Respiratory System Damaging Events

This article reviews factors related to adverse events occurring during or after tonsillectomy with a focus on obstructive sleep apnea (OSA). Cases were submitted via a survey to members of the Society for Pediatric Anesthesia and review of the Anesthesia Closed Claims Program. Death or permanent neurological injury occurred in 77% of reported cases. Events occurred across the care spectrum from surgery to post-release at home. Fifty-seven percent of the children fulfilled the at risk criteria for OSA. At risk children were more likely to be obese and have co-morbidities. These are of particular concern in association with reported opioid sensitivity in children with OSA. Obesity, a history of OSA, and the use of postoperative opioids increase the risk of postoperative respiratory events. Better evaluation of these risk factors must occur, postoperative follow-up and monitoring with at risk children must be in place, and some children are not candidates for out-patient tonsillectomy.

This analysis of claims since 1990 compared 87 claims for anesthesia in remote locations to 3287 claims from OR procedures. Remote location claims involved older and sicker patients and utilized MAC in 50% of claims. Claims from remote locations had more severe injuries than OR claims, with a higher proportion of death and respiratory damaging events. Our data suggests that anesthesia at remote locations poses a significant risk for the patient, particularly related to oversedation and inadequate oxygenation/ventilation during monitored anesthesia care.

The significant decrease in the proportion of claims for death or permanent brain damage from 1975 through 2000 seems to be unrelated to a marked increase in the proportion of claims where pulse oximetry and end-tidal carbon dioxide monitoring were used. After the introduction and use of these monitors, there was a significant reduction in the proportion of respiratory and an increase in the proportion of cardiovascular damaging events responsible for death or permanent brain damage.

Claims for airway injury form a major subgroup of anesthesia malpractice claims. Perforation of the pharynx or esophagus associated with difficult intubation may result in the delayed presentation of retropharyngeal abscess or mediastinitis.