Twenty-five years of doing (regional) anesthesia. Donald H. Lambert Have I learned anything?
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Transcript of Twenty-five years of doing (regional) anesthesia. Donald H. Lambert Have I learned anything?
Twenty-five years of doing Twenty-five years of doing (regional) anesthesia.(regional) anesthesia.
Donald H. LambertDonald H. Lambert
Have I learned anything?Have I learned anything?
Doing anesthesia is Doing anesthesia is notnot like like flying a plane… it is not even flying a plane… it is not even
closeclose
With your feet on the ground in With your feet on the ground in the operating room, things the operating room, things happen slowlyhappen slowly
Things happen fast when Things happen fast when approaching the ground at approaching the ground at 115 115 mphmph
Airline pilots would never put Airline pilots would never put up with a cockpit that looks up with a cockpit that looks
like ourslike ours
Small Plane InstrumentsSmall Plane Instruments
Operating Room Operating Room InstrumentsInstruments
A Glimpse of Instrument A Glimpse of Instrument FlyingFlying
Doing anesthesia is Doing anesthesia is notnot like like flying a plane… it is not even flying a plane… it is not even
closeclose
““Aviation is not inherently dangerous, Aviation is not inherently dangerous, but unlike the land (operating room) but unlike the land (operating room) and the sea, it is unforgiving of any and the sea, it is unforgiving of any incapacity, carelessness, or neglect.”incapacity, carelessness, or neglect.”
““Airplanes are wonderful machines.”Airplanes are wonderful machines.”
““Their only fault is an inability to forgive.”Their only fault is an inability to forgive.”
My personal close My personal close encounters with crashing encounters with crashing
patientspatients
In a plane, the pilot crashesIn a plane, the pilot crashes
In the operating room, In the operating room, the patient crashesthe patient crashes
Don’t talk patients into Don’t talk patients into having regional anesthesiahaving regional anesthesia
If a patient tells you they don’t If a patient tells you they don’t want a spinal or epidural because want a spinal or epidural because they will have a headache or they will have a headache or backache afterwardsbackache afterwards
They will have a headache or They will have a headache or backache afterwardsbackache afterwards
Guess what?Guess what?
Unless the patient really wants to Unless the patient really wants to know what is going on and insists know what is going on and insists on no sedationon no sedation
Please sedate patients Please sedate patients who are having regional who are having regional
anesthesiaanesthesia
““I’ll never have another spinal… it I’ll never have another spinal… it lasted too long and I didn’t like the lasted too long and I didn’t like the way it felt”way it felt”
““Are they almost done?”Are they almost done?”
Please sedate patients Please sedate patients who are having regional who are having regional
anesthesiaanesthesia
As Yogi Berra said, “It ain’t over until As Yogi Berra said, “It ain’t over until it’s over”it’s over”
The anesthetic isn't over after the The anesthetic isn't over after the patient is transferred to the PACUpatient is transferred to the PACU
Learn from the mistakes of Learn from the mistakes of othersothers
Air SafetyFoundation
Annual Reports(like the APSFand the Closed
Claims database)
Learn from the mistakes of Learn from the mistakes of othersothers
Learn from the mistakes of Learn from the mistakes of othersothers
High-Severity Injuries Associated with Regional Anesthesia in the
1990s
Cheney F: ASA Newsletter, 2001, pp 6-8
4,723 closed malpractice claims4,723 closed malpractice claims 35 insurers insuring 14,500 doctors35 insurers insuring 14,500 doctors
3,180 (67%) general anesthesia3,180 (67%) general anesthesia
1,133 (24%) regional anesthesia1,133 (24%) regional anesthesia
High-Severity Injuries Associated High-Severity Injuries Associated with Regional Anesthesia in the with Regional Anesthesia in the
1990s1990sDEATHDEATH
30 deaths30 deaths 30%30% (9) of deaths owing to (9) of deaths owing to cardiac arrestcardiac arrest
during spinal or epidural anesthesiaduring spinal or epidural anesthesia 1980-1990 = 1980-1990 = 40%40% cardiac arrest and death cardiac arrest and death
1970-1980 = 1970-1980 = 61%61% cardiac arrest and death cardiac arrest and death
10% (3) of deaths due to intravascular injection10% (3) of deaths due to intravascular injection
median payment for death $310,000median payment for death $310,000
mostly neuraxial narcotic or mostly neuraxial narcotic or neurolytic blockneurolytic block
High-Severity Injuries Associated High-Severity Injuries Associated with Regional Anesthesia in the with Regional Anesthesia in the
1990s1990sPERMANENT DISABLING INJURIESPERMANENT DISABLING INJURIES
cause not clear but presumed cause not clear but presumed needle traumaneedle trauma
hematoma usually associated with hematoma usually associated with heparinheparin
21% due to pain management 21% due to pain management (mostly chronic pain)(mostly chronic pain)
regional anesthesia claims are more likely to be of a regional anesthesia claims are more likely to be of a lower severity than those associated with general lower severity than those associated with general anesthesiaanesthesia
High-Severity Injuries Associated High-Severity Injuries Associated with Regional Anesthesia in the with Regional Anesthesia in the
1990s1990sCONCLUSIONSCONCLUSIONS
cardiac arrest/circulatory collapse associated with cardiac arrest/circulatory collapse associated with neuraxial block continues to be the leading cause neuraxial block continues to be the leading cause of regional anesthesia-related deathof regional anesthesia-related death
comparative safety of regional versus general comparative safety of regional versus general anesthesia cannot be determined (no denominators)anesthesia cannot be determined (no denominators)
death more common with general anesthesia, while death more common with general anesthesia, while permanent-disabling and non-disabling temporary permanent-disabling and non-disabling temporary injuries are more prevalent with regional anesthesiainjuries are more prevalent with regional anesthesia
Learn from the mistakes of Learn from the mistakes of othersothers
Obstetric Versus Non-obstetric Obstetric Versus Non-obstetric ClaimsClaims
Chadwick H: ASA Newsletter, 1999, pp 12-15
Obstetric ClaimsObstetric Claims
12% (434/3,533) for c-section (71%) or vaginal 12% (434/3,533) for c-section (71%) or vaginal delivery (29%)delivery (29%)
67% (290) with regional anesthesia67% (290) with regional anesthesia
47% for headache, pain during anesthesia, back pain, 47% for headache, pain during anesthesia, back pain, or emotional distressor emotional distress
these are more commonly associated with these are more commonly associated with regional anesthesiaregional anesthesia
almost all claims for pain during anesthesia are almost all claims for pain during anesthesia are associated with associated with cesarean deliverycesarean delivery
inadequate analgesia for labor and vaginal inadequate analgesia for labor and vaginal delivery is seldom a liability riskdelivery is seldom a liability risk
pain during cesarean sectionpain during cesarean section is a cause for concern is a cause for concern
Obstetric ClaimsObstetric ClaimsEVENTS LEADING TO INJURYEVENTS LEADING TO INJURY
respiratory events most commonrespiratory events most common
greatest incidence with general anesthesiagreatest incidence with general anesthesia
the single most common damaging event in the single most common damaging event in the obstetric closed claims files was convulsion the obstetric closed claims files was convulsion related to local anesthetic toxicity associated related to local anesthetic toxicity associated with epidural anesthesiawith epidural anesthesia
Obstetric ClaimsObstetric ClaimsEVENTS LEADING TO INJURYEVENTS LEADING TO INJURY
using effective test doses, fractionating local anesthetic using effective test doses, fractionating local anesthetic injections, and not using 0.75 percent bupivacaine hasinjections, and not using 0.75 percent bupivacaine has likely reduced the the risk of this injurylikely reduced the the risk of this injury
the number of claims involving convulsions has the number of claims involving convulsions has decreased substantially since 1984decreased substantially since 1984
Obstetric ClaimsObstetric ClaimsEVENTS LEADING TO INJURYEVENTS LEADING TO INJURY
nerve damage was the third most nerve damage was the third most common maternal injury claimcommon maternal injury claim
appears to be a result of direct trauma to appears to be a result of direct trauma to neural tissueneural tissue
a prominent feature was severe pain or a prominent feature was severe pain or paresthesia during needle or catheter paresthesia during needle or catheter placement or during local anesthetic injectionplacement or during local anesthetic injection
other mechanisms of injury, such as apparent other mechanisms of injury, such as apparent neurotoxicity and ischemic causes (epidural abscess, neurotoxicity and ischemic causes (epidural abscess, hypotension or vascular insufficiency) less commonhypotension or vascular insufficiency) less common
Obstetric ClaimsObstetric ClaimsEVENTS LEADING TO INJURYEVENTS LEADING TO INJURY
No cases of epidural No cases of epidural hematoma identifiedhematoma identified
I cannot control the level I cannot control the level of spinal anesthesiaof spinal anesthesia
If you can, please share your If you can, please share your method with memethod with me
I cannot control the level I cannot control the level of spinal anesthesiaof spinal anesthesia
HYPERBARICIMMEDIATELY
ISOBARICIMMEDIATELY
ISOBARIC AT 20MINUTES
HYPERBARIC AT20 MINUTES
I cannot control the level I cannot control the level of spinal anesthesiaof spinal anesthesia
Do we have to?Do we have to?
I no longer try toI no longer try to
I’m happier not I’m happier not tryingtrying
I cannot control the level I cannot control the level of spinal anesthesiaof spinal anesthesia
For longer operations I use For longer operations I use bupivacaine (10-15 mg) bupivacaine (10-15 mg) exclusivelyexclusively
For operations less than 1 hour I For operations less than 1 hour I usedused to use lidocaine, but no longer (TRI)to use lidocaine, but no longer (TRI)
I am now using chloroprocaine (I am now using chloroprocaine (this is this is an off label usean off label use) in place of lidocaine) in place of lidocaine
I don’t talk about it, eitherI don’t talk about it, either
I no longer torture I no longer torture pregnant patientspregnant patients
We would never tolerate the We would never tolerate the screaming that occurs during labor screaming that occurs during labor if that patient was in the PACU if that patient was in the PACU recovering from surgeryrecovering from surgery
What happened to JCAHO’s fifth What happened to JCAHO’s fifth vital sign?vital sign?
Of course we can not force analgesia Of course we can not force analgesia on a patient who wants to have painon a patient who wants to have pain
I no longer torture I no longer torture pregnant patientspregnant patients
How often do you sedate a patient How often do you sedate a patient when doing an epidural?when doing an epidural? In the operating room?In the operating room?
For a labor epidural?For a labor epidural? If not why not?If not why not?
I don’t sedate all patients, but some I don’t sedate all patients, but some patients are so frightened by the patients are so frightened by the procedure that it is cruel not to sedateprocedure that it is cruel not to sedate
I no longer torture I no longer torture pregnant patientspregnant patients
Patients not having an epidural Patients not having an epidural often get butorphanol for labor painoften get butorphanol for labor pain Why not something for the pain Why not something for the pain
associated with an epidural injection?associated with an epidural injection? Most patients get on average 20 ug of Most patients get on average 20 ug of
fentanyl per hour epidurallyfentanyl per hour epidurally Why not 50 to 100 ug fentanyl IV for the Why not 50 to 100 ug fentanyl IV for the
patient who can not sit still during the epidural?patient who can not sit still during the epidural?
Because we’ve always done it that way?Because we’ve always done it that way?
Back to the Analogy of Back to the Analogy of Anesthesia v. FlyingAnesthesia v. Flying
The Paradox:The Paradox:
If, as I say, flying is so much more If, as I say, flying is so much more dangerous than doing anesthesia, dangerous than doing anesthesia, then why are the airlines so much then why are the airlines so much safer than medicine?safer than medicine?
Back to the Analogy of Back to the Analogy of Anesthesia v. FlyingAnesthesia v. Flying
There is no ParadoxThere is no Paradox For the pilot, flying For the pilot, flying isis more dangerous more dangerous
than for the physician doing medicinethan for the physician doing medicine For the patient, medicine For the patient, medicine isis more more
dangerous than airline traveldangerous than airline travel Airlines never assume the risks that Airlines never assume the risks that
physicians assume when caring for patientsphysicians assume when caring for patients
Airlines just don’t fly when the risk is too greatAirlines just don’t fly when the risk is too great
Physicians don’t have that luxuryPhysicians don’t have that luxury
Some Differences Between Some Differences Between Airlines and AnesthesiaAirlines and Anesthesia Planes come with Planes come with a manual and 100 a manual and 100 hour inspectionshour inspections Planes abide by laws Planes abide by laws and rules of physicsand rules of physics
Patients come with no Patients come with no manual and often no manual and often no inspectionsinspections Patients abide by Patients abide by no laws or rules no laws or rules Pilots fly the Pilots fly the
same routes over same routes over and overand over Planes not Planes not airworthy are just airworthy are just not usednot used Pilots will not take Pilots will not take off if conditions are off if conditions are not just rightnot just right
Anesthesia Anesthesia conditions and routes conditions and routes vary widelyvary widely Patients not Patients not anesthesia- worthy are anesthesia- worthy are often “flown”often “flown” Anesthesiologists take Anesthesiologists take off frequently when off frequently when conditions not right conditions not right (emergencies)(emergencies)
Could this by why the airline industry is so much safer than medicine?!
Twenty-five years of doing Twenty-five years of doing (regional) anesthesia.(regional) anesthesia.
““It is better to be on the ground It is better to be on the ground wishing you were flying...wishing you were flying...
...than flying and wishing ...than flying and wishing you were on the ground.”you were on the ground.”
I have learned somethingI have learned something
Thank youThank youandand
fly safe!fly safe!