Risks of General Anesthesia for Liposuction Surgery
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 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 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.
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.
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.