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FROM A DEATH, TAKE WARNING: IN SURGERY, WATCH OUT WHO'S GIVING THE ANESTHESIA

No one can take surgery lightly. That is indeed the lesson to be learned from the needless death of Sarah Smith, who died after her heart stopped during cosmetic surgery Aug. 25.

With every bad outcome in a surgical procedure, there should be recommendations made and actions taken that will improve our chances at success the next time around.

What happened to Sarah Smith in the office of Dr. Anthony Pignataro may never be generally known. However, it is a reasonable assumption that the intravenous medications and local anesthetics had a major impact on the outcome.

Reports in The News said Sarah Smith received several different potent IV sedatives, including Versed and Valium, both agents commonly used to sedate patients before and during surgery. In addition, she received Pentothal, which is a potent sedative when given in low-dose infusion but is commonly used in higher doses to induce general anesthesia. All these medications could easily act together to induce general anesthesia.

General anesthesia depresses the central nervous system and brain and imparts a state of unconsciousness, rendering the patient unable to feel the pain of a surgical incision. A side effect is that it also depresses the respiratory and cardiovascular systems. The patient's breathing will slow or stop, and blood pressure and heart rate will decrease.

Physicians who are properly prepared for and trained in giving a general anesthesia can easily manage these side effects.

The most important task of the anesthesiologist is to maintain the patency of the airway and support the patient's breathing and circulation so that life can be maintained through this depressed state. Failure to do so will quickly result in disaster.

A possible explanation in a case like the Sarah Smith tragedy would be that the patient became unconscious and stopped breathing after a relatively large dose of sedatives. The body in such a case would be deprived of oxygen to vital tissues. The heart would slow and stop beating, with cardiac arrest leading to coma and death. The lower the cardiac reserve, the less likely the heart can be resuscitated once intervention has been started.

Any pre-existing problem with the heart might or might not be a factor.

One thing is for sure. When an IV is to be started for sedation purposes, the patient should be very clear about the skills of the person who is about to render him or her sedate. Each patient has a different tolerance to medications, and there can be varying effects and side effects to the drugs. What induces a state of calm and sedation in one patient may cause total cardiovascular and respiratory collapse in another.

The problem, of course, is that in most people, the well-trained professional can predict the drug's actions, but in a small number of patients the effects are unpredictable. Not knowing this, and not being prepared and trained to manage the negative effects of the IV drugs, is courting disaster. There is a slim line between heavy sedation and general anesthesia, and the untrained eye is less likely to discern the difference and intervene accordingly.

Anyone contemplating surgery should not go into it lightly.

If you are having surgery, whether it be major surgery or minor, in-hospital or out-of-hospital, if someone places an IV in your arm and informs you that you're going to get a little something to keep you calm, ask if there is an anesthesiologist immediately available, or if your surgeon and staff are trained in handling anesthetic catastrophes. If the answer is no, then think again.

It is also important to note that as the push to lower health-care costs increases, so will the push for surgeons to perform more of these so-called "minor" procedures in their offices, where anesthesiologists are not routinely available. Procedures such as breast biopsies, bronchoscopies, cardioversions and even the procedure that Sarah Smith underwent are routinely performed in a hospital setting with surgeon and anesthesiologist acting in concert.

Hospitals have systems for credentialing physicians who operate within them. The system also provides for setting policies for the monitoring of patient care during surgery as well as for the collection of data to assess patient outcome. The entire process ensures the continuum of quality care and sets the standards for operative care in New York State. Outside of these facilities, these policies are not as easily monitored and care may not meet the same set of standards.

The pressure to bring down health-care costs should not be allowed to reduce the standard of care. Now is the time to heed the warning. No one can take surgery lightly. Every patient should insist on the most qualified hospital, surgeon and anesthesiologist.

DR. DAVID ANTHONE is president of District VII, New York State Society of Anesthesiologists.

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