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    Rare condition continues debate over surgical settings

    By Jennifer Huddleston, staff writer      

    The recent death of Stephanie Kuleba, an 18-year-old high school senior from Boca Raton, Fla., has raised the profile of a rare condition that affects anywhere from one in 5,000 to one out of every 50,000 patients exposed to general anesthesia. [1]  

    Kuleba died March 22 after complications during corrective breast surgery performed in a doctor’s office. [2] Kuleba’s death is believed to have been caused by malignant hyperthermia, “a rare inherited disorder in which patients may develop life-threatening reactions when exposed to inhaled anesthetics for general anesthesia.” [3] The symptoms of malignant hyperthermia include increased carbon dioxide production, irregular or rapid heartbeat, dangerously high body temperature (higher than 110°F) and muscle rigidity or spasms. [4]

    The American Society of Anesthesiologists (ASA) states that complications of malignant hyperthermia, much like the condition’s symptoms, can include an increased heart rate, extreme rises in body temperature, muscle breakdown and changes in body chemistry that can cause excessive bleeding and organ failure. [5]  

    The ASA maintains that malignant hyperthermia can occur at any time during a procedure in which the patient is given general anesthesia, regardless of surgical setting. [6] However, the debate continues about the safety of surgeries performed outside of hospitals, a practice that has become commonplace in the U.S.

    According to the Ambulatory Surgery Center Association, fewer than 20 percent of the 10 million U.S. outpatient surgeries in 1980 were performed outside hospitals. In 2007, about half of the 43 million surgeries performed were done outside hospitals, with about 10 million each being conducted in doctors’ offices and stand-alone outpatient centers. [7]

    One of the biggest issues in the debate is whether or not physicians’ surgical settings in their offices can handle situations like Kuleba’s. While some physicians, patients and insurers support office surgeries and their more convenient, private settings and lower facility fees, some medical experts feel that certain procedures and anesthetics should not be done in non-hospital settings. [8]

    A study published in the March 2008 edition of the journal Dermatologic Surgery analyzed the 31 deaths and 146 hospitalizations that resulted from Florida office surgeries from March 2000 to March 2007. The results showed that patients suffered complications including anesthesia reactions, blood clots, heart emergencies, internal bleeding and seizures. [9]

    In those cases, at least 92 percent of the surgeons were board certified and credentialed to perform the surgery in a hospital, and 75 percent of the cosmetic-surgery patients who died were classified as very healthy. According to the study’s author, Brett Coldiron, a Cincinnati dermatologist, office surgeries can still produce bad outcomes despite an ideal surgeon, setting and patient. [10]

    The study found that the overwhelming majority of complications stemmed from using general anesthesia. Almost none occurred when using local anesthetics. [11]

    The only accurate test for the disorder is a muscle biopsy, and the only treatment is dantrolene sodium. For dantrolene sodium to be effective, it must be administered at the onset of the condition, and even then, death could still result. [12]

    “No matter how good you are, no matter if you do everything right, there’s still a chance of death,” said Dr. David Lubarsky, anesthesiology chairman at the University of Miami medical school. [13]

    Introduced in 1979, dantrolene sodium has reduced the malignant hyperthermia mortality rate from almost 80 percent in the 70s to less than 10 percent today. [14]

    According to research published in the April 2007 edition of the American Association of Nurse Anesthetists Journal, a new method of warming the diluent used to prepare dantrolene sodium can reduce the mixing time and allow for faster treatment of patients with malignant hyperthermia. In fact, the new method can reduce the standard two-minute process by 30 seconds or more, a significant breakthrough in treating a condition in which every second counts. [15]



    [1] Nutting, Pamela J. Gale Encyclopedia of Genetic Disorders Part II. 2005.

    [2] Lamendola, Bob. Study: More Risk in Office Surgeries. Orlando Sentinel. March 31, 2008.

    [3] American Society of Anesthesiologists. Details on Malignant Hyperthermia. ASAHQ.org. March 28, 2008.

    [4]  Nutting, Pamela J. Gale Encyclopedia of Genetic Disorders Part II. 2005.

    [5]  Ibid.

    [6]  Ibid.

    [7] Lamendola, Bob. Study: More Risk in Office Surgeries. Orlando Sentinel. March 31, 2008.

    [8]  Ibid.

    [9]  Ibid.

    [10]  Ibid.

    [11]  Ibid.

    [12] American Society of Anesthesiologists. Details on Malignant Hyperthermia. ASAHQ.org. March 28, 2008.

    [13]  Lamendola, Bob. Study: More Risk in Office Surgeries. Orlando Sentinel. March 31, 2008.

    [14]  Ibid.

    [15] American Association of Nurse Anesthetists. Research Reveals Way to Speed Up Treatment of Deadly Malignant Hyperthermia. AANA Press Release. May 7, 2007.



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