Anesthetic Complications: Regional Anesthesia

REGIONAL ANESTHESIA

In a closed claims analysis, peripheral nerve blocks were involved in 159 of the 6894 claims analyzed. Peripheral nerve block claims were for death (8%), permanent injuries (36%), and temporary inju-ries (56%). The brachial plexus was the most com-mon location for nerve injury. In addition to ocular injury, cardiac arrest following retrobulbar block contributed to anesthesiology claims. Cardiac arrest and epidural hematomas are two of the more com-mon damaging events leading to severe injuries related to regional anesthesia. Neuraxial hematomas in both obstetrical and nonobstetrical patients were associated with coagulopathy (either intrinsic to the patient or secondary to medical interventions). In one study, cardiac arrest related to neuraxial anes-thesia contributed to roughly one-third of the death or brain damage claims in both obstetrical and non-obstetrical patients. Accidental intravenous injec-tion and local anesthesia toxicity also contributed to claims for brain injury or death.

Nerve injuries constitute the third most com-mon source of anesthesia litigation. A retrospec-tive review of patient records and a claims database showed that 112 of 380,680 patients (0.03%) expe-rienced perioperative nerve injury. Patients with hypertension and diabetes and those who were smokers were at increased risk of developing peri-operative nerve injury. Perioperative nerve injuries may result from compression, stretch, ischemia, other traumatic events, and unknown causes. Improper positioning can lead to nerve compres-sion, ischemia, and injury, however not every nerve injury is the result of improper positioning. The care received by patients with ulnar nerve injury was rarely judged to be inadequate in the ASA Closed Claims database. Even awake patients undergoingspinal anesthesia have been reported to experience upper extremity injury. Moreover, many peripheral nerve injuries do not become manifest until more than 48 hr after anesthesia and surgery, suggest-ing that some nerve damage that occurs in surgical patients may arise from events taking place after the patient leaves the operating room setting.