The ASA closed claimed analysis program recently reported on injuries associated with regional anesthesia (Lee et al: Anesthesiology 2004;101:143-52). Davies JM (ASA Newsletter 2004;68 http://www.asahq.org/Newsletters/2004/06_04/davies06_04.html) has discussed recent trends in obstetrical anesthesia closed claims.. Davies notes that about 12% of the 310 claims in the 1990s were related to maternal death, and 6% to maternal brain damage in which the patient survived. They emphasized that a large proportion of the obstetrical claims were for relatively minor injuries such as headache, nerve damage, emotional distress, or back pain to name a few.
Despite the conclusions that complications from neuraxial anesthesia may have relatively smaller costs associated with them, a recent search using Factiva and Lexus Nexus has revealed a number of very expensive settlements as well as cases with successful defenses. As with my last attempt at reviewing recent anesthesia related medical malpractice cases (Clinical Advisory August 2007) my sources are limited and the information provided is also limited. My search does not in anyway provide information about the total number of settlements and my lack of legal training may make some of my interpretations suspect. The settlement awards in the case of verdicts for the plaintiffs are most likely shared among more than one defendant and may not represent the final settlement.
Elective C – section under spinal anesthesia resulted in death to the mother with a settlement of $6.7 million. The claim was made that there was an intravascular injection of lidocaine (Goldsmith v Lechiara, trial date January 2004)
C-section for fetal distress under spinal anesthesia resulted in anoxic brain injury to the mother with a settlement of $6.6 million (names withheld, settlement approval date October 2005). According to the information provided “The plaintiff was brought to the operating room where the defendant anesthesiologist injected spinal anesthesia …The anesthesiologist’s records indicated that during the procedure, the plaintiff’s upper extremities became uniformly mottled and that the oxygen saturation monitor on the plaintiff’s finger stopped functioning. The obstetric surgeons noted that the blood in the surgical field was dark, and the anesthesiologist was questioned about the oxygen saturation of the patient. The anesthesiologist determined that the patient was not breathing, cardiopulmonary resuscitation was commenced, and a code was called.”
C-section under epidural anesthesia resulted in claim of post cardiac arrest short-term memory loss, emotional labiality and inability to resume her career. Complicating the management of the patient was the fact that the patient was a dwarf and placement of the epidural was difficult. The patient developed breathing difficulties after injection of a single dose of local anesthetic through the epidural needle. The verdict for the defense was facilitated by the ability to demonstrate that the injection of the epidural and the subsequent resuscitation were within the standard of care. The defense was also able to present alternative explanations for the patient’s neurologic changes (case i.d. withheld, April 2007).
C-section under spinal anesthesia resulted in claim of mild hypoxic ischemic encephalopathy with resulting short term memory loss. There was a verdict for the defendant anesthesiologist (Johntee v Jefferson, trial date February 2006).
C-section under spinal anesthesia resulted in a claim of spinal nerve injury. There was a verdict for the defendant anesthesiologist (Schwander v. Esser, trial date April 2004).
Of greater interest are two papers that allow the beginning of an estimate of incidence. Mhyre investigated maternal deaths in Michigan between 1985-2003 (Anesthesiology 2007;106:1096-104) and noted that of 855 reported pregnancy associated deaths, 8 were found to be anesthesia related and 7 were found to be anesthesia contributing. Of particular interest was the finding that five of the deaths were related to hypoventilation or airway obstruction during emergence, extubation or recovery. With respect to regional anesthesia, a 32 year old became apneic and suffered cardiac arrest in the PACU after a c-section using spinal anesthesia, a 42 year old who received a spinal anesthetic for c-section and PCA for post op pain arrested 9 hours post surgery, a 50 year old developed a high spinal and cardiac arrest after an epidural test dose given for c-section, and a 42 year old experienced bradycardia and cardiac arrest after administration of a spinal anesthetic for elective c-section. Of particular importance from the point of view of risk was cardiac arrest and failed resuscitation in a 29 year old who underwent vacuum aspiration of an undesired first trimester pregnancy under deep sedation and was found pulseless and apneic 25 minutes after arrival in the PACU; attempts at resuscitation failed.
Auroy et al (Anesthesiology 2002;97:1274-80) provides results showing that in France during a 10 month period extending from August 1, 1998 – May 31, 1999, 487 participant anesthesiologists reported their complications after administering 5,640 spinal anesthetics. In this study there was 1 cardiac arrest, no episodes of respiratory failure, no seizures, 2 episodes of peripheral neuropathy, and no episodes of cauda equine syndrome, central neurologic events such as stroke, meningitis or deaths.
Though serious complications such as death, brain injury, cardiac arrest after regional anesthesia in the obstetrical population appears to be uncommon, severe injury can occur as indicated both by the ASA closed claimed study, the maternal death in Michiganstudy and my recent review of malpractice cases going to trial.
David S. Smith M.D., Ph.D.
