Patient is Killed From Depressed Respiratory Function Following Surgery

Case Overview

This OR operations case involves a patient in Arizona who underwent a surgical procedure to remove part of his colon. A preoperative workup including a pulmonary and critical care consultation was conducted by the defendant pulmonologist. The consultation revealed that the patient likely had a paralyzed left diaphragm from a workplace accident that occurred many years prior. The defendant recommended deep incentive spirometry. He also recommended that long acting opiates should be limited, and the suggested pain control should be by epidural analgesia to decrease the risk of respiratory depression. On the morning of the surgery the patient underwent a pre-anesthesia assessment. The anticipated anesthetic plan was listed as general. His anesthesia pre-op orders called for him to receive benzodiazepine as well as an opioid pain medication. The patient was taken to the operating room where an additional dose of benzodiazepine was given, and the patient was immediately intubated. Surgery ended and the anesthesiologist noted that the surgeon requested the patient remain on a ventilator. The patient was extubated. Instead of taking the patient to the surgical intensive care unit as ordered the patient was left in the post-anesthesia care unit waiting area. He was later seen by the defendant who observed him to be sleepy. He informed the post-anesthesia care unit staff to be careful about the use of narcotics in the light of the patient’s present clinical situation and past medical history. He was later found to be unresponsive, and was declared dead shortly afterwards.

Questions to the Pulmonology expert and their responses

How often do you treat patients with a similar past medical history to the one described in this case?

I treat patients with a similar past medical history on a weekly basis.

What measures should be taken pre-operatively, intra-operatively, and post-operatively to ensure the safety of the patients while under anesthesia?

Deep vein thrombosis prophylaxis is critical, including intermittent compression devices, and consideration for anticoagulation when deemed safe from a surgical perspective. Reduction of narcotics is important but challenging given peri-operative pain; however ketamine may provide analgesia without respiratory depression. Regional anesthesia such as an epidural may also help decrease narcotic use. Post-operative monitoring should include intensive or respiratory-specialized nursing with continuous pulse oximetry and telemetry, as well as consideration of continuous non-invasive capnography. ICU admission is warranted if body mass index is greater than 60 and/or if severe sleep apnea is confirmed or suspected. Consideration of CPAP and/or non-invasive ventilation should also be a component of care if there is evidence of apnea.

About the expert

This triple board certified pulmonologist has over ten years of experience in Medical Intensive Care Units. He received his medical degree from the University of Iowa College of Medicine, where he also completed his residency in internal medicine. He completed two fellowships, one research and one clinical in Pulmonary and Critical Care Medicine. In his current professorship at a large Iowa university, this doctor lectures on topics such as -˜Sedation, Anesthesia, and Airways in the ICU', and instructs continuing medical education classes for faculty and fellows regarding techniques useful for difficult airways. He is also published over twenty times on various critical care medicine trends and treatments in respected publications such as the American Journal of Respiratory Critical Care Medicine. This doctor has also been invited and asked to publish counterpoints answering questions such as: Should an anesthesiologist be the specialist of choice to manage the difficult airway in the intensive care unit? He has experience in MICUs and VA ICUs as well as specialty experience stemming from a two year clinical assignment as a consultant attending at a Respiratory Specialty Care Unit (RSCU). The RSCU is a unit for adult patients with lung diseases and complex medical problems. Patient populations include: COPD, obstructive sleep apnea, asthma, cystic fibrosis, slow-to-wean ventilator patients, neuro-muscular disorders, and patients who need less than intensive care, but more care than provided on acute medical/surgical units.

E-009677

Specialties:

Pulmonology