Delay in recognizing intraoperative complications

By Laura Hale Brockway, ELS, Assistant Vice President, Marketing, and 
Kassie Toerner, Senior Risk Management Representative

Presentation

A 58-year-old woman came to an orthopedic surgeon reporting unrelenting back pain and radiculopathy into her right leg. The patient described the pain as 10 out of 10. She had tried physical therapy and chiropractic therapy for her back pain without relief.

The patient’s history included morbid obesity (she was 5’4” and weighed 203 pounds), hypertension, coronary artery disease, rheumatoid arthritis, anemia, and sleep apnea.

The orthopedic surgeon ordered several studies that revealed stenosis and foraminal stenosis with severe central stenosis at L2-3 and L3-4. Studies also showed autofusion at L1-2 and possibly at L4-5.

The orthopedic surgeon recommended anterior lumbar interbody fusion at L5-S1 with osteotomies at L2 and L3 with cage reconstruction at L2-3 and L3-4 and probable fusion at L4-5. The patient would also require laminectomies and foraminotomies at L2 and L5 with instrumented posterior spinal fusion at T9 or T10 to the pelvis.

The patient consented to the procedures, and medical clearance was given by her primary care physician on June 16. Cardiovascular clearance (including an assessment and echocardiogram) was given by the patient’s cardiologist on May 10.

Physician action

On June 29, the patient was admitted to a local hospital for a two-stage spinal fusion surgery. Medications on admission included modafinil, ramipril, levothyroxine, zolpidem, etanercept, hydrocodone/acetaminophen, and nitroglycerine.

Anesthesiologist A provided anesthesia for both stages of the surgery. The first stage of surgery was uneventful. The patient remained in the ICU until the second stage two days later.

At 6:35 a.m. on July 1, Anesthesiologist A saw the patient for a pre-anesthesia visit. At 7:15, the patient was transferred to the OR and general anesthesia was used for induction. Anesthesiologist A placed a right internal jugular central venous catheter. A chest x-ray confirmed placement of the central line. A right radial arterial line was also placed before the procedure began.

The procedure began uneventfully at 7:57 a.m. Anesthesiologist A induced hypotension to minimize intraoperative blood loss, using small boluses of ephedrine to support a systolic blood pressure of above 80 mm Hg. The infusion of blood products continued through the central line and multiple venous samples were obtained without difficulty.

As the case progressed, the patient’s hemoglobin remained the same despite multiple units of packed red blood cells (PRBCs). The patient was also requiring greater doses of pressor agents and the use of ephedrine and phenylephrine to maintain her blood pressure.

At 12:30 p.m., the patient then lost the integrity of the somatosensory evoked potentials (SSEPs) in her right and left arm. Anesthesiologist A asked the orthopedic surgeon to stop the procedure and begin closing. The orthopedic surgeon agreed, but the patient sustained a small dural tear that had to be repaired followed by the closure of the wound. This process took 45 minutes.

During this time, Anesthesiologist A used norepinephrine for blood pressure support. He also called in another anesthesiologist and a vascular surgeon to assist. 

At 1:15 p.m., the patient was moved to the prone position. Her right side, including her neck, shoulder, and upper arm were swollen from infiltration of the CVP line. With help from Anesthesiologist B, a new left brachial line was placed and blood work was sent to the lab. The initial systolic blood pressure was over 100 mm Hg. A double-lumen catheter was placed in the left femoral vein and transfusion initiated. The patient’s HCT was around 14-15%.

Three units of PRBCs were transfused quickly and the patient’s next HCT was 28.7. The swelling had subsided, and the left and right chest seemed to be the same based on palpation. The patient was admitted to the ICU.

Postoperatively, the patient remained intubated and ventilated in critical condition. A CT scan showed anoxic brain injury, and care was withdrawn. The patient died on July 2.

Allegations

A lawsuit was filed against Anesthesiologist A. The allegations included:

• failure to assess the patency of the central line;
• failure to tell the surgeon to stop the procedure due to blood loss and hypotension; and
• failure to obtain additional adequate and patent intra-vascular access before placing the patient in the prone position

Legal implications

Defense consultants who reviewed this case were supportive of Anesthesiologist A. He confirmed placement of the central line by aspirating blood, transducing the central venous pressure, and obtaining a chest x-ray. The chest x-ray reported the catheter over the internal jugular vein and the brachiocephalic vein.

When the intraoperative complications occurred, Anesthesiologist A treated those immediately and aggressively. The outcome was unforeseeable.

In his deposition, Anesthesiologist A stated that he believed the central line became dislodged at 12:45 p.m. when he attempted to manipulate the patient’s neck to obtain better SSEP signals. He asked for the case to be stopped, but there was a delay because the orthopedic surgeon had to repair a dural tear, place the bone back in the gutters, and close a 15-to-18-inch incision.

The plaintiff’s expert argued that Anesthesiologist A should have insisted the procedure be stopped immediately, even if it meant not closing. This expert testified that had the patient been flipped within 30 minutes of the loss of the SSEPs, he believes they could have saved her. Another expert for the plaintiff was critical because the central line was in an “adequate but not ideal position.”

Disposition

This case was settled on behalf of Anesthesiologist A.

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‍More on improper performance.

Risk management for anesthesiologists.

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