18 year old QB in Georgia dies following "routine" shoulder surgery

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Mman

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Terrible

Add MH as possibility also
 
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Terrible

Add MH as possibility also
Could've been PE. Unfortunately have seen that happen in the outpatient setting in otherwise healthy person. Not too much information about the story. Maybe a surgical complication if a vessel was nicked and bleeding not recognized in time?
 
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Be interesting to hear what comes out of this as a HS quarterback died after shoulder surgery in Georgia.


LAST?

Airway?

HOCM?

Cerebral hypoperfusion in sitting position seems relatively unlikely in an otherwise healthy kid.
The posts online state "anesthesia related complication" but that could mean a lot of things:

1. Hypoperfusion of the brain in the sitting position
2. MH
3. Pulmonary Embolus
4. Anaphylaxis
5. Unrecognized esophageal intubation (highly unlikely)

"It was reported that Robbie Roper passed away succumbing to a major injury on Dec. 22, 2021 from anesthesia to the brain complications."
 



Despite its low incidence, intraoperative stroke associated with shoulder surgery, particularly in healthy patients at no risk for stroke, is a totally unexpected and devastating complication. Patients in the beach chair position are at risk for an intraoperative stroke if borderline low BPs, as measured in the arm, are used without appreciating the effect on CPP and CBF.
 
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If I had a dollar for every time the Ortho Surgeon complained about the BP being too high I would be retired right now. The pressure is always on to keep the BP as low as possible without jeopardizing patient safety.
 
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Perioperative stroke has a mortality rate of 60% versus 15% to 46% for stroke in general.38,39
 
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If I had a dollar for every time the Ortho Surgeon complained about the BP being too high I would be retired right now. The pressure is always on to keep the BP as low as possible without jeopardizing patient safety.

we determine intraop BP management in preop holding and not up for discussion during case. Have actually cancelled some cases preop because baseline BP too high.
 
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Sad story here in Atlanta. Details are very slim. Twitter rumors are going nuts. Media can’t even agree on any details (where was he, when was his surgery, etc.).

Sad reminder that even “routine surgery” on “very healthy” patients can have catastrophic outcomes.
 
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I'm always a little more on guard with these tren athletes than a 70 yo cad, htn, ckd, etc. A bad outcome is just so much more devastating.
 
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Come on now. It’s not a stroke due to beach chair. This is an 18 y/o athlete. Perhaps LAST if a large volume interscalene block was done. Maybe large volume aspiration if it was done under block and “sedation”. Possibly a lost airway/spasm. Certainly could be a surgical complication as well. The shoulder is pretty close to the chest. No details in the article so no point in speculation.
 
Unrecognized pneumothorax or cardiac arrest from the Bezold-Jarisch response (if he got a inter scalene block).
 
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My guess is lost airway.
You guys use an LMA in beach chair?
I do, sometimes…
 
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Unrecognized pneumothorax or cardiac arrest from the Bezold-Jarisch response (if he got a inter scalene block).
I’ve never seen Bezold-Jarisch from an interscalene having done close to 1,000 of these blocks. I have seen it plenty of times during epidural or spinal… interesting. Perhaps he stuck the needle too close to the neuroforamen and anesthetized the c-spine nerve roots?
 
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I’ve never seen Bezold-Jarisch from an interscalene having done close to 1,000 of these blocks. I have seen it plenty of times during epidural or spinal… interesting. Perhaps he stuck the needle too close to the neuroforamen and anesthetized the c-spine nerve roots?
I perform blocks prior to surgery, hence a LAST or other event is more likely to occur in the preop area. This boy died while in the OR so I suspect cardiac arrest or low BP as the cause of the event. Now, why did he have low BP or a cardiac event is the key to the mystery.
 
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Stories I'm seeing say that he was about a week out from surgery, vacationing with family when he was brought to an ED, found to be in liver failure with hepatic encephalopathy, and ultimately died. Nothing about this sounds like an anesthesia-related complication, more likely acetaminophen overdose.
 
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I’ve seen an ortho resident put the chin strap on wrong for beach chair position. After I readjusted it the kids head went from gray to pink. Fortunately I was lucky enough to see him doing it wrong or that kid would have been an organ donor.
 
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Are large muscular athletes at higher risk for anesthesia related complications even though they are ASA 1? I think they’re at higher risk for stuff like NPPE. IMO small females are lower risk. Very sad.
 
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Stories I'm seeing say that he was about a week out from surgery, vacationing with family when he was brought to an ED, found to be in liver failure with hepatic encephalopathy, and ultimately died. Nothing about this sounds like an anesthesia-related complication, more likely acetaminophen overdose.


From his HS principal.

CF86BE2D-4AEF-4D94-9763-FF6C88B90849.jpeg
 
I guess anesthesia really does get blamed for everything


Maybe he got halothane. Sevo is supposed to be safe but there are case reports.


 
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I’m shocked that he was a week out. When I read the original article that was slim on the details I was convinced it was 1) airway, 2) airway, 3) airway until proven otherwise.

My guess is lost airway.
You guys use an LMA in beach chair?
I do, sometimes…

Never. I feel like I’m pretty liberal with my LMA use, but I always intubate patients who are in beach chair. It takes five seconds to intubate someone, and with a block and being able to run 0.5 MAC of gas, you can take the tube out before they even have the sling on. It adds no time to the procedure and will give you so much more peace of mind during these cases.

Maybe he got halothane. Sevo is supposed to be safe but there are case reports.


Surgery centers in the USA still have halothane? More likely than that, I would think he may have been taking too many Norcos from the recent surgery. Mix in some alcohol that he was drinking while on vacation to celebrate his new offer…badness can surely happen.

The family must be devastated. RIP
 
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Horribly sad. Agreed that it sounds like an acetaminophen overdose. Maybe unaware that Norco contains it so you get the Norco plus 1000mg acetaminophen combo, plus or minus taking extra doses for pain.

Not unrelatedly, this (in addition to limiting narcs in general) is why I never prescribe Vicodin/Norco or Percocet.
 
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I use LMAs for these shoulders. I have even done it with block, face mask and prop gtt. <1% conversion to ett. No need for paralysis, no bucking on tube, no narcotics, no reversal needed. LMA is a much smoother anesthetic imo.

Really sad for this guy and his family though. Way too young with his whole life ahead of him...
 
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No need for paralysis, no bucking on tube, no narcotics, no reversal needed. LMA is a much smoother anesthetic imo.

I used to think this way as well, until I had an epiphany and realized that I don’t wring my hands and worry about paralysis and the reversal of it, bucking on a tube, etc for a routine procedure like a lap appy or a lap chole - why should I suddenly start worrying about these things for a shoulder scope? It took one or two questionable LMAs with hypoventilation etc in the sitting position for me to think “I’m too old for this ****” and decided to intubate everyone going forward. And to be clear, I don’t use narcotics either during the procedure (the 25-50 mcg of fentanyl I give for the block is still in effect during intubation). Not saying you can’t do it with an LMA — I just don’t want that kind of stress in my life.
 
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Sounds like acetaminophen overdose. Maybe this guy was taking both norco and Tylenol around the clock.
 
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I used to think this way as well, until I had an epiphany and realized that I don’t wring my hands and worry about paralysis and the reversal of it, bucking on a tube, etc for a routine procedure like a lap appy or a lap chole - why should I suddenly start worrying about these things for a shoulder scope? It took one or two questionable LMAs with hypoventilation etc in the sitting position for me to think “I’m too old for this ****” and decided to intubate everyone going forward. And to be clear, I don’t use narcotics either during the procedure (the 25-50 mcg of fentanyl I give for the block is still in effect during intubation). Not saying you can’t do it with an LMA — I just don’t want that kind of stress in my life.

I understand where you're coming from. I just do what I feel comfortable with. But I'm sure it'll just take a bad case or two to change my mind as well.

I don't give any narcotics for most of these cases. I like it because they are wide awake by the time they are in pacu. Seems like a lot of people can be blocked with some versed only.
 
Well this piece of news changes a lot. Doesn't sound like an anesthetic complication so much any more.
A lot of “experts” on social media are calling it an anesthesia complication.

The notice from the principal explains why we’ve gotten a boatload of questions the last couple of days - “does anesthesia cause elevated ammonia levels?” No, elevated ammonia levels typically come from liver failure. And the #1 cause of acute liver failure is Tylenol overdose. Perfectly plausible.
 
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I used to think this way as well, until I had an epiphany and realized that I don’t wring my hands and worry about paralysis and the reversal of it, bucking on a tube, etc for a routine procedure like a lap appy or a lap chole - why should I suddenly start worrying about these things for a shoulder scope? It took one or two questionable LMAs with hypoventilation etc in the sitting position for me to think “I’m too old for this ****” and decided to intubate everyone going forward. And to be clear, I don’t use narcotics either during the procedure (the 25-50 mcg of fentanyl I give for the block is still in effect during intubation). Not saying you can’t do it with an LMA — I just don’t want that kind of stress in my life.

It’s like I wrote this. I’m getting more chicken of stuff like this as I get nearer to retirement. I won’t even use LMAs in lateral positions. Peace of mind worth it
 
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It’s like I wrote this. I’m getting more chicken of stuff like this as I get nearer to retirement. I won’t even use LMAs in lateral positions. Peace of mind worth it
As I’ve always said - I’ve never been sorry that I intubated anyone. But lots of times I wish I had. IMHO beach chair, table turned, drapes covering everything = ETT.
 
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I’ve never seen Bezold-Jarisch from an interscalene having done close to 1,000 of these blocks. I have seen it plenty of times during epidural or spinal… interesting. Perhaps he stuck the needle too close to the neuroforamen and anesthetized the c-spine nerve roots?
It only happens with Interscalene in beach chair - unknown why it happens. It's strange though.

Complications after shoulder arthroscopy are quite interesting and varied. Lost airway from arthroscopic fluid blocking it has also been described.
 
I’ve never seen Bezold-Jarisch from an interscalene having done close to 1,000 of these blocks. I have seen it plenty of times during epidural or spinal… interesting. Perhaps he stuck the needle too close to the neuroforamen and anesthetized the c-spine nerve roots?


Probably not relevant in this particular case, but spinal anesthesia was a rare result of attempted ISB in pre ultrasound days.

 
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So, assuming the school email was accurate:

Pretty wide differential for post-operative ALF in a young healthy person. Ischemic, acute viral (HSV, HAV, HBV), AIH, clot, etc. But, most likely this was DILI from an idiosyncratic reaction rather than APAP. Augmentin (and other abx in general) is the most common culprit. Also possible he had undiagnosed underlying cirrhosis and this was decompensation from a general anesthetic but the time course is really fast for that.

We’ll probably never know so I think blaming anesthesia makes sense. 😈
 
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But, most likely this was DILI from an idiosyncratic reaction rather than APAP. Augmentin (and other abx in general) is the most common culprit.

He would have received cefazolin as his only antibiotic if this orthopedic surgeon is like everybody else. From some sort of DILI network that exists, there was a review and only 33 patients were identified with cephalosporin drug induced liver injury over an 8 year period. Seems rather unlikely to have been the culprit. I think most posters here think more likely acetaminophen simply because he was quite likely taking possibly large doses of acetaminophen for several days.

I mean 1/1,000,000 he got it from a single dose of Ancef? Wouldn't a week of high dose Tylenol be at least a little more likely culprit?
 
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Best I could infer from online reports was that DOS was 12/19 and death was announced on 12/22, POD3.
 
It’s hard to believe that two days of acetaminophen, even if it was doubled up by mistake, could cause fulminant liver failure in an otherwise healthy 18 year old. I’m surprised that nobody else has mentioned the possibility of concomitant ethanol ingestion being involved here.
 
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@Mman DILI Network is a great resource (best we have for sure: dilin.org). But it’s really rare for someone to get over 7500mg of APAP unintentionally even when they double up their Tylenol and Percocet (that happens all the time). We get a Tylenol overdose on service every few weeks and I can’t remember the last unintentional one that didn’t do fine with a little NAC. It’s the most common cause but not even close to antibiotics when you remove the intentional overdoses. Plus NAC doesnt help the idiosyncratic reactions (still given but much less evidence). He may have been PCN allergic, gotten something other than ancef for that. I’ve been surprised what patients received many times. The time course really argues for a drug given in the hospital.

Also, it kinda stops being 1:1,000,000 when you start with a population who all have ALF from something.

@Blockit EtOH and APAP is an interesting topic. Chronic use is bad but acute use is protective against APAP overdose. But EtOH doesn’t do anything this fast on its own and he’s probably too young to be cirrhotic from EtOH. My personal record is mid-20s.
 
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@Mman DILI Network is a great resource (best we have for sure: dilin.org). But it’s really rare for someone to get over 7500mg of APAP unintentionally even when they double up their Tylenol and Percocet (that happens all the time). We get a Tylenol overdose on service every few weeks and I can’t remember the last unintentional one that didn’t do fine with a little NAC. It’s the most common cause but not even close to antibiotics when you remove the intentional overdoses. Plus NAC doesnt help the idiosyncratic reactions (still given but much less evidence). He may have been PCN allergic, gotten something other than ancef for that. I’ve been surprised what patients received many times. The time course really argues for a drug given in the hospital.

Also, it kinda stops being 1:1,000,000 when you start with a population who all have ALF from something.

@Blockit EtOH and APAP is an interesting topic. Chronic use is bad but acute use is protective against APAP overdose. But EtOH doesn’t do anything this fast on its own and he’s probably too young to be cirrhotic from EtOH. My personal record is mid-20s.
Fulminant dili from a single intraop antibiotic dose? I get that zebras exist but I would want to know an apap level before I sent off that expensive send out workup in real life because common things are common. I have seen a few unintentional/subacute Tylenol overdoses and if they present late in the course they are beyond ****ed without a transplant.

Pt could have been taking a **** ton of Tylenol pre op for pain control then took a bunch of percocets after and pushed his flailing liver over the edge. Or maybe it was a rarer cause I’m sure the autopsy will tell.
 
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It’s hard to believe that two days of acetaminophen, even if it was doubled up by mistake, could cause fulminant liver failure in an otherwise healthy 18 year old. I’m surprised that nobody else has mentioned the possibility of concomitant ethanol ingestion being involved here.
I’m surprised you didn’t read the thread before saying that :)

The first time I brought up acetaminophen use, I also brought up concomitant alcohol use:

Surgery centers in the USA still have halothane? More likely than that, I would think he may have been taking too many Norcos from the recent surgery. Mix in some alcohol that he was drinking while on vacation to celebrate his new offer…badness can surely happen.
 
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Except “drinking on vacation” is protective from APAP overdose.

A Tylenol level is useless except for single ingestion (suicide attempts) and the work up for ALF is sent for every patient. I give up.
 
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Except “drinking on vacation” is protective from APAP overdose.

A Tylenol level is useless except for single ingestion (suicide attempts) and the work up for ALF is sent for every patient. I give up.
No need to get upset that a bunch of labs that arent coming back for a week anywhere besides a transplant hub aren’t sent stat from the er. Tylenol level comes back in an hour and if it’s high enough in the right clinical scenario it can be diagnostic, if it’s not then you can send off the big workup (which I assume includes cereluoplasmin which is absolutely ridiculous in this case).

I think you are anchoring on dili a bit here is all I am saying—the kid was maybe having pain leading up to the surgery and maybe he was taking 6-7g of Tylenol a day leading up to it, maybe no one checked his liver, maybe he stacked his postop meds on his prior home Tylenol regimen and he is a rsti case. Clinical history and a Tylenol level will be able to quickly clear this potential diagnosis although I digress that given his presentation it sounds like no matter what the diagnosis was he needed an emergent transplant workup so he must have presented late with advanced encephalopathy.
 
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We get a Tylenol overdose on service every few weeks and I can’t remember the last unintentional one that didn’t do fine with a little NAC. It’s the most common cause but not even close to antibiotics when you remove the intentional overdoses. Plus NAC doesnt help the idiosyncratic reactions (still given but much less evidence). He may have been PCN allergic, gotten something other than ancef for that.

Maybe the kid would have done fine with a little NAC, but possible he never ended up at the hospital until it was too late. I almost guarantee he was taking acetaminophen preoperatively. Also if they were PCN allergic, they still got Ancef 99.99% of the time.

So did something case report worthy that can be deadly kill the kid? Or did something super common that is unlikely to kill the kid do him in? It's trying to guess at one of several very unlikely pathways which is why young healthy kids almost never die from liver failure after minor surgery. Something that doesn't really ever happen happened.
 
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Comment​

This patient developed jaundice and severe hepatic injury within 3 days of surgery under sevoflurane anesthesia. The clinical course was typical of halogenated anesthetic liver injury with a rapid onset, mild eosinophilia, a hepatocellular pattern of injury and severe course. Risk factors included previous anesthesia (although the agent used was not known). Unexplained were the abnormal liver tests obtained before surgery and the equivocal serology of EBV infection. Results of tests for hepatitis C and E were not provided
 

Abstract​

A 20-year-old man underwent an outpatient general anesthetic procedure with sevoflurane for the correction of a bilateral gynecomastia. The patient had been first exposed to sevoflurane two years before, without any complication. He presented an overweight with a body mass index (BMI) of 31.4 kg/m2 and had an episode of “binge” drinking a few days before anesthesia. He became icteric from postoperative day 9, and after the worsening of liver function tests, the liver biopsy revealed centrilobular necrosis. The patient became encephalopathic and required urgent liver transplantation on postoperative day 30. The possibility of a sevoflurane-related fulminant hepatic failure is discussed.

 
It’s so odd that I’m accused of anchoring when my first post started with “pretty wide differential” and the other side of the argument is focused on a single possible cause but I tried to explain as best I can. To suggest that Tylenol pre-op and then post-op is how you can explain the timing is definitely reaching. For all we know, he was a fulminant Wilson’s patient and it had nothing to do with his surgery.
 
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