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.