Duties and responsibilities
Issues during surgery, labour and delivery: Managing the risks in anesthesiology
Originally published September 2014
Anesthesiology is a diversified specialty requiring expertise in many fields of medicine. It includes anaesthesia and perioperative care, emergency care, critical care, and treatment of acute and chronic pain. The specialty is also recognized for advancing safety measures and patient safety initiatives.
The CMPA reviewed 203 medico-legal cases involving anesthesiologists that closed between 2009 and 2013. In 65% of the cases there was good expert support for the anesthesiologists' care. In the cases with identified issues, 38% of patients had major and catastrophic outcomes including death.
The main risk areas for anesthesiologists include:
- airway management
- injuries associated with regional anaesthesia or analgesia
- injuries associated with intubation
- anaesthesia-related medication errors
- lack of informed consent
Issues in the intra-operative period and during labour
Monitoring and management problems during a procedure were generally associated with a delay in recognizing or managing a complication. This was seen in cases involving both general and regional anaesthesia. Various factors contributed to these issues including clinical judgment, technical skill, and equipment problems.
Case example: Delay to recognize and respond to signs of airway obstruction
Following a pre-operative assessment, an anesthesiologist performs spinal anaesthesia on a 45-year-old woman who will be undergoing a urologic intervention. Co-morbidities include morbid obesity, tobacco use, and obstructive sleep apnea. The anesthesiologist administers oxygen by facemask, monitors end-tidal CO2 by nasal catheter, and initiates IV propofol infusion at 70µg/kg/min. When the patient remains responsive to verbal stimuli and dislodges the nasal catheter, the anesthesiologist increases the infusion to 100µg/kg/min. Shortly after, the patient becomes hypotensive and hypoxic and goes into cardiac arrest. Aggressive resuscitation is successful and the patient is transferred to the ICU. The anesthesiologist discloses the event to the family. The patient is left with an anoxic brain injury affecting memory and cognition.
The family initiates a legal action alleging lack of informed consent, failure to properly assess the patient pre-operatively, and inadequate anaesthetic management. Experts in this case are all critical of the anesthesiologist for failing to monitor O2 saturation and administering higher than appropriate doses of propofol, and failing to recognize and react to signs of airway obstruction. There are additional concerns regarding an inadequate pre-operative assessment of the patient's sleep apnea. Without expert support, the CMPA pays a settlement to the patient on behalf of the member anesthesiologist.
Problems with regional anaesthesia or analgesia were often associated with labour and delivery, and orthopaedic surgeries. A common issue in the cases was catheter insertion (epidural and spinal) at the wrong level that was usually too high and that often lead to spinal cord injury. In one case, the expert was critical of the anesthesiologist's poor charting of the epidural technique.
In a small number of cases, complications resulted from vascular injuries during central line insertion or equipment malfunction.
Post-procedure problems often related to lack of monitoring of patients who experienced perioperative problems such as difficult intubation. Other problems involved inadequate directions to the healthcare team regarding monitoring parameters, or insufficient supervision of a resident. Some post-operative issues were attributed to other members of the team, such as a resident or nurse failing to contact the anesthesiologist when the patient's clinical condition was deteriorating. Cases involving a member and non-physician healthcare professionals often resulted in the CMPA and the hospital jointly paying a settlement.
A serious problem in the post-operative period was premature extubation, usually following difficult intubation or massive blood loss during surgery. In some cases, when the extubated patient developed respiratory difficulties, the anesthesiologist failed to recognize the need to re-intubate in a timely manner, or encountered difficulties re-intubating the patient. The patients in these cases were usually left with catastrophic outcomes including death.
The impact of consent and documentation
Inadequate or lack of consent is an allegation in many cases reviewed, including when the patient experienced an anaesthetic-related complication. In several cases, experts felt that the anesthesiologist should have obtained informed consent from the patient before administering any type of anaesthesia or analgesia, which includes a discussion about the associated risks and alternative forms of anaesthesia.
In some cases, while the physician stated there had been a full consent discussion with the patient, there was no documentation to support this statement.
The problems associated with documentation involved a lack of specific directions in the medical record advising staff about monitoring parameters, as well as failing to document discussions with the patient or family about the difficulties encountered and follow-up instructions.
Case example: Inadequate documentation calls into question post-operative patient monitoring
While administering IV anaesthesia to a 32-year-old woman undergoing diagnostic laparoscopy, an anesthesiologist has difficulty intubating. He seeks assistance from a colleague. After numerous attempts with various methods, the anesthesiologist decides to use a laryngeal mask airway (LMA), which is inserted without difficulty. The remainder of the surgery is uneventful. The anesthesiologist discloses the difficult intubation to the patient's husband and the potential complications such as edema and infection, and advises him on when to seek medical attention. The patient has no respiratory difficulties in the post-anaesthetic care unit and is discharged the same day.
Three days later, the patient presents to an emergency department with bruising and swelling of the neck. She is diagnosed with a deep soft neck tissue infection likely from a pharyngeal injury during intubation and is treated with IV antibiotics.
The patient initiates a complaint with the medical regulatory authority (College), alleging inappropriate intubation technique. The College is of the opinion that the anesthesiologist's approach and the decision to continue with the surgery were reasonable. However, the College finds the medical record documentation to be inadequate. The anesthesiologist's notes do not support that he observed or assessed the patient post-operatively, and there are discrepancies with his notes and those of the nurses. The College counsels the anesthesiologist to provide a reasonable period of observation and frequent re-assessments for a patient with a difficult intubation. He is also counselled to thoroughly document any discussions with the patient about airway risks, difficulties encountered during a procedure, and when to seek medical attention.
The following risk management strategies are based on expert opinions in the cases analyzed:
- Discuss the risks and benefits of the proposed anaesthetic approach, alternative options, and possible complications. Allow the patient the opportunity to ask questions. Verify that the patient appears to understand the information. Document this consent discussion in the medical record.
- Be aware of relevant current clinical practice guidelines for the practice of anaesthesia.
- Before commencing anaesthesia, verify that the equipment and monitors are in good working order.
- Confirm that alarms are functioning and audible.
- Consider altering your technique or promptly consulting a colleague when intubation is difficult or when repeated attempts at intubation have been unsuccessful.
- Ensure appropriate patient monitoring during and after anaesthesia, including vital signs, respiratory status, and pulse oximetry. Tell the team what issues require their attention. Recognize and react to any signs of potential problems in a timely manner.
- Confirm that the patient meets the criteria for extubation.
- Report problems with a monitor or equipment. If equipment malfunctions or fails during a procedure, take action and document the steps to address the problem (i.e. notifying the appropriate maintenance personnel and administration).
- Document the care provided thoroughly in the medical record.