Tumescent anesthesia

Definition
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Regional anaesthesia of the skin and subcutaneous fatty tissue known since about 1987 by application of large quantities of a local anaesthetic diluted about 100 times. In this way large areas of the body can be operated on under local anaesthetic, which previously could only be treated under general anaesthetic.

General definition
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Physiological saline solution or Ringer's solution are generally used as carrier substance. The most important effect of the carrier solution is the swelling of the tissue. The local anaesthetic consists of prilocaine (preferably) ropivacaine or lidocaine. Bicarbonate can be used as an additive to the tumescent solution to achieve an increase in tissue pH. This results in a better penetration of the substances into the tissue.

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Implementation
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Infiltration of large volumes (2.0 to max. 6.0 l) of a diluted local anaesthetic (see table). The application time until safe anaesthesia should not be less than one hour.

Undesirable effects
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Cave! Increase in meth-HB. Regular monitoring of O2 saturation and Meth-HB is recommended. Prophylactically, the intravenous administration of vitamin C is recommended. In case of a rapid increase of Meth-HB, slow intravenous administration of methylene blue (1-2 mg/kg bw i.v.), if necessary repeat after 4-6 hours.

Complication(s)
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Complications occur in about 1.5% of cases. The large amount of local anaesthetic can lead to severe cardiovascular problems and cardiac arrhythmia.

Literature
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Acosta AE (1997) Clinical parameters of tumescent anesthesia in skin cancer reconstructive surgery. A review of 86 patients. Arch Dermatol 133: 451-454
Breuninger H (2009) History of tumenescence anaesthesia. Act Dermatol 35: 290-292
Grassegger A, Haussler R et al (2001) Is the use of tumescence anesthesia in general anesthesia contraindicated? Anaesthesiologist 50: 363-364
Hempel V (2001) Is the use of tumescence anesthesia in general anesthesia contraindicated? Anesthesiologist 50: 363-364
small YES (1987) The tumenescent technique for liposuction surgery. At J Cosmet Surgery 4: 263-267
Selzle KET al. (2001) Tumescence local anesthesia in venous surgery. Central bl surgery 126: 517-521
Weinberg GL et al (1997) Malignant ventricular dysrhythmias in a patient with isovaleric academia receiving general and local anesthesia for suction lipectomy. J Clin Anesth 9: 668-670

Tables
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Tumescence solution according to Sattler

Active ingredient*	Quantity*
Prilocaine (lidocaine is used in the Klein solution)	500 mg
Epinephrine	1 mg
Sodium hydrogen carbonate	500 mg
Sodium chloride	9,000 mg
* The listed quantities/active ingredients refer to 1 l solution each according to Sattler

Advantages	Disadvantages
Excellent analgesia of large areas	Tumescent fluid in the Op-Area
Low blood loss	Considerable time required for analgesia
Persistent postoperative analgesia	Clear stress situation for patient and surgeon
Early Mobilization	Necessary patient guidance during the operation
Low preoperative diagnostics (blood count, coagulation, possibly ECG)	Moisture in the dressings due to escaping anaesthetic fluid