Hair Transplant surgery is a safe outpatient day surgery. Emergencies are uncommon but can appear suddenly. Many of the emergencies, but not all, are preventable through attentive pre-operative and intraoperative care. Clinic doctors and support staff must be prepared to manage emergencies. Potential medical conditions which may convert into life-threatening emergencies during Hair transplant are- Medication- Lidocaine toxicity, drug interactions( beta-blockers with adrenaline, lidocaine with Dilantin ), over sedation. Allergy/ Anaphylactic shock Hypotension- due to hypovolemia, cardiovascular shock, vasovagal syndrome. Cardiovascular- Angina, myocardial infarction, arrhythmias (cardiac arrest). Pulmonary- Dyspnea, Asthma, respiratory arrest. Neurologic- seizures, stroke Coagulation- bleeding diathesis Trauma- accidental injury/fall

1. Emergency situations During Hair
Transplant and How to Avoid Them.
Dr Seema Garg MBBS, MSc, FISHRS, ABHRS
Dr. Anil K Garg, MS, MCh, FISHRS, ABHRS
Rejuvenate Hair Transplant Centre, Indore.

2. Hair
Transplant
surgery is a
safe
outpatient
day surgery.
• Emergencies are uncommon but
can appear suddenly.
• Many of the emergencies, but not
all, are preventable through
attentive pre-operative and
intraoperative care.
• Clinic doctors and support staff
must be prepared to manage the
emergencies.

3. Mortality in Last 5 years -- India
Chennai case
• In 2016 a medical student of 22
years old died on 2nd day of
surgery.
• ? Septicemia
Mumbai case
43 years male died after 28 hours
of finishing the surgery on 7th
March 2019.
? Anaphylactic shock.

4. Potential medical conditions which may convert into life
threatening emergencies during Hair transplant are-
• Medication- Lidocaine toxicity, drug interactions( betablockers
with adrenaline, lidocaine with dilantin ), over sedation.
• Allergy/ Anaphylactic shock
• Hypotension- due to hypovolemia, cardiovascular shock, vasovagal
syndrome.
• Cardiovascular- Angina, myocardial infarction, arrythmias (cardiac
arrest).
• Pulmonary- Dyspnea, Asthma, respiratory arrest.
• Neurologic- seizures, stroke
• Coagulation- bleeding diathesis
• Trauma- accidental injury/fall

5. To avoid any
unwanted
event,
thorough pre
op
preparation
must be done
• History in detail- Existing conditions such as
diabetes, hypertension, bleeding disorders, history
of heart or cardiovascular disease, HIV, hepatitis,
and seizures can increase risk with surgery and
must be identified and treated to be safe.
• if patient is taking any medication, enquire in detail
- to avoid any drug interactions during surgery.
• History of allergy to any drug or other thing.
• Past surgical history- any reaction with local
anaesthesia.
• Pre op investigations to rule out any existing
disease.(CBC, LFTs, RFTs, Bleeding disorders, HIV,
Aust ag, RT PCR, Xray chest, ECG).
• Obtaining a medical clearance from the primary
treating physician is always advisable before
surgery.

6. Intra
operative
• It is advisable to have IV access in all patients.
• Xylocaine sensitivity test.
• It is safe to keep anesthetists in case of elderly
patient or patient with comorbidities.
• Prompt recognition of sign and symptoms of
emergencies.
• Be ready to manage.

7. 1. Vasovagal
syndrome /
Neurocardiogenic
syncope
• Most common emergency during surgery,
precipitated by pain, sight of blood, fear, anxiety
etc.
• It is due to reflex stimulation of the ANS leading to
bradycardia and hypotension resulting in
decreased blood flow to the brain and fainting.
• Can be prevented by giving----
1)preoperative sedation,
2)friendly environment,
3)keep talking to patient.

9. Management of
Vasovagal Syncope
As soon as signs and symptoms are noted—
• Terminate the procedure
• Place patient in supine position with leg
slightly raised.
• Monitor vital signs.
• If bradycardia persists, give inj.Atropine
0.5 mg IV/IM/SC
• Some patients may need IV fluids to
correct hypotension
• If No response– start BLS.

10. 2.
Anaphylaxis
• It is a serious condition that comes on quickly and
has potential to become life threatening.
• Symptoms can appear within minutes - up to 2
hours after exposure to allergen.
• Steroid and pheniramine , if given during surgery
may mask the primary anaphylactic reaction and
may invite fatal emergencies if biphasic reaction
occurs.

11. Anaphylaxis - Sign & Symptoms
• Itching, hives and flushed or pale skin.
• A rapid and weak pulse. Hypotension
• A swollen tongue or throat and airway
constriction and, associated with
wheezing and trouble breathing.
• Dizziness or fainting. Nausea, vomiting
or diarrhoea.
• Severe respiratory distress,
cardiovascular collapse, death

12. Diagnosis-Guideline by World allergy organisation
are-
Anaphylaxis is highly likely when there is--
Acute onset of an illness with involvement of the skin, mucosal
tissue, or both
and at least one of the following:
A) Respiratory compromise
B) Reduced blood pressure

13. Management
of
Anaphylaxis
by world
allergy
organization
Preliminary Step
Remove exposure to the trigger. Assess circulation,
airway, breathing, mental status, skin, and body weight
(mass)
Promptly and simultaneously -- Call for help.
Inject epinephrine (adrenaline) intramuscularly on the
mid-anterolateral aspect of the thigh, 0.01 mg/kg of a
1:1,000 (1 mg/mL) solution, to a maximum of 0.5 mg
When indicated at any time during the episode
Give high flow supplemental oxygen (6-8 L/min)
give 1-2 litres of 0.9% (isotonic) saline rapidly. ( 5-10
mL/kg in the first 5-10 min.)
Prepare to initiate CPR with continuous chest
compressions.

14. Anaphylaxis management cont---
• If reactions are sustained, the patient must be transferred to a hospital
by ambulance as quickly as possible.
• If we see any s/s of allergy or anaphylaxis which gets controlled by itself
or by treatment such patients should be kept under observation
minimum for 8 -48 hours, as anaphylaxis may be biphasic, appearing to
resolve only to return.
• Discharge medications--
Epi pen( autoinjector)
Corticosteroids
Antihistamines
•

15. 3.Over
sedation
with
injectable
sedatives
Symptoms -
•Early - Difficulty to arouse, slowed respirations,
slurred speech
•Late – respiratory arrest, cardiopulmonary arrest
PREVENTION
• It is not necessary to use injectable sedatives for
hair transplant patients.
However, if injectables are used they must be at
minimal dosages.
• Oral sedation and local anesthesia are adequate.

16. Management-
• Pulse oximetry and cardiac monitoring should be in
place.
• Resuscitation Equipment should be easily accessed.
• Antidote as per sedative
1. For meperidine (opioid derivatives)antidote is
naloxone.
dose is 0.4–1.0 mg IV
2. For benzodiazepines - flumazenil.
dose is 0.2 mg IV, repeated up to 1 mg

17. 4. Overdose
toxicity from
local
anesthetic
1. Accidental rapid intravenous injection.
2. Rapid absorption, such as from a very vascular site.
3. failure to monitor the doses being given and
keeping record of dose.
4. a perception that lidocaine is relatively safe
5. Increased susceptibility in patients with significant
comorbidities.
6. Drug Interactions- (Dilantin and betablockers
increases plasma level of lidocaine)

18. Prevention
• Avoid bolus injection without aspiration –
particularly in areas close to scalp arteries.
• Epinephrine, in concentrations of 5 mcg/ml
(1:200,000) along with local anaesthetic
will significantly reduce the peak blood
levels of lidocaine regardless of the site of
administration.

19. Safe dose of LA
• In HRS , LA is given in stages over a few hours,
not all at once.
• Beware of total safe dose and of potential
combined toxicity.
Drug safe single dose With adrenaline In a period of 24 hrs
lidocaine 300 mg 500 mg or or 4.5
mg/kg per dose
1000 mg maximum
bupivacaine 175 mg maximum
single dose
200 mg 400 mg/24 hours
ropivacaine 225 mg 400 mg/24h

20. Anesthesia log
• Maintain an anesthesia log for every
surgery. The log records the agent
dosage, and time of administration
and keeps a running total of each
agent.

21. Symptoms
of LA
toxicity
depends
on severity
of dose

22. Treatment
of LA
toxicity
1. Stop infiltration of
anesthetic agent.
2. Start IV lipids
3.If seizure –IV sedative
Diazepam/Mezolam
4. In Advance stages- activate
EMS and start with BLS.

23. 5.Hypertension
with
Bradycardia
• Drug interaction of epinephrine with non- selective
β-blockers may lead to hypertensive crisis.
• It is due to unopposed action of alpha receptors
on vascular smooth muscles leading to peripheral
vasoconstriction.
• Symptom- headache, restlessness, hypertension
with bradycardia.
• Treat as emergency, Stop the surgery, stop LA,
sedation, give Sublingual nifedipine.

24. 6.Hypertension
with
tachycardia
• Symptoms-restlessness, headache, raised BP,
tachycardia, palpitation.
• Treatment-stop adrenaline use, give sedation,
sublingual nifedipine, if not controlled shift to
hospital
• Prevention-Pre-operative detail examination, well
control of BP at least two weeks before surgery

25. 7.Hypoglycemia
• Overdose of hypoglycemic agent, quinine,
excessive alcohol.
• An irregular or fast heartbeat, Fatigue, Pale skin,
Anxiety, Sweating, Hunger, Irritability.
• Confusion, abnormal behaviour or both, Visual
disturbances, Seizures, Loss of consciousness.
• TREATMENT-oral glucose, if needed IV glucose,
hypoglycaemic drug dose adjustment.

26. 8.Hypovolemia
• Cause—preoperative poor hydration and
insufficient fluid intake during surgery. Inability to
control bleeding in FUT, adrenaline tachyphylaxis,
continuous oozing without surgeon’s attention
• Sign/symptoms-sweating, cold clammy skin,
hypotension, Initially tachycardia followed by
bradycardia
• Treatment—head low, IV fluids, control of bleeding
• Prevention—take care of hydration and close
watch on blood loss.

27. 9. Seizure
• CAUSE—may be because of hypoglycemia,
anesthetic toxicity, and patient with history of
convulsion.
• SYMPTOMS—convulsions, altered consciousness
• TREATMENTS-maintain respiratory airways and
prevent injury to patient, diazepam, treat the
cause, shift to hospital

28. 10.Cardiovascular
Event
• Angina/ Myocardial infarction / Arrythmias
• involve pain or discomfort in the left-center of
chest.
• May referred to neck, shoulders, back and jaw
with mild sweating, and pallor
• As pain continues, tachycardia or rhythm
disturbances may develop, and heart can’t
pump blood to brain, lungs, and other organs.
• increased pallor, respiratory distress occurs.
• Cardiac arrest

29. Treatment
1.Upon presentation of complaint, suspend
procedure.
2.Assess vital signs, establish IV access.
3. Administer 1 tablet of 325 mg aspirin (chewed)
and one table of nitroglycerine sublingual. (the dose
is 0.3 -0.6 mg sublingual every 5min; with a
maximum of three doses within 15 minutes)
4. Activate emergency response system, start CPR if
required.
5.Arrange transfer to hospital for evaluation.
6.Treat rhythm disturbances as indicated by ACLS
protocols

30. • NOTE--If procedure is incomplete, preserve tissue
in advanced holding solution (Hypothermasol with
ATP at 4º C ) for possible completion once patient
is stabilized.

31. Emmergency
Prepardness
• Whatever may be the cause most immediate
concern in an unresponsive patient(no normal
breathing or gasping and no pulse) is to prevent
Brain anoxia due to either lack of respiration or
circulation.
• TRAINING in BLS is must, paste a chart with BLS
protocol in operating room.
• Ensure the availability of all possible EMERGENCY
medicines.
• EQUIPMENTS- must be ready
• For activating EMS - Intensivist/anaesthetist
contact number and for Transport facility- contact
number of Hospital and ambulance should be
easily available to OT and reception staff.

32. Recommended
training for staff
in HRS
• Doctor-Minimum Basic Life support
training, preferably advanced cardiac
life support.
• OT staff- shall have done BLS training
or experience of working in
operating room or intensive care
unit.
• Training and rehearsing the OT staff
in emergency protocols is very
important.- Develop team approach
• Emergency Drugs and resuscitative
equipments should be handy
• Should know how to do CPR and
artificial breathing.

33. Transfer
arrangements
with local
hospitals
• In the rare event of unexpected
serious developments during or
immediately after a hair transplant
surgery, an arrangement should exist
with a nearby hospital for the
transfer of the patient.