Anesthetic Complications: Mortality and Brain Injury

MORTALITY AND BRAIN INJURY

Trends in anesthesia-related death and brain dam-age have been tracked for many years. In a Closed Claims Project report examining claims in the

period between 1975 and 2000, there were 6750 claims (Figure 54–3A and B), 2613 of which were for brain injury or death. The proportion of claims for brain injury or death was 56% in 1975, but had decreased to 27% by 2000. The primary pathological mechanisms by which these outcomes occurred were related to cardiovascular or respiratory prob-lems. Early in the study period, respiratory-related damaging events were responsible for more than 50% of brain injury/death claims, whereas cardio-vascular-related damaging events were responsible for 27% of such claims; however, by the late 1980s, the percentage of damaging events related to respi-ratory issues had decreased, with both respiratory and cardiovascular events being equally likely to contribute to severe brain injury or death. Respira-tory damaging events included difficult airway, esophageal intubation, and unexpected extubation. Cardiovascular damaging events were usually multi-factorial. Closed claims reviewers found that anes-thesia care was substandard in 64% of claims in which respiratory complications contributed to brain injury or death, but in only 28% of cases in which the primary mechanism of patient injury was cardiovascular in nature. Esophageal intubation, premature extubation, and inadequate ventilation were the primary mechanisms by which less than optimal anesthetic care was thought to have contrib-uted to patient injury related to respiratory events.The relative decrease in causes of death being attributed to respiratory rather cardiovasculardamaging events during the review period was attributed to the increased use of pulse oximetry and capnometry. Consequently, if expired gas analysis was judged to be adequate, and a patient suffered brain injury or death, a cardiovascular event was more likely to be considered causative.

A 2010 study examining the NHS Litiga-tion Authority dataset noted that airway-related claims led to higher awards and poorer outcomes than did nonairway-related claims. Indeed, airway manipulation and central venous catheter ization claims in this database were most associated with patient death. Trauma to the airway also generates significant claims if esophageal or tracheal rupture occur. Postintubation mediastinitis should always be considered whenever there are repeated unsuc-cessful airway manipulations, as early intervention presents the best opportunity to mitigate any inju-ries incurred.