Twenty-five years of doing (regional) anesthesia.

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

2. 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

3. Airline pilots would never put up with a cockpit that looks like ours

4. Small Plane Instruments

5. Operating Room Instruments

6. A Glimpse of Instrument Flying

7. 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.”

8. My personal close encounters with crashing patients • In a plane, the pilot crashes • In the operating room, the patient crashes

9. Don’t talk patients into having regional anesthesia • If a patient tells you they don’t want a spinal or epidural because they will have a headache or backache afterwards • Guess what? • They will have a headache or backache afterwards

10. Please sedate patients who are having regional anesthesia • Unless the patient really wants to know what is going on and insists on no sedation • “I’ll never have another spinal… it lasted too long and I didn’t like the way it felt”

11. 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 ain’t over until it’s over”

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

13. Learn from the mistakes of others

14. High-Severity Injuries Associated with Regional Anesthesia in the 1990s Learn from the mistakes of others Cheney F: ASA Newsletter, 2001, pp 6-8

15. 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

16. 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)

17. 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

18. Learn from the mistakes of others Obstetric Versus Non-obstetric Claims Chadwick H: ASA Newsletter, 1999, pp 12-15

19. 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

20. Obstetric ClaimsEVENTS LEADING TO INJURY • respiratory events most common • greatest incidence with general anesthesia

21. 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 haslikely reduced the the risk of this injury

22. 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

23. Obstetric ClaimsEVENTS LEADING TO INJURY • No cases of epidural hematoma identified

24. I cannot control the level of spinal anesthesia If you can, please share your method with me

25. I cannot control the level of spinal anesthesia

26. I cannot control the level of spinal anesthesia • Do we have to? • I no longer try to • I’m happier not trying

27. 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 don’t talk about it, either

28. 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 JCAHO’s fifth vital sign? • Of course we can not force analgesia on a patient who wants to have pain

29. 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 don’t sedate all patients, but some patients are so frightened by the procedure that it is cruel not to sedate

30. 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 we’ve always done it that way?

31. 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?

32. 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 don’t fly when the risk is too great • Physicians don’t have that luxury

33. 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)

34. Could this by why the airline industry is so much safer than medicine?!

35. 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.”

36. Thank youandfly safe!