Anesthesia Complications In Routine Surgery

The lines between conscious sedation, monitored anesthesia care, general anesthesia, and life-threatening central nervous system depression are blurry and thin.  As the death of Michael Jackson and prosecution of his personal physician has brought back into the spotlight (I hope), anesthesia medications like propofol are frighteningly dangerous if used improperly.  It’s not like taking an antihistamine and going to sleep for a couple hours. Even the “long acting” procedural sedation agents like Versed and Fentanyl work for at most an hour, whereas the short-acting agents like Propofol last for only a couple minutes.  They have to be constantly administered and the patient has to be constantly monitored.

We review a lot of medical malpractice cases, so it feels like I see the same tragic story once a month, either in the press or in cases at our firm. Recently, “parents of student who died after dental surgery sue for malpractice“:

The parents of a Woodstock teen who died 10 days after losing oxygen during a routine wisdom tooth surgery March 28 in Columbia are suing the anesthesiologist and the oral surgeon involved for medical malpractice, according to court records filed Nov. 30.

The suit claims that Dr. Krista Michelle Isaacs, the anesthesiologist, and Dr. Domenick Coletti, the oral surgeon, were negligent in their care of Olenick and failed to resuscitate her after her heart rate slowed to a “panic level” of 40 beats per minute and her body began losing oxygen.

Yahoo has an article examining the merits of wisdom tooth removal, but it seems the type of surgery wasn’t really the problem, nor the use of improper surgical techniques.  It happened to involve dental surgery, but it could have been any type of surgery; Ms. Olenick’s death was perhaps another example of anesthesia malpractice:

According to Dr. David Fowler, the state’s chief medical examiner, Olenick was first given a standard dose of anesthesia during the procedure that did not “get her deep enough so she was fully anesthetized.” More anesthesia was then administered by Isaacs, which was also standard procedure, Fowler said in an interview.

At approximately 8:05 a.m., Olenick began to experience bradycardia, or a slowing of her heart rate, according to the lawsuit. ”A little while later, the oxygen saturation in her blood started dropping,” Fowler said. Shortly thereafter, according to the autopsy report, Olenick went into hypoxic arrest.

The part of Ms. Olenick’s story that raised my eyebrows is how the patient showed bradycardia and then a little later showed a drop in oxygen saturation followed by hypoxia and cardiac arrest.  Bradycardia is a known side-effect of many anesthesia agents (consider this 1997 study on propofol), including Versed, which was likely used in the oral surgery procedure.  (On a comment on a blog called “No Midazolam,” it appears Ms. Olenick’s mother confirmed that Versed was one of the drugs used.)

Once a patient under anesthesia shows bradycardia, that’s a medical emergency, and action needs to be taken immediately. Here’s a medical malpractice case from Texas describing a similar situation:

[D]uring surgery, Mark had progressive bradycardia, an abnormally slow beating of the heart, which is a condition that is consistent with inadequate ventilation. This condition can lead to cardiac arrest. According to Dr. Fromm, if Mark was in good health before the operation and if he had been well-ventilated during surgery, he would have survived a sudden cardiac arrest during the surgery.

Adequate ventilation is critical during any surgery under general surgery, and I suspect that it contributed to Ms. Olenick’s brain damage, but another issue jumps out at me.

Given the timeline of events, if the anesthetic used really was Versed (the trade name for midazolam), then there’s a good chance Ms. Olenick died from a classic example of anesthesia malpractice: the failure to account for differing half-lifes of sedatives or dissociative agents and their reversal agents, creating an unexpected anesthesia rebound effect.  Midazolam, for example, can be reversed by the benzodiazepine antagonist Flumazenil, but Flumazenil has a half-life of 7-15 minutes, while midazolam has a half-life of 3 hours, with ”wide interindividual variability in both healthy individuals and critically ill patients.

We thus often see situations where the anesthesiologist or nurse anesthetist gives a little too much anesthesia, as shown by an unusual drop in heart rate or breathing — which can happen even without negligence, given the variability in patient’s responses — and then panics and gives a large dose of a reversal agent (naloxone if they gave fentanyl, flumazenil if they gave midazolam).  The patient then starts to become conscious again, so the anesthesiologist gives them more anesthesia to put them back under.

The problem, then, is that the anesthesia and the reversal agent are metabolizing independent of one another, with a shorter half-life for the reversal agent.  The patient then appears to be on the right course until the reversal agent wears off and the patient begins showing signs of an anesthesia overdose.  At that point, the surgeon and anesthesiologist are stuck with a difficult choice: there’s no way to align the dosages and timing of the anesthesia and the reversal agent, so the only options are to reverse the anesthesia again with a stronger dose and potentially wake the patient in the middle of a substantial medical procedure, or risk the patient suffering an overdose from the anesthesia.

The safer course is to reverse, but that can create a terrible situation for the patient (from “anesthesia awareness” to fully waking up in excruciating pain), so many physicians just stay the course and hope for the best.  Problem is, once the patient has passed through the initial complications from the anesthesia overdose, they often won’t exhibit many further signs until they’ll suddenly hit a threshold after which they’ll crash and stop breathing entirely.  At that point, cardiac arrest, oxygen deprivation, and brain damage are often inevitable.

I don’t know if that’s what happened to Ms. Olenick, but I’ve seen that same anesthesia-and-reversal-agent rebound situation repeated in several other cases, with the same general timeline in which a problem was indicated, reversal agents were given, more anesthesia was administered, and then a little while later the patient crashed and eventually died.

Of course, there are a lot of other potential problems as well.  They weren’t at a hospital but at an ambulatory surgery facility; was it fully compliant with licensing and industry standards?  (The most readable version of those standards, in my opinion, is the American Association of Nurse Anesthetists’ checklist for CRNAs to follow when practicing at doctor’s offices.)  Truth is, we don’t know much about how and how often adverse events occur as a result of anesthesiology malpractice, because an Anesthesia Incident Reporting System wasn’t set up for the United States until, literally, a few weeks ago.

Anesthesiology is in many ways still a developing field.  There are still heated debates over who may even administer anesthesia, and tremendous potential for abuse, like with the completely unlicensed employees at Kermit Gosnell’s clinic administering “lethal mixes of Demerol, promethazine and diazepam” to patients according to a crude dosage-by-weight chart.  Ms. Olenick wasn’t the first person to die from anesthesia errors during an otherwise routine surgery, and she won’t be the last.  Would she have been safer at a hospital?  Maybe.  Is wisdom teeth removal unnecessary?  Maybe.  But the core issue here is one of basic anesthesiology, and until we have more data about the problem from the reporting system we won’t even know where to start in addressing it.

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  • Guest

    Yet another thoughtful but scary post from you. Plaintiffs’ attorneys must be fun at parties. Generally, I think ASFs need very heavy regulation (with better enforcement), but, because you mentioned Gosnell, I wanted to add that his little shop of horrors has caused Pennsylvania to go too far. PA has just passed legislation that will treat reproductive health clinics that provide abortion services as ASFs. The effect of the legislation will only make vital reproductive health care less accessible (more costly and fewer providers) and won’t solve the problem of rouge doctors, like Gosnell, who flout the law anyway. There have to be better ways of protecting patient safety.

    • Anonymous

      It’s a shame. The Gosnell incident should have sparked a discussion about the lax enforcement of regulations of all doctor’s offices (including how ASFs routinely use general anesthesia, despite regulations instructing them not to), but instead the legislature used it as a political football to impose more burdens on women seeking reproductive health services.

      ________________________________

  • guest

    I find so many things wrong with your blog that I don’t know where to start. You don’t have a grasp of physiology nor pharmacology and its evident from the way you write. I appreciate trying to make sense of this case but what bothers me is that a little bit of knowledge is a bad thing for lawyers.

    A heart rate of 40 is not a”panic level” for a healthy teenager. Young adults can have heart rates drop into the 40′s and 30′s during normal sleep…no problem. What happened to this poor girl is that she went apneic and nobody noticed and that is why she became hypoxic. Furthermore your speculation about midazolam and flumazenil being used here is not a sound explanation but rather a display of a small bit of knowledge you have ascertained yet you don’t fully understand it. I am sure you have seen cases where those drugs were involved but nobody really conducts anesthesia the way you describe it unless they were not trained in anesthesia. Plain and simple, she was given too much of one or several drugs and stopped breathing. Most likely, she was given a combination of fentanyl, midazolam, and propofol which synergize when combined. Midazolam is relatively safe when used alone and should not be singled out as a problem here. I also suspect there was one or several flaws in the monitoring. All of this is very uncharacteristic of an anesthesiologist.

    So my real question for anybody that knows this case is this: was the anesthesiologist really in the room with the patient? I just can’t believe that she was.

    • http://www.litigationandtrial.com/ Max Kennerly

      It seems you only briefly skimmed my post, hence your confusion about my argument. E.g., I didn’t refer to a HR of 40 as a “panic level,” one of the articles I quoted did. When I wrote about it, I mentioned that sometimes the person administering anesthesia wrongly panics at a HR that low, and so administers a reversal agent (and administers too much of it), but then sees the patient start to awaken, and so administers more anesthesia, etc, etc, until they’re in a dangerous pattern of administration-and-reversal they can’t control.
      I think we probably agree about more than we disagree about. I don’t know the facts of this case beyond the press report; I’m speculating based on what I’ve seen in other cases. When you say, “I am sure you have seen cases where those drugs were involved but nobody really conducts anesthesia the way you describe it unless they were not trained in anesthesia,” I completely agree that it’s inappropriate to conduct anesthesia the way I described, but I must unfortunately tell you that it happens quite often. Often enough that I’ve personally seen it multiple times, and I’ve heard from other lawyers talking about similar cases. There are a lot of anesthesiologists doing a terrible job, and even more surgeons-who-think-they-can-do-anesthesia and CRNAs-who-don’t-know-when-they’re-over-their-head.
      Finally, you might be right that the anesthesiologist was not present in the room. I’ve seen that one before, too.

      • guest

        Yes, I knew you quoted the HR part; I was just trying to clarify that it was poorly stated. Again, the “chase your tail” story happens but probably not with midazolam for this particular case. It just seemed to be an unusual theory to go for when the simple and more common possibility is just plain overdose without paying attention to whether the girl is breathing. And that is what the real issue is here: vigilance.

        • Daniel

          I have to agree on that Max does not know what he’s talking about. In my many years of anesthesia practice I have never seen Fentanyl and Versed reversed and then given again, and then reversed again, and then given again, etc. It simply doesn’t work that way. If that did happen, I would assume it did from a non-anesthesia provider who does not understand how those drugs work, or a super negligent anesthesia provider who should not be administering anesthesia anyway.
          In cases where reversing those agents is imperative, the benefits of being alive outweigh the risks of not breathing and dying and therefore pain is secondary. If the procedure is that complex where excruciating pain would be expected if the patient woke up, then the anesthesia provider would simply convert to general anesthesia instead of reversing those agents. Office procedures are not that complex and an awake patient would probably experience discomfort, but is either discomfort or death because offices don’t have the means of converting to general anesthesia.
          Also, if an overdose with fentanyl and versed do occur, reversal is not always granted since the anesthesia provider can assist the patient with breathing until the return of breathing from the patient.
          Speak to a qualified provider before making assumptions.

        • http://www.litigationandtrial.com/ Max Kennerly

          You are almost correct that “it simply doesn’t work that way.” It shouldn’t work that way, but it sometimes does, the product of malpractice by the anesthesia provider. I’ve litigated these cases (and won, because, as you confirm, it’s ‘super negligent’).