What's behind deaths from anaesthesia complications?

On 18 March, a patient named Hosne Ara died after developing seizures following anaesthesia administered for a piles operation at Alok Healthcare, a private hospital in Tangail's Ghatail.

On 19 March, a 12-year-old patient, Tasfia Zaman Tonoya, did not regain consciousness after an appendectomy at Bashundhara Ad-din Medical College Hospital in Dhaka's Keraniganj. Police have arrested four doctors and the hospital manager in connection with the latter case.

These are not isolated occurrences. Over the past three months, six deaths have been reported nationwide following the use of anaesthesia during various procedures.

The rise in these incidents is attributed to several factors by medical professionals which include the discontinuation of halothane production, a previously common anaesthetic, and the presence of counterfeit halothane in circulation.

Halothane, a cost-effective drug used for anaesthesia during surgeries, has been banned by the US Food and Drug Administration (FDA) due to its harmful physical and environmental impacts.

ACI Pharmaceuticals, the manufacturer of halothane under the brand name Halosin, halted its production in Bangladesh last year.

However, some facilities had existing stocks of halothane. As the stocks depleted, to cover the shortage, counterfeit halothane from India entered the market. Additionally, adulterated halothane also appeared.

Experts believe the delayed action regarding counterfeit halothane by the health ministry has led to the rise in anaesthesia-related complications and deaths.

Bangladesh Society of Anaesthesiologists Secretary General Prof Dr Kawsar Sardar said, "We informed the health department about the non-availability of halothane in the country in July 2023 and proposed alternative arrangements. Following the Health Department's instructions, letters outlining five proposals were sent to hospital directors and the Ministry of Health and Family Welfare on 6 August."

However, the health minister only recently called upon the Bangladesh Society of Anaesthesiologists Critical Care and Pain Physicians to investigate the root causes and provide recommendations for solutions.

During a recent meeting with Director General (Health) Prof Dr Abul Bashar Mohammad Khurshid Alam, Bangladesh Society of Anaesthesiologists informed him about the presence of counterfeit halothane in the market and identified it as the primary cause of recent anaesthesia-related deaths.

Bangladesh Society of Anaesthesiologists urged a ban on unapproved halothane use at the meeting.

The organisation also called for a transition to safer alternatives such as isoflurane and sevoflurane with compatible vaporisers.

Furthermore, the Society suggested temporary emergency use of isoflurane in existing halothane vaporisers, training anesthesiologists on the use of alternative drugs and collaboration with drug companies to potentially lower isoflurane costs.

Dr Debabrata Banik, president of Bangladesh Society of Anaesthesiologists, told TBS, "We suspect the halothane imported from India is being adulterated. Additionally, existing hospital stocks are potentially being diluted with water to create more saleable bottles for the black market, where a bottle can fetch Tk5,000 compared to the original price of Tk1,500."

Banik, who is also a professor in the Department of Anaesthesia, Analgesia, and Intensive Care Medicine at Bangabandhu Sheikh Mujib Medical University, revealed that samples of the suspected counterfeit halothane have been sent for laboratory testing. The results are still pending.

DGHS mandates shift in medical practices

To address the issue, the DGHS has mandated a nationwide shift in anaesthesia practices.

The DGHS noted that funding will be allocated for acquiring compatible vaporisers and phasing out existing halothane models to ease the shift to isoflurane and sevoflurane.

Additionally, a nationwide virtual meeting with anesthesiologists and a letter to the Directorate General of Drug Administration aim to address the use of unapproved halothane and ensure a smooth transition to safer alternatives.

However, most small private hospitals do not have alternative vaporisers as the machines are expensive.

Medical experts further believe that many private hospitals, especially those outside Dhaka, are using adulterated halothanes imported from India.

Dr Abu Taher, medical officer (anesthesiologist), at Noakhali Sadar Hospital, highlighted critical issues in anaesthesia practices. 

"Only 1% of private hospitals in his region have machines for alternative drugs to halothane. Furthermore, we are seeing fake halothane in new bottles in the market," he said.

These counterfeit bottles can be identifiable by mismatched labels and loose caps. While his hospital rejects such substances, he expressed concern that many private hospitals nationwide may be using them.

Taher also noted the presence of fake pain medication used post-operatively. While he believes these may not be fatal, they contribute to increased complications.

"Every day, 8,000 to 10,000 major and minor surgeries are performed in the country, and some are complicated. But if all operating theatres had emergency management facilities, these complications could be reduced," he further added.

In a separate development, authorities discovered a black market operation producing counterfeit G-pethidine injections, a medication used during and after surgery.

Gonoshasthaya Pharmaceuticals Ltd possesses the sole authorisation to manufacture this drug. 

However, the Detective Branch busted a syndicate that had been converting G-Diazepam (a sleep medication) into fake G-pethidine for the past 7-8 years. Three individuals involved in this illegal operation were arrested.

Importance of anaesthesiologist consultation

Dr Shoman Aniruddha, an anesthesiologist at Mugda Medical College and Hospital, highlighted the importance of patient awareness.

"Patients often know the surgeon but not the anesthesiologist. Now, before the operation, you have to find out who the anesthesiologist is and whether they are a postgraduate degree holder. You should consult with the anesthesiologist before the operation. A skilled anesthesiologist can handle any complications that may arise during the operation."

Data from the Bangladesh Society of Anesthesiologists reveal a national shortage of qualified professionals, with only 2,400 anesthesiologists currently practising.

Prof Dr Kawsar Sardar emphasised the need for comprehensive pre-operative assessments.

"Identifying potential heart, kidney, liver, or lung issues is crucial. In our country, this is not done by anesthesiologists. Just as a surgeon assesses the patient and decides on the surgery, the patient should consult the anesthesiologist about any potential health complications," he added.