CRNA and patient death

Specialties CRNA

Published

So I have been researching on where I want to end up and CRNA has stuck for about a year. The question I want to ask current CRNAs is what is it like in the OR when a patient crashes and ultimately dies? What about complications of anesthesia that lead to death? I know that a lot of the times the death will fall back on the anesthesia team and I am just wondering how that has affected you as a provider(and I am aware you must carry insurance).

This is something that I know no one wants to experience but I have to be real and know that it happens. Can anyone share thoughts or experiences?

Specializes in Anesthesia.
Well, you picked the paper, I didn't.

As to your IOM paper that you're citing, are you referring to "To Err is Human: building a safer health care system" published by the IOM's Committee on Quality of Health Care in America? The one that claimed that anesthesia related deaths fell from 2 in 10,000 to 1 in 200-300k anesthetics per year in just 20 years? Yes, I'm familiar with that paper. I'm also aware that those numbers are thrown around blindly without any knowledge at all of what actually went into coming up with those conclusions.

Did you actually read that paper or are you just repeating what someone has told you? BTW, do you really find it that easy to believe that anesthesia safety has improved to that order of magnitude in such a short period of time?

Coming up with a hard and fast number has been extremely controversial because of the wild disparity of variables involved as you have demonstrated by pointing out that the number changes when you try to control for acuity alone. That is only one small factor in a constellation of factors that confound accurate risk stratification.

[h=3]"Timeline of Anesthesia-Related Complications and Improvements[/h]


    • 1950s – principal intraoperative complications were hypotension, hypoventilation and hypoxia; resultant improvements in cardiac resuscitation, more rational transfusion therapy, increased use of recovery rooms, and more efficient use of mechanical ventilators.
    • 1960s – significant safety advantages of a Post Anesthesia Care Unit (PACU); reduction in anesthesia-related deaths attributed to an increase in the number of qualified staff and the degree of supervision.
    • 1970s – mortality rate increased with the severity of disease and the need for emergent operations; four specific changes occurred:
      • 1) continued improvement in routine monitoring,
      • 2) increase in the ratio of attending anesthesiologists to residents,
      • 3) decrease in the case load per anesthesiologist, and
      • 4) introduction of Intensive Care Units (ICU's)

      [*]1980s – studies began to be performed on a national basis; major complications occurred more frequently in older patients, those undergoing emergency operations, and those with more extensive comorbidities as measured by the ASA physical status classification; postanesthesia respiratory depression was the largest cause of death and coma that were totally attributable to anesthesia; death rate was inversely related to seniority of the operating surgeon and to preoperative preparation of the patient." Pennsylvania Society of Anesthesiologists > Physicians > Anesthesia Safety

      [*]

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I have provided 3 links to support that mortality rate is very low in anesthesia and depending on how it is calculated could be >1:100000 if you rely solely on ICD codes (which is will always be flawed since it could be the surgeons coding, the anesthesia provider, or independent coder with the first two blaming each other and the last one going by whatever surgical/anesthesia notes that are available at the time) to greater 1:200,000 if you rely on more consistent factors used by the ASA to conduct these studies.

The reference for the 1:300,000 was provided in one of my links, if you have a basic understanding of reviewing literature it will be easy to find. The article that you seem to be debating the most clearly states that most anesthesia related deaths will be from patients of extreme age, PS4+, and high risk procedures. These are all discussed in one form or another in the links I already provided.

We're talking about deaths directly attributable to anesthesia or as a contribution to the death.

Your 1 in 200-300k number comes from a study by Eichorn in 1989 and included ASA 1 and 2 only, died on the table, and were reported to a malpractice carrier. I'd provide the citation, but I know an expert in literature reviewer when I see one.

We're not talking about the patients illness or injury contributing at all. Your confusing procedural and physical status risks with anesthesia contribution to death... not the same thing and not what your citations are addressing.

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"Timeline of Anesthesia-Related Complications and Improvements


    • 1950s – principal intraoperative complications were hypotension, hypoventilation and hypoxia; resultant improvements in cardiac resuscitation, more rational transfusion therapy, increased use of recovery rooms, and more efficient use of mechanical ventilators.
    • 1960s – significant safety advantages of a Post Anesthesia Care Unit (PACU); reduction in anesthesia-related deaths attributed to an increase in the number of qualified staff and the degree of supervision.
    • 1970s – mortality rate increased with the severity of disease and the need for emergent operations; four specific changes occurred:
      • 1) continued improvement in routine monitoring,
      • 2) increase in the ratio of attending anesthesiologists to residents,
      • 3) decrease in the case load per anesthesiologist, and
      • 4) introduction of Intensive Care Units (ICU's)

      [*]1980s – studies began to be performed on a national basis; major complications occurred more frequently in older patients, those undergoing emergency operations, and those with more extensive comorbidities as measured by the ASA physical status classification; postanesthesia respiratory depression was the largest cause of death and coma that were totally attributable to anesthesia; death rate was inversely related to seniority of the operating surgeon and to preoperative preparation of the patient." Pennsylvania Society of Anesthesiologists > Physicians > Anesthesia Safety

Not sure what this is supposed to be. All of these improvements culminated in the 1980's when the anesthetic death rate was 2:10000, according to the IOM. The death rate allegedly radically improved in the 20 years following, not addressed on your list. Does not explain an improvement by 2-3 orders of magnitude in 20 years. It was either that safe to begin with or the numbers are not accurate.

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Specializes in Anesthesia.
We're talking about deaths directly attributable to anesthesia or as a contribution to the death.

Your 1 in 200-300k number comes from a study by Eichorn in 1989 and included ASA 1 and 2 only, died on the table, and were reported to a malpractice carrier. I'd provide the citation, but I know an expert in literature reviewer when I see one.

We're not talking about the patients illness or injury contributing at all. Your confusing procedural and physical status risks with anesthesia contribution to death... not the same thing and not what your citations are addressing.

Who exactly is determining "anesthesia related" deaths. I stand by the number of deaths from anesthesia being between 1:200,00-1:300,000 and as every recent reference I can find states that anesthesia related complications have gone down in recent years there is no reason to doubt that the number of anesthesia related deaths is extremely rare and overall is still decreasing. This has also been evidenced by decreasing malpractice rates for CRNAs over the last decade.

What exactly is your educational background that makes you an expert on this subject?

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Specializes in Anesthesia.
Not sure what this is supposed to be. All of these improvements culminated in the 1980's when the anesthetic death rate was 2:10000, according to the IOM. The death rate allegedly radically improved in the 20 years following, not addressed on your list. Does not explain an improvement by 2-3 orders of magnitude in 20 years. It was either that safe to begin with or the numbers are not accurate.

I can't tell is if you're incapable or unwilling to look this stuff up your self. Survival After General Anesthesia Vastly Improved: Study

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I can't tell is if you're incapable or unwilling to look this stuff up your self. Survival After General Anesthesia Vastly Improved: Study

A summary in HealthDay news for healthier living?

Look, even in the Google book link you provided, significant weight of the article was based on Robert Lagasse's work in response to the IOM's number that you cite. He is the one that called into question that conclusion in the first place. Look in the reference section of the article you chose to argue with and see for yourself.

Lagasse shows that because of high variability of operational definitions, reporting sources and risk stratification, the conclusion is flawed and while anesthesia has become far safer, it isn't where so many say it is. It's in the selection you chose, not me.

Go back and do some reading.... it's good advice. You posted a link to Complications in Anesthesia. Look at number 7 of the reference list, look it up and read it.

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What exactly is your educational background that makes you an expert on this subject?

Since when does someone need to claim expert status to make an argument? Folks don't need to check in with anyone first in order to justify taking a position on something here, I hope.

We'd both end up needing to delete posts.

My educational background is not part of this discussion, but I will say that it's far deeper that you've given me credit for here.

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Specializes in Anesthesia.
A summary in HealthDay news for healthier living?

Look, even in the Google book link you provided, significant weight of the article was based on Robert Lagasse's work in response to the IOM's number that you cite. He is the one that called into question that conclusion in the first place. Look in the reference section of the article you chose to argue with and see for yourself.

Lagasse shows that because of high variability of operational definitions, reporting sources and risk stratification, the conclusion is flawed and while anesthesia has become far safer, it isn't where so many say it is. It's in the selection you chose, not me.

Go back and do some reading.... it's good advice. You posted a link to Complications in Anesthesia. Look at number 7 of the reference list, look it up and read it.

Unless you have some expert knowledge about anesthesia that you aren't sharing you don't have the background for this conversation. I understand the risks and benefits of anesthesia. I understand the monitoring equipment, the drugs we use, the protocols, etc.. You on the other hand have no background to even have a basic understanding of this. Anesthesia by all accounts is one of the safest specialities there is.

Your opinion on this subject means very little. You don't understand the topic and pointing out one or two authors that disagree exactly how safe anesthesia is has little bearing on the subject. Anesthesia safety isn't perfect, but you cannot name another speciality that routinely causes patients to stop breathing, lose their voluntary reflexes, and brings them back to baseline status a few hours later.

Since you keep claiming to be such a expert on the subject why has the mortality rate of c-sections went down so significantly (10-16x per MM&M) in the last couple of decades? Why is it customary for all ORs to have a stripe painted on the walls? Why did the stripe used to be so important to patient and OR safety?

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Specializes in Anesthesia.
Since when does someone need to claim expert status to make an argument? Folks don't need to check in with anyone first in order to justify taking a position on something here, I hope.

We'd both end up needing to delete posts.

My educational background is not part of this discussion, but I will say that it's far deeper that you've given me credit for here.

Your educational background is everything considering the discussion, and if it is so substantial then you should not mind sharing it. You have not provided one piece of peer reviewed evidence or anything else to justify your argument. Instead you come to this thread stating "false statement" without any kind of explanation or evidence to support your claim. What kind of response were you expecting after such an inflammatory response on a thread you were not even previously on?.

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Your educational background is everything considering the discussion, and if it is so substantial then you should not mind sharing it. You have not provided one piece of peer reviewed evidence or anything else to justify your argument. Instead you come to this thread stating "false statement" without any kind of explanation or evidence to support your claim. What kind of response were you expecting after such an inflammatory response on a thread you were not even previously on?.

OK...I take it back.... switch "false statement" with "that has been seriously challenged". Now, read the reference list in your google books link.

Or read it here:

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1944093

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Specializes in Anesthesia.
OK...I take it back.... switch "false statement" with "that has been seriously challenged". Now, read the reference list in your google books link.

Or read it here:

Anesthesia Safety: Model or Myth?:A Review of the Published Literature and Analysis of Current Original Data

Again this is one authors view nothing more nothing less. Trying to nail down the exact number for anesthesia mortality is always going to be difficult when the number is extremely low to begin with and when it will always be debatable whether it was the anesthetic, the surgery, and/or patient status that was the cause of death. Almost every surgeon I have worked with is quick to blame anesthesia when a complication happens even to the extent of placing it in their charting, telling family it was anesthesias fault etc. even when it was blatantly obvious when it had nothing to do with anesthesia. That is why hospital reporting and closed claim cases in the U.S. are going to provide the best sampling data to answer this question.

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Oh....BTW, I'm A CRNA. But I still don't think that being in anesthesia is a prerequisite for this conversation, for what its worth.

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