Interesting Case 2 :
A RELATIVELY NEW USE OF TUMESCENT ANAESTHESIA
67 yr female patient known case of type- II Diabetes mellitus, Hypertension and Ischemic heart disease on antiplatelets (Tab Ecospirin 75mg ) stopped from 5 days posted for excision of ? liposarcoma over back of approximately 12 ×15 x 10( depth ) cm.
FNAC - inconclusive
CT chest - tumour in subcutaneous plane not communicating with muscles and ribs below
Investigations within normal range
Cardiac risk - Class II
Patient posted for tumour resection under ASA- II
Plan of anesthesia -TUMESCENT ANAESTHESIA
Preparation of solution for Tumescent Anesthesia -
Inj 2% Lignicaine 40cc
Inj Sodium Bicarbonate 10% 5cc
Inj Adrenaline 1mg ( 1:1000) diluted till 500
cc in NS ( Lignocaine 1.6 mg/cc ) for administration of drug both around the lesion and base of lesion.
Patien was given sedation of Inj midaz 1mg + and Inj Pentazocine 30mg i.v.
Around 100 ml of this solution administered around the tumour subcutaneously followed by base of tumour ( total 100+150= 250 cc.)
15 minutes after last deeper injection,
patient had no sense of pain when checked with toothed forceps by surgeon. Intraoperative :
Inj Ketodex (100mg ketamine + 50 mcg dexmeditomedine diluted till 10cc ) Adminstration for sedation ( 2+1+1 cc)
Blood less surgical field noted
Intraoperatively patient was vitality stable
ADVANTAGES OF TUMESCENT ANESTHESIA IN THIS CASE -
1) Reduction in blood loss through both epinephrine-induced vasoconstriction as well as hydrostatic compression by the tumescent effect.
2)Sodium bicarbonate reduces pain associated with the injection of an acidic local anaesthetic solution
3) Max dose of 35mg /kg can be used.
4) Extended postoperative analgesia.
5) General Anaesthesia avoided as it may worsen Ischemic heart disease due to hemodynamic changes during endotracheal intubation.
Disadvantages
1) Accident administration into blood vessels lead to ishcaemic changes and arrythmias BUT as adrenaline is very diluted rise in Blood pressure and tachycardia are brief.
This was done under the guidance of Esteemed Professor of Anaesthesia Dr Prashant Lomate and able assistance of Dr Vishali Vennam
Tumescent anaesthesia describes the practice of injecting a very dilute solution of local anaesthetic combined with epinephrine and sodium bicarbonate into tissue until it becomes firm and tense (tumescent). It was initially described in the field of liposuction but now surgical applications for the technique are widely varied ranging across vascular surgery, breast surgery, plastic surgery and ENT procedures. Advantages include a reduction in blood loss through both epinephrineinduced vasoconstriction as well as hydrostatic compression from the tumescent effect. Sodium bicarbonate reduces pain associated with the injection of an acidic local anaesthetic solution. Due to the unique pharmacokinetic profile of this technique lidocaine doses of 35 mg/kg bodyweight have been shown to be safe for liposuction procedures. Tumescent lidocaine is absorbed very slowly from subcutaneous tissues producing lower, and more delayed, peak blood levels compared to other routes, as well as extended postoperative analgesia. Slow systemic absorption allows the rapid hepatic plasma clearance of lidocaine to maintain safe local anaesthetic blood levels.
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