Risks of General Anesthesia
Systemic Anesthesia and Liposuction Deaths
Liposuction surgery can be accomplished safely by general anesthesia or by
local anesthesia. However, general anesthesia is more dangerous. Virtually
all liposuction deaths that have ever been reported have been associated
with systemic anesthesia. In most cases the systemic anesthesia was not
directly involved, but it permitted the surgeon to do an excessive amount
of liposuction, or to do multiple unrelated surgical procedures on the same
day. This includes all five of the deaths recorded by the New York Medical
Examiner from 1993 to 1998 and reported in the New England Journal of Medicine.
(Rao RB, et al. Deaths related to liposuction. N. Eng. J. Med. 340:1471-1475,1999).
Local Anesthesia
Local Anesthesia is defined as the infiltration of local anesthesia directly into the tissues targeted for surgery, with or without outpatient oral medication for analgesia, sedation, or to reduce anxiety. This definition of local anesthesia does allow for the use of medications which are approved for patient self-administration at home.
Systemic Anesthesia
Systemic Anesthesia is defined as any anesthetic technique, with or without local anesthesia, that has a significant risk and potential for impairing the protective airway reflexes or for suppression of the respiratory drive. Thus, systemic anesthesia includes general anesthesia by inhalation of a volatile gas, total intravenous (IV) general anesthesia, and local anesthesia plus IV analgesia-sedation also known as monitored anesthesia care (MAC). The greatest risks of systemic anesthesia are the dose-dependent impairment of protective airway reflexes and respiratory depression.
Modified Tumescent Technique
Liposuction by the combination of tumescent infiltration and systemic anesthesia
is commonly known by any of the following names: Superwet Technique or Modified
Tumescent Technique for liposuction. These names refer to the same liposuction
technique which consists of the following: 1) a relatively small volume of
tumescent infiltration, 2) some form of systemic anesthesia, and 3) significant
volume of IV fluid supplementation. Tumescent liposuction totally by local
anesthesia does not use systemic anesthesia nor infusions of large volumes
of IV fluids.
Murphy's Law and Systemic Anesthesia
Systemic anesthesia is quite safe when delivered by a board certified anesthesiologist.
But according to Murphy's Law, nothing is perfect. Murphy's Law states that, "If
something can go wrong, it will." When Murphy's Law is applied to the use of
systemic anesthesia, it can be stated as, "If something can go wrong with systemic
anesthesia, it will; and when it does go wrong, the consequences can be catastrophic." The
greatest danger of systemic anesthesia is not any intrinsic pharmacologic property
of systemic anesthesia, but rather human error and poor clinical judgment by
those who use it.
To Error Is Human
Several studies have found that approximately 80% of serious complications
associated with anesthesia are the result of human error. Lack of attention,
haste, fatigue, stress, information overload, worries about pressure to cut
costs, and failure to communicate can all lead to inattention and failure to
recognize problems. Types of human error that lead to anesthesia related catastrophes
include improper interpretation of monitoring device data, failure to check
equipment properly, inadequate experience with equipment, incorrect drug dose,
and wrong drug given. An undetected accidental disconnection from a ventilator
can be fatal in patients unable to breathe without assistance.
Anesthesia Monitoring
There are anesthesiologists who assert that modern anesthesia is extremely
safe, and that this safety is largely attributable to widespread use of modern
anesthesia monitoring equipment. No amount of monitoring can overcome poor
clinical judgment or human error or carelessness.
Systemic Anesthesia
The greatest danger of systemic anesthesia is its tendency to release the surgeon
from common sense restraints and to permit too much liposuction. In other
words, it is not the systemic anesthesia, but the consequences of using
systemic anesthesia that is dangerous. Marathon surgery of up to 8 or more
hours duration, involving multiple diverse cosmetic procedures, or mega-volume
liposuction of more than four or five liters of fat or liposuction of too
many areas of the body are examples of doing surgery far beyond the bounds
of commonsense-safety. Succumbing to the urge to do too much cosmetic surgery
on one occasion is the greatest risk of systemic anesthesia.
Excessive Surgery Alert
With liposuction under local anesthesia, the patient can inform the surgeon
when there are symptoms of excessive surgery such as lightheadedness, dizziness,
difficulty breathing, or unusual pain. With liposuction under systemic anesthesia,
an unconscious patient cannot give an alert when the degree of surgical trauma
exceeds the safe limits. Prolonged and excessive surgery significantly increases
the risk of blood clots in the lung, fluid overload, excessive bleeding,
and serious infections. The true danger of systemic anesthesia is that surgeons
find it more difficult to detect when a patient has had too much surgery.
How Much Surgery Is Safe?
If a patient requests several different cosmetic surgical procedures, the
surgeon must choose between two situations: 1) divide multiple surgeries
into separate days (safer but more expensive because of the extra time required),
or 2) do multiple cosmetic surgeries on the same day (more dangerous because
of prolonged exposure to anesthesia and excessive surgery, but less expensive).
These two alternatives must be carefully evaluated. Using general anesthesia
complicates the analysis. Multiple exposures to systemic anesthesia increase
the risks of anesthetic procedures and anesthetic toxicity. On the other
hand, exposing the body to excessive surgical trauma increases the risks of
infection, increases the need for dangerous postoperative narcotics, and
prolonged bed rest increases the risk of pulmonary embolism. When financial
considerations or personal convenience are allowed to outweigh safety concerns,
the final choice is often in favor of marathon surgery.
Delayed Diagnosis of Injury
There are some unique hazards associated with the combination of systemic
anesthesia plus liposuction that are not as well known. The greatest danger
associated with a penetration of the abdominal cavity with a liposuction
cannula is the consequence of a delayed diagnosis. Under general anesthesia,
it is more likely that the surgeon will be unaware an intestinal wound and
even dismiss complaints of abdominal pain until there are signs of serious
infection. Under local anesthesia, such an injury would cause immediate pain
and prompt immediate hospitalization and a consultation by a general surgeon
without delay. Similarly, general anesthesia will contribute to a delay in
the diagnosis of a punctured lung, or fluid overload because of too much
IV fluids.
Some liposuction surgeons tell their patients that they can expect liposuction
by local anesthesia when in fact the anticipated anesthetic technique will
rely upon significant doses of IV sedation-analgesia. General anesthesia
and IV sedation-analgesia are similar in terms of both risks and requirements
for monitoring patients. Liposuction under systemic anesthesia should only
be done in an accredited or state licensed surgical facility.
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