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 - Dosage
http://tumescent.org/wp-content/uploads/Anesth-Analg-2016-Klein.pdf
FDA Lidocaine Labeling: 7mg/kg out-of-the bottle commercial • Based on 1948 Obstetric Epidural
Data• FDA Has No Data on Subcutaneous
Infiltration
Safety - Dosage
http://tumescent.org/wp-content/uploads/Anesth-Analg-2016-Klein.pdf
Dr Klein:• Maximum safe dosage TLA 28 mg/kg (non-lipo
cases)• Peak Plasma lidocaine level with TLA = 12
hours • Added liposuction reduces peak plasma
lidocaine levels by approx. 10 -30%• Peak Plasma lidocaine concentration should
NOT exceed 5 ųg/ml
Safety -Drug Interactions• Nurse Counseling• Drug Interactions• Bleeding Risk• Lidocaine Metabolism
• Prescribing• Antibiotic• Benzodiazepine – Lorazepam vs
Diazepam• Clonidine
Protocols- NO VARIATION
•Clear Staff Roles•Clear Physician Written Order• TEAM commitment to safe Dosage • Surgical Time out • Continued monitoring
Protocols- NO VARIATION• Forms and Record keeping• Calculating Dosage
and Limitations based on weight• Document volume
and dosage administered
Protocols- NO VARIATION• Forms and Record keeping• Labeling• Keep bottles used for
mixing until next day
• Vasovagal Syncope• Failure of physiologic mechanisms responsible or
maintain both blood pressure and cerebral blood flow – Dr Klein• Need response protocol• Preventive measures for syncope• Know ahead of time if patient is prone to fainting• Patient should NOT watch - Keep head bed down• Eat before appointment
Adverse Events – Vasovagal Syncope
• Sign: decreased respiration, decreased pulse rate, decreased blood pressure, decreased O2 sat, difficult to arouse.• Action:• Flumazenil 0.2 mg IV push for 15 seconds every minute for 1-5
doses• Repeat that sequence in 20 min if needed
Adverse Events – Lorazepam Toxicity
• Signs: drowsiness, lightheadedness, nausea, vomiting, nervousness, apprehension, euphoria, confusion, dizziness, blurred/double vision, tremors
• Action: • ER visit to have plasma level checked and possibly
stay overnight for observation (5 ųg/ml threshold) • Beware of mimic
Adverse Events – Lidocaine Toxicity
Adverse Events – Advanced Lidocaine Toxicity
• Signs: Dysrhythmia or seizures • Action: • Call 911. • Start O2• Alert EMS of the following medication recommendations:• Bretylium (for dysrhythmia)• Midazolam (for seizures): 5-7mg bolus, then 1-2 mg until
controlled. • Let EMS know not to use Diazepam
Adverse Events – Slow Lidocaine Absorption
• Signs: Toxicity occurring about 12 hrs after tumescent administration, usually after waking up from a nap. • Usually it will resolve in about 1-2 hoursAction: • Drink water• Sit slightly reclined (like watching tv)• Breathe in a paper bag • Staff call patient every 30 minutes • If occurs after 12 hours and /or the symptoms worsen /are
severe - go to the ER or call 911
•Mimicking behaviors of Lidocaine Toxicity• Benzodiazepine toxicity • Self-medicating (sedation drug, narcotic, alcohol)Action (if mild):• Monitor patient (or call every hour if patient at home)
until symptoms improve• Drink fluids• Relax• IF worsens, or severe, ER examination
Adverse Events – Beware of the Mimic
OUTSIDE THE BOX• Allergy to Lidocaine
• Drug challenge with allergist• Prilocaine (citanest)• Preservative Free Solution
• Histamine Reaction • Pre-treat with anti-histamine and H2 blocker• Preservative Free Solution
• Epinephrine Sensitivity • Slow infusion, avoid IV injection• Education• Preservative Free Solution• Epinephrine is responsible for the profound vasoconstriction and
consequent hemostasis essential to the tumescent technique – Dr Klein
Histamine Reaction Initial Picture
7 days post-
procedure
6 weeks post-
procedure
Action• No suture strips used• Oral Anti-histamine and
H2 blocker• Allergist drug challenge• Prilocaine, preservative
free solution, for subsequent procedures
OUTSIDE THE BOX• Liver Disease • Lidocaine metabolized in liver, • Rate of metabolism dependent on rate of blood flow to the
liver• Conditions that may cause compromised metabolism :
• Shock, Congestive heart failure, Beta-blockers, Cirrhosis
• Kidney Disease• Lidocaine clearance normal• Use caution regarding fluid overload
Empathy• Anxiety heightens pain• Anxiolysis• Verbal Anesthesia•Warm solution•Music• Relaxation APP• Target less tender sites for initial numbing• Patience and Gentleness
Prevention of complication is key:•Training•Witten Policy and procedure•Accurate record keeping•Written orders for TLA •Double check dosage calculations•Properly trained staff
Klein, Jeffrey A. (2000). Tumescent Technique , Tumescent Anesthesia & Microcannular Liposuction. St. Louis, Missouri: Mosby, Inc.
Klein, Jeffrey A. (2016). Tumescent Drug Delivery: Lidocaine and Beyond. [Power Point Slides]. Retrieved from: http://tumescent.org/TLA-AAD-2016.pdf
Klein, Jeffrey A. Collection of Articles: http://tumescent.org/tumescent-anesthesia-articles/
Klein, Jeffrey A. & Jeske, Daniel R. (2016). Estimated Maximal Safe Dosages of Tumescent Lidocaine. International Anesthesia Research Society. DOI: 10.1213/ANE.0000000000001119. www.anesthesia-analgesia.org May 2016 • Volume 122 • Number 5. Retrieved from http://tumescent.org/wp-content/uploads/Anesth-Analg-2016-Klein.pdf
Klein, Jeffrey A. (1990). Tumescent Technique for Regional Anesthesia Permits Lidocaine Doses of 35 mg/kg for Liposuction. J. Dermatol Surg Oncol 1990; 16:248-263. Retrieved from http://tumescent.org/tumescent-technique-for-regional-anesthesia-permits-lidocaine-doses-of-35-mgkg-for-liposuction/
References