Mortalità in anestesia
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Transcript of Mortalità in anestesia
Mortalità in anestesia
Claudio Melloni
Anestesia e Rianimazione
Ospedale di Faenza(RA)
What lessons have the ASA closed claims
teached to us?
What is a claim?
Claim is a demand for financial compensation by an individual who has sustained an injury from medical care.
Once a claim is resolved the file is closed
Che cosa sono gli ASA Closed claims?
Collection of 35 USA insurance companies
14500 anesthesiologists covered 50-55% of all USA practicing
anesthesiologists
Closed claim
Medical records Narrative statement by the
involved health care personnel Deposition summaries Outcome and follow up reports Cost of the settlement or jury award
Utilità dei closed claims
Collection of “ sentinel” events
Identification of areas of risk(and litigation….)
Provides direction for further analysis
Demography and general characteristics
Adults(91%>16 years) Generally healthy:asa 1 & 2 69% Non emergency surgery 75% GA 67% The database is not a collection of medically or
surgically compromised patients in whom the underlying disease plays a major role in the outcome;for this reason the closed claim database offers the unique opportunity to discern how the process of care contributes to the genesis of adverse outcomes…..
Problemi nella interpretazione dei dati
Data collected to resolve claims Not collected for outcome research Total number of anesthesia and patients unknown Unknown denominator for risk calculation Retrospective Lag time in
publication;closure,availability,study,calculations…publication
Geographic imbalance ? Interrater reliability;bias… Claims selectivity;only 30-33% of claims available are
evaluated….
Definizioni
Complication;adverse outcome or injury sustained by the patient
Damaging event:the specific incident or mechanism that led to the adverse outcome(e.g.airway obstruction)
Risarcimenti (*1000 $) Outcome median range
Death(1725) 216 260-14700 Brain damage adults(676) 673 2750-23200
Brain damage newborns(129) 499 3333-6800
Relationships associated with
payment
Appropriateness /unappropriateness
of caregravity of injury standard of care
Frequency of paymentmagnitude of paymentBetter
monitoring
Relationships emerged form studies of closed claims:
Frequency of payment linked to appropriateness of care,but not to severity of injury
magnitude of payment linked to both severity of injury and to standard of care
adverse outcome judged preventable with better monitoring were far costlier than those which were not considered preventable with better monitoring.
Cheney FW et al. Standard of care and anesthesia liability. JAMA 1989;261:1599‑1603 Tinker JH et al. Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis. 1999;71:535‑540.
Effect of outcome on physician judgements
Examination of the Closed Claims database suggests the presence of a recurrent association between the severity of an adverse outcome and accompanying judgments of appropriateness of care.
Caplan RA.Effect of outcome on physician judgement of appropriateness of care.JAMA 1991;265:1957-1960.
Severity of Severity of adverse outcomeadverse outcome
judgments ofjudgments of appropriatenessappropriateness of care. of care.
Effect of outcome on physician judgements:2
Specifically, non disabling iniuries are more often associated with ratings of appropriate care, while disabling injuries and death are more often associated with ratings of less than appropriate care.
Effect of outcome on physician judgements:3
This raises the possibility that highly unfavorable outcomes may predispose (bias) peer reviewers towards harsher judgments,while minor injuries may elicit less critical responses.
Study of peer review:1 cases from the Closed Claims database study of peer review with 112 practicing anesthesiologists
volunteered to judge appropriateness of care involving adverse anesthetic outcomes.
The original outcome in each case was either temporary or permanent.
For each original case, a matching alternate case was devised. The alternate case was identical to the original in every respect,
except that a plausible outcome of opposite severity was substituted. The original and alternate cases were randomly divided into two sets
and assigned to reviewers. The reviewers were blind to the intent of the study.
Study of peer review:2 The care in each case was independently rated by the
reviewers based upon the conventional criterion of reasonable
and prudent practice at the time of the event. Knowledge of the severity of injury produced a
significant inverse effect on judgments of appropriateness of care.
the proportion of ratings for appropriate care by 31 percentage points when the outcome was changed from temporary to permanent, and increased by 28 percentage points when the outcome was changed from permanent to temporary.
Effect of outcome on judgements of appropriate
care
0
10
20
30
40
50
60
70
actuallytemporary
changed topermanent
actuallypermanent
changed totemporary
% of appr
opriat
eness of
care
Schroeder SA et al. Do bad outcomes mean bad care? JAMA
199 1; 265:1995.
non disabling iniuries = appropriate care
disabling injuries and death = less than appropriate care.
Concern about peer review and bias
obstacle to objective evaluation of major medical risks….
Frequency and size of payments!!
Foster practices which result in minor but avoidable injuries….
If such injuries are pervasive…» Aggregate cost
Incidence % of claims related to the most common adverse
outcomes
0
5
10
15
20
25
30death
nerve damage
brain damage
airway trauma
pnx
eye injury
fetal/newborn injury
headache
stroke
awareness
aspiration
bckpain
myocardial infarction
burns
Most common damaging events:%
resp
cardiovasc
equipment
reg block techn.
surg.techn.
wrong drug dose
1382
717591
372278
209
Conclusioni Damaging events and adverse outcome show tight
clustering in a small number of specific categories; Damaging events:3 categories account for almost half of
claims;resp, equipment & cardiovascular account for 46% of claims:
Adverse outcome:death,nerve damage,brain damage account for almost 65% of claims
This clustering of damaging events and adverse outcome is of fundamental importance since suggests that research and risk management strategies directed at just a few areas of clinical practice could result in large improvements in professional liability.
Most common adverse outcomes Range of payments($*1000)
0
5000
10000
15000
20000
25000
deathnerve dam
age
brain damage
airway traum
a
eye in.
pnxfetal/new
born in,.
stroke
aspiration
back pain
headache
MI
burns
awareness
min
med
max
Most common adverse outcomes Median Payment:$*1000
0
100
200
300
400
500
600
700
median payment
deathnerve damagebrain damageairway traumaeye injurypnxfetal7newborn injurystrokeaspirationback painheadacheMIburnsawareness
Claims differ in different populations;
»FOR INCIDENCE
»FOR SERIOUSNESS
Morray J, Geiduschek J, Caplan R, Posner K, Gild W, Cheney FW: A comparison of
pediatric and adult anesthesia malpractice claims. ANESTHESIOLOGY 78:461-7, 1993
Chadwick,HS,Posner,K,Kaplan,RA,Ward,RJ,Cheney FW.A comparison of obstetric and
nonobstetric anesthesia malpractice claims.Anesthesiology 1991;74:242-249.
ob vs non ob:190 vs 1351» ob cases 67% CS,33% vaginal» 65% associati a anest reg,33% con
GA» 2 claims per non disponibilità
dell’anestesista!
ASA closed claims project Malpractice claims against
anesthesiologists:OB VS NON OB
0
5
10
15
20
25
30
35
40
%
ob nonob
morte (materna)danno cerebrale neonatalecefaleamorte neonataledolore dur.anestdanno neuraledanno cerebrale paz.distress emotivodolore dorso
Claims ostetrici:regionale vs GA.
0
5
10
15
20
25
30
35
40
45
%
reg GA
morte materna
danno cerebrale neonatale
cefalea
morte neonatale
dolore dur.anest
danno neurale
danno cerebrale paz
distress emoz
dolore dorso
*
*
*
*
Patogenesi del danno neonatale
45% attribuiti a cause anestetiche:
GA:4» 1 broncospasmo» 1 intub esofagea» 1 aspir polm» 1 ritardo anest.
» Regionale:13» 9 convuls da iniez
intravasc» 1 eclampsia» 1 ritardo disponibilità» 3 spinali alte
37% a probl ostetrici o congeniti,
13% con probl di rianimaz.
Dati relativi ai pagamenti:OB VS NON OB
claims non ob claims ob Claims obregionale generale
non pagati(%) 32 38 43 27
pagati(%) 59 53 48 63
pagamento mediano($) 85000 203000 91000 225000
range di pagamento($) 15000-6 milioni 675000-5.4 milioni 675-2.5 mil 750-5.4 mil
GA pagata il 63% vs 48% delle reg.
Conclusioni dai closed claims obs
Danno cerebrale neonatale è il claim più frequente,anche se solo il 50% è LEGATO ALL’ANESTESIA!.
Pagamento mediano per il danno cerebr. Neonatale:500.000 $ ,vs 120.000 $ dei danni ob;
Cefalea è il III problema: e risulta in pagamento il 56% delle volte……...
RESPIRATORY related events
Characteristics of respiratory related
claims high frequency of severe
outcomes:85% death or brain damage Costly payments($ 200.000 and +) 72% judged preventable by monitoring
(pulse oximetry and etCO2) Monitoring helpful in reducing
inadequate ventilation and inadeq.oxygenation
Classification of the most common respiratory system damaging events:% of 1382
cases.
diff intub
inadeq vent/O2
esoph intub
airway obstruct
aspiration
premat extub
bronchospasm
Trends in death and brain damage according to the basic
damaging event
05
101520253035404550
%
1980 1990
Resp eventcardiovasc eventequipment probl
Most common respiratory events associated with death and brain
damage
inadequate ventilationesophag intubdifficult intubother resp eventsadv resp events
inadequate ventilationesophag intubdifficult intubother resp events
1980
1990
Adv resp events
Other respiratory damaging events associated with death or
brain damage
0
2
4
6
8
10
12
%
1980 1990
air obsbronchospasmpremat extubaspir
Which is the impact of pulse oxymetry and
end tidal CO2 monitoring in death and brain damage?
Respiratory damaging events associated with death or brain damage by monitoring group
0
5
10
15
20
25
30
35
%
inadeq ventil esophag intub diff.intub
noneSpO2 onlySpO2+etCO2
799
102167
Cardiovascular damaging events associated with death or brain
damage
0
10
20
30
40
50
60
unexp./othercv event
neuraxcardiac arrest
inadeq fluid blood loss
19801990
Unexplained/other damaging cardiovascular events in the 90’s(137)(death and brain
damage)
arrhythMIpulm embstroke path abnormmultifactorial
How do end tidal CO2 and SpO2 monitoring affect the occurrence
of cardiovascular damaging events as the mechanism of brain damage or
death?
Cardiovascular damaging events associated with death or brain damage by monitoring group
0102030405060
none
SpO2 only
SpO2+etCO2
72194
192??
Conclusions from the data about the
future role of monitoring in the
prevention of severe anesthesia
related injury?
Better monitoring would have
prevented death or brain damage
Better monitoring would have prevented death or brain damage
in the 90’s
no
yes
Resp events:221
Cardiovascular events judged preventable by better monitoring
no
yes
Respiratory and cardiovascular events contribution to deaths and brain
damage(Cheney,FW Anesthesiology 1999;91:552-6)
0
10
20
30
40
50
60
70
80
%
'70 '80 '90
respcardiovascinadeq ventesoph.intub<standard of careplaintiff payment
Trends in death and brain damage
0
10
20
30
40
50
60
70
80
%
'70-79 '80-89 '90-94
nerve injurybrain damagedeath
“The fact that professional liability premiums for anesthesiologists have decreased significantly since the mid-1980s would imply an overall reduction in severe injuries.”
Emerging trends Claims fro death and permanent brain damage are
decreasing injuries attributed to inadequate ventilation and
oxygenation are decreasing;SpO2 and etCO2 monitoring are the most likely causes
relative increase in the proportion of cardiovascular damaging events and respiratory events not prevented by monitoring
better monitoring would not lead to further reductions in death and brain damage
Death associated with Regional anesthesia in the 90’s(97
cases):etiology
pain management
neuraxial block
notblock related
intravascinjectionother blockrelated
Neuraxial cardiac arrest
Sudden and unexpected severe bradycardia and /or
asystole occurring during neuraxial block with relatively stable
haemodynamics preceding the event.
Cardiac arrest associated with neuraxial block
900 cases in claims 1988; 14 cases of neuraxial cardiac arrest…..,all pts
were resuscitated,8 survived but only 1 regained a sufficient neurologic function…..
Hypothesis: poor cerebral perfusion pressures
engendered by closed chest cardiac massage in the presence of high sympathetic blockade.
Sudden cardiac arrest during regional anesthesia
Cardiac arrest during spinal anesthesia
Closed claim database:14/1000 (1978-86) Features consistent with a sentinel event:
» Young healthy adults for relatively minor surgery» Standard anesthetic techniques and monitoring» Arrest followed by prompt & brief CPR» All resuscitation successful» Death/severe brain damage;13/14 !!» Up tp the year 2000 other 41 cases were reported in the
literature(26 spi + 15 epid);but outcome much better…..
Risk factors for cardiac arrest during spinal anesthesia
Advanced age & high ASA physical status(Auroy)
baseline HR < 60 (Carpenter et al). ASA physical status I patients(ASA closed claims)
Current therapy with b-blockers block height >T6 patients who are <50 years old (Tarkkila)
patients with first-degree heart block (Liu)
Conclusions from cases of sudden bradycardia or asystole associated with
spinal anesthesia:
Cases do occur There are no clear clinical
predictors… Prompt recognition and treatment
keys to injury prevention.
Incidence of anesthesia related cardiac arrest/per 10.000
anesthetics
0
1
2
3
4
5
6
7
incidence mortality
BibouletOlssonAuroyNewland:directNewland: relatedNewland anesth.attribAubasAubas reg onlyTarkkilaGeffin
spinal
*10 !!
GA
GA