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The American Society of Anesthesiologists closed claims project: the beginning.

Unexpected cardiac arrest during spinal anesthesia: A closed claims analysis of predisposing factors. By Robert A. Caplan, Richard J. Ward, Karen Posner, and Frederick W. Cheney. ANESTHESIOLOGY 1988; 68:5―11. Abstract used with permission. Abstract: Fourteen cases of sudden cardiac arrest in healthy patients who received spinal anesthesia were discovered in a preliminary review of 900 closed insurance claims for major anesthetic mishaps. All patients were resuscitated from the intraoperative cardiac arrest, but six suffered such severe neurologic injury that they died in hospital. Of the eight survivors, only one patient exhibited sufficient neurologic recovery to allow independence in daily self-care. In view of the unexpected nature of these cardiac arrests—as well as the ultimate severity of injury— the cases were analyzed in detail to determine whether there were recurring patterns of anesthetic management that may have contributed to patient morbidity and mortality. Two patterns were identified. The first was the intra-operative use of sufficient sedation to produce a comfortable-appearing, sleep-like state in which there was no spontaneous verbalization. Cyanosis frequently heralded the onset of cardiac arrest in patients exhibiting this degree of sedation, suggesting that unappreciated respiratory insufficiency may have played an important role. The second pattern appeared to be an inadequate appreciation of the interaction between sympathetic blockade during high spinal anesthesia and the mechanisms of cardiopulmonary resuscitation. Prompt augmentation of central venous filling through the use of a potent α-agonist and positional change might have improved organ perfusion, shortened the duration of cardiac arrest, and lessened the degree of neurologic damage.