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Survey of Anesthetic Fatalities in Oral Surgery and a Review of the Etiological Factors in Anesthetic Deaths*

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Survey of Anesthetic Fatalities in Oral Surgery and a Review of the Etiological Factors in Anesthetic Deaths* [5] Survey of Anesthetic Fatalities in Oral Surgery and a Review of the Etiological Factors in Anesthetic Deaths* Harry M. Seldin, D.D.S. * Anesthetic fatalities, when they tality rate directly attributed to the occur in a dental office, are usually use of anesthetics for ambulatory highly publicized in the press. These patients in dental offices in the City reports present a picture completely of New York. We also compared out of proportion to the frequency this rate with that resulting from of such fatalities. On the other hand, the administration of anesthetics in anesthetic deaths occurring in hos- hospitals and medical offices by pitals are not considered news- physicians or nurse anesthetists su- worthy and are seldom, if ever, re- pervised by physician anesthesiol- ported in the lay press. ogists. In this comparative study The employment of any anesthe- only those anesthetic mortalities in tic agent, regional or general, is ac- hospitals and medical offices were companied by the danger of pos- used in which anesthesia had been sible loss of life. This holds true administered for procedures of ap- whether it is administered by a proximately similar severity and physician, nurse, or dentist, and duration to those performed in whether it is for medical, surgical, dental offices. Only those medical or dental procedures. Fatalities cases where the physical status of directly attributed to the use of the patient might be assumed to anesthetics, local and general, in have been similar to that of patients hospitals, have been reported in the usually encountered in dental and literature by Beecher' and others. oral surgical procedures were in- A comprehensive survey of the cluded in the survey. safety of anesthesia in the dental In New York City all deaths, re- office was published by Seldin and gardless of cause, must be reported Recant in 19552. We undertook to the Medical Examiner's office. this survey to determine the mor- The mortality files are classified ac- cording to the cause of death, as determined by the death certificate, * Presented to the American Dental hospital reports and autopsy, when Society of Anesthesiology, Miami Beach, Florida, Nov. 3, 1957. possible. The survey was made from [6] the records in the Medical Exam- Recently I made a nation-wide iner's office of anesthetic deaths for survey of anesthetic mortalities in the ten-year period 1943 to 1952 in- oral surgery for the years 1950 to clusive. It was estimated that dur- 1956 inclusive. A questionnaire was ing that ten-year period about sent to each member of the Amer- 90,000,000 administrations of local ican Society of Oral Surgeons and anesthetics and about 1,000,000 ad- a total of 406 questionnaires were ministrations of general anesthetics answered. Of these, 314 were com- were made by dentists in New York plete and 92 were incomplete (no City. records were given of the approx- The ten-year total of anesthetic imate number of administrations). deaths was 1,867. Total anesthetic These 92 oral surgeons simply mortalities in dental offices was 8; stated that they had no anesthetic anesthetic deaths during tonsillec- fatalities during the years 1950 to tomies and/or adenoidectomies was 1956 and that they kept no record 51; and anesthetic fatalities during of the number of administrations. The 314 ophthalmological procedures was completed questionnaires 15. indicated that these oral surgeons administered approximately 7,956,- Thus we see that the mean per- 627 anesthetics in their offices and/ centage of the 10-year total of anes- or hospitals. Of these, 4,244,449 thetic mortalities in New York City were local and 3,712,178, general. in dental offices was 0.43 per cent; There were 59 fatalities reported. for tonsillectomies and/or adenoi- Fifteen occurred in their offices, 43 dectomies, 2.7 per cent; and for occurred in hospitals and one in a ophthalmological procedures, 0.80 patient's home. The agents used per cent. It is of interest to note were as follows: that of the ten-year total of anes- Sodium Pentothal® anesthesia- thetic deaths in dental offices, two 19 fatalities. Sodium Pentothal®, nitrous oxide- were caused by local anesthetics and oxygen anesthesia-16 fatalities. six by general anesthetics. If we Sodium Pentothal®, nitrous oxide- oxygen, ether anesthesia-1 fatality. consider the fact that about one Nitrous oxide-oxygen anesthesia general anesthetic is administered 9 fatalities. Nitrous oxide-oxygen, ether anes- to every 90 local anesthetics, we see thesia-2 fatalities. that percentage-wise the local anes- Nitrous oxide-oxygen, trichlorethylene thesia anesthesia-2 fatalities. safety record surpasses by far Nitrous oxide-oxygen, Vi n e t h e n e the excellent record of general anes- anesthesia-I1 fatality (explosion). Ether anesthesia-5 fatalities. thesia. Regional anesthesia-3 fatalities. [7j Of the 59 anesthetic deaths prolonged or extensive surgical three were caused by regional anes- procedures, but the majority do thetics and 56 by general anesthe- most of these operations in their tics. Of the three local anesthetic offices. The fact that 43 of the 59 deaths one was in a hospital and mortalities occurred at hospitals and two in offices. Of the 56 general only 15 occurred in offices shows anesthetic deaths 42 occurred in that anesthesia administered in oral hospitals, 13 occurred in offices and surgery offices has a much higher one in a patient's home, in spite of safety record than anesthesia ad- the fact that there were significant- ministered in hospitals for oral sur- ly more general and local anesthe- gery procedures. This is probably tics administered at the offices of due to the fact that poor-risk pa- oral surgeons than at hospitals for tients are usually hospitalized. oral surgery. Intravenous barbitu- Intravenous barbiturates, when rates were administered in 37 of employed in anesthetic doses, pro- the 59 mortalities due to general duce depression of respiration and anesthetics. circulation. The fact that 37 of the The Safety of Anesthesia 59 deaths occurred where intra- in Oral Surgery venous anesthesia was employed The safety of anesthesia in oral and 19 fatalities where sodium Pen- surgery is certainly commendable tothal® was the sole agent would in- and compares favorably with other dicate that the intravenous barbi- surgical specialties. The six-year to- turates in general anesthesia are tal of anesthetic mortalities for oral not as innocuous as some people surgical procedures in offices and claim them to be. hospitals was one death in 1,414,816 The intravenous barbiturates administrations of regional or local should be used as hypnotics for in- anesthesia, and one in 66,289 ad- duction and not as the sole anes- ministrations of general anesthesia, thetic agents. A combination of as compared to the report by drugs, utilizing the advantageous Beecher and Todd3 of one death in properties of each to produce a 2,300 administrations of intravenous balanced anesthesia, is the safest anesthesia, one in 3,178 administra- method to employ. Clinical ex- tions of inhalation anesthesia and perience has shown that the use of one fatality in 7,600 administrations sodium Pentothal® for basal hyp- of regional and topical anesthesia. nosis and nitrous oxide and high Some oral surgeons prefer to oxygen mixtures for maintenance hospitalize all patients who need with small intermittent increments L8] of sodium Pentothal®, as needed, is hanced by using an aspirating syr- the most reliable method of man- inge as advocated by Monheim7. aging most anesthetic situations. In our office we have found that Complications with Local in the inferior alveolar block in- Anesthetics jection, over 30 per cent demon- In spite of the excellent safety strated the aspiration of blood, in- record of local anesthesia, fatalities dicating entrance of the needle into do occur from allergic reactions to a blood vessel. The complications these drugs. Waters and Gillespie4 arising from the administration of found six deaths in 4,835 adminis- local anesthetics in dentistry are trations of local anesthetics. Criep usually from the accidental injec- reported three deaths within one tion of the drug into a blood vessel. year from allergic reactions to pro- An anesthetic cLdose mray then be- caine. Adriani and Campbell"; re- come a toxic dose. This can on'v ported ten fatalities in 15 years at be prevented by making an aspira- Charity Hospital, New Orleans, tion test in every block injection. caused by the topical application of The early symnptoms of toxic tetracaine to the mucous membrane. overdose arc primarily those of The August, 1953, NewsLetter of central nervous system stimulation. the American Society of Anesthesi- This is followed by a proportionate ologists states: "There is a deep degree of central nervous system de- rooted impression among doctors pression. Usually the manifestations that any form of local anesthesia is of toxic overdose are mild and automatically safer than general transitory. Should the stimulation anesthesia, and that limited local result in convulsions, intravenous anesthesia is so innocuous that it barbiturates should be administered may be used on poor-risk patients slowly. without special precautions. Noth- Though allergic reactions to local ing could be further from the truth. anesthetics are rare, they may oc- All locally-acting anesthetic drugs cur, and this hypersensitivity to have the same inherent dangers of local anesthetic drugs may produce circulatory collapse if the blood con- anaphylactoid reactions that can centration is high, even for a short prove fatal. The symptoms of an time." anaphylactoid reaction consist of The excellent safety record of a sudden loss of vasomotor tonus, local anesthesia in dental offices is with the absence of pulse and blood due in large measure to small dos- pressure. Respirations become shal- age. This safety can be further en- low and finally cease.
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