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REASONS FOR DENIAL OF PAYMENT IN POBS
discussed in this chapter. Furthermore, these core princi-
ples have been endorsed by all of the accrediting bodies, all State Licensure. The reasons for denial of reimbursement
of the major surgical societies and organizations (includ- abound, but at the top of the list is state licensure. It is
ing the ASAPS, AACS, and ASDS), the ASA, Federation the policy of Blue Cross (BC) /Blue Shield (BS) and Medi-
of State Medical Boards, and many state medical societies. care that a facility not licensed by the state as a hospital or
Clearly, virtually all of organized medicine is now speak- ASC will not be reimbursed for facility-related expenses.
The Politics of Of¬ce-Based Anesthesia 223


However, this is not entirely true (vide infra). Because BC/BS ously. The hospitals are left with higher proportions of the
and Medicare are the two largest payers in the country, poorer paying Medicare, Medicaid, and BC/BS. Hospitals
their policies have a signi¬cant impact on the ability of are feeling this ¬nancial loss and turning to state legis-
physicians to run a successful of¬ce-based surgical prac- latures for relief. Some of the initiatives have focused on
tice. Many states have CON requirements for licensure, expanding CON and licensure requirements, others have
which makes it very dif¬cult if not impossible for a physi- focused on banning physician ownership of ASCs, and yet
cian to obtain a license for an OBS center. others are imposing new taxes.
In 2004, the state of New Jersey enacted two laws
impacting outpatient surgery. One law imposes a 6% tax
Accreditation. Many other third-party payers, such as
on cosmetic surgeons on gross revenues received for all
Aetna, Cigna, and United Healthcare, will reimburse OBS
cosmetic procedures (including Botox r injections). The
facilities for their facility-related expenses as long as they
other law imposes a 3.5% tax on gross revenues of for-
are accredited by one of the major accrediting bodies. It
pro¬t ASCs.
is the attitude of these carriers that accredited facilities
Illinois is considering a similar cosmetic surgery tax.
provide care that is just as safe as licensed hospitals and
The monies from these taxes are supposed to go to support
ASCs. And because they can simultaneously assure their
charity care at hospitals (in Illinois the money is earmarked
subscribers safe care and save money, to them it™s a “no-
for stem-cell research). Hopefully, these laws will be suc-
brainer.”
cessfully challenged on constitutional and commonsense
grounds. These laws make no sense.
OTHER REIMBURSEMENT ISSUES
What does make sense is creating a level playing ¬eld for
Site-of-Service Differentials. Medicare and BC/BS will not outpatient surgery by requiring accreditation of all such
directly reimburse nonlicensed facilities for facility-related facilities, HOPD, ASC, and POBS, and making BC/BS and
expenses (vide supra). Instead, they have created the “site- Medicare reimburse all accredited facilities (thereby saving
of-service differential.” Recognizing the cost savings on a taxpayers and subscribers potentially billions of dollars).
whole host of procedures (urologic, gynecologic, orthope- Allow the free-market economy to do what it does best. Bal-
dic, podiatric, and gastroenterologic, to name a few), third- ance quality with cost. Hospitals need to step up to the
party payers are reimbursing physicians performing these plate, cut their bureaucratic bloat and other waste, and
procedures in their of¬ce a higher professional fee than compete instead of lobbying state legislatures to continue
they would if the same procedures were done in the hospi- to buoy up their inef¬cient, obsolete model.
tal or ASC. The differential can range from a few hundred
to over a thousand dollars a case. Physicians don™t have to
THE FUTURE
have their facility licensed or accredited to get the increased
fee. These carriers appear to be talking out of both sides of The future of of¬ce-based surgery and anesthesia appears
their mouths. Indeed, Medicare, in 2005, published over to be on the right track. The states are addressing it, and
100 CPT codes for which they will no longer reimburse the professional societies appear to have a clear consensus
hospitals or ASCs. The reason given for the elimination of and have created a reasonable set of standards to guide
many of these codes is that they are being performed in the states. The accrediting bodies are speci¬cally address-
OBSs more than 50% of the time. Clearly, the intent is to ing POBS with reasonable, unobtrusive, inexpensive, one-
force procedures into the more cost-effective of¬ce-based day surveys to help to assure patients receive safe care
environment. But they are picking and choosing with the in this setting. Although some ¬ne-tuning of scope-of-
potential for compromising patient safety by not requiring practice issues, accreditation standards, alternative cre-
accreditation or licensure. dentialing mechanisms, and a few other issues needs to
occur, patient-care issues appear to be on the right track.
Mandatory reporting and the ability to track trends will be
Taxes. As market forces have shifted 50% of outpatient
bene¬cial”not only in POBS but also in all arenas where
surgery outside the hospital, the better payers tend to make
procedures are being performed”in making reasonable,
up a higher proportion of these cases, as discussed previ-
224 David Barinholtz


rational decisions on what needs to be done in the efforts accredited of¬ce-based anesthesia practices over a ten year
period. Personal Communication, March 2005.
to continuously improve patient safety and quality of
15. Hoef¬n SM, Bornstein JB, Martin G, et al.: General anes-
care. thesia in an of¬ce-based plastic surgical facility: A report on
more than 23,000 consecutive of¬ce-based procedures under
general anesthesia with no signi¬cant anesthetic complica-
REFERENCES tions. Plast Reconstr Surg 107:243,2001.
16. Perrot DH, Yuen J, Andreson RV, et al.: Of¬ce-based
1. SMG Marketing Group: Forecast of surgical volume in hos-
ambulatory anesthesia: Outcomes of clinical practice of
pital/ambulatory setting: 1981“2006. 1999; p27.
oral and maxillofacial surgeons. J Oral Maxillofacial Surg
2. Federal Register, Part III, Department of Health and Human
61:983,2003.
Services, Centers for Medicare and Medicaid Services, 42
17. Rehnquist J: Quality Oversight of Ambulatory Surgical
CFR Part 416, Medicare Program: Update of Ambulatory
Centers: A System in Neglect. Department of Health and
Surgical Center List of Covered Procedures; Proposed Rule,
Human Services, Of¬ce of Inspector General, February 2002,
November 26, 2004, p69182.
OEI-01“00“00450.
3. Klein JA: The tumescent technique for liposuction surgery.
18. American College of Surgeons: Statement on Patient Safety
J Am Acad Cosmetic Surg 4:263,1987.
Principles for Of¬ce-Based Surgery Utilizing Moderate
4. Allen JE: Boom in liposuction treatment carries risk. Asso-
Sedaton/Analgesia, Deep Sedation/Analgesia, or General
ciated Press, August 24, 1997.
Anesthesia. Bulletin of the American College of Surgeons
5. Hayden T, Sieder JJ: Death by Nip and Tuck. Newsweek
2004; p89.
August 9, 1999, p58.
19. Department of Justice/Federal Trade Commission: Improv-
6. Associated Press: Report: 18 died after basic cosmetic
ing Health Care: A Dose of Competition. July 2004,
surgery. The Palm Beach Post, March 7, 1999, p28A.
Chapter 8.
7. Associated Press: Expert: Sarasota doctor used too much
20. Silber, Williams SV, Krakauer H, et al.: Hospital and patient
anesthesia in fatal surgery. HeraldToday.com January 6, 2005.
characteristics associated with death after surgery. A study
8. Grazer FM, deJong, RH: Fatal outcome from liposuction:
of adverse occurrence and failing to rescue. Medical Care
census survey of cosmetic surgeons. Plast Reconstr Surg
30:65A,1992.
105:436,2000.
21. ASAPS Communications Department, American Society
9. Vila H, Soto R, Cantor A, et al.: Comparative outcomes anal-
of Plastic Surgeons, American Society for Aesthetic Plastic
ysis of procedures performed in physician of¬ces and ambu-
Surgery, Inc., Policy Statement on Accreditation of Of¬ce
latory surgery centers. Arch Surg 138:991,2002.
Facilities, Society Statement issued February 2000.
10. Coldiron B, Shreve E, Balkrishnan R: Patient injuries from
22. American Dental Association, Department of State Govern-
surgical procedures performed in medical of¬ces: Three
ment Affairs, #47 Associated Medical Costs, July 25, 2003.
years of Florida data. Dermatol Surg 30:1435, 2004.
23. AGA News Release: Three Gastroenterology Specialty
11. Venkat AP, Coldiron B, Balkrishnan R, et al.: Lower adverse
Groups Issue Joint Statement on Sedation in Endoscopy.
event and mortality rates in physician of¬ces compared with
American Gastroenterological Association, March 8, 2004.
ambulatory surgery centers: A reappraisal of adverse event
24. Meltzer, B: RNs Pushing Propofol. Outpatient Surgery Mag-
data. Dermatol Surg 30:1444,2004.
azine, Paoli, PA, Herrin Publishing Partners LP, 7:28,2003.
12. Guttman C: Of¬ce-Based Surgery Deaths: Who is Most at
25. ASA Statement: Guidelines for Of¬ce-Based Anesthesia.
Fault? Cosmetic Surgery Times March 2005; p4.
Approved by ASA House of Delegates, October 13, 1999.
13. Laurito CE: Anesthesia provided at alternative sites, in
26. American College of Surgeons: Guidelines for Optimal
Barasch PG, Cullen BF, Stoelting RK (eds.), Clincal Anesthe-
Of¬ce-Based Surgery, 2nd Ed., 2000.
sia, 4th ed., Philadelphia, Lippincott, Williams & Wilkins,
27. Federation of State Medical Boards, “Report of the special
2001; p1343.
committee on outpatient surgery (BD Rpt 02“3),” 2002.
14. Koch M, Barinholtz D: Combined data from two AAAHC
18 Staying Out of Trouble: The Medicolegal Perspective
Ann Lofsky, M.D.



INTRODUCTION
PATIENT SELECTION
FACILITY SELECTION
DOCUMENTATION
MONITORING
INTRAOPERATIVE MANAGEMENT
Emergency Planning
Fluid Management
LIPOSUCTION
OPERATING ROOM FIRES
THE RECOVERY PERIOD
Location
Recovery Room Staf¬ng
Monitoring
PATIENT DISCHARGE
WHAT TO DO IF YOU ARE SUED
Don™t Panic
Don™t Discuss It
Get the Facts Down
Spend Time on Activities You Enjoy




INTRODUCTION
rooms are regulated by state requirements that vary widely,
and anesthesia equipment typically runs the gamut from
From a pricing standpoint, malpractice carriers do not
state of the art to frankly antique.
routinely rate anesthesiologists who work in plastic
Despite all these considerations, from a legal standpoint,
surgery of¬ces any differently from those who work in
the standard of care”which is de¬ned as what a simi-
hospital operating rooms, but the claims they generate
larly trained, competent physician might have chosen to
often do have issues that are unique to the plastic surgery
do given the same circumstances”does not vary between
population or to an of¬ce environment. An anesthesi-
of¬ce and hospital operating rooms. An anesthesiologist
ologist working in an of¬ce is often the only one there
working in a small plastic surgery suite OR is held to the
who is skilled in airway and ¬‚uid management, and any
same standard of care as if the case were done in the oper-
additional help required, in terms of personnel or equip-
ating room of a large metropolitan hospital a few miles
ment, may be located some distance away. Of¬ce operating


225
226 Ann Lofsky


away. This practice also includes the handling of any and This case is somewhat unusual in that a patient may have
all unforeseen complications that might occur. intentionally failed to disclose pertinent medical informa-
Complications resulting in malpractice litigation tion, possibly owing to fears that the surgery might not
against anesthesiologists can stem from problems in any have gone forward. It is not a secret, however, that some-
stage of the process, from the patient preoperative evalu- times patients do seek cosmetic surgery for largely psycho-
ation through discharge. The following is a review of the logical reasons, and the anesthesiologist should at least be
most common categories of these claims with an emphasis alert for “red ¬‚ags” that might indicate patients are not
on the factors that make claims resulting from cosmetic entirely forthcoming regarding their medical condition or
surgeries unique. habits. If still unsure, a physician can ask that a patient be
sent for a complete preoperative evaluation and clearance.
A sixty-¬ve-year-old woman was scheduled for a facelift.
PATIENT SELECTION
She gave a history of smoking, high blood pressure, and ele-
vated cholesterol. Her preoperative evaluation consisted of a
Cosmetic surgery cases are, by de¬nition, elective. When
CBC and EKG , both felt by the anesthesiologist to be within
complications occur related to the preoperative condition
normal limits. The surgery was performed under local seda-
of the patient, the argument that “This patient needed
tion. Two hours into the procedure, she developed ST seg-
to have the surgery regardless” never applies. This places
ment changes and nitroglycerin paste was applied with some
an extra burden on anesthesiologists to ensure that each
improvement. Her blood pressure then fell but responded to
patient is optimized for surgery preoperatively and that
ephedrine and ¬‚uids. The procedure was completed in four
pertinent medical conditions have been suf¬ciently evalu-
hours, but in recovery, the patient remained hypotensive and
ated. (N.B. All claims described in this chapter in italics are
the EKG monitor showed multifocal PVCs. She was trans-
composites, incorporating details from numerous closed
ferred to a university hospital, where she ruled-in for acute
malpractice cases.)
myocardial infarction. The cardiologist there read her pre-
A twenty-year-old woman, 95 lbs. and 5 2 , presented
operative EKG as showing left ventricular strain and possible
to an of¬ce surgery center for breast augmentation under
lateral ischemia. In deposition, he stated that, had he seen
general anesthesia. She gave no pertinent medical history
that EKG preoperatively, he would have ordered a treadmill
and had no prior surgeries. She tolerated the surgery and
exam or stress echocardiogram before clearing this patient
anesthesia without incident, but in the recovery room, she
for surgery.
became obtunded and began seizing, which did not stop
An allegation in this case was the fact that the anes-
with intravenous benzodiazepines. She developed wide-
thesiologist had failed to seek cardiology evaluation or
complex bradycardia, progressing to a full cardiac arrest. The
clearance for this patient prior to surgery. Consider
paramedics were called and she was resuscitated and trans-
the possibility of undiagnosed underlying disease. From
ferred to a hospital, where she was ultimately declared brain
a medical-legal standpoint, if physicians fail to obtain
dead.
indicated consultations, they can be held to the standard of
One of the issues in this case was that well known to
care of physicians in the specialty they could have referred
the patient™s family and primary care practitioner, she
to, which in this case would be cardiology. If a reasonable
had struggled with anorexia and had lost more than
and prudent cardiologist would have cancelled the case
30 pounds in the three months prior to her surgery. Lab-
based on the preoperative EKG, an anesthesiologist might
oratory work after the arrest demonstrated severe elec-
also be found negligent for failing to do so.
trolyte abnormalities thought to have contributed to the
In the real world of anesthesia practice, comfortable
intractable seizures and arrhythmia. The anesthesiologist
working relationships develop between surgeons and anes-
and surgeon were both criticized for failing to question the
thesiologists. An anesthesiologist who works solely in one
patient about recent weight changes (see BDD in Ch. 15)
physician™s of¬ce may feel that he or she is in essence
and for requiring neither a history and physical nor clear-
an employee and therefore required to do whatever the
ance from the patient™s primary care physician. The of¬ce
surgeon needs. The standard of care for any anesthesia
preoperative questionnaire contained no inquiries about
provider, however, requires independent judgment. No
illicit drug or diuretic use.
Staying Out of Trouble: The Medicolegal Perspective 227


one is better able to assess a patient™s ability to withstand quently developed intractable vomiting with rupture of a
a given anesthetic than someone trained in that specialty. suture line. Her caretaker was forced to call the paramedics,
An anesthesiologist should always be prepared to defend who transported her to a large metropolitan emergency
the choice of the anesthetic for any patient and for the room for treatment, as the of¬ce had then closed. Although
decision to proceed with the surgery. this patient suffered no complications (other than severe
From the medical-legal perspective, the anesthesiolo- embarrassment), it was argued this was simply a surgical
gist is the ¬nal gatekeeper. Regardless of what the sur- case done in the wrong place at the wrong time with the
geon has planned or what the specialists have cleared the wrong staf¬ng.
patient for, the ultimate decision of whether or not to pro- Another issue is whether, for any given patient, the facil-
ceed with the case is always in the hands of the person ity is appropriate for the surgery anticipated. Some surgery
who pushes the induction dose. If something doesn™t feel centers and of¬ces have rules as to whether they will accept
right”perhaps a patient with an active upper respiratory ASA 3 and 4 patients. Higher risk patients such as the mor-
infection, or someone who appears pale or lethargic”it bidly obese, insulin-dependent diabetics, and sleep apnea
is always within the anesthesiologist™s rights and respon- patients might not be appropriate for every setting. Should
sibilities to either reschedule the case or obtain additional a patient with moderately severe asthma have surgery at a
information. facility without access to respiratory therapy and breathing
Again, because there is never an urgent threat to life or treatments?
limb in cosmetic surgery cases, they can always be safely Should a procedure with a possible large blood loss be
delayed for medical reasons or to obtain additional stud- done at a site without access to a blood bank? Should a
ies. Although perhaps a genuine fact of life and some- patient with an extensive cardiac history be done only in
thing anesthesiologists do take into consideration, con- a facility with the ability to urgently admit and monitor
cerns such as “The surgeon never would have used me overnight, if needed?
again if I had cancelled another case” or “additional test- These are questions that need to be addressed on a case-
ing would have been too expensive for this patient” will not by-case basis, but it is always better if the surgeon, anes-
likely be viewed sympathetically by jury members in court. thesiologist, and medical director (if one exists) have pre-
viously agreed on policies in place as to which patients are
and are not appropriate for the outpatient of¬ce setting.
FACILITY SELECTION
A thirty-two-year-old female, 5 3 and 335 lbs., had bilat-
eral breast reduction performed in an of¬ce surgery facility
Cosmetic surgery cases may be performed in hospital oper-
under general anesthesia. Postoperatively, she developed res-
ating rooms, surgery centers, or of¬ce-based ORs. The
piratory dif¬culty and had rales consistent with pulmonary
explanation for why any given case was done at a certain
edema. She was reintubated, and the paramedics were called
facility should, hopefully, be something more substantial
for transfer to the local hospital. This was technically dif¬-
than “that was just where it was scheduled.” Many fac-
cult because the gurney did not ¬t into the building™s elevator
tors are obviously taken into account, including the sur-
and they had to carry her down six ¬‚ights of stairs, delay-
geons™ and anesthesiologists™ schedules, patients™ prefer-
ing her arrival at the emergency room. She alleged cognitive
ences, their insurance statuses, and patients™ medical con-
dif¬culties secondary to prolonged hypoxia.
ditions. Medicolegally, the patient™s medical concerns take
For procedures that may be excessively long or com-
precedence over all others. One never wants to be sheep-
plicated, facilities with the ability to admit and monitor
ishly forced to admit that you made a decision primarily
patients overnight might be more appropriate. Accord-
based on ¬nancial issues.
ing to Dr. Mark Gorney, a past president of the American
One surgeon, doing a facelift on a high-pro¬le patient,
Society of Plastic Surgeons and former medical director of
opened his of¬ce OR on a Saturday, when it was nor-
The Doctors Company, a medical malpractice insurance
mally closed, and had only one nurse present in addi-
carrier, reviews of malpractice claims indicate that plastic
tion to the anesthesiologist. As everyone was anxious to
surgery procedures longer than six hours do seem to have a
leave the of¬ce, the patient was discharged home thirty
higher complication rate overall. “That doesn™t mean you
minutes after the procedure ¬nished. The patient subse-
228 Ann Lofsky


shouldn™t do them, but you should take that into account That advisory is important from a malpractice stand-
in your decision making process.”1 Surgeries expected to point because patients who have consented to the remote
last exceedingly long might be better scheduled in more possibility of death will have a hard time arguing that they
acute care environments, or consideration could be given never would have had anesthesia had they known a dental
crown could be loosened.3
to staging them into two or more smaller and shorter
procedures. It is also a good idea, when consenting patients for seda-
When problems develop, a common question posed by tion or regional blocks, to mention that general anesthesia
plaintiffs™ attorneys is “Why did you decide to operate is a remote possibility should the chosen alternative prove
on the patient there?” Even though it is often the sur- unsatisfactory. The patient should clearly understand what
geon™s decision where to book a case, the ¬nal decision type of anesthesia is anticipated and whether there are any
over whether or not a patient can be safely anesthetized in decisions to be made. If there were reasonable alternatives
any given situation is still considered to be the anesthesi- and you failed to mention that fact in advance (or docu-
ologist™s. ment that such a discussion took place), it could become
No one can force you to start a case wherein you don™t feel an issue in the event of litigation. Although informed con-
comfortable. sent is rarely the main reason why patients ¬le lawsuits
If an anesthesiologist has reservations, the time to voice against anesthesiologists, it may become a secondary issue
them is obviously before the case begins. when complications related to the anesthesia or surgery
occur.
Sometimes patients may not completely understand
DOCUMENTATION
what monitored anesthesia care (MAC) or intravenous
sedation is.
Good documentation, including legible and complete
They may have a mindset that they will be completely
anesthesia records, can signi¬cantly improve the chances
unconscious during the procedure and then become
of defending a malpractice claim. A panel of experts
frightened or angry if they are aware during the surgery
reviewing cosmetic surgery malpractice cases, where an
being performed. A substantial number of malpractice
anesthesiologist was a named defendant, found only one
claims for awareness do occur in patients having planned
out of eight had adequate documentation of an informed
consent for anesthesia.2 Whenever possible, the informa- intravenous sedation or regional blocks where general
anesthesia was never anticipated. In these cases, patient
tion regarding the planned anesthetic should be provided
expectations and understanding are key. Listen carefully to
by the anesthesiologist, not the surgeon. A single sen-
patients™ concerns and wishes preoperatively. If a patient
tence related to anesthesia buried in a surgical consent may
is adamant about not wanting to see or hear anything at all
not offer suf¬cient protection to an anesthesiologist if an
adverse event occurs.2 One or two sentences regarding the during surgery, this needs to be addressed early on. Either
the patient can be led to understand and agree to the rea-
informed consent, written by the anesthesiologist, can go
sons for sedation, or consideration needs to be given to
a long way toward making a malpractice claim defensible.
changing the plan to a general anesthetic.
The informed consent need not be extensive, but it
There is sometimes a tendency, when procedures are
should at least mention the type of anesthesia planned
performed in small of¬ces, to do things less formally.
(sedation, general, or regional) and the most common and
Charting standards for anesthesia, however, are univer-
severe injuries possible. A sample informed consent for
sal. Always adhere to all specialty standards and guide-
a general anesthetic might simply read: “Risks explained
lines regarding the documentation of vital signs, oxime-
including possible sore throat, dental injury, pneumo-
ter, and end-tidal CO2 readings, where appropriate, no
nia, and death. Questions answered. Patient concurs.”
matter how simple or short a procedure might be. In hos-
No patient entering surgery wants to hear about possible
pitals, charts are often reviewed for completeness by med-
death. This can, however, be phrased in a reassuring light:
ical records or medical staff committees. This may never
“Anesthesia is becoming safer all the time. Death related
occur in some of¬ces. No chart will be more thoroughly
to surgery is extremely uncommon these days, but I need
reviewed, however, than one involved in a malpractice
to mention this as a rare complication of anesthesia.”
Staying Out of Trouble: The Medicolegal Perspective 229


action, no matter where the surgical care it describes took certainly preferable to have dedicated anesthesia providers
place. present, if such is not the case, it is highly recommended
A ¬fty-eight-year-old overweight man had a facelift per- that someone other than the surgeon be designated to
formed in a plastic surgery of¬ce operating room under gen- watch the patient and the monitors while the operation
eral anesthesia. In the recovery room, he required several is taking place. There have been a number of disastrous
doses of intravenous morphine. Subsequently, he was noted outcomes that occurred when everyone™s attention was
to have shallow, labored respirations and was given nalox- focused on the operation and not on the patient.
one and transferred to a hospital for overnight admission. Whenever anesthesia is provided in an of¬ce, some-
The remainder of his course was uneventful, but he ¬led one present should be skilled in emergency airway man-
suit, claiming injuries and emotional distress. Review of the agement and Advanced Cardiac Life Support (ACLS)
records found no mention of informed consent for anesthesia protocols.
and no recorded vital signs for the entire two-hour recov- Anesthesiologists should keep their Code skills up to
ery room stay. Although the surgeon, anesthesiologist, and date and be aware of current ACLS guidelines. The author
nurses all testi¬ed that the patient was continuously on a once attended a weekend ACLS course where another anes-
pulse oximeter in the recovery area, and that blood pressure thesiologist excused his failure to correctly manage a sim-
and pulse were checked automatically at intervals, it was felt ulated Code situation by stating, “I only work in plas-
this case would be very hard to defend as to standard of care tic surgery of¬ces. I™ll never need this.” As malpractice
owing to the lack of appropriate documentation. cases will attest, plastic surgery of¬ces are certainly not
Anesthesiologists need to be proactive in charting every exempt from cardiac arrests, and anesthesiologists work-
case as if it could be the one involved in a malpractice ing in them will be expected to handle emergencies as any
action because, of course, this cannot be known with cer- skilled physician would.
tainty in advance. In medical malpractice handling, “If you A thirty-two-year-old man presented for a cosmetic eye
didn™t write it down, it didn™t happen.” Although that may procedure. A nurse administered intravenous midazolam
seem harsh, it can be necessary if a physician™s routine is and fentanyl for pain and agitation at the surgeon™s direction.
not documented anywhere in the medical record. Because A pulse oximeter was the only monitor used, but as the patient
many other things are documented, the implication may was moving frequently, it was either silenced or removed. At
be that if you forgot to chart it, maybe you also forgot to the conclusion of the one-hour procedure, the drapes were
do it or check it, no matter what “it” turns out to be. removed and the patient was noted to be profoundly cyan-
otic. All attempts at resuscitation were unsuccessful.
Although hypoxemia is not unique to plastic surgery set-
MONITORING
tings, a special warning is warranted regarding the silenc-
ing of monitor alarms.
Anesthesiologists performing plastic procedures should
Many anesthesia “disaster” claims occur because the pulse
use all standard monitors including blood pressure,
oximeter alarm is silenced and the anesthesiologist™s atten-
EKG, pulse oximeter, and end-tidal CO2 (for general
tion is temporarily diverted.
anesthetics).
Often these happen in the seemingly most innocuous
Vital signs should be recorded at regular intervals on
of circumstances, such as sedation cases with supposedly
the anesthesia record. When anesthesia records are not
awake patients or in long, otherwise uneventful surgeries
meticulous as to monitoring, it can make claims dif¬cult
where anesthesiologists might be tempted to let their guard
to defend, even when the problem is seemingly unrelated.
down, leaving the head of the bed or engaging in activi-
Sloppy anesthesia records may imply sloppy anesthesia
ties such as talking on the phone or reading. In these cir-
technique to a jury who will have little other tangible evi-
cumstances, the audible alarms on the monitors are the
dence to view at trial.
patients™ safety nets, and disabling them for other than
It is also, of course, important who is doing the monitor-
extremely brief episodes (i.e., Bovie interference) is ill
ing. It is not uncommon for surgeons to provide their own
advised. There is simply no defense for failing to use the
sedation for cases or to medically direct nurses or ancil-
monitors or failing to use them correctly.4
lary personnel to administer drugs for them. Although it is
230 Ann Lofsky


A similar scenario was the likely cause of the demise of on the fact that things may be getting out of hand. Situ-
Olivia Goldsmith, author of The First Wives™ Club, who ations that might appropriately be handled with a “wait-
in January 2004 was scheduled for a rhytidectomy at the and-see” attitude in a hospital might require different han-
Manhattan Eye and Ear Hospital. Information obtained dling in a remote of¬ce location. If breathing treatments or
from the New York Department of Health, through the inhalers are not available in an of¬ce, then even moderate
Freedom of Information Act, is strongly suggestive. How- wheezing that could exacerbate might be a cause for alarm
ever, because of the medicolegal rami¬cations of the case, and reason to consider transferring the patient or aborting
the complete story will not likely emerge (vide supra). the case.
It is also strongly encouraged that appropriate moni- A thirty-¬ve-year-old female presented to an of¬ce OR
tors be available both during the procedure and during for abdominal and thigh liposuction with monitored anes-
the recovery period”especially the capability for pulse thesia care. The surgeon injected a mixture of bupivi-
oximetry. Patients are variably awake after anesthesia caine, lidocaine, and epinephrine. Her pulse and heart
and can have unexpected reactions to postoperative pain rate increased substantially, and the surgeon complained
medication. because of increased bleeding, so the anesthesiologist injected
If another case has begun in the operating room using hydralazine and a beta-blocker. The blood pressure and
the sole set of available monitors, what will be left for a pulse rate started to fall precipitously and did not respond to
patient in recovery who needs them? Every of¬ce surgery atropine and ¬‚uids. The blood pressure was no longer obtain-
site should have protocols for monitoring patients in able by monitor. The anesthesiologist searched the drawers of
recovery, and the anesthesiologist should be aware of them the medication cart and could ¬nd no injectable ephedrine,
and able to have input regarding their appropriateness. The neosynephrine, or epinephrine. The locked emergency cart
anesthesiologist is responsible for a patient until they have for the facility contained airway equipment, but no drugs.
safely recovered from the effects of anesthesia, and there- The paramedics were called and responded approximately
fore should be noti¬ed if any vital signs are considered ten minutes later. Administering epinephrine intravenously,
abnormal. they stabilized the patient and transferred her to an emer-
It is, of course, not the monitors that are watching the gency room, but she was eventually declared brain dead and
patient. It is the person watching (and listening to) the removed from the ventilator.
monitors. There have been malpractice claims ¬led where In of¬ces, there may be no person designated to stock
patients were left to recover alone in rooms far away from anesthesia equipment and drugs. The anesthesiologist
all medical and of¬ce personnel, who failed to hear the should personally ensure that all emergency drugs and
monitors alarming. Obviously, if no one can hear the equipment are available and up-to-date. Emergency air-
alarms on monitors, they are essentially of no use at all. way devices, such as laryngeal mask airways (LMAs),
Anesthesiologists should know who will be present with should be present as well as appropriately sized endotra-
their patients for the entirety of their recovery periods and cheal tubes and laryngoscopes. Drugs should be checked
feel comfortable that they have the ability both to detect at intervals to remove outdated vials and replenish used
and react appropriately to any and all alarms. items. It is advisable to develop a checklist for emergency
medications such as those stocked in hospital operating
rooms. Although rarely used in of¬ces, they can make the
INTRAOPERATIVE MANAGEMENT
difference in avoiding catastrophic consequences owing
Emergency Planning to delays in the arrival of urgently needed emergency
supplies.
As has been mentioned, the handling of emergencies in
An anesthesiologist may have worked with the same
of¬ce operating rooms can be more dif¬cult than in a hos-
surgeon in the same of¬ce for years. Together, they will
pital OR. Help may be far away, so the need for it must be
likely have developed a routine and a rapport that allows
anticipated. Paramedics might need to be summoned or
them to anticipate problems and be prepared with solu-
the patient transferred by other means to an emergency
tions. Sometimes, however, anesthesiologists are called at
room or intensive care area before it is too late. Part of
the last minute and asked to work at sites with which they
this involves the anesthesiologist™s recognizing and acting
Staying Out of Trouble: The Medicolegal Perspective 231


are totally unfamiliar. Time should always be allotted to likely for the second scenario to play out in a patient with
become familiar with the anesthesia equipment, OR proce- preexisting COPD.
dures, and supply system of any new facility. An emergency Although statistical studies may not currently be avail-
situation will not be the best time to realize you don™t know able, it does seem from reviews of medical malpractice
where needed items are kept. claims that the outcomes for patients who arrest in remote
Anesthesiologists should be aware of the availability sites such as of¬ces and surgery centers are not as good as
and location of emergency supplies, including ACLS drugs those for patients in the operating rooms of fully staffed
and equipment, and where the nearest de¬brillator is. If hospitals. Even the fastest paramedics, it seems, cannot
dantrolene were required for an unanticipated malignant always get there in time to resuscitate patients and avoid
hyperthermic reaction, would you know where to get it? serious anoxic brain injuries. Anesthesiologists, therefore,
Although it™s not likely these things will be needed on any need to make sure they have all the supplies available that
given case, playing the odds works only until it doesn™t. they might require to stabilize their own patients in the
Anesthesiologists are always expected to be prepared for event of serious complications.
the worst. Even though rare occurrences, complications
Fluid Management
such as pneumothorax and pulmonary embolism can and
do occur with plastic surgery procedures. The anesthesi- Accurate assessments of ¬‚uid intake and output can be a
ologist needs to be both alert to the symptoms and signs problem in longer surgical cases. Large-volume liposuc-
of such unusual problems and be immediately prepared to tion (i.e., >5,000 cc) may involve considerable ¬‚uid shifts
treat them according to accepted guidelines. that may make intraoperative management dif¬cult. The
A twenty-three-year-old woman presented for bilateral California Medical Board discourages >5,000 cc liposuc-
reduction mammoplasty. The surgery proceeded unevent- tion in the of¬ce-based setting. Florida has also limited
fully. At the end of the case, the surgeon performed bilateral of¬ce-based liposuction to 4,000 cc. The use of compres-
intercostals nerve blocks with 0.25% bupivicaine for postop- sion garments tends to obliterate the “third space” created
erative pain control. The vital signs became unstable, with by the removal of fat deposits.
falling blood pressure and oxygen saturation. Suspecting a Efforts should be made to make sure the patient™s urine
reaction to the local anesthetic, the anesthesiologist admin- output remains in a reasonable range (at least 60 cc·
hour’1 ) as measured by a Foley catheter for longer surg-
istered ephedrine and epinephrine. The patient remained
intubated and on the ventilator. When she failed to stabi- eries. Some thought should be given, when administering
lize, the paramedics were summoned. On arrival they noted many liters of crystalloid, as to whether the patient actu-
poor breath sounds bilaterally. A needle was placed in a ally may need blood or blood products. Just because it
left intrathoracic space with an immediate out¬‚ow of air. isn™t available in the of¬ce doesn™t mean a patient doesn™t
The patient was ultimately diagnosed with bilateral tension need it. Aborting a surgical case or transferring a patient
pneumorthoraces. is never an easy or pleasant process for the anesthe-
As is the case with any unusual complication, if the pos- siologist, but when malpractice claims are reviewed by
sibility is never considered, it is unlikely it will be treated experts using 20/20 hindsight, it may be determined that
appropriately. When a patient becomes unstable and fails that was the only appropriate decision considering the
to respond to standard treatments, it is always a good idea circumstances.
to mentally run through a differential diagnosis of possi- The necessity of giving many liters of intravenous crys-
ble causes and rule out the worst-case scenarios clinically talloid in order to stabilize a patient™s vital signs or keep
rather than simply treating the most likely cause. Uncom- up urine output may be a sign to the anesthesiologist that
mon complications happen uncommonly, but that doesn™t things are getting out of hand. Malpractice cases reviewed
mean they won™t happen to you! The index of suspicion where intravenous intake is in the 10-liter-and-up range
for pneumothorax should also be raised any time needles in an of¬ce setting often have end results that might have
are used around the chest cavity, especially for intercostal been avoided had consideration been given to obtaining
blocks. A spontaneous pneumothorax, unrelated to injec- laboratory work or transfusing blood. One wonders, in
tions around the chest, is far harder to suspect. It is more reviewing such cases, if there was a discussion between the
232 Ann Lofsky


areas, with large volumes of fat aspirated.5 Whenever
surgeon and anesthesiologist as to how the case was going
and how much more surgery was anticipated. liposuction is performed, an anesthesiologist should be
Blood loss can be quite dif¬cult to determine in pro- aware of the extent of the procedure, including how much
cedures such as liposuction, where blood is mixed pri- local anesthesia is being used and how much volume is
marily with other ¬‚uids. Clearly, errors can be made on estimated to be aspirated, and should work with the sur-
both sides. Too much intravenous crystalloid causes a geon to determine a safe limit for the patient (see Chap-
dilutional anemia and ¬‚uid overloaded state, Circulating ter 8). Some facilities have their own policies as to what
clotting factors will be similarly diluted whereas too lit- the upper limits for acceptable liposuction volumes are
tle leads to hypovolemia with hypotension and low urine considered to be. Even if no such guidelines exist, anes-
output. thesiologists should be aware of what the standards in
Anesthesiologists may be accustomed to using labora- the community are and what specialty societies currently
tory work, such as blood counts and electrolyte studies recommend.
or monitored central venous pressures to guide them, but The American Society of Plastic Surgeons (ASPS) issued
these may not always be available or feasible in every of¬ce practice advisories on liposuction in 2003 and 2004.
setting. If extensive ¬‚uid shifts are expected or possible, Although it is important to remember that specialty soci-
the availability of chemistry and hematology labs and the eties do not establish the medical-legal standard of care,
ability to do invasive monitoring might be considerations many physicians have chosen to adhere to their guide-
in deciding where best to do a speci¬c case. lines. One recommendations states, “Regardless of the
A ¬fty-two-year-old previously healthy woman had large- anesthetic route, large volume liposuction (>5,000 cc total
volume liposuction, a facelift, and breast implants performed aspirate) should be performed in an acute care hospital or
in a plastic surgery of¬ce under general anesthesia. Blood in a facility that is either accredited or licensed. This gen-
pressure initially was 130/85, but several hours into the case, erous loophole leaves open the possibility that >5,000 ccs
it began to run 80“100 mm Hg systolic. This responded to of aspiration could be performed in an AAAASF accred-
intravenous ¬‚uid boluses of normal saline. After nine hours ited of¬ce facility. Liposuction volumes exceeding 5,000 cc
of surgery, the anesthesiologist had given 12 liters of ¬‚uid have been associated with higher morbidity and mortal-
and the patient™s urine output totaled 500 cc. She was extu- ity. Postoperative vital signs and urinary output should be
bated at the end of the case, but in recovery, her respirations monitored overnight in an appropriate facility by quali¬ed
became progressively more labored. Auscultation revealed and competent staff who are familiar with perioperative
care of the liposuction patient.”6,7 Although there is noth-
bilateral rales and wheezes. She was given intravenous
furosemide, but was eventually transferred by paramedics ing magical about the 5,000-cc number, what appears clear
to a medical center, where she was treated for pulmonary is that the complication rate rises as the volume of fat aspi-
edema. rated increases and possibly as the number of anatomical
sites aspirated increases as well.6,7
When procedures exceed the time and blood loss orig-
inally estimated, it is crucial for the anesthesiologist to A ¬fty-eight-year-old man had surgery in an of¬ce operat-
discuss with the surgeon whether the case should proceed. ing room that included liposuction of 7,500 cc, a facelift, and
Multiple procedure cases can be stopped before new pro- abdominoplasty. The patient™s blood pressure was running
cedures are begun, and the patient can return on another between 120 and 130 systolic, but after four hours, systolic
day. It can be dif¬cult to defend claims where the surgery pressures were in the 80s to 90s with a pulse rate of 110. The
was allowed to proceed under circumstances that should anesthesiologist gave volume, which raised the blood pressure
have caused the anesthesiologist concern. and lowered the pulse rate. By the end of the seven-hour case,
the patient had received 11 liters of normal saline. Blood loss
was estimated at 1,500 cc. In the recovery area, the patient
LIPOSUCTION
remained hypotensive and appeared pale and dusky. He was
Since its introduction into the United States, liposuction transferred to an emergency room, where his hemoglobin and
has advanced from a procedure for minor body contour- hematocrit were measured at 5 g/dL and 15%. He went on
ing to one with the ability to recontour multiple body to have a very stormy hospital course.
Staying Out of Trouble: The Medicolegal Perspective 233


Whenever the tumescent liposuction technique is uti- cerns about the patient™s well-being. A defense attorney or
lized, intake and output measurements should be made of jury member may someday ask, “Why didn™t you say some-
the ¬‚uid injected by the surgeon. Because a large propor- thing to the surgeon if you were concerned?” There is rarely
tion of the residual ¬‚uid will become intravascular, this a good answer to that question. Either you weren™t con-
should be taken into account in estimating intravenous cerned when you should have been or you failed to speak
¬‚uid requirements. Patients with large volumes of resid- up about it.
ual ¬‚uid from the wetting solution are at risk for ¬‚uid
overload and should be observed for an extended period
OPERATING ROOM FIRES
of time with consideration given to prophylactic diuretic
treatment.6,7 Intraoperative ¬res are not unique to plastic surgery. How-
The anesthesiologist should additionally be aware of ever, it is particularly devastating to a patient who has
the total dose of local anesthetic given by the surgeon come in for a cosmetic procedure to end up with a dis-
and be alert to potential signs of toxicity. Whereas lido- ¬guring burn. When procedures are performed on the
caine used in wetting solutions for liposuction is variably face under sedation, there is a necessary proximity of the
absorbed, it can still result in toxic blood levels. The ASPS operative site to supplemental oxygen provided by nasal
suggests limiting lidocaine dose to levels of 35 mg · kg’1 , cannula or facemask that makes this a time of particular
with the admonition that this level may not be safe in risk.
patients with low protein and other medical conditions.6,7 The three ingredients necessary to combustion are
It has also been recommended that epinephrine doses not (1) an increased oxygen environment, (2) a ¬‚ammable
exceed 0.07 mg · kg’1 , although apparently doses as high as substance, and (3) a heat source. Judging by numerous
10 mg · kg’1 have been safely used.6,7 (See Chapter 8). malpractice cases, an oxygen pool around the face, a paper
There is a safety concern when multiple surgical proce- drape, and a surgical cautery device are more than suf¬-
dures are combined, such as in the case described previ- cient to satisfy these requirements.
ously. The ASPS practice advisory recommends that large- A sixty-three-year-old man developed second- and third-
volume liposuction not be combined with certain other degree burns on his face when a cautery device ignited
procedures, such as abdominoplasty, because of the inci- the nasal cannula and drapes during a blepharoplasty. The
dence of serious complications noted.6,7 patient was given propofol during the injection of local anes-
Communication between the surgeon and anesthesiol- thesia, but at the time of the ¬re was completely awake. He
ogist is, therefore, crucial. It is important that the anesthe- was receiving oxygen 4L ¬‚ow continuously through the nasal
siologist be included in the planning process and be fully cannula. The charted oxygen-4 saturations were all 100%.
aware of the length and extent of the surgical procedure The patient sued because of the physical complications of
contemplated. It is always a judgment call to decide when the burn and also alleged psychological trauma from having
a surgery is simply becoming “too much” for any given witnessed the ¬‚ames.
patient, but the correct decision will likely be obvious to a Always an issue in malpractice claims involving burns
malpractice-claims reviewer using 20/20 hindsight. is whether the surgeon and anesthesiologist discussed dis-
Multiple or lengthy procedures may better be divided continuing the oxygen while a cautery or laser device was
and accomplished in separate operations. in use. Avoiding ¬res on facial cases might involve little
Patients usually prefer to “get it all over with in one ses- more than an acknowledgment that combustion is a risk
sion.” When the “one session” approach is explained as and that the surgeon agrees to inform the anesthesiolo-
a potential safety issue, it is much more easily accepted. gist before a heat source is used so that the oxygen can be
Obviously, the time for an anesthesiologist to voice con- temporarily turned off. When burns occur, the anesthesi-
cerns is ideally before the procedure gets underway. Once ologist is often asked why the oxygen was in use at the time.
the surgery has begun, the anesthesiologist can keep the “Because I always use it on awake sedation cases” is not a
surgeon apprised of how much has been aspirated” very compelling response to that question. If the recorded
especially when the volumes become large. It is never too oxygen saturation was near 100% at the time, it could be
late to stop a procedure if the anesthesiologist has real con- argued that the patient did not really require supplemental
234 Ann Lofsky


oxygen at that moment and could easily have tolerated a communication among the OR team and an awareness
short period without it. that such an event is always a potential risk.
If the reason for providing supplemental oxygen is
patient comfort because of stuf¬ness under the drapes,
THE RECOVERY PERIOD
consideration should be given to switching to compressed
air”which comprises only 21% oxygen, lessening the Judging by malpractice claims, the recovery period may
risk of ¬re. If a patient does require an enriched oxy- be one of the most dangerous for plastic surgery patients.
gen environment because of partial airway obstruction Part of this likely has to do with the variable monitoring
or desaturation without it, an argument may be made by standards used in of¬ces and surgery centers compared
plaintiffs™ attorneys or experts that the anesthetic could with hospitals™ postanesthesia recovery areas. As has been
have been more safely managed utilizing intubation or stated, claims have been seen for patients left to recover
a laryngeal mask airway (LMA) to provide higher oxy- alone in remote areas, far away from any medical person-
gen concentrations in an enclosed system, rather than nel. Because the anesthesiologist remains responsible for
insuf¬‚ating increased ¬‚ows of oxygen near the operative the patient until safely recovered from the anesthetic, any
site. mishaps during this period may incur substantial liability
Avoid using the drapes as a tent to enrich the entire area for the anesthesiologist as well. An anesthesiologist plan-
with oxygen. This essentially creates an oxygen balloon ning to perform anesthesia for a plastic surgery procedure
that may be ignited by sparks, causing the drapes to engulf should be aware of all recovery-room policies and should
in ¬‚ames as if a bomb had been detonated. Any oxygen feel comfortable that the following have been satisfactorily
delivered through a cannula or mask tends to naturally addressed.
pool under the drapes and may remain there for some
Location
time after the ¬‚ow meter has been turned off.
Additional risk management suggestions for preventing The location of the recovery room should be central
burns include using moist sponges and towels to drape enough to be easily accessible to all personnel who might
off the surgical ¬eld, keeping the electrocautery device in be required. It should be close enough to the operating
a holster when not in use, and avoiding foot pedal con- room to safely transport patients who are still under the
trols that might accidentally be deployed by stepping on effects of anesthesia. Recovery areas should be located so
them. Flammable agents such as alcohol or tincture-based as to assure that someone would hear audible alarms or a
products should be avoided as skin-preparation agents. patient calling for assistance. Otherwise, an assigned nurse
Petroleum-based eye ointments should be used with cau- should be continuously present. The danger is that seem-
tion in eye surgeries as they are potentially ¬‚ammable.8 If ingly awake patients arriving in the recovery room might
¬res do occur, all drapes and ¬‚ammables should be imme- be considered “¬nished” in the minds of the nurses who
diately removed. have other duties to attend to. As anesthesiologists are well
Oxygen and nitrous oxide should be immediately dis- aware, the level of consciousness of any patient can vary
continued until the ¬re is extinguished. Use sterile water, widely depending on the amount of stimulation and the
if possible, to douse the ¬re. It is strongly suggested that all addition of any postoperative pain medication. Patients
operating room areas have a ¬re extinguisher and that the must be frequently reassessed in this critical period.
anesthesiologist be aware of its location and how to use A ¬fty-six-year-old woman had a three-hour facelift per-
it. Ongoing care involves management of the burn and a formed under general anesthesia. She was transported to the
frank discussion with the patient and family. An accurate of¬ce operating room™s recovery area, which was a converted
record of all events surrounding the incident should be room on the opposite side of the of¬ce from the OR. The
kept”preferably in the patient™s medical record.8 plastic surgeon later explained that “Patients liked it there
Fires around the face may be largely preventable. Mal- because it was quiet and private.” She received 50 micrograms
practice cases involving OR ¬res are often indefensible of fentanyl intravenously for pain, which was repeated thirty
and can result in substantial losses. The most critical ele- minutes later. She stated she was comfortable and was awake
ment in preventing these claims does seem to be good and conversant.
Staying Out of Trouble: The Medicolegal Perspective 235


The nurse left the area to help get the operating room one else. Anesthesiologists might feel comfortable doing
ready for the next patient. When she returned to check on this in hospital recovery rooms, where they are familiar
the recovering patient about ¬fteen minutes later, she found with highly skilled recovery-room nurses. However, unfa-
her cyanotic and in full respiratory arrest. The woman was miliar staff at another facility might handle those orders
still attached to a pulse oximeter that was alarming, but very differently. For example, ordering morphine sulfate
it could not be heard by anyone in the operating room area. 2“4 mg intravenously every ¬ve minutes as needed for pain
Although a secretarial station was located directly across from could result in large doses being given to a patient over a
the room, the staff who normally worked there were out on relatively short interval. If the anesthesiologist writes the
lunch break during this episode. orders, he could ¬nd himself held at least partially respon-
Cases like this one are often indefensible because they sible for the results”even if he were no longer in atten-
represent a simple failure to monitor at-risk patients effec- dance.
tively. Anesthesiologists may also be named in claims such It is safest to be as speci¬c as possible with postoper-
as these because they have allowed their patients to recover ative orders, giving the recovery-room nurses some idea
in areas they should have known were understaffed or of when patients should be medicated and specifying pain
unsafe. If patients are “fast-tracked” and recovered in the scores and respiratory rates for which medication should
operating room until ready to stay in the waiting room be held. It is best to anticipate where problems could
or discharge area, the anesthesiologist needs to be present develop and to take steps to prevent them before they
until the patient is suf¬ciently awake, and then the patient occur.
can be supervised by quali¬ed personnel. A continuously present of¬ce staff member, who was not an
RN, recovered a twenty-three-year-old breast-augmentation
Recovery Room Staf¬ng patient. The only monitor used was an EKG. When
the patient became bradycardic, the monitoring personnel
At least as important a factor as where the recovery room
assumed it was due to the fact that the patient was sleeping
is located is who will be responsible for monitoring the
soundly. It was only when frequent PVCs and bizarre com-
patient there. Typically, the anesthesiologist is available
plexes appeared that the surgeon was summoned and a Code
until the patient is stable, and then a nurse or someone
was called. The patient developed anoxic brain damage.
else capable of medically evaluating the patient watches the
vital signs and monitors the patient™s needs for additional
Monitoring
medication. In short-staffed facilities, it is important that
whoever is assigned to the recovery room does not have Monitoring in the recovery area is at least as important as
competing responsibilities likely to draw attention away monitoring in the operating room”if not more so. The
from a recovering patient. anesthesiologist may not be in continuous attendance and
It can be an invitation to error if the person watching may need to rely on the monitors and alarms to notify
the patient has little or no medical training. Not every other personnel of a potential problem. Recovery areas
patient will be able to communicate that they are in trouble should have a full complement of monitors, including at
and someone must be alert for subtle signs before things least EKG, pulse oximeter, and blood-pressure monitoring
progress to an emergency situation. More than one claim capabilities. There should be a separate set of monitors for
has involved nonmedical personnel mistaking a recovering the recovery area if there is a possibility that a procedure
patient™s being quiet for stability, while failing to recognize might simultaneously be done elsewhere in the facility that
oversedation and respiratory insuf¬ciency until it was too would require the same monitors.
late. A forty-eight-year-old woman presented for breast aug-
Recovery-room personnel ought to have clear guide- mentation and liposuction, which was performed unevent-
lines from the surgeon and anesthesiologist as to exactly fully under general anesthesia. She spent between one and
when the physicians should be noti¬ed (i.e., when vital one-and-a-half hours in recovery and was medicated twice
signs fall outside of speci¬cally set parameters). Anesthesi- during that period with intravenous meperidine for pain. As
ologists should avoid writing pain-medication orders with she was standing up to get dressed in preparation for going
wide limits that leave dosing decisions largely up to some- home, she suddenly stated that she felt faint and collapsed on
236 Ann Lofsky


the ¬‚oor, unarousable. Although there were single readings ever a patient is placed under anesthesia, someone with
recorded for oxygen saturation, blood pressure, and pulse on advanced life support (ACLS) training will be available
her arrival in recovery, and a short EKG strip, those monitors on-site. Complications still can and do occur in recovery,
were on a wheeled cart that had been returned to the oper- and someone who is capable of handling them must be
ating room by the anesthesiologist when he began another present.
general anesthetic. There were no physicians available and no
other functional monitors in the facility with which to even
PATIENT DISCHARGE
assess the patient. The paramedics were summoned and on
arrival found the patient to be in ventricular ¬brillation. It Unlike other surgical specialties, plastic-surgery malprac-
was impossible to determine what the etiology of the syncope tice claims frequently involve issues regarding patients™
had been since the patient was completely unmonitored at discharge plans after the procedure. This may concern the
the time. timing of discharge or the decision of where to send the
From a malpractice-defense standpoint, probably the patient. Cosmetic-surgery patients may be admitted to a
single most important monitor is the pulse oximeter. hospital, discharged home, sent to outside facilities with
Should a patient develop problems, documentation that skilled nursing available, or to “hotels” with little medical
the oxygen saturation was always monitored and in a sat- capabilities. Clearly, each of these facilities is appropriate
isfactory range or that any desaturations were promptly for some patients, but the determination of which is best
noticed and corrected can go a long way toward proving for any given patient is a decision that should be made after
that the medical care provided was standard of care. It is considering the patient™s preference, the surgeon™s postop-
crucial to pick up hypoxia as soon as it occurs and imper- erative concerns, and the anesthesiologist™s evaluation of
ative that it be treated appropriately and promptly. the patient™s medical status.
Airway equipment should be readily available in the Some anesthesiologists simply defer this decision to oth-
recovery room, including supplemental oxygen. Someone ers, assuming it is outside of their customary responsibili-
with airway-management skills needs to be available while ties. From a liability standpoint, though, if it is deemed
a patient is still recovering from an anesthetic. From a that a patient ultimately suffered from residual anes-
medicolegal standpoint, charting is as important in recov- thetic effects or from inadequately monitored electrolyte
ery as it is in the OR. Blood pressure, pulse, and oxygen- or blood-count abnormalities, a resulting lawsuit might
saturation levels should be charted on the recovery-room well include the anesthesiologist in addition to the sur-
record at least every ¬fteen minutes. Physicians should be geon. When a patient has had extensive blood loss or
noti¬ed of any instability and written parameters should ¬‚uid shifts intraoperatively and laboratory work has not
exist for what is considered outside of normal limits. yet been obtained, it would be prudent to discharge that
Any medications should be charted with accurate times patient to a facility capable of obtaining laboratory studies
and dosages administered. As risk managers admonish, and monitoring vital signs to ensure that values remain in
“It isn™t what you do; it™s what you chart that counts!” an acceptable range. If the patient is continuing to bleed
Some complications may be unavoidable risks of anesthe- postoperatively, this may also require postdischarge mon-
sia, but the failure to pick them up promptly and treat itoring, even if the patient was quite stable throughout the
them aggressively is often a major problem leading to recovery period.
litigation. A sixty-two-year-old woman with hypertension and a
Reviewers of medical malpractice claims that contain smoking history had a bilateral blepharoplasty and browlift
issues regarding plastic surgery and recovery have rec- with abdominal and thigh liposuction performed in an of¬ce
ommended that a physician remain in the facility and be operating room late in the afternoon. The blood loss was
readily available during the full recovery period until the estimated at 500 cc. This was replaced with 3,500 cc. of
last patient has been discharged.2 This may be either the intravenous crystalloid over the six-hour case. The patient™s
anesthesiologist or the surgeon. However, an anesthesi- vital signs were stable in the recovery room. After two doses
ologist should verify that the surgeon will remain before of intramuscular opioids for pain, she was discharged after
personally leaving the area. It is further advised that when- one-and-a-half hours in recovery in the care of a nurse, who
Staying Out of Trouble: The Medicolegal Perspective 237


routinely watched patients overnight in a spare room of her been instructed on how best to handle this after discharge
own home. and knows whom to call with questions or concerns”
On arrival at her home, the nurse noted the patient was whether the surgeon, anesthesiologist, or primary care
quite drowsy and dosing on and off. Several hours later, she practitioner. If patients have been instructed to resume
complained of a feeling that she could not catch her breath. insulin or use inhalers, this should ideally be commu-
The surgeon was contacted by phone and he suggested loos- nicated in writing”and explained both to the patients
ening the bandages around her face. This was done, and the and to the individuals accompanying them home. Patients
patient again fell asleep. When the nurse returned to check on may not completely understand or remember what is told
her several hours later, she had no spontaneous respirations. to them in the immediate postop period because of the
Paramedics were called, but she could not be resuscitated. residual effects of sedative anesthetic agents. All discharge
One concern in the malpractice claim that resulted from instructions should be documented in the medical record
this case was the decision to discharge this patient to a pri- as well.
vate home in the light of the fact that she had had exten- Factors that may be important in deciding where a par-
sive surgery involving ¬‚uid shifts, she was elderly, and she ticular patient will go after discharge include the surgical
had underlying risk factors. Although a nurse was present, procedure performed, the patient™s condition during and
there was no ability to check blood pressure or oxygen after the surgery, and the preoperative medical conditions.
saturation. Another issue was the nurse™s and surgeon™s Physicians should not be reluctant to change discharge
responsibility for acting conservatively when the patient plans if one of these variables changes. It is not uncom-
complained of shortness of breath and possible dif¬culty mon for surgical procedures to run longer than planned
breathing. or for patients to remain more somnolent in recovery than
As is the case with the recovery room, it matters not was expected.
only what capabilities a postdischarge facility has but also One condition that has received increased attention in
who will be monitoring the patient while there. Although the anesthesiology literature in recent years is obstructive
plastic-surgery hotels may have skilled nursing available, sleep apnea. Patients with sleep apnea are at risk not only
they may not necessarily be assigned to every patient. If an during the operative period but postoperatively as well,
especially if they are being given parenteral opioids.9 Many
anesthesiologist feels that someone with medical training
should be checking on a patient after discharge, this should patients with sleep apnea do not obtain formal sleep stud-
actively be communicated to the surgeon. Too many mal- ies and have not been diagnosed at the time they present
practice cases involve lay caregivers admitting after an for surgery. The majority of them do not present with
adverse outcome that a patient complained of shortness of the classic Pickwickian appearance of obese males with
breath or dizziness or that they appeared pale or confused, short thick necks. Many of them have no obvious physi-
but that they were unsure of how signi¬cant that was or cal presentations”but they do have physiologically more
what they should do about it. compliant or narrowed upper airways.
Clearly, many patients can be safely recovered at home Even if patients are completely unaware they have this
or at hotels if they are given good discharge instructions condition, they may still be at substantial risk for serious
and if there is a family member or caregiver available who postoperative apneic periods and even death. In order to
understands the potentially troublesome symptoms and identify individuals at risk, patients must be asked specif-
signs for which they should be on the alert. It would cer- ically whether their sleeping partners have ever advised
tainly be worthwhile for anesthesiologists to be aware of the them of loud snoring or whether they suffer from excessive
discharge instructions that are given to their own patients. daytime somnolence that interferes with daily life func-
Patients should be instructed whom to call in the event tions. Patients who answer af¬rmatively to these questions
of questions and to dial 911 or proceed to an emergency should be advised about the possibility of sleep apnea and
treated similarly to those who carry that diagnosis.9
room for potentially life-threatening concerns.
If there are conditions speci¬c to an individual patient When patients with sleep apnea are given postopera-
(e.g., an asthmatic history, insulin-controlled diabetes), tive pain medication, consideration should be given to
the anesthesiologist should make sure that the patient has whether pulse oximeter monitoring is appropriate during
238 Ann Lofsky


this period to detect hypoxic apneic episodes. Pulse oxime- overnight. That is a medical determination best made by
ter monitoring can be accomplished safely in a variety of a physician.
settings”the critical factors being the presence of a mon- The timing of the last medications given should also
itor to identify hypoxic episodes and a person capable of be taken into consideration when determining a patient™s
responding to the alarms and taking appropriate action. readiness for discharge. A patient may be wide awake, con-
Patients who normally wear continuous positive pressure versant, breathing well, and well saturated, but if they have
airway devices (CPAP) at night should be advised to wear received (opioid) pain medication within the last half hour,
them in the postoperative period if at all possible. all could change within a short period of time. Patients
Reviews of malpractice claims indicate that when may also have allergic reactions to medication, and suf¬-
patients have tight abdominoplasty incision closures, they cient time should be allotted for those effects to become
may also be at risk from adverse respiratory events, even apparent before release from the facility.
if they have no apparent underlying predisposing factors. A ¬fty-seven-year-old man underwent an abdomino-
Although this does not seem to be well described in the plasty with liposuction in a plastic surgeon™s of¬ce. He arrived
anesthesia literature, some plastic surgeons indicate they in the recovery room in the early afternoon. One hour later,
are aware that increased abdominal pressure can make the he was medicated with 75 mg of meperidine intramuscularly.
work of breathing more dif¬cult. Having to overcome this Twenty minutes after that, he was described in the nursing
pressure during inspiration may make respirations shal- notes as ready for discharge, and he left the of¬ce in the pres-
lower than normal, and patients might be at risk, similar ence of the surgeon and anesthesiologist.
to sleep apnea patients, from opioid pain medications and The patient™s wife phoned the surgeon shortly thereafter.
during sleep. If patients have tightly closed abdominoplas- She stated that whereas he was initially awake and alert, he
ties, if they complain at all of feeling short of breath, or soon fell asleep and was snoring loudly in the car. On arrival
if they require substantial doses of parenteral pain med- home, he was too sleepy to walk. The surgeon told her to leave
ication, consideration should be given to postoperative the man lying down until he was more awake. A short time
monitoring with pulse oximetry or placement in a facility later, the wife noted he was not breathing. The patient was
where they will be closely observed overnight. taken to an emergency room, but he was declared dead on
When patients are sent to unmonitored facilities after arrival. An autopsy listed the cause of death as “respiratory
discharge, special attention should be given to the timing arrest in the recovery phase of general anesthesia.”
of discharge. The emphasis in recent years has been on Although there are no concrete guidelines for how long
“fast-tracking,” as newer shorter-acting anesthetic agents a patient should be observed in recovery after general
make recovery times quicker, and as more complex cases anesthesia, one hour is certainly within reason, and the
are being done under sedation or monitored anesthesia patient described did exceed that time in postoperative
care (MAC). Still, every facility should have standard- recovery. The problem arose in the interval of only ¬fteen
ized discharge criteria in place that includes evaluations minutes between the dose of intramuscular meperidine
of consciousness, oxygen saturation, circulation, respi- and the discharge home. Fifteen minutes was barely time
ration, and activity level. Problems in any one of these for the drug to act and certainly not the point of maxi-
areas should be promptly addressed and recti¬ed prior mal effect. Reviewers felt an interval of one hour after the
to sending a patient home. A patient with a preoperative last intramuscular opioid would have been more reason-
oxygen saturation of 99% on room air and a postoperative able. Reviewers also suggested that giving the drug intra-
reading of 92% should not simply be sent home because venously instead of intramuscularly would have had the
they meet minimal criteria for saturation. There should advantages of acting sooner and clearing faster from the
be some evaluation of what the problem is (e.g., underly- patient™s system.
ing bronchospastic disease, ¬‚uid overload, negative pres- Not infrequently, it is the anesthesiologist who is order-
sure pulmonary edema, splinting, aspiration pneumonia, ing medication in recovery. Although anesthesiologists
apneic episodes). Consideration should strongly be given may not even be present in the of¬ce when patients are
to whether such a patient needs further recovery time, discharged, they may ¬nd themselves liable for the deci-
transfer to an acute care facility, or supplemental oxygen sions of others to discharge patients home while still under
Staying Out of Trouble: The Medicolegal Perspective 239


Don™t Discuss It
the effects of anesthetics or postoperative medications. It
would, therefore, be wise for anesthesiologists to be aware Although it is tempting to review the facts and details of
of and have input into the discharge policies of all facilities a case with friends and colleagues, technically all discus-
where they will be anesthetizing patients. sions about a claim are legally discoverable by the plain-
tiff ™s attorney, with the exception of the formal peer-review
process and discussions with one™s own attorney and mal-
WHAT TO DO IF YOU ARE SUED
practice company claims representative. It is not uncom-
mon for the patient™s attorney to ask in a deposition, “With
Being sued is a fact of life for most anesthesiologists with
whom, if anyone, did you discuss this case?” An af¬rmative
busy practices. Although anesthesiology currently has one
answer provides an opportunity to subpoena any individ-
of the lowest frequencies for lawsuits among all medical
uals who might be able to furnish information regarding
specialties, the average anesthesiologist is still sued approx-
your mindset or conclusions about the anesthesia care. An
imately once every eight years. The good news is that the
unexpected patient death can be the stimulus for post-
vast majority of those lawsuits are successfully defended,
traumatic stages disorder (PTSD) for the involved anes-
with between 80“90% of them closing without any pay-
thesiologist. Do not hesitate to seek psychiatric help. Your
ments being made to patients.
therapist™s conversation with you is nondisconversable.
Don™t Panic Clearly, there will be discussions with the patient and
family. Refusing to discuss the case with them at all only
The stress of a lawsuit may leave an anesthesiologist feeling
gives the impression one is hiding something or is afraid.
isolated and alone. Unlike physicians in many other spe-
Although physicians are encouraged to be honest and open
cialties, anesthesiologists do not usually have consistent
with patients and their signi¬cant others regarding com-
and loyal patient bases. They may have only transient rela-
plications or untoward outcomes, it is important to avoid
tionships with the other physicians with whom they work.
placing blame or admitting one feels at fault. Patients have
Often it may seem like one is only as good as your last case.
a right to know the basic facts regarding what has hap-
Anesthesiologists sued for the ¬rst time frequently report
pened, and they additionally want to feel that their physi-
feelings of depression or dread or feel like their career is
cians care. “I am very sorry this happened” is an empathetic
in jeopardy. Familiarization with the legal process and the
show of support. However, “I really wish now that we had
knowledge that many other anesthesiologists have suc-
handled this differently” may be an invitation to litigation.
cessfully trod this same pathway can help alleviate that
Patients™ families often have amazing recall for what was
anxiety. The malpractice process can be long and drawn
told to them immediately after complications occur. Care
out, with many months elapsing between interviews with
should be paid to what is said in the heat of the moment.
claims representatives, meetings with attorneys, and depo-
sitions. However, anesthesiologists need to remember that
Get the Facts Down
life goes on.
Although suf¬cient attention should be devoted to the Write a detailed narrative of the facts as they occurred from
legal process to ensure its proper functioning, this should your perspective and keep it at home or separate from the
not substantially impact the performance of job func- patient™s medical record. This is for the anesthesiologist
tions or one™s personal life. It is simply one more thing and his defense team to have access to all pertinent infor-
an anesthesiologist must deal with in an often overbur- mation, and it should be documented while it is still fresh in
dened schedule. It may well take years for a legal case to one™s mind. This can serve as a starting point for explaining
slog toward completion, with mounds of paperwork gen- the case to an attorney and claims representative. Obtain
erated in the process, but this should not be the central copies of the pertinent medical records if possible. Once a
focus of life. The vast majority of one™s anesthesia peers case enters litigation, medical records may be sequestered
have likely been through similar processes, although it is and it can be months or even years before they are
not a subject often publicly discussed. It may well be, as subpoenaed.
one physician put it, “the cost of doing business for the One important caution here: DO NOT ALTER THE
business we are in.” MEDICAL RECORD after the fact. Although it might
240 Ann Lofsky


be tempting to make the records more perfect or clearer, plaintiff ™s attorney experts. The anesthesiologist™s attor-
records alterations are frequently discovered as such and ney will designate an expert on his behalf who will likely
will only impugn one™s credibility and honesty. If some- independently search the literature and help establish the
thing is not correct or important information has been standard of care.
omitted from the patient™s chart, it is permissible to add
Spend Time on Activities You Enjoy
an addendum, clearly labeled as such, and dated at the
actual time it was written. Remember that medical records Stress, overwork, and sleep deprivation can have only neg-
may have already been copied by the time one goes back ative effects on an anesthesiologist™s mental state and job
and reviews them and that it is important that all copies function. After being sued, it is more important than ever
be the same, or alternately that there be a very credible to have healthy outlets for recreation and stress release.
explanation for why that is not so. Run, ski, do yoga, meditate, or ¬nd something that helps
The medical record is not the place to plead the case. one get one™s mind onto something more positive. As
What is charted should be pertinent information regarding many anesthesiologists who have successfully navigated
the care of the patient. A patient™s chart is not the place the malpractice litigation process will attest, “This too shall
pass.”10
to explain in detail why something occurred or why there
was no one at fault. Stick to the facts. There will be plenty
of time for explanations during the legal process. Placing
REFERENCES
self-serving notes in the record in an attempt to convince
1. Personal communication, Mark Gorney, M.D. The Doctors
potential plaintiffs attorneys of one™s innocence may give
Company, www.thedoctors.com.
the impression that one is more concerned about one™s 2. Bristow J, Charles D, Gorney M, et al.: Plastic Surgery and
own welfare than the patient™s. Anesthesia: A Claims and Risk Reduction Workshop, The
Doctors Company Risk Management Advisory, 2000. www.
Plaintiff™s attorneys may simply review charts to see
thedoctors.com/risk/specialty/plasticsurgery/J4221.asp.
if there is anything that seems negligent. One physician
3. Lofsky, AS: Guidelines for Risk Management in Anesthe-
attempting to blame someone else is simply a red ¬‚ag. siology, The Doctors Company Risk Management Advisory,
1998. www.thedoctors.com/risk/specialty/anesthesiology/
Basically, this ensures that each physician will make the
J3221.asp.
case against the other, and the only one who will likely
4. Lofsky, AS: Alarms Save Lives, The Doctors Company
win will be the patient. Juries often conclude in such cir- Risk Management Bulletin, 2001. www.thedoctors.com/
cumstances that someone must be at fault if they are both risk/bulletins/alarms.asp.
5. American Society of Plastic Surgeons: Practice Advi-
blaming each other, so why not give the patient the money?
sory on Liposuction: Executive Summary, 2003. www.
It is always important to avoid public “¬nger pointing.” If
plasticsurgery.org/loader.cfm?url//commonspot/security/
one honestly believes that a nurse or surgeon is at fault, get¬le.cfm&PageID/765.
there will be opportunities to explain this to one™s attorney, 6. Iverson, RE, Lynch DJ, and ASPS Committee on Patient
Safety: Practice Advisory on Liposuction. Plast Reconstr Surg
who will know best how to handle that information.
113:1478,2004.
It is also helpful if time can be spent researching the per-
7. Friedberg BL: Inaccuracies and omissions with the report of
tinent medical literature. If there is information available The ASPS Committee on Patient Safety Practice Advisory on
Liposuction. Plast Reconstr Surg 117:2142,2005.
that might be relevant to one™s case, the anesthesiologist
8. Gorney M, Lofsky AS, Charles, DM: Playing with Fire, The
can furnish and explain this to his defense team. This may
Doctors Company Risk Management Advisory, 2002. www.
include online searches of medical journals for conditions thedoctors.com/risk/bulletins/¬reinor.asp.
similar to those experienced by the patient or reviews of 9. Lofsky AS: Sleep Apnea and Narcotic Postoperative
Pain Medication: A Morbidity and Mortality Risk, The
relevant medical society guidelines and standards. If there
Doctors Company Risk Management Bulletin, 2001.www.
is information available, it is always preferable to know
thedoctors.com/risk/bulletins/sleepapnea.asp.
this in advance and to be prepared to address it rather 10. Lofsky AS: You Are Not Alone: On Being Sued, The Doctors
than having it be a surprise to the anesthesiologist by the Advocate, 4th Quarter, 2000. www.thedoctors.com.
appendix A
A Guide to Perioperative Nutrition
David Rahm, M.D.



According to the author, nutritional supplementation in duces dysregulation of the immune system resulting from
the period before and after surgery can have a signi¬- changes in cell-mediated immunity. De¬cits in micronu-
cant impact on surgical outcome by reducing bruising, trients such as zinc, selenium, and vitamin B6 (common
swelling, and in¬‚ammation; promoting wound healing; in older adults) have a negative in¬‚uence on immune
enhancing immunity; and reducing oxidation generated response. Because aging and malnutrition exert cumu-
by surgery and anesthetic agents. However, supplements lative in¬‚uences on immune response, many older peo-
must be administered judiciously; some popular herbal ple have poor cell-mediated immune response and are
products are contraindicated before and after surgery. therefore at increased risk of infection. The appropri-
Insuf¬cient nutrition impairs wound healing and leaves ate use of nutritional supplements can be particularly
surgical patients more susceptible to perioperative com- helpful in improving immune response in aging sur-
plications. By addressing nutritional status and provid- gical patients with protein, energy, and micronutrient
ing focused guidance on nutritional supplementation, de¬cits.
the aesthetic surgeon can positively in¬‚uence surgical
outcome.

HERBAL MEDICINES, PHARMACEUTICALS,
OBESITY, AGING, AND NUTRITION AND ANESTHESIA

The risk of death from comorbid conditions increases With the greater availability of nutritional supplements,
exponentially as weight increases.1’3 Patients who are many Americans use herbal preparations for the manage-
poorly nourished, obese, and, especially, diabetic are par- ment of speci¬c symptoms and to combat changes asso-
ticularly prone to surgery-related complications, includ- ciated with aging. For example, men use saw palmetto to
ing wound infection and poor healing. Most Ameri- treat benign prostatic hyperplasia, and women use dong
cans consume diets too high in calories and de¬cient in quai to relieve menopausal symptoms. Many herbal users
essential nutrients. More than 70% of American adults do not understand the interaction of herbal medicines
do not even get two thirds of the recommended daily with pharmaceuticals or anesthesia, and so surgeons must
allowance (RDA) for one or more nutrients; consump- pay careful attention to the use of these products by their
tion of fruits and vegetables is notably poor.4’8 American patients. A smaller proportion of Americans use supple-
meals, loaded with packaged, processed, nutrient-poor ments to maintain good health. The authors of a study
foods, contribute to marginal de¬ciencies that result in a published recently in the Journal of the American Medi-
cal Association9,10 concluded that all adults should take
shortage of micronutrients and antioxidants that are par-
ticularly important to surgical patients undergoing anes- a daily multivitamin. This recommendation is based on
thesia, trauma, and wound healing. Older patients are research demonstrating that a multivitamin may help pre-
more susceptible to wound-healing problems because of vent chronic disorders such as heart disease, some cancers,
the interactions of body systems, environmental stresses, and osteoporosis. For aesthetic surgeons, knowing which
and disease. Although they have the capacity to heal well, nutrients to include and which to exclude is the basis of
older patients have a slower recovery rate. Aging also pro- perioperative supplementation.


241
242 David Rahm


ished outcomes if they are instructed to discontinue all
SUPPLEMENTS TO AVOID DURING
supplements rather than to eliminate only those that are
THE PERIOPERATIVE PERIOD
contraindicated. I recommend that surgical patients aug-
For several years, discussion about which nutritional sup-
ment the diet during the perioperative period with nutri-
plements are contraindicated during the perioperative
tional supplements. Although there is no universal agree-
period has been widespread.11’14 Although many familiar
ment regarding supplements and dosages in the periop-
supplement and botanical therapies are valuable, their use
erative period, Table A-2 shows nutrients that are useful
around the time of surgery can be problematic. The ¬ve
for individuals undergoing aesthetic surgery; this listing
most popular herbal products in the United States, Ginkgo
is based on the best available data and recent expert rec-
biloba, St. John™s wort, ginseng, garlic, and echinacea,15,16
ommendations. Perioperative supplementation can have
can all have negative side effects during this time. Adverse
a signi¬cant and measurable effect on surgical outcome
reactions that may be caused by supplements include pro-
by favorably affecting four primary mechanisms: reduc-
longed bleeding, interference with anesthesia, cardiovas-
tion of oxidation generated by surgery and anesthetic
cular disturbances, and interactions with pharmaceuti-
agents; enhancement of immunity; reduction of bruis-
cals. It is recommended by the American Society of Anes-
ing, swelling, and in¬‚ammation; and promotion of wound
thesiologists that supplements producing these effects be
healing.
avoided for at least two weeks before surgery and for at least
one week after.17 Table A-1 lists popular supplements that
should be discontinued during the perioperative period. OXIDATION AND ANTIOXIDANTS

Many anesthetic agents are a considerable source of cellular
oxidation, causing formation of reactive oxygen species or
SUPPLEMENTS RECOMMENDED FOR USE
free radicals, which in turn cause tissue damage and affect
DURING THE PERIOPERATIVE PERIOD
wound healing. Excessive free radicals have many harm-
Many herbs and nutraceuticals are potentially useful dur- ful effects, including suppression of immune function,
ing the perioperative period. Aesthetic surgeons can incor- disruption of normal cell activity, increased lipid peroxi-
porate nutritional guidance and supplementation into dation, and abnormal cross-linking of protein molecules
patient-care regimens to mitigate complications and opti- resulting in tissue stiffness. Bene¬cial antioxidants can
mize outcomes. Simple, short-term guidance on nutri- deactivate unstable free-radical molecules resulting from
tional therapies can also be effective in enhancing patient surgery, thereby playing an important role in the preven-
satisfaction. Recent statistics indicate that the likelihood tion of further damage. The administration of speci¬c
that a surgical patient will present with poor dietary habits nutrients and compounds before surgery can help protect
is quite high.4’8 Although a surgeon cannot change a patients against the more common forms of injury and
oxidation induced by anesthesia and surgery.19 The pres-
patient™s eating habits and lifestyle choices in the lim-
ited time between consultation and surgery, a focused ence of these antioxidants in the cell can either prevent
approach to nutrition is practical. It is important for free-radical formation or minimize damage by interrupt-
patients to know that caloric restriction is not recom- ing an oxidizing chain reaction. The body also produces
mended during the perioperative period. Patients fre- its own antioxidant defenses, including several enzymes
quently believe that the inactivity of recovery will cause such as catalase, superoxide dismutase, and glutathione
weight gain. However, the trauma of surgery and the subse- peroxidase; all three can also be taken in supplement form.
quent wound-healing process increase metabolic require- However, it is usually simpler for patients to take supple-
ments by 10% to 100%.18 Cutting calories during the peri- ments that enhance the activity of these naturally produced
operative period can therefore impair wound healing; the enzymes than to take the enzyme supplements directly.
reduction or elimination of bene¬cial nutritional supple- Vitamins and minerals, such as carotenoids, vitamins A
ments during the perioperative period can deprive the and C, selenium, and bio¬‚avonoids, act as antioxidants.
body of vital nutrients when they are most needed. Patients Because antioxidant systems and requirements in vari-
who normally take supplements may experience dimin- ous body organs differ, a combination of these substances
Appendix A 243



Table A-1. Supplements contraindicated during the perioperative period

Supplement Use Adverse effects

Bilberry (Vaccinium myrtillus) Visual acuity; antioxidant Antiplatelet activity, inhibition of clot
formation
Dong quai (Angelica sinensis) Relief of menopausal disorders, May potentiate anticoagulant
menstrual cramps medications
Echinacea (Echinacea angustifolia) Immune-system stimulant Can cause hepatoxicity;
contraindicated with hepatoxic
drugs (e.g., anabolic steroids,
methotrexate)

Ephedra (Ma huang) CNS stimulant, appetite suppressant, Hypertension, tachycardia,
antiasthmatic, nasal decongestant, cardiomyopathy dysrhythmia,
bronchodilator myocardial infarction
Feverfew (Tanacetum parthenium) Migraine preventive; used to relieve May affect clotting components;
allergy symptoms contraindicated with warfarin and
other anticoagulants
Fish oil Contains omega-3 derivatives DHA EPA and DHA inhibit platelet adhesion
and EPA; used to treat and aggregation; excessive doses
hypercholesterolemia and increased can inhibit wound healing
triglyceride levels
Garlic (Allium sativum) Antispasmodic, antiseptic, antiviral, Contraindicated with warfarin and
antihypertensive; used to treat other anticoagulants, NSAIDs,
hypercholesterolemia aspirin
Ginger (Zingiber of¬cinale) Antiemetic, antispasmodic Risk of prolonged clotting time;
contraindicated with warfarin and
other anticoagulants, NSAIDs,
aspirin
Ginkgo (Ginkgo biloba) Antioxidant; enhances cerebral blood Inhibition of platelet activity factor;
¬‚ow, alleviates vertigo and tinnitus contraindicated with warfarin and
other anticoagulants, NSAIDs,
aspirin
Ginseng (Panax gingseng, Improves physical and cognitive May interact with cardiac and
P. quinquefolium) performance; antioxidant hypoglycemic agents;
contraindicated with warfarin or
other anticoagulants, NSAIDs,
aspirin
Goldenseal (Hydrastis canadensis) Mild laxative; reduces in¬‚ammation May worsen swelling and high blood
pressure
Hawthorne (Crataegus laevigata) Used for ischemic heart disease, Potentiates actions of digitalis and
hypertension, angina, and chronic other cardiac glycosides
congestive heart disease
Kava kava (Piper methysticum) Sedative, analgesic, muscle relaxant, May potentiate CNS effects of
anxiolytic barbiturates, antidepressants,
antipsychotics and general
anesthesia
Licorice (Glycyrrhiza g/abra) Used to treat gastric and duodenal May cause high blood pressure,
ulcers, gastritis, and bronchitis hypokalemia, and edema
Melatonin Used for jet lag, insomnia, and May potentiate CNS effects of
seasonal affective disorder barbiturates and general anesthetics
Red clover (Trifolium pretense] Used to relieve symptoms of May potentiate existing anticoagulant
menopause medications
St. John™s wort (Hypericum Antidepressant for mild to moderate Contraindicated with other MAOIs or
perforation) depression SSRIs; photosensitivity; multiple
drug interactions
244 David Rahm



Table A-1. (Continued)

Supplement Use Adverse effects

Valerian (Valeriana of¬cinalis) Sleep aid, mild sedative Contraindicated with sedatives and
anxiolytics
Antioxidant; used in treatment of Anticlotting activity may prolong
Vitamin E cardiovascular disease bleeding time
Yohimbe (Corynanthe yohimbe) Aphrodisiac, sexual stimulant Hypertension; tachycardia; increases
potency of anesthetic agents

CNS = Central nervous system; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; MAOI = monoamine oxidase
inhibitor; NSAID = nonsteroidal anti-in¬‚ammatory drug; SSRI = selective serotonin-reuptake inhibitor.




els of several nutrients have been documented. At the
may provide the best protection against free-radical dam-
same time, surgery and anesthesia can increase antioxidant
age. The current evidence does not favor the use of large
requirements. For example, a decrease in the plasma con-
(megadoses) of individual nutrients. Administration of
centration of vitamin C during the postoperative period,
smaller, more measured doses of a broad spectrum of sev-
frequently affecting patients and associated with organ
eral supplements is recommended for antioxidant pro-
failure, has been postulated to be caused by increased
tection. With surgery, decreases in blood and tissue lev-



Table A-2. Supplements recommended for use in the perioperative period

Supplement/nutrient Mechanism of action Dosage range

Vitamin A (carotenoid or retinol Antioxidant; required for new cell growth 15,000“25,000 lU/d
palmitate) and maintenance and repair of (carotenoid/palmitate blend) limit
epithelial tissue use to 4 wk
Vitamin C (ascorbic acid) Antioxidant; necessary for tissue growth 500“750 mg daily (divided doses)
and repair; primary role in formation of
collagen
B vitamins “Anti-stress” group of water-soluble Best taken as B-100 complex: thiamine
vitamins; necessary for multiple (B1 ) ribo¬‚avin (B2 ), niacin (B3 ),
metabolic pathways pyridoxine (B6 ), biotin, pantothenic
acid, folic acid, cobalamin (B12 ),
choline, inositol
Zinc Antioxidant; essential for protein synthesis 15“21 mg/d
and collage formation
Selenium Antioxidant; inhibits oxidation of fats, 150“210 mcg/d
protects vitamin E
Copper Required for cross-linking of collagen and 1.5“2 mg/d
elastin; required for formation of
hemoglobin, red blood cells, and bone
Arnica montana Administered in homeopathic remedy for
bruising and swelling
Bromelain Proteolytic enzyme; used to minimize 1,500 mg/d, 2,000“3,000 MCU/d
in¬‚ammation and soft-tissue injury
Flavonoids (quercetin and citrus Antioxidant, anti-in¬‚ammatory; function 600“1,500 mg/d
bio¬‚avonoids) with vitamin C to prevent bruising and
support immune function

MCU = Milk clotting units
Appendix A 245


radical-scavenging activity in response to surgical A has been documented to boost immune responses in
trauma.20 Nutrient de¬ciency may be exacerbated because the elderly, people with marginal nutrition, and patients
patients typically fast before and after surgery. For the undergoing surgery.
many patients who take antioxidant supplements regularly
and may build up an increased requirement, a shortage of
BRUISING, SWELLING, AND INFLAMMATION
these nutrients is particularly detrimental.
An innovative approach used in aesthetic surgery to reduce
in¬‚ammation, swelling, and bruising is to provide tis-
IMMUNITY
sue levels of selective anti-in¬‚ammatory agents before the
Marginal nutritional status and aging are associated with induction of anesthesia and surgery. With injury caused
alterations in cellular physiology and immune function, by surgery comes the release of vasoactive substances and
both important factors for the surgical patient. Anesthe- pain-inducing chemicals. This proin¬‚ammatory process
sia, stress, and pain may also substantially alter the immune can be attenuated by botanical compounds such as brome-
system, with potential affects on postoperative function. lain, an enzyme derived from pineapple stem. Brome-
Nearly all nutrients play a crucial role in maintaining opti- lain supplementation before and after surgery has been
mal immune response; de¬cient or excessive intake can shown to reduce swelling, bruising, healing time, and pain.
negatively affect immune status and pathogen suscepti- Bromelain™s effectiveness as a selective anti-in¬‚ammatory
bility. Because nutrient status contributes to immuno- agent has been demonstrated in several published double-
competence, the lack of certain nutrients can suppress blind studies. It is most commonly used to treat in¬‚am-
immune functions that are fundamental to host protec- mation and soft-tissue injuries, and it has been shown to
speed healing from bruises and hematomas.25 Bromelain
tion. Excessive caloric intake and obesity can also in¬‚u-
ence immune mechanisms. Obesity can promote diabetes, treatment after blunt injury to the musculoskeletal system
which can signi¬cantly alter the immune state. In addition, results in reductions in swelling, pain (at rest and during
movement), and tenderness.26 Presurgical administration
immunity becomes weaker with aging, and this trend is
of bromelain can accelerate visible signs of healing.27,28
enhanced by poor nutrition. Zinc is particularly impor-
tant to the immune system, playing a vital role in more Bromelain has low toxicity in the recommended dosage
than 300 enzymes that facilitate chemical reactions needed ranges, and in human clinical trials it has been gener-
for immune function. Zinc is required for development ally well tolerated and free of side effects. Recently, aes-
and activation of T-lymphocytes, and even a moderate thetic surgeons have become familiar with the bene¬ts of
de¬ciency can adversely affect the immune system.21 Zinc bromelain in the treatment of in¬‚ammation and resorp-
de¬ciency can be manifested in increased susceptibility tion of hematomas. A second herbal remedy that has been
to a variety of pathogens through many pathways, rang- touted widely for use in plastic surgery is Arnica mon-
ing from the barrier of the skin to gene regulation within tana, which is administered in a homeopathic dilution
lymphocytes.22 Zinc affects these key immunologic medi- and has the potential to reduce pain and swelling and
ators because of its role in basic cell functions such as to improve healing of soft-tissue injuries. Many aesthetic
DNA replication, RNA transcription, cell division, and cell surgeons have recommended this compound, but, like all
activation. Small doses of zinc supplements can increase homeopathic remedies, arnica is the subject of consider-
T-lymphocyte levels and have the potential to decrease able debate in conventional medical circles. The available

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