ASA Closed Claims Project: Regional Anesthesia Claims...

ASA Closed Claims Project:

Regional Anesthesia Claims 1990 or later Lorri A. Lee MD

Department of Anesthesiology University of Washington, Seattle, WA

Lorri A. Lee, MD University of Washington

OVERVIEW

1. Closed Claims Project

2. Peripheral Nerve Blocks

3. Neuraxial Claims


ASA Closed Claims Project

• 35 insurance organizations since 1985

• 17 companies in current active panel

• 13,000+ anesthesiologists insured by

current panel of companies


On Site Anesthesiologist Reviewer

•Within 5 years of practicing

•Non-dental injury claims

•Adequate records to recreate scenario

•Assessment of anesthetic – related injury

•Assessment of SOC

•Severity of Injury

Scale of No Injury (0) to Death (9)


Claims sent to University of Washington

•Reviewed by 2 anesthesiologists

•Tie breaker resolved by 3rd anesthesiologist

•Entered into CCP Database

•Topics selected, analyzed, updated


Utility of Closed Claims Data

• Collection of “Sentinel Events”

• Identify areas of recurrent risk

• Provide direction for in-depth analysis

• Snapshot of anesthesia liability


Bias with Malpractice Claims

• No denominator for calculating

risk

• Small subset of injuries

• More severe, permanent injuries

• More substandard anesthesia

care


COMPLICATIONS OF REGIONAL ANESTHESIA

• Neuraxial cardiac arrest

• High block

• Unintentional intravenous injection

• Hematoma, abscess, meningitis

• Needle trauma:

• Paresthesia, weakness, paralysis

• Blindness

• Post-dural puncture headache

• Complications of sedation

• Inadequate analgesia, injection site pain

• Miscellaneous Lorri A. Lee, MD University of Washington

Peripheral Nerve Block Complications

Complications Associated With

Peripheral Nerve Blocks:

Lessons From The ASA Closed Claims Project

Lee LA, Posner KL, Kent C, Domino KB

Int Anesthesiol Clin. 2011;49(3):56-67



Inclusion Criteria:

• Peripheral Block Claims from 1990 and later

• Operative setting

•Blocks performed in the OR for post-operative

pain management included



Exclusion Criteria:

• Claims from 1970-1989 or unknown year

• Claims for:

Chronic or postoperative pain management

Eye Block claims


% of 189 claims

Sex 57% male

Age, mean (yrs) 47 +/- 14 yrs

(range 4-80 yrs)

ASA 1-2 69%

ASA 3-4 17%

Outpatient Surgery 64%

Peripheral Nerve Block Claims


0% 20% 40% 60%

Interscalene

Axillary

IVRA

Femoral

Ankle

Supraclavicular

Other

Type of Blocks Associated with

189 Peripheral Nerve Block Claims


0%

20%

40%

60%

80%

Severity of Injury for


Temporary/ Permanent/ Brain Death

Non-disabling Disabling Damage


0%

20%

40%

60%

80%

100%

Block-related Non-block-related

Block-related Injuries per Severity of Injury Group

in 189 Peripheral Nerve Block Claims

Temporary/ Permanent/ Death or Brain

Non-disabling Disabling Damage

(n=129) (n=30) (n=30)


Temporary / Non-disabling Injury (n = 129)

Block-related (% of 129) 71 (55%)

Type of Block:

Interscalene 50 (39%)

Axillary 34 (26%)

IVRA 17 (13%)

Other 28 (22%)



A 30 year old female

Carpal tunnel release supraclavicular block.

PACU: "difficulty with a large breath".

An X-ray showed 20% pneumothorax.

The patient was not counseled for this on the

preoperative anesthesia consent form.

The case was settled for $20,000.

CASE PRESENTATION


Permanent / Disabling Injury (n = 30)


Type of Block:


Axillary 9 (30%)

IVRA 2 ( 7%)

Other 5 (16%)



Death / Brain Damage (n =30 )


Type of Block:


Axillary 7 (23%)

IVRA 1 ( 3%)

Other 7 (23%)



0% 20% 40% 60%

Nerve Injury

Death

Pneumothorax

Brain Damage

Most Common Complications in

189 Peripheral Nerve Blocks


Damaging Events in


Damaging Event N (% of 189)

Block-related 100 (53%)

Other Block-related* 65 (34%)

Pneumothorax 12 (6%)

Inadvertent I.V. Injection 10 (5%)

Unexplained 7 (4%)

High Block 4 (2%)

Inadequate Analgesia 2 (1%)

*Needle damage to spinal cord or nerves, intraneural injection, hematoma, infection, etc Lorri A. Lee, MD

University of Washington

Damaging Events in


Damaging Event N (% of 189)

Non-Block-related 89 (47%)

Surgical / Patient Condition 18 (10%)

Other Anesthetic Events* 14 (7%)

Wrong Drug / Dose 12 (6%)

Cardiovascular Events 12 (6%)

Respiratory Events 11 (6%)

Equipment Problems 4 (2%)

No Event / Unspecified 18 (9%)

*Includes 7 claims with wrong-site block Lorri A. Lee, MD University of Washington

0% 20% 40%

brachial plexus

median

ulnar

spinal cord

phrenic

femoral

radial

sciatic

other

Temporary Injury

Permanent Injury

Location and Severity of 97 Nerve Injuries


Block-related, 68%

Unclear Mechanism,

4%

No Injury, 3%

Miscellaneous Causes, 25%*

*Includes pre-existing nerve injury, surgery, etc.

Mechanism of Injury in 97 Nerve Injury Claims


Mechanism of Injury for Peripheral Nerve

Block Claims with Death or Brain Damage

(n = 30)

N

Local Anesthetic Toxicity 7

Inadvertent Intravenous Injection / Absorption 5

Wrong Dose 2

Stroke 6

Prolonged Hypotension 5

(Beach Chair Position) (4)

Uncontrolled Preoperative Hypertension 1 Lorri A. Lee, MD University of Washington

Mechanism of Injury for Peripheral Nerve

Block Claims with Death or Brain Damage

(n = 30)

N

Premature Extubation / Hypoxia on PACU Arrival 3

Spinal Cord Injection under General Anesthesia 2

Inadvertent Intrathecal Injection 1

Myocardial Infarction 2

Other Respiratory / Cardiac Arrest 3

Other Damaging Events 7


CASE PRESENTATION

A 60 year old ASA 2 male w/ htn

Humerus fx under ISB w/ nerve stimulator

After the injection of 40ml of bupivacaine in divided

doses, the patient had a seizure. The patient complained

SOB prior to the seizure. A resident aspirated during the

injection. GA immediately induced. No postop problems

in the hospital record.

3 yrs later: suit for brain damage - memory loss and

cognitive dysfunction. Neurologists had conflicting views

as to the extent and cause. The case went to trial

and the jury awarded $3M. The judge reduced it to $1.5

million and the anesthesiologist settled for $950,000. Lorri A. Lee, MD University of Washington

Assessment of Standard of Care

in 189 Peripheral Nerve Block Claims

Appropriate, 65%

Less than Appropriate,

25%

Impossible to Judge, 10%


Summary for Peripheral Nerve Block Claims

• Overall, low percentage of total claims

• 2/3 of claims with temporary injuries

• 1/3 of claims with high severity injuries

o 50% block-related

Most commonly nerve injury and

local anesthetic toxicity

• Need protocols to prevent wrong site blocks


Neuraxial Regional Complications

Complications Associated with

Regional Anesthesia and Pain Medicine:

Findings From The ASA Closed Claims Project

Lee LA, Fitzgibbon D, Stephens LS, Domino KB

in Complications in Regional Anesthesia

and Pain Medicine

Neal and Rathmell, eds.


Inclusion Criteria:

• Neuraxial Regional Claims from 1990 and later

• Operative setting

•Blocks performed in the OR for post-

operative pain management included



Exclusion Criteria:

• Claims from 1970-1989 or unknown year

• Claims for:

chronic or postoperative pain

management

Obstetric claims



% of 443 claims

Age, mean (yrs) 57yrs (0.25 - 94 yrs)

Sex 51% male

ASA 1-2 52%

ASA 3-4 48%

Obesity 31%

Neuraxial Regional Claims


Subarachnoid, 45%

Lumbar Epidural, 45%

Thoracic Epidural, 5%

Combined Spinal +

Epidural, 2%

Caudal Epidural, 1%

Type of Neuraxial Block in 443 Claims


0%

20%

40%

60%

Nerve Damage

Neuraxial Cardiac Arrest

Dural Puncture

High Block

Most Common Block-Related Damaging Events

for Neuraxial Regional Claims (n=181)


Non-Block-related Damaging Events in

433 Neuraxial Regional Claims

% of 443

Non-Block-related 59%

Cardiovascular Event 14%

Respiratory Event 9%

No Event 9%

Surgical / Patient Condition 8%

Equipment 7%

Medication 4%

Unknown 4%

Other 4% Lorri A. Lee, MD University of Washington

Mechanism of Injury in 163 Neuraxial Regional

Claims Associated with Death or Brain Damage


% of 37

Subarachnoid 65%

Epidural 35%

Accidental Subarachnoid Block 11%

Inadequate Test Dose 3%

Type of Block in 37 Neuraxial Arrest Claims


Associated Factors in

37 Neuraxial Arrest Claims

% of 37

Pulse Oximetry 81%

Capnography 32%

Sedation 76%

Resuscitation Delay 49%

Arrest in Prone Position 16%

Repositioning on Table 18%

Epinephrine Not Administered 5%


Associated Factors for High Blocks (n = 14)

N

Subarachnoid 5

Epidural 9

Accidental Subarachnoid 9

Mean Age (yrs) 52

(0.25-76)

Sex 50%

male Lorri A. Lee, MD University of Washington

Mechanism of Injury for Permanent Nerve

Injury Claims with Neuraxial Anesthesia

(n = 71).


Associated Factors for

Neuraxial Hematomas (n = 27)

N (% of 27)

Vascular 13 (48%)

Orthopedic 9 (33%)

Abdomino-pelvic 5 (19%)

Coagulopathy 16 (59%)

Needle Trauma 6 (22%)

Catheter Removal on

Anticoagulation

4 (15%)


Associated Factors for

Neuraxial Hematomas (n = 27)

N (% of 27)

Symptom Onset

POD 0 9 (33%)

POD 1 5 (19%)

POD >1 5 (19%)

Delay in Diagnosis / Treatment 11 (41%)

Failure of Block Resolution POD 0 9 (33%)

Increased Motor Block 6 (22%)

Back Pain 5 (19%) Lorri A. Lee, MD University of Washington

Diagnosis of Neuraxial Hematoma

• MRI – T2 weighted image

• CT myelography

(plain CT may miss epidural

hematoma)


Treatment of Neuraxial Hematoma

• Prompt Surgical Evacuation

• Time from symptom onset to

decompression and the severity of

neurological deficits prior to

decompression correlate with recovery


CASE PRESENTATION

68 year old male

SAB for balloon angioplasty of the left iliac artery

Back pain after the spinal wore off in the PACU

Delay in workup epidural hematoma

Permanent paraplegia

Settlement $1.65 million


Associated Factors for Cauda Equina

Claims with Neuraxial Anesthesia (n = 15)

N

Lidocaine 13

Chlorprocaine 1

No local anesthetic (needle trauma) 1

Claims with Permanent Injury 14

Subarachnoid 8

Epidural 4

(Accidental subarachnoid block) (1)

Combined spinal + epidural 2 Lorri A. Lee, MD University of Washington

Complications with Temporary Injury Claims

with Neuraxial Anesthesia (n = 198).


Summary for Neuraxial Regional Claims

• > 1/3 of neuraxial claims with death or brain damage

• < 50% of neuraxial claims with temporary injury

• Maintain vigilance for neuraxial cardiac arrest and have full

resuscitative equipment and drugs available at all times

• Use test doses to prevent accidental subarachnoid blocks

and maintain vigilance for high blocks

• Avoid > 1% lidocaine for subarachnoid blocks

• Judicious use of neuraxial anesthesia in patients with

coagulopathy and high vigilance for neuraxial hematoma


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