• Anaesthesia · Apr 2020

    Review

    Learning from the law. A review of 21 years of litigation for nerve injury following central neuraxial blockade in obstetrics.

    Legal responses to obstetric neuraxial complications are best minimised by respecting patient autonomy, early provision of information, good communication and record-keeping.

    pearl
    • K McCombe and D G Bogod.
    • Department of Anaesthesia, Mediclinic City Hospital, Dubai Healthcare City, Dubai, UAE.
    • Anaesthesia. 2020 Apr 1; 75 (4): 541-548.

    AbstractMedicolegal claims for neurological injury following the use of central neuraxial blockade in childbirth represent the second most common claim against obstetric anaesthetists. We present an analysis of 55 cases from a database of 368 obstetric anaesthetic claims. Common themes that emerge from the analysis include: consent; nature of nerve injury (non-anaesthetic; direct; chemical; compressive); recognition; and management. Specific advice arising from these cases includes: the importance of informing patients of the risks of nerve damage; keeping below the conus of the cord for intrathecal procedures; responding appropriately if a patient complains of paraesthesia; and having a high index of suspicion if recovery of normal neurological function is delayed. As ever, principles of good practice, including respect for patient autonomy, early provision of information, good communication and a high standard of record-keeping, will minimise the frustration of patients that can then lead them to seek a legal route to redress if they suffer an injury following central neuraxial blockade.© 2019 Association of Anaesthetists.

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    pearl
    1

    Legal responses to obstetric neuraxial complications are best minimised by respecting patient autonomy, early provision of information, good communication and record-keeping.

    Daniel Jolley  Daniel Jolley
    summary
    1

    McCombe and Bogod report on their analysis of 55 medicolegal claims relating to obstetric neuraxial anaesthesia and analgesia.

    Why is this important?

    Not only is neurological injury the second most common reason for obstetric anaesthetic claims (behind inadequate regional anaesthesia resulting in pain during Caesarean section), the average claim cost is greater.

    McCombe and Bogod provide a factful exploration of many of the causes of neurological complications.

    Which themes emerged from their analysis?

    1. Consent, particularly around providing inadequate pre-procedure information of the risk of neurological injury1 and the challenges, medical and legal, to achieving informed consent.
    2. Nerve injury and it's mechanisms: non-anaesthetic causes2, direct trauma, chemical, and compression (abscess, haematoma).
    3. Complication recognition & management means timely follow-up and assessment, and maintaining a high index of suspicion for abnormalities. Remember the 4 hour rule: blocks should be regressing 4 hours after the last dose.

    Important reminders

    The level of spinal cord termination varies a lot among individuals, as does the level of Tuffier's line3. Considering the inaccuracy of spinal level identification by anaesthetists, there is a lot of potential to place a needle higher than expected.

    Bottom-line: the intrathecal space should be accessed at the lowest possible level, and "the L2/3 interspace should not be an option."

    And never allow chlorhexidine to contaminate gloves, the sterile workspace or neuraxial equipment.


    1. Noting from NAP3 the risk of nerve injury ranges from, temporary injury 1:1,000, prolonged (>6 months) 1:13,000, to severe (including paralysis) 1:250,000. 

    2. 'Obstetric palsy' (pelvic nerve compression) estimated by Bromage as occurring in 1:3000 deliveries; arterial obstruction & ischaemia 1:15,000; AV malformations 1:20,000. A prospective French study found postpartum neuropathy in 0.3%, 84% were femoral, and 69% resolved at 6 weeks. 

    3. Although generally accepted as being at the L4/5 interspace, in up to 50% of people the intercristal line might be at or above L2/3! 

    Daniel Jolley  Daniel Jolley
    comment
    0

    And surprising to no obstetric anaesthesiologists... 🤔🙄

    "...we have a case in our series in which a woman suffering from postpartum paraesthesia attempted a claim against the anaesthetist although she had received neither epidural nor spinal anaesthesia!

    It is often only when an anaesthetic medicolegal opinion is sought that the obstetric nature of the injury is appreciated."

    Daniel Jolley  Daniel Jolley

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