Incorrect Intubation Technique Causes Fatal Complication During Cardiac Surgery


    Surgery Expert Witness

    This case involves an elderly female patient with a history of mini stroke-like symptoms who was scheduled for a carotid endarterectomy. Prior to the procedure, the anesthesiologist sedated and intubated the patient. However, the anesthesiologist didn’t start the anesthesia induction until almost two hours after intubation and didn’t monitor patient’s vital signs during this time. When monitoring finally started, the patient had no C02 number. The anesthesiologist extubated and reintubated the patient, however, the reintubation went into the patient’s esophagus rather than trachea. The patient was without oxygen for 26 minutes and subsequently passed away.

    Question(s) For Expert Witness

    • 1. How frequently are you involved in the management of patients undergoing carotid endarterectomies?
    • 2. What is the standard of care, if any, for the surgical nurse during induction and initiation of anesthesia?

    Expert Witness Response E-008674

    I am a certified operating room nurse and have over 34 years of perioperative experience. I have been involved in 100+ procedures involving patients undergoing carotid endarterectomies. In this case, the surgical nurse absolutely has an obligation to be present and aware during induction and initiation of anesthesia. First, the nurse has a duty to make sure all the equipment in the room is functioning before allowing the patient to be admitted to the operating room and check the anesthesia machine with the anesthesiologist. Once the patient is admitted into the operating room, the nurse either connects or assists with connecting the patient to all the monitors. The nurse should be present during sedation and must monitor the same screen that the rest of the clinical team is looking at to make sure that vital signs are being displayed and are in the appropriate range. The nurse also has a duty to communicate with the medical team if there are signs that indicate there is the absence of a waveform/no number for CO2. It is unfathomable that the patient did not have oxygen for 26 minutes without anyone noticing the placement of the tube was incorrect. The bottom line is, the nurse and the rest of the clinical team had a duty to the patient and the standard of care was not met.

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