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Biomedical subjects

Karen B Domino

Publications and source records attributed to Karen B Domino.

At least 19 recordsLinked to original sources
PubMed2007

An update on pediatric anesthesia liability: a closed claims analysis.

BACKGROUND: Respiratory complications were associated with half of pediatric malpractice claims from the 1970s to 1980s in the ASA Closed Claims Database. Advances in pediatric anesthesia practice have occurred in the 1980s and 1990s and may be reflected in liability trends. METHODS: We reviewed 532 pediatric (age < or =16 yr) malpractice claims from our database over three decades (1973-2000), using logistic regression analysis to evaluate trends over time. Claims from 1990 to 2000 (1990s) were reviewed in detail to determine damaging events and injuries. Multiple logistic regression analysis evaluated factors associated with claims for death/brain damage (BD) compared with claims for less severe injuries. RESULTS: From 1973 to 2000, there was a decrease in the proportion of claims for death/BD (P = 0.002) and respiratory events (P < 0.001), particularly for inadequate ventilation/oxygenation (P < 0.001). However, claims for death (41%) and BD (21%) remained the dominant injuries in pediatric anesthesia claims in the 1990s. Half of the claims in 1990-2000 involved patients 3 yr or younger and one-fifth were ASA 3-5. Cardiovascular (26%) and respiratory (23%) events were the most common damaging events. Factors associated with claims for death/BD in the 1990s when compared with claims for less severe injuries were cardiovascular events (odds ratio [OR] = 6.6, 95% confidence interval [CI] = 2.5-17.8), respiratory events (OR = 3.7, 95% CI = 1.5-9.4), and ASA status 3-5 (OR = 3.1, 95% CI = 1.3-7.8). CONCLUSIONS: Death/BD remained the dominant injuries in pediatric anesthesia malpractice claims in the 1990s. Cardiovascular events joined respiratory events as the major sources of liability.

Anesthesia↗
PubMed2006

Ventilation and perfusion distribution during altered PEEP in the left lung in the left lateral decubitus posture with unchanged tidal volume in dogs.

Previous studies in anesthetized humans positioned in the left lateral decubitus (LLD) posture have shown that unilateral positive end-expiratory pressure (PEEP) to the dependent lung produce a more even ventilation distribution and improves gas exchange. Unilateral PEEP to the dependent lung may offer special advantages during LLD surgery by reducing the alveolar-to-arterial oxygen pressure difference {(A-a)PO2 or venous admixture} in patients with thoracic trauma or unilateral lung injury. We measured the effects of unilateral PEEP on regional distribution of blood flow (Q) and ventilation (V(A)) using fluorescent microspheres in pentobarbital anesthetized and air ventilation dogs in left lateral decubitus posture with synchronous lung inflation. Tidal volume to left and right lung is maintained constant to permit the effect on gas exchange to be examined. The addition of unilateral PEEP to the left lung increased its FRC with no change in left-right blood flow distribution or venous admixture. The overall lung V(A)/Q distribution remained relatively constant with increasing unilateral PEEP. Bilateral PEEP disproportionately increased FRC in the right lung but again produced no significant changes in venous admixture or V(A)/Q distribution. We conclude that the reduced dependent lung blood flow observed without PEEP occurs secondary to a reduction in lung volume. When tidal volume is maintained, unilateral PEEP increases dependent lung volume with little effect of perfusion distribution maintaining gas exchange.

Adaptation, Physiological↗
PubMed2006

Redistribution of blood flow and lung volume between lungs in lateral decubitus postures during unilateral atelectasis and PEEP.

The effect of left lung atelectasis on the regional distribution of blood flow (Q), ventilation (V(A)) and gas exchange on the right lung ventilated with 100% O2 was studied in anesthetized dogs in the lateral decubitus posture. Q and V(A) were measured in 1.7 ml lung volume pieces using injected and aerosolized fluorescent microspheres, respectively. Hypoxic pulmonary vasoconstriction (HPV) in the atelectatic lung shifted flow to the ventilated lung. The increased flow in the ventilated lung ensured adequate gas exchange, compensating for the hypoxemia due to shunt contributed by the atelectatic lung. Left lung atelectasis caused a compensatory increase in the ventilated lung FRC that was smaller in the right (RLD) than left (LLD) lateral posture, the effect of lung compression by the atelectatic lung and mediastinal contents in the RLD posture. The O2 deficit measured by (A-a)DO2 increased with left lung atelectasis and was exacerbated in the LLD posture by 10 cm H2O PEEP, a result of increased shunt caused by a shift in Q from the ventilated to the atelectatic lung. The PEEP-induced O2 deficit was eliminated with inversion to the RLD posture.

Adaptation, Physiological↗
PubMed2006

Injury and liability associated with monitored anesthesia care: a closed claims analysis.

BACKGROUND: To assess the patterns of injury and liability associated with monitored anesthesia care (MAC) compared with general and regional anesthesia, the authors reviewed closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1990. METHODS: All surgical anesthesia claims associated with MAC (n = 121) were compared with those associated with general (n = 1,519) and regional (n = 312) anesthesia. A detailed analysis of MAC claims was performed to identify causative mechanisms and liability patterns. RESULTS: MAC claims involved older and sicker patients compared with general anesthesia claims (P < 0.025), often undergoing elective eye surgery (21%) or facial plastic surgery (26%). More than 40% of claims associated with MAC involved death or permanent brain damage, similar to general anesthesia claims. In contrast, the proportion of regional anesthesia claims with death or permanent brain damage was less (P < 0.01). Respiratory depression, after absolute or relative overdose of sedative or opioid drugs, was the most common (21%, n = 25) specific damaging mechanism in MAC claims. Nearly half of these claims were judged as preventable by better monitoring, including capnography, improved vigilance, or audible alarms. On-the-patient operating room fires, from the use of electrocautery, in the presence of supplemental oxygen during facial surgery, resulted in burn injuries in 20 MAC claims (17%). CONCLUSION: Oversedation leading to respiratory depression was an important mechanism of patient injuries during MAC. Appropriate use of monitoring, vigilance, and early resuscitation could have prevented many of these injuries. Awareness and avoidance of the fire triad (oxidizer, fuel, and ignition source) is essential to prevent on-the-patient fires.

Adolescent↗
PubMed2006

The American Society of Anesthesiologists Postoperative Visual Loss Registry: analysis of 93 spine surgery cases with postoperative visual loss.

BACKGROUND: Postoperative visual loss after prone spine surgery is increasingly reported in association with ischemic optic neuropathy, but its etiology is unknown. METHODS: To describe the clinical characteristics of these patients, the authors analyzed a retrospectively collected series of 93 spine surgery cases voluntarily submitted to the American Society of Anesthesiologists Postoperative Visual Loss Registry on standardized data forms. RESULTS: Ischemic optic neuropathy was associated with 83 of 93 spine surgery cases. The mean age of the patients was 50 +/- 14 yr, and most patients were relatively healthy. Mayfield pins supported the head in 16 of 83 cases. The mean anesthetic duration was 9.8 +/- 3.1 h, and the median estimated blood loss was 2.0 l (range, 0.1-25 l). Bilateral disease was present in 55 patients, with complete visual loss in the affected eye(s) in 47. Ischemic optic neuropathy cases had significantly higher anesthetic duration, blood loss, percentage of patients in Mayfield pins, and percentage of patients with bilateral disease compared with the remaining 10 cases of visual loss diagnosed with central retinal artery occlusion (P < 0.05), suggesting they are of different etiology. CONCLUSIONS: Ischemic optic neuropathy was the most common cause of visual loss after spine surgery in the Registry, and most patients were relatively healthy. Blood loss of 1,000 ml or greater or anesthetic duration of 6 h or longer was present in 96% of these cases. For patients undergoing lengthy spine surgery in the prone position, the risk of visual loss should be considered in the preoperative discussion with patients.

Anesthesia↗
PubMed2006

Trends in anesthesia-related death and brain damage: A closed claims analysis.

BACKGROUND: The authors used the American Society of Anesthesiologists Closed Claims Project database to determine changes in the proportion of claims for death or permanent brain damage over a 26-yr period and to identify factors associated with the observed changes. METHODS: The Closed Claims Project is a structured evaluation of adverse outcomes from 6,894 closed anesthesia malpractice claims. Trends in the proportion of claims for death or permanent brain damage between 1975 and 2000 were analyzed. RESULTS: Claims for death or brain damage decreased between 1975 and 2000 (odds ratio, 0.95 per year; 95% confidence interval, 0.94-0.96; P < 0.01). The overall downward trend did not seem to be affected by the use of pulse oximetry and end-tidal carbon dioxide monitoring, which began in 1986. The use of these monitors increased from 6% in 1985 to 70% in 1989, and thereafter varied from 63% to 83% through the year 2000. During 1986-2000, respiratory damaging events decreased while cardiovascular damaging events increased, so that by 1992, respiratory and cardiovascular damaging events occurred in approximately the same proportion (28%), a trend that continued through 2000. CONCLUSION: 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.

Anesthesia↗
PubMed2006

Closed claims review of anesthesia for procedures outside the operating room.

PURPOSE OF REVIEW: The demand for anesthesia services is increasing due to more complex procedures being performed outside the operating room. We reviewed the literature and closed malpractice claims in the American Society of Anesthesiologists' Closed Claims database to assess liability and injury associated with anesthesia for procedures outside the operating room (nonoperating-room anesthesia, n = 24) compared with intra-operative surgical anesthesia (operating room, n = 1927) claims. RECENT FINDINGS: A higher proportion of patients in nonoperating-room anesthesia claims underwent monitored anesthesia care (58 vs. 6%, P < 0.001) and were at the extremes of age (50 vs. 19%, P = 0.003) than in operating room claims. Half of the nonoperating-room anesthesia claims occurred in the gastrointestinal suite. Inadequate oxygenation/ventilation was the most common specific damaging event in nonoperating-room anesthesia claims (33 vs. 2% in operating room claims, P < 0.001). The proportion of death was increased in nonoperating-room anesthesia claims (54 vs. 24%, P = 0.003). Nonoperating-room anesthesia claims were more often judged as having substandard care (P = 0.003) and being preventable by better monitoring (P = 0.007). SUMMARY: Nonoperating-room anesthesia claims had a higher severity of injury and more substandard care than operating room claims. Inadequate oxygenation/ventilation was the most common mechanism of injury. Maintenance of minimum monitoring standards and airway management training is required for staff involved in patient sedation.

Ambulatory Surgical Procedures↗
PubMed2005

Risk factors for relapse in health care professionals with substance use disorders.

CONTEXT: Substance use disorders among physicians are important and persistent problems. Considerable debate exists over whether use of major opioids, especially among anesthesiologists, is associated with a higher relapse rate compared with alcohol and nonopioids. Moreover, the risk factors for relapse with current treatment and monitoring strategies are unknown. OBJECTIVE: To test the hypothesis that chemically dependent health care professionals using a major opioid (eg, fentanyl, sufentanil, morphine, meperidine) as drug of choice are at higher risk of relapse. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 292 health care professionals enrolled in the Washington Physicians Health Program, an independent posttreatment monitoring program, followed up between January 1, 1991, and December 31, 2001. MAIN OUTCOME MEASURE: Factors associated with relapse, defined as the resumption of substance use after initial diagnosis and completion of primary treatment for chemical dependency. RESULTS: Twenty-five percent (74 of 292 individuals) had at least 1 relapse. A family history of a substance use disorder increased the risk of relapse (hazard ratio [HR], 2.29; 95% confidence interval [CI], 1.44-3.64). The use of a major opioid increased the risk of relapse significantly in the presence of a coexisting psychiatric disorder (HR, 5.79; 95% CI, 2.89-11.42) but not in the absence of a coexisting psychiatric disorder (HR, 0.85; 95% CI, 0.33-2.17). The presence of all 3 factors--major opioid use, dual diagnosis, and family history--markedly increased the risk of relapse (HR, 13.25; 95% CI, 5.22-33.59). The risk of subsequent relapses increased after the first relapse (HR, 1.69; 95% CI, 1.13-2.53). CONCLUSIONS: The risk of relapse with substance use was increased in health care professionals who used a major opioid or had a coexisting psychiatric illness or a family history of a substance use disorder. The presence of more than 1 of these risk factors and previous relapse further increased the likelihood of relapse. These observations should be considered in monitoring the recovery of health care professionals.

Adult↗
PubMed2005

Parkinson's disease mortality among male anesthesiologists and internists.

Clusters of Parkinson's disease (PD) among healthcare professionals have been interpreted as evidence of an infectious etiology. Anesthetic gases have also been associated with parkinsonism symptoms and PD among patients undergoing general anesthesia. We investigated PD mortality among large cohorts of male U.S. anesthesiologists (n = 33,040) and internal medicine physicians (n = 33,044). PD mortality for any mention on a death certificate was lower than rates in U.S. men during 1979-1995 for both groups, although anesthesiologists had a significantly elevated risk for PD as underlying cause of death for 10-year follow-up. Direct comparisons of mortality between the two cohorts indicated excess PD mortality in anesthesiologists for >10-year follow-up for any mention and for underlying cause of death. These findings lend some support to the hypothesis that infectious agents or anesthetic gases may be associated etiologically with PD.

Anesthesiology↗
PubMed2005

Management of the difficult airway: a closed claims analysis.

BACKGROUND: The purpose of this study was to identify the patterns of liability associated with malpractice claims arising from management of the difficult airway. METHODS: Using the American Society of Anesthesiologists Closed Claims database, the authors examined 179 claims for difficult airway management between 1985 and 1999 where a supplemental data collection tool was used and focused on airway management, outcomes, and the role of the 1993 Difficult Airway Guidelines in litigation. Chi-square tests and multiple logistic regression analysis compared risk factors for death or brain damage (death/BD) from two time periods: 1985-1992 and 1993-1999. RESULTS: Difficult airway claims arose throughout the perioperative period: 67% upon induction, 15% during surgery, 12% at extubation, and 5% during recovery. Death/BD with induction of anesthesia decreased in 1993-1999 (35%) compared with 1985-1992 (62%; P < 0.05; odds ratio, 0.26; 95% confidence interval, 0.11-0.63; P = 0.003). In contrast, death/BD associated with other phases of anesthesia did not significantly change over the time periods. The odds of death/BD were increased by the development of an airway emergency (odds ratio, 14.98; 95% confidence interval, 6.37-35.27; P < 0.001). During airway emergencies, persistent intubation attempts were associated with death/BD (P < 0.05). Since 1993, the Airway Guidelines were used to defend care (8%) and criticize care (3%). CONCLUSIONS: Death/BD in claims from difficult airway management associated with induction of anesthesia but not other phases of anesthesia decreased in 1993-1999 compared with 1985-1992. Development of additional management strategies for difficult airways encountered during maintenance, emergence, or recovery from anesthesia may improve patient safety.

Adult↗
PubMed2004

Chronic pain management: American Society of Anesthesiologists Closed Claims Project.

BACKGROUND: The practice of chronic pain management has grown steadily in recent years. The purpose of this study was to identify and describe issues and trends in liability related to chronic pain management by anesthesiologists. METHODS: Data from 5,475 claims in the American Society of Anesthesiologists Closed Claims Project database between 1970 and 1999 were reviewed to compare liability related to chronic pain management with that related to surgical and obstetric (surgical/obstetric) anesthesia. Acute pain management claims were excluded from analysis. Outcomes and liability characteristics between 284 pain management claims and 5,125 surgical/obstetric claims were compared. RESULTS: Claims related to chronic pain management increased over time (P < 0.01) and accounted for 10% of all claims in the 1990s. Compensatory payment amounts were lower in chronic pain management claims than in surgical/obstetric anesthesia claims from 1970 to 1989 (P < 0.05), but during the 1990s, there was no difference in size of payments. Nerve injury and pneumothorax were the most common outcomes in invasive pain management claims. Epidural steroid injections accounted for 40% of all chronic pain management claims. Serious injuries, involving brain damage or death, occurred with epidural steroid injections with local anesthetics and/or opioids and with maintenance of implantable devices. CONCLUSIONS: Frequency and payments of claims associated with chronic pain management by anesthesiologists increased in the 1990s. Brain damage and death were associated with epidural steroid injection only when opioids or local anesthetics were included. Anesthesiologists involved in home care of patients with implanted devices such as morphine pumps and epidural injections or patient-controlled analgesia should be aware of potential complications that may have severe outcomes.

Adult↗
PubMed2004

Injuries and liability related to central vascular catheters: a closed claims analysis.

BACKGROUND: To assess changing patterns of injury and liability associated with central venous or pulmonary artery catheters, the authors analyzed closed malpractice claims for central catheter injuries in the American Society of Anesthesiologists Closed Claims database. METHODS: All claims for which a central catheter (i.e., central venous or pulmonary artery catheter) was the primary damaging event for the injury were compared with the rest of the claims in the database. Central catheter complications were defined as being related to vascular access or catheter use or maintenance. Statistical analysis was performed using the chi-square test, Fisher exact test, or Z test (proportions) and the Kolmogorov-Smirnov test (payments). RESULTS: The database included 110 claims for injuries related to central catheters (1.7% of 6,449 claims). Claims for central catheter injuries had a higher severity of injury, with an increased proportion of death (47%) compared with other claims in the database (29%, P < 0.01). The most common complications were wire/catheter embolus (n = 20), cardiac tamponade (n = 16), carotid artery puncture/cannulation (n =16), hemothorax (n =15), and pneumothorax (n =14). Cardiac tamponade, hemothorax, and pulmonary artery rupture had a higher proportion of death (P < 0.05) compared with the rest of the central catheter injures. The proportion of claims for vascular access injury increased (47% to 84%) and use/maintenance injury decreased (53% to 16%) in 1994-1999 compared with 1978-1983 (P < 0.05). CONCLUSIONS: Claims related to central catheters had a high severity of patient injury. The most common complications causing injury were wire/catheter embolus, cardiac tamponade, carotid artery puncture/cannulation, hemothorax, and pneumothorax.

Catheterization, Central Venous↗
PubMed2004

Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claims analysis.

BACKGROUND: The authors used the American Society of Anesthesiologists Closed Claims Project database to identify specific patterns of injury and legal liability associated with regional anesthesia. Because obstetrics represents a unique subset of patients, claims with neuraxial blockade were divided into obstetric and nonobstetric groups for comparison. METHODS: The American Society of Anesthesiologists Closed Claims Project is a structured evaluation of adverse anesthetic outcomes collected from closed anesthesia malpractice insurance claims of professional liability companies. An in-depth analysis of 1980-1999 regional anesthesia claims was performed with a subset comparison between obstetric and nonobstetric neuraxial anesthesia claims. RESULTS: Of the total 1,005 regional anesthesia claims, neuraxial blockade was used in 368 obstetric claims and 453 of 637 nonobstetric claims (71%). Damaging events in 51% of obstetric and 41% of nonobstetric neuraxial anesthesia claims were block related. Obstetrics had a higher proportion of neuraxial anesthesia claims with temporary and low-severity injuries (71%) compared with the nonobstetric group (38%; P <or=0.01) and a lower proportion of claims with death or brain damage and permanent nerve injury compared with the nonobstetric group (P <or= 0.01). Cardiac arrest associated with neuraxial block was the primary damaging event in 32% of obstetric and 38% of nonobstetric neuraxial anesthesia claims involving death or brain damage. Eye blocks accounted for 5% of regional anesthesia claims. CONCLUSION: Obstetric claims were predominately associated with minor injuries. Permanent injury from eye blocks increased in the 1990s. Neuraxial cardiac arrest and neuraxial hematomas associated with coagulopathy remain sources of high-severity injury.

Adult↗
PubMed2004

The incidence of awareness during anesthesia: a multicenter United States study.

Awareness with recall after general anesthesia is an infrequent, but well described, phenomenon that may result in posttraumatic stress disorder. There are no recent data on the incidence of this complication in the United States. We, therefore, undertook a prospective study to determine the incidence of awareness with recall during general anesthesia in the United States. This is a prospective, nonrandomized descriptive cohort study that was conducted at seven academic medical centers in the United States. Patients scheduled for surgery under general anesthesia were interviewed in the postoperative recovery room and at least a week after anesthesia and surgery by using a structured interview. Data from 19,575 patients are presented. A total of 25 awareness cases were identified (0.13% incidence). These occurred at a rate of 1-2 cases per 1000 patients at each site. Awareness was associated with increased ASA physical status (odds ratio, 2.41; 95% confidence interval, 1.04-5.60 for ASA status III-V compared with ASA status I-II). Age and sex did not influence the incidence of awareness. There were 46 additional cases (0.24%) of possible awareness and 1183 cases (6.04%) of possible intraoperative dreaming. The incidence of awareness during general anesthesia with recall in the United States is comparable to that described in other countries. Assuming that approximately 20 million anesthetics are administered in the United States annually, we can expect approximately 26,000 cases to occur each year.

Adult↗