Stines

On 12/27/2023 at 2:54 PM, Dr. Ozlem Bicer Clinic said:

As Dr. Özlem Biçer, who followed and managed the patient throughout the whole process, I will try to explain both the process and the differences between anaphylactoid reaction, which is a type of acute severe allergic reaction, and intoxication in a language that non-doctors can understand. In both cases, some symptoms are common, some are different, and therefore doctors have to make a diagnosis with some differential diagnosis and indication criteria.  
 
The correct diagnosis is lifesaving not only during acute treatment but also in the long term, as it has to be taken into account in the medical treatments that the patient will receive throughout his/her life.
Patient who has been diagnosed with Jetocaine anaphylaxis should never, ever be injected with Jetocaine for the second time, because if the patient is given Jetocaine for the second time, the possibility of repetition of anaphylaxis reaction is very high.

But if you misdiagnose a patient with Jetocaine anaphylaxis and say that this is a Jetocaine intoxication, you bring up the possibility of giving this patient a second chance of anesthesia, in which case the patient's life is in danger with the risk of an anaphylactic reaction that may develop in the patient. This is my reason for sharing this post as a doctor. 

(The diagnose of this patient is an anaphylactoid reaction, which is a type of rapidly developing severge Type 1 allergic reaction. Because of this diagnose, this patient cannot be given Jetocaine anymore. 

Jetocain intoxication is a discussion self-displayed by over dosage or intraarterial administration, or by involvement of the central nervous system and cardiovascular system due to perfusion.

1. Although numbness around the mouth is the most well-known and the first thing that comes to mind in intoxication, it is also seen in anaphylactic reactions. Therefore, not all numbness around the mouth is intoxication.

2. Tremor in the hands and feet is a sign of allergic reaction, it is not a sign of central nerve system involvement, it is not epileptic seizure, it is not considered as an intoxication attack.  Central nervous system is not involved in this patient. So, it is not considered as intoxication.

3. Hypotensive and hypertensive episodes may occur in anaphylaxis, but bradycardia (i.e. low heart rate) is essential in intoxication. Bradycardia accompanies hypotension in the differential diagnosis.  There is no cardiac involvement in this patient. No bradycardia treatment has been used in any way. i.e. the cardiac system is not involved. i.e. intoxication is not considered.

4. Skin rash is very common in anaphylaxis. Allergic skin lesions are not expected in intoxication.  

5. This case was brought under control very quickly by applying allergic and anaphylaxis protocol. In case of intoxication, anti-allergy treatment would not have worked, the process would have been uncontrolled, and the progress would have dramatically deteriorated to respiratory arrest.

6. Anaphylaxis is a dose-independent process. Intoxication is a dose-dependent process.
The amount of anesthesia used in this patient is half of the daily dose limit that the patient can receive, even after taking into account the patient's weight (on average over 70kg). There was no overdose in this patient.  The reaction started before hairline anesthesia was administered. So even the total planned daily dose was not used. So, there is no overdose and intoxication are unthinkable.

In the specific case of this patient, needle-free anesthesia was administered by a licensed anesthesia technician. Needle-free anesthesia works on the principle of delivering anesthesia into the skin through pressure, without a needle. Due to the settings of the device, the amount given and the level at which it is given intradermal. There is no artery and vein in this level. 

For the intoxication, deep plan injection is required to enter the artery and vein network. It is not possible for this device to inject drugs at this depth. In addition, due to the settings of the device, each pulse dose is not enough to cause intoxication. All nurses and anesthesia technicians working in our clinic are postgraduate graduates. And all of them have intensive care experience. They are fully authorized and professional in the technique of administering an injection.  

7. If it was intoxication, the patient would have had to be followed up for at least 24 hours at the university hospital, drug absorption would have been rapidly decreased with IV lipophilic solution and a completely different treatment protocol would have been defined. Our patient's condition was not accepted as intoxication in all examinations performed at the university hospital (blood gas, liver enzymes and all intoxication tests), it was accepted as a rapidly developing type 1 allergic reaction (anaphylactoid reaction, considering that all anti-allergic interventions were correct and appropriate, and the patient's symptoms passed very quickly, the process was evaluated as anaphylactoid reaction and our full report was approved. In addition, the reason for transporting the patient by ambulance was to ensure that the patient was safer in intensive care conditions in case of angioedema due to anaphylaxis, and the university hospital confirmed that all the treatment performed in our clinic was correct and satisfactory.

8. ANAPHYLAXIS IS DOSE INDEPENDENT. The anaphylactic reaction may also occur at the test dose. Allergy testing is not performed to eliminate the risk of anaphylaxis. Allergy testing is a test performed on patients with multiple drug allergies in order to select the appropriate drug. It should be performed in immunology clinics. There is no such concept as prophylactic Jetocain allergy test in hair transplantation.   So, the answer to the question of whether it could have been prevented if the test had been done: NO.  There is no chance to prevent the patient from any anaphylaxis with allergy tests. If the test was done, anaphylactic shock would have occurred during the test also.

ANAPHYLAXIS AGAINST ANY DRUG CAN COME TO EVERY PATIENT, EVERY DOCTOR (WITH OR WITHOUT TESTING)
Anaphylaxis is therefore a manageable process, not a preventable one.   

Although there are many more differential diagnosis criteria that can be written, I think this is enlightening enough.
As a 26-year physician and 33-year member of the medical community, I am experienced enough to distinguish between anaphylactic reaction and intoxication. I and my entire team are technologically and scientifically equipped for all kinds of emergencies that may occur before and after the hair transplant procedure. The fact that the patient was diagnosed very quickly, and the process was managed correctly is the biggest proof of this.

Hair Restoration Network is one of the most reliable and ethical forums that I respect the most. What they do to inform patients correctly is admirable. I am eternally grateful to Melvin and all members for this.  As always, I respect everyone's support, criticism and comments on the forum.
However, we would like to emphasize that while even no doctor can diagnose the patient without knowing the patient's clinic, without seeing the process, without evaluating the vital signs, without examining the patient in all details, misleading the patient with shortcut research from Google can cost the patient's life. I invite all members to sensitivity in this regard,

If anyone has more questions, they can forward to Mrs. Ozen and contact to  me directly.
 
Best Regards,
Ozlem Bicer, MD

Thank you for the post Doctor. It was very informative and cleared up my concerns.

Hey everyone. Dr. Bicer has reached out to me and told me she will be making a detailed post soon. Hopefully that clears things up. Thanks.

On 12/24/2023 at 2:43 PM, shiba1985 said:

from google:

 

Early symptoms are circumoral numbness, tongue paresthesia, and dizziness. Sensory complaints may include tinnitus and blurred vision. Excitatory signs, such as restlessness, agitation, nervousness, or paranoia, may progress to muscle twitches and seizures.

On 12/24/2023 at 3:21 PM, JoeD said:

Bingo 

 

Can get allergy tested to be certain, but this was a freak thing that can happen with any procedure using high volume of local anesthesia (lidocaine)…. most likely can still get a hair transplant.  

7 hours ago, duchaine said:

I will be brutal...
From my personal experience, you need to understand that this "clinic" do not have to tools the handle an adverse reaction.
Som if the doc is scared that something could be wrong, he/she abort the surgery. Then the/she say "I aborted to protect you from this or that".
But keep in mind...they try to protect themselves as first thing.
 

Well this thread is taking a turn. From the symptoms you guys posted (and what I was able to gather from my own research), I agree with you all that my reaction seemed to be much closer to what we'd expect from lidocaine toxicity rather than anaphylaxis. I am still concerned why Dr. Bicer did not mention lidocaine toxicity at all to me; she only described my reaction as "anaphylaxis" and an "allergic reaction." I will reach out to her soon to see what she has to say.

@JoeD you mentioned earlier that lidocaine toxicity is caused by the technician inadvertently injecting lidocaine into a blood vessel or artery. Can lidocaine toxicity be caused by anything other than technician error? If not I will have to demand my deposit back from the clinic.

1 minute ago, shiba1985 said:

In your whole life, have you ever had any injections for dental procedures. Sounds weird. Was it lidocaine toxicity or lidocaine allergy.

Had a couple of dental procedures as a kid that involved local anesthesia. Didn't have a reaction to any of them.

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Glad you are safe though. 

Thanks

16 hours ago, JoeD said:

Not necessarily an allergic reaction…. Everything, except rash, sounds like some of the lidocaine went intra-vascular (ie in a blood vessel, an artery) by accident.   

Well that's concerning. Haven't really considered this seriously until now. Now that I think of it, I am almost certain I heard the Turkish word for "toxicity" being mentioned by the doctor and staff in their conversations with each other when the incident first started. It was one of the only words I was able to make out (it sounds nearly identical to the English word). Maybe they suspected toxicity initially but moved to anaphylaxis when the condition progressed and more symptoms started to show? Can an anaphylaxis episode cause toxicity? I know hardly anything about this sort of stuff.

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I wonder if the IV med they gave you was steroids for allergy vs intra-lipid for lidocaine toxicity.

Is there any way to tell? It was a clear liquid in a tube and was administered twice, if I remember correctly.

31 minutes ago, Berba11 said:

Thanks for the info. I think it might be wise to suggest they do a simple and easy test pre-op/the night before if you’re still in contact with Dr Bicer. It seems like an obvious oversight to not do such an easy test. 
 

As much as they deserve praise for their handling of the situation as it manifested, I think it’s negligent to not be doing an anaesthetic reaction test beforehand. 

I guess the question becomes how common is it for hair transplant clinics to test for anesthesia allergies in patients who haven't indicated any potential allergy issues. From what I've read it doesn't seem common, but, again, I could be wrong.

Edit: Also, I did speak with Bicer on this subject. She said allergy testing can only be done in a hospital setting to ensure access to specialists in case of a serious reaction.

On 12/20/2023 at 10:40 AM, duchaine said:

Did you have pre-op medicines?
Anti-hystaminic and cortisone?

No

On 12/19/2023 at 11:38 PM, hairman4321 said:

oh wow interesting, glad they took care of you. i wonder also if this is the only anesthetic they can use or if there aren't others? anyway best to prioritise your health and stay safe.

From what I understood from Dr. Bicer, an allergy to one anesthetic suggests increased risk of allergy to others. For an elective cosmetic procedure like a hair transplant, the risk of this happening again probably isn't worth it.

On 12/20/2023 at 6:29 AM, Berba11 said:

I'm really pleased to hear everything resolved well and it sounds like Dr Bicer and her team did a thorough and careful job of responding to the situation and looking after you until recovery.

That said, I do have to ask... Did they not perform a test first to see if you were allergic? At Eugenix, on each occasion I was there (and maybe more than once on each occasion), they administered some aneasthetic into my forearm/upper wrist to make sure there was no reaction. Did Dr Bicer not do something similar? If not I'd suggest they need to improve their pre-op protocol. They obviously knew what they were doing once it happened, but potentially your situation could have been avoided.

No, but to be fair I've been researching hair transplants for a while and have only ever heard of Indian clinics like Eugenix doing that. I could be mistaken. Although honestly yeah, the pre-op felt kinda rushed (doctor said my surgery was large and would take a very long time and she wanted to start as early as possible). That's probably my one criticism. I don't think it contributed to this incident, though.

Here's one for the books:

Last week I headed into Dr. Bicer's clinic for my planned 3500 graft hair transplant, excited to finally knock out the transplant I've been anxiously awaiting for over a year. Upon arrival, I'm greeted by Dr. Bicer and her coordinator Ozen. The next hour or so is fairly typical: I ask Dr. Bicer a few questions, fill out paperwork, discuss potential hair lines, have my blood drawn, head shaved, etc. Things are going smoothly. At this point I'm ready for surgery so I'm fitted into a patient gown and brought to the surgery room. A technician begins the process of numbing my donor area with injections of anesthesia. This hurt like hell but was tolerable. During this period I began to notice a slight trembling in my legs, but I chalked it up to anxiety and didn't think much of it.

Once the initial does of anesthesia were administered, the technician began to prod the back of my head and asked me to let her know if I still felt even the slightest pain anywhere - if there was still some pain in a spot, she'd administer more anesthesia to that area. Crucially, she also began asking me how I felt more generally. She did a good job of asking me this every 30 seconds or so. It was somewhere at this point where I felt a wave of numbness wash over the area around my mouth and upper throat. Thinking this was strange, I informed the technician of this the next time she asked how I was doing. The technician immediately got up and informed Dr. Bicer, who herself was close by preparing for extraction work. Within seconds, Dr. Bicer moved in to take a look at me and immediately recognized that I was showing symptoms of an allergic reaction to the Lidocaine anesthetic. She stopped the procedure straight away and informed me that I was having a serious allergic reaction, and that this meant the surgery had to be aborted. She began talking with the nurses and technicians in the operating room; I don't speak Turkish but I recognized the seriousness of the situation through everyone's tone of voice and facial expressions.

At this point I noticed the numbness in and around my mouth was getting worse: my jaw felt heavy, I could hardly feel my tongue, and I was having difficulty speaking clearly. I apparently also had a massive rash on my upper chest (I didn't notice this at the time, but Dr. Bicer told me about it afterwards). The trembling I talked about earlier spread from my legs to the rest of my body and increased in severity. Mentally, I entered a confused daze and began panicking about the situation (I thought there was a good chance that my vanity was about to cost me my life, and that I would die in a foreign country). Dr. Bicer began administering oxygen to me through a nasal cannula - she said this would help the anesthesia wear off faster. She also administered some kind of emergency anti-allergy medicine to me via IV. The staff began phoning an ambulance. Dr. Bicer was speaking to me regularly at this stage, informing me that my vitals looked good but that I would be sent to a hospital out of an abundance of caution.

I was feeling much better already by the time I arrived to the hospital. It was one of the university hospitals in Istanbul, I forget the name. While there, I met with a neurologist who asked about my medical history and performed a neurological exam by asking me to open my mouth, raise my eyebrows, smile, etc. Everything looked good. I was told to stay at the hospital for about 30 more minutes to make sure nothing else popped up. Dr. Bicer was watching me this whole time and regularly asked me how I was doing. She tells me that Lidocaine is used in pretty much every hair transplant and my allergy means I'm no longer a candidate for hair transplant surgery. After this we went back to the clinic where I was refunded the cost of the procedure, and I collected my things and went back to my hotel. As you can imagine, I was mentally exhausted at this point so I took a big nap. Dr. Bicer asked me to send her regular updates on WhatsApp about how I was feeling and to return to the clinic in the morning. The next morning, I head back to Bicer's clinic and ask a few questions and say farewell to the team. I spent the remainder of the day taking a nice touristic trip through Istanbul; unfortunately it was raining and cold that day, but I enjoyed my time regardless (Istanbul really does live up to the hype, I have to say). I took my flight home the next day.

Takeaways

Hair transplants are extremely long and extremely complicated procedures. I know this forum does a good of stressing how important doctor involvement is to these procedures (not only for the final result but also for patient safety), and everyone reading this story should take it as further confirmation of this fact. I am only 29 years old with no major medical issues and have never had an allergic reaction in the past, so this incident really did come out of nowhere. God knows what would've happened if I had gone to a hair mill with poorly-trained technicians and no doctor around: the technicians probably would have dismissed my symptoms as normal and told me to calm down. Proper technician training and Dr. Bicer's presence in the operating room really saved my life here. After this incident, I would also personally no longer recommend any doctors that work on two or more patients at a given time. Things can go wrong suddenly and a medical doctor needs to be immediately available to respond rapidly to any situation. One of the main reasons I chose Dr. Bicer in the first place was because I knew she only operated on a single patient each day, and it seems my decision paid off massively.

So here ends my hair transplant journey, over almost as soon as it started. For the time being, I've resigned myself to continuing to shave my head, but I may give some thought to pursuing SMP in the future. I've been lurking on this forum for years, hoping one day to post a thread of my own chronicling my transplant progress and asking for feedback from experienced members; but alas, it seems it just wasn't in the cards for me. I did learn a lot on this forum, and I wanted to thank all the members who contributed into making this forum such a great repository of information. If it weren't for this website, I'd likely have gone to a cheap hair mill and, as I know now, that probably would've ended badly (to say the least).

Thanks again everyone.