title: Perioperative Complications in Obstructive Sleep Apnea Patients Undergoing Surgery: A Review of the Legal Literature.
abstract: BACKGROUND
  Obstructive sleep apnea (OSA) is common in patients undergoing surgery. OSA, known or suspected, has been associated with significant perioperative adverse events, including severe neurologic injury and death. This study was undertaken to assess the legal consequences associated with poor outcomes related to OSA in the perioperative setting.
  
  
  METHODS
  A retrospective review of the legal literature was performed by searching 3 primary legal databases between the years 1991 and 2010 for cases involving adults with known or suspected OSA who underwent a surgical procedure associated with an adverse perioperative outcome. OSA had to be directly implicated in the outcome, and surgical mishaps (i.e., uncontrolled bleeding) were excluded. The adverse perioperative outcome had to result in a lawsuit that was then adjudicated in a court of law with a final decision rendered. Data were abstracted from each case regarding patient demographics, type of surgery, type and location of adverse event, associated anesthetic and opioid use, and legal outcome.
  
  
  RESULTS
  Twenty-four cases met the inclusion criteria. The majority (83%) occurred in or after 2007. Patients were young (average age, 41.7 years), male (63%), and had a known diagnosis of OSA (96%). Ninety-two percent of cases were elective with 33.3% considered general procedures, 37.5% were ears, nose and throat procedures for the treatment of OSA, and 29.1% were considered miscellaneous interventions. Complications occurred intraoperatively (21%), in the postanesthesia care unit (33%), and on the surgical floors (46%). The most common complications were respiratory arrest in an unmonitored setting and difficulty in airway management. Immediate adverse outcomes included death (45.6%), anoxic brain injury (45.6%), and upper airway complications (8%). Overall, 71% of the patients died, with 6 of the 11 who suffered anoxic brain injury dying at an average of 113 days later. The use of opioids and general anesthetics was believed to play a role in 38% and 58% of cases, respectively. Verdicts favored the plaintiffs in 58% of cases and the defendants in 42%. In cases favoring the plaintiff, the average financial penalty was $2.5 million (±$2.3 million; range, $650,000--$7.7 million).
  
  
  CONCLUSIONS
  Perioperative complications related to OSA are increasingly being reported as the central contention of malpractice suits. These cases can be associated with severe financial penalties. These data likely underestimate the actual medicolegal burden, given that most such cases are settled out of court and are not accounted for in the legal literature.
authors.affiliation: From the *Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals, Case Western Reserve University, Cleveland, Ohio; †Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio; and ‡Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Nick
authors.initials: N
authors.lastname: Fouladpour
authors.forename: Rajinish
authors.initials: R
authors.lastname: Jesudoss
authors.forename: Norman
authors.initials: N
authors.lastname: Bolden
authors.forename: Ziad
authors.initials: Z
authors.lastname: Shaman
authors.forename: Dennis
authors.initials: D
authors.lastname: Auckley
mesh_terms: D000328:Adult; D035881:Compensation and Redress / Q000331:legislation & jurisprudence; D016208:Databases, Factual; D005260:Female; D006801:Humans; D016365:Liability, Legal / Q000191:economics; D008297:Male; D008318:Malpractice / Q000191:economics / Q000331:legislation & jurisprudence*; D019300:Medical Errors / Q000191:economics / Q000331:legislation & jurisprudence*; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000191:economics / Q000209:etiology* / Q000401:mortality; D018570:Risk Assessment; D012307:Risk Factors; D020181:Sleep Apnea, Obstructive / Q000150:complications* / Q000175:diagnosis / Q000191:economics / Q000401:mortality; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000191:economics / Q000331:legislation & jurisprudence* / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult