Information about the emergency Usher's wife underwent in Brazil recently came to light. Two months after giving birth to the couple's second son, Raymond, 38, traveled to Brazil to have liposuction on her stomach by São Paulo plastic surgeon Dr. Silvio Sterman.According to the doctor involved, Tameka Raymond went into "cardiac arrest" while being anesthetized before a liposuction procedure. She was quickly revived and then placed in an induced coma(?) for 24 hours as a precaution and apparently remains in stable condition in a Sao Palo hospital. The news wire is reporting that she was discharged today and will be returning stateside shortly.

Ellen Dastry, spokeswoman for plastic surgeon Silvio Sterman, says Tameka Raymond checked into the Sao Rafael Hospital last Friday for a "simple liposuction." Dastry said that Raymond suffered a cardiac arrest while being anesthetized for the procedure "but was revived in less than a minute by heart massage." She was then placed in an induced coma before being taken to the intensive-care unit, a procedure Dastry said was "absolutely normal" and performed in order to "avoid unnecessary complications."

I'm a little confused about what may have happened here. It doesn't sound like she had a malignant hyperthermia (see related post here) reaction, but I can't figure out the rationale for the "induced coma". That would not be a normal treatment for a heart attack or lethal arrhythmia (irregular heartbeat), but could be present with malignant hyperthermia.

In a brief search for some consensus in the anesthesia literature on this I found some reference in a recent text which wrote

"Postpartum concerns include a decreased blood hemoglobin and the increased risk of pulmonary aspiration. Anemia is almost always present as a result of physiologic anemia of pregnancy combined with blood loss during and following delivery"

That's pretty tangential to this case, but it's all I can find with superficial snooping. Now liposuction after childbirth would not be expected to be a particularly bloody procedure, it is still something to consider.

More important would be questioning the logic of doing liposuction that early after pregnancy. I'd submit it would be someone with poor judgment who would proceed with that surgery on a practical basis. Good results with lipo rely upon contraction of the skin after it's debulked. There a are a number of circulating hormones associated with pregnancy that predispose tissue to expand to accommodate the developing embryo. Those mediators have clearly not normalized at only two months, and the patient has not reached a plateau in terms of her weight or abdominal wall tone at that point. Pro ceding with surgery is likely to not achieve the expected results in most instances. When would be a "normal" recommendation to proceed in the short term? Think closer to 9-12 months post delivery.

Of note, the NY Daily news is reporting that that the patient may have not been truthful with her surgeon about how far post partum she was. Evan a few months may have been the difference in her being deemed fit for surgery in this instance.


So what else could have happened?

Well, as the fluid used to perform liposuction has adrenaline and local anesthetic solution in it, a large intravascular bolus of this could precipitate a heart arrhythmia or event. Dilated veins in the postpartum abdominal wall may be more likely "targets" to be inadvertently speared by the infusion cannula used to put fluid in to tumesce the tissues for liposuction.

Just a thought!

Rob

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An autopsy has confirmed that the South Florida teenager, Stephanie Kuleba, who died this Spring after corrective breast surgery (reportedly for significant asymmetry and inverted nipples) suffered from a rare genetic disease that had been speculated to have causes her death. Genetic testing at the University of Pittsburgh shows she possessed the genetic mutation RYR-1 which is responsible for most cases of the malignant hyperthermia (MH) response to certain inhaled anesthetics. However, over 80 genetic defects have now been potentially associated with MH. As these mutations are inheritable, they will vary in rates among the population and some increased clusters of MH mutation carriers have been suggested in states like Wisconsin, Nebraska, West Virginia and Michigan.

The exact incidence of Malignant hyperthermia is unknown, but the rate of occurrence has been estimated to be as frequent as one in 10,000 or as rare as one in 100,000 patients who undergo general anesthesia. (A range that big suggests they have no idea to me) There is no practical screening test to determine if a patient has the rare condition so you rely on family history or consultation questions to identify high risk patients. Again, the incidence is so rare there is no way to prevent these MH events from happening. The signs that develop are usually suble (ie. a tense jaw) before they're not (ie. 104 degree temp and cadiovasular collapse).


Despite her doctors efforts to treat the Ms. Kuleba during the event with the medication Dantrolene, her parents claim her Plastic Surgeon's office was not prepared to care for their daughter once they had figured out that she was suffering from the hidden hereditary condition and have (in the great American tradition) announced their intention to file a lawsuit.

When MH is identified or suspected, time becomes valuable for salvage treatment. As soon as the malignant hyperthermia reaction is recognized, all anesthetic agents are discontinued and the administration of 100% oxygen is recommended. Dantrolene should be administered by continuous rapid IV "push" beginning at a minimum dose of 1 mg/kg, and continuing until symptoms resolve or the maximum cumulative dose of 10 mg/kg has been reached.

Kulebas' family attorney Roberto Stanziale, has said the teenager should have received as many as seven vials of the drug as an initial dose. On medical records Stanziale obtained following her death, one doctor noted she received one vial of the antidote. The other doctor wrote she received two. It's not known at what time the drug was administered or whether there was enough Dantrolene available at Dr. Schuster's Boca Raton clinic, Schuster Plastic Surgery. Both doctors have defended their actions, saying the situation was handled appropriately and that Kuleba received the Dantrolene dose needed once they consulted with the Malignant Hyperthermia Association (MHA) hotline and called an expert at the Mayo Clinic in Minnesota.

This dosing issue and it's timing is going to be a big issue in the lawsuit. You can't really give informed consent for MH as it's so rare so that shouldn't be an issue (although that will likely be claimed by a plaintiff's attorney). According to the brochure for Dantrolene, each vial contains 20 mg of the drug. As it's suggested in her anesthesiologists notes, she received 2 vials initially (40mg) while they called the MHA hotline to confirm treatment (as again it's so rare no one really has a lot of experience with treating it). That 40mg dose is in the ballpark for the recommended range (by weight) for initial treatment for most thin teenagers.

At the end of the day, I'm not sure what's going to be achieved with this lawsuit. It sure seems like reasonable steps were initiated by her doctors after the event to try and save this girls life. There is only so much you can do when unforeseen or extremely rare complications arise and no amount of preparation can prevent some bad outcomes. Contrast the hostile posture of the Kuleba family attorney with this MH tragic event during orthopedic surgery on a 20 year old described by Dr. Henry Rosenberg, President of the Malignant Hyperthermia Association of the United States. The pain of the medical staff and their communion with the deceased's family is moving.

I hope that this event will continue to foster more discussion on oversight for office-based surgery and anesthesia. It's ironic that it's actually been Plastic Surgery that been the most progressive in regulatory oversite in ambulatory surgery. While this case was an anesthesia complication rather then a surgical one, the who's, where's , and how's of who can (or should) be doing surgery is overdue for more scrutiny.


Rob

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From the Palm Beach Post comes the tragic death of Florida teen, Stephanie Kuleba, from a rare allergic reaction to inhalation anesthetics called malignant hyperthermia (MH). Wikipedia describes it succinctly as a idiosyncratic reaction that "induces a drastic and uncontrolled increase in skeletal muscle oxidative metabolism which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if untreated."

There's really no way to screen for this process and a patient can die quickly. Most surgeons and anesthesiologists may go their entire career and never see a true case of it. I was talking to one of my colleagues the other day about office based surgery and he said he was unlikely to return to doing that after seen a near fatal MH on a cosmetic surgery case he was doing in an ambulatory surgery center adjacent to a hospital.

I'm not sure what the take home message from this is. It's such a rare event that it's hard to justify having exotic protocols at all times in low risk procedures. Most office surgery suites maintain a supply of Dantrolene, a medicine to treat MH which is almost $2500 per dose and must be restocked often to stay current. There's plenty of adverse events more common then MH, but we don't have aortic balloon pumps or cardiac bypass machines routinely laying around for that. It already sounds like that the family has hired an attorney who is already assuming an aggressive posture in his comments to the media so I'm sure we'll see some legal proceedings even if perfect care for MH was instituted.

Rob

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