Table 1. 18 Procedure-related office surgery deaths in Florida. 3/1/00 – 7/1/14 Case # Patient Surgical Complication Provider Anesthesia Outcome Date problem Procedure Anes Facility Board Hosp Prob? Accredited? Cert? Priv.? To hospital, 1 Abdomino- Shortness of death from 4/12/00 plasty, breath at home Plastic General by pulmonary Obesity Liposuction following day Surgeon CRNA No embolus AAAASF Y Y 2 Bronchospasm 4/14/00 Hypertrophic Breast during Plastic General by MD To hospital, breast reduction induction Surgeon anesthesiologist Yes death No Y Y Shortness of breath 3 following day, To hospital, 6/6/00 Abdominal Abdomino- pulmonary Plastic General by MD cardiac deformity plasty embolus Surgeon anesthesiologist No arrest, death No Y Y 4 Intravenous 6/26/00 Facial Rhinoplasty, Facial Plastic sedation by To hospital, dystrophy chin implant Bradycardia Surgeon CRNA Yes death No Y Y 5 Anaphylaxis, 8/29/00 Unwanted Termination of cardiac arrest, To hospital, pregnancy pregnancy death OB/GYN Local Yes death No Y Y 6 Hemodialysis Unstable blood Inter- 9/15/00 End stage renal catheter pressure after ventional To hospital, disease placement procedure Radiologist Local No death AAAHC Y Y 7 Lipodystrophy Liposuction, Death that 2/13/01 of laser Death autopsy Plastic General by night at abdomen/hips Resurfacing pending Surgeon CRNA No home AAAASF Y Y Shortness of 8 Dialysis breath Inter- 6/8/01 Poor dialysis catheter Hypotension, ventional To hospital, catheter replacement death Radiologist Local No death No Y Y Cardio- Emergency 9 pulmonary Intravenous surgery, 1 11/29/01 distress, low Gastro- sedation by death soon Rectal bleeding Colonoscopy blood pressure enterologist operating MD No after No Y Y Taken to hospital, 10 corrective 2/4/02 Upper endo- Pharyngeal/ Intravenous surgery, Hemoccult scopy, colon- esophageal Gastro- sedation by death 8 days positive stool oscopy perforation enterologist operating MD No later No Y Y 11 Inter- 4/2/02 Internal ventional To hospital, Jaundice Liver Biopsy bleeding Radiologist Local No death No Y Y 12 Cardio- Intravenous 7/29/02 Cosmetic pulmonary Plastic sedation by To hospital, surgery Facelift arrest in office Surgeon operating MD Yes death AAAASF Y Y Neck lift, Collapsed 2 13 Cosmetic abdomino- days later, Pulmonary 8/7/02 surgery/ hernia plasty, hernia pulmonary Plastic General by MD embolus, repair repair embolus Surgeon anesthesiologist No Death AAAHC Y Y 14 236 Transported to 3/21/03 Unwanted Termination of Amniotic fluid IV sedation by hospital, pregnancy pregnancy embolism OB/GYN operating MD No deceased No Y Y 15 Excess abdominal Deceased at 5/12/03 skin & muscle Abdominoplasty & Pulmonary General by MD home post-op laxity liposuction embolism Plastic surgery Anesthesiologist No day 1 AAAASF Y Y 16 9/25/03 Hypotrophic Cosmetic IV sedation by Deceased on breasts Breast implant Rapid bradycardia surgeon operating MD Yes table in office No Y N 1 Deceased 24hrs Liposuction sub- after surgery at Deceased 17 Brow Ptosis, mental area/ home for General by MD following day 11/13/03 recessive chin Bleparoplasty unknown cause Plastic Surgery Anesthesiologist No unknown cause No Y Y 18 11/24/03 Deceased Fat excess Liposuction & fat General by MD 9 days post-op abdomen transfer Fat embolism Plastic Surgery anesthesiologist No at home AAAASF No Y 19 Transported 1/7/04 hospital, Abdominoplasty, Respiratory/Renal General by MD deceased 3 days Macromastia breast reduction failure post-op Plastic Surgery anesthesiologist Yes post-op No Y Y 20 Death in 4/13/04 Cardiorespitatory IV sedation evening at Lipodysmorphy Liposuction arrest Plastic Surgeon CRNA No facility No Y Y 21 5/4/04 Coronary Artery Cardiac Cardiorespitatory Transfer to Disease Catheterization arrest Cardiologist Local No hospital, death AAAHC Y Y Cardiorespitatory 22 arrest at home due 8/1/04 Abdominal to deep vein General by MD To hospital 3 lipodystrophy Abdominoplasty thrombus Plastic surgeon anesthesiologist No days later, death No Y Y Discharged home, to 23 Lipodystrophy hospital in 11/18/04 with redundant Liposuction/ General by MD evening, death skin Abdominoplasty Pulmonary edema Plastic surgeon anesthesiologist No at hospital No Y Y 24 Discharged 9/28/04 Bilateral Renal Shock wave Cardiorespiratory General by MD home, death in Calculi lithotripsy arrest at home Nephrologist anesthesiologist No evening JCAHO Y Y 25 9/29/04 Severe CAD, Cardiac Cardiacrespiratory Death on the Carotid Stenosis Catheterization arrest on the table Cardiologist Local No table in office JCAHO Y Y Dissection of distal left main ostium of 26 Cardiac LAD and proximal 4/15/05 catheterization, portion of intravascular circumflex Transfer to Chest pain , SDB ultrasound coronary artery Cardiologist Local No hospital, death No Y Y 27 Lung Cancer, 11/1/05 Bronchopleural Interventional IV sedation by MD Transfer to Fistula Stent placement Unknown Radiologist anesthesiologist No hospital, death No Y Y Transfer to hospital, never regained 28 consciousness, 4/19/06 Oral and removed from Fixation of Maxilllofacial IV sedation by life support 4 Fractured mandible fractured mandible Allergic reaction surgeon operating MD Yes days later No No Y Pulmonary 29 Facelift, minibreast embolus and 6/15/06 lift, Pulmonary death 3 days Cosmetic Surgery abdominoplasty embolus Plastic Surgeon Unknown No post-op No Y No 2 30 Abdominal and 11/13/06 upper arm Pulmonary General by MD Transfer to lipodystrophy Liposuction embolus Plastic Surgeon anesthesiologist No hospital, death AAAASF Y Y Transfer to 31 Oral and hospital, death 11/16/06 Maxillofacial IV Sedation by following Nasal deformity Septorhinoplasty Bradycardia Surgeon operating MD Yes morning AAAHC Y Y 32 3/7/07 Ultrasound guided Vascular Transfer to Varicose veins sclerotherapy Anaphylaxis surgeon None No hospital, death AAAHC Y Y 33 6/29/07 Change in visual Fluorescein Hypotension/pulsel Transfer to acuity angiogram ess Retina surgeon Local No hospital, death No Y Y Brow lift, cervicomeloplasty, 34 with submental 8/22/07 Brow ptosis, facial lipectomy and Post operative Transfer to rhytides platysmaplasty bleeding Plastic surgeon General No hospital, death AAAASF Y Y Cardiac arrest due to hypokalemia 35 (from previously 11/30/07 Breast undiagnosed Transfer to Breast hypoplasia augmentation bulimia) Plastic surgeon General No hospital, death JCAHO Y Y 36 Low back pain, Non-responsive, Anesthesiologist 2/6/08 lumbar Lumbar epidural pupils fixed and , pain Transfer to radiculopathy block dilated management Local No hospital, death JCAHO N Y 37 3/21/08 Cardiolite spect Ventricular Transfer to CAD/hypertension stress test fibrillation Cardiologist None No hospital, death No Y Y 38 3/21/08 Breast Malignanat Transfer to Hypomastia augmentation hyperthermia Plastic surgeon General Yes hospital, death AAAASF Y Y CoC 39 Pain, nausea, intra- (Commission on 4/24/08 Cirrhosis, r/o CT guided liver abdominal Interventional Transfer to Cancer), malignancy biopsy bleeding radiologist Local No hospital, death AAAHC Y Y 40 5/13/08 Aging face and Facelift and Myocardial Transfer to eyes blepharoplasty infarction Plastic surgeon Local No hospital, death AAAASF N Y Bilateral 41 brachioplasty and Cardiovascular 6/5/08 Skin laxity and bilateral collapse Transfer to breast ptosis mastopexy postoperatively Plastic surgeon General No hospital, death AAAASF Y Y Severe respiratory depression due to 42 Scars, overdose of pain rx 8/15/08 gynecomastia, Abdominoplasty from variety of lipodystrophy liposuction physicians Plastic surgeon General No Death at home FSMB Y Y 3 Breast Post operative 43 augmentation after Death due to admission, 8/26/08 placement of tissue patient’s illicit death due to AAAASF and Breast hypoplasia expander drug use Plastic surgeon General No illicit drug use FSMB Y Y Postop 44 admission to 10/14/08 Mitral Right/left heart Pulmonary artery MICU, death regurgitation catheterization rupture Cardiologist Local No 2/2 PEA AAAHC Y Y Abdominal 45 elastosis, Abdominoplasty 2/21/09 lipodystrophy of and liposuction of To hospital, flanks and bra rolls bra rolls/flanks Postop shock Plastic surgeon General No death 2/2 shock No Y Y 46 PEA, hypotension, To hospital, 7/15/09 LOC evolved into Interventional death presumed ESRD AV shuntogram vfib Radiologist Conscious sedation No 2/2 PE No Y Y Coded, to 47 hospital ICU, 3/4/10 death from Dental caries Extraction of teeth Pneumonia, sepsis OMFS Conscious sedation No sepsis N Y Y d/c home Breast initially, sudden 48 lift/augmentation respiratory 4/1/10 and revisional distress, Breast hypoplasia abdominoplasty PE, "clots" Plastic surgeon General No admitted, death AAAASF Y Y 49 4/26/10 Unwanted Termination of Amniotic fluid To hospital, Pregnancy pregnancy embolus OB/GYN General No death N N N 50 5/18/10 Angiogram with Retroperitoneal Vascular Hypotension, to Vascular stenosis intervention bleeding surgeon Conscious sedation No hospital, death N Y Y 51 Liposucation with Hypotension, To hospital, 10/25/10 fat transfer to tachypnea, death, ? PE vs Lipodystrophy buttocks tachycardia Plastic surgeon General No fat embolism N Y Y 52 11/16/10 Unwanted Termination of To hospital, pregnancy pregnancy Hemorrhage OB/GYN General No death N Y N Liposuction of 53 abdomen/flanks/ 12/27/10 back and fat To hospital, Lipodystrophy transfer to buttocks Fat embolism Plastic surgeon General No death N Y N Lower blepharoplasty, 54 neck lift revision, 5/16/11 Bilateral neck anterior To hospital, laxity platysmaplasty Cardiac arrest Plastic surgeon General No death N Y Y 55 Ultrasound guided 11/4/11 therapeutic To