Twenty-five years of doing (regional) anesthesia.

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Twenty-five years of doing (regional) anesthesia.
Have I learned anything?

• Donald H. Lambert

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Doing anesthesia is not like flying a plane it
is not even close

• With your feet on the ground in the operating
  room, things happen slowly

• Things happen fast when approaching the ground at
  115 mph

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Airline pilots would never put up with a cockpit
that looks like ours
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Small Plane Instruments
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Operating Room Instruments
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A Glimpse of Instrument Flying
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Doing anesthesia is not like flying a plane it
is not even close

• Aviation is not inherently dangerous, but unlike
  the land (operating room) and the sea, it is
  unforgiving of any incapacity, carelessness, or
  neglect.

• Airplanes are wonderful machines.

• Their only fault is an inability to forgive.

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My personal close encounters with crashing
patients

• In a plane, the pilot crashes

• In the operating room, the patient crashes

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Dont talk patients into having regional
anesthesia

• If a patient tells you they dont want a spinal
  or epidural because they will have a headache or
  backache afterwards

• Guess what?

• They will have a headache or backache afterwards

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Please sedate patients who are having regional
anesthesia

• Unless the patient really wants to know what is
  going on and insists on no sedation

• Ill never have another spinal it lasted too
  long and I didnt like the way it felt

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Please sedate patients who are having regional
anesthesia

• Are they almost done?

• The anesthetic isn't over after the patient is
  transferred to the PACU

• As Yogi Berra said, It aint over until its
  over

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Learn from the mistakes of others
Air SafetyFoundationAnnual Reports(like the
APSF and the Closed Claims database)
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Learn from the mistakes of others
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Learn from the mistakes of others

• High-Severity Injuries Associated with Regional
  Anesthesia in the 1990s

Cheney F ASA Newsletter, 2001, pp 6-8
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High-Severity Injuries Associated with Regional
Anesthesia in the 1990sDEATH

• 4,723 closed malpractice claims
• 35 insurers insuring 14,500 doctors
• 3,180 (67) general anesthesia
• 1,133 (24) regional anesthesia

• 30 deaths

• 30 (9) of deaths owing to cardiac arrest during
  spinal or epidural anesthesia

• 1980-1990 40 cardiac arrest and death

• 1970-1980 61 cardiac arrest and death

• 10 (3) of deaths due to intravascular injection

• median payment for death 310,000

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High-Severity Injuries Associated with Regional
Anesthesia in the 1990sPERMANENT DISABLING
INJURIES

• mostly neuraxial narcotic or neurolytic block

• cause not clear but presumed needle trauma

• hematoma usually associated with heparin

• 21 due to pain management (mostly chronic pain)

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High-Severity Injuries Associated with Regional
Anesthesia in the 1990sCONCLUSIONS

• regional anesthesia claims are more likely to be
  of a lower severity than those associated with
  general anesthesia

• cardiac arrest/circulatory collapse associated
  with neuraxial block continues to be the leading
  cause of regional anesthesia-related death

• comparative safety of regional versus general
  anesthesia cannot be determined (no denominators)

• death more common with general anesthesia, while
  permanent-disabling and non-disabling temporary
  injuries are more prevalent with regional
  anesthesia

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Learn from the mistakes of others

• Obstetric Versus Non-obstetric Claims

Chadwick H ASA Newsletter, 1999, pp 12-15
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Obstetric Claims

• 12 (434/3,533) for c-section (71) or vaginal
  delivery (29)

• 67 (290) with regional anesthesia
• 47 for headache, pain during anesthesia, back
  pain, or emotional distress

• these are more commonly associated with regional
  anesthesia

• almost all claims for pain during anesthesia are
  associated with cesarean delivery

• inadequate analgesia for labor and vaginal
  delivery is seldom a liability risk

• pain during cesarean section is a cause for
  concern

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Obstetric ClaimsEVENTS LEADING TO INJURY

• respiratory events most common

• greatest incidence with general anesthesia

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Obstetric ClaimsEVENTS LEADING TO INJURY

• the single most common damaging event in the
  obstetric closed claims files was convulsion
  related to local anesthetic toxicity associated
  with epidural anesthesia

• the number of claims involving convulsions has
  decreased substantially since 1984

• using effective test doses, fractionating local
  anesthetic injections, and not using 0.75 percent
  bupivacaine has likely reduced the the risk of
  this injury

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Obstetric ClaimsEVENTS LEADING TO INJURY

• nerve damage was the third most common maternal
  injury claim

• appears to be a result of direct trauma to neural
  tissue

• a prominent feature was severe pain or
  paresthesia during needle or catheter placement
  or during local anesthetic injection

• other mechanisms of injury, such as apparent
  neurotoxicity and ischemic causes (epidural
  abscess, hypotension or vascular insufficiency)
  less common

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Obstetric ClaimsEVENTS LEADING TO INJURY

• No cases of epidural hematoma identified

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I cannot control the level of spinal anesthesia

• If you can, please share your method with me

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I cannot control the level of spinal anesthesia
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I cannot control the level of spinal anesthesia

• Do we have to?

• I no longer try to

• Im happier not trying

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I cannot control the level of spinal anesthesia

• For longer operations I use bupivacaine (10-15
  mg) exclusively

• For operations less than 1 hour I used to use
  lidocaine, but no longer (TRI)

• I am now using chloroprocaine (this is an off
  label use) in place of lidocaine

• I dont talk about it, either

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I no longer torture pregnant patients

• We would never tolerate the screaming that occurs
  during labor if that patient was in the PACU
  recovering from surgery

• What happened to JCAHOs fifth vital sign?

• Of course we can not force analgesia on a patient
  who wants to have pain

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I no longer torture pregnant patients

• How often do you sedate a patient when doing an
  epidural?

• In the operating room?

• For a labor epidural?

• If not why not?

• I dont sedate all patients, but some patients
  are so frightened by the procedure that it is
  cruel not to sedate

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I no longer torture pregnant patients

• Patients not having an epidural often get
  butorphanol for labor pain

• Why not something for the pain associated with an
  epidural injection?

• Most patients get on average 20 ug of fentanyl
  per hour epidurally

• Why not 50 to 100 ug fentanyl IV for the patient
  who can not sit still during the epidural?

• Because weve always done it that way?

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Back to the Analogy of Anesthesia v. Flying

• The Paradox

• If, as I say, flying is so much more dangerous
  than doing anesthesia, then why are the airlines
  so much safer than medicine?

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Back to the Analogy of Anesthesia v. Flying

• There is no Paradox

• For the pilot, flying is more dangerous than for
  the physician doing medicine

• For the patient, medicine is more dangerous than
  airline travel

• Airlines never assume the risks that physicians
  assume when caring for patients

• Airlines just dont fly when the risk is too great

• Physicians dont have that luxury

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Some Differences Between Airlines and Anesthesia

• Planes come with a manual and 100 hour
  inspections

• Patients come with no manual and often no
  inspections

• Planes abide by laws and rules of physics

• Patients abide by no laws or rules
  

• Pilots fly the same routes over and over

• Anesthesia conditions and routes vary widely

• Planes not airworthy are just not used

• Patients not anesthesia- worthy are often
  flown

• Pilots will not take off if conditions are not
  just right

• Anesthesiologists take off frequently when
  conditions not right (emergencies)

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Could this by why the airline industry is so much
safer than medicine?!
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Twenty-five years of doing (regional) anesthesia.
I have learned something
It is better to be on the ground wishing you
were flying...
...than flying and wishing you were on the
ground.
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Thank youandfly safe!