INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE TUMESCENT ANESTHESIA 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.
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
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
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.
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE 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
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).
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE 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
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’ wil 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.
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE 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 wil have problems with the next one,
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
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE 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 is rapidly and almost exclusively eliminated by p450 If lidocaine is not metabolized the blood level will rise following tumescent infiltration.
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
Patients may be on antibiotics or placed on preop.antibiotics Avoid
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
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE
– Nifedipine: 9 hs. – Metronidazol: 8hs
– Alprazolam – Diazepam – Flurazepam – Midazolam – Triazolam
– Amiodorone – Ditiazam – Felodipine – Nicardipine – Nifedipine – Verapamil
Categories of CYP 3A4 Inhibitors Potentially affecting Lidocaine
– Fluconaze – Itraconazole – Ketaconazole – Miconazole
– Carbamazepine – Divalproex – Valproic acid
– Ritonavir – Indinavir – Saquinavir – Nelfinavir
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE
– Flouxetine – Fluvoxamine – Nefazodone
– 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
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
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE
↑ Lidocaine half life ↓ Volume of distribution
↑ Lidocaine half life ↓ Protein binding
↑ Lidocaine half life ↓ Volume of distribution
Women: half life & volume of distribution independent of age
↑ Free unbound lidocaine by ↓ a1-acid glycoprotein (aag)
↓cardiac output and hepatic blood flow, ↓ Lidocaine clearance. ↑plasma lidocaine levels by 20% to 30%
↓ Cardiac output ↑ Cardiac arrhythmia potential
↓ O2 carrying capacity of red blood cells ↓ Cardiac output ↓ Pulmonary ventilation
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE
↑ Unbound (active) lidocaine ↑ Fluid shift to extra vascular tissue
Excess fluid volume or rate of administration
(E.g. hypoalbuminemia, hypoosmolality, hypokalemia,etc)
↑ 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, antidepressant.
Patients with eating disorders or extreme alterations in diet or nutritional habits should also be cleared by a
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
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE 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
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
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE
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
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
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
– 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
Carticaine Septocaine Dosing
– Infiltration dental anesthesia in adults
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE
– 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%
– 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
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE
Reported in some patients undergoing IVRA No reported during dental anesthesia
Hypotension Arrhytmias ( epinephrine) Adverse reactions
Dizzines Agitation Nervousness Anxiety Headache disorientation Tremors Seizures
– Inadvertent intravascular injection appears to account for many cases of CNS reactions. – Paresthesia
– Few minutes of anesthesic block and persisted for an average of 50 minutes
INTERNATIONAL CONSULTANTS IN AESTHETIC MEDICINE
Erythematous nonpruritic skin rashes IVRA Adverse effects
Pruritus Erythema Teratogenicity
– US food and Drug Adm pregnancy category C (Prod Septocaine)
– 0.038% articaine – 1:1.000.000 epinephrine – 0.00095% trimacinolona – 0.08% NaHCO3
Prof. Dr. Alexander Proelß WS 2013/2014 TEIL 2: VÖLKERRECHT UND AUßENVERFASSUNGSRECHT Rechtsquellen des Völkerrechts (Überblick) 1. Rechtsnatur des Völkerrecht • Die Rechtsnatur des Völkerrechts wird teilweise in Frage gestellt, weil der Gehorsam der Rechtsunterworfenen nicht durch eine obligatorische physische Sanktion erzwungen werden kann (enger Rechtsbegriff). •
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