1. Obesity in the Closed Claims Database
Karen B. Domino, MD, MPH
Professor and Vice Chair
Anesthesiology and Pain Medicine
University of Washington, Seattle, WA
Director, Anesthesia Closed Claims Project

2. No commercial financial disclosures
The Anesthesia Closed Claims Project is funded by the Anesthesia Quality Institute.

3. Learning Objectives
Describe perioperative complications associated with morbid obesity in the Anesthesia Closed Claims database
Assess most frequent causes of adverse outcomes associated with morbid obesity Closed Claims
Apply these findings to improving safety in the perioperative care of morbidly obese patients

4. Overview Project methodology Morbidly obese vs. non-obese
Case examples

5. Anesthesia Closed Claims Project
16 insurance organizations
13,000+ anesthesiologists insured by current panel of companies
Organizations cover ~36% of practicing anesthesiologists in U.S.

6. Study Methodology On-site review by MDs
Standardized data collection instrument
Review by committee
Damaging events: incident or mechanism leading to adverse outcome
Adverse outcome: injury sustained by patient

7. Utility of Closed Claims Data
Study of infrequent events
Collection of “Sentinel Events”
Identify areas of recurrent risk
Provide direction for in-depth analysis
Snapshot of anesthesia liability

8. Bias with Malpractice Claims
No denominator for calculating risk
Small subset of injuries
More severe, permanent injuries
More substandard anesthesia care

9. Anesthesia Closed Claims Project Database (exclude chronic pain)
Inclusion Criteria
Anesthesia Closed Claims Project Database
N = 10,811
Perioperative - Yr
(exclude chronic pain)
n = 2,612
Adults
(Age 18 +)
n = 2,444
Morbidly Obese
BMI > 40
n = 263
Not Obese or
BMI <30
n = 915
BMI 30-39
n = 483
Missing BMI
n = 783

10. Demographics: Morbidly Obese vs. Non-obese
Female (%)
60%
59%
ASA 1-2 (%)
21%*
59%*
Elective case
82%
86%
Age (yrs) (SD)
46 (13)
51 (17)
Inpatients
84%*
67%* OB
14% 8% GA
72%
*p<0.001
N=10,811

11. Severity of Injury: Morbidly Obese vs. Non-obese
Percent in each group
*p=<0.001
N=10,811

12. Specific Injuries in Morbidly Obese (n=263)
Eye %
MI %
Burn %
CVA %
Awareness 2%
Back pain 2%
Other
16%
Death
46%
Aspiration
Pneumonitis 6%
Airway
Trauma 8%
Nerve
Damage
14%
Brain
Damage
10%
N=10,811

13. Damaging Events: Morbidly Obese vs. Non-obese*
*p<0.001
Percent in each group
N=10,811

14. Specific Damaging Events: Morbidly Obese vs. Non-obese
Difficult intubation
17 (6%)*
25 (3%)*
Inadequate ventilation
33 (12%)*
50 (6%)*
Premature extubation
21 (8%)*
18 (2%)*
Pulmonary embolus
9 (3%)*
6 (1%)*
High block
8 (3%)*
8 (1%)*
*p<0.01
N=10,811

15. Liability: Morbidly Obese vs. Non-obese
*p<0.01
Percent in each group
$435,200*
$244,650*
N=10,811

16. Difficult Intubation 50 y.o. ASA 3 woman (BMI 49)
Laparoscopic gastric bypass
GA-ET (propofol /rocuronium)
3 attempts to intubate
Bag-mask ventilation difficult
LMA-poor ventilation, SpO2
Code 15 min after induction
Tracheostomy 20 min after induction
Brain damage
$600,000 settlement

17. Inadequate Ventilation and Oxygenation
65 y.o ASA 3 man - DM, HTN, OSA
Colonoscopy with propofol (400mg)
SpO2 97%, HR 70 initially
Multiple PVCs then HR 40
Procedure end: pt. blue, SpO2 75%, HR 49
Bag-mask ventilation, CPR
Anoxic brain damage – died
$1,000,000 settlement

18. Post-Op Respiratory Depression
27 y.o. ASA 2E woman
BMI 52, probable OSA
Laparoscopic salpingectomy
Uncomplicated GA
D/C home (2 hours PACU)
Husband woke pt. for hydrocodone
6 hrs. later dead in bed

19. Premature Extubation 60 y.o. female (BMI 45) with OSA/HTN
Elective eye surgery
Awake fiberoptic intubation (3 attempts)
Extubated when opening eyes
Airway obstruction with SpO2
Unable to ventilate/intubate
Emergency tracheostomy
Patient died
$850,000 settlement

20. High Block after Accidental Intrathecal Injection
35 y.o. ASA female (BMI 74)
Labor at 41 weeks
Epidural L4-5 using LOR
Difficult to thread catheter
O.2% ropivacaine with fentanyl 100mcg
Catheter threaded – No CSF
Anesthesiologist left
Pt. apneic, unconscious, HR 80 within 10 minutes
C-section
Baby died/mother brain damage
$1,500,000 settlement

21. Safety Issues Identified by Closed Claims Review
Proportion of deaths
Respiratory events
Difficult intubation
Inadequate ventilation/oxygenation
Premature extubation
Pulmonary embolus
High block/total spinal

22. Welcome to the Closed Claims Project and its Registries
OSA
Anesthesia Awareness Registry
NINS