Anesthesiology: A Claims Review Panel Report

A panel of five anesthesiologists reviewed 23 malpractice claims to identify patterns that could lead to patient injury.

Documentation

In a significant number of the 23 cases reviewed, defensibility was compromised by insufficient information in the record. In one case involving patient awareness during surgery, the anesthesiologist neglected to document that the patient was receiving an inhalation anesthetic at the time of the alleged awareness. In another case, long intervals between the documentation of vital signs raised questions about the quality of care in a critically ill patient who died on the operating table. Vital signs such as pulse and blood pressure should be recorded every five minutes, and end tidal carbon dioxide (CO₂) and oxygen saturation data should be recorded at least every 15 minutes.

The presence or absence of paresthesia during performance of a block should be documented. In a case of lumbar nerve root injury, the patient described classic paresthesia during placement of an epidural catheter. There was no mention, however, of either the presence or absence of paresthesia in the anesthesia record.

End Tidal CO₂for Verification of Endotracheal Tube Placement

End tidal CO₂is an American Society of Anesthesiologists Standard of Basic Intraoperative Monitoring for verification of proper endotracheal tube placement. The presence of CO₂at the time of endotracheal tube placement should be documented on the record. In addition, CO₂should be monitored for six breaths after tube placement to ensure that the CO₂initially being measured is not coming from the stomach from previously aspirated exhaled air. If it is coming from the stomach, end tidal CO₂will decrease to zero by the sixth breath. It also should be recognized that during a cardiac arrest, end tidal CO₂may decrease to very low levels, or even to zero, if blood is not being moved through the lungs. If there is a question about whether the tube could be dislodged from the trachea during CPR, then direct laryngoscopy should be carried out to ensure that the tube is still correctly placed. Extubation and reintubation during cardiac arrest occurring within 15 to 20 minutes of the induction of anesthesia raises doubt as to whether the tube was correctly positioned in the first place—especially if the presence of end tidal CO₂is not explicitly documented after the initial intubation.

Another problem involving endotracheal tube placement pertains to the postanesthesia care unit (PACU). Verification of endotracheal tube placement with CO₂is standard practice in the operating room; it is difficult to justify not adhering to the same standard in the PACU. While capnography is certainly not standard care in the PACU, inexpensive, portable colorimetric CO₂detectors are readily available and should be utilized.

Equipment Malfunction

If an unexpected, unexplained anesthesia catastrophe occurs that could possibly be related to an anesthesia machine malfunction, the machine should be taken out of service, sequestered, and checked by appropriate personnel in the presence of representatives from the hospital, the anesthesia department, and the manufacturer.

Two patients suffered unexplained cardiac arrest while receiving anesthesia from the same machine 10 months apart. Only after the second identical catastrophe occurred was the machine properly checked. It was determined that the vaporizer was delivering twice the concentration of agent as the dial indicated. Obviously, an anesthesia agent analyzer could have prevented these catastrophic events, which resulted in permanent brain damage in both patients.

Awareness and Pain During Anesthesia

One high-risk cardiac patient was awake and paralyzed during repeat coronary artery bypass graft surgery. The anesthesia used was a high-dose narcotic with Ethrane. A minimal dose of an hypnotic agent (2 mg Versed) was administered during the eight-hour surgery. It should be kept in mind that awareness is possible during high-dose narcotic administration when very light doses of hypnotics are administered concomitantly.

A related problem is that of pain after receiving a regional block for a C-section. Patients should be advised that if they receive lumbar epidural or spinal anesthesia, they may have unpleasant sensations during the C-section, especially prior to delivery of the baby. This should be explicitly mentioned when the choice of anesthesia is being discussed with the patient. Reassurance, a caring manner, and appropriate analgesic and/or general anesthesia should be administered if pain and discomfort are experienced during the C-section under regional anesthesia.

Airway Management

Airway management is a key part of anesthesia practice. In the aftermath of a difficult intubation, the patient and surgeon and/or primary care physician should be alerted to watch for the symptoms of retropharyngeal abscess or mediastinitis, which can occur from esophageal/ pharyngeal tears. These symptoms include fever, dysphagia, chest pain, and subcutaneous emphysema. Delayed treatment can lead to significant morbidity or even mortality.

Another airway management problem is the prevention of endobronchial intubation. Auscultation of bilateral breath sounds, with a documented sensitivity of about 50 percent, is notoriously inaccurate. A more accurate and reproducible method of preventing endobronchial intubation is that of taping the endotracheal tube at the teeth, at 23 cm in adult males and at 21 cm in adult females. It should be noted that these parameters hold for average-size adults (5’6’’ and taller in males, and 5’3’’ and taller in females).

Documentation of where the endotracheal tube is taped at the teeth is much more specific than auscultation of breath sounds, which is a subjective and often unreliable measurement.

Epidural/Intrathecal Narcotics

Two patients suffered respiratory arrest a number of hours after administration of intrathecal or epidural narcotics. One patient suffered brain damage, and the other died. The issue in both cases was the monitoring of the patient on the ward after discharge from the PACU.

When anesthesiologists use such narcotics, they should be sure that the hospital nursing staff has rigorous protocols for monitoring narcotized patients on the wards.

Nerve Injury After Lumbar Epidural Block

Two cases of cauda equina syndrome after lumbar epidural anesthesia were reviewed. In one case, the patient had a total spinal after an injection of 15 cc of 2 percent lidocaine with epinephrine. In the other case, the patient had had an uneventful lumbar epidural anesthetic of 2 percent lidocaine with epinephrine and Duramorph for postoperative pain.

While the injury may have been related to the unintentional intrathecal injection of 2 percent lidocaine in the first case, the second case was totally unexplainable. Fractionation of injection of the local anesthetic solution into the epidural space may have made the intrathecal placement of the catheter apparent prior to injection of the total dose of 2 percent lidocaine.

J3224 9/04