Safe Dex: A Unique Approach To Eyes, Hips, Legs, And Buttocks
Andrew Linn, M.D.

Case Presentation:
A forty-five year-old ASA I female presented for lower blepharoplasy, mini rhytidectomy, and liposuction of the abdomen, hips, thighs, and buttocks. The case is booked for seven hours. Medical history is significant for anxiety disorder, chronic sinusitis and mucositis causing excessive secretions, and asthma. She has a history of PONV, motion sickness, and tolerance to pain medications. On the morning of surgery she stood 5’4”, weighed 140 pounds, with a Class I airway. Her BP was 150/90, pulse 72, RR 12, Temp 97.6, O2 sat 95% on RA. CXR was normal, and all labs within normal limits. After thorough chart review, and discussion with surgical team, the plan GA with ETT was decided upon. Anesthesia was
induced uneventfully.
The case began with the surgeon performing the lower blepharoplasty. Systolic blood pressure was kept near 90mm Hg as requested by the surgeon, and the head of the bed was raised to 30degrees.One and onehalf hours into the case, the surgeon began injecting 1% lidocaine with 1:200,000 epi into the face in preparation for the “mini rhytidectomy.” As he injected, the patient moved and her O2 sat dropped to 80%. Chest auscultation revealed distant to absent breath sounds. Albuterol was given and the anesthetic deepen,
with improvements to O2 saturation. The surgeon resumed the local anesthetic injection and within one minute her heart rate increased to 140 bpm, and blood pressure rose to 188/120. This intravascular injection of local anesthetic was treated with labetolol. The surgery proceeded uneventfully for two hours, at which time the patient was reprepped and draped in preparation for liposuction. The surgeon used 4,000 mL of subdermal infiltration of tumescent local anesthetic (0.1% lidocaine with 1:1,000,000 epi). The
liposuction went uneventfully for two hours, with moderate progressive increase of heart rate and blood pressure. The duration of the case was 7 and one-half hours. Just after extubation, blood was noted to be coming from under the patient’s right eye, and the eye appears proptotic. The decision is made to reexplore the eye. Considering the patient had just received 7.5 hours of GA, and had within the past 30 minutes received a full reversal dose of Neostigmine, it was decided to use local anesthetic and a dexmedetomidine
infusion as the anesthetic. During the exploration, the surgeon finds an expanding inferior rectus hematoma, and calls for an intraoperative ophthalmology consult to evaluate possible orbital compartment syndrome. Opthalmology evaluated the patient, and advised that retrobulbar bleeding and compartment syndrome were unlikely. A CT scan to further evaluate was performed postoperatively and definitively ruled-out compartment syndrome of the orbit.

Discussion
The patient described in this case is a classic representation of those patients highlighted by the Closed Claim Project, regarding office-based claims. Despite only accounting for 14 out of 5480 claims, the demographics were middle-aged (mean 45 years), female, ASA 1-2, having elective surgery under general anesthesia or MAC; the most common surgery type being cosmetic. The results further yielded that officebased claims had a higher proportion of deaths related to the respiratory system, i.e., bronchospasm, airway obstruction and inadequate oxygen or ventilation. It was also noted that 46% of these office-based claims
were deemed preventable by better monitoring, specifically pulse-oximetry in the post-operative period. Payment accounted for 92% of these claims with a median amount of $200,000[4]. Despite these potentially alarming findings, there has been a significant increase in the number of office surgical procedures (400,000 in 1984 8.3 million in 2000). This has been driven by factors such as patient and physician convenience, ease of scheduling and reduced costs[5].
A comprehensive review of the literature has confirmed safety in the office-based setting. Hoefflin et al. found no deaths and no significant complications among 23,000 consecutive office-based procedures under general anesthesia. Liposuction is the most commonly performed out-patient surgery. Hanke et al. evaluated the safety of tumescent liposuction (under local anesthesia) in 15,336 patients and found no deaths, emboli, visceral perforation or thrombophlebitis[5].
In the article by Rees et al., regarding hematomas requiring surgical evacuation following face lift surgery, a plausible argument is made for maintaining a normotensive intra-operative blood pressure to ensure meticulous hemostasis is achieved, since in a hypotensive patient potential bleeding points may be missed[8].
The unique aspect of this case was the conversion from a GA to MAC. There are many drug
combinations that are used in MAC anesthesia. DEX, with its sedative, amnestic, and analgesic properties appears useful as an adjunct or as a primary agent. The key, however, is to individualize the pharmacologic plan for each patient, titrate to effect, and understand the pharmacology and side effects of each medication choice. When adding a new drug, one must be aware of its pharmacology and drug interactions.

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