lets talk about this case

[Idiopathic]

http://lawmedconsultant.com/1986/2m-lesson-in-anesthesia-malpractice

is it hubris? "provider x couldnt intubate you but im sure i can".

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[Oggg]

Well, he did intubate the patient successfully for the surgery, so apparently it wasn't hubris unless he traumatized the airway and then extubated in a light plane of anesthesia without checking for a leak around the tube.

Glottic edema from traumatic intubation or oversized tube? or perhaps the real obstruction was subglottic stenosis from the prior trach? Still doesn't really make sense that they couldn't save him with a tracheostomy + epi for bronchospasm. Perhaps the tracheostomy was somehow above a subglottic stenosis (I'm speculating wildly) and that's why the trach didn't work?

Maybe an awake fiberoptic intubation would've been less traumatic and wouldn't have led to glottic edema? Maybe not. Certainly the MDA could've pushed for spinal, but what if the patient absolutely refused?

 

[jetproppilot]

http://lawmedconsultant.com/1986/2m-lesson-in-anesthesia-malpractice

is it hubris? "provider x couldnt intubate you but im sure i can".

Acute asthma attacks involve a TRIAD of pathophysiology, so it takes a Triad of Treatment to completely treat them:

1) Bronchospasm: Most asthma attacks can be handled with albuterol (et al) nebulizers. Severe ones like this should put the clinician into aggressive mode right off the bat, treating the bronchospasm aggressively with IV epinephrine, as well as aggressively treating the other two arms of the triad.

2) Airway edema/inflammation caused by inflammatory response: Solumedrol 125mg IV right away.

3) Tenacious mucous plugging: IV hydration and pulmonary toilet ameliorates this.

Also sit the pt near bolt upright to assist his ventilatory drive. He's fat. This will help.

Racemic epi nebulizer also for stridor if there is any.

Maybe all this stuff if done at the first hint of a problem would've helped, maybe not.

That's what I would've done first. All the above at once.

 

[Dhanwanthari]

interesting/unfortunate case. thanks for posting.

I'm impressed with first the decision for RSI (rather than awake intubation) after that history in an obese,asthmatic, difficult airway. However, the preop airway exam could have been unremarkable (thin neck, MPCL1, full range of motion, nl ) and then due to potential for bronchospasm, desat an RSI could have been appropriate w/ rescue devices (LMA, bourgie, glidescope, FOI, scalpel [you pick]) available.

Now if this patient had a convincing STOP BANG score and was an obese (read: OSA) pt without CPAP therapy prior to elective surgery and insisted on GETA -- then he's an ASA4 perioperatively and either gets a polysomnogram and a course of CPAP or he gets regional for this elective procedure. If he still were to insist and institutionally we "do these cases in these patients all the time", he gets a narcotic free GA without nondepolorizing relaxation and a full disclosure of his anesthetic risks (death, death, trach, death, postop mech. ventilation, sore throat, death, etc.)

"Between 4:00 P.M. and 4:30 P.M., the patient’s ETCO2 levels remained elevated between 43 and 46. "
-this could be below an OSA pt's baseline PaC02.... how much relaxant and narcotic was given? ... and only 10 minutes since reversal of how many twitches

Throughout all of this he was able to be mask ventilated and oxygenated.... then reintubated, then with difficult oxygenation.

It is at this point that I wonder what could have been done differently to improve this patient's oxygenation (confirm tube placement, albuterol, steroids, rac epi, IV epi, Sevoflurane, theophylline, sacrifices to Jobo?, ECMO/Bypass).

Also pt had a funky epiglottis (? of neg pressure pulm edema from upper airway obstruction)

So the plaintiffs' claim that the defendant did not "immediately recognize and appreciate the patient’s post-operative respiratory crisis, and immediately re-intubate the patient after initial attempts to ventilate him with a bag and mask failed." --Is this really the issue that lead to this patients demise. The tube did not save this patient rather the inability to oxygenate with a tube in the trachea. Not removing the tube could have been the saving grace for this patient until all narcotics, gas, nondepolarizers, airway edema was out of the picture (especially in light of a prev. difficult airway) (read: sorry sir, the tube just can't come out yet).

Also, when this begins to transpire in the OR, I call the attending surgeon into the room immediately and have him on board from the beginning. He or she will appreciate not having to be brought up to speed while prepping the neck.

Again, the issue perhaps starts at the beginning -- with the anesthetic assessment and planning -- 37 yo prev. diff intubation, obese asthmatic having an elective procedure under GETA most likely with nondepolarizing relaxation and narcotics. (read: hubris) Perhaps this is why the 2 mil was handed over.

Dhan wan

 

[Dhanwanthari]

Hubris could still apply for giving this cohort of patients' this anesthetic for a minor elective case.

We've M&M'd cases like this and leak test, tube exchanger were all not popular due to unpredictable results/efficacy... if you're thinking about these things perhaps the tube should stay in was the consensus in the cases we've reviewed...

Spinal is the tip of the iceberg for what you can offer this guy.

One of my mentors uses the word death, trach, mechanical ventilation to overcome these patient's fears of regional if otherwise not contraindicated... Paternalistic or ethically appropriate?

Patient refusal is dynamic and greatly influenced by patient education.

 

[miamidoc2b]

Well, he did intubate the patient successfully for the surgery, so apparently it wasn't hubris unless he traumatized the airway and then extubated in a light plane of anesthesia without checking for a leak around the tube.

Glottic edema from traumatic intubation or oversized tube? or perhaps the real obstruction was subglottic stenosis from the prior trach? Still doesn't really make sense that they couldn't save him with a tracheostomy + epi for bronchospasm. Perhaps the tracheostomy was somehow above a subglottic stenosis (I'm speculating wildly) and that's why the trach didn't work?

Maybe an awake fiberoptic intubation would've been less traumatic and wouldn't have led to glottic edema? Maybe not. Certainly the MDA could've pushed for spinal, but what if the patient absolutely refused?

What is a "MDA"?

 

[PMPMD]

What is a "MDA"?

MD Anesthesiologist.

 

[nap$ter]

tough to comment on a case written up by a legal team... like the telephone game with a toddler.

but, to speculate...

a. regional should not be used as a shield to avoid a difficult airway or comorbidities - these factors should be prepared for and controlled from the get-go. you will eventually get burned...

b. doing a RSI in a patient with the history given sounds negligent - but we weren't there (and it was successful).

c. the primary problem looks to me to have been incomplete neuromuscular blockade reversal. 3 minutes after extubation the trouble began; initially, when masked, sats would recover - sounds like a weak fat guy to me. subsequently, bronchospasm with edema and a difficult airway combined to kill the guy.

was there malpractice? yes, in the case of b. did it kill the guy? i dunno, but it doesn't matter at that point.

 

[Idiopathic]

im well aware that one absolute contraindication to regional technique is patient refusal. this is phrased as "patient wished to be asleep for surgery". i think we can all agree that this case likely has a very different course if this patient does not get intubated for this procedure (even though the initial RSI/intubation appears to be uneventful).

my question is: would you ever refuse to do a case like this if the patient refuses regional? with so many apparent risk factors for postoperative m+m, is it prudent to accept say a 1% serious perioperative event incidence (perhaps low estimation?) and prescribe general just because its what the patient wants? we have these cases where we would rather do regional than general but we go along with the patients wishes, but everything about this case screams to not perform general anesthesia (history, comorbidities, exam, duration of surgery)

 

[Idiopathic]

tough to comment on a case written up by a legal team... like the telephone game with a toddler.

but, to speculate...

a. regional should not be used as a shield to avoid a difficult airway or comorbidities - these factors should be prepared for and controlled from the get-go. you will eventually get burned...

b. doing a RSI in a patient with the history given sounds negligent - but we weren't there (and it was successful).

c. the primary problem looks to me to have been incomplete neuromuscular blockade reversal. 3 minutes after extubation the trouble began; initially, when masked, sats would recover - sounds like a weak fat guy to me. subsequently, bronchospasm with edema and a difficult airway combined to kill the guy.

was there malpractice? yes, in the case of b. did it kill the guy? i dunno, but it doesn't matter at that point.

so i agree with everything you say, performing regional still dictates you have a plan to secure a difficult airway, but thats okay too (video DL or FOI handy). it sounds like they were just "hoping" that he would come around and when he didnt they had no avenues. i have definitely been in similar situations and come through fine (as im sure we all have) but this stuff terrifies me.

 

[24858]

interesting/unfortunate case. thanks for posting.

I'm impressed with first the decision for RSI (rather than awake intubation) after that history in an obese,asthmatic, difficult airway. However, the preop airway exam could have been unremarkable (thin neck, MPCL1, full range of motion, nl ) and then due to potential for bronchospasm, desat an RSI could have been appropriate w/ rescue devices (LMA, bourgie, glidescope, FOI, scalpel [you pick]) available.

Now if this patient had a convincing STOP BANG score and was an obese (read: OSA) pt without CPAP therapy prior to elective surgery and insisted on GETA -- then he's an ASA4 perioperatively and either gets a polysomnogram and a course of CPAP or he gets regional for this elective procedure. If he still were to insist and institutionally we "do these cases in these patients all the time", he gets a narcotic free GA without nondepolorizing relaxation and a full disclosure of his anesthetic risks (death, death, trach, death, postop mech. ventilation, sore throat, death, etc.)

"Between 4:00 P.M. and 4:30 P.M., the patient’s ETCO2 levels remained elevated between 43 and 46. "
-this could be below an OSA pt's baseline PaC02.... how much relaxant and narcotic was given? ... and only 10 minutes since reversal of how many twitches

Throughout all of this he was able to be mask ventilated and oxygenated.... then reintubated, then with difficult oxygenation.

It is at this point that I wonder what could have been done differently to improve this patient's oxygenation (confirm tube placement, albuterol, steroids, rac epi, IV epi, Sevoflurane, theophylline, sacrifices to Jobo?, ECMO/Bypass).

Also pt had a funky epiglottis (? of neg pressure pulm edema from upper airway obstruction)

So the plaintiffs' claim that the defendant did not "immediately recognize and appreciate the patient’s post-operative respiratory crisis, and immediately re-intubate the patient after initial attempts to ventilate him with a bag and mask failed." --Is this really the issue that lead to this patients demise. The tube did not save this patient rather the inability to oxygenate with a tube in the trachea. Not removing the tube could have been the saving grace for this patient until all narcotics, gas, nondepolarizers, airway edema was out of the picture (especially in light of a prev. difficult airway) (read: sorry sir, the tube just can't come out yet).

Also, when this begins to transpire in the OR, I call the attending surgeon into the room immediately and have him on board from the beginning. He or she will appreciate not having to be brought up to speed while prepping the neck.

Again, the issue perhaps starts at the beginning -- with the anesthetic assessment and planning -- 37 yo prev. diff intubation, obese asthmatic having an elective procedure under GETA most likely with nondepolarizing relaxation and narcotics. (read: hubris) Perhaps this is why the 2 mil was handed over.

Dhan wan

I believe bronchospasm treatment was covered in detail in one of the latest issues of Anesthesiology and from what I remember theophyline is not considered to be a useful treatment and was cautioned not to use it.
Has anyone ever used ketamine in a bronchospastic episode? Also in that Anesthesiology review article it also didnt consider ketamine to be useful.

 

[Idiopathic]

id consider ketamine in the induction of a severe asthmatic but wouldnt use it as acute therapy in an attack.

i think on the whole people dont go to epi quickly enough in these situations

 

[pgg]

Late to the thread, but -

Now if this patient had a convincing STOP BANG score and was an obese (read: OSA) pt without CPAP therapy prior to elective surgery and insisted on GETA -- then he's an ASA4 perioperatively and either gets a polysomnogram and a course of CPAP

Do you really postpone suspected OSA'ers and send them back out so they can get sleep studies and CPAP machines? I can't believe anyone actually does this.

[If a patient is identified as an OSA'er at a preop appointment] the anesthesiologist and surgeon should jointly decide whether to (1) manage the patient perioperatively based on clinical criteria alone or (2) obtain sleep studies, conduct a more extensive airway examination, and initiate indicated OSA treatment in advance of surgery. If this evaluation does not occur until the day of surgery, the surgeon and anesthesiologist together may elect for presumptive management based on clinical criteria or a last-minute delay of surgery.

What I and (I think) just about everybody does if one of these patients shows up DOS without any preop eval or workup, is elect for that presumptive management bit.

I.e. assume the patient has OSA, and lean toward regional, minimize narcotics, ensure adequate reversal prior to extubation, monitor longer and more closely postop, etc.

or he gets regional for this elective procedure. If he still were to insist and institutionally we "do these cases in these patients all the time", he gets a narcotic free GA without nondepolorizing relaxation and a full disclosure of his anesthetic risks

Why no nondepolarizers? In this particular case incomplete reversal may have been a factor, but that's not a reason to not use these drugs given an appropriate dose, complete reversal, not extubating before he meets criteria.

 

[urge]

The information presented wasn't enough to allow me to arrive to any conclusion about malpractice. All I can gather is that there is a bad outcome you are pretty much screwed.

I was more interested in the other lawsuit where the anesthesiologist won 8 million after being wrongfully terminated from his job. Which begs the question "when is it ok to terminate you after a bad outcome?"

http://lawmedconsultant.com/2068/federal-jury-awards-anesthesiologist-8.8m/

 

[PinchandBurn]

what about the REVERSAL agent used in the case. Could it have precipitated bronchospasm?

I guess we need to also know....which reversal meds did he give (glyco and neostim or was it atropine with neostigm)?

Also did they push the reversal first followed by the anticholiergic agent (neostig bolus then glyco bolus)? i guess we will never know.....

 

[PMPMD]

what about the REVERSAL agent used in the case. Could it have precipitated bronchospasm?

I guess we need to also know....which reversal meds did he give (glyco and neostim or was it atropine with glyco)? Also did they push the reversal first followd by the anticholiergic agent (neostig bolus then glyco bolus)? i guess we will never know.....

Probably glycopyrrolate and neostigmine, I don't think people are using atropine/edrophonium much these days. Also, I don't recommend the atropine/glyco combination you refer to...

 

[btbam]

Actually I just used edrophonium/atropine in a south GA hospital. It comes prepackaged in an ampule under the name "Enlon-Plus".

 

[PinchandBurn]

. Also, I don't recommend the atropine/glyco combination you refer to...

i dont either

 

[Dhanwanthari]

Why no nondepolarizers? In this particular case incomplete reversal may have been a factor, but that's not a reason to not use these drugs given an appropriate dose, complete reversal, not extubating before he meets criteria.

Why use NMB's if you don't need them?

You can remove the idea of incomplete reversal if you never give nondepolarizers in the first place. Also, if your aren't the one redosing NMB's in the room or deciding when to reverse (i.e, you are supervising multiple rooms), it is nice to remove these human "errors" in said relaxant administration/overadministration/underreversal.

I like keeping my patients as far away from a Viby-Mogensen cohort as possible, if possible.

Inguinal hernia = don't need them, propofol and volatile (although hyperalgesic) provide some relaxation as well.
Ventral hernia = sure, could help your surgical colleagues repair

We don't delay cases if the patient needs a PSG and CPAP. We assume they have it, call them ASA3/4 and push for non-GETA and opioid sparing techniques.

No anesthesia is safer than no anesthesia. Trust no one... that one twitch may be from a stealth-administered 1cc of neostigmine (seriously, someone told me this is how they get twitches back for their attending MD's if none are present WTF). Remove the variables ... take away the keys to the panzer.