Staying In the OR and Out of Court
Lynn Fitzgerald Macksey
RN MSN CRNA

Shakespeare
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 How attorneys think about you, your practice, and how to win against you during lawsuits.
**examples of cases
**tips and techniques TIPS
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MEDICAL MALPRACTICE CASES
 Criminal

Usually not for medical cases unless it’s a crime against society

Punishment includes incarceration and punitive damages
 Civil

Tort Law
 Medical malpractice / negligence
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MEDICAL MALPRACTICE CASES
Civil Disputes
Arise when plaintiffs (patients) believe they have been unfavorably affected by the actions of another, the defendant (CRNA) — and so seek judicial relief, that is, a courtroom judgment.
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 Surgeon liable for any errors in the OR.
 This, however, has changed.
 Each caregiver can now be named in a medical malpractice suit and is responsible for his/her own actions.
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 Four Elements of Medical Malpractice
1.
2.
3.
4.
Duty
Breach of duty, i.e., negligence
Causal connection
Injuries/Damages
Without all four of these, negligence cannot be proven.
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 It is a relationship between the healthcare provider and the patient – when care has started or anytime a patient needs help.
 If there is no duty…there is no case.
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 Negligence is the failure to do that which is consistent with good and acceptable practice… the “Standard of Care”.
 What is reasonable and prudent?
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 A qualified expert witness speaks to the standard of care.
 Opinions are expressed in degrees of likelihood.
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 Negligence occurred if the plaintiff can prove the CRNAs care fell below the Standard of
Care.
 The plaintiffs must then prove they were injured as a direct result of the CRNAs negligence ….this is known as causation .
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 A causal connection must be established between the breach of duty and the injury or harm to the patient / plaintiff.
 Who determines causation?
 Expert witness : nurse, physician, pathologist, toxicologist, etc.
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 In a anesthesia med-mal case, one of the experts jobs is to identify the role of each provider involved in the case.
 Including actions which may have contributed to adverse outcomes ~~ and actions which may have prevented or reduced injury .
WHAT DID
YOU
DO TO PROTECT THE PATIENT?!
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 The forseeability issue : was it foreseeable that a particular act could cause harm or damage?
 The CRNA has a responsibility to foresee harm and eliminate risks.
 Ex: m edication errors , nerve damage
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 “But For The” negligence issue: that is the injury that would not have occurred
“but for a particular act” .
 The expert witness will attempt to explain that, if it hadn’t been for the conduct of the defendant, the patient would not have been injured.
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 Causation is more difficult to prove than duty or breach of duty.
 Even though the patient may have an obvious injury, the cause of the injury may not be clear.
 This is where the defense focuses.
 The defense will suggest other causes for the injury, only one of which may have been the
CRNA’s negligence.
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 Because causation can be so difficult to prove, the court allows plaintiffs to argue their case using the theory of res ipsa loquitur -
“The thing speaks for itself.”
#1 : the injury must be of a type that would not ordinarily occur unless someone were negligent.
#2 : the defendant had exclusive control over whatever caused the plaintiff’s injury.
#3 : the injury could not have resulted from anything the plaintiff voluntarily did.
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 When res ipsa loquitur is used, the plaintiff is allowed to prove negligence by presenting only circumstantial evidence.
 This is opposite from most malpractice cases ordinarily, the court presumes the defendant used ordinary care until the plaintiff proves otherwise.
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 Plaintiffs must show they suffered some type of damage and because of the injury, they are entitled to monetary compensation.
The plaintiff’s attorney has the burden of proof.
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 Financial

Medical costs, wage loss…
 Physical
 Disfigurement

Loss of sensation: hearing, touch, smell…
 Loss of consortium
 Mental

Pain, anguish, loss of joy…
 Includes past and future loss
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 The bottom line?
 Does the attorney think they can win?
 Are all of the elements present?
 Is the patient credible?
 Are the damages sufficient to justify the expense and time required to prosecute a case?
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 Most attorneys want to see a major physical injury or a loss of earning capacity before they take on a case.
 Look at the degree and extent of the injury.
 Has full recovery been made?
 What is the short and long term prognosis?
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Doesn’t always matter.
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Verdict: $9 million
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1995, instead of having his right foot removed, a Florida diabetic man had his left leg cut off below the knee .
In the end, the proper foot also had to be amputated and the patient was left with no legs.
Verdict: $1 million
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When the surgeon could not find the necessary titanium rods required for patient back surgery, the surgeon removed the handle from a nearby screwdriver and used it instead.
Verdict: $5.6 million
28

In 2007, it was discovered that doctors at a Rhode
Island hospital had performed brain surgery on the wrong side of their patient’s brain… on three different patients.
The second incident prompted the state to enforce greater oversight among their neurosurgeons.
The third “wrong side of the brain” incident occurred
29 three months later.

An Ohio doctor was arrested in
1988 for experimenting in a series of reconstructive vaginal procedures on female patients without their consent.
Upon his arrest, it was discovered that the doctor had been undertaking these procedures for 22 years, on over 2000 women.
Verdict information unavailable
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In 1998, Saturday Night Live alum Dana Carvey, underwent a double bypass heart operation to address recurring heart problems.
Postoperatively, the star found that his chest pains continued.
It was in a follow-up appointment that Carvey realized that his surgeon had bypassed the wrong coronary artery.
Verdict: $7.5 million
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 Unwritten organizational factors in the anesthesia and surgery environment may exacerbate human error.
 “Production pressure” may cause adverse outcomes as cost constraints affect clinical practice.
 Include such things as -
 inadequate preoperative evaluation
 necessary monitors not being used.
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 In a 1991 case, an attending MDA and an anesthesiology resident were found to have failed to have a sufficiently small endotracheal tube on hand during hip surgery on a 5-month old child. Unsuccessful intubation attempts were alleged to have continued for an inordinately long period.
 The child suffered severe hypoxia causing a persistent vegetative state.
 Verdict: $9 million
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 Legal verdicts increasingly address
“premature extubation” as an important plaintiff’s allegation in cases where postextubation respiratory compromise results in traumatic reintubation, awareness, or hypoxemia.
 Recent premature extubation verdicts in
Michigan and Virginia have ranged form
$450,000 to $700,000 .
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How can we meet production expectations while minimizing patient safety and professional liability risks -
** Maintaining safe practice guidelines.
** Increased communication between ALL providers involved in a patient’s care.

 A 40-year-old male died of a cardiopulmonary arrest during a surgical biopsy procedure when the anesthetist performed a premature extubation of the patient.
 The plaintiff contended that the defendant hospital was negligent in failing to have a twitch monitor present during the procedure.
Verdict: $2 million
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 A case involving premature extubation that also alleged the intraoperative administration of excessive fluid, leading to severe facial edema resulted in multi-million dollar verdict on behalf of an 8-year-old child.
 The jury formed the opinion that the MDA should have known the extubation was not safe under those circumstances.
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 A set of anesthesia techniques aimed at speeding recovery from anesthesia and improving outcomes, with the overall goal of reducing health costs.
 Inappropriate use of or overaggressive fasttracking actually reduces the quality of patient care and increases liability.
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 In general, 1 fatality occurs in every 500 medical encounters.
 An almost perfect medical process (99.9%) in an average community hospital would still result in accidents, such as:
* 15 retained instruments ,
* 1 7 transfusion reactions , or
* 1,000 medication delivery errors… annually!!
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Closed Claims Data
 Closed Claims are medical malpractice claims related to significant anesthesiarelated patient injuries and demand of payment made by injured parties or their representatives.
 this data is evaluated in-depth to determine relationships between
 treatment,

 injuries sustained, and the basis of lawsuits.
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 1985
 ASA started the Closed Claim Project
 2001
 the AANA published their findings regarding CRNAs involved in closed claims.
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 This data has led to higher standards of care and mandatory monitoring.
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 Using this information can help to
 improve clinical practice
 evaluate new therapies
 anticipate problems
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 Medical malpractice is not only based on medical malpractice or negligence, but other issues such as -
 lack of informed consent,
 treatment beyond scope of consent,
 assault and battery, and
 abandonment.
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 Overall injury rate in US hospitals ~4%
 1 in 8 injured patients file claims
 The #1 type of patient to sue :
* healthy adults
* undergoing routine elective surgery
* females > males
* 50% of claims involve obese patients
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$34 to $32 million http://depts.washington.edu/asaccp/sites/default/files/pdf/Click%20here%20for%20_12.pdf
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#1 lawsuit: (29%) death
#2 lawsuit: (19%) peripheral nerve damage
#3 lawsuit: (9%) brain damage
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 Central Venous Catheter placement (16.5%)
 Low risk incidences (15%)
 Emotional damage, headache, pain during regional anesthesia and back pain after neuraxial anesthesia.
 Misuse or failure of equipment (10%)
 Burns (6%)
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 Wrong drug dose (4%)
 Eye injury (3%)
 Recall / Awareness (2%)
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Death or brain damage was precipitated by respiratory events
(45%) and cardiovascular events (25%)
51

A 6-year-old child received general anesthesia for a dental restoration procedure. His only history was mild asthma.


After extubation, the child’s oxygen saturation dropped quickly; he became diaphoretic and lethargic. CRNA had the circulator get a fan to blow over the child to cool him off. The child coded.
The child’s autopsy showed hemorrhagic changes to the lungs with no heart abnormality.
 Experts concluded the child had a unrecognized laryngospasm.
Verdict: case still in review
J. Hill, Virginia; 2010
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20 year old female undergoing MAC sedation for cervical surgery in an ambulatory surgery center.
CRNA administered deep sedation causing respiratory and cardiac arrest resulting in anoxic brain injury.
 The patient had sickle-cell disease which was not gleaned from preoperative interview.
 Patient had also taken pain medication the morning of surgery which was not known to the CRNA.
Verdict: $851,000
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 Adverse outcomes associated with respiratory events are the single largest class of serious injury in the ASA Closed Claims
Study.
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 Two-thirds of adverse respiratory events are due to:
 inadequate ventilation (38%),
 esophageal intubation (18%), and
 difficult tracheal intubation (17%)
 Inadequate ventilation was characterized by the highest proportion of cases in which care was considered substandard (90%).
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A 41-year-old female having outpatient surgery for carpal tunnel syndrome died after she suffered an acute hypoxic and hypotensive episode during sedation anesthesia.
 The defendants denied negligence and contended that being a smoker was the proximate cause of decedent's death.
Verdict Award: $0
BARNA, ESTATE OF v. HACKENSACKTOWN COMMUNITY HOSPITAL; BODNER, M.D.; MURPHY, M.D.; ET. AL 56

Wrongful death to decedent who died after being comatose for 3 years.
 Anesthesiologist unable to properly intubate decedent during toe amputation surgery which resulted in lack of oxygen, cardiac arrest and subsequent comatose condition.
Verdict: $1,742,000
JOHNSON, v. P.A.S.
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1205 - Extubated at end of case, tongue noted to be swollen, sats 89% on arrival to PACU. Facemask on 10 liter flow.
1253 - coughing up bloody secretions, right neck and tongue grossly swollen. Sats dropping, multiple physicians called and consulted.
1425 – Pt now unable to speak, sats 82% - to OR for emergency trach. Multiple attempts at intubation; (same)
MDA tried multiple times for cricothyrotomy. General surgeon in another OR and unaware of this patient.
1437 - General surgeon pulled out of another surgery and emergency trach done.
Sats between 20-70% for 24 minutes.
Postoperatively, patient is unresponsive to all stimuli and dies several days later.
Lucas; 2011
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Verdict: case still in review

 Airway trauma
 Larynx (33%)
 Pharynx (19%)
 Esophagus (18%)
 Trachea (14%)
 Temporomandibular joint [TMJ] (10%)
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In an Oregon case, a woman with prior TMJ problems underwent general endotracheal anesthesia for tonsillectomy.
 Postoperatively, she developed disability associated with the TMJ – she claimed she was not told of risks of endotracheal intubation in light of her condition.
Settlement of $350,000
Lonnie Smith Sexton v. Kaiser Foundation Hospitals, Oregon; 1993
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A 40-year-old female suffered perforation of the upper airway, resulting in swallowing problems, during an endotracheal intubation.
She later developed a mediastinal abscess.
 The plaintiff alleged the defendant made perforation is a known risk of the procedure.
Verdict: $0
UECK v. BAIDYA, M.D.
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 Aspiration
 Aspiration occurs primarily during induction but can also occur anytime intraoperatively, postoperatively, and during all types of anesthesia; i.e.: regional or sedation anesthesia.
 Large percentage of these patients have associated brain damage and/or death.
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A sixty-four year-old woman required general anesthesia for incarcerated ventral hernia. She aspirated gastric contents at induction and died one month later.
 The plaintiff alleged that the CRNA failed to take extra precautions for the patient’s conditions
(obesity, symptoms of bowel obstruction, narcotic medication) which all increased the risk of aspiration. No mention of cricoid pressure in this case.
Verdict: $210,000
63 In BB v. BW, CRNA, Kanabec County, Minnesota; 1994

 In another case of a patient who aspirated stomach acids during induction of anesthesia and died.
 The blame was on the anesthesiologist who did not apply cricoid pressure during induction of anesthesia, despite a history of gastric reflux and obesity. This case was decided based on cricoid pressure.
Verdict: $966,000
Luellen Makeny v. Parisian M.D.
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Difficult airway management during perioperative period occurs

Induction 67%

Surgery 15%

Extubation 12%

Recovery 6%
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During surgery a 30-year-old female died from cerebral anoxia after undergoing a cesarean section and elective tubal ligation.
 Surgeon noticed dark red blood; patient had an unrecognized right mainstem intubation.
Verdict: $837,600
FOSTER, ESTATE OF v. CHOI, M.D.
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In a 2008 case, an 11month-old infant undergoing surgery to remove a superfluous digit experienced profound hypoxic encephalopathy.
The episode occurred during induction after LMA insertion but the MDA could not ventilate.
Verdict: $2 million
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Difficult airway algorithm – do you know it?
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In 2002, the family of a 61-year-old woman who died sued the anesthesiologist.
 The woman had been extubated following a hysterectomy, requiring an emergent tracheotomy, which was subsequently dislodged in the ICU causing hypoxia, cardiac arrest, and death.
Verdict: $2.2 million
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 Difficult original intubation (4 attempts) with swelling of throat
 Trendelenburg position for 7 hours
 Known laryngeal polyps
 Morbidly obese patient with a large neck
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 Difficult Airway
:

Death 46%
 Difficult Airway

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All adverse respiratory events in PACU are found to be preventable with the use of continuous pulse oximetry.
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Remember this case?
 An attending and a resident were found guilty and had to pay $9 million dollars for failing to have a sufficiently small ETT on hand for a 5month old who now is in a persistent vegetative state.
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TIPS:
 All emergency equipment ready… whether giving GETA, regional, neuraxial, sedation or out-of-department procedures.
 ALWAYS!!!! Suction on and ready, Bougie, ambu available, oral airways, blades and handles, OETT ready to go.
 Preformulated reintubation plan.
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 A 44-yr old female having left ankle surgery.
She had been disconnected from the ventilator to turn from the supine to the prone position.
The circuit was then reconnected and the vent was turned on BUT the ventilator did not start and alarms had been turned off .
 The patient suffered anoxic encephalopathy and permanent brain damage after being apneic for ~ 8 minutes.
Verdict: $12 million
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Anesthesia Equipment & Monitors
TIPS:
Monitors and alarms are invaluable, particularly end-tidal carbon dioxide detectors, pulse oximeters, train-of-four monitors, oxygen analyzers, and ventilator disconnect alarms.
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Anesthesia Equipment & Monitors
 Misuse of equipment
 3x more likely than equipment failure
 Mis/disconnects of breathing circuit largest contributor to patient injury
 Equipment failure
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Anesthesia Equipment & Monitors
TIPS:
 Reviewers judged that over half of the claims
(53%) of equipment misuse or failure could have been prevented by pulse oximetry, capnography, or a combination of these two monitors.
 Constant vigilance
 Proper equipment check before using
78

Anesthesia Equipment & Monitors
TIPS:
 Check all anesthesia equipment to confirm good operation at start of each day.
 Adhere to all institutional safety precautions to minimize the risk of injury.
79

TIPS:
Formulate a patient-specific anesthetic plan and discuss with the patient.
Document plan discussion.
80

 Informed Consent was problematic in 1% of closed claims
 Anesthetic plan and possible complications not explained
 Failed to discuss a change in anesthesia plan with the patient.
 Provider failed to honor a patient request
 i.e.: no medical student involved
81

TIPS:
 Discuss the anesthetic plan and make sure you understand what your patient expects regarding the anesthetic.
 Discuss and document Do Not Resuscitate orders.
 Do not go against patient wishes regarding students in the OR.
82

TIPS:
 Patients should understand that no anesthetic technique is risk-free.
 Protecting yourself comes down to
DOCUMENTATION.
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 A cursory review of a patient’s history can lead to patient harm and medical malpractice.
 In one emergency case, a patient required emergency surgery for left hemothorax. The patient had several serious medical problems, including a very recent cardiopulmonary arrest.
 The CRNA only received an oral report preoperatively from the anesthesiologist.
84

 Remember the patient with sickle cell who had taken pain medicine that morning….
 Would it have changed your anesthetic if you had known about the chronic disease and the preoperative opioid?
 What questions could you have asked to help glean this information from the patient?
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Preanesthetic Assessment
TIPS:
A thorough preoperative assessment is mandatory and leads to appropriate planning to reduce the chance for difficulties during anesthesia care….you cannot reduce risk to zero but will minimize any catastrophe.
Documentation of preanesthetic evaluation is essential.
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Preanesthetic Assessment
TIPS :
Preexisting Conditions
Know what the condition of the patient is in when you begin care – has patient already experienced trauma? has a neuro deficit? teeth missing?...
…anything that has not been documented… chart it!
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Preanesthetic Assessment
TIPS:
Complete and thorough assessment including -
 Medical and surgical history
 Previous anesthetics
 Current medications
 Cardiac status: METS score
 Respiratory/Pulmonary status
 e tc….
88

Respiratory - perioperative
TIPS:
 Good preoperative airway assessment
 Have all emergency airway equipment available for any suspect airways…ambu, Bougie, oral airways, laryngeal mask airways.
 Be intimately familiar with Difficult Airway Algorhythm.
 Continuously monitor capnography and oxygen saturation.
 Alert, timely recognition of respiratory emergencies & action saves lives.
89

Respiratory - intubation
TIPS:
 Make your first look your best look with intubation.
 Known difficult airway? Surgeon should be readily available to perform a surgical airway if needed.
90

 For any difficult or esophageal intubation, alert the surgeon and the patient to watch for –
 early signs (pneumothorax and subQ emphysema)
 late signs (mediastinitis or retropharyngeal abscess).
 Letter to patient?
91

Before capnographyit took > 5 minutes to confirm correct placement of endotracheal tube.
With capnographyconfirmation occurs within seconds and death / brain damage from esophageal intubation
↓ from 11% to 3 % of claims.
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TIPS:
Use
Capnography monitoring along with
Pulse ox monitoring
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Respiratory - monitoring
 One study demonstrates that 72% of negative respiratory outcomes could have been
prevented by combined oximetry with capnography monitoring….so use both monitors whenever possible.
Preventable injuries are 11x costlier in medical-malpractice cases.
94

TIPS:
 In aspiration risk cases, analysis should focus on risk identification and reduction.
 Patients who are at extra risk for aspiration of gastric contents require special preparation with preoperative medication and choice of anesthetic techniques.
 i.e.: i f patient is obviously distended…keep head of bed up until stomach can be drained.
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TIPS:
 Cricoid pressure has both bad press and good but better to do it.
 Any aspiration prevention techniques must be documented.
 The risk of aspiration may never be completely eliminated.
96

TIPS:
 Make sure patient is not in Stage II depth of anesthesia, respiratory rhythm is regular, tidal volume adequate, able to lift head and/or following commands; 4/4 twitches on
Train of Four monitor are present.
 Preformulated reintubation plan
97

 Cardiovascular events occurs most often during.…

 maintenance of general anesthesia
> 50% due to blood loss or electrolyte mismanagement .
98

TIPS:
 All patients get pre-induction EKG – print out a strip, note ST values
 Patient’s history worrisome?

Perioperatively, monitor ST segment changes, electrolytes, labs, ABGs…
 Keep up with blood losses
 Treat electrolyte imbalances
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



Ulnar (25%)
Brachial plexus
Lumbosacral
(19%) nerve root (92%)
Spinal cord (13%)
 Successful nerve damage lawsuits due to:
 undocumented padding (57%)

 undocumented positioning (55%) improper positioning (36%)
100

A 38-year-old female suffered a foot drop after undergoing a laparotomy. The plaintiff contended that the defendant was negligent for failing to properly pad the stirrups.
 The defendant contended that alternate padding could have posed a larger risk.
Verdict: $400,000
GLASCOCK v. SIMPSON, M.D.
101

TIPS:
 Meticulous positioning and padding in all patients.
 Supine position document “bilateral shoulders < 90º; bilateral arms on padded arm boards; cervical spine in neutral position, etc.”
 Prone position - swimmers position with arms above head: “bilateral shoulders and elbows
< 90º. Eyes and nose checked q15.”
102

TIPS:
 Assess and document –
 preexisting patient conditions and deficits
 positioning
 padding
103

A 72 year old man underwent a nerve block to his left leg. The patient claimed he suffered permanent nerve and musculature injury in his left leg.
negligence claims; they stated they acted within the applicable standard of care at all surgery for a hematoma.
Verdict: $127,500
Robert Cormier v. Duane Dixon, M.D.; and Robert Steinberg, M.D.
104

TIPS:
 Risks are associated with any nerve block.
Nerve damage can occur no matter how perfect the block is placed or how well you position the patient ….
…protecting yourself comes down to patient education and documentation !
105

 There is an increase in claims in patients that receive blocks, especially in anticoagulated patients.
TIPS
 Assess and document preexisting nerve deficits and coagulation status before inserting peripheral nerve block.
106

 Drug-related errors occur in 1 out of 5 doses hospital patients.
 Annual cost of drug-related errors was estimated to be $2.8 million for a 700-bed teaching hospital.
 There are often immediate and major physiologic effects associated with a drug administration errors.
 There are many deaths.
107

 While a wide variety of drugs were involved in drug errors, two drugs in particular were most commonly involved. In one study -
 succinylcholine was involved in 35 cases, and
 epinephrine was involved in 17 cases and had deadliest outcomes
108

During an elective hysterectomy on a 64 yo female, the CRNA believed the patient was low in blood volume and decided to hang a bag of Hespan.
 Instead of Hespan, a lidocaine drip was hung.
The patient went into cardiac arrest and later died.
Verdict for $1,560,700
E.D., IND. & AS EXECUTOR OF ESTATE OF F.D., DECEASED v. UNITED STATES OF AMERICA 109

TIPS:
 Bar coding of anesthesia-related drugs in the operating room has been designed for anesthesia.
 Whether these systems are effective in preventing drug administration errors is unknown at the current time.
110

TIPS:
 Don’t assume!!!
 Check each vial label as you remove from drawer.
 Label syringe with appropriate label.
 Be able to see the label as you draw up drug into syringe.
 Check syringe and label before giving drug to patient.
111

A 53 yo female developed rapid breathing and tachycardia in PACU after surgery for a fractured elbow. No temperature was taken for two hours after surgery. When checked it was 103 degrees F.
Dantrolene was discussed by anesthesiologists but never given.
 The defendants argued the decedent did not have malignant hyperthermia and it was not the cause for her death.
Verdict: $367,360
Leal vs. (1) Freeman, M.D. (2) Latif, M.D. (3) Macklin, M.D. 112

TIPS:
 When a MH crisis arises, providers must focus on identification of the problem and rapid intervention.
 You must be aware the MH can occur during and 24 hours after at the end of anesthesia.
 Delays in diagnosis of MH greatly increases the chance of death.
113

 Interaction of sedatives , opioids , and intermittent monitoring of patient postoperatively greatly increases risk of adverse outcomes.
 1/3 involved respiratory depression
 1/3 involved death or brain damage
114

A patient alleged that she suffered hypoxic brain damage, with cognitive deficits, when morphine was administered to her following knee surgery.
 Claimed that staff negligently administered an excessive amount of morphine and caused a lack of oxygen and brain damage.
Verdict: $999,999
PETERSON v. LARAMIE COUNTY MEMORIAL HOSPITAL D/B/A UNITED MEDICAL CENTER 115

A 54-year-old patient recovering from reconstructive breast surgery suffered hypoxemia and permanent brain damage after overdosing on morphine through a patientcontrolled analgesia pump.
 The patient was not on telemetry and was not considered to be at high risk for respiratory depression.
Verdict: $1.7 million
Atkisson v. Miami Veterans Affairs Medical Center , 116

 Major negative outcomes in chronic pain management include nerve injury, paralysis, brain damage, death, meningitis, pneumothorax from –
 Inadequate follow-up
 Insufficient monitoring (i.e. continuous pulse oximeter)
117

TIPS:
 Continuous oxygen monitoring for patient’s receiving PCA or epidural anesthesia.


Intermittent but frequent neurologic monitoring.
Have narcan readily available.
 Patients with OSA may require a higher level of monitoring…possibly treated with CPAP?
 Have both capnography and pulse ox monitors on high risk patients at all times! (all patients??)
118

 Sympathetic blockade and cardiovascular events
 54% of cardiac arrests after neuraxial anesthesia were thought to be undetected respiratory insufficiency and sympathetic blockade (profound hypotension).
119

Plaintiff presented for cesarean, received a spinal, and allegedly developed severe hypotension resulting in a permanent and disabling injury to the cauda equina.
 Defendants' claimed that plaintiff's injuries were more consistent with childbirth than with medical malpractice.
 Last Demand: $2,500,000
 Last Offer: None
120
C.K. v. COUNTY GENERAL HOSPITAL, MB, M.D., SJ, M.D. AND IH, M.D.

A woman received epidural analgesia postoperatively after total knee replacement.
 She contended that she continued to receive epidural medication for two and one-half days even though she suffered increasing neurological deficits in her legs and feet.
Verdict: $5 million
Bothe, et al. v. DelaCruz et al., Lee County Illinois 1999
121

A 62-year-old female alleged that she suffered a spinal nerve injury that resulted in total paraplegia after she received a spinal catheter after a vehicle accident.
Verdict: $22 million
DVG, M.D.; K, M.D.; R, M.D.; W, M.D.; Southern XXXX Medical Center
122

A 20-year-old woman in labor received epidural analgesia. She was found 20 minutes after an infusion pump for the epidural had been started. She was in cardiopulmonary arrest.
 Plaintiff contended that the anesthesiologist and
CRNA failure to recognize that the medication was being given into the subarachnoid space rather than the epidural space and failed to properly monitor the mother’s vital signs.
Verdict $2.3 million
123
Britteny And Ariel Lingold, Minors, B/N/F And Natural Father, William Lingold, Jr. V. John Bowden, M.D. And Rockdale Anesthesia

25 year old female was in labor with her second child.
Defendant anesthesiologist administered an epidural at the patient’s request. For ~ 30 mins, the patient was awake and alert.
 The patient then went into cardiopulmonary arrest.
 Plaintiff alleged that defendant negligently administered the epidural in the spinal space instead of the epidural space .
 Last Demand: $2,000,000
 Last Offer: $100,000
124

TIPS:
 Patient is nauseous? – immediately check blood pressure, treat if hypotensive.
 Sympathetic blockade and cardiovascular event practice suggestions –
 Prophylactic atropine administration
 Use of epinephrine early in resuscitation
125

TIPS:
 Severe hypotension can occur even with appropriate local anesthetic doses
 Constant vigilance and preparedness for emergency management of airway, breathing, and circulation is paramount
 This vigilance requires frequent monitoring of the anesthetic dermatome level as well as the patient’s vital signs and ability to communicate verbally
126

TIPS:
 Again, occurrence of side effects does not in itself indicate negligence; negligence is likely to occur when providers fail to monitor and react appropriately if such effects occur.
127

 Burns attributable to –
 IV bags or bottles (35%)
 Warmers (23%)
 Cautery with fire (19%)
 Cautery without fire (12%)
 Airway lasers (2%)
 MRI at pulse oximetry site (2%)
 Defibrillator paddles ((1%)
 EKG leads (1%)
128

The plaintiff alleged that the fire started when a
Bovie ignited 100% oxygen that was being administered by a CRNA.
 The fire resulted in burns to patient’s throat and face.
Verdict: $250,000
129

TIPS:
Prevent burns by:
 Arrange surgical drapes to avoid trapping high concentrations of oxygen; avoid nitrous oxide.
 Communication with surgeon is KEY when using laser or cautery during surgery
 FiO2 decreased as low as possible when either laser or cautery is used
 Do not use Bair Hugger tube without connecting to upper or lower body Bair blanket
130

 81% of POVL claims related to ischemic optic neuropathy and correlated with large blood losses, prolonged hypotension, prone positioning, and vaso-occlusive disease.
 13% of POVL claims correlated with direct pressure on the eye globe, emboli and low retinal perfusion pressure.
131

TIPS:
 Maintain mean arterial pressures at > 60-70 mm Hg especially for patient in prone or sitting positions.
 Maintain hemoglobin > 9.4
 Keep neck in midline to prevent venous congestion in the head.


Normothermia, euglycemia, and urinary output
> 0.5 mL/kg/hr.
Chart “eyes and nose check” along with vital signs on anesthesia record in any patient in prone position.
132

 Increase in CVP-related claims in last decade from both injury and death due to
 cardiac tamponade
 vascular injury.
TIPS:
 Almost half of these claims deemed preventable by the -
 implementation of ultrasound,
 waveform to confirm cannulation of vein,
 interval or continuous waveform monitoring. 133

 Liability from peripheral catheters: 2% of database
 Median payout $50,000
 Most claims due to soft tissue injury from IV catheter (extravasation);
 strongest association occurred in setting of cardiac surgery;
 results from delayed recognition of IV catheter malfunction in tucked arm.
134

TIPS:


Especially with caustic or vasoactive additives in solution…can cause tissue destruction.
Certain drugs should only be given by central line.
Questionable PIV?…taped securely, ability to check during surgery…don’t just force fluid through.
 Have multiple PIV when arms are tucked and can’t get to them during surgery.
135

 Substandard care judged in 42% of cases involving intraoperative awareness and due to:
 Failure to turn on agent vaporizer
 Vaporizer malfunction
 Failure to anesthetize sufficiently during induction
 Inadvertent paralysis of conscious patient
136

 Recall claims occurred most often during general anesthesia given to -
 Women
 Opioids used
 Muscle relaxation used
 No volatile anesthetic used
137

TIPS:
 Prevent awareness –
 Use BIS monitor, maintain between 40-60
 Monitor for unexpected tachycardia and or hypertension
 Monitor volatile anesthetic levels in vaporizers
“The most important “monitor” is the anesthesia provider.”
138

TIPS:
 The medications and techniques used in fast-tracking must be part of a carefully planned program with close surveillance of patients and outcomes .
139

 Mistakes by humans are inevitable BUT they become either difficult to correct or permanent when not caught early.
 We must be prepared for something to go wrong – inspect your work at every step and frequently during care!
140

Correlated with outcomes




Inappropriate care
Lack of vigilance
Preventable outcomes
Airway incidents
Not Correlated
 Preop physical status
 Patient age
 Type of surgery
 Age of anesthesia provider
 Years of CRNA certification
141

While unforeseen difficulties can occur, even with poor outcomes, the defense of the anesthesia provider may focus on the lack of forseeability and that appropriate crisis interventions were provided .
142

How to help avoid patient injury and being named in a lawsuit
We must improve identification of high-risk patients and recognize the insufficiency of intermittent monitoring, and move toward having continuous monitors on high-risk patient at all times.
143

How to help avoid patient injury and being named in a lawsuit
Aware and mindful check of anesthesia machine and all equipment before every case
Have plenty of choices and sizes of endotracheal tubes, LMAs, laryngoscope blades, suction, emergency airway equipment
(bougie’s, Glidescope, etc.)
144

Be Prepared for Emergencies
Basic emergency care and back-up plans are an integral part of anesthetic care.
145

How to help avoid patient injury and being named in a lawsuit
Perform a thorough assessment of patient’s airway and Mallampati score. Ask if patient has had previous anesthetic and/or ever been told they have a “difficult airway”?
Anticipate or known difficult airway?
Where is difficult airway cart?….need an airway surgeon?....have Glidescope in room?....have extra anesthesia providers in the OR?
146

Address specific risks based on patient’s medical/surgical history.
Obtain informed consent for the patient-specific planned anesthetic.
Discuss common anesthetic risks and chart conversation.
147

How to help avoid patient injury and being named in a lawsuit
Check your syringe and drug vial before, during, and after drawing up a drug.
Check labels before starting drug or drip.
Consider patient’s history and allergies before starting drug or drip.
148

Monitor the patient’s physiologic condition as appropriate for the anesthetic.
Implement and adjust the anesthetic based on the patient’s physiologic response.
Monitoring includes patient position.
149

Don’t just extubate a patient at the end of the case!
Any question of fluid overload, assess the patients ability to breathe around the ETT.
150

Of all pertinent information - show physiologic responses, adjustments that are made, and outcome from those interventions.
Chart “who” knew “what”, and “when” they knew it.
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