Anaesthesia, 2010, 65, pages 435–442 Editorial

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and activities, and called upon other References 10 Lim V, Stubbs JW, Nahar N, et al.
professional organisations to do the 1 Meinshausen M, Meinshausen N, Politicians must heed health effects
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Cambridge, UK

Editorial
The hidden cost of neuraxial regional anaesthesia over the period twelve-year period up to 2007. This
anaesthesia? 1995–2007 [1]. Their study indicates may be compared with 62 claims
that there was a total cost from litigation involving drug administration errors
In this month’s Anaesthesia, Syzpula and to the National Health Service of just over the same period that cost
colleagues report on litigation related to over £1 million per year for the £4.3 million [2].

 2010 The Authors

Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland 437
Editorial
. ....................................................................................................................................................................................................................
Unfortunately, as the authors recog-
nise, the relative safety of regional
anaesthesia cannot be determined from
reports of this type because we do not
know how many blocks were per-
formed during the period examined,
or the total number of complications
arising from those blocks; we know
only the number of complications that
led to successful claims. Closed-claim
analysis will tend to underestimate the
true incidence of complications because
not all patients who suffer complications
will sue [3]. Furthermore, we cannot
accurately establish the real severity of
the complications, but must deal with
only the Courts’ assessment of the
financial impact of injuries.
The costs awarded for obstetric
regional anaesthesia claims (median
£5 678) were higher than those awarded
for non-obstetric regional anaesthesia
claims (median £3 337). Neuraxial
block accounted for all of the obstetric
claims and 82% of the non-obstetric
claims. The interpretation of these fig-
ures must be in the light of how the
Courts determine the amount of money
awarded in damages. Sums are awarded
to compensate loss of earnings and
requirement for ongoing care; thus,
complications resulting in the death of a
patient may not receive as great an award
as those causing issues requiring ongoing,
expensive care. However, the eight
deaths that were recorded were awarded
a median award of £42 000 (with a
largest payment of £178 000), whereas
the 68 severe complications received
only £6 000 (but with a largest pay-
ment of £2 070 000); this may have
been influenced by care needs for a
child who may also have been injured.
Interestingly, it may be observed that
the severity of non-fatal complication
did not correlate well with the
amounts awarded, with the cost per
case greater for moderate complications
than for moderate ⁄ severe ones as
assessed by the authors.
When one turns to the type of regional
anaesthesia performed, the results may be
interpreted as sobering or encouraging,
depending on which type of anaesthesia
one practises. The total cost of damages
following complications of neuraxial
regional anaesthesia was £12 million,
438
the cost for ophthalmic regional anaes-
thesia claims was £0.36 million and the
cost for all other peripheral blocks
excluding ‘unspecified’ was £0.12
million. This is partly related (see Table
3 in the authors’ manuscript) to the
catastrophic complications that may
occur following neuraxial anaesthesia.
Perhaps surprisingly, damages awarded
following lower limb blocks (£116 000)
far exceeded those awarded following
upper limb blocks (£1 000).
The cost of awards related to central
neuraxial blockade amounted to 89% of
all regional anaesthesia claims. Of these,
81% were for complications related to
epidurals (72% of all claims). One can
only speculate on the reasons for these
findings; perhaps, a greater number of
epidurals are performed, complications
occur more frequently and ⁄ or are more
likely to be successfully settled follow-
ing neuraxial blockade, or more simply,
complications are less frequent follow-
ing peripheral nerve blockade. The
worrying possibility is that epidural
anaesthesia is not as safe as we once
thought. The Third National Audit
Project of the Royal College of Anaes-
thetists on major complications follow-
ing neuraxial block estimated the
incidence of adverse sequelae following
peri-operative epidural block at
between 1 in 6000 and 1 in 12 000
and the incidence of paraplegia or death
at approximately 1 in 100 000, which
the authors of the report found reassur-
ing [4]. The size of the awards presented
by Szypula et al. serve as a reminder that
although severe complications after
neuraxial block are rare, when they do
occur they have a major impact on
patients’ lives.
Brull and colleagues reviewed 32
studies primarily investigating neuro-
logical complications of regional anaes-
thesia [5]. The rate of both temporary
and permanent neuropathy after spinal
and epidural anaesthesia was 3.78:10
000 (95% CI 1.06–13.50:10 000) and
2.19:10 000 (95% CI 0.88–5.44:
10 000), respectively. For peripheral
nerve blocks, the rate of neuropathy
after interscalene brachial plexus
block, axillary brachial plexus block,
and femoral nerve block was 2.84:100
(95% CI 1.33–5.98:100), 1.48:100 (95%
Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65, pages 435–442
CI 0.52–4.11:100), and 0.34:100 (95%
CI 0.04–2.81:100), respectively. This
might suggest that there is less risk of
neurological complications following
central neuraxial than peripheral blocks.
However, they also stated that the rates
of permanent neurological injury after
spinal and epidural anaesthesia were
0–4.2:10 000 and 0–7.6:10 000, respec-
tively, with only one case of permanent
neuropathy reported in 16 studies of
neurological complications after periph-
eral nerve blockade. This second state-
ment probably reflects both the rare but
serious sequelae following central neur-
axial blockade and a high incidence of
temporary neurological symptoms with
very rare permanent neurological dam-
age following peripheral block. This
may have more relevance to patients
and also in relation to successful damage
claims.
What conclusions should we draw
from Szypula and colleagues’ report?
Caution is certainly advisable, given the
afore-mentioned lack of a denominator
to lend context to the numerator pro-
vided. Caution is also advisable given
that the real severity of claims is skewed
to the Courts’ view of financial impact.
However, we feel that it is wise to
bear in mind the potentially major
impact on patients’ lives of the compli-
cations related to regional, and in
particular, epidural, anaesthesia. A large
multi-centre Australian study of epidural
analgesia following major surgery did
not show the 20% reduction in mortality
and morbidity it was powered to find,
and patients in both the treatment and
control (non-epidural) groups demon-
strated low pain scores [6]. This may
have influenced a reduction in epidural
usage in Australia and New Zealand [7].
One cannot dispute the excellent
dynamic analgesia that regional analgesia
can provide postoperatively. However,
now that epidural analgesia is routinely
administered on the open ward, hypo-
tension and failure are frequently
encountered and its success relies on
the presence of an efficient, on-site
acute pain service to deal swiftly
with these problems and other compli-
cations that occur. The paucity of clear
evidence of benefit and risk relating
to the use of peri-operative epidural
 2010 The Authors
Anaesthesia, 2010, 65, pages 435–442
. ....................................................................................................................................................................................................................
analgesia means that anaesthetists should
still make risk-benefit calculations for
each patient.
We should also perhaps be
encouraged that the amount of damages
awarded following peripheral regional
anaesthetic blockade was so small. The
evidence is limited here in much the
same way as was discussed regarding
epidurals: the lack of a denominator
makes firm conclusions inadvisable.
However, this evidence may provide
further encouragement that peripheral
nerve blocks result in few significant
injuries.
Finally, we would also emphasise
the importance of informed consent
before the performance of regional
anaesthetic techniques and the record-
ing of clear and detailed notes of any
procedure performed. In the eyes of
the Courts, it is not the occurrence of
a complication that determines fault
and the award of damages, but the
failure to demonstrate that a responsi-
ble and appropriately cautious tech-
nique was employed.
Editorial
Sedation – is delegation
appropriate?
Very few, if any, senior professionals
personally perform all the activities for
which they are responsible, and dele-
gation of specific tasks to others who
are less well trained and qualified is
commonplace. Where long-term, close
working relationships exist and super-
vision is both direct and continuing, it
may be possible to maintain high
standards of practice without external
validation of process. However, in the
modern health service, this situation
seldom pertains. It is therefore essential
that the competence of those carrying
out delegated tasks is ensured and that
the systems in which they operate are
safe. There are several conflicting
concerns when the delegation of tasks
or the extension of roles is discussed.
 2010 The Authors
Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Editorial
Competing interests 3 Bedforth NM, Aitkenhead AR,
JGH provides medicolegal reports that Hardman JG. Haematoma and abscess
sometimes concern regional anaesthesia. after epidural analgesia. British Journal
N. M. Bedforth
of Anaesthesia 2008; 101: 291–3.
4 Cook TM, Counsell D, Wildsmith
Consultant Anaesthetist & Honorary
JA. Major complications of central
Special Lecturer
neuraxial block: report on the
J. G. Hardman
Associate Professor & Reader Third National Audit Project of the
Honorary Consultant Anaesthetist Royal College of Anaesthetists. British
Queen’s Medical Centre, University of Journal of Anaesthesia 2009; 102: 179–
Nottingham 90.
Nottingham, UK 5 Brull R, McCartney CJ, Chan VW,
Email: nbedforth75@me.com El-Beheiry H. Neurological
complications after regional anesthesia:
References contemporary estimates of risk. Anes-
1 Szypula K, Ashpole KJ, Bogod D, thesia and Analgesia 2007; 104: 965–74.
Yentis SM, Mihai R, Scott S, Cook 6 Rigg JR, Jamrozik K, Myles PS, et al.
TM. Litigation associated with Epidural anaesthesia and analgesia and
regional anaesthesia: an analysis of outcome of major surgery: a rando-
claims against the NHS in England mised trial. Lancet 2002; 359: 1276–82.
1995–2007. Anaesthesia 2010: 443–52. 7 Werrett G, French R. Epidural
2 Cranshaw J, Gupta KJ, Cook TM. analgesia: first do no harm. Anaesthesia
Litigation related to drug errors in 2008; 63: 553–4.
anaesthesia: an analysis of claims
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Some professions will see an extension that integrating new roles can be
of their role as something that will difficult.
provide additional interest and respon- Anaesthetic practice, in its widest
sibility and may enhance both their sense, faces a number of challenges in
status and remuneration. Managers may service delivery. It is not feasible, far less
consider that getting an alternative affordable, for every patient in the UK
employee to undertake a task will who requires sedation to be cared for
either be less expensive per se or will exclusively by a fully trained anaesthe-
allow greater flexibility in staffing. tist. Indeed, it may not be feasible for
However, those who currently under- this to apply to every patient who
take the task may perceive a threat to requires anaesthesia, the establishment
their status, autonomy and job security, of epidural analgesia or the provision of
and wish to retain control. Patients and intensive care. How then should the
their representatives will not be alone specialty respond to proposals that some
in considering quality of service and of our traditional roles are undertaken
safety to be of paramount importance, by others; what, for example, should we
and at times it can be difficult for those make of reports such as the article in this
not directly involved to separate gen- issue by Edwards et al. [1], suggesting
uine concern about safety from ele- that it is safe for non-anaesthetists to
ments of job protection. Almost all of administer propofol and alfentanil to
the above could relate to many differ- patients who are undergoing oocyte
ent professions and it is well known retrieval?
439