[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. Prompt and [I9] correct treatment can be life saving. 4. Increased carbon dioxide level in the blood. The ensuing chemical im- The administration of antihista- balance may cause respiratory depres- mines such as diphenydramine sion and cardiac dilatation. 5. Cardiac and cardiovascular valvular (Benadryl®), 20 to 30 mg. intra- disease (acquired or congenital). venously, vasoconstrictors such as 6. Hypoxia, either acute and I)ro- nounced or chronic, in form, as found epinephrine 1:1000, 0.3 to 0.5 ml. in long standing pulmonary disease. Ef- intramuscularly, aminophyline, 7/2 ficient oxygenation at all times is a basic concept of acceptable anesthetic practice. grains intravenously, and 20 mg. hy- 7. Inadvertent administration of an drocortisone hemisuccinate (buf- undesirable drug or inaccurate dosage of the correct drug. fered) in 5 cc. of sterile saline, in- 8. Unrecognized administration of an travenously, can be used to combat unindicated and harmful compressed gas. Labels on gas cylinders, as well as on anaphylactic reactions. Oxygen containers for drugs, require identifica- should also be administered under tion before administration. 9. Cardiovascular effects of anesthlesia pressure. or surgery. Reflexes, possibly of vagal origin. Complications with General 10. Certain endocrine and metabolic Anesthetics disturbances." Cardiac arrest, cardiac standstill Though cardiac arrest may oc- or cardiac asystole, untreated, will cur at any time during anesthesia, terminate promptly in death. No it most frequently occurs during anesthetic agent can be specifically induction and emergence. Cardio- blamed for cardiac asystole. Misuse vascular emergencies are usually of an agent and errors incidental to secondary to respiratory emergen- its administration are the respon- cies. Mechanical or physiologic ob- sible etiological factors in anesthetic struction of the airway, inefficient fatalities. carbon dioxide elimination and in- sufficient oxygen in the anesthetic According to Ruth, Buckley and mixture are the prime causes of Krown8 two or more of the follow- respiratory difficulties. ing ten conditions are present when Our efforts as dentist anesthe- cardiac asystole occurs: siologists should be directed toward "1. Anemia and decreased circulatory improving our excellent record and fluid volume. Inadequate oxygen carry- ing capacity of the blood is well known providing still greater safety for our as a cause of major dysfunctions of patients. This can be accomplished both heart and brain. 2. Overdose of anesthetic agent. Ef- by a correct evaluation of the pa- fects of this on the respiratory centers tient and selection of the anesthetic or vasomotor center or both, can result in secondary heart failure. agent or agents that conform to the 3. Anxiety of the patient; increased physical status of the patient. Hypo- epinephrine outflow sensitizes the myo- cardium to cardiac arrhythmias. tension and anoxia should be [10]

Anesthetic Deaths in Oral Surgery 1950 - 1956 inclusive

From Members of the American Society of Oral Surgeons: Total number of replies ...... 406 Total number of complete replies ...... 314 Total number of incomplete replies ...... 92 Total number of LOCAL anesthetics administered...... 4,244,449 Total number of GENERAL anesthetics administered ...... 3,721,178 Total number of mortalities ...... 59

ANESTHETICS ADMINISTERED OFF I CE HOSPITAL HOME TOTAI.

Nitrous Oxide-Oxygen 7 9 Nitrous Oxide-Oxygen Vinethene® 1* 1 Nitrous Oxide-Oxygen Trichlorethylene 2 2

Nitrous Oxide-Oxygen Ether 3 2 2 Sodium Pentothal® 3 15 1** 19 Sodium Pentothal® Nitrous Oxide- 1 15 16 Oxygen Sodium Pentothal® Cyclopropane Local 1 1 Sodium Pentothal® Gas Oxygen Ether I 1 Ether 5 5 Local 2 1 3

TOTAL 15 43 1 59

* Explosion, in office-anesthetic was nitrous oxide-oxygen Vinethene®. ** Intravenous barbiturate administered in patient's home. [11]

Local Anesthetic Deaths in Medicine and Dentistry - Comparison of Published Statistics

REPORTER TOTAL PROCEDURES ANESTHETIC ANESTHETIC MEAN MORTALITY CASES DEATHS PERCENTAGE

Furstenberg 30,000 Tonsillectomies Cocaine Hydro- 3 0.010 and others' chloride

Ireland, 39,298 Ear, nose, Cocaine Hydro- 7 0.018 Ferguson & Stark2 and throat chloride and Tetracaine Hydrochloride Schindler3 22,251 Gastroscopy Cocaine Hydro- 3 0.013 chloride and Tetracaine Hydrochloride

Williams3 6,378 Nose and Cocaine Hydro- 2 0.013 throat chloride Seldin and 90.000,000 All dental Local anesthetics, 2 0.00002 Recant4 procedures mainly, procaine hydrochloride

Beecher and 7,600 General Topical and 1 0.01 Todd5 surgery Regional Seldin 4,244,449 Oral Local Anes- 3 0.00007 + surgery thesias

1. Furstenberg, A. C., and others, "Evaluation of cocaine anesthesia: Perpetuation of the equivocal concepts," Tr. Am. Acad. Ophth. 55:643 July-Aug. 1951. 2. Ireland, P. E., Ferguson, J. M. W, and Stark, E. J., "Clinical and Experimental Comparison of Cocaine and Pontocaine as Topical Anesthetics on Fatalities in Otolaryngological Practice," Laryngoscope 61:767, Aug. 1951. 3. Schindler, R., "Results of Questionnaire on Fatalities in Gastroscopy," Amt. J. Digest Dis. 7:293, July 1940. 4. Seldin, H. M., Recant, B. S., "The Safety of Anesthesia in the Dental Office," J. of 0., S. Vol. 13, pp. 199-208, July 1955. 5. Beecher, Todd, Ann. Surg. 140:2, 1954. [12] avoided, especially in patients with bolisms. Therefore, the mean mor- cardiovascular disease.9 Adreno- tality percentage, instead of being cortical insufficiency should be cor- 0.00007+, is now 0.000069. rected with cortisone. Atropine With the additional figures re- should be used for patients taking ceived and recompiled, the total is rauwolfia alkaloids. High oxygen one death in 63,054 general anes- percentages should be administered thetics administered and one death with the anesthetic agent and an in 1,438,678 regional or local anes- open airway maintained at all thesias. times. References Marked apprehension should be 1. BEECHER, H, K., "First Anesthesia controlled. It is advisable to post- Death with some Remarks Suggested by it on Fields of Laboratory and pone surgery for a cardiac patient Clinic in Appraisal of New Anes- who comes to the office in a state thetic Agent", Anesthesiology, 2:443, July, 1941. of marked anxiety and apprehen- 2. SELDIN, H. M. and RECANT, B. S., sion. "The Safety of Anesthesia in the Dental Office", Journal of Oral Sur- Conclusion gery, 13:199-208, July, 1955. 3. BEECHER, H. K. and TODD, A., An- The studies and reports pre- nals of Surgery, 140:2, 1954. sented in this paper clearly show 4. WATERS, R. M. and GILLESPIE, M. A., "Deaths in Operating Rooms", that anesthesia in the office of the Anesthesiology, 5:113, March, 1944. oral surgeon and dentist, when ad- 5. CRIEP, L. H. and RIBEIRO, C. C., "Allergy to Procaine Hydrochloride ministered by a qualified anes- with Three Fatalities", J.A.M.A. 151: thetist, dentist or nurse, has a 1185, April 4, 1953. much lower than 6. ADRIANI, J. and CAMPBELL, B., mortality rate "Fatalities Following Topical Ap- anesthesia administered in hospitals plication of Local Anesthetics to Mucous Membrane", J.A.M.A. 162: or medical offices. Dec. 22, 1956. Addendum 7. MONHEIM, L., Local Anesthesia and Pain Control in Dental Practice, C. Since the completion of this V. Mosby Co., St. Louis, 1957. report five additional replies to our 8. RUTH, H. S., BUCKLEY, M. L. and KROWN, K. K., "Cardiac Asystole", questionnaire were received making JA.M.A., Vol. 164, No. 8, June 22, a new total of 8,099,290 anesthetics 1957. 9. COAKLEY, C. S., "Anesthesia for Pa- administered, of which 4,316,027 tients with Cardiovascular Disease were local and 3,783,263 were for Ambulatory Oral Surgery", Newsmonthly of the American general. There were four additional Dental Society of Anesthesiology, deaths occurring in hospitals under Feb., 1957. 10. EDWARDS, GEo., MARTON, H. J., Pentothal®- cyclopropane anesthe- PASK, E. A. and WILIE, W. D., sia, two of which were cardiac "Death Associated with Anesthesia, A Report on 1,000 Cases", Anes- failures and two, pulmonary em- thesia, 11:194, July, 1956.