IARS 2017 Annual Meeting and International Science Symposium
Improving Health Through Discovery and Education
May 6-9, 2017 • Washington, DC
Obesity in the Closed Claims Database
Karen B. Domino, MD, MPH
Professor and Vice Chair
Anesthesiology and Pain Medicine
University of Washington, Seattle, WA
Director, Anesthesia Closed Claims Project
IARS 2017 Annual Meeting and International Science Symposium
Improving Health Through Discovery and Education
May 6-9, 2017 • Washington, DC
DISCLOSURES
No commercial financial disclosures
The Anesthesia Closed Claims Project is
funded by the Anesthesia Quality Institute.
Learning Objectives
• Describe perioperative complications
associated with morbid obesity in the
Anesthesia Closed Claims database
• Assess most frequent causes of adverse
outcomes associated with morbid obesity
Closed Claims
• Apply these findings to improving safety in
the perioperative care of morbidly obese
patients
Overview
• Project
methodology
• Morbidly obese vs.
non-obese
• Case examples
Anesthesia Closed Claims Project
• 16 insurance organizations
• 13,000+ anesthesiologists
insured by current panel of
companies
• Organizations cover ~36%
of practicing
anesthesiologists in U.S.
Study Methodology
•
•
•
•
On-site review by MDs
Standardized data collection instrument
Review by committee
Damaging events: incident or mechanism
leading to adverse outcome
• Adverse outcome: injury sustained by
patient
Utility of Closed Claims Data
• Study of infrequent events
• Collection of “Sentinel Events”
• Identify areas of recurrent risk
• Provide direction for in-depth analysis
• Snapshot of anesthesia liability
Bias with Malpractice Claims
• No denominator for
calculating risk
• Small subset of injuries
• More severe, permanent
injuries
• More substandard
anesthesia care
Inclusion Criteria
Anesthesia Closed Claims Project Database
N = 10,811
Perioperative - Yr 2000 +
(exclude chronic pain)
n = 2,612
Adults
(Age 18 +)
n = 2,444
Morbidly Obese
BMI > 40
n = 263
Not Obese or
BMI <30
n = 915
BMI 30-39
n = 483
Missing BMI
n = 783
Demographics: Morbidly Obese
vs. Non-obese
Female (%)
ASA 1-2 (%)
Elective case
Age (yrs) (SD)
Inpatients
OB
GA
*p<0.001
Morbidly Obese
Non-obese
(n=263)
(n=915)
60%
21%*
82%
46 (13)
59%
59%*
86%
51 (17)
84%*
14%
72%
67%*
8%
72%
N=10,811
Severity of Injury:
Morbidly Obese vs. Non-obese
Percent in each group
50%
Morbidly obese (n=263)
Non-obese (n=915)
40%
*p=<0.001
30%
20%
10%
0%
Death
Permanent,
Significant
Temporary, Minor
N=10,811
Specific Injuries in Morbidly Obese
(n=263)
Eye
MI
Burn
CVA
Awareness
Back pain
3%
3%
2%
2%
2%
2%
Other
16%
Death
46%
Aspiration
Pneumonitis
6%
Airway
Trauma
8%
Brain
Damage
10%
Nerve
Damage
14%
N=10,811
Damaging Events:
Morbidly Obese vs. Non-obese
Percent in each group
40%
*
*p<0.001
Morbidly obese (n=263)
Non-obese (n=915)
30%
20%
10%
0%
Respiratory
Cardiovascular
Equipment
Regional
N=10,811
Specific Damaging Events:
Morbidly Obese vs. Non-obese
Morbidly Obese
(n=263)
Non-obese
(n=915)
Difficult intubation
17 (6%)*
25 (3%)*
Inadequate ventilation
33 (12%)*
50 (6%)*
Premature extubation
21 (8%)*
18 (2%)*
Pulmonary embolus
9 (3%)*
6 (1%)*
High block
8 (3%)*
8 (1%)*
*p<0.01
N=10,811
Liability:
Morbidly Obese vs. Non-obese
Percent in each group
70%
*p<0.01
Morbidly obese (n=263)
Non-obese (n=915)
60%
50%
$435,200*
40%
$244,650*
30%
20%
10%
0%
Appropriate Care
Payment Made
N=10,811
Difficult Intubation
• 50 y.o. ASA 3 woman (BMI 49)
• Laparoscopic gastric bypass
• GA-ET (propofol /rocuronium)
• 3 attempts to intubate
• Bag-mask ventilation difficult
• LMA-poor ventilation,
SpO2
• Code 15 min after induction
• Tracheostomy 20 min after induction
• Brain damage
• $600,000 settlement
Inadequate Ventilation
and Oxygenation
• 65 y.o ASA 3 man - DM, HTN, OSA
• Colonoscopy with propofol
(400mg)
• SpO2 97%, HR 70 initially
• Multiple PVCs then HR 40
• Procedure end: pt. blue, SpO2 75%,
HR 49
• Bag-mask ventilation, CPR
• Anoxic brain damage – died
• $1,000,000 settlement
Post-Op Respiratory
Depression
• 27 y.o. ASA 2E woman
• BMI 52, probable OSA
• Laparoscopic
salpingectomy
• Uncomplicated GA
• D/C home (2 hours
PACU)
• Husband woke pt. for
hydrocodone
• 6 hrs. later dead in bed
Premature Extubation
• 60 y.o. female (BMI 45) with
OSA/HTN
• Elective eye surgery
• Awake fiberoptic intubation (3
attempts)
• Extubated when opening eyes
• Airway obstruction with
SpO2
• Unable to ventilate/intubate
• Emergency tracheostomy
• Patient died
• $850,000 settlement
High Block after Accidental
Intrathecal Injection
• 35 y.o. ASA female (BMI 74)
• Labor at 41 weeks
• Epidural L4-5 using LOR
• Difficult to thread catheter
• O.2% ropivacaine with fentanyl 100mcg
• Catheter threaded – No CSF
• Anesthesiologist left
• Pt. apneic, unconscious, HR 80 within
10 minutes
• C-section
• Baby died/mother brain damage
• $1,500,000 settlement
Safety Issues Identified by
Closed Claims Review
•
•
Proportion of deaths
Respiratory events
• Difficult intubation
• Inadequate
ventilation/oxygenation
• Premature extubation
• Pulmonary embolus
• High block/total spinal
Welcome to the Closed Claims Project and its Registries
 Closed Claims Project
 OSA
 Anesthesia Awareness Registry
 NINS
www.asaclosedclaims.org
[email protected]