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Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 89-90

From hypodermoclysis to massive infiltration – Tumescent local anesthesia

Consultant Vascular Surgeon, Kauvery Hospitals, Salem, Tamil Nadu, India

Date of Submission22-Feb-2022
Date of Acceptance22-Feb-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Karthikeyan Sivagnanam
Consultant Vascular Surgeon, Kauvery Hospitals, Salem, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_13_22

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How to cite this article:
Sivagnanam K. From hypodermoclysis to massive infiltration – Tumescent local anesthesia. Indian J Vasc Endovasc Surg 2022;9:89-90

How to cite this URL:
Sivagnanam K. From hypodermoclysis to massive infiltration – Tumescent local anesthesia. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:89-90. Available from:

Tumescent local anesthesia (TLA) is an improvised technique of local anesthesia, which involves infiltration of local anesthetic agent along with a mixture of other medications into the fluid. This infiltration into the subcutaneous layer offers good pain relief that is utilized as a regional anesthesia without systemic toxicity of local anesthetic agent though used in large quantities as it does not enter the systemic circulation.[1]

TLA was originally devised for use in liposuction although the technique has been extended in the surgical management of burns care, vascular surgery, and other plastic surgical procedures involving skin and subcutaneous tissue. In Klein JA illustrated this technique during the Dallas Meeting of the American Society for Aesthetic Plastic Surgery.[2] The historical connection to this was published by Welch from old literature belonging more than 100 years ago,[2] wherein this technique was noted in a book by Frederick Christopher's Minor Surgery in 1930. It has pictorial illustrations of the various devices used to generate pressure to infiltrate the solution into the subcutaneous tissue called hypodermoclysis. Hypodermoclysis in Greek is literally “to wash out below the skin;”[2] a technique utilized as a way of administering large volumes of fluid for replacement before the advent of intravenous technique for fluid administration. This technique was used to give even up to 3000–4000 cc of fluids over a 24 h period.

At about the same time, this similar infiltration anesthesia was simultaneously used under the name “Vishnevsky Local Anesthesia.”[3] It was published in 1932 by A. V. Vishnevsky in his book, Local Anesthesia by Creeping Infiltrate Method. They also used a diluted lidocaine solution injected in subcutaneous plane and performed surgeries of the breast and thyroid.

It is a relatively safe way to achieve extensive regional anesthesia of skin and subcutaneous tissue with a high total dose but a low risk of systemic toxicity. The subcutaneous infiltration of a large volume of very dilute lidocaine and epinephrine causes the targeted tissue to become swollen and firm, or tumescent, and offers a good alternative to extensive anesthesia. The safe dosage of tumescent lidocaine is attributed to the work of Klein and Jeske published in the Journal of Anesthesia and Analgesia.[4] TLA solution contains 1 g lidocaine and 1 mg epinephrine in 100 ml plus 10 mEq sodium bicarbonate in 10 ml added to 1000 ml of 0.9% physiologic saline.[4] This gives a final lignocaine concentration of 1 g/bag containing 1110 ml which equates to 0.9 g/l. Sodium bicarbonate decreases the discomfort of large volume of subcutaneous tumescent infiltration.[5]

Ambulatory endovenous thermal ablation of varicose veins performed under tumescent TLA has been reported in numerous literatures. It has been safely performed under TLA as day-care procedures with sufficient patient comfort.[6] A concentration of 0.1% lidocaine used with an average volume of about 5–10 ml/cm of treated vein[7] offers good pain relief. This is delivered in the perivenous space either manually or with an infusion pump so that, on completion of the process, the ablation catheter intravenously is surrounded by the fluid which displaces the blood from the vein. This offers a good contact between the vein wall and the device which increases the thermal heat delivered to the vein wall, and the perivenous liquid offers a cushion to the surrounding tissues as a heat sink avoiding thermal injury to the skin along the ablated areas. The maximum safe dosage of lidocaine in TLA for venous procedures has not been well studied. However, 35 mg/kg with epinephrine has been reported as a safe dose in plastic surgical procedures in the literature.[8]

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  References Top

Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg 1993;92:1085-98.8  Back to cited text no. 1
Welch JD. History of tumescent anesthesia, part I: From American surgical textbooks of the 1920s and 1930s. Aesthet Surg J 1998;18:353-7.  Back to cited text no. 2
Kargopoltseva GA, Vasilyev SA, Vasilyev YS, Welch JD. The history of tumescent anesthesia, part II: Vishnevsky's anesthesia from Russian textbooks, 1930 to 1970. Aesthet Surg J 2002;22:46-51.  Back to cited text no. 3
Klein JA, Jeske DR. Estimated maximal safe dosages of tumescent lidocaine. Anesth Analg 2016;122:1350-9.  Back to cited text no. 4
McKay W, Morris R, Mushlin P. Sodium bicarbonate attenuates pain on skin infiltration with lidocaine, with or without epinephrine. Anesth Analg 1987;66:572-4.  Back to cited text no. 5
Nyamekye IK. A practical approach to tumescent local anaesthesia in ambulatory endovenous thermal ablation. Phlebology 2019;34:238-45.  Back to cited text no. 6
Wallace T, Leung C, Nandhra S, Samuel N, Carradice D, Chetter I. Defining the optimum tumescent anaesthesia solution in endovenous laser ablation. Phlebology 2017;32:322-33.  Back to cited text no. 7
Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16:248-63.  Back to cited text no. 8


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