Dr. Hernandez-Perez, professor of medicine, School of Medicine, National University of San Salvador, outlined his position at the American Academy of Cosmetic Surgery annual meeting here.
"Why not use IV sedation in liposuction surgery? I use it in all my cases of liposuction — always," Dr. Hernandez-Perez says, "We have never seen any adverse events with IV sedation because we are always working with a certified anesthesiologist who is experienced in liposuction," he adds.Outcome-driven decisions "In my practice, I use conscious sedation through an IV catheter. In this way, IV sedation is practically synonymous with conscious sedation, and during surgery all my patients are able to obey verbal orders. This is the real advantage," Dr. Hernandez-Perez says, who is also chairman of the Meso-American Academy of Cosmetic Surgery.
He says he most often uses the combination of midazolam at 0.3 mg/kg and fentanyl at 5 mcg/kg to10 mcg/kg for procedures lasting three hours or longer. Occasionally propofol at 0.2 mcg/kg to 0.3 mg/kg is also incorporated.
Northwestern University researchers using a similar conscious sedation regimen of IV midazolam and fentanyl, as well as a local anesthetic, also reported high patient satisfaction. There were no intraoperative complications and no major postoperative complications among 266 abdominoplasties performed over six years.
"I prefer my patients not to remember any disturbing moment during surgery and recall the procedure as completely comfortable and painless," he says, adding, "that no longer than one hour after surgery, the patient is able to leave the surgical facility."
Standards on the fence The American Academy of Dermatology Guidelines of Care for Liposuction also caution that "IV anxiolytics, sedatives, or narcotics analgesics can increase the risk of morbidity and mortality if not used in a proper setting with appropriately trained and credentialed personnel."
The guidelines also recognize an ongoing debate over whether to use IV sedation or general anesthetic in conjunction with tumescent liposuction. Tumescent solutions, including lidocaine and epinephrine, may result in less postoperative pain and decreased blood loss. However, there is also a "potential for fluid overload with the administration of IV fluids and use of a tumescent solution."
Significant morbidity and deaths have been reported with liposuction performed under general anesthesia, conscious sedation and with IV anesthetics. However, data from a small study cohort under general anesthesia showed no evidence of system toxicity.
"I deeply respect the position of cosmetic surgeons who avoid IV sedation during liposuction, but I prefer to work with happy and safe patients," Dr. Hernandez-Perez says. "On the other hand, I am taking advantage to condemn surgeries performed in operating rooms not prepared for that, lacking for instance, IV lines or conditions to take out a patient suffering from a complication. Fatalities have occurred when the surgery was performed in a hotel or in a garage at the home of the patient."
A Columbia University study group also notes that tumescent liposuction supplemented with monitored IV conscious sedation "provides a middle ground between general anesthesia and purely tumescent liposuction."
Safe location Tumescent liposuction performed in office with local anesthetics has been shown to be safer than those conducted in a hospital. However, causes other than IV sedation, such as combined procedures and possible cross contamination are influencing those outcomes, according to Dr. Hernandez-Perez.
Wake Forest University researchers surveyed 505 surgeons about the number of liposuction surgeries, location for the procedure, use of conscious sedation, the number of non-fatal serious adverse events requiring hospitalization, as well as how many fatal complications, over a six year period. The results showed higher serious adverse events among patients undergoing tumescent liposuction in hospitals, but mostly because the procedures were more complicated with multiple procedures or large volume liposuction and patients were given combined forms of anesthesia typically reserved for hospital use.