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Wake-Up Call

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This past August, Joan Rivers underwent a routine endoscopy at an outpatient clinic in Manhattan. She should’ve returned home that day. But, instead, her airway was compromised, causing a shortage of oxygen to the 81-year-old comedienne’s vital organs. 

Rivers went into cardiac arrest, dying a week later. An investigation conducted by the U.S. Department of Health and Human Services determined that anesthesia—combined with improper resuscitative measures—led to her death. 

Questions abound. Why didn’t Rivers have the endoscopy in a hospital? How could the medical staff let her fall into cardiac arrest? Is anesthesia really safe for people Rivers’ age? 

Cardiac arrest during an endoscopy happens rarely, making Rivers’ death all the more tragic. But it does bring to light an oft-overlooked truth: Anesthesia
carries risks that increase as patients age. 

One of them is postoperative delirium. Two recent studies in the medical journal, Anesthesia & Analgesia, document the phenomenon—a state of confusion that can last for two or more days and involve memory loss, hallucinations and trouble speaking. The average age of patients in the 2011 study was 79. The results showed that, regardless of the kind of anesthesia used or the duration of the sedation, 45 percent experienced postoperative delirium. Of those who’d lived independently before the sedation, 39 percent had delirium to such an extent that they were discharged to a nursing home or other care facility. 

Exact causes of extended delirium are unknown. Generally speaking, seniors’ brains require less medication to become sedated, so the calibration has to be precise. And their kidneys and livers are usually less efficient at processing anesthetic drugs, so they remain in the body longer than normal.

Of late, there is some good news about anesthesia. A 2014 study by the American Society of Anesthesiologists showed that the rate of complications in 3.2 million cases had dropped from 11.8 to 4.8 percent. And complications weren’t higher among those who had evening or holiday procedures, as was the common wisdom. In fact, relatively healthy patients recovering from daytime surgery had the highest rates of minor complications. The ASA study did show, however, that those older than 50 had the highest risk of serious complications. 

Experts agree that all patients—and especially seniors—can do a lot to lower the chance of complications. For one, stop herbal and vitamin supplements two to three weeks before surgical procedures. Seemingly innocuous substances like St. John’s wort, vitamin E, aspirin and even garlic can interact badly with anesthesia. The FDA doesn’t regulate supplements, so the extent of side effects is undocumented. And doctors don’t know how long they stay in your system. 

Also, be honest about your alcohol intake and cigarette smoking. Main Line Health’s patient guidelines on anesthesia state that both “can affect your body just as strongly (and sometimes more strongly) than many prescription medications.” Because of the way cigarettes and alcohol affect the lungs, heart, liver and blood, “these substances can change the way an anesthetic drug works during surgery,” the guidelines say.

Any prescriptions, herbals or vitamins that seniors are taking should be listed on cards kept in their wallets. “If a patient can’t speak or is suffering from dementia or memory loss, the medication list tells us what’s wrong,” says Dr. Catherine DiGregorio, an anesthesiologist with Crozer-Keystone’s Comprehensive Pain Management centers at Brinton Lake and in Upland. “If I see XYZ medication, I’ll know he has high blood pressure, a thyroid problem or something else.” 

The type of anesthesia used can also make a difference. In Rivers’ case, it was propofol, the substance infamously involved in Michael Jackson’s death. Propofol is safe when it’s correctly administered. The outpatient clinic in New York City improperly documented how much was given to Rivers, and its staff “failed to identify deteriorating vital signs and provide timely intervention,” the HHS report states.

That’s something DiGregorio finds quite shocking. “In any procedure done with anesthesia, blood pressure is retaken every three to five minutes,” she says. “If it keeps declining, we treat it immediately. We use small doses of powerful medications to bring up that pressure. At the same time, the medical team figures out what’s happening. We never let someone lie there with low blood pressure, especially not an older person.”

If the worst happens, anesthesiologists are certified in advanced life support. “We run codes and resuscitate people all the time,” DiGregorio says. “We go into every situation saying, ‘What happens if we need a backup plan?’ And we usually have several.”

DiGregorio believes it may have been a nurse supervising Rivers’ sedation. And while that’s legal, she advises against it-. “Nurses are an important part of every care team,” she says. “But you want as many trained professionals as possible to take care of you. Physicians—including an anesthesiologist—should be at the head of those teams.”

This is especially true for endoscopies, during which the endoscopist and the anesthesiologist share a patient’s airway. “The entire team needs a well-thought-out plan and excellent communication,” she says. “If the endoscopist wants to look down there without a breathing tube, the anesthesiologist needs to discuss if that’s appropriate or not. The airway can get swollen. There can be a laryngospasm, where the vocal cords spasm and tighten very quickly.”

All of which leads to the obvious conclusion that having a qualified anesthesiologist on hand is critical—and patients should never hesitate to ask for one to supervise their sedation. “We’re internists, cardiologists and pulmonologists all in one,” says DiGregorio. “We’re the doctors you never meet or don’t remember, but we get you in and out of surgical procedures safely.”

Anesthesia Checklist

Questions older patients should ask.

Source: American Society of Anesthesiologists

1. Is a nurse or anesthesiologist overseeing my sedation?

2. Is the anesthesiologist a geriatric specialist?

3. If I stop taking my medications beforehand, will there be side effects?

4. Can my doctor conduct a cognitive exam during the preoperative interview?

5. Which postoperative side effects are normal and which aren’t?

6. What pain relievers are safe to take after my procedure?

7. Whom should I call if I don’t feel well after I’m discharged?

Dr. Catherine DiGregorio says anesthesia is safe for seniors, but nothing is foolproof.

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