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 patients 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 patients 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