JULY 18, 2024
Originally published by our sister publication Anesthesiology News
NEW YORK—In this issue, our series exploring anesthesia-related litigation examines a case in which it was alleged that the hospital, anesthesia team and anesthesiologist failed to properly manage a patient postoperatively with several missteps that ultimately led to the patient never regaining consciousness.
“This was a horrible outcome for the patient and his family, obviously, but also for the team taking care of
Originally published by our sister publication Anesthesiology News
NEW YORK—In this issue, our series exploring anesthesia-related litigation examines a case in which it was alleged that the hospital, anesthesia team and anesthesiologist failed to properly manage a patient postoperatively with several missteps that ultimately led to the patient never regaining consciousness.
“This was a horrible outcome for the patient and his family, obviously, but also for the team taking care of the patient,” said Patricia Fogarty Mack, MD, a professor of clinical anesthesiology at Weill Cornell Medical College, in New York City,
Mack, who was not involved in the case, and Michael Schoppmann, JD, the CEO of MLMIC Insurance Co., discussed the case at the 2023 annual PostGraduate Assembly in Anesthesiology.
Case and Circumstances
The patient was a 54-year-old man with a body mass index of 43.4 kg/m2 undergoing cystoscopy and transurethral resection of the prostate. His medical history included benign prostatic hyperplasia, diabetes, hypertension and obstructive sleep apnea (OSA).
After induction of general anesthesia, the CRNA administered 120 mg of rocuronium. The surgery started at 8:10 a.m.; the CRNA administered more rocuronium at 8:50 a.m. and again 40 minutes before the procedure ended. At 9:40 a.m., they administered muscle relaxant reversal; there was no twitch monitoring of the patient.
At 9:50 a.m., the patient was extubated, but he began to flail his arms and legs before transfer to the PACU. His oxygen (O2) saturation fell and he was ventilated with an Ambu bag and mask. Two minutes later, the anesthesiologist placed a laryngeal face mask (LMA) and the patient’s O2 saturation increased to 95%. Thirteen minutes later, after determining the patient had good muscle strength and could follow commands, the anesthesiologist removed the LMA; the patient’s O2 saturation plunged to 50% and his heart rate fell to 40 beats per minute. A nurse pressed the code button, but it was nonfunctional and the scrub technician ran to the PACU for help.
At 10:07 a.m., the anesthesiologist returned, intubated the patient and placed him on a ventilator; code blue was called at 10:08 a.m. At 10:24 a.m., the patient went into rapid atrial fibrillation and was administered amiodarone and phenylephrine drips; he was transferred to the ICU for cooling therapy after the cardiac arrest. The patient never regained consciousness. Diagnosed with metabolic encephalopathy, respiratory failure and hypoxia, he remained in a vegetative state, requiring lifelong care.
Experts reviewing the case identified overmedication with rocuronium, premature extubation and credibility concerns in the electronic health record as the main liability issues.
The allegations included a failure to follow or meet the standard of care, to appreciate the significance of the patient’s medical history, failure to timely intubate, and delay in calling for help by activating a code.
Eventually, the case settled out of court for $3,299,00 and $629,674 in expenses, with the anesthesiologist bearing 39% of the cost and the anesthesia group and hospital responsible for 30% each; as this was an older case, settlement and expenses would likely have been significantly higher today.
What Went Wrong? What Could Have Been Done Better?
Mack questions some of the allegations; for instance, was the patient’s medical history insufficiently accounted for? “The only thing I see here is maybe the OSA contributed.”
Was the muscle relaxant too high a dose for a nearly 300-pound patient? “I don’t agree with that.” She found other allegations more plausible.
“I think lack of twitch monitoring is a reasonable allegation. Whether or not it was available is another story, and that would be a systems issue if it was not. The decision to extubate close to the second dose of rocuronium is problematic without accurate ability for quantitative assessment of recovery from neuromuscular blockade,” she said.
Things might have looked a bit more favorable for the defense if they had not experienced the code button malfunction, or if they’d had backup systems in place. Also, there was some mention of an incident report being filed in the medical record: “That’s a no-no; don’t do that,” Mack said.
It would have been helpful to have had an accurate time line of events and measures documented in the medical record; some of the recordkeeping in this case raised credibility concerns.
“In the medical record, you can see everything. Every time you touch it, it’s recorded down to the tiniest keystroke and can all be introduced at trial,” Schoppmann said.
He acknowledged that patient care is always the priority during a case, and that minute-by-minute documentation is challenging, if not impossible. “But there is an expectation that you’ll be able to accurately, if retrospectively, reconstruct what took place in an accurate time line.”
Mack pointed out that any changes made to the record retrospectively will be captured, “but if you change it for accuracy, you can include a memo saying that after the event was over, the team sat together and this is our best recollection.”
As for the possible systems errors—the lack of twitch monitoring and malfunctioning call button—Schoppmann encouraged anesthesiologists to assess the structures in their ORs, as well as their institutions’ policies and procedures, and to take measures to correct them if you find them lacking or out of accordance with standards. “If they aren’t matching your judgment, you have to change them.”
By Monica J. Smith
Mack and Schoppmann reported no relevant financial disclosures.
Editor’s note: None of the cases explored in this series occurred at Weill Cornell Medical Center.
