Since the first public demonstration of anesthesia, known as “ether day” took place in Boston on October 16, 1846, many things have changed in the world of anesthesia. New medications have been developed, and technology has become a key part of making anesthesia safer. However, there has always been an important human element in the administration and management of anesthesia required to maintain safety. To become an anesthesiologist a physician has to be trained in residency for 4 years. After which the physician may opt to do a fellowship for another year. Many similarities have been described and used between aviation and anesthesia. The motto for the American Society of Anesthesiologists (ASA) is vigilance and, just like in the aviation industry, constant adjustment, communication, knowledge and reliance on technology are required to produce an excellent anesthetic and safe results for patients.
In 1984, the ASA recognized that serious complications were occurring during the administration of anesthesia. The ASA was the first medical society to address concerns about safety by creating the ASA Closed Claim database. The database was created to evaluate anesthesia injuries in an effort to improve patient safety. It now contains more than 8,954 claims – with 5,230 claims since 1990.
Claims for surgical anesthesia have decreased in recent years. However, claims for acute and chronic pain management have increased, and anesthesia has changed dramatically over the last few decades. Namely, it has become more specialized. Subspecialties such as cardiothoracic anesthesia, regional anesthesia, ambulatory anesthesia, obstetric anesthesia, critical care, pain medicine and pediatric anesthesia have all developed to maturity in recent decades. Each subspecialty comes with its own benefits, risks, and complications for patient treatment. This proliferation of specialized approaches can help us understand how anesthesia has become safer, but not risk free.
The ASA’s Closed Claims Project reviews and analyses closed claims files of United States professional liability insurance companies. The insurance companies participating in the project include state-wide organizations. These comprise both physician-owned and private companies, as well as companies insuring anesthesiologists in multiple states.
According to the database, in the 2000s (1) (3), the areas of anesthesia responsible for the most claims were as follows:
Surgical anesthesia claims with monitored anesthesia care (MAC), in which patients undergo local anesthesia along with sedation and analgesia, increased in the 2000s to 10% of claims. While regional anesthesia involved 19%.
The most common serious complications associated with any type of anesthesia were:
Other reports have shown similar numbers. Most frequent injuries reported were (2):
When looking at the database, death is still the leading outcome in anesthesia claims between 1990-2007. Nerve injury accounted for 22% of claims. Two thirds of these injuries were temporary and non-disabling, while the remaining one third were permanent and disabling. Airway injury accounted for 7% of injuries.
In the last two decades, claims for MAC (monitored anesthesia care) anesthesia, acute, and chronic pain have increased significantly. According to the most recent report from the Society for Ambulatory Anesthesia (SAMBA), more than two-thirds of surgical procedures in the U.S are done in surgical centers and medical offices. In many cases, MAC is the preferred technique for these procedures. In the 1980s, MAC claims represented 2% of claims – this figure has risen to 10% in 2000 and after. Although the use of airway instrumentation is minimal at most, and the amount of anesthetic is usually much less in a MAC technique. Death was more common with MAC techniques than in general or regional anesthesia. One possible explanation is that MAC may provide a false sense of safety to anesthesia providers. Thereby increasing the possibility of negative outcomes.
On the other hand, the amount of regional anesthesia claims has not changed over time, accounting for nearly 20–25% of claims in each decade. However, the introduction of ultrasound guided regional anesthesia (USGRA) may have caused a decline in the number of recent claims, as USGRA has slowly become the standard of care over the last 7 years.
It is possible to separate different complications and events when looking at the different steps involved in anesthesia care.
Teeth damage is the most common non-threatening complication in anesthesia (20.8%). Injuries to the teeth are most commonly associated with airway care during general anesthesia. On the other hand, difficulties with a patient’s airway is one of the most feared and serious complications faced by anesthesiologists, with the possibility of death or permanent brain damage. Difficult airways were encountered on induction in 67% of cases, during surgery in 15% of cases, on extubation in 12%, and in 5% of cases during recovery. It is important to mention that death and permanent brain damage from difficult intubation at induction of anesthesia has declined since adoption of the ASA practice guidelines for management of difficult airway.
During MAC anesthesia, the airway is not protected; however potent medications are given to keep the patient comfortable during the procedures. It is not surprising then that medication overdose by anesthesiologists was the most common mechanism of injury. It accounted for 21% of MAC claims. Drug combinations of propofol and benzodiazepines or opioids (such as versed and fentanyl) were involved in over half of over sedation cases.
Other risk factors involved were advanced age, ASA physical status of 3–5 and/or obesity, and performing a procedure in a remote location. Care was judged to be substandard in the majority of cases. It was also determined to be preventable with better monitoring, including pulse oximetry, end-tidal capnography, or both. Burn injuries are also more common during MAC than general or regional anesthesia. Fires accounted for nearly a fifth of MAC claims and were more common during surgery on the head, face and neck. In all cases with burns, an electrocautery tool was used with supplemental oxygen supplied via a nasal canula, face mask, or face tent.
Newborn death/brain damage still constitute a large number of claims (21%). As do maternal nerve injuries (21%), which are largely temporary and nondisabling. Severe disabling spinal cord injuries occurred in 10% of nerve injury claims due to direct spinal cord injury, epidural hematoma, abscess, or anterior spinal artery syndrome.
Management of Chronic Pain
Malpractice claims for chronic pain medication involved mostly young men suffering from chronic back pain (53%), who were primarily treated with opioid analgesics (94%). Fatal outcome was highly prevalent in these scenarios, accounting for nearly 60% of claims. The use of long-acting opioids, such as oxycodone and methadone, alone or in conjunction with other psychoactive medications, was considered the primary cause of death in over 60% of claims. Chronic pain management presents a challenge to physicians due to the patient population served, the use of invasive techniques, and the prescription of very strong medications. Analysis have shown that two intertwined major factors contributed to 82% of claims: patient non-compliance with the treatment, and/or substandard care provided by the physician.
Anesthesia has become safer over time, but it is still not without risks. Every single anesthesia sub-specialty strives to provide the best and safest patient care. The use of potent medications, in combination with invasive procedures to protect the airway and provide pain relief, has inherent risks that anesthesiologists must face every day in their clinical practice.