Perioperative management of cosmetic liposuction

Recent qualms about the safety of aesthetic lipoplasty may be attributable more to support system flaws than to technical process deficiencies. The au thors here focus on perfunctory patient monitoring when sedative or analges ic drugs are given, cavalier infiltration of mega-dose lidocaine, cursory i ntraoperative patient observation by team members with conflicting responsi bilities, anesthesia providers unfamiliar with the unique surgical physiolo gy of liposuction, hurried-discharge policies that virtually ignore the res idual depressant effects of sedatives and analgesics, and compressive dress ings that impair postoperative chest-wall expansion and venous return. Wher eas pulmonary embolism remains the leading process cause of morbidity from liposuction, complications from austere resource allocation to dedicated pa tient monitoring should be largely preventable. Not all lipoplasties requir e an anesthesia provider but-when heavy sedation, megadose lidocaine, or bo th, are projected-a trained team member dedicated exclusively to patient sa fety and comfort should be a minimum patient care standard. The potential r ole of lidocaine cardiotoxicity in tumescent anesthesia is widely underappr eciated and that of hypothermia goes mostly unrecognized. These, plus large ly preventable or potentially correctable perioperative events such as pulm onary edema, fluid imbalance, or improperly administered sedative and analg esic drugs, demand upgrading and expansion of monitoring, resuscitative, an d recuperative facilities in physician offices. In fact, ASPS guidelines ur ge that anesthesia services be engaged for dedicated patient care whenever "major" liposuction or conscious sedation is projected, because liposuction is neither as benign nor as simple a procedure as heretofore reputed. To a ssess objectively the operative and anesthetic risk of obesity, document bo dy mass index for the preoperative record; morbid obesity (body mass index greater than or equal to 35.0),for instance, is a known risk multiplier for sedatives and analgesics. Other system issues such as the dynamic profile of high-dose lidocaine pharmacokinetics, the deportation of fat globules in the bloodstream, and the incidence of intraoperative hypothermia remain as unresolved topics for interdisciplinary, multi-institutional clinical rese arch.