Thursday, November 1, 2012

Anesthesia Errors During Outpatient Procedures--Some Questions To Ask Your Team

Many patients have the perception that anesthesia in simple outpatient procedures is "no big deal." After all, day in and day out, colonoscopies, upper airway endoscopies, and other diagnostic tests under anesthesia go without a hitch. For the most part, they're right.

But anesthesia for any procedure is like airflight: it requires a successful takeoff (introducing the drugs that knock you out, known as "sedation") and a landing (reversing those drugs and returning you to consciousness).  As we all know from airflight, occasionally there is a crash. Unlike an FAA investigation of a plane crash, which is public and transparent, anesthesia error--medical mistakes involving serious injury or death are not investigated for public consumption and education. In fact, many times patients' families are left to guess or speculate as to what really happened behind the curtain.

But from having investigated and handled a few of these cases, here's four basic questions you or any loved one should ask if you're having an outpatient scope or procedure of any kind involving anesthesia:

1. Who is doing the sedation—the Doctor performing the procedure, an anesthesiologist, or a Certified Registered Nurse Anesthetist (CRNA) under the direction of the Doctor performing the procedure?

Take colonoscopies, for example. If the Doctor doing the colonoscopy is also perfoming the sedation (and many do) they tend to give you less sedation than an anesthesiologist might.  They will typically induce you into a state of either "moderate" or "deep" sedation. Moderate sedation means you are arousable to verbal stimuli (“hey Sarah, wake up”).  It's a tradeoff of sorts: You're less likely to get into trouble from a respiratory depression standpoint with "moderate" sedation, but you may feel a bit of pain temporarily.

Compare that to deep sedation, which an anesthesiologist might be more inclined to induce during a procedure. Deep sedation means you are only arousable to painful stimuli, like them pinching you or rubbing your sternum. It's better for pain relief  and amnesia during the procedure but here's a potential problem: sedation is a continuum. Often there's a fine line between deep sedation and "general" anesthesia, which means you're unconscious, even to painful stimuli.

Why does all this matter? One of the major risks of anesthesia is respiratory depression due to the effects of the anesthesia drugs. If respiratory depression occurs, it can cause a lack of oxygen and circulation to the brain, which can cause anoxic brain damage, cardiac arrest, and even death.  You don't need to be "overdosed" on anesthesia drugs to lapse into respiratory depression.

So any patient should want to know: what level of sedation are you shooting for? Whatever that answer is, more importantly the next question is…..

2. How will I be monitored during the procedure?

The gold standard and the BEST AND MOST ACCURATE monitoring is “end tidal C02 monitoring.” This measures how much carbon dioxide (CO2) you expel breath by breath. How much or how little CO2 you’re expelling is the most accurate measurement of how well you’re VENTILATING.

Pulse oximetry (that little thing they put on your finger) only tells you if you’re getting enough oxygen (O2). You can be getting lots of O2 but if you’re not taking it in because the anesthesia drugs are preventing you from doing so by depressing your respiration (you’re not ventilating well), the pulse ox monitor won't necessarily show it until the respiratory depression reaches a crisis level. The CO2 monitor will alert the Doctor/anesthesiologist/CRNA of an IMMEDIATE possible respiratory depression problem.

If you have general anesthesia during an operation, for example, it is standard for your monitoring device to include a CO2 monitor (in addition to the basic vital signs monitoring like BP, Heart rate, pulse oximeter). However, some outpatient centers did not bother with CO2 monitoring for outpatient procedures until recently. In 2011, the American Society  Of Anesthesiology (ASA) mandated CO2 monitoring even for moderate sedation:

During deep or moderate sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs AND monitoring for the presence of exhaled carbon dioxide unless precluded by the nature of the patient, procedure, or equipment.

 Why did the ASA mandate CO2 monitoring? According to a 2009 study of outpatient procedure anesthesia error claims or lawsuits spanning 19 years, inadequate oxygenation/ventilation was the most common respiratory-related adverse event in outpatient procedure claims, occurring 7 times more frequently than in hospital operating room claims. And the injuries that occurred in outpatient facilities were more often judged as being preventable by better monitoring.

 So ask the facility or the doctor performing the procedure in the office if they'll be using a CO2 monitor. If they aren't, they’re possibly being cheap and cutting corners on safety and don’t want to spend the money for more advanced monitoring. If that's the case I’d pass and go somewhere else.

3. When I’m moved from the room to recovery, are the monitors kept on or removed?

Most places will leave the monitors on as they transport you from the procedure room to the recovery room. If they don't, that doesn't necessarily mean it's unsafe because it's usually a short trip from the procedure room to the recovery room. But it can be an issue if there was a problem during the procedure (say your heart rate dropped and they had to give you drugs to bring it back up again) and you now need to be moved so the room can be cleared for the next procedure.

4. Are all of your nurses ACLS certified?

This stands for "Advanced Cardiac Life Support." This is training and certification for nurses and physicians so they'll know what to do and what drugs to give if a patient has a life threatening condition during or after the procedure for any reason. Most outpatient centers require ACLS certification. But if you're having the procedure done in an office setting, this may be an important question to ask.

Anyone giving you anesthesia for an outpatient procedure, no matter where it is--hospital, outpatient center, or doctor's office--should be willing to answer these simple questions.

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