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Back to Scientific Papers Menu TUMESCENT ANESTHESIA Print Article
 
TUMESCENT ANESTHESIA I
The concentration of Lidocaine and Epinephrine depends on the treatment area.
Total drug dosage depends on the patients weight, mg/kg ratio.
Dose: Quantity of medicine given in time, measured in mg.
Important to minimize side effects.
   

HISTORY

1920 Hypodermoclysis for fluid replacement and drug administration.
1920 The addition of epinephrine to the anesthetic solution to cause vasoconstriction and to prolong
  the local anesthetic effect.
1924 Massive infiltration analgesia with weak analgesic solutions for anesthesia.
1933 Pressurized and motorized infusion pumps.
Long flexible needles and an on/off handle to control the anesthetic flow.
   
A. V. VISCHNIEVSKY

Hydraulic preparation of the tissues.
The first and most important rule after infiltration is to wait until the anesthesia spreads.
The tumescent technique is as important as the surgery technique.
   
TUMESCENT ANESTHESIA II
Maximum dosage of tumescent lidocaine with epinephrine is a concentration between 0.05% and
  0.1%, this up to 45mg/kg.
The traditional concentration of lidocaine with epinephrine at 0.5%, 1% or 2% is of 7 mg/kg.
   

TUMESCENT ANESTHESIA IV

The medic has to write down how to perform the tumescent anesthesia.
Know the weight of the patient.
Maximum dosage in mg/kg.
The exact quantity of each drug that will be included in the tumescent solution in mg/lt o meq/lt.
   

TUMESCENT ANESTHESIA V

The team must know the dosage used in mg and the mg/kg ratio.
The solution must specify the quantity of lidocaine and epinephrine (mg/lt) and the quantity of
  meq./lt of bicarbonate.
It is easier to work in mg/lit
Lidocaine to 1% -Conservatism!!
 

TUMESCENT ANESTHESIA V

Train the person that will prepare the TA.
Eyes-on or hands on supervision.
Prepare the solution in the operating room immediately before the each surgery.
Store the empty ampoules.
No Diazepam in the 24 hours. Post-op.
   

TUMESCENT ANESTHESIA VI

We prefer the normal saline solution.

The anesthetist must be present.
Must know the TA.
Must write down everything that it is applied to the patient.
Must be careful with the dosage that is written specially if it is associated with
  another type of anesthesia.
   

TUMESCENT ANESTHESIA VII

Lidocaine and epinephrine-concentration in accord with the clinical
  requirements.
Years of experience and precise observation have helped us to evaluate the
  ideal concentration.
The “goal” is to achieve the minimum concentration for each component that allows us to operate
  without causing any pain.
   

TUMESCENT ANESTHESIA VIII

Fibroses Areas: abdomen sup., breast, posterior hip area; associated with more bleeding. Need
  more.
Microcannulas: Less pain.
If you use microcanulas, that allow for the use of less concentration of drugs and produces less
  discomfort.
   
TUMESCENT ANESTHESIA IX
If we treat a number of different areas the same day, we must use the minimum concentration in
  order not to exceed the security limits of the dosage. (mg/kg).
Epinephrine = Adrenaline
 

TUMESCENT ANESTHESIA XI
Epinephrine is an alfa and beta agonist.
Cause Increase of Cardiac Work and peripheral VC and increase of  the arterial pression.
Tumescent anesthesia is a powerful capillary vasoconstrictor producing a good hemostasia.
   

TUMESCENT ANESTHESIA XI

Antecedents of Adverse history with epinephrine.
Not the same as in odontology.
Patients that use nasal drops (with pseudoephedrine), dietary supplements with ephedrine, can
  lead to tachicardy.
Metabolic disorders, hyperthyroidism, feocromocitomas
Patients with hidden cardiac pathologies (mitral prolapse).
   

TUMESCENT ANESTHESIA XII

The TA has minimum risks if

Limit the quantities to small volumes.
If there are no problems, you can continue on the following days.
   

TUMESCENT ANESTHESIA XIII

There are variations in the concentration of the epinephrine according to the areas
Fibrosis Zones: 1mg/liter of solution.
Fat Zones:0.65mg/liter
Beta blockers and epinephrine interact producing an adverse reaction blocking the Beta receptors
  and stimulating the Alfa receptors: Hypertension crisis.
   

TUMESCENT ANESTHESIA XV

Epinephrine is injected, in 5 to 15’ will produce the blanching and VC.
There were no problems with patients that use beta blockers with TA.
Low absorption of the TA.
The method to introduce the drug and the ratio of absorption are decisive.
 

TUMESCENT ANESTHESIA XV

The systematic slow absorption of the epinephrine in the TA causes that the risks of an adverse
  reaction due to interaction of epinephrine and the beta blockers to be minimum.
Although we haven’t had a problem with a patient, we have to assume that we will have problems
  with the next one, so, be always ready and on guard.
   

TUMESCENT ANESTHESIA XVI

The Tumescent solution must be prepared before the surgery in the OR, it mustn’t be stored if
  prepared, because the lidocaine will decant and the epinephrine becomes unstable to a ph>5 and
  light.
   

TUMESCENT ANESTHESIA XVII

Never add Bicarbonate of Sodium to the Bupivacaine, PRODUCES INMEDIATE DECANTATION.
If you injected by Intradermal or Subcutaneous it can produce necrosis to the dermis.
   

TUMESCENT ANESTHESIA XVIII

Klein use triamcinolone 10 mg / lt. To reduce the incidence of the local inflammation.
Normal Saline Solution (0,9 %CLNa), According to the pharmacopoeia of the USA, it contains
  154meq./lt of sodium and chlorine. The plasma contains 142meq.Na./lt.
   

TUMESCENT ANESTHESIA XIX

The NaHCO3 10meq/lt is added to the lidocaine solution to neutralize the pH and reduce the pain
  when the lidocaine is infiltrated in subcutaneous form.
That means that 1 liter of tumescent solution contains 164meq of Na.
   

TUMESCENT ANESTHESIA XX

Ringer lactate (USP)
130meq/l  Na
109meq/l  Cl
29 meq/l  lactate
4meq/l  K
2,7meq/l  calcium
 

TUMESCENT ANESTHESIA XXI

The adult body produces 1200-1500mmol of lactate per day (50 -60 mmol/hour) the liver
  metabolizes 60% and the kidney metabolizes and excrements the other 40%.
Big quantities: alkalosis.
Predisposes to a TVP TVP.
Cardiac Arritmias.
Reduces the vagal pain.
Medications potentially causing lidocaine toxicity
Inhibitors of cytochrome p450 3a4 (cyp3a4) compete with lidocaine as substrates for this enzime.
Lidocaine toxicity.
Lidocaine is rapidly and almost exclusively eliminated by p450
If lidocaine is not metabolized the blood level will rise following tumescent infiltration.
Lidocaine toxicity.
Patients should be carefully questioned about medications being taken prior to surgery.
Commonly used drugs are cimetidine, flurazepam and thyroxine.
Cardiac medications may include amiodarone, diltiazam, metoprolol, nifepidine and verapamil.
Lidocaine toxicity
Patients may be on antibiotics or placed on preop.antibiotics
Avoid
 

Chloramphenicol

 

Clarithromycin

  Erythromicin
  Tetracycline
  Metronidazole
  Miconazole
Drugs which inhibit cytochrome p450
Amiodarone, carbamazepine(tegretol), cimetidine
Danazol, dexametasona, fluoxetine (prozac)
Flurazepam, itracaanazole, ketaconazole.
Chloramphenicol, clarithromycin, erythromycin
Metronidazole, nifedipine, pentoxifylline
Propofol, terfenadine, thyroxine
  Plasma half life
  Fluoxetine: 1-3 days    4-- 6 days
  Propofol: 1-3 days
  Nifedipine: 9 hs.
  Metronidazol: 8hs
  CYP 3A4 Inhibitors
Benzodiazepines
  Alprazolam
  Diazepam
  Flurazepam
  Midazolam
  Triazolam
Calcium Channel Blockers
  Amiodorone
  Ditiazam
  Felodipine
  Nicardipine
  Nifedipine
  Verapamil
Categories of CYP 3A4 Inhibitors Potentially affecting Lidocaine
Anti-fungal Medications
  Fluconaze
  Itraconazole
  Ketaconazole
  Miconazole
Anti-seizure Medications
  Carbamazepine
  Divalproex
  Valproic acid
CYP 3A4 Inhibitors
Macrolide Antibiotics
  Clarithromycin
  Erythromycin
Proteasa inhibitors
  Ritonavir
  Indinavir
  Saquinavir
  Nelfinavir
SSRI antidepressants
  Flouxetine
  Fluvoxamine
  Nefazodone
CYP 3A4 inhibitors
Drugs for cholesterol
  Cervivastatin
  Atorvastatin
  Lovastatin
  Simvastatin
Drug metabolized by cytochrome P450 3A4
  Alprazolam, amiodarone, amlodipine, astemizole, atorvastatin, carbamazepine, cerivastatin, cimetidine, cisapride, cyclosporine, danazol, dexamethasone, diltiazem, erythromicin, felodipine, fluoxetine, fluconazole, flurazepam, fluvoxamine, grapefruit juice, imipramina, indinavir, itraconazole, isioniazid, isradipine, ketoconazole, losartan, lovastatin, methadone, methylpredinosolone, metronidazol, miconazole, mibefradil dihydrochloride, midazolam, nefazodone, nelfinavir, nicardipine, nifedipine, norfloxacin, paroxetine, omeprazole, pentoxifylline, propafenone, propanolol, quinidine, ritonavir, sertraline, sildenafil, simvastatin, tamoxifen, terfenadine, tetracycline, theophylline, thyroxine, triazolam, troglitazon, troleandomycin, valproic acid, verapamil
   
ADVERSE EFFECTS
Fatal and near fatal pulmonary edema.
Recently been reported.
Complications of the tumescent technique.
Increased hydrostatic intracapillary pressure, altered alveolar capillary membrane permeability, and
  a decrease in plasma oncotic pressure.
   

ADVERSE EFFECTS II

Lidocaine is an amida-type of local anesthesia.
Blocks nerve conduction.
By altering membrane permeability to sodium.
Depresses diastolic depolarization
And ventricular automaticity by direct suppression of myocardial cellular function.
 

ADVERSE EFFECTS III

Two active metabolites contribute to lidocaine’s therapeutic and toxic effects.
Monoethylglycinexylide   megx
Glycinexylidide   gx
Decreased cardiac output
Lidocaine half life
Volume of distribution
Increase plasma levels
Liver disease
Lidocaine half life
Protein binding

Increase plasma levels

Kidney disease
Significant only if severe impairment
Obesity
Lidocaine half life
Volume of distribution
Advanced age & sex
Men: ↑ half life in elderly
Women: half life & volume of distribution independent of age
Oral contraceptives
Free unbound lidocaine by ↓ a1-acid glycoprotein (aag)
Beta blockers

Cardiac output and hepatic blood flow

Lidocaine clearance.
Plasma lidocaine levels by 20% to 30%
Tricyclic antidepressants

Epinephrine activity

Anorexiants
Epinephrine-like activity
Hypokalemia
Cardiac output
Cardiac arrhythmia potential
Hypophosphatemia
O2 carrying capacity of red blood cells
Cardiac output
Pulmonary ventilation
Hypoalbuminemia
Unbound (active) lidocaine
Fluid shift to extra vascular tissue
Excess fluid volume or rate of administration
Dilution of intravascular contents
(E.g. hypoalbuminemia, hypoosmolality, hypokalemia, etc.)
Propocol
Cardiac output
Cimetidine
Lidocaine half life
Protein binding
Lidocaine clearance 30%
   

PRACTICAL CONSIDERATIONS I

Volume is limited to 3000ml TO 5000ml.
Lidocaine not exceeding 35 mg/kg of body W
Patient without any potential as morbid conditions or risk factors.
Patients with one or two morbid conditions or risk factors be considered for a less volume.
Administer the tumescent formula in increments (500ml) separated by procedure site or area to be
  suctioned.
   

PRACTICAL CONSIDERATIONS II

Begin procedure within 15-20 minutes after completion of injection.
Patient with a history of taking certain categories of medications should be cleared by appropriate
  medical specialists. Diet drugs, cardiovascular, endocrine, antipsychotic, antidepress.
Patients with eating disorders or extreme alterations in diet or nutritional habits should also be
  cleared by a specialist.

 

TO MINIMIZE THE RISK OF TUMESCENT MEDICATION ERRORS

Use safety labels to identify the patient, the bag number and to unambiguously identify its content.
Do not prepare tumescent anesthesia solution without a written detailed medication order signed
  by surgeon.
Dosages of lidocaine and epinephrine should be specified in terms of milligrams.
Write patient’s name on safety label & apply label to bag.
Immediately after adding a drug into bag, circle the milligram dose printed on label.
 

MINIMIZE RISK II

Avoid medication errors by mixing only one bag at a time. Then set the filled bag aside before
  mixing the next bag.
Do not permit distractions or conversation while mixing bags.
If there is any doubt about a bag’s content, discard the bag, and mix a new bag
Save the empty drug bottles, vials, and containers until the case is completed, so that if there is
  any question about the dosage, one can check to be certain that the number of empty drug
  containers corresponds to the correct amount of drug in the bags.
   

MINIMIZE RISK III

Record the exact amounts of administered lidocaine, and volumes of parenteral fluids.

Ex.  Safety labels. bag#
  For subcutaneous tumescent infiltration only
  Lidocaine  250mg      500mg      750mg     1000mg …………mg
  Epinephrine  0,5mg       0,65mg      1mg       1,5mg   ……….mg
  Na Bicarb 10 meq.  In 1000 ml  0,9%NaCl
  Patient’s name:    Date:
   

BUPIVACAINE

Longer action than Lidocaine
With epinephrine 27%  more
Decrease of myocardium function
Decrease of the contraction
Decrease of the cardiac frequency
Coronary VC
Inhibition of alfa 2 adrenergic receptors
Keeps a high pressure with a myocardium depressed action
   

BUPIVACAINE

Don’t use in tumescent anesthesia, is dangerous
It produces fatal arrhythmias, 6 times more toxic than Lidocaine
 

PRILOCAINA

Acts faster than Lido
Fast hepatic metabolism and also in kidneys
Safe drug in healthy patients
No studies on large amount of drug
No FDA approval
   

ARTICAINE

Is the most widely used local anesthetic agent in dentistry.
Amide structure is similar to that of other local anesthetics.
Contains and additional ester group
Which is quickly hydrolyzed by esterases
The time to maximum drug concentrations
Occurs about 10 to 15 minutes
After submucosal injection of articaine 4%80mg
The mean maximum plasma drug concentration
  400 mug/l articaine w/epinephrine 1:200000
  580 mug/l articaine wout/epi
   

ARTICAINE

The elimination half time is about 20.
The rapid breakdown of the articaine to the inactive metabolite articainic acid.
Is related to a very low systemic toxicity.
Consequently to the possibility of repeated injections
Equal analgesic efficacy along with lower systemic toxicity
Permits the use of articaine in higher concentrations that other amide type local anesthetics.
Complete anesthesia.
Can be observed in nearly 90% of all cases.
Using articaine 4% 60-80 mg with epi 1:200000
Is better able to diffuse through soft tissue and bone that other local anesthesia.
The plasma protein binding rate of articaine and articainic acid is 70%
It has been concluded that an unintentional intravascular injection of articaine 80 mg does.
Not cause toxic effects in healthy individuals.
 

ARTICAINE

Carticaine
Septocaine
Dosing
Infiltration dental anesthesia in adults
  0,5 to 2,5 ml of 4% w/epi
  up 3.4 ml. Is given for nerve block
Oral surgery
  1 to 5,1 ml is given
Epidural anesthesia
  30 ml 2% wout/epi
Intravenous regional anesthesia (upper limb surgery)
40 ml of 0,5% administered over 0,5 to 2 minutes
Peak plasma levels occur approximately 15 minutes after dental infiltration
Is metabolized predominantly via plasma and tissue esterases to an inactive metabolite.
Some hepatic metabolism may occur
Should be stored at 25C (77F)
Protect from light and freezing
Rapidly hydrolyzed by blood and tissue esterases (up to 90% combined) to articainic acid.
Liver 5 to 10%.
Cytochrome P450 isoenzyme system 5 to 10%
  Metabolites
Articainic acid
  Plasma
  Inactive
Articainic acid glucuronide
  Urine
  Inactive
  Contraindications
Prior hypersensitivity to amide local anesthetics
Prior hypersensitivity to sodium metabisulfite
Infection at site of injection
Shock (potential for exacerbation)
  Is an intermediate-duration
  Amide-type local anesthetic agent
  Its amide structure is similar to that of lidocaine, etidocaine and prilocaine
  But differs by the presence of a thiophene instead of a benzene ring
  Also possesses an additional ester group which is rapidly hydrolyzed by blood/tissue esterases.
  The tiophene nucleus imparts good lipid solubility.
  Greater than lidocaine.
  Less toxic than lidocaine.
Rapid hydrolysis
  Adverse reactions
Blood
  Hematologic effects
Methemoglobinemia
  Reported in some patients undergoing IVRA
  No reported during dental anesthesia
  Iv mehylene blue (1 to 2 mg/kg)
Cardiovascular
  Hypotension
  Arrhytmias ( epinephrine)
  Adverse reactions
Central nervous system
  Dizzines
  Agitation
  Nervousness
  Anxiety
  Headache disorientation
  Tremors
  Seizures
Inadvertent intravascular injection appears to account for many cases of CNS reactions.
Paresthesia
  Loss of sensation
  Burning
  Tingling
High dental concentration
  Gastrointestinal effects
Nausea and vomiting
  Occurred occasionally
  Ocular
Ophthalmic effects
  Diplopia (intraoral)
  Mydriasis
Few minutes of anesthesic block and persisted for an average of 50 minutes
  Skin
Dermatologic effects
  Erythematous nonpruritic skin rashes IVRA
  Adverse effects
Hypersensitivity
  Urticaria
  Edema
  Pruritus
  Erythema
  Teratogenicity
US food and Drug Adm pregnancy category C (Prod Septocaine)
  Tumescent local anesthesia
0.038% articaine
1:1.000.000 epinephrine
0.00095%  trimacinolona
0.08% NaHCO3
  850 patients
 

 

 
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