Over the years, I have seen an increasing number of medical malpractice claims arising from the alleged failure to identify obstructive sleep apnea (OSA) when clearing a patient for anesthesia, surgery, and even opiate based pain management, whether it be perioperative pain management or other acute pain management.
Unquestionably, any patient undergoing general anesthesia for surgery is at significantly increased risk with OSA than otherwise. As a result, they are placed in higher risk categories. But what about the non-surgical patient admitted for acute pain management? Strategies aimed at opioid cessation can be particularly beneficial for these patients, reducing the risks associated with opioid use.
We wrote an entire blog on medical malpractice nuclear verdicts, read it here!
Pain management is a crucial aspect of healthcare that involves the diagnosis, treatment, and prevention of pain. Effective pain management can significantly improve the quality of life for individuals suffering from acute or chronic pain conditions. Pain medicine is a multidisciplinary field that incorporates various techniques, including pharmacological, non-pharmacological, and complementary therapies, to manage pain.
The primary goals of pain management are to reduce pain severity, alleviate suffering, and improve functional outcomes. A comprehensive pain management plan should be tailored to the individual’s specific needs, taking into account their medical history, current condition, and personal preferences. Pain management can be provided in various settings, including hospitals, clinics, and private practices, by a healthcare team consisting of pain physicians, nurses, physical therapists, psychologists, and other healthcare professionals.
Current guidelines from organizations such as the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the American Academy of Pain Medicine recommend a multimodal approach to pain management. This includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs), opioid and non-opioid analgesics, as well as non-drug therapies such as physical therapy, cognitive behavioral therapy, and, in some cases, transcutaneous electrical nerve stimulation (TENS). While some patients explore herbal remedies, these are generally not part of formal clinical guidelines due to limited evidence on efficacy and safety. The multimodal approach aims to effectively reduce pain while minimizing the risks and side effects associated with relying on any single treatment.
While any relationship between alleged opioid induced respiratory depression (OIRD) and OSA has not been conclusively confirmed, there is evidence to indicate that patients with OSA may be at higher risk of OIRD, and therefore, a physician considering prescribing opioids to such patients should proceed cautiously.
In a recent Lippincott summary Opioids for Acute Pain Management in Patients with Obstructive Sleep Apnea: A Systematic Review, it is suggested that “the intrinsic nature of opioids to suppress respiratory function is of particular concern among patients with OSA.” The summary goes on to say that “the association of OSA with increased perioperative risk has raised the question of whether patients with OSA are at higher risk for opioid-induced respiratory depression (OIRD) compared to the general population.” Finally, the summary concludes: “While quality evidence is needed, retrospective analyses indicate that critical, life threatening OIRD may be preventable with a more cautious approach to opioid use, including adequate monitoring.”
The potential benefits of using perioperative gabapentin to manage pain in patients with OSA should also be considered, as it may reduce the risk of OIRD.
The emergency department (ED) is a critical setting for pain management, where patients often present with severe pain or acute pain requiring immediate attention. ED physicians and nurses play a vital role in assessing and managing pain, using a combination of clinical judgment and evidence-based guidelines.
A clinical practice guideline for pain management in the ED typically includes an initial assessment of pain severity, followed by administration of appropriate analgesics, such as oral or intravenous acetaminophen, non-opioid analgesics, or opioid analgesics when needed. Non-pharmacological interventions, including positioning, immobilization, ice or heat application, and reassurance, can also support effective pain control.
The use of multimodal therapy—including regional anesthesia techniques and non-opioid analgesics—can help reduce opioid consumption requirements and minimize adverse events such as respiratory depression. ED staff should remain vigilant about the risks associated with opioid use, particularly in opioid-tolerant patients, and follow safe prescribing practices. Regular monitoring and reassessment of pain are essential to ensure adequate pain control and to adjust treatment plans as needed.
Although not an Indigo case, a recent medical malpractice verdict in South Florida is on point. In May 2020, a 54-year-old male, a husband and father, was admitted to a South Florida hospital with a bout of acute pancreatitis. Over the first 28 hours following admission, the patient received 27 doses of Dilaudid, an opioid medicine, for pain management, before suffering respiratory collapse. He was taken off life support within a week and passed away.
In the plaintiff’s case, it was argued that the treating physician failed to determine whether the patient had OSA. Had he done so, he would have learned the patient did have OSA and would have ordered increased monitoring, including telemetry and pulse oximetry to keep an eye on any possible signs of respiratory depression. It was alleged that the failure to order the increased monitoring allowed the patient to develop respiratory depression and, by the time the nurses learned about it, it was too late.
In the defendant’s case it was argued that the treating physician followed an appropriate regimen of Dilaudid dosing, with an eye on the medical history he took from the patient, including the patient’s statement that he did not suffer from any respiratory issues.
In September 2023, following a 2 week trial, the jury returned a verdict for the plaintiff in the amount of $20M after just 4 hours of deliberation. Although the jurors were not polled, it appears, like me, they had concerns that the patient’s statement that he did not suffer from any respiratory issues was not sufficient to rule out OSA. The failure to monitor for OSA could be considered an adverse event that contributed to the patient's outcome.
Although the lawyers for the physician were able to mount a defense, clearly the jury did not find it persuasive. I’m no clinician but my experience in reviewing these kinds of cases leads me to believe that clearly documenting that OSA was asked about and considered is important. It’s possible that in the South Florida verdict, the decedent’s passing had nothing to do with OIRD, but such an argument would have been far more convincing had OSA been appropriately considered, managed, and documented in the patient’s care. That might be the difference between simply defending a case at trial and winning that case at trial.
The healthcare team plays a crucial role in pain management, working together to provide comprehensive care to patients with acute or chronic pain conditions. Effective communication and collaboration among team members—including pain physicians, nurses, pharmacists, physical therapists, and psychologists—are essential for developing and implementing a personalized pain management plan.
The healthcare team should be knowledgeable about a range of pain management strategies, including pharmacological, non-pharmacological, and complementary therapies, to provide evidence-based care. Staying informed through clinical guidelines, professional education, and summaries of the latest research helps ensure care is up-to-date, including the appropriate use of non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, and non-opioid analgesics.
Importantly, the healthcare team should aim to address the underlying cause of pain when possible, rather than focusing solely on symptom relief, to provide effective pain relief and improve functional outcomes. By working together, the healthcare team can help reduce the burden of pain on individuals and society, improve medical outcomes, and enhance patients’ overall quality of life.
Regular education and training on pain management guidelines and research updates can help healthcare teams deliver high-quality, up-to-date care.
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