From Fox News:

Following the death of 81-year-old Joan Rivers from cardiac arrest on Sept. 4, questions have arisen as to the safety of the procedure she underwent at an outpatient endoscopy clinic and whether she was under general anesthesia. While the procedure and her level of sedation have not been confirmed, one expert said that neither age nor sedation should be a risk if a facility is properly able to handle emergencies.

“I think that age is not as big a factor as what kind of resources do you have to take care of the patient,” Dr. Howard Nearman, former chief of anesthesiology at University Hospitals Case Medical Center in Cleveland, Ohio, told “As people are living longer, we’re now seeing all kinds of people undergoing all kinds of major procedures well into their 80s, 90s. It’s not as much about age as it is resources— both equipment, drugs and personnel to take care of any potential problems.”

Yorkville Endoscopy clinic, where Rivers underwent a procedure, has stated that their anesthesiologists utilize light to moderate sedation, not general anesthesia.

When a patient is under light sedation, it’s as though they took sleeping pills or sedatives; they are easily awoken and may not even sleep. Under moderate sedation, patients require more stimulus to wake, but they’re still breathing, maintaining blood pressure and have all their basic reflexes intact.

One risk factor of light sedation is laryngospasm. The patient is asleep and still has some of his reflexes, but if anything goes down into the vocal chords or general area of the airway opening, this can cause the laryngeal muscles to go into spasm which could close off the airways.

Nearman noted that this typically only occurs in children, and that only 1 percent of adults have issues.
Going into deep sedation and general anesthesia, a patient will lose his reflexes and may not be able to breathe on their own. When a patient does not have his reflexes, there is the risk that the airway could get blocked. The airway could be blocked by secretion, blood, gastric contents or other fluids, which could prevent breathing, at which point the body does not get sufficient oxygen and could go into cardiac arrest, Nearman said.

Most of the time, during general anesthesia the airway is protected and kept open by a tube during a procedure. It’s possible that for a patient who was not under general anesthesia but under moderate or deep sedation, doctors may not insert a tube in order to inspect the vocal cords. This could lead to a laryngospasm, Nearman said.

“Laryngospasm is not fatal unless it’s not handled properly,” he said. “It’s really fairly simple to handle, just apply positive airway pressure with a mask so that you’re breathing for the patient… that usually ‘breaks’ the laryngospasm. If that fails, administer them a very short-acting paralyzing agent…the vocal chords just open up. That works every time.”

When a patient undergoes sedation, there is the possibility they could fall into deeper sedation or general anesthesia, Nearman noted. However, the provider should know the rescue therapy procedures were complications to arise.

“People who give moderate sedation are trained in that and allegedly understand how much drugs and the titrated effect, but it can still slip into [deeper sedation],” Nearman said. “It’s all a slippery slope.”

According to Nearman, a patient’s age is not a restriction against sedation or anesthesia, but a relative contraindication to factor in, as well as other medical conditions, to ensure safety.

“There’s no law saying once you hit a certain age, that you can’t do certain procedures in certain ages,” he said.

In 1985, Rivers spoke to Good Morning America about her heart arrhythmia, or an abnormal heart rhythm. Nearman noted that there are many types of arrhythmias.

“I think that the kind of arrhythmia would raise a red flag into considering what settings the anesthesia or procedure would be done in,” he said.

As for the safety of general anesthesia, Nearman said the risks are minimal.

“It varies depending on the kind of procedure and condition of the patient, but in general, it’s extremely safe to go under general anesthesia— we’re  talking about having less than 1 in 10,000, maybe 1 in 100,000 chance for anything to happen from the anesthesia itself.”

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