July 16, 2009
Editor’s Note: Dr. Zeltzman scored a coup in getting the trust representatives of the AVMA PLIT to participate in a conference call for publication.
|This 6-month-old cat suffered a tracheal tear during a spay. The radiograph shows subcutaneous emphysema and pneumomediastinum.|
Every day, the trust representatives of the AVMA Professional Liability Insurance Trust receive liability insurance claims related to anesthesia.
The representatives agreed to speak candidly with me to help Veterinary Practice News readers avoid 10 common anesthetic complications. For this purpose, we imagined 10 scenarios.
Kiki the Yorkie is dropped off for a lameness exam. She is so excitable that sedation is required to examine her knees and hips. Kiki dies. Necropsy reveals grossly abnormal heart valves. Your last physical exam was performed nine months earlier during a vaccination consultation and was normal. No physical exam was performed today.
Take-home message: Every patient who undergoes sedation or anesthesia should have a thorough physical exam, which should be documented in the medical record. Normal and abnormal findings should be recorded. As lawyers say, “If it’s not written, it didn’t happen.”
Ms. Murphy is a good friend of the practice. She drops off Lovey the Pomeranian for her yearly dental. During the warm and fuzzy conversation that invariably occurs, no paperwork is signed. Lovey dies. Ms. Murphy decides she’s not a friend after all.
Message: All pet owners should sign a detailed consent form summarizing the medical, legal and financial aspects of what was discussed during the consultation.
Max would be a fairly nice cat if he didn’t have all his teeth and nails. A quick punch biopsy is performed under anesthesia. Max dies. After watching a TV show, Max’s owner accuses you of using mask anesthesia. You assure your lawyer that Max was intubated. But this doesn’t appear anywhere in your medical record.
Message: Placing an endotracheal tube in all anesthetized pets is a simple safety measure that should be encouraged, except maybe for the quickest procedures. Again, if an endotracheal tube was used, it should be documented, including its size.
Fluffy the poodle needs a tooth extraction today. Her owner has been hit hard by the lousy economy and to “help her out” you don’t offer blood work. Fluffy dies. Necropsy reveals shriveled kidneys.
Message: Preanesthetic blood work should be recommended. If the owner declines—if that is even an option at your practice—a note should be made in the chart. Even better, the owner should sign it off.
Molly the kitty needs a dental today. Your technician intubates her and anesthesia is uneventful. A few hours after extubation, Molly looks like a blimp because of subcutaneous emphysema. A tracheal tear is suspected. Click here for tips on how to avoid tracheal tears.
Message: Feline tracheal tears (photo above) can lead to malpractice claims. It’s important to know standard safety measures for avoiding such complications.
|A pulse oximeter is used on an anesthesized Dalmatian.|
Buddy the Labrador needs radiographs under anesthesia to rule out hip dysplasia. While your technician processes the films, Buddy dies. A lawyer’s review of your medical record indicates that no monitoring equipment was used during the seemingly quick procedure.
Message: Pulse oximeters are becoming more widespread and using one on anesthetized patients may be considered standard of care (photo at right). At the least, an anesthetized patient’s vital signs should be monitored with appropriate equipment handled by a trained technician.
Lucy the German shepherd dies as you close her abdomen. Her enterotomy was straightforward, and you successfully retrieved the rock she swallowed. Analysis of her anesthetic log reveals that she was kept on 5 percent isoflurane throughout surgery. Six months later, your technician vaguely recalls that Lucy “kept waking up” and needed to be on 5 percent gas. There is no trace of heart rate or blood pressure monitoring in the chart.
Message: Vital signs (TPR, capillary refill time, blood pressure, oxygen level, etc.) should be tracked periodically on a dedicated anesthesia form, which should be kept in the medical record. How often these numbers are recorded is an important decision. Checking them every five minutes is probably not extravagant.
Rocky’s lipoma removal was uneventful, though he needed to be “bagged” constantly. Technician B kindly relieves Technician A so she can have lunch. They discuss a few points as you concentrate on the surgery. Suddenly, the obese Golden stops breathing. There is no obvious explanation until the bag falls on the floor with a loud “pop.” Rocky died of a pneumothorax.
Message: Complications still occur because the pop-off valve was forgotten in the closed position, so it is important to keep it open. Commercial devices can prevent this risk. Called pop-off occlusion valves (photo at right) or pop-off valve restrictors, they allow the technician to push a button to give a breath to the patient without closing the pop-off valve. Call this an insurance policy for less than $60.
Maggie’s spay went very well. Anesthesia was smooth. After the Maltese is placed in her cage, still intubated, your technician picks up the phone to reassure the owner, who happens to call right at that time: “Everything went great and Maggie is resting comfortably.” When the technician comes back to extubate Maggie, she is found dead.
Message: A large percentage of anesthetic deaths seem to occur in the immediate postoperative period, whether the patient is still intubated or shortly after being extubated. It is important not to become complacent during that time and to continue very careful monitoring.
Close monitoring is especially important in brachycephalic patients. As the saying goes, they should not be extubated “until they walk.” Even after that, they should be closely monitored.
Remarkably, many owners of brachycephalic patients are unaware that their dog has a higher anesthetic risk. Discussing this risk should be part of the surgical consultation and it should be documented.
Blondie the cocker is closely monitored during her knee surgery. Your new technician records every conceivable vital sign: TPR, capillary refill time, blood pressure, oxygen and carbon dioxide levels, just as she has been instructed. She is very diligent about recording these numbers every five minutes. Still, Blondie dies.
Message: Careful review of the anesthetic log shows that the blood pressure had been steadily dropping for the past half hour. This suggests a key point: The best monitoring equipment can still get you in trouble without excellent communication. Your staff should be able to analyze the data, feel free to tell you about a problem and know what to do when hypotension occurs.
These suggestions by our liability musketeers are based on some of the most common claims the trust representatives deal with.
The bad news is that all these patients died, but luckily not at your clinic. The good news is that these anesthetic complications are avoidable by following the logical and reasonable suggestions.
These simple tips are especially important because claims have a sneaky tendency to occur several months after an incident. By then, assuming you even remember the patient, you won’t recall the minute details required by your state board, insurer and lawyer: what you told the client during the consultation, the size of an endotracheal tube you didn’t even place yourself, etc.
This is why documenting everything that happens is so critical. This applies to every member of the veterinary team: receptionists, kennel helpers, technicians and doctors. You might want to consider discussing these crucial points during a staff meeting.
Phil Zeltzman, DVM, Dipl. ACVS, is a small-animal board-certified surgeon at Valley Central Veterinary Referral Center in Whitehall, Pa.
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