When one liter does not equal 1000 milliliters: implications for the tumescent technique.

BACKGROUND: Tumescent anesthesia has revolutionized the practice of liposuction. Inherent to the tumescent technique is the use of large volumes of dilute solutions of lidocaine with epinephrine instilled into subcutaneous fat deposits. Precise formulation of the tumescent anesthesia is essential to liposuction technique. OBJECTIVES: To determine the actual volumes of fluids contained in intravenous (IV) 1 L bags of saline used for tumescent anesthesia, to calculate volumes supplied in 50 cc stock solutions of 1% lidocaine, and to measure the amount of fluid retained by peristalic pump tubing used for infiltration. METHODS: The amount of saline contained in fifteen 1 L saline bags from three different manufacturers was calculated using graduated cylinder methodology. The volume of tumescent anesthesia retained by peristaltic pump tubing was calculated by expelling the contents of the filler tubing and measuring it. The actual amount of 1% lidocaine contained within fifteen 50 ml "stock" 1% lidocaine bottles from different manufacturers and with different lot numbers was calculated by transferring the contents into graduated cylinders. RESULTS: One liter IV bags of physiologic saline contained an average volume of 1051 ml (range 1033-1069 ml). The 50 ml bottles of 1% lidocaine with epinephrine contain an average of 54 ml of anesthetic (range 52.5-55 ml). Infusion tubing for use with peristaltic pumps may retain 46-146 ml of tumescent anesthesia. CONCLUSION: One liter IV bags of normal saline contain more than 1 L, having an average volume of 1051 ml. Common methods of preparation of 0.05% lidocaine with 1:1,000,000 epinephrine and sodium bicarbonate can increase the total amount of fluid in the tumescent anesthesia to 1112 ml for 0.05% solutions and preparation of a 0.1% solution contains an average volume of 1162 ml. The fluid contained in each bag may be increased over labeling by as much as 11-16%. Final concentrations of lidocaine in tumescent anesthesia may be reduced due to extra fluids. A 0.05% lidocaine solution may have a final lidocaine concentration of 0.045% and a 0.1% lidocaine solution may have an actual concentration of 0.086%. Lidocaine concentrations may be reduced by as much as 10-14%. Extra anesthesia fluid is also contained within stock 50 ml bottles of 1% lidocaine. Dermatologic surgeons should be aware of extra fluid possibly contained within tumescent anesthetic preparation, be aware of the extra anesthesia supplied in standard 1% lidocaine bottles, and possible decreased concentration of lidocaine within the final tumescent anesthesia.

Elder care and the dermatologic surgeon.

BACKGROUND: The elderly are an increasing percentage of the population and dermatologic surgeons will be caring for more senior citizens. OBJECTIVE: Understanding issues in geriatric care will help both surgeons and patients have productive and rewarding encounters. METHODS: Approaches to the care of elders are detailed in this article. Surgical tips for the senior patient are prescribed. RESULTS: Older patients need more time and may need special assistance. Multiplicity of disease increases with age. A third-party interview can be helpful in gathering information. The elderly have sensory loss and benefit from extra attention, follow-up telephone calls, and therapeutic touch. Written handouts and instructions printed in large type are excellent. Dermatologic care should be kept as simple as possible with surgical closures designed to require minimal attention. Be cognizant of the social services available for the elderly and watch for dermatologic signs of internal disease. A skin care program for the elderly is helpful and cosmetic procedures are of interest to seniors. CONCLUSIONS: Dermatologic surgeons can provide excellent care to elders. An understanding of gerontologic issues and surgical tips can help the dermatologic surgeon care for the older patient.

Intraoperative autologous transfusion during elective infrarenal aortic reconstruction: a decision analysis model.

PURPOSE: The use of intraoperative autologous transfusion devices expanded during the last decade as a result of the increased awareness of transfusion-associated complications. This study was designed to determine whether routine use of an intraoperative autologous transfusion device (Haemonetics Cell Saver [CS]) during elective infrarenal aortic reconstructions is cost-effective ($50,000/QALYs threshold). METHODS: A decision analysis tree was constructed to model all of the complications that are associated with red blood cell replacement during aortic reconstructions for both abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease (AIOD). It was assumed that a unit of CS return (CSR; 250 ml/unit) equaled a unit of packed red blood cells (PRBCs) and that all CS transfusions were necessary. Transfusion requirements (AAA:PRBC = 2.8 +/- 3.2 units, CSB = 3.7 +/- 3.2 units; AIOD:PRBC = 3.1 +/- 3.0 units, CSR = 2.1 +/- 1.7 units) were determined from retrospective review of all elective aortic reconstructions (AAA, N = 63; AIOD, N = 75) from Jan. 1991 to June 1995 in which the CS was used (82.1% of all reconstructions). Risk of allogenic transfusion-related complications (transfusion reaction, hepatitis B, hepatitis C, human immunodeficiency virus, human T-cell lymphotropic virus types I and II) and their associated treatment costs (expressed in dollars and quality-adjusted life years (QALYs) were obtained from the medical literature, institutional audit, and a consensus of physicians. RESULTS: Routine use of the CS during elective infrarenal aortic reconstructions was not cost-effective in our practice. Use during reconstructions for AAA repairs cost $263.75 but added only 0.00218 QALYs, for a rate of $120,794/QALY. Use during reconstructions for AIOD was even more costly at $356.68 and provided even less benefit at 0.00062 QALYs, for a rate of $578,275/QALY. The sensitivity analyses determined that the routine use of the CS would be cost-effective in our practice only for AAA repairs if the incidence of hepatitis C were tenfold greater than the baseline assumption. The model determined that CS was cost-effective if the CSR exceed 5 units during reconstructions for AAA and 6 units during reconstructions for AIOD. CONCLUSIONS: The routine use of the CS during elective infrarenal aortic reconstructions is not cost-effective. The use of the device should be reserved for a select group of aortic reconstructions, including those in which cost-effective salvage volumes are anticipated. Alternatively, the CS should be used as a reservoir and activated as a salvage device if significant bleeding is encountered.

Intraoperative autologous transfusion during elective infrarenal aortic reconstruction.

Intraoperative autologous transfusion devices have been purported to reduce allogenic transfusions and their associated complications. However, the value of their routine use during elective cardiovascular operations remains undefined. This study was designed to examine the efficacy of the Haemonetics Cell Saver (CS) during elective aortic reconstructions and identify predictors of clinically significant (> or = 500 cc) and cost-efficient (> or = 1250 cc) salvage volumes. The medical records of all patients undergoing elective infrarenal aortic reconstructions between January 1991 and June 1995 were retrospectively reviewed to determine blood loss, CS return, predictors of clinically significant/ cost-efficient CS returns, blood products transfused, and estimated cost per unit CS return. The CS was used for 138 (82.1%) of all reconstructions during the study period. Estimated blood loss (2127 +/- 1467 vs 1415 +/- 1047) and CS return (927 +/- 790 vs 515 +/- 408) were significantly greater in patients with aneurysms (AAA, N = 63) compared to those with aortoiliac occlusive disease (AIOD, N = 75). CS returns > or = 500 cc were common (79.4% AAA, 52.0% AIOD) and predictors of > or = 500 cc CS returns were large aneurysms (6.79 +/- 1.84 vs 5.72 +/- 0.71 cm) and male sex (82.0 vs 46.2%) in AAA patients and lower preoperative platelet counts (262 +/- 93 vs 311 +/- 113 K/mm3), concomitant renal revascularizations (20.5 vs 0%), and prolonged operative time (7.9 +/- 2.4 vs 6.9 +/- 2.1 hr) in AIOD patients. In contrast, CS returns > or = 1250 cc were relatively uncommon (28.6% AAA, 5.3% AIOD), and predictors of these CS returns were found only for AAA patients and included any concomitant vascular procedures (38.8 vs 15.6%) and the need for suprarenal aortic clamping (27.8 vs 6.7%). Despite the use of the CS, 73.8% of all patients required allogenic packed red blood cells with a mean of 3.0 +/- 3.1 units transfused in the perioperative period; no difference was seen between AAA and AIOD patients. The calculated cost for a unit of CS return was +128.77 for the AAA patients and +231.91 for the AIOD patients. Not using the CS and substituting the return with allogenic packed red blood cells would have saved +252.80 and +352.84 for the AAA and AIOD patients, respectively. Routine use of the CS during elective infrarenal aortic reconstructions is not cost efficient and should be abandoned. Use of the device should be reserved only for complex reconstruction.