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!