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

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

Anesthesia Closed Claims Project Database (exclude chronic pain) 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 (%) 60% 59% ASA 1-2 (%) 21%* 59%* Elective case 82% 86% Age (yrs) (SD) 46 (13) 51 (17) Inpatients 84%* 67%* OB 14% 8% GA 72% *p<0.001 N=10,811

Severity of Injury: Morbidly Obese vs. Non-obese Percent in each group *p=<0.001 N=10,811

Specific Injuries in Morbidly Obese (n=263) Eye 3% MI 3% Burn 2% CVA 2% Awareness 2% Back pain 2% Other 16% Death 46% Aspiration Pneumonitis 6% Airway Trauma 8% Nerve Damage 14% Brain Damage 10% N=10,811

Damaging Events: Morbidly Obese vs. Non-obese * *p<0.001 Percent in each group N=10,811

Specific Damaging Events: Morbidly Obese vs. Non-obese 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 *p<0.01 Percent in each group $435,200* $244,650* 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 OSA Anesthesia Awareness Registry NINS www.asaclosedclaims.org kdomino@uw.edu