From: dhug2223@uxa.cso.uiuc.edu (David H. Uttal)
Newsgroups: sci.med
Subject: Re: Risks of anesthesia
Date: 1 Oct 92 14:46:29 GMT
Article-I.D.: news.BvG6DI.7Fv
Organization: University of Illinois at Urbana

ME.DMG@forsythe.stanford.edu (David Gaba M.D.) writes:

>In response to some of the questions concerning anesthetic risk
>for both epidural and general anesthesia:

>This is an extremely complex question.  First of all, one has to
>define whether one is talking about "young healthy patients" vs.
>patients with underlying medical diseases.  Incidentally, while
>pregnancy is "normal" from an evolutionary standpoint, it certainly
>alters some physiologic factors in women that makes them more
>vulnerable to certain risks of surgery and anesthesia.

>Second, it is quite rare to have anesthesia without surgery.  There
>are a number of combined risks in which both surgical factors
>and anesthesia factors play a role.  This can be especially true
>for chidbirth where both physicians involved are treating two
>patients simultaneously -- sometimes with conflicting goals
>(i.e. what's safest for the mother could impart risks to the
>fetus, and vice versa).  Separating out the "causes" of adverse
>outcomes in any study is extremely difficult.

>Third -- it has become nearly impossible in the US to conduct
>an appropriate prospective study of anesthetic and surgical
>complications, in part because of the connection between such
>events and litigation.  This makes it difficult to acquire
>full and open data about any such events.

>Extrapolating from older studies the "standard" risk figure for
>ALL patients having surgery (old&young, sick and healthy) and
>for catastrophic (death or brain damage) outcomes due SOLELY to
>"anesthesia" is 1:10,000.  A more recent study in Britain gives
>1 in 180,000 surgical cases resulting in a DEATH solely from
>anesthesia (that 1 in the study was in an emergency appendectomy)
>and 1 in 1800 due to some combination of factors including
>anesthesia (others being underlying medical or surgical disease
>state, surgery itself, etc.).

>However, the overall risk of all negative outcomes is unknown,
>and the accuracy of the British figures to the US (or to larger
>areas of Britain than the original study) is uncertain.

>As to general anesthesia vs. regional (epidural, spinal, or major
>nerve block) overall the risks of minor problems and for
>catastrophes is thought to be about equal.  Certain combinations of
>underlying diseases, and surgical operations will provide
>for the possibility that one approach is safer than the other
>in the hands of a given individual (who like all professionals
>will be somewhat more skilled in different kinds of procedures).
>We anesthesiologists spend a lot of time deciding what approach
>(and all its sub-issues) would be best for each individual patient
>and surgery.

>For childbirth, for pain relief from labor, clearly regional
>anesthesia with relatively low concentrations of epidural
>local anesthetics is the most effective choice, assuming that
>"natural" techniques are insufficient (quite common!).  Yes there
>are risks but overall the rate is extremely low.

>For C sections, it depends on many factors, including how urgent the
>C Section is, and the presence or absence of other underlying
>problems (like clotting abnormalities which can arise during
>certain pregnancy complications).  Most elective and unplanned but
>not urgent/emergent C sections are done under epidural (or spinal)
>anesthesia, in large measure because most delivering mothers
>prefer to be awake to experience the birth.  It is probably safer
>than general anesthesia because during pregnancy the emptying of
>the stomach is affected and the mother may be at risk for
>aspirating vomit into the lungs during a general anesthetic to a
>much larger degree than in other age-matched healthy people. (Still
>a relatively uncommon event nonetheless).

>For people facing surgery or childbirth who have questions about
>anesthesia, the most important thing they can do is have a serious
>conversation with an anesthesiologist concerning these issues and
>to discuss the different alternatives that are available.

Talking to the anesthesiologist is a wonderful idea, but in how many
hospitals is this really possible?  Since there's no way to predict
when the woman will go into labor, it is impossible to know which
doctor will be on call at the time.  Thus, chances are you will be
unable to speak with the physician who will actually adminster the
anesthesia.  In my wife's case, we got to talk to the anesthesiologist
for about 2 minutes before the epidural was adminstered.  Fortunately,
things went well, but it was very clear that we had to take whoever
was working that day.  In fact, the same is true regarding the o.b.
who actually delivers the baby.  What good are birth plans if the
doctor on call, who actually delivers the baby, comes in 5 minutes before
the baby is delivered and doesn't even have time to read the chart,
much less the birth plan.  This may sound cynical and is based largely
on personal experience, but we found that all of the talking and planning
was viewed by the physicians as "something parents feel they have to do", 
but that the actual delivery and decisions are made quickly and without
much regard to parents extensive discussions and planning.  For example,
we had told every nurse and physician for 7 months before the birth
that my wife didn't want an episotomy unless it was absolutely necessary.
Well, when the attending physician came in (obviously completely unaware
of our wishes), the first thing he did was reach for the scissors.
I stopped him, and no episotomy was done.  But the point is that all
of the planning in the world makes no difference if doctors aren't
aware of the plans when the time comes.  Having a baby in a big
hospital can be like ordering something special at MacDonald's:  yes,
they can accommodate your wishes, but you have to remind them over
and over again, or else they just follow the routine.
.


>Incidentally, the anesthesia profession has a very active program
>of research and education concerning improving patient safety.
>Anyone interested in finding out about such programs can
>contract the Anesthesia Patient Safety Foundation at:

>520 N. Northwest Highway
>Park Ridge, IL 60068-2573
>708 825 5586
>Fax -- 708 825 1692

>***** STANDARD DISCLAIMER********

>The above is for information only and does NOT constitute
>giving medical advice

>************************************

>David Gaba, M.D., Assoc. Prof of Anesthesia (with Tenure)
>                  Stanford University School of Medicine