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Questions Surround Teen Death From Anesthesia During Breast Surgery

Posted by Jane Akre
Wednesday, March 26, 2008 12:28 AM EST
Category: Major Medical, Protecting Your Family
Tags: FDA and Prescription Drugs, Defective Drugs, Wrongful Death, Medical Malpractice, Plastic Surgery, Anesthesia

A teenage girl from Florida died during breast augmentation surgery from a reaction to anesthesia.



IMAGE SOURCE:  WikiMedia Commons/ breast augmentation/ from FDA.gov 

She was a pretty, popular, high school cheerleader from Boca Raton Florida.

18-year-old Stephanie Kuleba was going to have breast augmentation surgery to correct asymetrical breasts and an inverted aerola.  

But the West Boca High School senior died after having complication from anesthesia given during her surgery.

The questions now is whether this death could have been prevented by proper screening prior to surgery or by adequate intervention at the surgical clinic. 

Right now, attorney Roberto Stanziale tells IB News, the family is planning her funeral. Here is what they know so far:

"She went in for the surgery at 8:05 in the morning, by 9:45, an hour and 40 minutes later, the paramedics had been called and she had been rushed to Delray Medical Center where, basically, 24 hours later, she died,"said Stanziale. 

Doctors believe the cause of death was malignant hyperthermia, MH, a rare genetic disorder that can be triggered by anesthesia in sensitive people. 

There is no simple test to determine if one has MH.  Most reactions are found in children and young adults.

In those individuals, general anaesthesia can induce an increase in body temperature above 110 degrees as the body is unable to supply oxygen and remove carbon dioxide.

Eventually there is circulatory collapse and death can follow if the antidote dantrolene, a muscle relaxer, is not given immediately. Dantrolene sodium, is still the only recognized treatment for an MH crisis. 

The Kuleba's family attorney says he will determine if the antidote was available in this outpatient clinic as part of the professional accreditation requirements. 

The Malignant Hyperthermia Association of the United States says there is a preoperative evaluation and screening for those at risk and Stanziale tells IB News that Stephanie did meet with the anesthesiologist prior to surgery.

"We don't have the medical records yet" he says, "so whether any further evaluation was done prior to surgery should be in the records. The family says that they met with the anesthesiologist and he asked her if she had anything to eat and whether she had anesthesia before," Stanziale says.

Her board-certified plastic surgeon Dr. Stephen Schuster said in a statement, "I am devastated by the loss and I feel for the family."

The blonde teen was going to study medicine, ironically plastic surgery, at the University of Florida. Instead Sunday night she was remembered at the high school where students held a candlelight vigil.

The American Society of Plastic Surgeons indicates that more teens than ever are having cosmetic breast surgery. Some are given surgery as a gift from parents.

The Society reports that nearly 348,000 breast augmentations were performed last year up 64 percent from 2000. #


Posted by Barry L. Friedberg, M.D.
Wednesday, March 26, 2008 6:04 PM EST

Florida teen death: Anesthesia choice likely creates another avoidable tragedy in cosmetic surgery

Corona del Mar, CA

She wasn’t as famous as Olivia Goldsmith, author of The First Wives Club, but Stephanie Kubela’s death was just as avoidable.

Complications from rare genetic disorder, malignant hyperthermia (MH), appear to be the cause of the Florida teenager’s needless death.

Triggering agents for MH are inhaled general anesthetic (GA) agents (i.e. halothane, desflurane and sevoflurane) and the muscle relaxant, succinycholine (SCH), used to intubate the airway.

GA is the predominant choice of anesthesia cosmetic surgery, so her surgeon was within the ‘standard of practice’ in that choice – expedience over outcomes.

Unfortunately, GA or the ‘standard of practice’ includes many unnecessary, avoidable and potentially fatal risks to patients choosing to have surgery that has no medical reason or indication.

Among those avoidable risks are MH, blood clots to the lungs, airway mishaps leading to lack of oxygen to the patient’s brain, postoperative nausea and vomiting (PONV), and postoperative cognitive disorder (POCD).

All of these risks can and should be avoided by having surgeons and patients choose a kinder, gentler anesthetic technique – propofol ketamine or minimally invasive anesthesia (MIA)® pioneered by Friedberg.

Neither propofol nor ketamine are triggering agents for MH. Had Ms. Kubela received MIA, she would likely be alive today. BIS monitoring of the patient’s brain gives a numerical value of propofol sedation at which ketamine can be given without negative side effects.

In 2005, The Doctors’ Company (TDC) Newsletter extolled the safety of propofol ketamine over general anesthesia for prevention of blood clots to the lungs. TDC is a medical malpractice carrier with a high percentage of plastic surgeons as insured.

No airway mishaps have been reported with MIA. With minimal trespass, patients tend to breathe normally and require little assistance or intervention to keep their airways open. No lack-of-oxygen accidents have been reported with MIA.

MIA has the lowest published rate of PONV, highly desirable, especially for facelift and tummy tuck patients.

Sometimes MIA is called ‘Goldilocks’ anesthesia. BIS monitoring eliminates the common anesthesia practice of giving too much for fear of giving too little. The opportunity for POCD is thereby greatly minimized.

More anesthesia providers are recognizing the advantages of MIA. Both surgeons and anesthesia providers need to be asked to provide it to optimize patient safety for cosmetic surgery.

Barry L. Friedberg, M.D. has been in active practice exclusively in office-based anesthesia for cosmetic surgery since 1992. He has published 30 letters to the editor, 14 articles and 6 book chapters including 3 in Anesthesia in Cosmetic Surgery recently published by Cambridge University Press.

More information can be found @ LINK , a patient oriented, non-commercial web site.

Disclaimer: Dr. Friedberg is not employed by Aspect Medical Systems, makers of the BIS monitor. He is not a stockholder or a paid consultant. The opinions expressed herein are his professional opinion based on 11 years experience with BIS monitoring.

Anonymous User
Posted by Jane Akre
Wednesday, March 26, 2008 6:28 PM EST

Still to be determined here is whether this was an ambulatory center that is required to have the antidote available - Or a doctors office. The state tried to make requirments for doctors office procedures much stricter a few years ago after a number of deaths in a state with a high number of outpatient procedures.
Anyone in the know about Dr. Schuster's practice?
Thanks !! ja

Anonymous User
Posted by J in GA
Thursday, March 27, 2008 11:07 AM EST

So glad Dr. Friedberg stepped in to offer his usual advertisement for his MIA technique that quite honestly is MUA (Minimally Used Anesthesia).

Anonymous User
Posted by Maximally Annoyed Anesthesia
Thursday, March 27, 2008 9:55 PM EST

Dr. Friedberg is using this woman's death as a platform to ADVERTISE for the surgery center where he practices? Classy.

Anonymous User
Posted by Parents, Where are they thinking?
Friday, March 28, 2008 1:59 PM EST

The bigger question is who at 18 years old needs to be worried about how large their breasts are! How about she focus on something more important in life. You cant honestly tell me some father would allow their attractive daughter to have one more excuse to have some creep guy stalk her.

Anonymous User
Posted by Maximally Irritated Anesthesiologist
Sunday, March 30, 2008 2:36 PM EST

Dr Friedberg's comments and advertising are disturbing to say the least. I'm sure if the anesthesia provider had any reason to suspect MH beforehand then no triggering agents would have been used. To imply that non triggering agents should be routinely used is ludicrous and expensive. He didn't say if he owns stock in diprivan (propofol).

The questions are: was this surgery performed in a licensed center or a physician's back office, was dantrolene available and was the MH quickly diagnosed and treated? MH is a serious metabolic derangement that is very difficult to manage. It takes many people working together for many hours, even days to resolve the crisis. My sympathy to the family and the devastated anesthesia provider.

Anonymous User
Posted by Shelly Davis
Monday, March 31, 2008 5:23 PM EST

As a mother of 3 boys, whom is a confirmed 3rd generation carrier of MH, I am saddened to her this young girl died, because her death might not have had to happen if the facility and the medical staff were completely ready to be able to treat this.

MH is a very rare disorder and because it is not a "popular" or "well documented" disorder it is listed as an "rare" or "orphan" disorder, therefore there is not much funding available to research this, because there is no money to be made from it. There is no “pill” to make it go away. So therefore it is not profitable to the drug companies.

Unfortunately, because this is such a rare disorder most people do not know that MH goes beyond just what can happen during surgery, there are many people whom live with on a daily basis that have other issues, like unexplained fevers, not being able to tolerate excessive heat, a constant feeling of dehydration, muscle spasms that would make the worst Charlie Horse seem tame, debilitating dizzy spells that literally shut down your ability to function as a human being and worse yet, vertigo that never goes away. But again, there isn’t much funding to research MH, and it is such a crying shame.

There is only one "cure" for it, Dantrolene, and this will only work if they catch it in time to administer it and even then at best, there are life long after effects that people suffer once they have had an "episode".

To be tested for this disorder is a very painful process in which they take muscle from your thigh, just above the bone to test with "triggering agents". I know, I have had it done, they took 3 inches of muscle, they tell you that the procedure can damage nerves (believe me I know) and it leaves such a beautiful scar for life.

Even the testing centers are few and far between, because again, there is no money to be made off of it and it is not a cheep test. I was lucky enough that Kaiser paid for mine and I know they paid out to UC Davis about 15,000 to have it done. I would have paid for it myself if Kaiser didn't.

I feel that surgery is such a huge thing that should never be done lightly. I have had to have several surgeries in my life and it was up to me to make sure that the people dealing with my LIFE are well prepared to handle a MH crisis. It is up to everyone to research the procedure fully, ask as many questions as you need to and make sure that the facility you go to is fully prepared to handle anything and everything that might happen.

What concerns me is that any trained Anesthesiologist should have been able to tell the signs long before it got out of hand. I know that this comment might upset those Anesthesiologist’s out there, and I am not saying that they don’t know what they are doing, but there are signs that would alert the Anesthesiologist that something is not right well before the last stage of an episode which is the core body temperature going sky rocketing. By then it is often too late. They are taught in school how to handle MH, what to look for and how to deal with it. When ever I have had a surgery, I spend over a hour with the anestheiologist because most have never had "a case of MH" in their professional lives. I often feel like a odd ball because what I have is so rare.

The Malignant Hyperthermia Foundation has so much information that every doctor’s office, dental office and hospital in the country that performs ANY TYPE OF SURGERY should have a copy of their procedure manual on how to handle a MH crisis. There should always be Dantrolene on hand for any surgery. It just makes sense.

I hope that my comments helped someone out there, and apologize to those I might have offended. I understand that this was this poor young ladies first surgery. This is such a shame. My heart goes out to her family. I do hope that in light of this sad time, that now maybe there will be more funding available so that everyone can be safe during any surgery, more testing sites will become available (there are only about four in this country, two are in California) and that no other family has to suffer as this poor girls family is now.

Thank you.

Anonymous User
Posted by Jane Akre
Monday, March 31, 2008 11:07 PM EST

Thank you Shelly for your thoughtful comments. I'm sorry you have this condition but thankful that at least you know about it.

What type of anesthesia do you tell the anesthesiologist he/she can use if you need surgery?

Are they aware of the situation? And is Dantrolene commonly available in the OR where you live? Or in outpatient clinics or Ambulatory Surgical Centers if you have them where you live?

Also to MI Anesthesiologist- I can't image anything worse for your profession- Where you practice is Dantrolene commonly ready to administer, that is mixed with water and ready to be drawn and injected, during any and all surgeries? I imagine it varies from state to state depending on the medical boards requirements. Does accreditation by The Joint Commission mandate Dantrolene be available and ready to go during surgeries?

Thank you! Jane Akre

Anonymous User
Posted by JDeW
Sunday, April 06, 2008 7:54 AM EST

As a practicing nurse anesthetist, it is much safer for patients with a known history or known family history of MH to undergo anesthesia than someone who unexpectedly reacts such as in this case. The inhalation agents and succinycholine must be avoided. There are alternatives such as Total IV Anesthesia that can provide general anesthesia safely to the patient, along with additional preparations with the anesthesia machine to help rid of trace gases.

It is not practical to mix Dantrolene with water daily. It is far too expensive and I imagine the supply in the US would run out within days. It must be immediately available to mix if a reaction occurs, however.

Posted by Barry L. Friedberg, M.D.
Sunday, April 06, 2008 2:26 PM EST

In response to the 'sour grape' artists : J in GA, maximally annoyed and irritated anesthesiologist:

Posted by Barry L. Friedberg, M.D.
Sunday, April 06, 2008 2:26 PM EST

In response to the 'sour grape' artists : J in GA, maximally annoyed and irritated anesthesiologist:

Anonymous User
Posted by Harry J. Freebird, B.S.
Wednesday, April 09, 2008 5:17 PM EST

The doc figured out how to copy and paste in his spam, but can't figure out how to reply?

Comments for this article are closed.

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