-remifen-
ug · kg’1 · min’1 . Administer no more than a total of tanil (PKR) have been administered and have found niches
Propofol Ketamine Beyond Cosmetic Surgery 71

in everyday clinical practice. PK and PKF are used for to rede¬ne mass-casualty anesthesia care and be ready for
many breast surgeries. PKS is often used for abdominal any perioperative challenge.
hysterectomies, back cases, and some abdominal general
surgery. PKR is most often used for ENT cases with or REFERENCES
without spontaneous ventilation. In fact, these techniques 1. www.doctorfriedberg.com
2. Friedberg BL: Anesthesia for facial cosmetic surgery, chap-
have come to be requested on a regular basis by patients
ter in Herlich AN (ed.): Anesthesia for oral and maxillofa-
and surgeons.
cial surgery. International Anesthesiology Clinics. Baltimore,
Aside from clinical research, the TARGIT Center is Lippincott, Williams & Wilkins, 41:13,2003.
designing a syllabus and educational seminar to teach and 3. Guit JBM, Koning HM, Coster ML, et al.: Ketamine as
analgesic for intravenous anesthesia with propofol (TIVA).
train physicians and nurses the science and art of delivering
Anaesthesia 46:24,1991.
TIVA. In the end, research, education, and implementa- 4. Bonnano FG: Ketamine in war/tropical surgery, a ¬nal trib-
tion of TIVA should make military anesthesia world class. ute to the racemic mixture. Internat J Care Injured 33:323,
5. Meeks M: 86th Combat Support Hospital After Action
Report on Anesthesia in Operation Iraqi Freedom, 2003.
6. Grathwohl K: Personal communication regarding TIVA in
Operation Iraqi Freedom, 2004.
The Triservice Anesthesia Research Group Initiative on
7. Grathwohl K: E-mail correspondence from the front. June 2,
TIVA is a step in the right direction for improving mass- 2005.
casualty anesthesia. As physicians, we must be ready to 8. Himmelseher S, Durieux ME: Revising dogma: Ketamine
for patients with neurological injury. Anesth Analg 101:524,
care for large numbers of casualties in any setting. The
mass-casualty environment simply might not be able to
9. Poffenbarger G: Personal communication regarding TIVA in
support inhalation anesthesia. Therefore, TIVA has to be Operation Iraqi Freedom, 2004.
10. Hutson C: Total intravenous anesthesia in austere environ-
taught and utilized so that our patients will receive the
ments. Military Medicine (in press) 2005.
best level of care. As Hutson10 described, “TIVA is a sim-
ple and ¬‚exible technique applicable to all surgical case
types. It has a small logistical footprint and can be easily
administered in any environment independent of electric-
ity and compressed gases. TIVA offers enhanced physio-
logic stability, fast emergence and reduced post-operative
JUN 25, 2004 6:50
care requirements translating directly into provider ef¬- PM

ciency and multitasking.” This is exactly the type of impact
Corona del Mar (AP)
that anesthesiology can make in preparing the American
Local anesthesiologist Barry Friedberg is doing his part for
health care system for possible mass-casualty situations.
our wounded troops in Iraq. And, until a few weeks ago,
he didn™t even know it. He didn™t know it until the Army
called him to personally brief doctors at the Brooke Army
Medical Center in San Antonio, Texas.
It seems the Army had read about the portability of Dr.
Anesthesiology is a medical specialty that must continually
Friedberg™s anesthesia techniques and were adapting them
reevaluate it methods. The motto of the American Soci-
to their front line hospitals. His procedures eliminate the
ety of Anesthesiologists is “vigilance.” All anesthesiologists
use of narcotics and don™t require the use of oxygen tanks
should strive to be in a constant state of vigilance. Fur-
that are dif¬cult to come by in Iraq.
thermore, physician consultants in anesthesiology must
In Texas, a shocked and puzzled Dr. Friedberg said he
be forward thinkers. The care provided to patients has to
found himself “amazed” the Army was interested in his
be ¬rst class.
procedures. Why? He™d developed them while going from
Applied anatomy, pharmacology, physiology, and com-
of¬ce-to-of¬ce anesthetizing patients on whom local cos-
mon sense can and will improve patient outcomes. PK
metic surgeons were performing tummy tucks and breast
anesthesia and other combinations of intravenous agents
will be the anesthetics of the future. It is the military™s duty
8 Lidocaine Use and Toxicity in Cosmetic Surgery
Adam Frederic Dorin, M.D., M.B.A.

Bene¬ts, Pitfalls, and Controversies
Pitfalls and Complications
Third-space ¬‚uid shifts
Iatrogenic error
Pulmonary edema
Pulmonary embolism
Epinephrine toxicity
Lidocaine toxicity
Anesthetic implications
Suggestions for Clinical Practice
Preoperative assessment

practice, and the politics or practical concerns of pushing
the envelope toward higher, “megadose” tumescent lido-
The use and toxicity of lidocaine in modern cosmetic sur-
caine solutions. As there are ample resources to address
gical practice is arguably the most important topic for
the basic structure of the lidocaine molecule, and multiple
any anesthesiologist or surgeon working in this ¬eld of
books and articles on the basic science and pharmacoki-
medicine. Lidocaine toxicity, primarily in the context of
netics of lidocaine, no space is wasted in displaying this
suction assisted lipectomy (SAL), lipoplasty, or liposuc-
information. Similarly, the related subjects of peribulbar
tion, has historically accounted for a signi¬cant propor-
versus topical anesthesia in ophthalmic surgery and tran-
tion of patient morbidity and mortality.
sient neurotoxic symptoms in lidocaine spinal anesthesia
This chapter covers lidocaine pharmacology, the history
are not analyzed in this context.
of lidocaine use in the context of cosmetic/plastic surgical

Lidocaine Use and Toxicity in Cosmetic Surgery 73

potent but retains a half-life of ten hours. Both MEGX
and GX metabolites add to the therapeutic effects of lido-
Lidocaine, an amide molecule synthesized from cocaine, caine. Both are culpable in the clinical toxic effects of
was ¬rst applied in the practice of medicine in 1948.1 As lidocaine.5
clinical applications and the advancement of medicine Lidocaine prevents electrical conduction by stabilizing
expanded the role of lidocaine, this drug found a niche cell membranes. This is achieved by preventing membrane
applied topically and subcutaneously for local anesthesia permeability to calcium-dependent sodium and potas-
for a variety of surgical procedures. Lidocaine is used intra- sium shifts. These shifts effectively block nerve conduc-
venously to treat ventricular arrhythmias. Dilute solutions tion. In the cardiac muscle, lidocaine blocks both open
of lidocaine mixed with epinephrine are administered and inactivated sodium channels, decreasing the slope of
as tumescent solution for liposuction cosmetic surgery. phase 4 depolarization and the threshold potential. This
Lidocaine is available as a topical solution (2“4% or 20“ decreases myocardial automaticity. In ischemic cardiac tis-
40 mg · ml’1 ), a rectal suppository (10% or 100 mg · sue, this effect is more pronounced, in effect synchronizing
ml’1 ), viscous lidocaine (2% or 20 mg · ml’1 ), and a myocardial cells and making reentrant arrhythmias less
jelly (2%); there also exists a topical ointment (5% or 50
mg · ml’1 ), an aerosol (10%), and a solution for sub-
cutaneous and intravenous administration (0.5“2% or
5“20 mg · ml’1 ).2
Lidocaine displays very good absorption following In the practice of cosmetic surgery, surgeons and anesthe-
all routes of administration. Absorption from the oral siologists attempt to calculate the “maximal safe dose” of
mucosa avoids ¬rst-pass metabolism and is thus very lidocaine for use in subcutaneous in¬ltration or tumescent
rapid. Absorption from the GI tract undergoes hepatic solutions. For simplicity, the historical or time-honored,
¬rst-pass metabolism, resulting in only about 35% of dose-related toxicity of lidocaine in subcutaneous in¬ltra-
ingested lidocaine reaching the systemic circulation.3 The tion will be assessed ¬rst. The controversy and facts regard-
volume of distribution of lidocaine is 1.6 L · kg’1 . In ing tumescent solutions will be addressed (vide infra). Pro-
the very young and the very old, this volume of dis- longed surgical cases involving both SAL or liposuction
tribution can be signi¬cantly higher. The plasma half- and other cosmetic procedures (e.g., rhinoplasty and/or
life of lidocaine is eight minutes; the terminal half-life breast augmentation) can create complex physiologic sce-
of lidocaine is ninety minutes. Plasma lidocaine levels narios in which determination of the “cutoff ” level of safe
fall rapidly following parenteral administration. Follow- lidocaine dosing can be a dif¬cult calculation. Subcuta-
neous lidocaine injection has been limited to 4.5 mg · kg’1
ing a bolus intravenous injection, lidocaine has a rela-
without epinephrine and 7.0 mg · kg’1 with epinephrine.
tively short duration of action (ten to thirty minutes)
due to rapid tissue redistribution. Ninety percent of lido- The addition of epinephrine to a solution of lidocaine
caine clearance is due to hepatic metabolism, and 10% of will nearly double the duration of lidocaine activity. Lido-
lidocaine is excreted unchanged in the urine. The pKa of caine has inherent vasodilating properties. At the capillary
lidocaine is 7.8. Lidocaine is approximately 50% protein bed level, vasodilation acts to accelerate the “washout” or
bound.4 absorption of lidocaine from injected tissues. The vasocon-
There are several caveats regarding lidocaine meta- striction produced by the addition of epinephrine works
bolism consistent with basic physiology. Lidocaine blood to offset vasodilation from the lidocaine. Hence, the anal-
levels will be elevated in the setting of acidosis (e.g., gesic effect of the lidocaine/epinephrine combination is
hypercarbia secondary to inadequate airway manage- increased. Because of this action, there is a decreased peak
ment, regional infection, or sepsis) due to decreased blood level of lidocaine. This allows the patient to tolerate
the administration of a larger initial dose.5 The physiologic
protein binding. In addition, there are two major lido-
caine metabolites: monoethylglycinexylidide (MEGX) toxicity of lidocaine will become apparent to the clinical
and glycinexylidide (GX). MEGX retains 83% of the activ- practitioner in the sequence of CNS effects (e.g., mental
ity of lidocaine and has a half-life of two hours; GX is less status changes), and then cardiac deterioration and arrest.
74 Adam Frederic Dorin

Today™s patient often takes so many medications, both
Table 8-1. Blood lidocaine levels and
prescription and herbal, that it can be dif¬cult to fully
manifestations of toxicity
assess their anesthetic impact in a brief preoperative visit
ug · ml’1 (see Chapter 14 and Appendix A). Some of those medica-
Clinical state in the awake patient
tions act as inhibitors of the liver cytochrome P450 (3A4)
1. 1.5“5.0 Therapeutic
isoenzyme system. Dorin categorizes these drugs along
2. 5“10 Dizziness, tinnitus, patient complaint of
metallic taste on the tongue, lethargy the same lines as the mechanisms of systemic toxicity that
3. 10“20 Delirium, disorientation, eventually occur with increasing doses of lidocaine. CNS impairment
seizures and coma
typically occurs ¬rst with increasingly toxic levels of serum
4. >20 Probable cardiac arrest
Selective serotonin reuptake inhibitors (SSRIs) are a
class of antidepressants that inhibit the cytochrome P450
Under both IV sedation and general inhalation anesthe-
system. This class of drug includes sertraline, paroxe-
sia, the CNS signs tend to be obscured! Only the termi-
tine, nor¬‚uoxetine, ¬‚uoxetine, ¬‚uvoxamine, and citalo-
nal, cardiovascular signs of toxicity are manifest (i.e., A-V
pram. Newer agents in this class of antidepressants have
dissociation and hypotension). Under MAC/Sedation, in
been appearing on the market on a yearly basis. Other
the context of intermittent benzodiazepine or continuous
antidepressant medications, such as nefazodone, may also
propofol administration, the seizure threshold of lidocaine
hypothetically affect lidocaine metabolism and potentially
will be elevated. An elevated seizure threshold may poten-
predispose to toxic levels of serum lidocaine. The main
tially contribute to a false sense of security if the serum
offending class of agents is the SSRIs.
and tissue levels of the sedating agents fall more rapidly
This is not to suggest that psychiatric medications should
than the blood level of lidocaine.
be discontinued preoperatively.
The hemodynamic changes associated with lidocaine
It should also not be inferred, with other medications
toxicity are primarily the consequence of direct cardiac
effects, resulting in hypotension, A-V block, and asystole.6 listed herein (e.g., nondiuretic antihypertensives), that
patient baseline medications should be suspended prior
A blood concentration of lidocaine in the range of 1.5“5.0
ug · kg’1 is considered therapeutic (see Table 8-1). to SAL or liposuction. Rather, these medications are listed
in the context of better understanding the full gamut of
In an awake patient, blood levels in the range of 5“
10 ug · kg’1 will characteristically result in dizziness, physiologic factors in¬‚uencing potential lidocaine toxicity.
With increasing lidocaine blood levels, cardiac impair-
tinnitus, patient complaint of metallic taste on the
ment will present itself in lidocaine toxicity after CNS
tongue, and lethargy. These symptoms may be obscured
when patients are sedated. At the levels of 10“20 ug · symptoms. Calcium-channel blockers, diltiazem, nifedip-
kg’1 , the awake patient will experience delirium and ine, and verapamil can potentially augment the risk of lido-
caine toxicity through inhibition of the liver cytochrome
disorientation, which will eventually lead to seizures and
P450 system. Sometimes patients, either preoperatively,
coma. Finally, blood levels of lidocaine greater than 20 ug
· kg’1 will signi¬cantly predispose a patient for cardiac intraoperatively, or postoperatively, receive sublingual
nifedipine for clinically signi¬cant hypertension. How
arrest. The toxicity of lidocaine (not unlike many drugs
many times does an anesthesiologist or nurse consider the
that undergo hepatic metabolism) will be heightened
possibility of potentiating lidocaine toxicity when giving
(and the threshold lowered) in the setting of congestive
heart failure (CHF) and liver cirrhosis. (Both heart failure
Other types of common patient medications that may
and cirrhosis lead to a decreased clearance of the drug.)
justify altering the total dose of lidocaine given intraop-
The use of some drugs by patients, such as beta-blockers
eratively fall into the general groups of “bugs and drugs.”
(decreased cardiac output) and cimetidine (cytochrome
Along the lines of antibiotics, the “¬‚oxin” medications
P450 system), will result in the further enhanced toxicity
of lidocaine.5 Editor™s note: This concern may be more (nor¬‚oxacin, cipro¬‚oxacin, and spar¬‚oxacin) and the
“mycin” medications (erythromycin and clarithromycin)
hypothetical than is clinically apparent ”BLF.
Lidocaine Use and Toxicity in Cosmetic Surgery 75

should be remembered. Antifungals, such as ketocona- cardiorespiratory arrest. The lidocaine level in this patient
was measured at 21.2 ug · kg’1 . 9
zole and ¬‚uconazole, are also inhibitors of the cytochrome
P450 3A4 isoenzyme system. Methadone also inhibits the Before the heated debate about liposuction lidocaine
liver™s P450 system as well. Other medications that not levels surfaced in the mid to late 1990s, a 1991 Ameri-
uncommonly appear in a patient™s preoperative work- can Journal of Cardiology article foreshadowed the dis-
sheet are tamoxifen, for breast cancer, and methyl- cussions to follow with the report of serious lidocaine
prednisolone. The immunosuppressant cyclosporine and toxicity resulting from the subcutaneous in¬ltration of
the antiseizure medication valproic acid should be lidocaine (with epinephrine) in ten patients undergoing
added to the list of inhibitors of the cytochrome P450 cardiac catheterization. Two of these sequential patients
system. became lethargic and had measured lidocaine levels of
6.8 ug · kg’1 and 7.2 ug · kg’1 following doses of 25 mg ·
kg’1 and 47 mg · kg’1 , respectively.10

The appropriate treatment of lidocaine toxicity consists
primarily of administering 100% Fi O2 , securing the air- In the early 21st century, there remains a vigorous debate
way, and providing support of the blood pressure. IV ben- among cosmetic surgical specialties about the terminol-
zodiazepines have been the mainstay of therapy for ogy of fat removal by aspiration. The parlance of plastic
seizures. Hypotension may be treated with pressors surgeons tends to “suction assisted lipectomy”(SAL) or
and increasing IV ¬‚uids. Atropine may be useful for “lipoplasty,” whereas the parlance of cosmetic surgeons
bradycardia. tends to “liposuction.” Plastic surgeons tend to use the
Avoid IV lidocaine for the correction of arrhythmias. term “wetting solution” in preference to the “tumescent”
Correction of hypoxemia, seizures, acidosis, and formula (i.e., 500 mg lidocaine, 1 mg epinephrine, and 12.5
hypotension will usually eliminate arrhythmias. Acido- meq NaHCO3 in NSS) promoted by dermatologist Klein
sis may be best treated by increasing minute ventilation. in 1987. The ¬nger-pointing and blame-placing regard-
Current ACLS guidelines discourage the use of bicar- ing “who” has caused “what” complication of lidocaine
bonate in this setting. Correcting acidosis prevents lido- toxicity continues to the present day.
caine from becoming more available as a free drug in the Patients have experienced death at the hands of both
circulation. dermatologists and plastic surgeons. Williford, comment-
ing on Coldiron et al.,11 concluded that “ultimately, this
Practitioners should avoid using phenytoin as an anticon-
vulsant due to its synergistic, untoward cardiac action.6 debate should not be about the internecine battle: us
Lidocaine toxicity has been found following every possi- against them in an Alamo last stand posturing. It should
ble route of drug administration or exposure. In children, be about honoring the duty of discovering what is most
oral administration has resulted in generalized seizures, appropriate, cost-effective, ef¬cacious, and safe for our
with lidocaine levels ranging from 3.8“10.6 ug · kg’1 .7 patients”12 (see Chapter 17). Additionally, tumescent tech-
In the case of a four-week-old infant, seizure, respiratory nique with minimal or no sedation is compared against
arrest, and coma resulted from an intravenous dose of “super wet” technique with major neuraxial or general
50 mg lidocaine.8 In this case, the lidocaine peak level inhalation anesthesia.
reached 5.39 ug · kg’1 . In a case of topical lidocaine use In an article published in 2000, Gorney asserts that
by a ¬fty-¬ve-year-old woman with cutaneous lymphoma “lidocaine toxicity” is probably the second or third most
common cause of fatal outcome in lipoplasty.13 In that
lesions, the patient applied 5% topical lidocaine ointment
over approximately 60% of her body surface area to treat same year, a study by Grazer and de Jong of more than
pruritus. The patient continued this activity for nine days 100 liposuction deaths purported to show no deaths due
to lidocaine toxicity.14 In a 1999 New England Journal of
and eventually developed grand mal seizures and a full
76 Adam Frederic Dorin

Medicine article entitled “Deaths Related to Liposuction,” tial leg vein compression eliminates deep pelvic vein con-
Rao15 reports several deaths associated with tumescent gestion. IV sedation techniques that preserve the normal
or wetting solutions. Rao makes the observation that the “muscle pump” of the legs appear to provide a greater mar-
deaths were associated with epinephrine concentrations gin of safety than relying on the sequential compression
stockings.16 General inhalation anesthesia may still leave
of 1:2,000,000. This represents a concentration of 0.5 mg in
1,000 cc in contrast to Klein™s recommended 1 mg in 1,000 cc. the patients in substantial postoperative pain. Patients in
The conventional tumescent epinephrine concentration is pain tend not to ambulate as often or as much as patients
1:1,000,000. In one patient who received the 1:2,000,000 who have had preemptive analgesia. Patients medicated
epinephrine dilution, the cause of death was exsanguina- with opioids for postoperative pain also tend to ambu-
tion. Though not conclusively demonstrated, the reduced late less. Lesser ambulation exacerbates the tendency to
vasoconstriction provided by the lower epinephrine con- venous stasis and potential pulmonary embolic phenom-
centration, when combined with a large-volume liposuc- ena. Having anesthesiologists present in the surgical suite
tion, is suspected as the etiology of the exsanguination. In provides the superb advantage of having a specialized pair
these cited studies and reports, the lidocaine concentra- of hands to deal with airway complications. The anesthe-
tion was 0.1 mg% or lower, in doses less than 60 mg · siologist has an independent focus on monitoring patient
kg’1 . In addition, liposuction was performed within vital signs.
roughly three to four hours of injection, and approximately Lillis, in the Journal of Dermatological Oncology (1988),
claimed that 90 mg · kg’1 lidocaine was safe.17 Hildreth,
the same volume of aspirate was removed as was initially
infused. reporting in 1998 at the World Congress of Liposuction
A perusal of the modern literature, as well as articles, on a study that involved thousands of patients, made the
claim that lidocaine in doses of 80 mg · kg’1 was “safe.”18
web sites, and “blogs,” reveals a stark contrast between
specialties on the issue of lidocaine-related toxicity in cos- The California legislature enacted total liposuction aspi-
metic surgery (primarily SAL or liposuction combined rate limit of 5,000 ml. Many plastic surgeons inject approx-
with additional cosmetic procedures). Cosmetic surgeons imately the amount they plan to aspirate. In Friedberg™s
series of patients,19 female patients weighed an average of
tend to blame IV sedation and/or general anesthesia for
patient complications. 60 kg; 5,000 ml injected with 500 mg lidocaine in each 1,000
ml bag calculates to a lidocaine dose of 42 mg · kg’1 . In
Following the adoption of pulse oximetry as a stan-
dard of care (1990), mortality from anesthesia declined to his clinical experience, the epinephrine-induced delayed
1:250,000. Drastic reduction of hypoxic insults and deaths absorption of lidocaine contributes to the safety of mega-
are generally believed to be the cause of the diminished dose lidocaine tumescent injection. Further, the seizure
mortality estimate. A proportional decrease in anesthesiol- threshold of lidocaine is elevated by the concomitant use
ogist malpractice premiums followed. Grazer and deJong of continuous propofol at BIS <75. Removing some of
claimed the anesthesia mortality ¬gure is 1:5,000 or ¬fty the injectate with the aspirate solution also contributes to
times greater than recognized in the anesthesia commu- safety with megadose lidocaine use.
Coldiron et al.11 reviewed deaths occurring in the of¬ce
nity. How can one make sense of the enormous dispar-
ity in mortality ¬gures? A possible explanation may be setting using three years of mandatory reporting of patient
that Grazer and deJong™s deaths included those from pul- death data from the state of Florida. In contrast, Grazer and
monary embolism and other non-lidocaine-related out- deJong™s data were derived from a survey based on volun-
tary reporting.14 The Florida data demonstrate that 42%
comes. Pulmonary embolism arises from venous stasis in
the leg and deep pelvic veins. Patients are more predisposed of those of¬ces reporting deaths and 50% of the of¬ces
to venous stasis when anesthetics that provide profound reporting hospital transfers in the perioperative period
muscle relaxation (i.e., major neuraxial block or general were accredited by an independent accreditation agency.
inhalation anesthesia) are administered. Sequential com- In addition, 96% of physicians reporting surgical incidents
pression stockings are advocated to minimize leg veins were board-certi¬ed and had hospital privileges. Coldiron
et al.11 concluded that regulatory restrictions on of¬ce
stasis. However, it is presently unknown whether sequen-
Lidocaine Use and Toxicity in Cosmetic Surgery 77

procedures have little effect on overall patient safety if pay considerable sums of money for SAL or liposuction.
they fail to identify and address the issue of cosmetic surg- Most practitioners would probably agree this patient pop-
eries, in particular, those that are performed under general ulation is ¬ercely independent. Cosmetic patients demon-
anesthesia. strate the pro¬le of an active, energetic lifestyle. These
patients place a high value on time, mobility, and quick
postsurgical recoveries. Anything that adds these qualities
to the anesthetic side of SAL or liposuction is a value-added
component to the patient™s perioperative experience.
Megadose tumescent anesthesia is such a value-added
Bene¬ts, Pitfalls, and Controversies
component. The addition of higher total doses of lido-
The 2000 national statistics for the American Society for
caine to the SAL or liposuction translates, potentially, into
Dermatologic Surgeons and the American Society of Plas-
greater tissue analgesia. In addition, more areas of work
tic Surgeons both put the number of SAL or liposuc-
can be performed in one operative setting, and greater
tion procedures performed in the United States at about
450,000.20 The 2003 census by the American Society for volumes of tissues can be infused and aspirated. Push-
ing the volume/dosage envelope of the lidocaine/epineph-
Aesthetic Plastic Surgery (ASAPS) records the number of
lipoplasty procedures for that year at 384,626.21 By all rine tumescent solution means a bigger “bang for the
accounts, in recent years, SAL or liposuction ranks as the
Americans like to accomplish more at whatever they™re
number one cosmetic surgical procedure performed on an
doing. Likewise, medical practitioners like to get as much
annual basis in the United States.
of their treatment done in a single patient encounter. With
Tumescent liposuction involves the infusion of a dilute
the addition of direct patient remuneration in cosmetic
solution of lidocaine and epinephrine into the subcu-
surgeries, the signi¬cance of doing (and collecting) more
taneous fat layer. This serves to thicken the fat layer
in one visit becomes inherently obvious.
in preparation for aspiration. The physical pressure of
the tissue distention in addition to the vasoconstric-
tion from the epinephrine serves to decrease blood loss. Bene¬ts”clinical
Lidocaine provides local analgesia during the proce- Historically, the injection of ¬‚uids has been used to provide
dure and in the immediate postoperative period. Large- a hydrodissection of tissue planes. Hydrodissection pre-
volume liposuction procedures (i.e., >4,000 ccs of fat) dated SAL or liposuction and was never used to facilitate
will likely need to rely on adequate levels of IV sedation, the aspiration of fat. Modern-day liposuction was pop-
major neuraxial block, or general anesthesia for patient ularized by Klein, a dermatologist, who reported clinical
comfort. trials with several liters of a subcutaneous, isotonic injec-
Since SAL or liposuction was introduced in the United tate containing a very dilute lidocaine (0.05“0.10%) and
epinephrine (1:1,000,000) solution.22 The term “tumes-
States in 1983, signi¬cant complications, as well as deaths,
have been reported in medical journals and the lay press. cent” gained traction because of the effect the solution had
First, what are the general and somewhat obvious bene- on tissues. Tumescence caused the fatty tissues to become
¬ts of liposuction with megadose lidocaine? Next, how do engorged or swell. Vasoconstriction of the subdermal
some of the pitfalls and controversies impact the use of plexus caused the overlying skin to appear blanched. Klein
high-dose lidocaine? touted his new approach as one that could achieve an inde-
pendent state of local tissue anesthesia. Klein described his
Bene¬ts”practical approach as “regional anesthesia.” In contradistinction to
The bene¬ts of megadose lidocaine SAL or liposuction Klein, anesthesiologists use the term “regional anesthesia”
build on the inherent appeal of the procedure itself. As an to signify major neuraxial block (e.g., spinal or epidural).
alternative to rigorous dieting and exercise, SAL or lipo- Compared to the blood losses not infrequently requir-
suction allows patients to quickly shed inches in sculpted ing transfusion with “dry” liposuction, Klein reported
areas of the body. Cosmetic surgical patients continue to nearly bloodless surgery with his tumescent approach.
78 Adam Frederic Dorin

Klein also reported that postoperative analgesia was reli- paperwork burdens by third-party payers combined with
able and sustained. Tumescent solutions were shown to decreasing remuneration for services were additional fac-
result in a slower release of lidocaine from injected tissues tors driving many plastic surgeons and other physicians to
into the general circulation. As a result, Klein and oth- seek a fee-for-service model in which to practice.
ers demonstrated maximum mean lidocaine serum lev-
els of about 1.3 ug · ml’1 , peaking at twelve to fourteen Pitfalls and Complications
In 1999, Grazer and de Jong14 reported (in a voluntary
hours after injection and then declining over another six to
fourteen hours.23 The pharmacokinetic pro¬le of tumes- survey of 1,200 cosmetic plastic surgeons) a mortality rate
cent or “wetting” solution is strikingly similar to a one- of 19.1 in 100,000 lipoplasty surgeries. This statistic repre-
compartment sustained-release drug model. By relying on sents 95 reported and veri¬ed deaths out of almost 500,000
the protein/tissue binding characteristics of the lidocaine cases. The total number of SAL or liposuction cases per-
molecule and the vasoconstrictive qualities of epinephrine, formed in North America over the course of the Grazer
lidocaine is essentially withheld from the general circula- and de Jong study period was close to one million cases.
tion for longer periods of time than conventional local, The study period was four and a half years.
subcutaneously injected medication. To put the issue of SAL or liposuction risk and lido-
caine toxicity into context, all the potential perioperative
Bene¬ts”political surgical complications should be reviewed. Then, the risks
related to megadose tumescent liposuction require some
One doesn™t need statistics or peer-reviewed journals to
prove the point that a large percentage of liposuction pro-
cedures in the United States is being performed by individ-
uals who are not general/plastic surgery trained. Perusing
the advertisement pages of most newspapers and glossy Every surgery can result in hemorrhage. Even a “minor”
periodicals establishes this point. The list of health care surgery like a simple mole removal or scar revision in a
professionals who have incorporated liposuction into their patient who unknowingly suffers from a blood-clotting
menu of services include dermatologists, otolaryngolo- de¬ciency can result in signi¬cant blood loss. SAL or lipo-
gists, family practitioners, obstetrician-gynecologists, and suction perioperative complications can range from poor
others. Klein and other advocates of tumescent technique wound healing to life-threatening injury. Multiple factors
offered weekend training seminars. Cosmetic as well as may impact the potential for bleeding in liposuction. Some
some plastic surgeons attended. Prior to 1990, few, if any, believe that waiting thirty to forty-¬ve minutes after com-
plastic surgery residency training programs offered train- pleting the injection of the tumescent or “wetting” solu-
ing in “super wet” SAL or tumescent liposuction. Plastic tion provides superior hemostasis. The use of progressively
surgeons trained before 1990 were also obliged to learn smaller cannula (i.e., 3“6 mm compared with 8“12 mm)
SAL at weekend courses or even from the sales represen- probably has contributed to less laceration of larger arteri-
tatives of companies selling cannulae and suction pumps. oles. Although underlying and unsuspected coagulopathy
Some have even reported rare sightings of dentists and may play a role, it is more likely that the undisclosed patient
anesthesiologists performing liposuction. Modern tumes- use of herbal, over-the-counter agents (i.e., Ginkgo Biloba,
cent technique has contributed to the expanded practice St. John™s Wort, garlic, and Vitamin E) are the culprits in
settings of SAL or liposuction. Furthermore, the promo- excess bleeding (see Chapter 14 and Appendix A). Inap-
tion of the tumescent technique has allowed this surgical propriate IV ¬‚uid therapy may also contribute to a dilu-
procedure to safely and successfully adapt to the diverse tional coagulopathy. Limitation of total volumes in Florida
practice settings of hospitals, freestanding ambulatory sur- (4,000 ccs fat) and California (5,000 ccs total aspirate) has
gical centers, and of¬ce-based surgical suites. contributed to the increased safety of SAL or liposuction.
With improvements in local anesthesia, and the ease IV ¬‚uids need to be administered sparingly, if at all, under
with which relatively large volumes of fat could be safely these limitations. Speci¬cally, the potentially lethal formula
aspirated in one sitting, SAL or liposuction quickly became of replacing 3 ccs of IV ¬‚uid for every 1 cc of fat aspirated
a cash cow for many physicians. Increasingly onerous merits sound condemnation.
Lidocaine Use and Toxicity in Cosmetic Surgery 79

All of the preceding factors can have a signi¬cant in¬‚u- the creation of raw, subdermal trauma can be signi¬cant.
ence on the degree of intraoperative and postoperative Tissue trauma occurs independent of whether manual or
bleeding. Compression garments are commonly utilized ultrasound cannula are utilized. This injury causes tissues
for SAL or liposuction procedures to help the skin redrape and vessels to lose normal integrity; combined with the
more smoothly. The external pressure tends to obliterate risk of extensive and lengthy surgeries that involve large
volumes of fat aspiration (i.e., >4,000 ccs), third-space
the potential third-space effect created by the removal of
fat. shifts can result in serious hemodynamic ¬‚uctuations in
One cannot apply the same principles of volume replace- the postoperative setting. There may be signi¬cant elec-
ment to potential third-space ¬‚uid shifts in SAL or liposuction trolyte imbalances. The attentive practitioner will order
as one would when dealing with extensive skin burns. postoperative labs to quickly identify and correct any dis-
No compression garments mitigate the third-space turbances. The practice of applying postoperative com-
losses in burn victims. Inappropriate, aggressive ¬‚uid pression garments is thought to substantially mitigate the
administration may place the SAL or liposuction patient at degree of third-space ¬‚uid shifts (vide supra).
risk for ¬‚uid overload and dilutional coagulopathy. A drop
Iatrogenic error
in oxygen-carrying capacity may occur as the hemoglobin


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