Pharmacokinetics and safety of epinephrine use in liposuction

Patients are routinely exposed to high-dose epinephrine infiltration during large-volume liposuction. Because of the serious cardiovascular side-effect profile of catecholamine overdose, the authors examined the safety of larger-volume liposuction by assessing epinephrine pharmacokinetics. Five female volunteers with American Society of Anesthesiologists physical status of I or II, aged 29 to 40 years and weighing 75.9 to 95 kg, underwent liposuction. The wetting solution contained 7.3 mg (SEM, 0.7 mg) of epinephrine, corresponding to 0.09 mg/kg (0.04 mg/kg). Total plasma epinephrine and norepinephrine concentrations were assessed by high-performance liquid chromatography. Approximate exogenous epinephrine absorption was calculated after correction for estimated endogenous epinephrine production. Pharmacokinetic assessments were performed using standard equations. The total plasma epinephrine peak occurred at the final intraoperative reading (5 hours after induction) and was 323 pg/ml (24.8 pg/ml), three to four times maximum baseline resting levels. The norepinephrine level was slightly elevated throughout the study period, with a reversal of the normal epinephrine/norepinephrine ratio (<0.5:1) demonstrated intraoperatively (>5:1). Estimated time to peak exogenous epinephrine level ranged from 1 to 4 hours from the start of infiltration. Area under the plasma concentration versus time curve was approximately 2089 to 2610 pg x hour/ml. Peak exogenous epinephrine concentration was estimated to be 286 to 335 pg/ml. Clearance was 764,508 ml/hour and volume of distribution was 0.4 liter/kg (0.006 liter/kg). Total absorbed epinephrine was estimated, 1.8 mg to 2.2 mg, equivalent to 25 to 32 percent of the infiltrated dose. The reversal of the normal epinephrine/norepinephrine ratio and the fact that norepinephrine levels were within normal range implied that the majority of plasma epinephrine measured was exogenously infiltrated and not endogenously synthesized. On the basis of these observations, pharmacokinetic analyses were performed. Although unequivocal toxic epinephrine levels were not demonstrated, epinephrine peaks were three to four times the maximum observed in normal resting patients. Peak levels were comparable to those observed during major physiologic stresses, such as exercising to exhaustion, open abdominal surgery, or cross-clamping the aorta during surgical repair. Furthermore, epinephrine has been associated with myocardial infarction, arrhythmias, and fatal asystole in susceptible patients at these levels. Patients should be carefully screened for clinical evidence of hemodynamic and cardiac pathology before larger-volume liposuction is undertaken, as it may result in unnecessary high risk for patients who have preexisting cardiovascular disorders. Healthy American Society of Anesthesiologists physical status I or II patients should have sufficient cardiac reserve to tolerate these catecholamine levels.     

Capillary gas chromatographic method for the measurement of small concentrations of monoethylglycinexylidide and lidocaine in plasma

The major metabolite of lidocaine, monoethylglycinexylidide (MEGX) is currently used as a dynamic marker of liver function. It has been proven, in recent advances, that the determination of MEGX formation after intravenous injection of lidocaine was an effective means of assessing liver dysfunction in critically ill patients. An accurate and sensitive gas chromatographic method has been developed for the determination of small quantities of MEGX formed in such cases. The procedure involves a solid-phase extraction and injection of the extract (splitless mode) into a gas chromatograph equipped with a capillary column and nitrogen–phosphorus detector. The limit of detection is 1 ng/ml and the limit of quantification is 2.5 ng/ml. The response is linear up to 50 ng/ml. The inter- and intra-assay coefficients of variation for MEGX and lidocaine are between 5 and 9%. This method can be used for the determination of small concentrations of MEGX in plasma and could be applied to analysis of small amounts of many other nitrogenous molecules.     

Pharmacokinetics of granisetron in rat blood and brain by microdialysis.

To characterize the pharmacokinetics of protein-free granisetron in blood and brain we implanted microdialysis probes into the jugular vein and cerebral frontal cortex of the rat. Granisetron (3 or 6 mg/kg, i.v., n=6) was then administered, and microdialysates from blood and brain were collected from both sites and assayed by a validated high-performance liquid chromatographic method. Pharmacokinetics parameters were calculated from the corrected dialysate concentrations of granisetron versus time data. The elimination half-lives of granisetron in blood and brain were 51.3+/-5.5 and 69.7+/-6.3 min for 6 mg/kg, and 50.7+/-4.3 and 74.3+/-12.5 min for 3 mg/kg, respectively. Granisetron rapidly entered the extracellular fluid of cerebral frontal cortex at Tmax of 24 min. The results suggest that simultaneous microdialysis in blood and brain can be usefully applied to study the pharmacokinetics of granisetron in the periphery and the central nervous system.     

Improvements in cardiovascular risk profile with large-volume liposuction: a pilot study

In this study, the authors investigated the physiologic effects of the altered body composition that results from surgical removal of large amounts of subcutaneous adipose tissue. Fourteen women with body mass indexes of greater than > 27 kg/m2 underwent measurements of fasting plasma insulin, triglycerides, cholesterol, body composition by dual-energy x-ray absorptiometry (DXA), resting energy expenditure, and blood pressure before and after undergoing large-volume ultrasound-assisted liposuction.There were no significant intraoperative complications. Body weight had decreased by 5.1 kg (p < 0.0001) by 6 weeks after liposuction, with an additional 1.3-kg weight loss (p < 0.05) observed between 6 weeks and 4 months after surgery, for a total weight loss of 6.5 kg (p < 0.00006). Body mass index decreased from (mean +/- SEM) 28.8 +/- 2.3 to 26.8 +/- 1.5 kg/m2 (p < 0.0001). This change in body weight was primarily the result of decreases in body fat mass: as assessed by DXA, lean body mass did not change (43.8 +/- 3.1 kg to 43.4 +/- 3.6 kg, p = 0.80), whereas DXA total body fat mass decreased from 35.7 +/- 6.3 to 30.1 +/- 6.5 kg (p < 0.0001). There were significant decreases in fasting plasma insulin levels (14.9 +/- 6.5 mIU/ml before liposuction versus 7.2 +/- 3.2 mIU/ml 4 months after liposuction, p < 0.007), and systolic blood pressure (132.1 +/- 7.2 versus 120.5 +/- 7.8 mmHg, p < 0.0002). Total cholesterol, high-density lipoprotein cholesterol, plasma triglycerides, and resting energy expenditure values were not significantly altered after liposuction.In conclusion, over a 4-month period, large-volume liposuction decreased weight, body fat mass, systolic blood pressure, and fasting insulin levels without detrimental effects on lean body mass, bone mass, resting energy expenditure, or lipid profiles. Should these improvements be maintained over time, liposuction may prove to be a valuable tool for reducing the comorbid conditions associated with obesity.     

Outcome study in liposuction breast reduction

Liposuction as a primary modality of treating breast hypertrophy has been reported in the literature; however, many of these reports are small series and personal experiences. This report is the first outcome study to attempt to validate the effectiveness of liposuction as a primary method of breast reduction surgery. Questionnaires were sent to 117 patients who had undergone liposuction breast reduction surgery in our office during a 4-year period. Seventy-eight questionnaires were returned (67 percent response rate). The patients were asked about their complaints, their surgical results, and their satisfaction with the operation. Complaints such as neck and back pain, shoulder ruts, and intertrigo were improved or eliminated in the vast majority of patients. Women returned to work in 5 days on average and resumed full exercise in 2 weeks. Eighty percent of patients were either very or completely satisfied with their outcomes, 87 percent would choose the liposuction method again, and 92 percent would recommend the liposuction method to a friend. This study demonstrates that liposuction breast reduction is an effective method of breast reduction surgery.     

LC-MS determination of oxidized and reduced glutathione in human dermis: a microdialysis study

A simple, highly selective, sensitive and reproducible liquid chromatography-electrospray ionization mass spectrometry method has been developed for the direct and simultaneous determination of reduced (GSH) and oxidized (GSSG) glutathione in microdialysis samples from human dermis. Chromatographic separation was carried out on an MODULO CART QS KROMASIL 5C18 (250 mm × 2 mm × 5 μm) analytical column at a flow rate of 0.25 ml/min. An isocratic mode was used and consisted of acidified water and acetonitrile (50/50, v/v). To improve the sensitivity, silver nitrate was added as post-column reagent. A trap mass spectrum was used equipped with an ESI interface. The limits of detection and quantification were respectively 0.12 and 0.4 ng/ml for GSH and 0.2 and 0.5 ng/ml for GSSG. Intra-day and inter-day accuracy and precision were determined and the variability was less than 6.2% (R.S.D.).     

Metabolism during anaesthesia and recovery in colic and healthy horses: a microdialysis study

Background  

Muscle metabolism in horses has been studied mainly by analysis of substances in blood or plasma and muscle biopsy specimens. By using microdialysis, real-time monitoring of the metabolic events in local tissue with a minimum of trauma is possible. There is limited information about muscle metabolism in the early recovery period after anaesthesia in horses and especially in the colic horse. The aims were to evaluate the microdialysis technique as a complement to plasma analysis and to study the concentration changes in lactate, pyruvate, glucose, glycerol, and urea during anaesthesia and in the recovery period in colic horses undergoing abdominal surgery and in healthy horses not subjected to surgery.     

Ethanol but not acetaldehyde induced changes in brain taurine: a microdialysis study

Summary. Research has suggested that catalase plays a role in mediating ethanols psychopharmacological effects. Catalase is an enzyme that oxidizes ethanol to acetaldehyde. It has been reported that when catalase activity is reduced by 3-amino-1,2,4-triazole (AT), rats reduce their intake and preference for ethanol. The present study assessed the effects of AT on the brain amino acids levels following ethanol administration in Wistar rats. The study consisted of three parts. In the first part, we found no effects of acute and chronic intraperitoneally administered acetaldehyde on amino acids dialysate levels in nucleus accumbens. In the second part, AT was administered five hours prior to ethanol or its vehicle. Ethanol significantly affected the levels of taurine in rat pre-treated with AT. In the final part, ethanol was administered following the pre-treatment with AT but the dependent variable was the concentration of ethanol in the brain.     

Somatostatin release in the hippocampus in the kindling model of epilepsy: a microdialysis study

Somatostatin biosynthesis in the hippocampus is activated during and following kindling epileptogenesis. The aim of this study was to investigate whether this phenomenon is associated with enhanced somatostatin release in vivo. Experiments have been run in awake, freely moving rats, implanted with a bipolar electrode in the right amygdala (for kindling stimulation), and with a recording electrode and a microdialysis probe in the left hippocampus. Basal somatostatin-like immunoreactivity (-LI) release was significantly greater in kindled than naive rats. In naive rats, a 2-min perfusion with 100 mM K(+) did not affect behavior and EEG recordings and nonsignificantly increased somatostatin-LI release; a 10-min K(+) perfusion evoked numerous wet dog shakes, electrical seizures (class 0; latency congruent with 8 min, duration congruent with 8 min), and somatostatin-LI release ( congruent with 350% of basal); and a single kindling after-discharge (4 +/- 3-s duration in the hippocampus) also evoked somatostatin-LI release ( congruent with 200% of basal). In kindled rats, a 2-min 100 mM K(+) perfusion evoked hippocampal discharges in three of seven animals (latency congruent with 2 min, mean duration congruent with 1.5 min) and increased somatostatin-LI release ( congruent with 250% of basal); a 10-min K(+) perfusion evoked behavioral seizures (class 1 to 5, latency congruent with 4 min, mean duration congruent with 12 min) with numerous wet dog shakes and robust somatostatin-LI release ( congruent with 350% of basal); and a kindling stimulation evoked generalized seizures (class 4 or 5, 77 +/- 15-s duration in the hippocampus) with remarkable somatostatin-LI release ( congruent with 300% of basal). These data demonstrate that hippocampal somatostatin release is increased in the kindling model in vivo.     

Extracellular norepinephrine in the medial hypothalamus increases during feeding in chicks: a microdialysis study

Norepinephrinergic function in the medial hypothalamus is important for the regulation of feeding behavior in chicks as well as in rats. This study was conducted to clarify the variation of extracellular norepinephrine (NE) in the medial hypothalamus, including the paraventricular nucleus (PVN) and the ventromedial hypothalamic nucleus (VMN), during feeding behavior of layer-type chicks. To measure extracellular NE and 4-hydroxy-3-methoxyphenylglycol (MHPG), a major metabolite of NE, we used microdialysis and high-pressure liquid chromatography (HPLC) with electrochemical detection. After the collection of baseline samples, food-deprived animals were allowed access to the food for 3 h. Extracellular NE significantly increased during the first hour of access to food, and then returned to baseline levels. MHPG also increased during the feeding, but its increase continued throughout the remainder of the experiment. This study suggests that the variation of NE in the medial hypothalamus may be involved in the control of feeding in layer-type chicks.     

Blood loss in major liposuction procedures: a comparison study using suction-assisted versus ultrasonically assisted lipoplasty.

The blood loss that accompanies liposuction procedures has always been a concern. Tumescent injection of the targeted area of liposuction with dilute lidocaine and epinephrine solution has minimized intraoperative blood loss. Proponents of a newer ultrasonically assisted lipoplasty technique have claimed many benefits over traditional suction-assisted lipoplasty. However, few quantitative data are available on the intraoperative blood loss and the significance of postoperative anemia using the ultrasonic method. A prospective clinical observational design was used to investigate 38 patients undergoing suction-assisted lipoplasty and 37 patients undergoing ultrasound-assisted lipoplasty in whom the liposuction aspirate was expected to be more than 1000 ml. These patients were investigated with preoperative measurement of hemoglobin, platelet count, prothrombin time, partial thromboplastin time, and postoperative measurement of hemoglobin on the seventh postoperative day. In addition, hemoglobin concentration and whole blood volume were calculated from the infranatant portion of the liposuction aspirate. The mean +/- SD volume of the liposuction aspirate was 2901 +/- 1471 ml for suction-assisted compared with 2741 +/- 1086 ml for ultrasound-assisted lipoplasty. The mean +/- SD of whole blood volume in liposuction aspirate per case was 36 +/- 50.82 ml for suction-assisted lipoplasty and 36 +/- 28.62 ml for ultrasound-assisted lipoplasty. The mean +/- SD of the preoperative hemoglobin concentration was 13.93 +/- 0.99 g/dl for suction-assisted lipoplasty and 14.05 +/- 1.16 g/dl for ultrasound-assisted lipoplasty, whereas the mean +/- SD of the postoperative hemoglobin concentration was 13 +/- 1.42 g/dl for suction-assisted lipoplasty and 13.05 +/- 1.32 g/dl for ultrasound-assisted lipoplasty. The mean decrease in hemoglobin on the seventh postoperative day was 0.93 +/- 0.92 g/dl for suction-assisted lipoplasty and 1 +/- 0.64 g/dl for ultrasound-assisted lipoplasty. The volume of whole blood loss was estimated to be 12.4 ml in each 1000 ml of liposuction aspirate when using suction-assisted lipoplasty versus 13.1 ml when using ultrasound-assisted lipoplasty. All procedures were done under general anesthesia, and patients were discharged home on the same day. No blood transfusion was required. This study shows that blood loss using the ultrasonic technique is slightly higher, though insignificant, than when using suction. However, this study did not demonstrate a difference in the postoperative hemoglobin decrease between the two techniques.     

Determination of unbound cefmetazole in rat blood by on-line microdialysis and microbore liquid chromatography: a pharmacokinetic study

A specific and sensitive microbore liquid chromatographic method for the determination of unbound cefmetazole in rat blood was developed. A microdialysis probe was inserted into the jugular vein/right atrium of a Sprague–Dawley rat. Cefmetazole (10 mg/kg, i.v.) was then administered via the femoral vein. Dialysates were automatically injected into a liquid chromatographic system via an on-line injector. Isocratic elution of cefmetazole was achieved by LC–UV within 10 min. Intra- and inter-assay accuracy and precision of the assay were 10%. The detection limit of cefmetazole was 20 ng/ml. Pharmacokinetic analysis of results indicated that unbound cefmetazole levels in rats best fit a biexponential decay model.