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

Photo - Thirteen of Clubs

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Air Next: How A Crypto Scam Collapsed On A Single Spelling Mistake

It is today a proven fraud, nailed by the French stock market watchdog: Air Next resorted to a full range of dubious practices to raise money for a blockchain-powered e-commerce app. But the simplest of errors exposed the scam and limited the damage to investors. A cautionary tale for the crypto economy.

Sky is the crypto limit

Laurence Boisseau

PARIS — Air Next promised to use blockchain technology to revolutionize passenger transport. Should we have read something into its name? In fact, the company was talking a lot of hot air from the start. Air Next turned out to be a scam, with a fake website, false identities, fake criminal records, counterfeited bank certificates, aggressive marketing … real crooks. Thirty-five employees recruited over the summer ranked among its victims, not to mention the few investors who put money in the business.

Maud (not her real name) had always dreamed of working in a start-up. In July, she spotted an ad on Linkedin and was interviewed by videoconference — hardly unusual in the era of COVID and teleworking. She was hired very quickly and signed a permanent work contract. She resigned from her old job, happy to get started on a new adventure.

Others like Maud fell for the bait. At least ten senior managers, coming from major airlines, airports, large French and American corporations, a former police officer … all firmly believed in this project. Some quit their jobs to join; some French expats even made their way back to France.

Share capital of one billion 

The story began last February, when Air Next registered with the Paris Commercial Court. The new company stated it was developing an application that would allow the purchase of airline tickets by using cryptocurrency, at unbeatable prices and with an automatic guarantee in case of cancellation or delay, via a "smart contract" system (a computer protocol that facilitates, verifies and oversees the handling of a contract).

The firm declared a share capital of one billion euros, with offices under construction at 50, Avenue des Champs Elysées, and a president, Philippe Vincent ... which was probably a usurped identity.

Last summer, Air Next started recruiting. The company also wanted to raise money to have the assets on hand to allow passenger compensation. It organized a fundraiser using an ICO, or "Initial Coin Offering", via the issuance of digital tokens, transacted in cryptocurrencies through the blockchain.

While nothing obliged him to do so, the company owner went as far as setting up a file with the AMF, France's stock market regulator which oversees this type of transaction. Seeking the market regulator stamp is optional, but when issued, it gives guarantees to those buying tokens.

screenshot of the typo that revealed the Air Next scam

The infamous typo that brought the Air Next scam down

compta online

Raising Initial Coin Offering 

Then, on Sept. 30, the AMF issued an alert, by way of a press release, on the risks of fraud associated with the ICO, as it suspected some documents to be forgeries. A few hours before that, Air Next had just brought forward by several days the date of its tokens pre-sale.

For employees of the new company, it was a brutal wake-up call. They quickly understood that they had been duped, that they'd bet on the proverbial house of cards. On the investor side, the CEO didn't get beyond an initial fundraising of 150,000 euros. He was hoping to raise millions, but despite his failure, he didn't lose confidence. Challenged by one of his employees on Telegram, he admitted that "many documents provided were false", that "an error cost the life of this project."

What was the "error" he was referring to? A typo in the name of the would-be bank backing the startup. A very small one, at the bottom of the page of the false bank certificate, where the name "Edmond de Rothschild" is misspelled "Edemond".

Finding culprits 

Before the AMF's public alert, websites specializing in crypto-assets had already noted certain inconsistencies. The company had declared a share capital of 1 billion euros, which is an enormous amount. Air Next's CEO also boasted about having discovered bitcoin at a time when only a few geeks knew about cryptocurrency.

Employees and investors filed a complaint. Failing to find the general manager, Julien Leclerc — which might also be a fake name — they started looking for other culprits. They believe that if the Paris Commercial Court hadn't registered the company, no one would have been defrauded.

Beyond the handful of victims, this case is a plea for the implementation of more secure procedures, in an increasingly digital world, particularly following the pandemic. The much touted ICO market is itself a victim, and may find it hard to recover.

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