Wednesday, March 26, 2008

Anesthesia related death during plastic surgery

From the Palm Beach Post comes the tragic death of Florida teen, Stephanie Kuleba, from a rare allergic reaction to inhalation anesthetics called malignant hyperthermia (MH). Wikipedia describes it succinctly as a idiosyncratic reaction that "induces a drastic and uncontrolled increase in skeletal muscle oxidative metabolism which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if untreated."

There's really no way to screen for this process and a patient can die quickly. Most surgeons and anesthesiologists may go their entire career and never see a true case of it. I was talking to one of my colleagues the other day about office based surgery and he said he was unlikely to return to doing that after seen a near fatal MH on a cosmetic surgery case he was doing in an ambulatory surgery center adjacent to a hospital.

I'm not sure what the take home message from this is. It's such a rare event that it's hard to justify having exotic protocols at all times in low risk procedures. Most office surgery suites maintain a supply of Dantrolene, a medicine to treat MH which is almost $2500 per dose and must be restocked often to stay current. There's plenty of adverse events more common then MH, but we don't have aortic balloon pumps or cardiac bypass machines routinely laying around for that. It already sounds like that the family has hired an attorney who is already assuming an aggressive posture in his comments to the media so I'm sure we'll see some legal proceedings even if perfect care for MH was instituted.


Anonymous said...

I was doing frequent vital signs on a fairly fresh post-op that recovery had just transferred to our floor. Her temp was pretty low, so I put on extra blankets and kept monitoring her temp. She woke up a little and complained about being hot (and something else I can't remember, but it wasn't what we'd normally consider an emergency), so I checked again, and she was getting closer to normal temps. That's when her family finally remembered that she always ran cooler temps than normal -- according to them she was usually high 96s to low 97s. She wanted the extra blankets off.

So because of the other somewhat minor complaint, and her supposed low basal temp (that wasn't documented anywhere), I called Anesthesiology and reported it. She didn't give any orders, but said she'd check in on her. She showed up in about 1-2 minutes!

The patient turned out fine; the anesthesiologist ordered some PRN meds for her other complaint. I mentioned something about how quickly she came to the unit, and she explained how she wanted to rule out an unusual post-op temperature controlling issue that could go bad quickly. I put a special note in the patient's chart about her low temps, and explained to her family to make sure all medical people knew about it in the future so they'd know if she was running a fever even with 99.1, and worry about post-op temps being different from normal.

It wasn't long afterwards that we all had to take a mandatory malignant hyperthermia inservice. If I remember correctly (it's been quite a few years), MH can be hereditary.

Anonymous said...

Since a lot of plastic surgery deaths seem to be related to anesthesia, what can patients do to reduce this risk? I know the risk is small but it's still something to consider.

Should patients request local anesthesia with sedation instead of general anesthesia for short, less invasive procedures?

Barry L. Friedberg, M.D. said...

Anesthesia Choice Creates Avoidable Tragedy In Cosmetic Surgery

She wasn't as famous as Olivia Goldsmith, author of The First Wives Club, but Stephanie Kubela's death was just as avoidable, according to Barry L. Friedberg, M.D., a globally recognized expert in cosmetic surgery anesthesia.

Complications from rare genetic disorder, malignant hyperthermia (MH), appear to be the cause of the Florida teenager's needless death.

Triggering agents for MH are inhaled general anesthetic (GA) agents (i.e. halothane, desflurane and sevoflurane) and the muscle relaxant, succinycholine (SCH), used to intubate the airway.

GA is the predominant choice of anesthesia cosmetic surgery, so her surgeon was within the 'standard of practice' in that choice -- expedience over outcomes.

Unfortunately, GA or the 'standard of practice' includes many unnecessary, avoidable and potentially fatal risks to patients choosing to have surgery that has no medical reason or indication.

Among those avoidable risks are MH, blood clots to the lungs, airway mishaps leading to lack of oxygen to the patient's brain, postoperative nausea and vomiting (PONV), and postoperative cognitive disorder (POCD).

All of these risks can and should be avoided by having surgeons and patients choose a kinder, gentler anesthetic technique -- propofol ketamine or minimally invasive anesthesia (MIA) pioneered by Friedberg.

Neither propofol nor ketamine are triggering agents for MH. Had Ms. Kubela received MIA, she would likely be alive today. BIS monitoring of the patient's brain gives a numerical value of propofol sedation at which ketamine can be given without negative side effects.

In 2005, The Doctors' Company (TDC) Newsletter extolled the safety of propofol ketamine over general anesthesia for prevention of blood clots to the lungs. TDC is a medical malpractice carrier with a high percentage of plastic surgeons as insured.

No airway mishaps have been reported with MIA. With minimal trespass, patients tend to breathe normally and require little assistance or intervention to keep their airways open. No lack-of-oxygen accidents have been reported with MIA.

MIA has the lowest published rate of PONV, highly desirable, especially for facelift and tummy tuck patients.

Sometimes MIA is called 'Goldilocks' anesthesia. BIS monitoring eliminates the common anesthesia practice of giving too much for fear of giving too little. The opportunity for POCD is thereby greatly minimized.

More anesthesia providers are recognizing the advantages of MIA. Both surgeons and anesthesia providers need to be asked to provide it to optimize patient safety for cosmetic surgery.

Dr. Rob Oliver said...

Well, I'm aware of Dr. Friedberg's well known POV re. IV sedation versus general anesthesia but I'm not sure it's as cut and dried as that.

IV sedation is much more unpredictable in most practictioners hands I'd submit. There are many more deaths annually from airway issues then there are from malignant hyperthermia per se., so that particular justification is a bit dodgy when applied to the population at large. Other benefits suggested are still speculative at this point in time.

I think the big driving force towards more use is simply the increase in office based surgery. In many states IV sedations is a loophole for closer scrutiny by state regulators of facilities and practicioners.

barry l friedberg, md said...

Re: Dr. Oliver's comment about the unpredictable nature of IV sedation:

There is a 19-fold inter-individual difference in how patients metabolize propofol.

Therefore, any dosing scheme based on patient body weight and vital signs will be unpredictable!

Unlike many practitioners like Dr. Oliver, my patients have no difficulty with the concept of measuring what you are trying to medicate; i.e. the brain.

Monitoring the brain effect of propofol iv sedation with a BIS monitor is like taking an open book test.

Trending EMG as a secondary trace and responding to spikes in it as if they were heart rate or blood pressure changes makes iv sedation truly 'cut and dried.'

A point well taken is the issue of airway issues.

The Doctors' Company (TDC) is a medical malpractice insurer that insures a large number of plastic surgeons. The Fall 2005 TDC Newsletter about deep vein thrombosis (blood clots) and pulmonary emboli (blood clots to the lungs) said:

"... the immobility associated with general anesthesia is a risk factor for thromboembolism. Newer techniques for intravenous sedation that include the use of propofol drips, often in combination with other drugs, have made it possible to perform lengthy or extensive surgeries without general anesthesia and WITHOUT the loss of the patient’s airway protective reflexes." reference #11

11. Friedberg BL: Propofol-ketamine technique: dissociative anesthesia for office surgery. Aesthetic Plastic Surgery Journal 1999,23;70.

jizo said...

my surgeon, who has his own operating theater [in addition to nearby hospital privileges] uses a special patient warming system throughout.
in addition to top-notch anaesthesiologiests, his RN and surgical techs watch temp as well as other functions
cosiest surgery ever!
now i know why.

Anonymous said...

Plastic surgery make attractive to human body. But sometime plastic surgery can give bad effect on human body. There were some complications due to the surgery and the area became infected. It may be end your death.
Alcohol Rehab

Anonymous said...

I just wanted to leave a quick note. "There's plenty of adverse events more common then MH..."
That should be a than because it's a comparison. Where has grammar gone?

mediainc said...

Sounds scary, but I guess most professional Doctors are well trained in doing such procedure. Just pick the best Doctor in you're place.

cosmetic surgery upland