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Under The Knife, At Risk: Study Shows Rising Death Rates From General Anesthesia

Modern medicine makes it possible to perform ever riskier operations on ever older patients. The result? A rising rate of post-anesthesia deaths, according to a study published in the Germany Medical Association's Deutsches Ärzteblatt journal.

About 7 out of every 1 million patients placed under general anesthesia die
About 7 out of every 1 million patients placed under general anesthesia die
Andreas Fischer

People have always been afraid of general anesthesia. Many fear they won't wake up from this "artificial sleep" – actually more of a coma, albeit drug-induced and reversible. In the 1940s, for every one million patients operated on under full anesthesia, 640 died. By the end of the 1980s, fatalities were down to four per every million, thanks to modern safety standards and better medical training.

However, a recent article published in the Deutsches Ärzteblatt, the German Medical Association's official international science journal, shows that after decades of decline, the worldwide death rate during full anesthesia is back on the rise, to about seven patients in every million. And the number of deaths within a year after a general anesthesia is frighteningly high: one in 20. In the over-65 age group, it's one in 10.

Indeed, the older patients are the heart of the matter. "The rise in deaths from anesthesia–related causes is not because of a decrease in the quality of anesthesiological care. It's due to the fact that more and more older patients ... are being operated on," says Dr. André Gottschalk, author of the study, and acting director of the Clinic for Anesthesiology, Intensive Medicine and Pain Therapy at Bochum's university hospital.

Anesthesia can be particularly risky on older patients with heart problems or high blood pressure. "Anesthesia and an operation mean stress for the body," says Gottschalk. "For a patient to die on the operating table is rare -- but for patients with serious problems in their medical history, post-traumatic stress after a long operation can under some circumstances lead to death."

Complications relating to anesthesia are rare, and can usually be brought under control very quickly. "In exceptional cases there may be an allergic reaction to something in the anesthetic, or the insertion of the breathing tube into the windpipe doesn't work right away," says Gottschalk.

To begin anesthesia, a high dose of anesthetic is required that usually sends a patient's blood pressure plummeting downward. Everybody reacts differently, however, and not always as expected. "It can sometimes be extremely difficult to estimate how much anesthetic to administer to an overweight patient," Gottschalk explains. He notes that an overdose can lead to rapid decline in blood pressure and requires immediate administration of drugs to raise blood pressure.

Ancient origins

During the operation, anesthetists monitor and regulate breathing and circulation; during longer operations, fluid balance, blood loss, and urine elimination. Many patients feel unwell when they wake up – women and non-smokers are often particularly sensitive. "Until recently, nearly every third patient felt nauseous," says Gottschalk. "However, things are improving with the new intravenous drugs and researchers continue to try and find substances that are even better tolerated."

Historically, anesthetic methods have been more modest. The Egyptians, Greeks and Romans used extracts from plants like poppy, mandrake, or henbane to dull pain. Alcohol was also used. As early as 1800, Humphry Davy discovered that laughing gas (nitrous oxide) stopped pain, however anesthesia through gas inhalation continued to be rarely used – many doctors believed that pain helped healing.

"Modern anesthesia began towards the end of the 19th century, and was mainly driven by surgeons themselves. In many cases, operating just wasn't an option unless they could free patients from pain," explains Michael Sander, deputy director of the Clinic for Anesthesiology at Berlin's Charité hospital. A breakthrough – inhaling ether – came in 1846.

But in the early years, the use of ether created the risk of explosions in the operating room, says Sander. Today, high-quality gases like Sevofluran, Desfluran or Xenon are used in a "total care" approach, a finely tuned system with many components.

The first step before starting anesthesia is giving the patient a strong painkiller. The next step is administering strong sleeping medication like Propofol, which garnered much attention in connection with Michael Jackson's death. This puts the patient in something resembling a hypnotic state. To stop the patient's ability to move, the anesthetist administers a substance that interrupts the signals sent from the brain to movement muscles.

The freedom from pain not only makes the operation possible, it's also important during the recovery phase. The patient can breathe fully, thus reducing the risk of inflammation of the lungs. Warming the patient during the operation, getting him or her moving again as soon as possible, and keeping the artificial breathing phase as short as possible, all help protect patients from infection.

But despite all precautionary measures, there are risks to general anesthesia. "In emergencies, the whole team has to function right automatically because there's no time to think," says Gottschalk. "For that to happen, I recommend regular simulations with the whole team, so that communication works when there's a real emergency."

Read the original article in German

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