The Medico-Legal Advisor ®
ANESTHETIC MISHAPSAnesthesia has undergone enormous development since the discovery of the first anesthetic over 100 years ago. New drugs as well as refinements in techniques and equipment are in large part responsible for our ability to perform many of the sophisticated operations routinely performed today. Anesthesia has no therapeutic benefit of its own. Therefore, the ideal administration of an anesthetic should place the patient at no risk beyond that of the surgical procedure. The public presumes anesthesia is safe to the point that they routinely demand no choice in either the type of anesthesia used or in the personnel who administer it. Yet any surgeon would tell you that the choice of anesthetist (here used to include both anesthesiologists (M.D.s) and CRNA's (certified registered nurse anesthetists) in all but the trickiest operations is far more important to patient survival than is the choice of the surgeon. Anesthesia mishaps occur frequently and most are unreported. Estimates of frequency of occurrence are based on studies of individual hospitals or consortiums designed for the collection of such data. Professional pride and the current medico-legal climate combine to discourage reporting and encourage attempts at covering up and shifting blame. MISHAPS LISTED ACCORDING TO SEVERITY
Reported in descending order of frequency. Our choice of terms is perhaps misleading. Trivial mishaps are only trivial in the sense that they do not cause mortality or significant long-term morbidity and are clearly not trivial to those injured. Aspiration pneumonia does not always result in a satisfactory outcome. It was the sole or contributing cause of death in 13% of patients in one study. Yet most cases, properly recognized and treated, result in only a temporary increase in post-operative morbidity. Trivial
Catastrophic:
Catastrophic mishaps outnumber those of a trivial nature by a wide margin. In all studies reviewed, human error accounted for most of the mishaps. In a small percentage of the cases co-existing disease was classified as a contributory or sole cause. Heart disease and lung disease were most commonly identified in those cases as contributory. Bear in mind that we are speaking only of deaths related to anesthesia mishaps which account for a fraction of perioperative mortality. Intraoperative cardiac arrest is the most terrifying of anesthesia mishaps (we avoid the word misadventure since analysis of existing records clearly indicates that chance or bad luck have little to do with most anesthesia deaths). Cardiac arrest occurs under anesthesia with a frequency of between 1.7 and 4 per 10,000 anesthetics and involves more than 2,000 patients per year in the U.S. How many more we cannot estimate since there is no uniform reporting requirement. Three quarters of those patients who arrest from anesthesia will be resuscitated and live, yet only a small number will leave the hospital alive and well. The remainder will either die in the post-operative period or will require long-term care for central nervous system damage. Faulty technique accounts for nearly one half of all cases of anesthesia death or cerebral damage. Most common under this category is inadvertent esophagel intubation with the endotracheal tube resulting in fatal lack of oxygenation of the lungs. Failure to intubate the patient with disease of the neck or oropharynx is second. Included are neck hematomas and swelling of the throat from ludwigs angina or peritonsillar abscess. Misuse of ventilator apparatus is nearly as common as failure of proper endotracheal intubation. Listed In diminishing order of frequency are:
laziness-failure to adequately assess the patient preoperatively or monitor him postoperatively. Failure to monitor blood loss and/or provide adequate fluid replacement is an error often mentioned but probably not a frequent cause of catastrophe. Fluid overload resulting in pulmonary edema and cardiac failure is probably a much more common error. Anesthetic overdose, mostly overdoses of intravenous agents, is very common and accounts for many deaths, especially those which occur in the recovery room. Inhalation anesthetics are less commonly involved. One common scenario involves the patient who receives an opiate preoperatively or early in the performance of a short procedure. He is not intubated or is extubated prior to leaving the operating suite. Drowsiness or some lack of responsiveness is noted as he reaches the recovery room. A few minutes later he arrests, often unnoticed. Sublimaze (fentanyl) is often the drug involved in such mishaps. Other opiates alone or in combination with a tranquilizer follow close behind. Lack of careful monitoring of the patient and accidental overdose are two common causes of deaths by anesthetic overdose. Absolute overdoses are much less common. Drug reactions (i.e., unusual sensitivity or allergy) are rare causes of anesthetic deaths. Accidental intravenous injection of some agents and injection of agents into the spinal canal intended for the epidural space do account for some deaths and other serious but retrievable mishaps. Administration of the wrong drug is an indefensible error. Giving concentrated intravenous potassium is probably the most common such error and results in instantaneous cardiac arrest. Most operating rooms, especially those stung by such errors, have adopted policies requiring double checking of the ampoule prior to injection of drugs by the surgeon but no one checks the anesthetist who handles the intravenous injection of several drugs during the average anesthetic. Anesthesia record keeping is archaic and grossly inadequate as anyone knows who has tried to review an anesthetic mishap. No permanent records of monitoring are kept other than the anesthetist's hen-scratching on the graphic sheet. Because the same person is responsible for administering the anesthetic and recording its course, clumsy alterations sometimes appear when the record has been pre-recorded but a disaster intervenes. In most mishaps no dictated explanatory note is every found. Lack of documentation seems to be a defensive maneuver. Monitoring of the patient in the operating room is Improving. Monitoring only the patient's cardiac rhythm is inadequate since disturbances in rate and rhythm are late signs of hypoxia. Monitoring of the oxygen content in the gaseous mixture as it enters the patient is becoming the standard and should save many lives. The evaluation of an anesthetic mishap is quite challenging. First, one must discover who was administering the anesthetic when the mishap occurred. Often if the anesthetist was on break this will not be recorded and such breaks are common time frames for discovering or producing a disaster. An anesthetist may perform the anesthesia but the record may be signed by the anesthesiologist. Cases occur where the supervising anesthesiologist was not in the suite or even the building when the anesthetic was given yet signed the record. Nurse anesthetists are often under the employ of the hospital or the anesthesia group but may be independent contractors. Most commonly they are supervised by physician anesthesiologists but the academy for nurse anesthetists has fought hard for their use as independent agents not requiring anesthesiologist supervision. Anesthesiologists, while frequently acting as independent practitioners are often under some sort of franchise agreement with hospitals. Operating room nurses often identify closely with the patient's welfare in operating room mishaps and may be counted on occasionally to blow the whistle on the anesthetist who tries to cover up and to identify those involved. In summary, anesthesia is relatively safe today. Most mishaps can be attributed at least in part to pilot error but it may be difficult to determine what part the patient's disease played in the disaster. Anesthesiologists can be counted on to exhibit the usual signs of human frailty. They have the advantage of no permanent monitoring record and the ability, either innate or taught, of making their records quite mysterious and illegible. |