"please keep me updated about oximeters "
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Dangers of Surgery Outside (or Inside) Hospital
"For patients with certain high-risk conditions such as sleep apnea, a common disorder involving pauses in breathing during sleep, experts say it is generally better to have surgery in a hospital or a facility that is adjacent to one. But even then, things can go wrong, particularly if there isn’t adequate information about a patient’s medical condition.
Ruthell Howard, a newspaper copy editor, stopped breathing during minor surgery in 2005 under sedation with the drug propofol, sustained severe brain damage and died in a nursing home at age 50 two years later. She suffered from both sleep apnea and a condition that caused inflammation in her lungs. Her sister-in-law, Myrna Howard, says Ruthell was a conscientious and careful patient, but she may not have been aware of the extent of the risks.
One lesson for patients, Ms. Howard says, is to fully disclose any conditions that might put them at risk during surgery and to make sure their medical records have been reviewed prior to any procedure.
But she also says doctors and nurses have a duty to elicit information, especially if there are language barriers or a patient’s medical knowledge is limited. “There are too many patients going into surgery who might not fully appreciate the dangers,” she says."
-- excerpted from http://online.wsj.com/article/SB10001424052970204900904574300273421...
Ruthell Howard, a newspaper copy editor, stopped breathing during minor surgery in 2005 under sedation with the drug propofol, sustained severe brain damage and died in a nursing home at age 50 two years later. She suffered from both sleep apnea and a condition that caused inflammation in her lungs. Her sister-in-law, Myrna Howard, says Ruthell was a conscientious and careful patient, but she may not have been aware of the extent of the risks.
One lesson for patients, Ms. Howard says, is to fully disclose any conditions that might put them at risk during surgery and to make sure their medical records have been reviewed prior to any procedure.
But she also says doctors and nurses have a duty to elicit information, especially if there are language barriers or a patient’s medical knowledge is limited. “There are too many patients going into surgery who might not fully appreciate the dangers,” she says."
-- excerpted from http://online.wsj.com/article/SB10001424052970204900904574300273421...
Views: 104
Replies to This Discussion
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Permalink Reply by Edward Grandi on
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The ASAA has two patient education bulletins on CPAP in the hospital.
Both are accessible from our web site - www.sleepapnea.org
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Permalink Reply by Sandra Kay Goodwin on
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M doctor wants me to have a gastric by pass, but I have severe sleep apnea and I don't think I want to take that chance. I would prefer the lap band if I have to have one done. I have Central apnea wherre my brain isn't sending messages to my heart and lungs to tell me to breathe.
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Permalink Reply by Mary L. Montovio on
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ALWAYS, ALWAYS, disclose everything to your doctor and when you do a pre surgical testing and interview.
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This is so scary. Everyone with Sleep Apnea or for that matter, any other serious medical condition that could cause problems during a surgery, should write it down and place it with your driver's license. Being a retired Deputy Sheriff, that is one of the first places (after giving first aid) my fellow officers and I look when someone has been in an accident or is unconscious. This is the quickest way to alert the medical staff. You could also wear a medical alert bracelet.
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Permalink Reply by Jim Nadolny, BS, CRT on
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Patients with OSA are at higher risk during intubation (putting the tube in for surgery). The extra tissue or anatomical obsticals that create obstruction during sleep, can also make for a difficult intubation. See this article on Anesthesia Safety and OSA...http://www.apsf.org/resource_center/newsletter/1997/summer/sleepapn...
Obstructive Sleep Apnea patients are also at higher risk of cardiovascular disease. Next month I am having an author write about the link on http://cpapcritic.com . A proper screening should always be done prior to surgery and these factors taken into account.
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I had gastric bypass in September 2008 and I have never regretted it. I promise you it is a good thing. The lap band is not nearly as effective. In both surgeries they will put you clear out so there is no difference in anesthesia. So you may as well go for the one that is most effective. Before doing either surgery they check your heart, lungs and send you for psych testing to be sure you are ready. They also tell you to bring your cpap to the hospital. So far I have lost 130 pounds and I feel so much better!! If there is anything I can help you with please email me. Gastric bypass is something that I support big time!! I am a nurse so I thourghly researched it before I did it.
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I have a bigger problem - both Central Sleep Apnea and Obstructive Sleep Apnea, and the Obstructive is coming at least partly from a retrognathic lower jaw (receding chin, manidble - lower jaw - is back a bit, so looks like I have almost no chin, and I can only sleep on my back - tongue flops back and blocks air flow, but oral appliance to advance the jaw not all that helpful since I can't advance the lower jaw much due to long-standing TMJ i.e. jaw joint problems).
What sedatives, pain medications, medications in general (Rx and Over the Counter), and anesthesia can safely be given during a procedure? I may need a rectocele and cystocele repair soon (aging problems, things drop down and cause problems). I also may want the lower jaw advanced forward. Even for an endoscopy, which I periodically need, I would need sedation.
If no one knows what is safe, could someone recommend a top expert in the Central Sleep Apnea whom I can consult? Thank you.
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Dear Sleepguide Members, the above story is tragic but keep in mind that Propofol was not the issue nor was the lack of disclosing her medical history of sleep apnea a contributing factor to the negative outcome. The crux of the matter is that if you are going to have sedation, which can be MORE dangerous than general anesthesia, you must make sure you are cared for by someone who can rescue a patient who stops breathing or whose airway obstructs. Many have touted sedation as being safer than general anesthesia and nothing can be further from the truth. Decades ago studies revealed the highest risks were associated with procedures during which patients were "sedated". Patients today want to feel nothing, know nothing, remember nothing during their procedures and in order to accomplish this, a patient needs to have a very deep level of sedation, one which many times compromises the airway and ventilation of the patient. To assume that general anesthesia is riskier than sedation demonstrates ignorance. I have seen procedures performed under "sedation" which should be called general anesthesia without airway management and I would NEVER allow my family members to be cared for this way. In addition if a patient is to have "sedation" for "minor surgery", the most important thing to do is to make sure that the sedation is administered by an anesthesiologist or at the very least a nurse anesthetist. I have been providing anesthesia care for nearly 20 years and I have never had a patient who died during surgery. Yet if you look at complications associated with "sedation" procedures, you have to wonder, how many people must die before laws are enacted to protect patients. The fact that Ms. Howard failed to disclose her history of sleep apnea is irrelevant and do not let anyone tell you that had they had that information it would have made a difference. Today I provide anesthetics for patients who do not have the diagnosis of sleep apnea but who I am concerned may have that medical condition. Still, after recommending that these patients undergo a sleep study in order to determine the correct diagnosis, these patients undergo safe anesthetics and go home. The bottom line is that patients who might have severe sleep apnea, may not have the diagnosis but still we as anesthesiologists need to make sure that the outcome is good and that is why we are there. Patients having sedation should have two monitors used during their care, a pulse oximeter and a carbon dioxide monitor, in addition to the standard monitors of blood pressure, ECG and heart rate. Everyday I stop patients from breathing intentionally and they do not die, I breathe for them and that is what Ms. Howard should have had done. In addition, I wonder if this patient had a pulse oximeter which tells you beat to beat indirect oxygen levels in the patients blood stream? Anyone who practices sedation without at least a pulse oximeter is definitely practicing outside of the standard of care. I do not know the details of Ms. Howard's case but for a patient to die while being sedated, should be extremely rare. I have anesthetized and sedated over 15,000 patients in the last 18 years and I have not had this type of outcome. Medical history is good to have, but it is not the medical history that dictates what to do when a patient stops breathing or their airway becomes obstructed. I still do not understand this patient's outcome.
B Robles MD
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Hi Cathy, I live on the east coast and we have trouble getting approvals for GBypass. My BMI is a few points low on the scale of things. I am 53, 5'3" tall and weigh 201. I have severe OAS and I have had a UVPP that was useless. I suffer from Diabetes type 2, High blood pressure, elevated heart rate, high trigicerides, adhesions, and more. I have been trying to get someone to listen to me and say that it would really help my conditions by having the GP. What do you think?
Cathy s said:I had gastric bypass in September 2008 and I have never regretted it. I promise you it is a good thing. The lap band is not nearly as effective. In both surgeries they will put you clear out so there is no difference in anesthesia. So you may as well go for the one that is most effective. Before doing either surgery they check your heart, lungs and send you for psych testing to be sure you are ready. They also tell you to bring your cpap to the hospital. So far I have lost 130 pounds and I feel so much better!! If there is anything I can help you with please email me. Gastric bypass is something that I support big time!! I am a nurse so I thourghly researched it before I did it.
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Permalink Reply by Steven Y. Park, MD on
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Coincidentally, a study just published in Sleep Medicine showed how common sleep apnea is in a typical academic medical center's population of people undergoing surgery. Here's the link. In brief, patients were initially screened via questionnaire for sleep apnea and about 1/4 were found to be at high risk. Of these high risk patients, a polysomnogram revealed that 82% had significant obstructive sleep apnea.
As an otolaryngologist that performs lots of procedures in the upper airway (for sleep apnea as well as a variety of other non-sleep apnea related conditions), I'm always extra careful about anyone that I operate on, especially if they have even routine conditions such as a deviated nasal septum or chronic ear conditions. By definition, if you have chronic nasal congestion or ear infections, your airway will be compromised to some degree. I tell my anesthesiologists to assume that all my patients may have sleep apnea, whether or not it's officially diagnosed. It's ironic that I became interested in sleep-breathing problems as a result of a complication after sleep apnea surgery early in my career (the patient did fine).
Here are some thoughts and steps that I take to make sure airway complications don't happen:
1. For general anesthesia, the intubation can be difficult due to the constricted anatomy, but once the tube is in, you're pretty safe, as long as the tube is in. However, once you take out the tube, this is when bad things can happen. If you extubate deeply, and without the tube in place to stent open the airway behind the tongue, then you can obstruct. Many anesthesiolgists use an oral airway or a nasopharyngeal airway to keep things open just after extubation. This works in most cases, but not all the time.
2. If there's any possibility of sleep apnea, I make sure the tube is pulled when the patient is completely awake. Yes, it takes a little longer to wake up the patient, but it's better than a patient obstructing post-extubation.
3. If you know you're going to have a difficult intubation, go straight for a video guided intubation with experienced anesthesiologists, rather than the traditional method. You'll have less trauma, less bleeding and less throat pain after the procedure.
4. If you're ever going to do UPPP surgery alone (it should be a rare situation), expect a higher chance of obstruction after extubation. This is because you didn't address the underlying cause of the sleep apnea in most cases, which is the tongue. Once I started doing tongue base procedures in addition to the UPPP, patients wake up smoothly and without any complications.
5. Talk to your anesthesiologist before the surgery and have a discussion about potential issues that may arise, and have a plan in place regarding how you're going to intubate, what type of agents/medications will be used, and how you're going to extubate.
I agree that procedures done under "sedation" are riskier for the reasons stated in this post. When we had a rash of patients dying after surgical procedures in New York City many years ago, the vast majority were performed using sedation only. In this era of high volume, high turnover environments in the OR, you can see how complications can happen.
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Permalink Reply by Gordon Osmond on
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I was not aware of this. I am having a "local" in a couple of week's time. I shall be aware.
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Permalink Reply by Mack D Jones, MD, SAAN on
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Dr Robles has hit on the crux of the issue of death from "sedation." We are entrusting physicians, mostly surgeons, with our lives with these procedures and too many have no knowledge of OSA. Prolonging apneas in an OSA patient can kill and does. Up to 90% of OSA subjects are undiagnosed. The informed physician is aware of this and treats every patient as a potential case. This tragedy is not likely to occur in the hands of an anesthesiologist of nurse anesthetist, since breathing is part of the essence of their specialty. Of course a problem can arise post-op, as Dr Roble noted, if the appropriate monitors are not used no matter who is in charge. Let's put a stop to this licensed killing before another innocent victim goes to his/her grave.
B Robles MD said:Dear Sleepguide Members, the above story is tragic but keep in mind that Propofol was not the issue nor was the lack of disclosing her medical history of sleep apnea a contributing factor to the negative outcome. The crux of the matter is that if you are going to have sedation, which can be MORE dangerous than general anesthesia, you must make sure you are cared for by someone who can rescue a patient who stops breathing or whose airway obstructs. Many have touted sedation as being safer than general anesthesia and nothing can be further from the truth. Decades ago studies revealed the highest risks were associated with procedures during which patients were "sedated". Patients today want to feel nothing, know nothing, remember nothing during their procedures and in order to accomplish this, a patient needs to have a very deep level of sedation, one which many times compromises the airway and ventilation of the patient. To assume that general anesthesia is riskier than sedation demonstrates ignorance. I have seen procedures performed under "sedation" which should be called general anesthesia without airway management and I would NEVER allow my family members to be cared for this way. In addition if a patient is to have "sedation" for "minor surgery", the most important thing to do is to make sure that the sedation is administered by an anesthesiologist or at the very least a nurse anesthetist. I have been providing anesthesia care for nearly 20 years and I have never had a patient who died during surgery. Yet if you look at complications associated with "sedation" procedures, you have to wonder, how many people must die before laws are enacted to protect patients. The fact that Ms. Howard failed to disclose her history of sleep apnea is irrelevant and do not let anyone tell you that had they had that information it would have made a difference. Today I provide anesthetics for patients who do not have the diagnosis of sleep apnea but who I am concerned may have that medical condition. Still, after recommending that these patients undergo a sleep study in order to determine the correct diagnosis, these patients undergo safe anesthetics and go home. The bottom line is that patients who might have severe sleep apnea, may not have the diagnosis but still we as anesthesiologists need to make sure that the outcome is good and that is why we are there. Patients having sedation should have two monitors used during their care, a pulse oximeter and a carbon dioxide monitor, in addition to the standard monitors of blood pressure, ECG and heart rate. Everyday I stop patients from breathing intentionally and they do not die, I breathe for them and that is what Ms. Howard should have had done. In addition, I wonder if this patient had a pulse oximeter which tells you beat to beat indirect oxygen levels in the patients blood stream? Anyone who practices sedation without at least a pulse oximeter is definitely practicing outside of the standard of care. I do not know the details of Ms. Howard's case but for a patient to die while being sedated, should be extremely rare. I have anesthetized and sedated over 15,000 patients in the last 18 years and I have not had this type of outcome. Medical history is good to have, but it is not the medical history that dictates what to do when a patient stops breathing or their airway becomes obstructed. I still do not understand this patient's outcome.
B Robles MD
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