Julia Metzner

Closed claims’ analysis

Background:The purpose of this study was to identify the patterns of liability associated with malpractice claims arising from management of the difficult airway. Methods:Using the American Society of Anesthesiologists Closed Claims database, the authors examined 179 claims for difficult airway management between 1985 and 1999 where a supplemental data collection tool was used and focused on airway management, outcomes, and the role of the 1993 Difficult Airway Guidelines in litigation. Chi-square tests and multiple logistic regression analysis compared risk factors for death or brain damage (death/BD) from two time periods: 1985–1992 and 1993–1999. Results:Difficult airway claims arose throughout the perioperative period: 67% upon induction, 15% during surgery, 12% at extubation, and 5% during recovery. Death/BD with induction of anesthesia decreased in 1993–1999 (35%) compared with 1985–1992 (62%; P < 0.05; odds ratio, 0.26; 95% confidence interval, 0.11–0.63; P = 0.003). In contrast, death/BD associated with other phases of anesthesia did not significantly change over the time periods. The odds of death/BD were increased by the development of an airway emergency (odds ratio, 14.98; 95% confidence interval, 6.37–35.27; P < 0.001). During airway emergencies, persistent intubation attempts were associated with death/BD (P < 0.05). Since 1993, the Airway Guidelines were used to defend care (8%) and criticize care (3%). Conclusions:Death/BD in claims from difficult airway management associated with induction of anesthesia but not other phases of anesthesia decreased in 1993–1999 compared with 1985–1992. Development of additional management strategies for difficult airways encountered during maintenance, emergence, or recovery from anesthesia may improve patient safety.

The risk and safety of anesthesia at remote locations: the US closed claims analysis.

Purpose of review A growing number of procedures are performed outside the operating room. In spite of their relatively noninvasive nature, serious adverse outcomes can occur. We analyzed claims from 1990 and later in the American Society of Anesthesiologists Closed Claims database to assess patterns of injury and liability associated with claims from anesthesia in remote locations (n = 87) compared with claims from operating room procedures (n = 3287). Recent findings Compared with operating room claims, remote location claims involved older and sicker patients (P < 0.01), with 50% of remote location claims involving monitored anesthesia care. The proportion of claims for death was increased in remote location claims [54 vs. 29% (operating room claims), P < 0.001]. Respiratory damaging events were more common in remote location claims (44 vs. 20%, P < 0.001), with inadequate oxygenation/ventilation the most common specific event (21 vs. 3% in operating room claims, P < 0.001). Remote location claims were more often judged as being preventable by better monitoring (32 vs. 8% for operating room claims, P < 0.001). Conclusion Data from the American Society of Anesthesiologists, Closed Claims database suggest that anesthesia at remote locations poses a significant risk for the patient, particularly related to oversedation and inadequate oxygenation/ventilation during monitored anesthesia care. Similar anesthesia and monitoring standards and guidelines should be used in all anesthesia care areas.

Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider.

Purpose of review Our goal is to review the recent years novel and relevant literature on the practice of sedation/anesthesia in the nonoperating room setting. Risk factors and outcomes were evaluated related to locations, providers, and anesthetic regimens. Recent findings Administration of sedation/anesthesia for patients undergoing uncomfortable or painful interventions outside the operating room is an expanding practice involving a wide variety of practitioners. With a growing emphasis on cost, efficiency, and patient satisfaction, propofol alone or in combination with other sedatives/analgesics has become popular for procedural sedation among nonanesthesiologists. Although major adverse events are rare in this setting, potentially risky complications, such as respiratory depression and desaturation, still occur and their importance cannot be neglected. In this context, the American Society of Anesthesiologists Closed Claims and the Pediatric Sedation Research Consortium databases convey some valuable data. The bulk of reported complications are related to anesthetic drug-induced respiratory depression or airway obstruction leading to hypoxemia or hypoventilation. There are several new studies highlighting the importance of capnography in detecting impending airway or respiratory adverse events. Summary The current incidence of complications associated with sedation in the nonoperating room environment remains irresolute. Although there are many studies on sedation practices in the out-of-operating room setting, high-quality studies are lacking. There are no data comparing practice outcomes between different practitioners and specialties.

Treatment of severe lactic acidosis during the pre-anhepatic stage of liver transplant surgery with intraoperative hemodialysis

Severe uncompensated lactic acidosis manifesting during the pre-anhepatic stage of orthotopic liver transplant surgery is an uncommon event, but it poses serious concern because of the additional lactate production and impaired elimination by the liver that develops during the anhepatic and allograft reperfusion stages of the procedure. A man with end-stage liver disease secondary to hepatitis C and hemochromatosis and normal renal function, who developed severe lactic acidosis in the pre-anhepatic stage of liver transplantation, was treated successfully with intraoperative, continuous venovenous hemodialysis. Hemodialysis effectively corrected the patients lactic acidosis and removed lactate, which contributed to hemodynamic stability during the anhepatic and graft reperfusion stages of his liver transplant surgery.

Antinociceptive effect induced by the combined administration of spinal morphine and systemic buprenorphine.

We evaluated the antinociceptive effect of combined spinal administration of morphine and systemic administration of buprenorphine.Experiments were performed on male Wistar rats. Nociception was measured using the tail immersion test. Buprenorphine was injected intraperitoneally (IP) and morphine was injected intrathecally (IT) via a catheter implanted in the subarachnoid space. Interaction of drugs was analyzed using a dose addition model. Both IT (1-5 [micro sign]g) morphine and IP (50-500 [micro sign]g/kg) buprenorphine increased the latencies of nociceptive responses in a dose-dependent manner. IT morphine (4 [micro sign]g) and IP buprenorphine (100 [micro sign]g/kg) produced 62.9 +/- 6.3 and 48.8 +/- 6.6 percent of the maximal possible effect (%MPE), respectively. The combined administration of 2 [micro sign]g of IT morphine and 50 [micro sign]g/kg IP buprenorphine produced a %MPE of 97.1 +/- 3.4. The analysis of drug interaction revealed that IT morphine interacted with IP buprenorphine in a supraadditive manner while producing a potent antinociceptive effect. Implications: The concurrent administration of spinal morphine and systemic buprenorphine produces an antinociceptive effect that is greater than what could have been predicted from individual dose-response curves. This mode of interaction allows maintenance at a significant level of analgesia with reduced doses of opioids, which minimizes the incidence of undesirable side effects. (Anesth Analg 1998;87:583-6)

Ambulatory surgery: is the liability risk lower?

Purpose of review To summarize the currently available data on malpractice claims related to ambulatory anesthesia and provide an insight into the emerging patterns of anesthesia liability in this practice setting. Recent findings At present, studies are mixed about how the continued growth of outpatient surgery will impact liability for anesthesiologists. Data derived from the ASA Closed Claims Project suggests that malpractice claims for major damaging events are less common in the outpatient settings than in inpatient settings. Correspondingly, the payment amounts for outpatient claims are significantly lower than those for inpatients. Nevertheless, nondisabling adverse events are common and involve respiratory, cardiac, equipment-related, and drug errors. In addition, the vast majority of injuries in outpatient claims was the result of substandard care and judged preventable by better monitoring. Although major incidents leading to malpractice suits are less, new liability exposure may be on the horizon, due to the changing landscape of ambulatory practice that permits care for sicker patients who require more complex surgeries. The areas of potential concern include postoperative discharge criteria, care for the obstructive sleep apnea patient, and the choice of anesthetic techniques such as neuraxial blocks and monitored anesthesia care. Summary With steady increase in outpatient surgery, anesthesiologists are confronted with new areas of liability. More data are needed to identify these risks and reduce exposure to malpractice claims.

Dexmedetomidine Does Not Affect Evoked Potentials During Spine Surgery.

BACKGROUND:The effect of dexmedetomidine on evoked potentials (EPs) has not been elucidated. We aimed to investigate the effect of dexmedetomidine on somatosensory, motor, and visual EPs. METHODS:After IRB approval, 40 adult patients scheduled for elective spine surgery using total IV anesthesia with propofol and remifentanil were randomly assigned to receive either dexmedetomidine (n = 20) or placebo (n = 20) in a double-blind, placebo-controlled trial. After obtaining informed consent, positioning, and baseline EPs recording, patients were randomly assigned to either IV dexmedetomidine 0.6 &mgr;g/kg infused over 10 minutes, followed by 0.6 &mgr;g/kg/h, or a corresponding volume of IV normal saline (placebo). EP measures at 60 ± 30 minutes after initiation of study drug were defined as T1 and at 150 ± 30 minutes were defined as T2. Changes from baseline to T1 (primary end point) and from baseline to T2 (secondary end point) in EP latencies (milliseconds) and amplitudes (microvolts) were compared between groups. Data presented as mean ± SD (95% confidence interval). RESULTS:Data from 40 patients (dexmedetomidine: n = 20; age, 54 ± 3 years; 10 males; placebo: n = 20; age, 52 ± 2 years; 5 males) were analyzed. There was no difference between dexmedetomidine versus placebo groups in primary end points: change of somatosensory EPs at T1, latency: 0.01 ± 1.3 (−0.64, 0.65) vs 0.01 ± 1.3 (−0.64, 0.65), P = 0.43 (−1.24, 0.45); amplitude: 0.03 ± 0.14 (−0.06, 0.02) vs −0.01 ± 0.13 (−0.07, 0.05), P = 0.76 (−0.074, 0.1); motor EPs amplitude at T1: 65.1 ± 194.8 (−35, 165; n = 18) vs 109.2 ± 241.4 (−24, 243; n = 16), P = 0.57 (−113.5, 241.57); visual EPs at T1 (right eye), amplitude: 2.3 ± 3.6 (−0.4, 5.1; n = 11) vs 0.3 ± 6.0 (−3.3, 3.9; n = 16), P = 0.38 (−6.7, 2.6); latency N1: 2.3 ± 3.6 (−0.4, 5.1) vs 0.3 ± 6.0 (−3.3, 3.9), P = 0.38 (−6.7, 2.6); latency P1: −1.6 ± 13.4 (−11.9, 8.7) vs −1.4 ± 8.1 (−6.3, 3.5), P = 0.97 (−9.3, 9.7) or secondary end points. There were no differences between right and left visual EPs either at T1 or at T2. CONCLUSIONS:In clinically relevant doses, dexmedetomidine as an adjunct to total IV anesthesia does not seem to alter EPs and therefore can be safely used during surgeries requiring monitoring of EPs.

Anesthetic management of acute mesenteric ischemia in elderly patients.

Ischemic insult to the splanchnic vasculature can jeopardize bowel viability and lead to devastating consequences, including bowel necrosis and gangrene. Although acute mesenteric ischemia (AMI) may occur at any age, the elderly are most commonly affected due to their higher incidence of underlying systemic pathology, most notably atherosclerotic cardiovascular disease. Treatment options include pharmacology-based actions, endovascular, and surgical interventions. AMI remains a life-threatening condition with a mortality rate of 60% to 80%, especially if intestinal infarction has occurred and surgical intervention becomes emergent. Early recognition and an aggressive therapeutic approach are essential if the usually poor outcome is to be improved. Anesthetic management is complex and must account for comorbid disease as well as the patients presumptive acute deterioration. Blood pressure support typically involves careful, but often massive, fluid resuscitation and may also additionally require pharmacologic support.

Simulation for Maintenance of Certification

Maintenance of certification (MOC) is a process through which practitioners are able to show continuing competence in their areas of expertise. Simulation plays an increasingly important role in the assessment of students and residents, as well as in the initial practice certification for health care professionals. The use of simulation as an assessment tool in MOC has been sluggish to be universally accepted. This article discusses the role of simulation in health care education, how simulation might be effectively applied in the MOC process, and the future role of simulation in the MOC process.

An analysis of risk factors and adverse events in ambulatory surgery

License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Ambulatory Anesthesia 2014:1 3–10 Ambulatory Anesthesia Dovepress