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August 2001
Volume 65 |
Number 8
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| Update on Office-Based
Anesthesia: Caveats on the Professional Finger-Pointing |
Rebecca S. Twersky, M.D., Chair
Committee on Ambulatory Surgical Care and Task Force on Office-Based
Anesthesia
The term “office-based anesthesia,” or OBA, should
no longer leave anesthesiologists pondering its meaning or its
implications. ASA has taken center stage in establishing its “Guidelines
for Office-Based Anesthesia” — adopted by state medical
boards, accreditation organizations and surgical specialty societies
as the foundation for office-based anesthesia care. In addition,
through the efforts of the ASA Committee on Ambulatory Surgical
Care and the Task Force on Office-Based Anesthesia, a manual titled
“Office-Based Anesthesia: Considerations for Anesthesiologists
in Setting Up and Maintaining a Safe Office Anesthesia Environment”
was published by ASA.* This manual serves as a resource to ASA
members who currently practice or plan to practice in the office
setting.
Nevertheless, contentious issues have thrust anesthesiology into
the middle of what is perceived as professional finger-pointing
between dermatologists and other specialists, primarily anesthesiologists
and plastic surgeons. Several articles have been published by
dermatologists in their journals and most recently in the Journal
of the American Medical Association (JAMA). 1
Brett Coldiron, M.D., of the Departments of Dermatology and Otolaryngology,
University of Cincinnati, published a Research Letter in the May
23/30th issue of JAMA reporting on the “first” prospective
analysis of verifiable data of mandatory reporting of injuries
from surgical procedures performed in medical offices in the state
of Florida.
Dr. Coldiron contacted the offices that reported surgical incidents
or deaths during the 12-month period starting in February 2000
when the reporting became mandatory. There were 31 procedure-related
complications or deaths. He concludes by stating that there is
“greater risk of death from office procedures performed under
general anesthesia.” However, careful scrutiny of his summary
spreadsheet fails to support his conclusions. There were seven
deaths: One patient died from an anaphylactic reaction to contrast
media; the other six involved procedures performed under general
anesthesia. Although there were complications, some of which required
hospital admission, no deaths were associated with local anesthesia,
regional block or intravenous (I.V.) sedation. So what may readers
conclude from this? That general anesthesia is dangerous and was
implicated in the six deaths, of course! But this is not true!
Upon reviewing the details of those six deaths, three deaths
occurred during abdominoplasty/liposuction — two died several
days later from pulmonary embolism; the third patient died during
the night after discharge, probably the result of procedure-related
problems rather than an unfortunate outcome of general anesthesia.
Another patient died from bleeding several days after “endotracheal
intubation” for a tonsillectomy. The article suggests a possible
linkage between postoperative bleeding and anesthesia! Two of
the deaths were related to general anesthesia: one acute bronchospasm
and the other due to unexplained bradycardia and asystole. Since
the total number of procedures in the office is unknown, it is
also difficult to compare the incidence rate with hospitals or
ambulatory surgical facilities. An anesthesiologist or nurse anesthetist
administered all general anesthesia in these incidents.
In addition to his conclusion that there is a greater risk of
death from office procedures performed under general anesthesia,
Dr. Coldiron states that liposuction under general anesthesia
may deserve closer scrutiny since many of the most serious complications
occurred with this procedure. Would it not have been more correct
to state what the data do support? That is, any liposuction surgery
causes relatively more adverse incidents in office practice than
other cosmetic procedures.
For the record, dermatologists rarely, if at all, conduct tumescent
liposuction under general anesthesia. Is it that Dr. Coldiron
is trying to misrepresent the data to support his contention that
liposuction under general anesthesia, as preferred by plastic
surgeons, somehow is less safe than liposuction under tumescent
anesthesia, as is favored by dermatologists? It should not surprise
us since this has been the party line of the American Society
for Dermatologic Surgery (ASDS), as noted on its Web site <www.asds-net.org>.
In 1999, Coleman et al. published an article that reviews the
database of the Physicians Insurance Association of American (PIAA)
Data Sharing Project for claims from 1995-97 to determine who
should perform liposuction and where it should be performed. 2
The data showed that dermatologists who perform small-volume liposuction
under tumescent local anesthesia accounted for only two out of
the 257 claims. The PIAA claims data did not even include specifics
about anesthetic techniques or the use of general anesthesia for
liposuction! Nevertheless, in quoting Dr. Coleman, ASDS concluded
that the primary predictor of complications after liposuction
was the use of general anesthesia! “The practice styles of
dermatologists who perform smaller volume liposuction with true
tumescent local anesthesia results in less injury and, consequently,
fewer lawsuits than surgeons who perform large-volume liposuction
using general anesthesia often combined with the tumescent technique,
a risky combination,” noted Dr. Coleman, a clinical professor
of dermatology at Tulane University School of Medicine, New Orleans.
ASDS listed “the use of general anesthesia” as being
among the three biggest concerns patients should have when considering
treatment and selecting a physician. 3 Based
on this data, however, there is no conclusive evidence that one
anesthetic technique is safer for liposuction than another. Alternative
analysis of the same database by plastic surgeons supports this.
4
It is unclear whether the dermatologic surgeons are inadvertently
or deliberately confusing the risks of general anesthesia with
allowing an increase in the extent of surgical procedures. One
can only speculate that the political intention of the dermatologists
is to remove tumescent liposuction from office-based surgery regulation
or accreditation since it is done purely under local anesthesia
with minimal, if any, sedation. “Ninety-eight percent of
adverse liposuction-related malpractice decisions were surgeons
who traditionally rely upon systemic anesthesia.” (Carl Johnson,
M.D., April 25, 2001, testifying to the South Carolina Board of
Medicine).
It is more appropriate to look at the standards the cosmetic
and plastic surgeons have established for liposuction when combined
with I.V. sedation or general anesthesia. 5
Indeed, the official journal for the American Society of Plastic
Surgeons recently published on the safety of general anesthesia
in the office in more than 23,000 consecutive office-based procedures,
and no deaths were reported. 6 True, there are
specific considerations of which anesthesiologists must be aware
when providing care for the patient undergoing cosmetic surgery,
specifically liposuction. 7 The perioperative
complications associated with liposuction have included pulmonary
embolism, lidocaine toxicity, pulmonary edema, organ perforation,
inappropriate sedation and hypothermia. For example, 60-70 percent
of the tumescent solution may be absorbed, thereby altering the
administration and replacement of fluids by the anesthesiologist.
When lidocaine is infiltrated for tumescent anesthesia, it is
used in doses far in excess of the 7 mg/kg used in regional anesthesia.
While these doses of 35 mg/kg or greater have been promoted as
“safe” since it is highly diluted and combined with
epinephrine, the anesthesiologist should confer with the surgeon
on the mixture to avoid fatal lidocaine toxicity.
The purpose of this discussion is not only to raise awareness
within our specialty of the risks and hazards of the procedures
for which we provide anesthesia, but also the risks and hazards
of the politics of office-based surgery and anesthesia. Responses
have been written to the editor of JAMA, ASPS and ASA are looking
closely at the Coldiron data, and dialogue continues between ASA
and ASDS leadership. If nothing else, this finger-pointing strengthens
the case for supervision of office-based surgery and anesthesia.
References:
1. Coldiron B. Patient injuries from surgical
procedures performed in medical offices (Research letter). JAMA.
2001; 285(20):2582.
2. Coleman WP, Hanke CW, Lillis P, et al. Does
the location of the surgery or the specialty of the physician
affect malpractice claims in liposuction? J Dermatol Surg. 1999;
25:343-347.
3. The American Society for Dermatologic Surgery.
Guiding principles of liposuction. Dermatol Surg. 1997; 23:1127-1129.
4. Bruner JG, DeJong RH. Lipoplasty claims experience
of US insurance companies. Plast Reconstr Surg. 2001; 107:1285-1291.
5. Rohrich RS, Muzaffar AR. Fatal outcomes from
liposuction: Census survey of cosmetic surgeons (Discussion).
Plast Reconstr Surg. 2000; 105(1):447-448.
6. Hoefflin SM, Bornstein JB, Gordon M. General
anesthesia in an office-based plastic surgical facility: A report
on more than 23,000 consecutive office-based procedures under
general anesthesia with no significant anesthetic complications.
Plast Reconstr Surg. 2001; 104:243-251; discussion 252-257.
7. De Jong RH, Grazer FM. Perioperative management
of cosmetic liposuction. Plast Reconstr Surg. 2001; 107:1039-1044.
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Rebecca S. Twersky,
M.D., is Professor of Clinical Anesthesiology, State University
of New York (SUNY) Health Science Center at Brooklyn, New
York. |
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