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PLASTIC SURGERY 101

Consider risk of anesthesia

By DR. CARLOS WOLF

carloswolfmd@aol.com

Q:I have been hearing and reading about the 18-year-old who died while undergoing breast surgery. Can you tell me in ''basic English'' what you think happened? I have a daughter who is having cosmetic surgery and I'd like some peace of mind.

A: The concerns and worries you have are perfectly normal. After reading about the events in the media and hearing the buzz from the medical community, it appears that a condition called malignant hyperthermia (MH) caused the teen's death. MH is a genetic condition that makes certain individuals react to anesthesia in a very adverse way.

Unfortunately, unless someone in your family has had the problem, it is not easily diagnosed before the chain reaction begins. Patients who may be susceptible are those who have a family history of problems with anesthesia or people who have certain muscle disorders. If there is a family history, a test can be performed in which a muscle biopsy may determine whether someone is predisposed to MH.

So, what is MH and is it something that just happens? MH starts when a susceptible individual is exposed to an inhalant (gas) anesthetic along with muscle relaxants. It doesn't always start the same way but this is the general gist. When the muscles are exposed to these agents, a chain reaction begins that causes the muscles to contract, releasing certain chemicals that create a hypermetabolic state (more active).

With all these chemical reactions going on, the patient's temperature begins to rise and may top 110 degrees. Soon, cells rupture, potassium levels rise and the heart may stop. It's like a runaway train that cannot be stopped. Fortunately, there is an antidote for this condition and it's called Dantrolene.

The most important factor, however, is to make a quick diagnosis. Once a diagnosis is made and the patient is treated, the survival rate can be higher than 80 percent. The key is early diagnosis and early aggressive treatment.

So, how is MH diagnosed and treated? When a patient is given anesthesia, certain things are expected to happen. When something unexpected occurs, the anesthesiologist usually checks to make sure it's not equipment failure. The doctor then usually checks the patient to make sure everything is OK.

When MH begins, the patient might appear to have more muscle rigidity (contractions) and the CO2 (carbon dioxide that we blow out of our lungs) might start to rise, which should be picked up by a CO2 monitor in the operating room. Before or after this (that's how medicine is) the patient's temperature may start to go up. There are many other complicated features, but you get the picture.

It's not as simple as a non-physician would make it out to be. By the time the temperature has gone up, Dantrolene should be infused (injected intravenously) and the patient should be packed in ice to lower the temperature.

While this scenario is thankfully extremely rare, it is something to consider when having elective surgery. This is the same reason that it is important to ask all those questions I have repeatedly emphasized over the years about the qualifications of your surgeon and where you are going to have your surgery.

Now, there is one additional question to ask: ''Do you have Dantrolene in your surgery center?'' And finally, while we as physicians try to make surgery as safe as it can possibly be, some things just happen.