SAFE Anesthesia and Minimizing Blood Loss

  • Eric Swanson


Enhanced recovery after surgery (ERAS) has received recent attention. Surgery has traditionally relied on the anesthesia provider to mask the pain centrally, with little regard for peripheral anesthesia at the tissue level.

General endotracheal anesthesia remains the most commonly used type of anesthesia for large body contouring cases. However, general anesthesia with muscle relaxation may be implicated in the formation of deep venous thromboses. Instead the author recommends SAFE (spontaneous breathing, avoid gas, face up, and extremities mobile) anesthesia. Total intravenous anesthesia maintains mean arterial blood pressure. Avoiding paralysis preserves the calf muscle pump. Other advantages derive from avoiding anesthetic gas, such as reducing the risk of postoperative nausea. Recovery times are quicker. Prone positioning, which adds unnecessary risks and operating time for patient positioning, may be eliminated.

Bupivacaine is a much longer-acting anesthetic than lidocaine, but it has been regarded with caution because of cardiac toxicity. The author evaluated plasma levels of this anesthetic when administered in a dilute form into the abdominal subcutaneous tissue before abdominoplasty. Plasma levels rose slowly, and a wide margin of safety was maintained. A bupivacaine infusion, using the body’s fat cells as a slow-release mechanism, offers a superior alternative to regional nerve blocks.

Evaluation of hematocrits after liposuction reveals substantial third-space blood loss into the tissues. Aspirate volumes >5 L are associated with an estimated blood loss of >1 L. The prudent surgeon will anticipate blood loss and avoid postoperative anemia. Simply using a superwet method rather than tumescent infusions makes patient overhydration unlikely.

The goal of surgery and anesthesia should be to minimize the physiological, metabolic, and hemodynamic impact of surgery so as to optimize safety and enhance the recovery.


Anesthesia SAFE Total intravenous Bupivacaine Lidocaine Blood loss Liposuction Superwet Physiological 


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© Springer International Publishing AG 2018

Authors and Affiliations

  • Eric Swanson
    • 1
  1. 1.Swanson CenterLeawoodUSA

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