◊ BACKGROUND AND OBJECTIVES:
Concern for block-related injury and liability has dissuaded many anesthesiologists from using regional anesthesia for eye and extremity surgery, despite many studies demonstrating the benefits of regional over general anesthesia. To determine injury patterns and liability associated with eye and peripheral nerve blocks, we re-examined the American Society of Anesthesiologists Closed Claims Database as part of the American Society of Regional Anesthesia and Pain Medicine's Practice Advisory on Neurologic Complications of Regional Anesthesia and Pain Medicine.
◊ METHODS:
Claims with eye or peripheral nerve blocks performed perioperatively from 1980 through 2000 were analyzed. The liability profile of anesthesiologists who provided both the eye block and sedation for eye surgery was compared with the profile of anesthesiologists who provided sedation only. The injury patterns associated with peripheral nerve blocks and payment factors were analyzed.
◊ RESULTS:
Anesthesiologists who provided both the eye block and sedation for eye surgery (n = 59) had more injuries associated with block placement (P < .001), a higher proportion of claims with permanent injury (P < .05), and a higher proportion of claims with plaintiff payment (P < .05), compared with anesthesiologists who provided sedation only (n = 38). Peripheral nerve blocks (n = 159) were primarily associated with temporary injuries (56%). Local anesthetic toxicity was associated with 7 of 19 claims with death or brain damage.
◊ CONCLUSIONS:
Performance of eye blocks by anesthesiologists significantly alters their liability profile, primarily related to permanent eye damage from block needle trauma. Though most peripheral nerve block claims are associated with temporary injuries, local anesthetic toxicity is a major cause of death or brain damage in these claims.
◊ Reviewed by A. Van Zundert, MD
Catharina Hospital-Brabant Medical School Eindhoven, Netherlands
Anesthesiologists may be liable if they choose to perform eye blocks themselves. Despite the vast amount of evidence of low incidence of block-related injuries, needle trauma with eye blocks does occur. Training for ophthalmic blocks is not a requirement of anesthesia training in the USA, and therefore some anesthesiologists may have inadequate experience. It is true that eye surgery is most often performed in older, sicker patients, where adverse effects such as cardiac events, oversedation, inadequate oxygenation/ventilation can complicate eye surgery. These patients can be more sensitive to opioids, benzodiazepines and induction agents. However, catastrophes can usually be attributed to the spread of local anesthetics into the optic nerve sheath, entering the subarachnoid space and central nervous system. Again, wrongly placed injections of local anesthetics are often the cause. Peripheral nerve blocks can also result in disasters for the patient such as death and permanent nerve injuries. Even pneumothorax was associated with 10% of brachial plexus blocks. The application of ultrasound to identify nerves and surrounding structures (e.g. blood vessels, bone, lung) should make blocks more reliable and safer, although evidence reports are awaited. Test doses with epinephrine and incremental injections of local anesthetics have been advocated as well to reduce risks of intravascular injections of local anesthetics.
Complications due to regional anesthesia techniques will never be eliminated completely. However, a well-trained, vigilant and skilled anesthesiologist, is the minimum requirement a patient can expect when he has to undergo surgery under monitored regional anesthesia. A good knowledge of anatomy is thereby essential. Skills trained on a regular basis and updated according to our modern practice should eventually lead to fewer complications. We should try to visualize as much as possible our peripheral nerve blocks, using ultrasound. Imaging the needle and the local anesthetic spreading around the nerves during injection, certainly will contribute to avoid inadvertent placement of local anesthetics. Nevertheless complications will occur. The recent successful introduction of 20% intralipid during cardiovascular resuscitation may thereby improve outcome.
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