Regarding "Tumescent technique without epinephrine for endovenous laser therapy and serum lidocaine concentration".

Abstract

I read with interest the paper by Hudson et al1Hudson A.J. Whittaker D.R. Szpisjak D.F. Lenart M.J. Bailey M.M. Tumescent technique without epinephrine for endovenous laser therapy and serum lidocaine concentration.J Vasc Surg Venous Lymphat Disord. 2015; 3: 48-53Abstract Full Text Full Text PDF Scopus (8) Google Scholar on the serum lidocaine concentrations after tumescent anesthesia injection during endovenous laser ablation and congratulate them on the work. Tumescent anesthesia has been used for decades, especially in dermatosurgery and phlebology, and collection of data about peak lidocaine serum concentrations at different infiltration sites and with different compositions of tumescent solution is very welcome. Several statements in the text deserve comment. The term tumescent liposuction was not introduced in the 1980s by “the plastic surgery community”; it was introduced by Dr J. Klein, a dermatologist, and for years the approach had even faced a sort of reluctance to use it among plastic surgeons. Thus, it was the dermatologic community putting forward and widely using tumescent anesthesia, first for liposuction, then in many other settings. The authors further commented on the (un)safety of tumescent anesthesia and cited the paper by Rao et al,2Rao R.B. Ely S.F. Hoffman R.S. Deaths related to liposuction.N Engl J Med. 1999; 340: 1471-1475Crossref PubMed Scopus (274) Google Scholar who reported five deaths related to tumescent liposuction and cardiotoxicity during a 3-year period. However, readers may be misled, as all these liposuctions, performed by plastic and general surgeons with anesthesiologists present, were actually not tumescent liposuctions as patients had been operated on in general anesthesia, intravenous analgesia, or conscious sedation. They had been intravenously administered several drugs in various combinations (midazolam, meperidine, fentanyl, propofol, morphine) along with large volumes of intravenous fluids. These drugs, with their known toxicity profiles along with probably unnecessary overhydration (patients were infused 1.7 to 7 L of fluid in addition to tumescent solution!), clearly make it impossible to establish a causative link to “megadose” of lidocaine from tumescence. At the same time, there has not been published a single fatal case during office-based, exclusively tumescent liposuction as usually performed by dermatologists.3Habbema L. Safety of liposuction using exclusively tumescent local anesthesia in 3,240 consecutive cases.Dermatol Surg. 2009; 35: 1728-1735Crossref PubMed Scopus (64) Google Scholar When the term tumescent anesthesia is used, it should mean that it is the only type of anesthesia applied; otherwise, it should always be specified that it is only an adjunct method of anesthesia. Tumescent technique without epinephrine for endovenous laser therapy and serum lidocaine concentrationJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 3Issue 1PreviewEndovenous laser therapy (EVLT) requires tumescent lidocaine anesthesia. Although it is well known that the absorption of local anesthetic varies according to the injection site, little evidence exists establishing the maximum recommended safe dose for extravascular injections such as those used for EVLT. The aim of this study was to evaluate plasma concentration of lidocaine over time after administration of tumescent lidocaine during EVLT procedures in healthy volunteers. Full-Text PDF ReplyJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 3Issue 3PreviewWe thank Dr Pavlovic for his astute comments and the opportunity to elaborate on a number of points from our work. Tumescent liposuction was indeed introduced by Dr Jeffrey Klein, who is a dermatologist and is cited in our discussion. Our reference to the “plastic surgery community” was used to describe the surgical procedures performed rather than the specific surgical specialty or professional board to which the various practitioners belong. Today, practitioners from a variety of medical and surgical specialties apply this technique originally developed by Dr Klein. Full-Text PDF