The risks from Anaesthesia

There is one branch of medical science (anaesthesiology) whose contribution to the treatment of the sick and the infirm is no less important and significant than that of physicians and surgeons. Indeed without the assistance, of these practitioners, surgery however minor would not be possible.

Most people assume that general anaesthesia is so commonly administered for routine surgery that there is absolutely no danger associated with the procedure. In fact, the average patient who is led into the operation theatre by nurses rarely pauses to think about the potentially dangerous side-effects of general anaesthesia though a few anxious patients, for psychological reasons, prefer surgery to be performed with the help of local anaesthetics whenever possible. Therefore, the average surgeon chooses either of the two, i.e. general anaesthesia or a local anaesthetic depending on the nature of the ailment, the type of surgery to be performed and the facilities available in a particular hospital. However, it has to be conceded that lay people in general are perhaps totally unaware of the dangerous complications that are sometimes associated with general anaesthesia as illustrated in the two cases mentioned below.

 A tall and hefty merchant marine checked into a hospital in New York for a minor eye surgery. His anaesthetist was a student nurse trainee: he emerged from his operation a quadriplegic, mute and blind.

Eventually, he died of kidney infection, a complication of his paralysis. About a decade later a 17-year old boy was admitted to a hospital in Toronto, Canada, for correction of a nose injury. The operation was considered minor and routine, devoid of risks. Unfortunately, his heart failed during the operation. Although surgeons revived him, the boy lapsed into a coma and died.

Surgeons in both cases argued that the patients had been accidental victims of a rare and undetected genetic disease called ‘malignant hyperthermia’ which was merely triggered by anaesthetic gases that would normally be safe and effective. In the case of the former patient, physicians had to face a lawsuit that charged that they had failed to monitor the patient’s anaesthesia adequately and to treat its adverse effects in time. No wonder doctors in advanced countries are getting increasingly worried about such possible legal complications while resorting to surgical procedures. Suspicion is gradually growing among surgeons that general anaesthesia be far more hazardous than they had once thought. It is estimated that in North America every year more than fifty thousand people die either directly due to anaesthesia or at least due to some factor related to anaesthesia. It is also estimated that 1 in 10,000 healthy patients undergoing elective surgery with anaesthesia dies for no clear reason. Even such supposedly minor procedures as tonsillectomy and cystoscopy under anaesthesia have produced unexpectedly high mortality rates.

However, according to some physicians in Canada who have been concerned about the issue many of these deaths can be preventedl. They consider it absolutely necessary to carry out a large scale safety test of the four most common chemical agents used to maintain general anaesthesia: halothane, fontanel citrate, isoflurane and enflurane, as in their view the relative safety of these agents is not known and very limited information is available on the risks associated with the chemicals used.

Most surgeons are aware of the usual post anaesthesia complaints. These include dizziness, loss of concentration and occasional hair loss, but even these are still not properly understood. Surgeons also feel that though such hazards as bronchial spasm, erratic fluctuation of blood pressure and impaired brain and liver functions are recognised they have never been systematically and properly analysed.

Therefore, the Canadian doctors who are desirous of carrying out a safety test in respect of the chemicals used in general anaesthesia would first like to get information from a few health centres where some 26,000 patient volunteers would receive randomly one of the four anaesthetics being studied. Though they expect that the drugs will show significant differences in safety, they do not exactly know what they will find. Some other doctors feel that the above exercise may not be fruitful and that only a massive study of hundreds of thousands of patients over a long period of time would yield useful information. While agreeing that general anaesthesia must be studied more carefully, they are at the same time inclined to believe that more useful lessons can be drawn by comparing general with regional or local anaesthetics.

According to them, general anaesthesia is used too often where safer local anaesthetics might be just as effective and serve the purpose.

It is thus, gradually beginning to be realised that anaesthetics themselves are not the only hazard, nor are they the worst. For example, in the United States acute care hospitals reportedly perform roughly 24 million operations each year. In order to handle this load there are only 18,000 anaesthetists and about 1800 residents in anaesthesia. The overflow is taken on by nurse anaesthetists and others many of whom have little or no training in anaesthesiology. If this is the state of affairs in the United States, one could imagine the desperate situation in less advanced countries and developing countries.

Many risks contribute to anaesthesia-related deaths. In Canada, one study revealed that disconnected tubing and faulty equipment are responsible for a large portion of several hundreds of such deaths every year.

But the cruel reality is that clear cut mistakes which doctors prefer to euphemistically describe as ‘misadventures’ may account for up to 85 per cent of anaesthetic accidents.

Some of the most common causes of death are failure to make sure that the patient is getting enough oxygen; failure to monitor or support the patient’s breathing after surgery; and failure to place a tube securely in the patient’s airway resulting in fatal inhalation of vomit.

A study of medical history reveals many other equally spectacular and unfortunate cases. In 1978, a woman reportedly died after an operation due to suffocation. The plastic tube meant to carry oxygen to her lungs had been mistakenly inserted in the passage to her stomach instead. In 1979, a 35-year old woman died from an air embolism after an otherwise successful operation. Here the anaesthetist had apparently injected the very last ounce of blood from her transfusion, a procedure that increases the risk of air entering into the patient’s circulatory system. Normally, anaesthetists leave some blood in the syringes to guard against such a fatal mishap.

But this doctor had failed to take this simple precaution. So when an unforeseen complication arose—in this case a filter became clogged—the result had spelt disaster for the patient. It is this kind of negligence that makes one wonder whether the profession of anaesthesiology is taking a critical look at itself, in all its aspects or whether patients themselves must be aware of the anaesthesia and surgery they are subjected to by their doctors.

There is perhaps no easy answer to such a question. However, an increasing awareness of the possible hazards of general anaesthesia and the type of study the Canadian doctors have in view would open the practice of anaesthesiology to more intense self- examination as well as more careful scrutiny. If such a study yields data and anaesthetists can use to safeguard their patients’ lives, the study would be well worth the money and time spent.

However anaesthesia is considered generally safe now. This is because of the following eleven factors.

1. Development of separate faculty of anaesthesia and training. transforming anaesthetists as preoperative physicians with extensive knowledge of internal medicine, physiology, pharmacology and related branches.
2. Introduction of safer drugs for general anaesthesia with smoother and comfortable” in and out “of anaesthesia…. like propofol, sevoflurane, opoids like fentanyl and remifentanil.
3. Development of better monitors which give in depth information of patient condition and alarms as relevant.
4. A safety checklist format of operating where after each part of anaesthesia, relevant checklists and guidelines are followed keeping the patient safe from anaesthetic complications.
5. Deciding whether a treatment requires major surgery or just sedation. There are any number of surgical and investigative procedures which do not need general anaesthesia . These include dental surgery, circumcision, breast biopsy, cataract. Local anaesthesia sedation offers anaesthesia personnel and the surgeon great flexibility in tailoring the degree of anaesthesia to the needs of the patient. Procedures that once required patients to stay overnight in the hospital are now performed safely in office and outpatient surgical suites. The utilisation of these anaesthetic applications enables patients to undergo lengthy and complex procedures as outpatients and then more readily and safely be discharged home. The choice and route of anaesthesia administration is paramount to the patient’s overall surgical experience. If, upon discharge, the patient is alert, has minimal pain, and has no nausea or vomiting, then the surgical experience was a positive one.
6. Monitored anaesthesia care combines intravenous sedation with local anaesthetic injection, infiltration including tumescent anaesthesia , or nerve blocks Conscious sedation is a combination of medicines to help you relax (a sedative) and to block pain (an anaesthetic) during a medical or dental procedure. You will probably stay awake, but may not be able to speak.
7. Conscious sedation lets you recover quickly and return to your everyday activities soon after your procedure (Conscious sedation is Produced by tranquillisers like Diazepam, and Lorazepam and antidepressants like serotonin Reuptake inhibitors (PROZAC)
8. A nurse, doctor, dentist, or even a anaesthesiologist will give you conscious sedation in the hospital or outpatient clinic. . The medicine will wear off quickly, so it is used for short, uncomplicated procedures. You may receive the medicine through an intravenous line (IV, in a vein) or a shot into a muscle. You will begin to feel drowsy and relaxed very quickly. If your doctor gives you the medicine to swallow, you will feel the effects after about 30 to 60 minutes. Your breathing will slow and your blood pressure may drop a little. Your health care provider will monitor you during the procedure to make sure you are OK. This provider will stay with you at all times during the procedure.
9. You should not need help with your breathing. But you may receive extra oxygen through a mask or IV fluids through a catheter (tube) into a vein.
10. You may fall asleep, but you will wake up easily to respond to people in the room. You may be able to respond to verbal cues. After conscious sedation, you may feel drowsy and not remember much about your procedure.
11. A word about anaesthesiologists before I end the article. Inside the operation theatre the role of the anaesthesiologist is in a sense as crucial as that of the surgeon for without his presence a surgeon cannon begin to operate on a patient. Such a realisation has still not dawned on people in general.

In preparing this article, I have relied heavily on my discussions with Manoj Kumar a brilliant young anaesthesiologist . He started his career in Kamineni Hospital, Hyderabad and moved to Europe where he worked in several advanced medical institutions in France, Dublin, and London. At a very young age he became a Fellow of the Royal College of Anaesthetists in London The valuable inputs provided by him regarding the latest advances in the field of anaesthesiology were illuminating. and conferred on my article a stamp of authenticity.