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the incidence of postsurgical infection and its associated evidence from clinical trials indicates that homeopathic
complications. Vitamin A also helps regulate the immune arnica™s toxicity is negligible and that arnica is safe for use
system.23,24 Studies in animal models and cell lines show in the perioperative period.29 However, cosmetic surgeons
that vitamin A and related retinoids play a major role in should be cautious. In a small percentage of patients who
immunity, including lymphopoiesis, cytokine expression, take excessive doses of arnica before surgery, bleeding and
antibody production, and the function of nearly all white bruising during surgery may be increased. It is probably
blood cells. In particular, natural killer cells, macrophages, wise to advise patients to refrain from taking arnica dur-
and lymphocytes are activated by vitamin A. Vitamin ing the preoperative period. Until homeopathy is better
246 David Rahm


understood, it would be wise to keep an open mind with >100X the RDA), typically produce symptoms that are
reversible.32 The use of vitamin A does require some
regard to arnica and to maintain communication with
patients who use it. caution: It should not be used by pregnant women and
should be used only for short periods in women who may
become pregnant. The importance of perioperative nutri-
WOUND HEALING
tion is growing with the increased likelihood that surgical
patients will have age- and obesity-related problems. It is
Wound healing is an orderly progression including in¬‚am-
important for surgeons to make patients aware of supple-
mation, epithelialization, angiogenesis, and the accumu-
ments that are known to cause perioperative problems and
lation of cells necessary to heal the tissue. Like many other
to recommend supplements that boost patient nutrition
bodily functions, wound healing is often straightforward
in the critical period surrounding surgery.
and successful. However, a patient in poor health may not
heal so easily. From a nutritional standpoint, raw mate-
REFERENCES
rials are required for the formation of new tissues and
1. Eckel RH, Krauss RM: American Heart Association call to
blood vessels. This complex activity can be severely ham-
action: Obesity as a major risk factor for coronary heart
pered by a diet lacking in essential nutrients. Several of
disease. Circulation 97:2099,1998.
the nutrients listed in Table A-2 can affect wound heal- 2. Allison DB, Fontaine KR, Manson JE, et al.: Annual
deaths attributable to obesity in the United States. JAMA
ing. Vitamin C is a key requirement for proper wound
282:1530,1999.
healing. Adequate levels of vitamin C are necessary for
3. Calle EE, Thun MJ, Petrelli JM, et al.: Body mass index and
function of the enzyme protocollagen hydroxylase, which mortality in a prospective cohort of US adults. N Engl J Med
produces collagen, the primary constituent of granula- 341:1097,1999.
4. Block G: Dietary guidelines and the results of food consump-
tion tissue. The importance of vitamin C in the wound-
tion surveys. Am J Clin Nutr 53:356S,1999.
healing process has long been recognized. It is evident
5. Kant AK, Schatzkin A: Consumption of energy-dense,
from clinical experience and reported studies that wound nutrient-poor foods by the US population: Effect on nutrient
healing requires more vitamin C than diet alone can easily pro¬les. J Am Coll Nutr 13:285,1994.
6. Breslow RA, Subar AF, Patterson BH, et al.: Trends in food
provide.30 The need for daily replenishment through sup-
intake. The 1987 and 1992 National Health Interview Sur-
plements is increased because vitamin C is water-soluble veys. Nutr Cancer 28:86,1997.
” any excess is excreted rather than stored. Ophthalmol- 7. Kant AK, Schatzkin A, Block G, et al.: Food group intake pat-
terns and associated nutrient pro¬les of the US population.
ogists routinely administer vitamin C to patients under-
J Am Diet Assoc 91:1532,1991.
going corneal transplantation, in which optimal wound
8. van der Wielen RP, deWild GM, de Groot LC, et al.: Dietary
healing is critical. The relative safety and effectiveness intakes of energy and water-soluble vitamins in different cat-
of vitamin A in surgical patients is well documented.31 egories of aging. J Gerontol A Biol Sci Med Sci 51:B100,1996.
9. Fletcher RH, Fair¬eld KM: Vitamins for chronic dis-
Vitamin A™s signi¬cant wound-healing activity is related
ease prevention in adults: Clinical applications. JAMA
to the use of corticosteroids before surgery. Anti-
287:3127,2002.
in¬‚ammatory corticosteroids signi¬cantly impair wound 10. Fair¬eld KM, Fletcher RH: Vitamins for chronic disease pre-
healing by interfering with in¬‚ammation, ¬broblast pro- vention in adults: Scienti¬c review. JAMA 287:3116,2002.
11. O™Hara M, Kiefer D, Farrell K, et al.: A review of 12 com-
liferation, collagen metabolism, and reepithelialization.
monly used medicinal herbs. Arch Fam Med 7:523,1998.
These actions are mediated by the antagonism of var- 12. Miller LG: Herbal medicinals: Selected clinical considera-
ious growth factors and cytokines. Vitamin A restores tions focusing on known or potential drug-herb interactions.
Arch Intern Med 158:2200,1998.
the in¬‚ammatory response and promotes epithelialization
13. Larkin M: Surgery patients at risk for herb-anesthesia inter-
and the synthesis of collagen and ground substances.16
actions. Lancet 354:1362,1999.
As noted in Table A-2, a typical recommended daily dose 14. Cupp MJ: Herbal remedies: Adverse effects and drug inter-
is 25,000 IU for no longer than four weeks total periop- actions. Am Fam Physician 59:1239,1999.
15. Ernst E: The risk-bene¬t pro¬le of commonly used herbal
eratively. Reported incidences of vitamin A toxicity are
therapies: Ginko, St. John™s Wort, Gingseng, Echinacea, Saw
relatively rare, averaging fewer than ten cases per year
Palmetto, and Kava. Ann Intern Med 136:42,2002.
from 1976 to 1987. The overconsumption of vitamin A 16. Petry JJ: Surgically signi¬cant nutritional supplements. Plast
supplements, occurring after ingestion of 500,000 IU or Reconstr Surg 97:233,1996.
Appendix A 247


17. Ang-Lee MK, Moss J, Yuan CS: Herbal medicine and peri- 25. Blonstein JL: Control of swelling in boxing injuries. Practi-
operative care. JAMA 286:208,2001. tioner 203:206,1969.
18. White DA, Baxter M: Hormones and metabolic control, 2nd 26. Masson M: Bromelain in blunt injuries of the locomotor
ed. London, UK: Edward Arnold 1994. system. A study of observed applications in general practice.
19. Kelly FJ: Use of antioxidants in the prevention and treatment Fortschr Med 113:303,1995.
of disease. J Int Fed Clin Chem 10:21,1998. 27. Tassman GC, Zafram JN, Zayan GM: Evaluation of a plant
20. Irvin TT: Vitamin C requirements in postoperative patients. proteolytic enzyme for the control of in¬‚ammation and pain.
Int Vitamin Nutr Res Suppl 23:277,1982. J Dent Med 19:73,1964.
21. Beck FW, Prasad AS, Kaplan J, et al. Changes in cytokine 28. Tassman GC, Zafram JN, Zayan GM: A double-blind
production and T cell subpopulations in experimentally crossover study of a plant proteolytic enzyme in oral surgery.
induced zinc-de¬cient humans. Am J Physiol 272:E1002, J Dent Med 20:51,1965.
1997. 29. Lawrence WT: Arnica, Safety and Ef¬cacy Report. Plast
22. Shankar AH, Prasad AS: Zinc and immune function: The Reconstr Surg 15:1164,2003.
biological basis of altered resistance to infection. Am J Clin 30. Bartlett MK, Jones FM, Ryan AE: Vitamin C and wound
Nutr 68:447S,1998. healing: Ascorbic acid content and tensile strength of healing
23. Ross AC: Vitamin A and retinoids, in Shils ME, Olson J, Shike wounds in human beings. N Engl J Med 226:474, 1942.
M, et al.(eds.), Modern nutrition in health and disease, 9th 31. Wicke C, Halliday B, Allen D, et al.: Effects of steroids and
ed. Baltimore, Williams & Wilkins, 1999. retinoids on wound healing. Arch Surg 135:1265,2000.
24. Gerster H: Vitamin A functions, dietary requirements and 32. Bendich A, Langseth L: Safety of vitamin A. Am J Clin Nutr
safety in humans. Int J Vitam Nutr Res 67:71,1997. 2:358,1989.
appendix B
Re¬‚ections on Thirty Years as an Expert Witness
Norig Ellison, M.D.



and reach a conclusion. Lawyers on both sides will bring
INTRODUCTION
in expert witnesses to educate the jurors on what con-
Threat of malpractice litigation is a fact of life in American
stitutes “Standard of Care” and if a particular treatment
Medicine and well recognized. That the threat and its costs
was appropriate. In fact, in a medical malpractice case, the
vary greatly by both specialty and geography is equally well
jury™s decision often will depend on which side™s expert
recognized (e.g., an academic anesthesiologist in Philadel-
witnesses are the most credible.1
phia pays more than three times what comparable insur-
As a defense expert witness, I have had frequent
ance costs in San Francisco). Physicians in California credit
opportunity to review the statements of plaintiff ™s expert
the Medical Injury Compensation Reform Act (MICRA)
witnesses. Often as I compare my analysis to that of the
of 1975 for their low premiums and physicians in Pennsyl-
plaintiff ™s expert witness, I marvel how two individuals
vania attribute high premiums to an inability to convince
educated in the same profession and practicing the same
the state legislature to pass a “MICRA” equivalent. This
specialty can profess such divergent opinions as to stan-
failure currently has the potential to effect healthcare in
dard of care in general or a speci¬c physician™s practice in
Pennsylvania adversely. For example:
particular after reviewing the same set of documents.
“Peer” is de¬ned as “one of equal standing with
1. Premiums for category 5 (highest risk) specialists
another.”2 If a pediatric cardiac anesthesiologist is being
are more than $200,000 annually.
sued, does that mean the jurors will be pediatric cardiac
2. Young physicians trained in high-risk specialties are
anesthesiologists? Absolutely not! In addition to the fact
electing to go elsewhere.
that it would be unlikely to ¬nd a suf¬cient number of
3. Hospitals are closing labor and delivery suites to
them within a given jurisdiction to serve as jurors, physi-
avoid carrying insurance coverage for same.
cians would almost certainly be eliminated from consid-
On the positive side, in Pennsylvania, anesthesia has moved eration by the plaintiff ™s lawyer because of potential bias
progressively from category 5 to category 3 over the past toward the defending physician. That helps explain why,
twenty years. This move re¬‚ects the national improvement as previously mentioned, the jury may lack the expertise
in the safety of the anesthetized patient (Fig. B-1). to reach a conclusion based on just the facts.
Surely, however, the expert witnesses on both sides
would certainly be a pediatric cardiac anesthesiologist.
WHO CAN BE AN EXPERT WITNESS?
Unfortunately, this is not required. In thirty-seven states,
expert witnesses are required only to possess a medical
Most witnesses in a trial do not express an opinion “ that is,
license in their state of residency (Table B-1).
they only testify to the events which they have “witnessed”
While it may be true that, at one time, there was a
or to the facts as they know them. In contrast, expert wit-
“conspiracy of silence” that kept physicians from tes-
nesses are speci¬cally recruited by lawyers on both sides
tifying against other physicians, that day is long gone.
of a case to express their opinions on the issue, especially
Why do physicians testify on behalf of the plaintiff?
on medical malpractice cases. Why is this so? The “jury
Some might testify to discourage “bad physicians” from
of peers,” who will judge the facts, lack the expertise to
practicing medicine. Another motivating factor is the
take the facts as presented to them by the “fact witnesses”


248
Appendix B 249


Who should be recruited as defense expert witnesses?
ASA
Mortality
Membership
Rate Partners or close associates would be acquainted with the
0.001 40,000
local standard of care, but the plaintiff ™s lawyer will quickly
bring out the close association and thereby plant the pos-
30,000
0.00075
sibility of biased testimony in the juror™s mind.
In selecting any expert witness, be it for the plaintiff
0.00005 20,000 or the defendant, consideration should be given to such
obvious issues as a similar area of practice, certi¬cation
in the specialty, and experience in the subspecialty (e.g.,
10,000
0.00025

pain, critical care) if appropriate, and national reputation
as evidenced by publications or positions held in national
0
0
1940 1950 1960 1970 1980 1990 2000
specialty organizations. Less obvious, but equally impor-
Year
tant, is the impression the witness will make on the jury. A
Figure B-1. Anesthesia mortality versus ASA membership. The
distinctive accent, be it from abroad or just another region
inverse relationship between mortality and available anesthesiol-
ogists is clearly shown by the exponential decrease in mortality of the country, may offend jurors who are parochial. Expert
being mirrored by an exponential increase in ASA membership.
witnesses must also be able to respond quickly to opposing
ASA, American Society of Anesthesiologists. From the American
lawyers™ attempts to impugn their testimony.
Society of Anesthesiologists with permission of the publisher.


¬nancial rewards that can be obtained. Regardless, the
CLOSED CLAIMS PROJECT OF THE AMERICAN
AMA Board of Trustees has af¬rmed that it encourages
SOCIETY OF ANESTHESIOLOGISTS (ASA)
physicians to recognize their ethical duty as learned profes-
sionals to assist in the administration of justice by serving In 1984, the ASA Closed Claims Project began to collect
as experts.3 data from closed claim ¬les of (currently thirty-¬ve) co-
operating malpractice insurance companies. This data
identi¬ed the major causes of anesthesia-related patient
injury. In this way, ASA can determine where to place
Table B-1. States with no expert
emphasis when trying to improve both the care and safety
witness provisions
of the anesthetized patient.4
Alabama Nebraska
While the cooperating insurance companies cover more
Alaska Nevada
than 60% of the practicing anesthesiologist in America, the
Arizona New Hampshire
California New Jersey total number of anesthetics administered by these anesthe-
District of Columbia New Mexico siologists is unknown”thus, there is no denominator to
Georgia New York
go with the numerator and an incidence cannot be calcu-
Hawaii North Carolina
lated. However, after twenty years of data collection, it is
Illinois North Dakota
Indiana Oklahoma possible to look at trends over time and the response to
Iowa Oregon
interventions. Each year the June issue of the ASA Newslet-
Kansas Pennsylvania
ter features reports from the Professional Liability Com-
Kentucky South Carolina
mittee and these reports re¬‚ect both these trends and the
Louisiana South Dakota
Maine Utah responses to interventions. For example:
Maryland Vermont
Massachusetts Virginia
1. Claims for death and brain damage have decreased,
Michigan Washington
con¬rming that the severity of anesthesia-related
Minnesota Wisconsin
damage has decreased (Fig. B-2).
Missouri Wyoming
Montana 2. Conversely, the claims for nerve damage have
remained constant. In certain susceptible patients,
Reprinted from Ellison (1) with permission of the publisher.
nerve injury may occur in spite of conventionally
250 Norig Ellison


% OF TOTAL CLAIMS IN TIME PERIOD
50%

Death
40% 41% Brain damage
*
Nerve injury
32%
30%


22%
20%
* 18%
16%
15% 15%
12%
*
10%
9%
*
0%
1970-79 1980-89 1990-94
n=674 n=2904 n=783
N = 4,459 Claims

Figure B-2. The incidence of death, brain damage, and nerve injury as a percentage of total claims in a given time period. A signi¬cant
reduction in the proportion of claims for death and brain damage occurred between 1970“79 and 1990“1994 (p 0.01, test). Reproduced
with permission from Anesthesiol 91:552,1999.


accepted methods of positioning and padding.5 pulse oximetry in the mid 1980s and adoption of
capnographic con¬rmation of tracheal intubation
Therefore, the occurrence, especially of an ulnar
as an ASA standard at that time undoubtedly con-
neuropathy postoperatively, does not necessarily
tributed to this improvement also.
mean malpractice.
3. Claims for respiratory damaging events have clearly
decreased (Fig. B-3). ASA™s ¬rst practice parameter, MALPRACTICE INSURANCE CLAIMS
Management of the Dif¬cult Airway, was approved
A larger, but more general, source of data regarding
in 1992 and revised in 2002 in response to the recog-
malpractice litigation is available from the Physician™s
nition of this major risk.6 The decrease re¬‚ects favor-
Insurance Association of America that summarizes data
ably on the effect of the parameter. The advent of
reported by eighteen physician-owned insurance compa-
nies covering all specialties in every region of the country.7
This data source permits a comparison of anesthesia-
50
related claims to other specialties. For example, in terms of
average payout, over $250,000 of all cases between 1985“
40
*
1997 anesthesia ranked third (Table B-2) and, in terms of
Percentage




30 average payout of all claims paid, anesthesia ranks eighth
(Table B-3).
20
An analysis of “the most expensive locations” helps
*
explain why anesthesia premiums are what they are. Nearly
10
half the claims (46.6%) originate in the two locations
where anesthesiologists primarily work: the operating
0
1975-79 1980-89 1990+
room and the labor and delivery suite (Fig. B-4).
Figure B-3. Claims for respiratory damaging events as a propor- The most common reason for malpractice claims in
tion of all claims is the database for each time period. — p < 0.5
general as well as for anesthesia and surgery are listed
for the 1975“90 and 1990+ time periods. Reproduced with per-
in Table B-4. In all twenty-four specialties, “no medical
mission from ASA Newsletter 60:11,1996.
Appendix B 251



Table B-2. Expert witness requirements by state

State Rules

Arkansas Prohibits testimony from expert witnesses whose compensation depends on outcome of suit.
Health care provider shall not be required to give expert opinion testimony against himself or
herself except with respect to discovery
Colorado Expert witness must be licensed physician and substantially familiar with standard of care on date
of injury
Connecticut Expert witness must be licensed physician practicing for ¬ve years before date of injury
Delaware Expert testimony on deviation from applicable standard unless panel found negligence to have
occurred and caused injury complained of Expert witness must have knowledge of locality or
similar locality in order to testify
(Locality rule: any Delaware physician in active practice may testify as to standard of care)
Florida Expert testimony by licensed physician in same practice or practicing for ¬ve years before
claim ¬led
Idaho Expert witness must have knowledge of community standards
Mississippi Expert witness must be licensed physician
Ohio Expert testimony limited to licensed physician or surgeon who devotes three-quarters of his or her
time to active clinical practice or teaching
Rhode Island Only those persons whose knowledge, skill, experience or training quali¬es them as experts will
be permitted to testify
Tennessee Expert witness must be licensed in Tennessee or contiguous state and practice for one year
preceding date of injury
Texas Expert witness must be practicing physician or training medical residents
West Virginia Expert witness must be licensed physician and engaged in the same or substantially similar
medical ¬eld as defendant

Reprinted from Ellison (1) with permission of the publisher.




misadventure” (NMM) was listed among the top three rea- Part of this range can be explained by history of lawsuits
sons, but only in anesthesia and psychiatry was NMM the and performance of high-risk procedures such as invasive
top reason. NMM means the physician did nothing wrong pain management. The remainder is essentially geograph-
but was involved in the patient™s care in some way”and ically determined with the highest premiums occurring in
on occasion contributed to the payment, obviously some- Florida, Illinois, Michigan, and Ohio.
times signi¬cantly. Interestingly, when 1985 premiums are adjusted for
A more complete analysis of anesthesia-related claims is in¬‚ation and compared to the 2004 premiums, the former
provided in Figure B-5. The troika of death, brain damage, is 35% higher (Fig. B-6). The aforementioned improve-
and peripheral neuropathy comprises 62% of all claims. ments in patient safety due to the adoption of monitors
In the remaining 38%, another four categories comprising and practice standards/guidelines have been credited for
14% presumably are related to anesthesia procedures: air- these savings.
way trauma, pneumothorax (central line cannulation or It is paradoxical, and at the same time the administra-
high peak conspiratory pressure), headache (post-lumbar tion of anesthesia is becoming safer, malpractice insur-
puncture), and aspiration. ance premiums are increasing. Why? Mills has addressed
the issue of increasing premiums.9 While adverse patient
outcomes are the underlying factor in establishing rates,
MALPRACTICE INSURANCE COSTS
the costs associated in both resolving and defending claims
have increased between 1994 and 2000, 84% for the former
A recent survey of forty-six medical liability insurance car-
and 39% for the latter. Volatile jury awards have also con-
riers found the average premium for an anesthesiologist
tributed (Table B-5). Superimposed on these factors have
was $20,611, but the range was from $3,458 to $62,400!8
252 Norig Ellison



Table B-3. Which specialties have the biggest payouts?

% of paid claims
$250,000 and over Average payout

1. Neurology 24 $662,715
2. Pediatrics 26 662,275
3. Anesthesiology 21 639,153
4. Surgery, Ob/Gyn 26 631,890
5. Radiation therapy 26 626,590
6. Dermatology 12 607,997
7. Pathology 25 603,208
8. Neurosurgery 30 598,850
9. Surgery, cardiovascular 19 584,722
and thoracic
10. Emergency medicine 16 575,622
11. Cardiology, 22 575,123
non-surgical
12. Gynecology 12 574,333
13. Gastroenterology 13 559,336
14. Psychiatry 16 548,217
15. Surgery, general 17 532,389
16. Otorhinolaryngology 19 523,413
17. Internal medicine 19 523,167
18. Radiology 15 503,778
19. FP/GP 14 500,229
20. Surgery, orthopedic 16 490,909
21. Surgery, urologic 14 485,345
22. Ophthalmology 16 466,625
23. Surgery, plastic 8 461,257

For claims that lead to indemnity payments of at least $250,000, some spe-
cialists take a harder hit than others. As a group, Ob/Gyns wind up with the
biggest total payout. Data are from 1985“1997.



been insurance-industry“related factors. Between 1994 tice insurer, leaving the malpractice market completely.
and 2000, there was signi¬cant competition within the Both the loss of competition with the decrease in insur-
malpractice insurance industry, resulting in a reluctance to ers and a decrease in investment income, the latter
increase premiums despite increased losses. This resulted a national factor totally unrelated to the malpractice
in several large companies becoming insolvent and oth- issue, have further contributed to the premium increase
ers, including St. Paul, which was the largest malprac- (Table B-6).


Malpractice “hot spots”

% of claims
Patient™s room 11.6
Labor and delivery room 6.9
Operating room 33.9
Critical-care unit 1.7
Radiology department 3.8
Emergency department 6.7
Other inpatient 6.1
Total outpatient 30.2

Figure B-4. Malpractice “hot spots.” Reproduced with permission from Medical Economics, August 24, 1998, p 118.
Appendix B 253



Table B-4. How 23 specialties compare in number of claims

% closed with
Claims payout Average payout

Surgery, Ob/Gyn 22,217 36.43 $216,392
Internal medicine 20,319 27.36 153,028
FP/GP 17,372 37.42 122,172
Surgery, general 16,812 36.06 143,415
Surgery, orthopedic 15,729 30.07 130,563
Radiology 8,162 29.96 127,466
Surgery, plastic 6,105 29.47 83,379
Anesthesiology 5,940 36.65 176,544
Pediatrics 4,783 29.61 226,818
Ophthalmology 4,516 30.29 133,252
Surgery, cardiovascular 4,159 24.01 164,727
and thoracic
Surgery, urologic 3,849 30.32 122,087
Neurosurgery 3,798 28.74 235,738
Otorhinolaryngology 2,530 32.20 151,282
Emergency medicine 2,217 28.37 140,038
Neurology 2,194 20.48 215,358
Cardiology 1,978 18.85 182,453
Dermatology 1,874 32.17 103,285
(non-surgical)
Gynecology 1,812 32.76 109,333
Psychiatry 1,557 22.86 136,021
Radiation therapy 1,297 22.66 208,879
Gastroenterology 1,105 21.88 127,315
Pathology 1,006 30.72 204,955
(non-surgical)

Overall, 89.5 percent of the claims recorded by the PIAA from 1985 through 1997
have been closed. In the nearly 32 percent of cases that resulted in an indemnity
payout, the average paid was $154,910.
The ¬gures in this table give only a general idea of how specialties compare. The
number of claims is not weighted according to the number of physicians in each
specialty. Reprinted from Preston (7).




Figure B-5. Most common complications in the ASA Closed Claims Project database. Some claims involve multiple complications.
Figures have been rounded. Reproduced with permission from ASA Newsletter 60:15, 1996.
254 Norig Ellison


Inflation“Adjusted Anesthesia Malpractice Premiums
Table B-6. Factors that In¬‚uence malpractice
premium rates
$35,000

$30,000 Medical Quality of care
Premium in 2004 Dollars




$31,514
Nature and severity of injury
$25,000
Defensibility
$20,000 Documentation




$21,778




$20,611
Legal Volatility of jury award
$15,000 $16,095
Level of tort reform
$10,000 Limits of coverage
Increasing defense costs
$5,000
Economic Validity of rate level
$0 Competition entering and exiting
1985 2002 2003 2004
malpractice market
Increases and decreases in investment
Evaluation Year
income
Figure B-6. In¬‚ation-adjusted anesthesia malpractice premiums.
Mean premiums for liability insurance. For anesthesiologists in
Reprinted from Mills (9) with permission of the American
the United States adjusted for in¬‚ation in 2004 dollars using the
Society of Anesthesiologists
U.S. Consumer Price Index. Adjusted premiums during 2002“04
were still more than 30% below these in 1985. Reproduced with
permission ASA Newsletter 68:6,2004.



PREVENTIVE MEDICINE

The term “defensive medicine” has been used to describe
Table B-5. What specialists are sued for
one™s practice of ordering unnecessary tests to protect
Average against lawsuits. Here the term “preventive medicine” is
payout
used to describe steps that are taken to avoid preventable
All Fields errors. To prevent patient mix-up or wrong side/site
Improper performance $134,360
surgery, three steps are recommended:
No medical misadventure 139,411
Errors in diagnosis 169,037
1. Both the anesthesiologist and the circulating nurse
Failure to supervise or monitor case 189,461
independently or jointly con¬rm the patient™s name
Medication errors 114,192
Surgery, general and the planned procedure with the patient on
Improper performance $144,419 arrival in the operating room.
No medical misadventure 135,377
2. Prior to induction, the surgeon or his designee mark
Errors in diagnosis 180,318
the operative site.
Failure to supervise or monitor case 160,570
Performed when not indicated or 136,931 3. After the induction and prior to the incision, a
when contraindicated
“TIMEOUT” is called where the surgeon, anesthe-
Anesthesiology (top ¬ve causes)
siologist, and nurse jointly identify the patient and
No medical misadventure $168,107
agree on the procedure. Recording the timeout on
Improper performance 118,074
Intubation problems 228,514 the anesthesia record is encouraged.
Problems monitoring patient during 270,224
surgery Documentation legibly and contemporaneously of the
Tooth injuries 8,333
administration of anesthesia is essential. If a second
Internal medicine (top ¬ve causes)
sheet is needed before the time graph is ¬lled up, going
Errors in diagnosis $178,189
No medical misadventure 123,117 on to a second sheet is preferred to a cramped inade-
Improper performance 123,910
quately documented record. Equally important is a care-
Failure to supervise or monitor case 160,944
ful documentation of what may be done in the PACU or
Medication errors 108,418
ICU. The Anesthesia Patient Safety Foundation advocates
Appendix B 255


electronic records to address both the legibility and timing Outcome of Malpractice Case Closed in 2001

1%
issue. Plaintiff Verdict
The increasing use of electronic instruments in the OR
6%
hastened the demise of ether and cyclopropane as anes- Defense Verdicts
thetic agents, thus eliminating the risk of explosion from
these agents. Today, intra-operative ¬res most commonly
32%
involve head and neck procedures with the surgical instru- 61% Dropped/Dismissed
Settlements
ment, either electrocautery or laser, as the ignition source.
Use of supplemental oxygen will increase this risk. Com-
munication and coordination between surgeon and anes-
thesiologist are essential to prevent this risk.
Burns due to inappropriate attempts to warm Sources: Physician Insurers Association of America

patients”either with heated bags or unauthorized use Figure B-7. Outcome of malpractice cases closed in 2001. Repro-
duced with permission from Physician Practice 13:32,2003.
of thermal blankets/hot air sources”are other clearly pre-
ventable injuries.


EXPERT WITNESS CASE REVIEW may not belong to the ASA. In these cases, at least the tes-
timony offered can be labeled irresponsible and in future
Long before a malpractice case comes to trial, expert wit-
cases, this fact can be introduced to attack the credibility
nesses will be recruited by both the plaintiffs™ and defen-
of the professional expert witness.
dants™ lawyers. Indeed, if the former™s expert concludes
that there is no evidence of malpractice, that may be the
end of the case. Unfortunately, plaintiff ™s lawyers always
FINAL REFLECTIONS
seem able to ¬nd an anesthesiologist who is willing to say
anything to anybody for a price. The good news is that only 7% of malpractice cases go
Indeed, a major problem regarding expert witness tes- to trial and 85% of those return a verdict for the defense
timony has been dealing with these “professional wit- (Fig. B-7). The bad news is that 32% of cases are settled,
nesses” who appear willing to testify anywhere, anytime, invariably with a payment that may be substantial. How-
to anything. Defense counsel for many years cautioned ever, in many cases, a small payment is made “to make the
about taking any action against these individuals for fear case go away,” the thought being that the expense of a trial
of being accused of witness tampering. The American would be greater than a small payment.
Academy of Neurosurgeons (AANS) deserves credit for Nevertheless, the current system is broken. Many
standing up and challenging irresponsible witnesses who patients are compensated who have not been injured. The
develop new theories of causation unsupported by scien- “no medical misadventure” discussed previously attests to
ti¬c evidence to explain how/why a physician commit- this.
ted malpractice. The AANS expelled a member who was Patients who are injured may not be compensated due
considered to have offered irresponsible testimony. This to failure to ¬le claims or inadequate legal representation.
case went all the way to the U.S. Supreme Court, which Do I know of any such cases? No, but the statement has
af¬rmed the right of a professional society to police its been repeated so many times that I suspect somewhere,
members. sometime there may have been a patient who was not com-
In 2004, the ASA House of Delegates approved a mecha- pensated.
nism for reviewing testimony of expert witnesses in closed A new system of medical injury compensation is needed.
cases and, if appropriate, recommending sanctions. These Alternatives include binding arbitration by impartial pan-
may include either suspension or expulsion of members els, no-fault insurance, specialized health courts such as
who are found to have provided irresponsible testimony. currently exist in the areas of taxes, worker™s compensa-
One problem is that the anesthesia professional witness tion, and labor issues.
256 Norig Ellison


REFERENCES 6. Caplan RA, Benumof JL, Berry FA, et al.: Practice guidelines
for management of the dif¬cult airway. Anesthesiol 2003;
1. Ellison N: Role of the Expert Witness in Malpractice Litiga-
98:1269“1277.
tion. Problems in Anesthesia 13:515, 2004.
7. Preston JH: Malpractice danger zones. Medical Economics
2. Merriam-Webster™s Dictionary, 10th ed. Spring¬eld, MA,
August 24, 1998, p 106.
Merriam-Webster Inc., 1993.
8. Domino KB: Availability and cost of professional liability
3. Reardon TR, et al.: Expert witness testimony. AMA Board
insurance. ASA Newsletter. Park Ridge, IL, American Society
of Trustees Report 5-A-98, June 1998 Handbook of AMA
of Anesthesiologists 60:5,2004.
House of Delegates.
9. Mills EC: Why are my malpractice insurance rates increasing?
4. Cheney FW: The ASA closed claims project. Anesthesiol
ASA Newsletter. Park Ridge, IL, American Society of Anes-
91:552,1999.
thesiologists 66:13,2002.
5. Cheney FW: Perioperative ulnar nerve injury”A contin-
10. Administrative procedure for expert witness testimony. ASA
uing medical and liability problem. ASA Newsletter. Park
2004 House of Delegates Handbook. Park Ridge, IL, American
Ridge, IL, American Society of Anesthesiologists 62:10,
Society of Anesthesiologists, p. 410.
1998.
Index




in MIA„, 12, 42“45
risks associated with, 78, 133
abdominoplasty
non-opioid (NOPA), 42
American Academy of Cosmetic Surgery
general anesthesia for, 162
postoperative nausea/pain and, 4
(AACS), 183
local anesthesia for, 109, 111
analgesics. See non-opioid analgesics;
American Association for Accreditation of
minimally invasive anesthesia r for,
opioid analgesics
Ambulatory Surgery Facilities
psychological aspects of, 189
anatomy. See sensory anatomy
(AAAASF), Inc., 11, 211, 212
respiration risks of, 238
androgenetic alopecia (AGA), 186
American Board of Anesthesiology
accreditation
anesthesia
(ABA), Inc., 48
for anesthesiologists, 201
goals of, 132
American Dental Association (ADA), 47
for dentist anesthesiologists, 48
history of, 86
American Dental Board of Anesthesiology
differing standards for, 212, 218
primary components of, 37
(ADBA), 48
issues in, 211
anesthesia practitioner, 218
American Osteopathic Association
for of¬ce-based anesthesia, 14, 211, 212
anesthesiologist
(AOA), 211
reimbursement and, 223
attitude of, 20, 43
American Society for Aesthetic Plastic
Accreditation Association for Ambulatory
due diligence by, 200
Surgery (ASAPS), 77
Health Care (AAAHC), 211
education by, 19, 21“22, 44
American Society for Dermatologic
acetaminophen
as ¬nal gatekeeper, 226, 228
Surgery (ASDS), 77, 183
dental procedures and, 55
medical care by, 172
American Society of Anesthesiologists
in MIA„, 5, 9
MIA„ and, 45
(ASA)
in TIVA, 116, 117
vs. nurse anesthetist, 217
clinical levels of sedation by, 13
acne treatment, 185
questions to ask, 56
Closed Claims Project of, 249, 253
adrenergic alpha-agonists
anesthetic agents, selecting, 114, 157
membership/specialties of, 48
dental anesthesia and, 55
anesthetic toxicity, 140, 149
mortality vs. membership in, 249
regional anesthesia and, 136
anorexia, 192
of¬ce-based guidelines by, 157
for TIVA, 115, 116
antacids, 179
physical status classi¬cations by, 172
adrenergic beta-agonists, 17, 118, 119
anti-aging procedures, 184
American Society of Plastic and
Advanced Cardiac Life Support (ACLS),
antibiotics, 74
Reconstructive Surgeons (ASPRS), 79
17, 229
anticoagulants, 134
American Society of Plastic Surgeons
adverse events, 79, 215. See also
antidepressants, 74
(ASPS)
complications, perioperative
antiemetic agents
accreditation and, 201
aging, 184, 241
dental anesthesia and, 56
DVT task force by, 166
airway continuum, 120
prophylactic use of, 19, 59, 178
liposuction statistics by, 77
airway patency management
antifungals, 75
plastic surgery statistics by, 183
algorithm for, 8, 18
antihypertensives, 74
American Society of Regional Anesthesia
in cosmetic procedures, 121
anti-in¬‚ammatory agents. See
(ASRA) and Pain Medicine, 134
in dental procedures, 49, 50“53
non-steroidal anti-in¬‚ammatory
analgesia, adequate
devices for, 18, 120, 121, 122
agents (NSAIDs)
BIS monitoring and, 3
interventions for, 12
Anti-kickback Statute, 201
inferences regarding, 8, 45
legal issues in, 236
antioxidants, 242
levels of, 11
Aldrete score, 164
antiseizure agents, 75
patient movement and, 3, 8, 42
allergy history, patient™s, 18
anxiety, 177
analgesia, preemptive
alloplastic body augmentation, 111
anxiolysis,
clonidine and, 9
alopecia, 186
aspiration, 49, 162
dissociative effect for, 44, 46
ambulatory surgery (AS)
aspiration pneumonitis, 178
essential concepts of, 43
growth of centers for, 171
assessment. See pre-anesthetic assessment
ketamine and, 5
vs. of¬ce-based surgery, 207



257
258 Index


bromelain, 245
assistance for sedation, 11, 12, 13 consent, informed patient, 21, 22, 228
browlift, 102, 159
asthma history, patient™s, 18 consultations, 226
bruising, 245 consumer of anesthesia care. See patient
bulimia nervosa, 192
back pain, 138, 140 as consumer
bupivacaine, 4, 9, 140
bariatric surgery, 189 continuing education (CE), 48
burns, 233, 255
benzodiazepines corticosteroids, 185
buttock augmentation, 111, 190
ketamine and, 39 cosmetic surgery
butyrophenones, 119
in regional anesthesia, 136 business of, 156
for sedation, 13 competition in, 203
caffeine, 8, 16
for TIVA, 115, 116 growth of, 183
calf augmentation, 111, 190
beta-blockers. See adrenergic risk expectations for, 1
cardiac arrest, 139, 141
beta-agonists top procedures for, 208
cardiac destabilization, 17, 74
bicarbonate, 140 cosmetics, topical, 185
cardiac patients, 173
billing/payment for anesthesia care, 204, cost considerations
catheterization, urinary, 8, 15
208, 222 general anesthesia and, 157
central nervous system function,
bispectral analysis, 26 of malpractice insurance, 251
monitoring, 33“35
Bispectral Index„ of¬ce-based anesthesiology and, 202,
Certi¬cate of Need (CON) laws, 215, 216
components of, 25 204
certi¬cation, 48“49, 201, 213
range of, 26, 27 of¬ce-based surgery and, 208
cervical plexus, 98, 99
sedation levels and, 3 coughing, 18, 52
cheek implant, 184
validating/assessing, 26“28 COX-2 inhibitors, 55, 116, 118
chemical peel, 184
Bispectral Index„ monitoring
chest radiograph, 177
advantages of, for patient, 21 dairy products, 16
children
as case management tool, 8, 43 Deep Venous Thrombosis Prophylaxis
ketamine in, 39
in dental anesthesia, 54 task force (ASPS), 166
lidocaine in, 75
differentiating MIA„, 11 dementia, 50
PK technique used for, 65, 66
during general anesthesia, 32, 157 dental anesthesia
chin implant, 184
ketamine and, 4, 6 airway management in, 50“53
“chinner,” 12
overview of, 3 education/certi¬cation for, 47“49
chloroprocaine, 137, 140
patient movement and, 43, 45 pain control in, 55
clonidine
pharmacologic responses and, 35“36 patient monitoring in, 52, 53, 54
dental anesthesia and, 55
with supraglottic device, 12 technique for, 48, 54
for epidural anesthesia, 140
titrating propofol with, 13, 17 types of dentists for, 219“220
as premedication for MIA r , 7, 8, 11, 41
in TIVA, 122 dental procedures, cosmetic, 47, 49“50
BIS„ algorithm, 26 dentist anesthesiologist (DA), 48, 220
for spinal anesthesia, 138
BIS„ monitor, 25 dermabrasion, 184
for TIVA, 115, 116
BIS„ trend, 30 des¬‚urane, 157
Closed Claims Project (ASA), 249, 253
“blanched” surgical ¬eld, 8, 43, 45 devices, medical/surgical, 36. See also
coagulation abnormalities, 133, 134
blepharoplasty, 163, 184 supraglottic devices
cocaine, 85
blood loss, 78, 232 dexamethasone, 55, 119, 178
collagen injection, 184
blood sugar, 8, 16 dexmedetomidine
compliance issues, 201
board certi¬cation. See certi¬cation vs. clonidine in MIA„, 9
complications, perioperative
body augmentation/contouring, 111, dental anesthesia and, 55
due to combustion, 233, 255
186“191 for TIVA, 115, 116
legal issues in, 231
body dysmorphic disorder (BDD), 191 diabetic patients, 16, 174
reducing, 245
body-image dissatisfaction, 187, 189, diazepam, 6, 9, 40
of tumescent liposuction, 78“80
191 dietary supplements. See herbal
con¬‚ict of interest, 201
body lift, circumferential, 109 supplements; mineral supplements;
conscious sedation, 11
body piercing, 190 vitamin supplements
consciousness, recovery of, 27
bone contouring/grafting, 184 diphenhydramine, 9
consciousness monitoring. See also
“botulinophilia,” 192 discharge criteria, 164, 236“239
Bispectral Index„ monitoring
botulinum toxin injection, 184 dissociative effect
in clinical situations, 35“37
brachial plexus block, 147 de¬ned, 5, 9
CNS function and, 33“35
brain abnormalities, 35“36, 50 essential concepts of, 41
de¬ned, 24
breast augmentation, 159, 186“189 and ketamine in MIA„, 41“42
EEG in, 24“25
breast surgery/procedures preemptive analgesia and, 44
during general anesthesia, 30“33
local anesthesia for, 107, 108 diuretics, 15
monitors for, 25, 28“30
using PK technique, 61, 63 documentation, 54, 228“229, 239, 254
as neurophysiologic monitoring, 122
Index 259


dopamine antagonist, 179 evaluation, patient. See pre-anesthetic banning, in of¬ce-based settings, 210
droperidol, 178 assessment BIS de¬nition of, 3
expert witness. See witness, expert comparing techniques for, 157
ear, 99, 100 eye, surgery around. See blepharoplasty; consciousness monitoring during,
eating disorders, 192 infraorbital nerve block; supraorbital 30“33
education/training nerve de¬ned, 11
by anesthesiologist, 21“22, 44 eye protection, 51, 163 informing patient of, 228
of dentist anesthesiologist, 48“49 vs. MIA„ technique, 13, 15
of patient, 20“22 face preemptive analgesia and, 5, 9, 42, 44
tumescent liposuction and, 78 local anesthetic techniques for, 102, screening for of¬ce-based, 157
elective cosmetic surgery, 1, 204 103, 104 genital enhancement, 190
electric stimulator device, 56, 125 psychological aspects and, 183“186 gluteal augmentation, 111, 190
electrocardiogram (EKG) monitoring, 17, sensory innervation of, 87“88 glycopyrrolate
176, 229 facelift, 158, 184 as premedication for MIA, 7
electrocautery devices, 35 facial implants, 184 side effect of, 20
electroencephalogram (EEG) monitoring, facial resurfacing, 163 for TIVA, 118, 119
24“26, 33“35 facial skeletal procedures, 184 gynecological procedures, 64, 65
electromyogram (EMG) monitoring, facility for anesthesia care. See also
33“34 of¬ce-based anesthesiology (OBA) H2 -receptor antagonists, 179
emergence, monitoring during, 32 dental care and, 56 hair replacement procedures, 186
emergency contingencies evaluating proposed, 215 hallucinations, 44
for endotracheal intubation, 176 legal issues for selecting, 227“228 head
legal issues in, 229, 230 PK technique and, 60 local anesthetic techniques for, 88“90
limiting surgeries to avoid, 214 screening for, 157 sensory innervation of, 87“88, 104
in of¬ce-based setting, 81, 166, 199 staf¬ng, 235 headache, postoperative, 8, 16
for operating room ¬res, 233 fast tracking, 157, 164, 238 after epidural anesthesia, 140
emesis. See nausea and vomiting (PONV), fat injection, 184 after spinal anesthesia, 139
postoperative Federal False Claims Act of 1985, 201 hematomas, 245
emetogenic agents, 4, 9, 14 federal regulations, 222 hemodynamic monitoring, 29
emetogenic anesthesia, 4, 14 fees, 202 hemorrhage, 78, 232
endotracheal intubation, 31, 50“52 fentanyl hepatic history, patient™s, 19
endotracheal tube dental anesthesia and, 55 herbal supplements, 174, 175, 242,
for dental anesthesia, 51 for epidural anesthesia, 140 243“244
development of, 120 for general anesthesia, 158 HIPAA (Health Insurance Portability
during laser resurfacing, 163 for TIVA, 116 and Accountability Act of 1996), 18,
during rhinoplasty, 162 ¬nasteride, 186 201
end-tidal carbon dioxide (EtCO2 ) ¬res, operating room, 233, 255 histamine H2 antagonists, 179
5-HT3 inhibitors
monitoring, 30 history, medical. See pre-anesthetic
in anesthetic regimens, 29 dental anesthesia and, 56 assessment
for dental anesthesia, 53 to prevent PONV, 178 Horner™s syndrome, 147
legal issues in, 229 for TIVA, 119 hospital privileges, 213
in MIA„ technique, 3, 14 ¬‚uid management hydration. See ¬‚uid management
in TIVA, 120, 121 cosmetic surgery and, 7, 15 hyperhidrosis, 192
enuresis, 8, 15 legal issues in, 231 hypertension, 15, 17, 173
ephedrine, liposuction and, 161 hyperthermia, 165, 175
epidural anesthesia, 139“141 in MIA„ technique, 14 hypnosis, 3, 8, 11
epidural spread, 147 to prevent PONV, 177 hypoglycemia, 8, 16
epinephrine ¬‚uid shift, third space, 79, 161 hypo-pigmentation, 185
lidocaine and, 73 food intake hypothermia, 161
for nerve blocks, 147, 149 cosmetic surgery and, 8
for spinal anesthesia, 137 MIA„ technique and, 14, 15“16 iatrogenic error, 9, 79, 215
tachycardia due to, 17 prior to surgery, 178 ibuprofen, 118
for TIVA, 118 forehead immunity, 245
toxicity of, 80 anesthesia techniques for, 88“90, 102 immunosuppressants, 75
error, iatrogenic, 79, 215 sensory innervation of, 89 induction of anesthesia, 31
EtCO2 monitoring. See end-tidal carbon inferior alveolar nerve block (intraoral),
dioxide (EtCO2 ) monitoring gag re¬‚ex, hyperactive, 49, 52 96
etomidate, 36 general inhalation anesthesia in¬‚ammation, 245
260 Index


local anesthesia blocks
length of procedures, 227“233
information, patient. See pre-anesthetic
for cervical plexus, 99
level-of-consciousness monitoring.
assessment
of inferior alveolar nerve, 96
See consciousness monitoring
infraorbital nerve block, 90“94
of infraorbital nerve, 90“94
levobupivacaine, 140
infratrochlear nerve, 89
of mandibular nerve (V3), 90, 97
liability
infusion pumps, 61
of maxillary nerve, 94
discharge and, 236
innervation. See sensory anatomy
of mental nerve, 95, 96
documentation and, 228
Institute of Medicine (IOM), 49
for scalp/forehead, 88“90, 97, 98
“hot spots” for, 252
insurance for cosmetic surgery, 18
in United Kingdom, 61, 62
informed consent and, 22, 228
intercostal nerve block, 148
of zygomaticotemporal/facial nerves,
liposuction and, 231
vs. paravertebral nerve block, 147
91, 92, 93
occurrence of, de¬ned, 201
technique for, 148, 149
local anesthetics
in of¬ce-based setting, 218, 225
intervention for sedation, 11, 12, 13
for dental anesthesia, 52
during recovery, 132, 234, 236
dental procedures and, 48
for epidural anesthesia, 139
licensure, 215
intraoperative considerations. See also
mechanism of action of, 85
lidocaine
complications, perioperative;
for peripheral nerve blocks, 147
for epidural anesthesia, 140
consciousness monitoring; speci¬c
for spinal anesthesia, 137
history of, 85
surgery
toxicity of, 140, 149
for laryngospasm, 5
legal issues in, 230
location for anesthesia care. See facility for
mega-dosing, 77“82
for MIA„ technique, 3, 5, 14, 17
anesthesia care
in MIA„ technique, 4
for TIVA, 127
for patient movement, 45
for tumescent liposuction, 81
MAC. See monitored anesthesia care
pharmacology of, 73
intravenous anesthesia. See also sedation,
(MAC)
as premedication for MIA, 7
intravenous; total intravenous
malignant hyperthermia (MH), 165, 175
for spinal anesthesia, 137
anesthetic (TIVA)
malpractice insurance
topical, 51
combining agents in, 114
claims for, 250, 253
toxicity of, 74, 75“77, 80
history/development of, 69, 113“114
costs for, 251
toxicology of, 73“75
informing patient about, 228
payouts by, 252
in tumescent liposuction, 77“82, 102
intravenous anesthetics, 136
rates for, 225, 254
lipectomy. See suction-assisted lipectomy
Iraq, 70“71
malpractice liability. See liability
(SAL)
iso¬‚urane, 157
malpractice litigation, 239, 248, 254, 255
lipo-atrophy, 184
mammaplasty, 108
lipoplasty, 75, 189
jaundice patients, 19
mandibular nerve/block, 95, 97
liposuction
Joint Commission on Accreditation of
marketing, 201“203
ASPRS guidelines for, 79
Healthcare Organizations (JCAHO),
mass casualty anesthesia, 68“71
¬‚uid management and, 7, 15, 231
211
mastopexy, 108, 160
legal issues and, 232
maxillary nerve/block, 88, 94
limiting volumes for, 215
ketamine
media, mass, 183
terminology for, 75
BIS monitoring and, 36
medical record. See documentation
liposuction, tumescent
CNS action of, 41
Medicare patients, 201
bene¬ts, 77“78
dental anesthesia and, 55
reimbursement for, 208, 217, 222
complications/pitfalls, 78“80
dosing, and side effects, 39“41, 44
medications, patient™s prescription, 15, 16
general anesthesia for, 160
in MIA„ technique, 5, 8, 9
mental nerve block, 95, 96
implications/suggestions for, 80“82
in PK MAC, 11, 60
mepivacaine, 137, 140
legal issues and, 233
in regional anesthesia, 136
methylenedioxymethamphetamine
overview, 101, 109
tachycardia due to, 17
(MDMA), 39
lips, 100, 101
tips for administering, 6
metoclopramide, 178, 179
litigation. See malpractice litigation
for TIVA, 116, 117
MIA„ technique. See minimally invasive
local anesthesia
ketorolac, 9, 178
anesthesia (MIA) r
for body contouring, 106“107
for ear, 99, 100
labetalol, 17 midazolam, 7, 116, 177
for face, 102, 103
laboratory tests, 177 military medicine, 68“71
history of, 84
laryngeal mask airway. See supraglottic mineral supplements, 242, 244, 245
for lips, 100
devices minimally invasive anesthesia (MIA) r
for nose, 92, 100
laryngeal re¬‚exes, 11, 14“17 algorithms for, 6, 8, 18
role of, 123
laryngospasm, 5, 14 classi¬cation of, 11, 13, 15
tips for, 8
laser resurfacing, 42, 163, 184 de¬ned, 5, 11, 41, 63
tumescent, 101, 102, 103, 104
lawsuits. See malpractice litigation drugs compared to those used with, 42
in United Kingdom, 61, 62
legal issues. See liability; standard of care educating surgeon regarding, 19, 44
Index 261


errors to avoid in, 9, 44, 45 in general anesthesia, 158 opioid analgesics
major principles in, 8, 20 and PONV, 60, 177 dental anesthesia and, 55, 56
premedication in, 6“7 N-methyl-D-aspartate (NMDA) epidural anesthesia and, 140
rationale for, 1“3, 12 receptors, 5, 39“43 general anesthesia and, 158
types of surgeries using, 2, 10 “no medical misadventure” (NMM), 250 MIA„ and, 17, 42
minimally invasive surgery/procedures non-opioid analgesics, 117“118 MIA„ and, 9
growth of, 183 non-opioid preemptive analgesia PK technique and, 60
psychological aspects of, 184 (NOPA), 42 regional anesthesia and, 136
using MIA„ technique, 2 non-steroidal anti-in¬‚ammatory agents TIVA and, 116, 117
minoxidil, 186 (NSAIDs), 55, 116, 118 oral device. See supraglottic devices
monitored anesthesia care (MAC), 11 nose oral pharyngeal airway. See supraglottic
monitoring, patient, 24, 229, 235. See also general anesthesia for, 162 devices
Bispectral Index„ monitoring; local anesthetic techniques for, 92, 100, otoplasty, 65, 66
consciousness monitoring; types of 101 oxidation, cellular, 242
physiologic monitoring psychological aspects and, 183 oxygen administration
morbidity/mortality nurse anesthetist, 48, 217 avoiding combustion in, 233
and ASA membership, 249 nurses, of¬ce-based, 22, 218, 221 laser resurfacing and, 42
and breast implants, 188 nutrition, 243. See also food intake; herbal to prevent PONV, 177
of dental anesthesia, 52 supplements; mineral supplements; in TIVA, 120, 121
and herbal supplements, 174 vitamin supplements 241 oxygen saturation monitoring
of liposuction, 75“77, 78, 161 nystagmus, horizontal, 40“41 in dental anesthesia, 53
in of¬ce-based setting, 208“209 laryngospasm and, 5
morphine, 140 obesity, 189, 241 legal issues in, 229, 236
muscle dysmorphia, 192 occipital nerve block, greater, 98 in PK MAC, 6
muscle relaxants, 51, 119 of¬ce-based anesthesiology (OBA). See during sedation, 12
also facility for anesthesia care
nasopharyngeal airway. See supraglottic accreditation for, 14 pacemakers, 35
devices ASA guidelines for, 157 pain management, intraoperative, 84, 85
nausea and vomiting (PONV), business of, 199, 201“203 pain management, postoperative
postoperative competition to, 203 after general anesthesia, 164
anesthesia and, 59 de¬ned, 207 after MIA„, 8“9
dental anesthesia and, 55 development of, 113 anesthesia affecting, 5
general anesthesia and, 165 differing standards for, 212, 218 dental anesthesia and, 55
MIA„ and, 8, 9, 19, 40“41 expectations of, 20“22 preemptive analgesia and, 4, 8, 43, 44
PK technique and, 67 ¬nancial aspects of, 202, 204 paravertebral nerve block, 141“148
preventing, 19, 126, 177“178 growth of, 171 advantages of, 144
risk for/types of, 123“125 importance of BIS in, 53“54, 122 anatomy of areas for, 141, 142, 143, 144
therapy/treatment for, 125“127 importance of ketamine in, 36 vs. intercostal nerve block, 147
neck morbidity/mortality of, 76 procedures using, 144
anesthesia techniques for, 99, 102, 103 outcomes of, 19 technique for, 145, 146
sensory innervation of, 87“88, 98, 104 professional organizations for, 221 patient as consumer
nerve block. See local anesthesia blocks; regulation of, 15, 156, 199 business of enticing, 156
neuraxial blocks; peripheral nerve safety of, 78, 166 dental anesthesia and, 56
blocks solutions to problems with, 210 maintaining, 204
neuraxial blocks of¬ce-based surgery (OBS) media™s in¬‚uence on, 183
ASRA on, 134 de¬ned, 207 questions to ask by, 56
physiologic effects of, 132 expectations of, 156 target markets of,
risks associated with, 133 growth/bene¬ts of, 207 patient information/history. See
safety of, 132 nursing care in, 22 pre-anesthetic assessment
types of, 137“141 outcomes in, 56 patient movements
neurologic symptoms/injury, 140. See also placing limits on, 214 during anesthesia, 3, 9
brain abnormalities 138 problems/issues with, 208“209 BIS monitoring and, 42, 43
neurophysiologic monitoring. See also rationale for, 1“3, 9 ketamine and, 8
Bispectral Index„ monitoring; safety of, 13, 15, 81, 82 patient selection/screening. See
consciousness monitoring, 122 types of, 2 pre-anesthetic assessment
nitrous oxide (N2 O) On-Q r pump, 9 payment. See reimbursement
payment for anesthesia care. See
BIS monitoring and, 35 Operation Iraqi Freedom (OIF), 70“71
reimbursement
in dental anesthesia, 53“54 ophthalmic nerve, 87
262 Index


preoperative considerations. See also
pectoral augmentation, 107, 190 reimbursement, 204, 208, 222
speci¬c surgery
peripheral nerve blocks, 132, 133, remifentanil, 56, 158, 178
limiting patients for, 214
141“150 re-operation rate, 200
for MIA„, 14, 15“16
pharyngeal airway. See supraglottic rhinoplasty, 12, 162, 183
for regional anesthesia, 132“135
devices rhytidectomy, 102, 158, 184
for TIVA, 127
pharyngeal re¬‚exes, 12, 49 risk management, 235, 256. See also safety
prescription medications, patient™s,
phobia, dental, 50 233, 254
15, 16
physical examination, 176 risk-bene¬t, 1, 3
preventive medicine, 254
physical status classi¬cations (ASA), 172 rocuronium, 118, 119
privacy statute (HIPAA), federal, 18
physician™s of¬ce-based setting (POBS), ropivacaine, 140, 149
procaine, 85
209. See also of¬ce-based surgery
professional organizations, 221
(OBS) 207 safety
propofol
PK MAC. See propofol-ketamine (PK) dental anesthesia and, 48, 56
body weight and, 17
MAC general anesthesia and, 157
incremental induction of, 5, 17
plastic surgery/surgeons during laser resurfacing, 42, 163
for MIA„, 8, 12, 13, 41, 44
vs. cosmetic, 204, 218 of liposuction, 75“77
patient movement and, 44
liposuction and, 75, 78, 160 of MIA„ technique, 13
PONV and, 177
numbers of, 183 nurse anesthetist and, 217
in regional anesthesia, 136
PONV and, 117 of of¬ce-based anesthesia, 199
registered nurse and, 221
reimbursement for, 204 in of¬ce-based setting, 82
for TIVA, 116, 117
speciality of, 200 of of¬ce-based surgery, 13, 15, 81, 166
propofol-ketamine (PK) MAC
platysmaplasty. See neck procedures pre-anesthetic assessment and, 172
administering, 4
pneumonitis, aspiration, 178 of regional anesthesia, 132
with BIS monitoring. See minimally
pneumothorax, 147, 149 scalp
invasive anesthesia (MIA) r
podiatrists, 220 local anesthetic techniques for, 88“90,
post anesthetic care unit (PACU), 164 97, 98
breast surgery using, 61, 63
Postanesthesia Discharge Scoring System sensory innervation of, 89, 97, 98
de¬nition of, 11
(PADSS), 164 scar removal, 185, 190
development of, 6
post-dural puncture headache (PDPH), scope of practice issues, 217
gynecological procedures using, 64, 65
139, 140 scopolamine, transdermal, 178
intercostal nerve block and, 62
postoperative symptoms/management. screening, patient. See pre-anesthetic
for military/mass casualties, 68“71
See also recovery period; speci¬c assessment
otoplasty using, 65, 66
cosmetic procedure second division nerve block, total, 94
in United Kingdom, 60“61, 62, 66
after general anesthesia, 164 sedation, intravenous. See also total
psoralens, 185
after peripheral nerve blocks, 147, 149 intravenous anesthetic (TIVA)
psychiatric disorders, 183, 191“192
after regional anesthesia, 138, 140 MIA„ technique as, 11, 13, 15
psychological considerations, 183, 192
in anesthetic regimens, 5, 8 unpleasant memories of, 20
pulmonary edema, 80
in dental anesthesia, 55 sedation levels
pulse oximeter. See oxygen saturation
ketamine and, 40“41, 43, 44 BIS levels and, 3
monitoring
legal issues during, 234 dental procedures and, 48
in MIA„ regimen, 8“9, 19, 20, 21 described, 11
radiograph, 177
in PK regimen, 16, 59, 67 interventions for, 11
recovery period. See also postoperative
in TIVA regimen, 123“127, 128 in regional anesthesia, 135, 136
symptoms/management
pre-anesthetic assessment. See also selective serotonin reuptake inhibitors
legal issues during, 234
preoperative considerations (SSRIs), 74
regaining consciousness in, 27
anesthetic history in, 175 self-promotion. See marketing
for regional anesthesia, 150
goals for, 172 sensory anatomy
re¬‚exes, life-protecting, 14
information obtained for, 16, 17“19 of face, 88
regional anesthesia
legal issues in, 226“227 of head/neck, 87“88, 104
IV agents for sedation in, 136
medical history in, 172 of mandibular nerve, 95
monitoring/sedation in, 135
for of¬ce-based GA, 157 of maxillary nerve, 88
overview of, 132
overview, 171 of neck (cervical plexus), 98
preoperative assessment for, 132“135
physical examination in, 176 of scalp/forehead, 89, 97, 98
recovery and discharge for, 150
preexisting conditions in, 19, 166 regulation. See also accreditation; licensure sensory perception, 44, 49
pre-operative tests in, 176 serotonin agents. See 5-HT3 inhibitors;
of dental anesthesia, 48“49, 53
verifying information in, 254 at federal level, 222 selective serotonin reuptake
pregnancy status, patient™s, 18, 176 of of¬ce-based anesthesia, 15, 156, 199 inhibitors (SSRIs)
premedication, 6“7, 177 at state level, 221 sevo¬‚urane, 157
Index 263


site-of-service differentials, 223 supratrochlear nerve, 89 trigeminal nerve, 87, 88
surgeon Triservice Anesthesia Research Group
skin, sensory perception of, 44
Initiative on TIVA (TARGIT), 69“71
skin grafting, 185 as anesthesia practitioner, 218
skin pigmentation loss, 185 anesthesiologist and, 226 tumescent anesthesia
for facelift, 102, 103, 104
sleep apnea, 237 credentials of, 200
smoking status, patient™s, 17 MIA„ technique and, 19“20, 45 for liposuction. See liposuction,
tumescent
Society for Of¬ce Anesthesiologists plastic vs. cosmetic, 218
swelling, 245 for necklift, 102, 103
(SOFA), 222
sodium citrate, 179
ultraviolet light treatment, 185
sphenopalatine nerve block, 101 tachycardia, 17
United Kingdom, 60

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