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Lidocaine Toxicity

Case Study
INTERNATIONAL JOURNAL OF COSMETIC SURGERY AND AESTHETIC DERMATOLOGY
Volume 3, Number 1, 2000

In reference to Gorney's (1) remarks in "Liability issues in aesthetic surgery," in which he said "lidocaine toxicity ... is probably the second or third most common cause of fatal outcome in lipoplasty ... such deaths occurred in the surgical suites of nonsurgeons)," there were no literature references supporting this assertion. There are no published cases of lidocaine toxicity deaths with conventional liposuction standards to date. The Grazer and de Jong (2) study of more than 100 liposuction deaths had no death due to lidocaine toxicity.

The conventional lidocaine administration standard is 0.1 mg% or lower lidocaine concentration, with 1:1,000,000 epinephrine delivered to the fat in dosages less than 60 mg/kg. Liposuction should be performed within 3-4 hours and roughly the same total volume or somewhat more total volume should be removed as was infused. This is the recommendation for a healthy patient who is not taking drugs known to cause toxicity when combined with lidocaine or epinephrine(3,4). Dermatologists use as much as 2:1 tumescent solution to aspirate. More dilute epinephrine has been associated with death (5), although the causal relationship is unknown. Rao (6) reported that three of four deaths were associated with epinephrine concentrations 1:2,000,000.

There is too much politics-based science. For example, dermatologists say, without supporting evidence, that general anesthesia is extremely dangerous when combined with liposuction. Some have also been bashing monitored anesthesia care (MAC). Anesthesia techniques are among the greatest advances in modern medicine and experienced surgeons understand just how elegant anesthesia has become. Physicians who have operated only with local anesthesia and cannot conceive of using an anesthesiologist to administer intravenous sedation or general anesthesia have a vested political interest in discrediting physicians who use all the modern tools.

Discrediting the use of local anesthesia is obviously the political agenda of certain other groups. The net effect of this smug, self-serving warfare is to alienate an already paranoid public against plastic and cosmetic surgery. The layperson views all this internecine warfare as nonsense. We are doing to ourselves what the silicone controversy recently did to us. Physicians should use the best anesthesia, local or systemic, to produce the most consistent results and safety in the particular physician's hands, and keep an open mind as to which specialist perfected it.

Lidocaine is an exceedingly safe drug but the dose limits in tumescent liposuction that cause toxicity are still unknown. Two separate unpublished studies using thousands of patients (7,8) have found that doses of 80 mg/kg were safe. And while sedation-related deaths are reported fairly frequently, with respect and care these advanced tools can be used safely. Negligence is with us and always will be. Even the most experienced, well-trained, and careful surgeons make mistakes or have mishaps. Beginning surgeons tend to make more mistakes. The deaths we have seen have been due to surgeon error for the most part. Attacking the current conservative lidocaine administration standards is without merit.

References

  1. Gorney, M.: Liability issues in aesthetic surgery. Aesthet Surg J 2000; 20(3):226-227.
  2. Grazer, F.M., and de Jong, R.H.,: Fatal outcomes from liposuction: Census survey of cosmetic surgeons. Plast Reconstr Surg 2000;105(1):436-446.
  3. Shiffman, M.A.: Medications potentially causing lidocaine toxicity. Am J Cosmet Surg 1998;15:3-5.
  4. Foster, C.A., and Aston, S.J.: Propanolol-epinephrine interactions: A potential disaster. Plast Reconstr Surg 1983;72:74-78.
  5. Chavez, P., personal communications, 1998.
  6. Rao, R.B., Ely, S.F. and Hoffman, R.S.: Deaths related to liposuction. N. Engl J Med 1999;340(19):1471-1475.
  7. Lillis, P., personal communications, 1998.
  8. Hildreth, B. Large Volume Liposuction. Presented at the World Congress of Liposuction, Pasadena, CA, October 9-11, 1998

Editor's Note:
I agree with Dr.Yoho that the specialty turf wars over liposuction only lead to misinformation to the lay public and do absolutely nothing to alleviate their fears. I am in agreement that each specialist performing the procedure should use the type of anesthesia they feel is the safest. It was disturbing to me when a plastic surgeon commented recently in a well-known consumer magazine that the five deaths reported recently in the New England Journal of Medicine were related to the misuse of the tumescent technique.

Let us first understand the difference between the tumescent technique and the tumescent solution. The tumescent technique involves using the tumescent solution (lidocaine 0.05%, epinephrine 1:1,000,000) anywhere from 1:1 up to 2:1 tumescent solution to aspirate, with less than 55 mg/kg of lidocaine injected. Most important, the procedure as described by Dr. Jeffrey Klein is performed strictly under local anesthesia, without general anesthesia or I.V. sedation. Therefore, when tumescent solution is injected in conjunction with I.V. or general anesthesia, the procedure no longer qualifies as the tumescent technique. This is extremely important, because when there is a mortality under general anesthesia during a liposuction surgery and the patient has received tumescent solution, one cannot put the blame on the tumescent technique.

The five liposuction surgeries mentioned were performed under general anesthesia. If you look closely at all five cases, only one patient had a slightly elevated level of lidocaine, and that was probably due to lidocaine given during the resuscitative process. All five patients had at least one other procedure performed at the same time as the liposuction. There were numerous possibilities for the causes of death, but clearly not the tumescent technique or even the tumescent solution. Even though there was not clear-cut cause and effect for the lidocaine, somehow the tumescent technique was faulted.

The plastic surgeon stated that you must therefore only go to a board-certified plastic surgeon because you may die from liposuction. What is quite disturbing is that four out of five patient deaths were performed by plastic surgeons. This type of misleading information to the public is alarming and perpetuates the liposuction turf wars.

Let us report the truth, even though it might not be in the reporting physician's best interest. I would also like to comment on the use of local anesthesia versus general anesthesia. I do agree with Dr.Yoho when he states that there is no supporting evidence that general anesthesia is extremely dangerous when combined with liposuction. I do feel that there is definitely a higher inherent risk for liposuction under general anesthesia as opposed to liposuction performed strictly under the tumescent technique. Depending on what study you quote, general anesthesia carries a 1:10,000-1:20,000 mortality rate. I do agree that these mortality figures might include surgery of a sicker patient population than the typical liposuction patient. In addition, the patient undergoing liposuction under general anesthesia is likely to have other procedures performed at the same time, which will increase operating time and possible morbidity and mortality.

I try to be objective when evaluating data, but because I am a cosmetic dermatologic surgeon, my opinion might be skewed toward the pure tumescent technique of performing liposuction. Let us all try to be more impartial to each other and — most of all — to our patients.

Howard D. Sobel, M.D. Co-Editor-in-Chief