What’s New in the Patient Safety World
May 2011
ASA Updates Advisory for Prevention of Perioperative Peripheral Neuropathies
In our September 29,
2009 Patient Safety Tip of the Week “Perioperative
Peripheral Nerve Injuries” we noted that peripheral nerve injuries are now
among the most common reasons for anesthesia-related malpractice claims.
The American Society
of Anesthesiologists has just updated its “Advisory
for the Prevention of Perioperative Peripheral Neuropathies”, originally
published in 2000. It’s called an “advisory” rather than a guideline because it
relies heavily on expert opinion given the relative paucity of an evidence base
in the literature for prevention of peripheral nerve injuries during anesthesia
or sedation in various settings.
It points out that
the preoperative assessment should take into account history of neurological
symptoms, diabetes, alcohol use and consider potential risk factors such as
body habitus, gender, vascular disease, and arthritis or other deformities.
Both extremes of weight are important considerations (remember that many
patients who develop peroneal nerve palsies have a history of recent
significant weight loss, voluntary or involuntary, with loss of the protective
fat pad likely being a contributory factor.) Almost any pre-existing peripheral
neuropathy renders nerves more prone to the effects of compression. Some
neuropathies, particularly the “hypertrophic” neuropathies where peripheral
nerves may be palpably enlarged, render patients even more vulnerable in
perioperative settings.
The advisory does do
a good job of identifying which peripheral nerves or plexuses are most
vulnerable to harm in the perioperative setting. And it provides reasonable recommendations
for proper positioning to help reduce the risk of nerve injuries in the upper
and lower extremities when the patient must be in various positions (eg. supine
vs. prone).
It also has a
discussion about the use of padding, arm boards, chest rolls, etc. to minimize
the risk to specific nerves. But it does note that padding may also have
unintended consequences, particularly if it is applied to tightly. The section
on the effects of equipment is also interesting, though almost all the literature
is from isolated case reports or small series. However, items such as automated
blood pressure cuffs, shoulder braces or rests, Foster frames, self-retaining
retractors, leg holders, surgical stockings, pneumatic compression devices,
stirrups (particularly when patient is in the lithotomy position), slings,
continuous passive motion machines, etc. have all been implicated in peripheral
nerve injuries.
We refer you back to
our September 29, 2009 Patient Safety Tip of the Week “Perioperative
Peripheral Nerve Injuries” for many other examples of peripheral nerve
injuries occurring in the perioperative setting.
While there is no
good evidence base on the practice, we advocate that the need for positioning
or repositioning to be discussed during the pre-surgical huddle (or the
surgical timeout) and that the duration of the procedure be announced
periodically so that consideration can be given to repositioning the
at-risk patient. At any rate, now is a good time to review your perioperative
procedures for preventing peripheral nerve injuries.
Reference:
The American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies presents an updated report of the Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies. Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies: An Updated Report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Anesthesiology 2011; 114(4): 741-754
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