Death is not supposed to follow outpatient surgery. Maybe a little nausea and vomiting. Maybe some hypothermia. But not death.

So it was that we were startled when we heard about the toddler from Peebles, Ohio, who died last month after a tonsillectomy at Clinton County Outpatient Surgery, a freestanding, physician-owned ASC.

Her name was Hannah. Hannah Yutzy. She was 3 years old. She and her 9-year-old sister were scheduled to have their tonsils removed that same morning. Hannah went first. The surgery went fine, but something went terribly wrong when she was extubated. "They told us that when they pulled out the (endotracheal) tube, she was fighting for air," said a relative. Hannah was air-lifted to Children's Med-ical Center of Dayton, where at 10:02 a.m. on March 13, officials say she was pronounced dead.

Autopsy results are pending. The ASC's medical director hasn't returned numerous calls. An investigator with the county coroner who interviewed Hannah's surgeon and anesthesiologist said that "both were at a loss to explain what had happened and were very upset." An official with the county health department wouldn't explain what she meant when she called it "a deplorable accident that hopefully wasn't done on purpose."

We know from the literature that anesthetic complications and hemorrhage cause the majority of deaths in tonsillectomy. We know that outpatient tonsillectomy may be associated with increased morbidity in premature infants or those with sleep apnea. And we know that the incidence of mortality from adenotonsillar surgery ranges from 1 in 16,000 to 1 in 35,000 cases.

As important as the circumstances surrounding Hannah's death are, her story also serves as a stark reminder that, as the complexity of the procedures and patients is steadily increasing in the outpatient setting, so, too, is the incidence of morbidity and mortality. When ambulatory surgery was first proposed, it was primarily limited to peripheral or minimally invasive procedures performed on relatively healthy individuals. Yes, things have changed.