ASA Closed Claims Project:
Regional Anesthesia Claims 1990 or later Lorri A. Lee MD
Department of Anesthesiology University of Washington, Seattle, WA
Lorri A. Lee, MD University of Washington
OVERVIEW
1. Closed Claims Project
2. Peripheral Nerve Blocks
3. Neuraxial Claims
Lorri A. Lee, MD University of Washington
ASA Closed Claims Project
• 35 insurance organizations since 1985
• 17 companies in current active panel
• 13,000+ anesthesiologists insured by
current panel of companies
Lorri A. Lee, MD University of Washington
On Site Anesthesiologist Reviewer
•Within 5 years of practicing
•Non-dental injury claims
•Adequate records to recreate scenario
•Assessment of anesthetic – related injury
•Assessment of SOC
•Severity of Injury
Scale of No Injury (0) to Death (9)
Lorri A. Lee, MD University of Washington
Claims sent to University of Washington
•Reviewed by 2 anesthesiologists
•Tie breaker resolved by 3rd anesthesiologist
•Entered into CCP Database
•Topics selected, analyzed, updated
Lorri A. Lee, MD University of Washington
Utility of Closed Claims Data
• Collection of “Sentinel Events”
• Identify areas of recurrent risk
• Provide direction for in-depth analysis
• Snapshot of anesthesia liability
Lorri A. Lee, MD University of Washington
Bias with Malpractice Claims
• No denominator for calculating
risk
• Small subset of injuries
• More severe, permanent injuries
• More substandard anesthesia
care
Lorri A. Lee, MD University of Washington
COMPLICATIONS OF REGIONAL ANESTHESIA
• Neuraxial cardiac arrest
• High block
• Unintentional intravenous injection
• Hematoma, abscess, meningitis
• Needle trauma:
• Paresthesia, weakness, paralysis
• Blindness
• Post-dural puncture headache
• Complications of sedation
• Inadequate analgesia, injection site pain
• Miscellaneous Lorri A. Lee, MD University of Washington
Peripheral Nerve Block Complications
Complications Associated With
Peripheral Nerve Blocks:
Lessons From The ASA Closed Claims Project
Lee LA, Posner KL, Kent C, Domino KB
Int Anesthesiol Clin. 2011;49(3):56-67
Lorri A. Lee, MD University of Washington
Peripheral Nerve Block Complications
Inclusion Criteria:
• Peripheral Block Claims from 1990 and later
• Operative setting
•Blocks performed in the OR for post-operative
pain management included
Lorri A. Lee, MD University of Washington
Peripheral Nerve Block Complications
Exclusion Criteria:
• Claims from 1970-1989 or unknown year
• Claims for:
Chronic or postoperative pain management
Eye Block claims
Lorri A. Lee, MD University of Washington
% of 189 claims
Sex 57% male
Age, mean (yrs) 47 +/- 14 yrs
(range 4-80 yrs)
ASA 1-2 69%
ASA 3-4 17%
Outpatient Surgery 64%
Peripheral Nerve Block Claims
Lorri A. Lee, MD University of Washington
0% 20% 40% 60%
Interscalene
Axillary
IVRA
Femoral
Ankle
Supraclavicular
Other
Type of Blocks Associated with
189 Peripheral Nerve Block Claims
Lorri A. Lee, MD University of Washington
0%
20%
40%
60%
80%
Severity of Injury for
189 Peripheral Nerve Block Claims
Temporary/ Permanent/ Brain Death
Non-disabling Disabling Damage
Lorri A. Lee, MD University of Washington
0%
20%
40%
60%
80%
100%
Block-related Non-block-related
Block-related Injuries per Severity of Injury Group
in 189 Peripheral Nerve Block Claims
Temporary/ Permanent/ Death or Brain
Non-disabling Disabling Damage
(n=129) (n=30) (n=30)
Lorri A. Lee, MD University of Washington
Temporary / Non-disabling Injury (n = 129)
Block-related (% of 129) 71 (55%)
Type of Block:
Interscalene 50 (39%)
Axillary 34 (26%)
IVRA 17 (13%)
Other 28 (22%)
Peripheral Nerve Block Claims
Lorri A. Lee, MD University of Washington
A 30 year old female
Carpal tunnel release supraclavicular block.
PACU: "difficulty with a large breath".
An X-ray showed 20% pneumothorax.
The patient was not counseled for this on the
preoperative anesthesia consent form.
The case was settled for $20,000.
CASE PRESENTATION
Lorri A. Lee, MD University of Washington
Permanent / Disabling Injury (n = 30)
Block-related (% of 30) 21 (70%)
Type of Block:
Interscalene 14 (47%)
Axillary 9 (30%)
IVRA 2 ( 7%)
Other 5 (16%)
Peripheral Nerve Block Claims
Lorri A. Lee, MD University of Washington
Death / Brain Damage (n =30 )
Block-related (% of 30) 8 (27%)
Type of Block:
Interscalene 15 (50%)
Axillary 7 (23%)
IVRA 1 ( 3%)
Other 7 (23%)
Peripheral Nerve Block Claims
Lorri A. Lee, MD University of Washington
0% 20% 40% 60%
Nerve Injury
Death
Pneumothorax
Brain Damage
Most Common Complications in
189 Peripheral Nerve Blocks
Lorri A. Lee, MD University of Washington
Damaging Events in
189 Peripheral Nerve Block Claims
Damaging Event N (% of 189)
Block-related 100 (53%)
Other Block-related* 65 (34%)
Pneumothorax 12 (6%)
Inadvertent I.V. Injection 10 (5%)
Unexplained 7 (4%)
High Block 4 (2%)
Inadequate Analgesia 2 (1%)
*Needle damage to spinal cord or nerves, intraneural injection, hematoma, infection, etc Lorri A. Lee, MD
University of Washington
Damaging Events in
189 Peripheral Nerve Block Claims
Damaging Event N (% of 189)
Non-Block-related 89 (47%)
Surgical / Patient Condition 18 (10%)
Other Anesthetic Events* 14 (7%)
Wrong Drug / Dose 12 (6%)
Cardiovascular Events 12 (6%)
Respiratory Events 11 (6%)
Equipment Problems 4 (2%)
No Event / Unspecified 18 (9%)
*Includes 7 claims with wrong-site block Lorri A. Lee, MD University of Washington
0% 20% 40%
brachial plexus
median
ulnar
spinal cord
phrenic
femoral
radial
sciatic
other
Temporary Injury
Permanent Injury
Location and Severity of 97 Nerve Injuries
Lorri A. Lee, MD University of Washington
Block-related, 68%
Unclear Mechanism,
4%
No Injury, 3%
Miscellaneous Causes, 25%*
*Includes pre-existing nerve injury, surgery, etc.
Mechanism of Injury in 97 Nerve Injury Claims
Lorri A. Lee, MD University of Washington
Mechanism of Injury for Peripheral Nerve
Block Claims with Death or Brain Damage
(n = 30)
N
Local Anesthetic Toxicity 7
Inadvertent Intravenous Injection / Absorption 5
Wrong Dose 2
Stroke 6
Prolonged Hypotension 5
(Beach Chair Position) (4)
Uncontrolled Preoperative Hypertension 1 Lorri A. Lee, MD University of Washington
Mechanism of Injury for Peripheral Nerve
Block Claims with Death or Brain Damage
(n = 30)
N
Premature Extubation / Hypoxia on PACU Arrival 3
Spinal Cord Injection under General Anesthesia 2
Inadvertent Intrathecal Injection 1
Myocardial Infarction 2
Other Respiratory / Cardiac Arrest 3
Other Damaging Events 7
Lorri A. Lee, MD University of Washington
CASE PRESENTATION
A 60 year old ASA 2 male w/ htn
Humerus fx under ISB w/ nerve stimulator
After the injection of 40ml of bupivacaine in divided
doses, the patient had a seizure. The patient complained
SOB prior to the seizure. A resident aspirated during the
injection. GA immediately induced. No postop problems
in the hospital record.
3 yrs later: suit for brain damage - memory loss and
cognitive dysfunction. Neurologists had conflicting views
as to the extent and cause. The case went to trial
and the jury awarded $3M. The judge reduced it to $1.5
million and the anesthesiologist settled for $950,000. Lorri A. Lee, MD University of Washington
Assessment of Standard of Care
in 189 Peripheral Nerve Block Claims
Appropriate, 65%
Less than Appropriate,
25%
Impossible to Judge, 10%
Lorri A. Lee, MD University of Washington
Summary for Peripheral Nerve Block Claims
• Overall, low percentage of total claims
• 2/3 of claims with temporary injuries
• 1/3 of claims with high severity injuries
o 50% block-related
Most commonly nerve injury and
local anesthetic toxicity
• Need protocols to prevent wrong site blocks
Lorri A. Lee, MD University of Washington
Neuraxial Regional Complications
Complications Associated with
Regional Anesthesia and Pain Medicine:
Findings From The ASA Closed Claims Project
Lee LA, Fitzgibbon D, Stephens LS, Domino KB
in Complications in Regional Anesthesia
and Pain Medicine
Neal and Rathmell, eds.
Lorri A. Lee, MD University of Washington
Inclusion Criteria:
• Neuraxial Regional Claims from 1990 and later
• Operative setting
•Blocks performed in the OR for post-
operative pain management included
Neuraxial Regional Complications
Lorri A. Lee, MD University of Washington
Exclusion Criteria:
• Claims from 1970-1989 or unknown year
• Claims for:
chronic or postoperative pain
management
Obstetric claims
Neuraxial Regional Complications
Lorri A. Lee, MD University of Washington
% of 443 claims
Age, mean (yrs) 57yrs (0.25 - 94 yrs)
Sex 51% male
ASA 1-2 52%
ASA 3-4 48%
Obesity 31%
Neuraxial Regional Claims
Lorri A. Lee, MD University of Washington
Subarachnoid, 45%
Lumbar Epidural, 45%
Thoracic Epidural, 5%
Combined Spinal +
Epidural, 2%
Caudal Epidural, 1%
Type of Neuraxial Block in 443 Claims
Lorri A. Lee, MD University of Washington
Lorri A. Lee, MD University of Washington
0%
20%
40%
60%
Nerve Damage
Neuraxial Cardiac Arrest
Dural Puncture
High Block
Most Common Block-Related Damaging Events
for Neuraxial Regional Claims (n=181)
Lorri A. Lee, MD University of Washington
Non-Block-related Damaging Events in
433 Neuraxial Regional Claims
% of 443
Non-Block-related 59%
Cardiovascular Event 14%
Respiratory Event 9%
No Event 9%
Surgical / Patient Condition 8%
Equipment 7%
Medication 4%
Unknown 4%
Other 4% Lorri A. Lee, MD University of Washington
Mechanism of Injury in 163 Neuraxial Regional
Claims Associated with Death or Brain Damage
Lorri A. Lee, MD University of Washington
% of 37
Subarachnoid 65%
Epidural 35%
Accidental Subarachnoid Block 11%
Inadequate Test Dose 3%
Type of Block in 37 Neuraxial Arrest Claims
Lorri A. Lee, MD University of Washington
Associated Factors in
37 Neuraxial Arrest Claims
% of 37
Pulse Oximetry 81%
Capnography 32%
Sedation 76%
Resuscitation Delay 49%
Arrest in Prone Position 16%
Repositioning on Table 18%
Epinephrine Not Administered 5%
Lorri A. Lee, MD University of Washington
Associated Factors for High Blocks (n = 14)
N
Subarachnoid 5
Epidural 9
Accidental Subarachnoid 9
Mean Age (yrs) 52
(0.25-76)
Sex 50%
male Lorri A. Lee, MD University of Washington
Mechanism of Injury for Permanent Nerve
Injury Claims with Neuraxial Anesthesia
(n = 71).
Lorri A. Lee, MD University of Washington
Associated Factors for
Neuraxial Hematomas (n = 27)
N (% of 27)
Vascular 13 (48%)
Orthopedic 9 (33%)
Abdomino-pelvic 5 (19%)
Coagulopathy 16 (59%)
Needle Trauma 6 (22%)
Catheter Removal on
Anticoagulation
4 (15%)
Lorri A. Lee, MD University of Washington
Associated Factors for
Neuraxial Hematomas (n = 27)
N (% of 27)
Symptom Onset
POD 0 9 (33%)
POD 1 5 (19%)
POD >1 5 (19%)
Delay in Diagnosis / Treatment 11 (41%)
Failure of Block Resolution POD 0 9 (33%)
Increased Motor Block 6 (22%)
Back Pain 5 (19%) Lorri A. Lee, MD University of Washington
Diagnosis of Neuraxial Hematoma
• MRI – T2 weighted image
• CT myelography
(plain CT may miss epidural
hematoma)
Lorri A. Lee, MD University of Washington
Treatment of Neuraxial Hematoma
• Prompt Surgical Evacuation
• Time from symptom onset to
decompression and the severity of
neurological deficits prior to
decompression correlate with recovery
Lorri A. Lee, MD University of Washington
CASE PRESENTATION
68 year old male
SAB for balloon angioplasty of the left iliac artery
Back pain after the spinal wore off in the PACU
Delay in workup epidural hematoma
Permanent paraplegia
Settlement $1.65 million
Lorri A. Lee, MD University of Washington
Associated Factors for Cauda Equina
Claims with Neuraxial Anesthesia (n = 15)
N
Lidocaine 13
Chlorprocaine 1
No local anesthetic (needle trauma) 1
Claims with Permanent Injury 14
Subarachnoid 8
Epidural 4
(Accidental subarachnoid block) (1)
Combined spinal + epidural 2 Lorri A. Lee, MD University of Washington
Complications with Temporary Injury Claims
with Neuraxial Anesthesia (n = 198).
Lorri A. Lee, MD University of Washington
Summary for Neuraxial Regional Claims
• > 1/3 of neuraxial claims with death or brain damage
• < 50% of neuraxial claims with temporary injury
• Maintain vigilance for neuraxial cardiac arrest and have full
resuscitative equipment and drugs available at all times
• Use test doses to prevent accidental subarachnoid blocks
and maintain vigilance for high blocks
• Avoid > 1% lidocaine for subarachnoid blocks
• Judicious use of neuraxial anesthesia in patients with
coagulopathy and high vigilance for neuraxial hematoma
Lorri A. Lee, MD University of Washington