Anesthesia Patient Safety Podcast

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

• Anesthesia Patient Safety Foundation • Episode 261

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Navigating the complex landscape of patient safety requires vigilance, knowledge, and adaptability. Today's episode takes us on a journey through two critical safety concerns that exemplify the challenges anesthesiologists face in diverse clinical settings.

We begin with an eye-opening exploration of cosmetic surgery safety in Colombia, which has emerged as a top global destination for aesthetic procedures. Despite performing nearly 500,000 cosmetic surgeries annually, Colombia faces alarming safety statistics—mortality rates potentially ten times higher than global averages for anesthesia-related deaths. This stark disparity highlights how regulatory gaps, substandard facilities, and inadequate patient selection can create perfect storms for adverse outcomes. The discussion illuminates how anesthesiologists can serve as safety champions by implementing rigorous standards and protocols.

The conversation then pivots to a surprisingly common yet overlooked danger in pediatric anesthesia: the administration of oxymetazoline. What seems like a routine medication becomes hazardous when delivery systems designed for upright, conscious patients are used on supine, anesthetized children. Through practical demonstrations and creative problem-solving, we uncover how simple modifications to delivery methods—specifically using atomizers with precisely filled syringes—can prevent potentially dangerous overdoses and create standardized, position-independent dosing.

Both topics underscore a central theme: anesthesia safety demands thoughtful adaptation of standards to fit unique circumstances. Whether dealing with international variations in practice or the specialized needs of pediatric patients, the commitment to "no one shall be harmed by anesthesia care" requires constant vigilance and innovation. We'd love to hear your experiences with similar challenges—have you encountered safety variations in different practice settings, or developed creative solutions to common problems? Visit APSF.org to explore our resources and join the conversation about advancing anesthesia patient safety worldwide.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/261-patient-safety-challenges-from-global-cosmetic-tourism-to-pediatric-medication-dosing/

© 2025, The Anesthesia Patient Safety Foundation

Speaker 1:

You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.

Speaker 2:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm 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 articles between issues to discuss. We have a wide range of topics for today, from safe cosmetic surgery in Colombia 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, we'd like to recognize Fresenius Cobby, a major corporate supporter of APSF. Fresenius Cobby has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, fresenius Cobby. We wouldn't be able to do all that we do without you.

Speaker 2:

Our first article between issues is Safety in Cosmetic Surgery a look at the vital role of anesthesiology in Columbia, published online in May 2025 and written by Luis Fernando Alvarez and Felipe Urdaneta. To follow along with us, head over to APSForg 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 today. 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 introduced 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 Anesthetic Plastic Surgery. Did you know that in 2022, there were almost 500,000 cosmetic surgical procedures performed in Colombia? 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 Colombia, which has less regulations, leading to increased risks due to substandard medical and surgical practices, poor infection control and outdated medical equipment.

Speaker 2:

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 how much we like to dive into the literature literature and you know how much we like to dive into the literature. International data reveals that mortality associated with anesthesia is between 1 in 100 to 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 Anka and Richard Ehrman.

Speaker 2:

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. 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 for office-based anesthesia, with important considerations for patient selection, monitoring, facility management and personnel, including qualification, training and credentialing for anesthesia 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 blueprint for setting up and operating cosmetic procedure centers.

Speaker 2:

The APSF Consensus Statement for the Safe Conduct of Non-Operating Room Anesthesia is an excellent resource based on a report from the 2022 Stolten Conference. Important considerations for keeping patients safe include provisions for safe anesthesia, 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 anesthesia care. For more information about the APSF consensus statement, I will include the link in the show notes and you can check out episode number 117, crucial Patient Safety Issues in Nora highlights from the 2022 APSF Stolten Conference. There are many important considerations related to facility equipment, medication and supplies, staffing and teamwork, pre-procedural care and patient selection, intra-procedural care, post-procedural care and continuous quality improvement. Here are two recommendations that fall under the continuous quality improvement heading. Number one anesthesia personnel should establish a quality review process to identify possible new safety risks and improve care on a regular basis. And number two periodic emergency response simulations should be performed to review system communication equipment and educational infrastructure.

Speaker 2:

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 Stolting 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 Oximetazolin in the Pediatric Operating Room, published online in May 2025 and written by Robert Vernick and colleagues. I will include a link to this article in the show notes. Here we go. In the show notes, here we go.

Speaker 2:

Oximetazolin 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 operating room 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.

Speaker 2:

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 one in the article for a picture of the 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, one spray is intended to dispense about 0.03 mL 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. Bottle is inverted, since the straw entrains less medication. Bottles with a small orifice can deliver much higher doses of medication, even over 1 ml. Check out the supplemental video in the article for a demonstration.

Speaker 2:

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 pediatric 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 pediatric patients and offering a strategy for deliberate and safe administration. Do you use oxymetazoline for pediatric 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 other APSF 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 keep patients safe during anesthesia care.

Speaker 2:

If you have any questions or comments from today's show, please email us at podcast at apsforg. 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 aSForg for detailed information and check out the show notes for links to all the topics we discussed today, the June 2025 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 apsforg and click on the newsletter heading. The first one down is the current issue, which is now the June 2025 APSF newsletter. Stay tuned for all new podcast episodes on these articles coming soon. Episodes on these articles coming soon. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.