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The Joan Rivers' case revealed that safety protocols can be ignored. So how can patients, especially pregnant patients, be reassured that they are in good hands?
Since the demise of Joan Rivers at an outpatient surgery center last year, there has been increased public awareness of the necessary questions that should be asked and precautions that should be taken to ensure patient safety.
Although most physicians and facilities have implemented best practices, educating the patient about expected standards could help keep systems in check. In the Joan Rivers case, there were many overlooked procedural and clinical aspects of care that were evidenced in qualified public reports on the case. These oversights now serve as reminders to both clinicians and patients of the importance of doing things by the book.
And for pregnant patients needing non-obstetric surgery, there are additional concerns related not only to the baby but also to the physiological changes that occur during pregnancy. For maximum patient safety, perhaps a pregnant patient should avoid any surgical procedure at an ambulatory center, if possible, opting for any necessary procedure to be performed in a hospital setting.
Credentialing and privileges. Ensure the surgeon is properly credentialed and has privileges to perform the surgery at the selected facility. One would think this is a no-brainer; yet, in the Rivers case, the surgeon did not have privileges to perform any procedure at the outpatient center where her surgery took place.
Proper monitoring of vitals and oxygen levels. In the case of Joan Rivers, the lack of recognition of pre-deteriorating vital signs and intervention was not timely. Vital signs were deteriorating for over 14 minutes on the OR table without any intervention.
Height and weight. An accurate measure of height and weight are an absolute must before any surgery, as this data is what determines the appropriate dosages of anesthesia and any other drugs administered along with anesthesia. Ms River’s body weight was never recorded. Her actual height and weight should have been recorded on the first sheet of the physician's orders before any medications were written and documented in the nursing assessment. In fact, height and weight should have been verified before any medication was administered in particular anesthetics.
Consent. First, having a personal doctor perform a surgery, especially if it isn't their specialty, is risky. In the case of Joan Rivers, the report said that there was no documentation indicating that Ms. Rivers gave consent for her personal physician to conduct a procedure. Patients should be signing both surgical and anesthesia consent before receiving any medications and prior to your surgery.
Emergency protocols. Ambulatory surgery centers should be well-equipped to handling any potential crises, and staff should be competent to manage early any emergency. There was significant delay in the case of Ms Rivers in the initiation of life-saving measures. It's important to know how possible emergencies are handled at ambulatory surgical centers.
Patient engagement. The best protection is an ask-and-answer session between the patient and physician before any scheduled procedure that will take place outside of a hospital. The act of asking questions and receiving answers is key to patient engagement and will ultimately help protect both parties from potential harm. This takes a little homework on the patient's part, so patients should be encouraged to do their research. And if a patient is unsure about what to ask, they should speak with a nurse.
Considerations for Pregnant Patients on next page
In addition to the above considerations, the physiological changes in pregnancy require another layer of awareness. Understanding and managing the risks to both mother and the unborn child are critical, even in the very early stages of the first trimester, for the prevention of harm.
Every year in the United States, about 80,000, or 1 in 50, pregnant women require non-obstetric surgery, with many surgeries taking place in an outpatient setting. According to the American Society of Anesthesiologists' statement on non-obstetric surgery in pregnancy, no currently used anesthetic agents have been linked to any teratogenic effects in humans when used at standard concentrations. However, there are other factors that must be considered to maximize patient safety.
Oxygen levels. The physiological changes of pregnancy affect more than just the reproductive system. Changes in the airways of pregnant women make adequate pre-oxygenation important, and the oxygen levels of pregnant patients require close monitoring throughout surgery.
A result of weight gain in pregnancy is that capillaries become engorged and can lead to upper airway edema and decreased internal tracheal diameter. In the third trimester particularly, a weight shift occurs that prevents the diaphragm from fully expanding, which can affect breathing. Because intubation failure rates for pregnant patients (1:280) are 8 times higher than those for non-pregnant patients (1:2,240), it is important for anesthesia to choose an appropriately sized endotracheal tube.1
Pregnant patients also have decreased functional residual capacity, which increases the risk of oxygen desaturation. In an article in Outpatient Surgery, Paloma Toleda, MD, MPH, an anesthesiologist affiliated with Northwestern University, explains the changes: “Though they consume more oxygen, their PaO2 levels stay largely unchanged. However, due to an increase in alveolar ventilation, they have an uncompensated respiratory alkalosis, with PaCO2 values ranging between 28 and 32 mm Hg. This relative hypocapnea is important to maintain during surgery, especially laparoscopic procedures, because maternal hypercapnea can result in fetal acidosis.”
Most pregnant women won't know to ask about how their oxygen levels will be monitored during the procedure, but it's an important question.
Pain management. Many outpatient surgeries require some form of pain management after the procedure. With an estimated 600,000 to 2 million patient-controlled analgesia (PCA) errors each year, pregnant women requiring PCA for post-surgical pain should be closely monitored for early respiratory depression.
Good news for patients. Obstetricians tend to be very protective of their patients, and there is an expectation that anesthesiologists or anesthesia care providers be credentialed and competent in providing anesthesia to pregnant patients. The best advice for a pregnant woman who is facing a required outpatient surgery is to ask their OB which anesthesiologists they recommend.
Duncan PG ,Pope WD,Cohen MM, Greer N. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology. 1986;64:790-794.
Radfar F. Laparoscopic surgery in pregnancy: precautions and complications. Available at: http://www.laparoscopyhospital.com/laparoscopic_surgery_in_pregnancy_precautions_and_complications.html. Accessed January 21, 2015.
Stepp K, Falcone T. Laparoscopy in the second trimester of pregnancy. Obstet Gynecol Clin North Am. 2004;31:485-496.
Toledo P. Anesthesia alert: anesthesia for the pregnant patient. Outpatient Surgery. July 2013. Available at: http://www.outpatientsurgery.net/surgical-services/general-anesthesia/anesthesia-alert-anesthesia-for-the-pregnant-patient--07-13. Accessed January 21, 2015.