In the operating room with Dr. Luis Botero, plastic surgeon

Please note that some of the images in this article have been edited to preserve patient privacy.  

Today, Dr. Luis Botero has invited me to observe surgery at IQ Interquirofanos in the Poblado section of Medellin.  He is performing full-body liposuction and fat grafting of the buttocks.

Dr. Luis Botero, in the operating room

Dr. Luis Botero, in the operating room

The facility: IQ Interquirofanos

Interquirofanos is located on the second floor

Interquirofanos is located on the second floor

IQ Interquirofanos is an ambulatory surgery center located on the second floor of the Intermedica Building across the street from the Clinica de Medellin (sede Poblado).  The close proximity of this clinic to a hospital is an important consideration for patients in case of a medical emergency.

The anesthesiologists estimate that 90% of the procedures performed here are cosmetic surgeries but surgeons also perform gynecology, and some orthopedic procedures at this facility.

The are seven operating rooms that are well-lit, and feature modern and functional equipment including hemodynamic monitoring, anesthesia / ventilatory equipment/ medications.  There are crash carts available for the operating rooms and the patient recovery areas.

There are fourteen monitored recovery room beds, while the facility currently plans for expansion.  Next door, an additional three floors are being built along with six more operating rooms.

Sterile processing is located within the facility with several large sterilization units.  There is also a pharmacy on-site.  The pharmacy dispenses prosthetics such as breast implants in addition to medications.

The only breast prosthetics offered at this facility are Mentor (Johnson & Johnson) and Natrelle brand silicone implants (Allergan).  In light of the problems with PIP implants in the past – it is important for patients to ensure their implants are FDA approved, like Mentor implants.

In the past seven years, over 31,000 procedures have been performed at Interquirofanos.  The nurses tell me that during the week, there are usually 30 to 35 surgeries a day, and around 15 procedures on Saturdays.

Prior to heading to the Operating Room:

Prior to surgery, patients undergo a full consultation with Dr. Botero and further medical evaluation (as needed).  Patients are also instructed to avoid aspirin, ibuprofen and all antiplatets (clopidogrel, prasugrel, etc) and anti-coagulants (warfarin, dabigatran, etc.) for several days.  Patients should not resume these medications until approved by their surgeon.

Complication Insurance

All patients are required to purchase complication insurance.  This insurance costs between 75.00 and 120.00 dollars and covers the cost of any treatment needed (in the first 30 days) for post-operative complications for amounts ranging from 15,000 dollars to 30,000 dollars, depending on the policy.   All of his clients who undergo surgery at IQ Interquirofanos are encouraged to buy a policy from Pan American Life de Colombia as part of the policies for patient safety at this facility. International patients may also be interested in purchasing a policy from ISPAS, which covers any visits to an ISPAS-affiliated surgeon in their home country.

Today’s Procedures: Liposuction & Fat Grafting

Liposuction – Liposuction (lipoplasty or lipectomy) accounts for 50% of all plastic surgery procedures.   First the surgeon makes several very small slits in the skin.  Then a saline – lidocaine solution is infiltrated in to the fat (adipose) tissue that is to removed. This solution serves several purposes – the solution helps emulsify the fat for removal while the lidocaine-epinephrine additives help provide post-operative analgesic and limit intra-operative bleeding.  After the solution dwells (sits in the tissue) for ten to twenty minutes, the surgeon can begin the liposuction procedure.  For this procedure, instruments are introduced to the area beneath the skin and above the muscle layer.

During this procedure, the surgeon introduces different canulas (long hollow tubes).  These tubes are used to break up the adipose tissue and remove the fat using an attached suctioning canister.  To break up the fat, the surgeon uses a back and forth motion.  During this process – one hand is on the canula.  The other hand remains on the patient to guide the canulas and prevent inadvertent injury to the patient.

fat being removed by liposuction

fat being removed by liposuction

Due to the nature of this procedure, extensive bruising and swelling after this procedure is normal.  Swelling may last up to a month.  Patients will need to wear support garments (such as a girdle) after this procedure for several weeks.

Types of liposuction:

In recent years, surgeons have developed different techniques and specialized canulas to address specific purposes during surgery.

Standard liposuction canulas come in a variety of lengths and bore sizes (the bore size is the size of the hole at the end of the canister for the suction removal of fat tissue.)  Some of these canulas have serrated bores for easier fat removal.

Ultrasound-assisted liposuction uses the canulas  to deliver sound waves to help break up fat tissue.  These canulas are designed for patients who have had repeated liposuction.  This is needed to break up adhesions (scar tissue) that forms after the initial procedure during the healing process.

Laser liposuction is another type of liposuction aimed at specifically improving skin contraction.  This is important in older patients or in patients who have excessive loose skin due to recent weight loss or post-pregnancy.  However, for very large amounts of loose skin or poor skin tone in areas such as the abdomen, a larger procedure such as abdominoplasty may be needed.

During laser liposuction, a small wire laser is placed inside a canula to deliver a specific amount of heat energy to the area (around 40 degrees centrigrade).  The application of heat is believed to stimulate collagen production (for skin tightening).  Bleeding is reduced because of the cautery effect of the heat – but post-operative pain is increased due to increased inflammatory effects.  There is also a risk of burn trauma during this procedure.

There have been several other liposuction techniques that have gone in and out of fashion, and many of the variations mentioned are often referred to by trademark names such as “Vaser”, “SmartLipo”, “SlimLipo” which can be confusing for people seeking information on these procedures.

Fat Grafting

Fat from liposuction procedure to be used for buttock augmentation

Fat from liposuction procedure to be used for buttock augmentation

Fat grafting is a procedure used in combination with liposuction.  With this procedure, fat that was removed during liposuction is relocated to another area of the body such as the buttocks, hands or face.

In this patient, Dr. Botero injects the fat using a large bore needle deep into the gluteal muscles to prevent a sloppy, or dimpled appearance.  Injecting into the muscle tissue also helps to preserve the longevity of the procedure.  However, care must be taken to prevent fat embolism*, a rare but potentially fatal complication – where globules of fat enter the bloodstream.  To prevent this complication, Dr. Botero carefully confirms the placement of his needle in the muscle tissue before injecting.

Results are immediately appreciable.

fat being injected for buttock augmentation. (Photo edited for patient privacy).

fat being injected for buttock augmentation. (Photo edited for patient privacy).

The Surgery:

Patient was appropriately marked prior to the procedure.   The patient was correctly prepped, drapped and positioned to prevent injury or infection.  Ted hose and sequential stockings were applied to lessen the risk of developing deep vein thrombosis.  Pre-operative procedures were performed according to internationally recognized standards.

Sterility was maintained during the case.  Dr. Botero appeared knowledgeable and skilled regarding the techniques and procedures performed.

His instrumentadora (First assistant), Liliana Moreno was extremely knowledgeable and able to anticipate Dr. Botero’s needs.

Circulating nurse: Anais Perez maintained accurate and up-to-date intra-operative records during the case.  Ms. Perez was readily available to obtain instruments and supplies as needed.

Overall – the team worked well together and communicated effectively before, during and after the case.

Anesthesia was managed by Dr. Julio Arango.   He was using an anesthesia technique called “controlled hypotension”.  (Since readers have heard me rail about uncontrolled hypotension in the past – I will write another post on this topic soon.)

Controlled Hypotension

However, as the name inplies – controlled hypotension is a tightly regulated process, where blood pressure is lowered to a very specific range.  This range is just slightly lower than normal (Systolic BP of around 80) – and the anesthesiologist is in constant attendance.  This is very different from cases with profound hypotension which is ignored due to an anesthesia provider being distracted – or completely absent.

With hypotensive anesthesia – blood pressure is maintained with a MAP (or mean) of 50 – 60mmHg with a HR of 50 – 60.  This reduces the incidence of bleeding.

However, this technique is not safe for everyone.  Only young healthy patients are good candidates for this anesthesia technique.  Basically, if you have any stiffening of your arteries due to age (40+), smoking, cholesterol or family history – this technique is NOT for you.  People with high blood pressure, any degree of kidney disease, heart disease, peripheral vascular disease or diabetes are not good candidates for this type of anesthesia. People with these kinds of medical conditions do not tolerate even mild hypotension very well, and are at increased risk of serious complications such as renal injury/ failure or cardiovascular complications such as a heart attack or stroke.  Particularly since this is an elective procedure – this is something to discuss with your surgeon and anesthesiologist before surgery.

The patient today is young (low 20’s), physically fit, active with no medical conditions so this anesthesia poses little risk during this procedure. Also the surgery itself is fairly short – which is important.  Long/ marathon surgeries such as ‘mega-makeovers‘ are not ideal for this type of anesthesia.

Dr. Julio Arrango keeps a close eye on his patient

Dr. Julio Arango keeps a close eye on his patient

However, Dr. Arango does an excellent job during this procedure, which is performed under general anesthesia.   After intubating the patient, he maintained a close eye on vital signs and oxygenation.  The patient is hemodynamically stable with no desaturations or hypoxia during the case.  Dr. Arango remains alert and attentive during the case, and remains present for the entire surgery.  Following surgery, anesthesia was lightened, and the patient was extubated prior to transfer to the recovery room.

He also demonstrated excellent knowledge of international protocols regarding DVT/ Travel risk, WHO safety protocols and intra-operative management.

Surgical apgar score: 9  (however, there is a point lost due to MAP of 50 – 60 as discussed above).

Results of the surgery were cosmetically pleasing.

Post -operative care:

Prior to discharge from the ambulatory care center after recovery from anesthesia the patient (and family) receives discharge instructions from the  nurses.

The patient also receives prescriptions for several medications including:

1. Oral antibiotics for a five-day course**. Dr. Botero uses this duration for fat grafting cases only.

2. Non-narcotic analgesia (pain medications).

3. Lyrica ( a gabapentin-like compound) to prevent neuralgias during the healing period.

The patient will wear a support garment for several weeks.  She is to call Dr. Botero to report any problems such as unrelieved pain, drainage or fever.

Note: after some surgeries like abdominoplasty, patients also receive DVT prophylaxis with either Arixtra or enoxaparin (Lovenox).

Follow-up appointments:

Dr. Botero will see her for her first follow-up visit in two days (surgery was on a Saturday).  He will see twice a week the first week, and then weekly for three weeks (and additionally as needed.)

* Fat embolism is a risk with any liposuction procedure.

**This is contrary to American recommendations as per the National Surgical Care Improvement Project (SCIP) which recommends discontinuation within the first 24 hours to prevent the development of antibiotic resistance.

Why quality of anesthesia matters: who is administering your anesthesia?

I know some readers find some of my reporting dry and uninspired, particularly when talking about methodology, measurements and scales such as Surgical Apgar Scoring.  But the use of appropriate protocols, safety procedures and specialized personnel is crucial for continued patient safety.

There is a saying among medical professionals about our patients.. We want them all to be boring and routine.   That is what I strive for, for each and every one of my readers – safe, boring and routine.

Excitement and drama are only enjoyable when watching Grey’s Anatomy or other fictionalized medical dramas.  In real life, it means something has drastically and horribly gone awry.  Unlike many of its fictional counterparts – outcomes are not usually good.

this patient is in trouble.. But at least someone is watching the monitor.. (and there is a monitor)..

this patient is in trouble.. But at least someone is watching the monitor.. (and there is a monitor)..

In a not-so-sleepy hollow of upstate New York, a medical tragedy serves to illustrate this point, while also bringing up questions regarding the procedure.  While we don’t know the circumstances behind this case – (and don’t really want to speculate on this specific case), it does open the discussion on the quality of anesthesia and anesthesia-monitoring for non-general anesthesia procedures.  This includes procedures using sedative-hypnotics, epidurals and anesthetic combinations.  This is often referred to as “twilight” or “conscious sedation” procedures.

People tend to think of these procedures as being entirely safe – whether it is so-called “sleep dentistry’ or any variety of scope procedures (endoscopy, colonscopy, bronchoscopy).  In fact, many of these procedures are often done in out-patient settings; dentists’ and doctors’ offices without the services of an anesthesiologist or CRNA (nurse anesthetist) and/or appropriate monitoring.

This is extremely  troubling – especially since a slew of research papers over the years have clearly demonstrated that this is not safe.  In an eye-opening paper published several years ago, over 70% of non-anesthesia trained physicians underestimated the patient’s level of sedation during gastroenterology procedures.  (While I can not find a copy of this article online – its publication led to changes in the recommendations related to administration of anesthesia by non-anesthesia providers).

In an notable survey published on dental anesthesia, 35% of respondents providing anesthesia during dental procedures had no formal training in anesthesia.

Too often, the medical professionals (non-anesthesia specialty) underestimate the level of anesthesia achieved and critical safeguards to prevent potential patient injury are not taken.  One weekend course, or online continuing education course is not sufficient training.

In the case cited above, a young woman underwent an endoscopy procedure.  During this procedure – the patient became hypotensive (low blood pressure) and hypoxic (oxygen-starved) resulting in severe brain damage and disability.  The patient is now unable to see, or speak.  This devastating outcome is a clear example of the risks during these types of procedures due to anesthesia.

While the  details of the case above differ (patient was in a hospital) the family is now suing claiming that the patient did not receive prompt medical attention when these events occurred.

Unconscious, overmedicated and unmonitored in the office: Recipe for disaster

More concerning in my view, is for all of those patients undergoing these very procedures outside of hospital facilities – away from trained experts.  In many cases, the office patients are given medications without any continuous monitoring devices such as continuous telemetry and oxymetry (which detect low blood pressure and hypoxia immediately) versus ‘spot-check’ methods that office staff may employ.

For example; several years ago, one of my good friends worked as a nurse in a gastroenterologists office.  While she was a well-trained and excellent nurse – she was not a trained anesthesia provider – nor was she provided with the adequate equipment to monitor or treat anesthesia complications.

What equipment, you ask?  The office had no cardiac monitoring – (hemodynamic monitoring).  There were no reversal agents available in case of oversedation, no supplemental oxygen for respiratory depression/ hypoxia – and most critically – no crash cart in case of cardiac or respiratory arrest. (While the law requires this in some states, that doesn’t  guarantee that the provider has the appropriate equipment.)

In the office where my friend worked, the nurse administered a set amount of sedation under the guidance of the gastroenterologist.  During the procedure, vital signs were checked every 15 minutes (giving the patient 14 minute intervals to develop serious procedures unnoticed by anyone).

Was this the right or safe way to care for patients?  No, absolutely not – but it remains a common practice in doctors’ offices around the country.

The death of Michael Jackson

Another more extreme but famous example of the dangers of ‘unmonitored anesthesia’ is the death of Michael Jackson during the administration of propofol by a Dr. Conrad Murray in Mr. Jackson’s home.  During the investigation, it was noted that not only was the patient (Michael Jackson) without continuous hemodynamic monitoring (and oxymetry) – he was left unattended for significant periods while Dr. Murray conducted business and placed numerous telephone calls.  While this is an extreme example – it also demonstrates the dangers of anesthesia administration without qualified personnel, appropriate monitoring or rescue equipment.

In 2009 Metzer et. al. reviewed all liability claims and summarized this along with their previous research regarding related anesthesia injury and concluded, “Data from the American Society of Anesthesiologists, Closed Claims database suggest that anesthesia at remote locations poses a significant risk for the patient, particularly related to oversedation and inadequate oxygenation/ventilation during monitored anesthesia care.”

If you are planning to have any sort of procedure requiring any sedation or anesthesia (other than local anesthesia like lidocaine), ask the following questions:

– Who will be administering my anesthesia/ sedation?  What are their credentials and training in anesthesia?

– How will I be monitored during this procedure?  Who will be monitoring me?  What type of safety protocols are in place for peri-procedural monitoring?

– What if there is a problem?  Do you have the equipment necessary to reverse sedation?  perform urgent intubation?  resuscitation?

If this procedure is being performed in a doctor’s office or outpatient surgery center: – What happens if a complication develops during this procedure?  Is there a hospital nearby for emergencies?

References / Resources

Boynes SG, Moore PA, Tan PM Jr, Zovko J. (2010).  Practice characteristics among dental anesthesia providers in the United States.  Anesth Prog. 2010 Summer;57(2):52-8. doi: 10.2344/0003-3006-57.2.52.  (free full text – linked in article above).

Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. (2006).  Trends in anesthesia-related death and brain damage: A closed claims analysis.  Anesthesiology. 2006 Dec;105(6):1081-6.   (full text available).  This study clearly showed the benefit of continuous pulse oxymetry and other hemodynamic monitoring to prevent catastrophic complications.

Cohen, L. & Aisenburg, J. (2008).  Endoscopic sedation: Preparing for the future.  Gastrointestinal endoscopy clinics of north America; 18(4).

Hangsheng Liu, PhD;  Daniel A. Waxman, MD;  Regan Main,                                  Soeren Mattke, MD, DSc (2012).  Endoscopies and Colonoscopies and Associated Spending in 2003-2009.  JAMA. 2012;307(11):1178-1184. doi:10.1001/jama.2012.270   The authors attempt to estimate the frequency in which qualified anesthesia providers are used during gastroendoscopy procedures.

Metzner J, Posner KL, Domino KB (2009). The risk and safety of anesthesia at remote locations: the US closed claims analysis.  Curr Opin Anaesthesiol. 2009 Aug;22(4):502-8. doi: 10.1097/ACO.0b013e32832dba50.

Paspatis GA, Tribonias G, Paraskeva K.  (2010).  Level of intended sedation.  Digestion. 2010;82(2):84-6. doi: 10.1159/000285504. Epub 2010 Apr 21.  Article discussing the issues regarding sedation during endoscopy procedures.

Robbertze R, Posner KL, Domino KB. (2006). Closed claims review of anesthesia for procedures outside the operating room.  Curr Opin Anaesthesiol. 2006 Aug;19(4):436-42. Review.

Smartphones and Facebook in the operating room

I hope everyone enjoyed posts about Colombian life and culture, but now that I am back in the United States – we will get back to our more serious discussions about patient safety and issues in health care.  One of the things we have talked a lot about in the past – and cover extensively in the Hidden Gem book series is operating room quality and safety measures.  This includes using objective measurement tools such as the Surgical Apgar score (created by physician and author, Dr. Atul Gawande) and the safety checklist.

Surgeon as pilot 

These checklists were designed to be similar to the mandatory checklists used by pilots.    They were originally designed in the 1930’s to prevent pilot errors and accidents as planes become more and more complex.

Tools to measure and improve practice

These tools do more than just rate (or grade) operating room safety procedures – they encourage a ‘culture of safety’ and adherence to practices and procedures designed to prevent errors or mistakes.  This means that the more people use (and become familiar with) these practices – the better they get at detecting and preventing errors.

The importance of these checklists has been recognized for years, but is just now gaining in traction. It wasn’t until 2009, that the World Health Organization recommended use of the checklist in hospitals internationally.

Checklists and hospital reimbursement

American hospitals now use the checklist religiously because ‘core measures’  – and reimbursement are tied to its use.  These ‘core measures’ were established a decade ago as part of quality assurance procedures for Medicare and Medicaid.  American hospitals that do not participate (or score poorly) on core measures such as surgical safety procedures – risk not getting paid for their services.  (There are core measures for other patient care items as well, such as the care of patients having a heart attack, or pneumonia).

Surgical Apgar Score

The surgical apgar score, (and similar scales) have been slower to catch on.  This is unfortunate in my opinion, because this tool has the greatest chance of really improving patient care and preventing patient harm.  The surgical apgar score works by basically rating and grading the actual care of the patient in the operating room.

When consumers think about patient care in the operating room – we tend to focus on the surgeon.  But surgery and surgical skill are only a part of the picture.  The anesthesiologist/ nurse anesthestist and anesthesia care team are critical to the safety and health of the patient – and their inattention / or distraction can be disasterous for patients.  But even when disaster is averted – frequent distractions can lead to increased complications.  Sometimes the effects are subtle; such as twenty or thirty minutes of ‘borderline’ low blood pressure and post-operative organ dysfunction from intra-operative ischemia.

But is anyone paying attention?

But is anyone paying attention?

We all know it happens, but too many anesthesiologists are busy playing on Facebook to address the realities of the situation.

Unfortunately, this is a common problem in operating rooms worldwide

Unfortunately, this is a common problem in operating rooms worldwide

None of this is news to long-time readers, but several new articles confirm the utility of safety checklists and operating room safety practices.  (One of the articles somewhat ironically reports that injuries to patients were not as reduced as anticipated by previous studies – because the checklist was not always used / or used correctly.  The authors note that the checklists reduced patient injuries and complications – when they were actually used.


Additional posts on this and similar topics:

Reputation, Ranking and Objective measures – talking about the ‘core measures’.

More about the surgical apgar score – from our sister site.

The original Surgical Apgar score

Additional references

I will be updating this section frequently over the next few days.

Medscape summary articles:

Hilt, Emma, (2012). Surgical checklist from WHO improves safety and outcomes.  Medscape, November 2012.

Source articles:

Fudickar, A., Horle, K., Wiltfang, J. & Bein, B. (2012). The effect of the WHO surgical checklist on complication rate and communication.  Dtsch. Artztebl Int 2012, 109(42): 695-701.  The authors of this German paper examined / analyzed 20 different studies looking at the use of surgical checklists.

Jorm CM, O’Sullivan G. (2012). Laptops and smartphones in the operating theatre – how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction?  Anaesth Intensive Care. 2012 Jan;40(1):71-8.

Patterson P. (2012). Smartphones, tablets in the OR: with benefits come distractions.  OR Manager. 2012 Apr;28(4):1, 6-8, 10.  [no free full text available].

Pereira, Bruno Monteiro Tavares et al. Interruptions and distractions in the trauma operating room: understanding the threat of human error. Rev. Col. Bras. Cir. [online]. 2011, vol.38, n.5 [cited  2012-12-18], pp. 292-298 .