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Medicolegal Perspectives of Regional Anaesthesia

SM Basu

Perhaps the word law or legal appears to everyone as a threat. to us, the medical
practitioners it can just be taken up as a threat to the professional autonomy, allowing the
freedom or autonomy only within the law of land. This chapter aims to provide core information
on medicolegal aspects which will enable us to interact with the legal system to resolve the
issues in question.

Conset or consent to treatment

It is the most fundamental agreement between the doctor and the patient forming the
basis of medicolegal bondage.

A consent is an “INFORMED CONSENT” (valid in Sec 90 IPC) if it is given voluntarily

(without anyone forcing it to do so) by a patient aged more than 12 years having the capacity or
ability to understand the nature of transaction with the knowledge of enough information
including the possibility of cure or any alternative mode of treatment with the advantages,
disadvantages and the risk involved in each endeavour which have been divulged by the doctor
concerned. Medicolegal consent requires all these interdependent elements and an absence of
any one will make the consent nuil and void.

When the patient is younger (up to 12 years) or in emergency situations or in mentally

unsound condition, next of kin or the legal guardian may consent to treatment.

Conset for Anaesthesia

Though the most critical moments of surgical patients’ lives are spent under anaesthesia,
it may appear very insignificant ions to the public at large till an anaesthetic accident occur. The
price of an error of judgment even for a second or a small technical fault is paid heavily by the
patient being translated as life long morbidity or mortality. This can be only comparable to the
activities of an aviation pilot. But he is not answerable in case of mishaps as he snatches away
hundreds of lives with his own. But we anaesthetists have to answer and as such the consent for
anaesthesia is very vital to us.
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Anaesthetists need to explain the anaesthetic procedure in very simple language starting
from premedication, intravenous infusion, induction – maintenance, recovery, postoperative
problems of pain (the mode of relief), nausea/vomiting, etc.

Similarly when a regional technique is chosen the prick of the nerve block or the prick of
the lumbar puncture, the numb feeling of the part of the body, and postoperative headache need
to be explained. The inherent risks of the two (general or regional) are explained with the
remoteness of such possibility according to literature. Apart from this the reason of opting the
technique which will iutweigh the benefit of being fully unconscious should be explained to the
patient.

The patient must be aware of all these before consenting to anaesthesia, in presence of a
witness (next of kin, guardian or friend of the patient).

Legal Consequences of Lack of Consent

1. It may lead to patient’s right for remedies under civil or criminal law.
2. It is considered as a trespass to individual’s self determination and respect for integrity.

Common Legal Issues raised regarding the Consent

1. Improper explanation during consultation

Remedy : Consent to be signed in presence of a witness.
2. Improper disclosure of the inherent risks
Remedy : Even if it is remote the usual risks are to be explained.
3. Improper disclosure of perioperative advice
Remedy : Adequate advice to be followed before, during and after anaesthesia eg Spinal
(intrathefcal block) – to have enough drinks and to lie recumbent (?), etc. are to be given.

Suspected litigant prone patient : Get the consent signed by witness, mentioning detail
discussion.

Negligence

In the Concise Oxford Dictionary negligence connotes careless state of mind which may
amount to recklessness or indifference.
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In law ‘negligence’ is defined as breach of duty owned by one person to another

resulting in injury to the latter or omission to do something which a reasonable man guided upon
those considerations which ordinarily regulate the conduct of human affairs would do. Medical
personnels are expected to provide reasonable degree of shill, knowledge and care as per
qualification and experience earned by the doctor. Any deficiency in any sphere will make the
doctor liable to ‘negligence’.

In developed countries, anaesthetic practice is fraught with relentless allegations of

medical negligence. But the plaiuntiff (usually the former patient or patient’s next of kin) must
prove three essential elements to establish liabilities:

(a) Must prove the deviation from requisite medical standard care; presenting evidence that
in the care of the patient the defendant anaesthetist concerned did something which an ordinary
person of his skill, care and diligence would not have done under the same or similar
circumstances or the dendant failed or omitted to do something that was expected from an
anaesthetist of reasonable skill, care and diligence.

The terminology ‘standard care’ is variable, hence the phrase under the same or similar
circumstances is applicable. This will be guided by patient’s condition as well as the other
aspects e.g. the nature of the procedure, the availability or quality of equipment, which will be
considered in evaluating anaesthetist’s responsibility.

(b) Extent at the time of the incident that brought to the law suit. The law recognizes
that it is neither fair nor proper to consider recent developments in judging the actions of an
anaesthetist that occurred long back. Court cannot take action according to availability of newer
agents, monitoring devices or standard developed in 1999 in an incident which occurred in 1990.
(c) Testimony of a qualified anaesthetist who is in active medical practice. This has been the
standard practice in developed countries. The defence attorney in most cases ascertain carefully
the identity, qualification, experience and present assignment of the person before the trial.

Record keeping
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Realizing value of record keeping of anaesthetic events it was first started by Harvey
Cushing in 1895 which led to an updated from by Nosworthy in 1943. Presently every big
hospital in developed countries has its own anaesthetic record card.

From the medicolgeal point of view a comprehensive anaesthetic record is of immense

value, providing a potentially strong basis of defence in respect of any claim for negligence
against anaesthetist.

After this preamble of a few medicolegal terminologies and their implications let us turn
our attention to the principal topic “Medicolegal perspectives of Regional Anaesthesia”.

MEDICOLEGAL PERSPECTIVES OF REGIONAL ANAESTHESIA

It can be observed that during the last decade the pendulum has swung back with an
increasing interest and enthusiasm to regional, anaesthesia, with this, the global interest in day
care surgery has worked as a catalyst to this renaissance. But unfortunately while compiling the
common complications of Regional Anaesthesia one can easily gauze the severity or degree of
morbidity. Though serious complications are rare and death is still a rarity – any one
complication can very well invite a legal action for damages against the anaesthetist.

Some complications of Regionl Anasthesia

Blocks Complications

A. Brachial plexus block6

Interscalene Phenic nerve paralysis, Hoarseness due to

block of recurrent laryngeal nerve

Supraclavicular Pneumothorax

Axillary Direct trauma to Ulnar, Median and Radial

nerves
B. Stallate Ganglion Block Horner’s Syndrome (ptosis, meiosis and

enophtalamos), Pneumothorax
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C. Intra Venous Regional Drowsiness, Tinnitus, Tingling of the lips,

Anesthesia (IVRA)7 Convulsion, Death.
D. Spinal (intrathecal) and epidural blocks
Complication Couse
I. Headache8 Low pressure CSF
High pressure CSF
II. Paralysis of nerves9 Hydrostatic disturbance inside the cranial
Vault

All the cranial nerves except

Oculomotor (III), Glossopharyngeal

(IX), Vagus (X)

III. Meningitis10-13
The most dreaded Spread of infection or
Complication chenicals
IV. Miscellaneous14-16
1. Damage to spinal cord direct injury by the
and nerve root needle
2. Horner’s syndrome Seepage from extrandural analgesia due
to high sympathetic block.
3. Tranverse myelitis
4. Cauda eqina syndrome Chemical contaminants, local anaesthetic
(pain in limb and itself or combination, or infection
Progressive motor
(paralysis)
5. Chronic adhesive
Aracnoiditis
6. Paraplegia
7. Pathologica changes
in the spinal cord Local analgesics
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8. Anterior spinal
artery syndrome ? Adrenaline
9. Intracraniaal complications17-19
Very rarely subdural
haematoma, cerebral uncus
herniation, intracranial
haemorrhage

E. Complications due to faculty positioning during regional anesthesia

(a) Femoral (Anterior
crural)20 neurophaty
(b) Lateral femoral21
Cutaneous nerve parasthesia
(Meralgia Paresthetica)
(c) Peroneal nerve palsy22
Wide abduction and external rotation’
(only possible as the lower limbs are numb)
Maintaining lithotomy position
(i) Strecting, compromised
blood supply