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Perioperative Peripheral Nerve Injury After General Anesthesia: A Qualitative Systematic Review

Chui, Jason, MBChB, FANZCA*; Murkin, John M., MD, FRCPC*; Posner, Karen L., PhD; Domino, Karen B., MD, MPH

doi: 10.1213/ANE.0000000000003420
Patient Safety: Narrative Review Article
Continuing Medical Education

Perioperative peripheral nerve injury (PNI) is a well-recognized complication of general anesthesia that continues to result in patient disability and malpractice claims. However, the multifactorial etiology of PNI is often not appreciated in malpractice claims given that most PNI is alleged to be due to errors in patient positioning. New advances in monitoring may aid anesthesiologists in the early detection of PNI. This article reviews recent studies of perioperative PNI after general anesthesia and discusses the epidemiology and potential mechanisms of injury and preventive measures. We performed a systematic literature search, reviewed the available evidence, and identified areas for further investigation. We also reviewed perioperative PNI in the Anesthesia Closed Claims Project database for adverse events from 1990 to 2013. The incidence of perioperative PNI after general anesthesia varies considerably depending on the type of surgical procedure, the age and risk factors of the patient population, and whether the detection was made retrospectively or prospectively. Taken together, studies suggest that the incidence in a general population of surgical patients undergoing all types of procedures is <1%, with higher incidence in cardiac, neurosurgery, and some orthopedic procedures. PNI represent 12% of general anesthesia malpractice claims since 1990, with injuries to the brachial plexus and ulnar nerves representing two-thirds of PNI claims. The causes of perioperative PNI after general anesthesia are likely multifactorial, resulting in a “difficult to predict and prevent” phenomenon. Nearly half of the PNI closed claims did not have an obvious etiology, and most (91%) were associated with appropriate anesthetic care. Future studies should focus on the interaction between different mechanisms of insult, severity and duration of injury, and underlying neuronal reserves. Recent automated detection technology in neuromonitoring with somatosensory evoked potentials may increase the ability to identify at-risk patients and individualize patient management.

From the *Department of Anesthesia & Perioperative Medicine, University of Western Ontario, London, Ontario, Canada

Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington.

Accepted for publication March 30, 2018.

Funding: The Anesthesia Closed Claims project is supported by the Anesthesia Quality Institute, the quality component of the American Society of Anesthesiologists.

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Jason Chui, MBChB, FANZCA, Department of Anesthesia & Perioperative Medicine, University of Western Ontario, University Hospital, C3-106, 339 Windermere Rd, London, ON N6A 5A5, Canada. Address e-mail to Jason.chui@lhsc.on.ca.

© 2018 International Anesthesia Research Society
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