Although the public’s attention to healthcare stories has been focused lately on the untimely death of Prince from an opioid overdose, there’s an untold celebrity-related story related to the settlement reached last month in the malpractice lawsuit filed by Melissa Rivers after the death of her mother, Joan Rivers. Melissa hopes that the outcome of the settlement will "spark conversation" about patient safety when surgeons operate in their offices. Well, here’s that conversation.
While the complete facts surrounding Ms. Rivers’ death may never be known, newspaper reports indicate that Rivers suffered a lack of adequate oxygen during the administration of general anesthesia that was likely caused by an obstruction in the upper portion of her throat. Such an obstruction is caused by either a collapse of the muscles surrounding the throat (as with sleep apnea) or by a physiologic response called “laryngospasm”, a strong involuntary closure of the vocal cords when they are stimulated during anesthesia. As an anesthesiologist, I know that both of these potentially life-threatening responses occur frequently during general anesthesia, but they are easily remedied by administering a drug called succinylcholine. Succinylcholine instantaneously relieves the obstruction and allows oxygen to pass into the lungs.
For this reason, succinylcholine is one of the most important drugs in the anesthesiologist’s “bag”. An anesthesiologist without succinylcholine is as unimaginable as an emergency room without a defibrillator. Both are rarely used, but when they are, lives are saved. Unfortunately, at the Institute for Safe Medication Practices, we have been made aware in recent years about numerous office-based surgery centers that purposely do not stock this important life-saving drug. How can that be? The answer lies in a seemingly unrelated and complex story that involves an anesthesia-related disease called malignant hyperthermia.
Malignant hyperthermia (commonly called MH) is a rare and dangerous complication of anesthesia that occurs in people with a peculiar mutation of their muscle cells. The vast majority of MH cases are associated with the administration of an anesthesia gas, but much less commonly it occurs when a patient receives succinylcholine. Malignant hyperthermia is quite rare - of the many millions of anesthetics performed each year in the U.S., only several hundred patients will develop this complication.
A trained anesthesiologist will recognize MH by noticing certain signs such as an unexplained rise in heart rate or carbon dioxide excretion, severe muscle rigidity, or an unusually high body temperature. It is rarely fatal because there exists an antidote, a drug called dantrolene. Dantrolene cures MH in almost all cases. That’s why the Center for Medicare and Medicaid Services (CMS) will not grant certification to a facility that stocks anesthesia gas or succinylcholine but doesn’t stock dantrolene. No certification, no payment from Medicare or Medicaid.
So, here’s the dilemma: many office-based surgery centers have chosen not to stock dantrolene because it costs about $1,000 a year to keep on hand. In their defense, it will likely never be used because MH is so rare, and many of these centers do not use anesthesia gas and only use succinylcholine for rare emergencies. But, if they don’t have dantrolene available, they can’t be certified. They solve this dilemma by not buying succinylcholine, and as a result, they are forced to sacrifice patient safety. CMS and its accreditation agencies, such as the Joint Commission, have it wrong: they should mandate the availability of succinylcholine, not dantrolene.
The public should be aware of this modern medical safety dilemma, and should know about the life-saving drugs that we administer to anesthetized patients on a daily basis. Before agreeing to receive general anesthesia for a procedure in a doctor’s office, patients should make sure that succinylcholine will be available in the event that it’s needed to save their life. Patients and healthcare workers need to have these difficult conversations. Their families will thank us when we do.
Ron Litman, DO is the medical director of Institute for Safe Medication Practices in Horsham, Pa. Litman is also a professor of anesthesiology and pediatrics at The Perelman School of Medicine at the University of Pennsylvania and The Children’s Hospital of Philadelphia.
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