Episode #261 Patient Safety Challenges: From Global Cosmetic Tourism to Pediatric Medication Dosing

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are going to be discussing the June 2025 APSF Newsletter articles soon, but first we have a couple of Articles Between Issues to discuss. We have a wide range of topics for today from safe cosmetic surgery in Columbia to the use of Oxymetazoline for pediatric patients. So, go ahead and refill your coffee cup or lace up your sneakers because we have quite a show for you today.

Before we dive further into the episode today, we’d like to recognize Fresenius Kabi, a major corporate supporter of APSF. Fresenius Kabi has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Fresenius Kabi – we wouldn’t be able to do all that we do without you!”

Our first article between issues is “Safety in Cosmetic Surgery: A Look at the Vital Role of Anesthesiology in Colombia” published online in May 2025 and written by Luis Fernando Álvarez and Felipe Urdaneta. To follow along with us, head over to APSF.org and click on the Newsletter heading. The second one down is Articles between issues. From here, scroll down until you get to our featured article. I will include a link in the show notes as well.

This is a Letter to the Editor. Let’s hear from the authors. They introduce cosmetic surgery which often involves patients who are healthy and working age looking to enhance their appearance and improve self-esteem. Cosmetic surgery has advanced considerably and there is an increased volume of office-based and ambulatory cosmetic surgical procedures. The focus for this article is Columbia which has emerged as a top destination for cosmetic surgery ranking second in South America after Brazil and fourth in the continent after the United States and Mexico in the number of annual cosmetic procedures according to the International Society of Aeswthetic Plastic Surgery. Did you know that in 2022, there were almost 500,000 cosmetic surgical procedures performed in Columbia? These procedures include blepharoplasty, facelift, rhinoplasty, breast augmentation and reduction, abdominoplasty, liposuction, as well as injectables, facial rejuvenation, and hair removal. These procedures are often done in the private sector in Columbia which has less regulations leading to increased risks due to substandard medical and surgical practices, poor infection control, and outdated medical equipment. There is a growing threat to anesthesia patient safety as the demand for cosmetic procedures increases leading to inappropriate practices and inadequate patient selection. You may have seen a news article about severe adverse events following cosmetic surgery or heard anecdotal reports, but there is not very much in the medical literature and you know much we like to dive into the literature. International data reveals that mortality associated with anesthesia is between 1 in 100,00-200,000 patients. There is no official government data, but retrospective data reveals that the mortality rate of cosmetic procedures could be as high as 1 in 20,000 patients, that is 10 times higher than the global numbers!! That is a lot of risk for patients. There is a call to action for further investigation and addressing these significant patient safety concerns. Anesthesia professionals, cosmetic surgeons, and their respective medical associations should strive to bring down this complication rate and decrease perioperative mortality following cosmetic procedures around the world. The APSF is a leader in perioperative patient safety and may be able to provide guidance to improve current practices for cosmetic surgery and anesthesia in Columbia. Additional resources, information, insights, and guidance may help to improve the current practice standards, safety, quality, and patient satisfaction going forward.

Let’s take a look at the reply from Diana Anca and Richard Urman, “Office-based Aesthetic Procedures: How Can We Make It Safer?” Safety concerns regarding cosmetic procedures include location of procedure, patient selection, surgeon qualifications, and credentialing. Keeping patients safe during office-based procedures requires that the facilities have the necessary equipment, personnel, space, and are ready to respond to emergencies such as anaphylaxis, local anesthetic toxicity, and difficult airway. Regulations for quality standards and accreditation often vary by state or country and this variability may increase the risk for patient safety at certain centers. There are professional society guidelines from the American Society of Anesthesiologists Guidelines for Office-Based Anesthesia with important considerations for patient selection, monitoring, facility management, and personnel including qualification, training, and credentialing for anaesthesia professionals. I will include a link to these guidelines in the show notes as well. It is also important to make sure that the surgeons or proceduralists performing these cosmetic procedures have appropriate training, qualifications, credentialing, and are practicing within their scope of certification. The good news is that there is a blue print for setting up and operating cosmetic procedure centers. The APSF consensus statement for the safe conduct of nonoperating room anesthesia is an excellent resource based on a report from the 2022 Stoelting Conference. Important considerations for keeping patients safe include provisions for safe anesthesia, facilities setup and management, equipment, medications and supplies, staffing, perioperative care and quality assurance. Anesthesia professionals who work at these centers can serve as leaders on the perioperative team, working with the interdisciplinary team to implement these guidelines and protocols to help keep patients undergoing cosmetic surgery safe during anestheisa care.  For more information about the APSF Consensus statement, I will include the link in the show notes and you can check out episode #117 Crucial Patient Safety Issues in NORA: Highlights from the 2022 APSF Stoelting Conference. There are many important considerations related to the facility; equipment, medication, and supplies; staff and teamwork; Preprocedural care and patient selection; Intraprocedural Care; Postprocedural Care; and Continuous Quality Improvement. Here are the two recommendations that fall under the Continuous Quality Improvement heading:

1. Anesthesia personnel should establish a quality review process to identify possible new safety risks and improve care on a regular basis.
2. Periodic emergency response simulations should be performed to review system, communication, equipment, and educational infrastructure.

Non-operating room anesthesia is one of the APSF’s Patient Safety Priorities and a lot of work has been done in this area to help improve patient safety including several APSF Newsletter articles, support for research grants, and the 2022 APSF Stoelting Conference which focused on Crucial Patient Safety Issues in Office-Based and Non-Operating Room Anesthesia.

If you provide office-based and non-operating room anesthesia care, we hope that you will check out the entire statement and work to implement all of the recommendations at your center as you work towards improving anesthesia patient safety.

Our next featured article between issues is “Safe and Deliberate Use of Oxymetazoline in the Pediatric Operating Room” published online in May 2025 and written by Robert Vernick and colleagues.

May 22, 2025. I will include a link to this article in the show notes.

Here we go. Oxymetazoline is a topical vasoconstrictor that may be given intranasal to help decrease bleeding and improve visualization during a nasotracheal intubation. The benefit for using this medication is the local vasoconstriction, but there are some important side effects. Excessive administration may cause hypertension and/or bradycardia which could cause adverse events in patients with cardiovascular disease. During administration of intranasal oxymetazoline, there is a risk for excessive administration since the method for delivery in the OR may not be consistent with the mechanism for delivery designed by the manufacturer. The delivery system was designed to be used with the bottle in the upright position on a patient who is also sitting upright. This may not be the case in the operating room especially for pediatric patients requiring nasotracheal intubation. Instead, pediatric patients are usually asleep and laying supine during oxymetazoline administration requiring that the bottle be inverted to administer the medication.

The oxymetazoline bottle has an integrated pump system that is designed to deliver a mist into the nares. Some designs have a small orifice to control the dose and other designs use a straw to connect the medication supply to the administration tip. Check out Figure 1 in the article for a picture of Oxymetazoline spray bottles with integrated pump delivery and manual mist systems. Both of these systems are designed for administration with the bottle in the upright position. When the bottle is squeezed in the upright position, 1 spray is intended to dispense about 0.03ml of oxymetazoline. If you turn the bottle upside down, all bets are off and the dose of oxymetazoline is unpredictable. Bottles with the integrated straw are more likely to deliver a reduced dose when the bottle is inverted since the straw entrains less medication. Bottles with the small orifice can deliver much higher doses of the medication, even over 1ml. Check out the supplemental video in the article for a demonstration. There is a real risk for overdose of oxymetazoline when the bottle is inverted and squeezed into the nose which may lead to systemic effects and adverse events especially in pediatric patients.

The good news is that there is a way to deliver oxymetazoline safely for paediatric patients, but it takes a little bit of work and ingenuity. The authors suggest using an atomizer fitted to a 1ml syringe. Check out Figures 2 and 3 in the article for a visual of this process. The bottle can be opened to remove a specific dose of medication in the syringe to make sure that you are administering the correct dose that does not depend on positioning. Thank you to the authors for highlighting this threat to patient safety of excessive administration of oxymetazoline to paediatric patients and offering a strategy for deliberate and safe administration.

Do you use oxymetazoline for paediatric patients as part of your practice? How do you ensure that you are delivering the appropriate dose? Is this something that you would consider using in your practice or at your institution? One of the APSF’s patient safety priorities is Medication Safety and this article helps to highlight important drug effects and a process for avoiding inadvertent overdosage due to inappropriate use of the medication delivery system. Using a syringe and atomizer with the correct dose of oxymetazoline is an important way to help keep patients safe during anesthesia care.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

The June 2024 APSF Newsletter has been released! We are so excited to feature many of these excellent articles here on the podcast. In the meantime, you can check out the articles online over at APSF.org and click on the Newsletter heading. The first one down is the current issue which is now the June 2024 APSF Newsletter. Stay tuned for all new podcast episodes on these articles soon.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2025, The Anesthesia Patient Safety Foundation