Successful lawsuit for intraoperative awareness

[GravelRider]

The question is would there be a successful lawsuit if BIS was used?

Maybe, maybe not. This is why documentation is so important and is your biggest defense against a lawsuit. If you had great documentation, including a BIS, a lawyer might have told the patient that this could be a difficult case to win and might not have taken it. Inconsistencies in documentation, illegible documentation, or missing documentation are big reasons why malpractice suits are filed in the first place.

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[facted]

Maybe, maybe not. This is why documentation is so important and is your biggest defense against a lawsuit. If you had great documentation, including a BIS, a lawyer might have told the patient that this could be a difficult case to win and might not have taken it. Inconsistencies in documentation, illegible documentation, or missing documentation are big reasons why malpractice suits are filed in the first place.

Documentation issues are definitely a problem and can totally make a lawsuit. However, a BIS wouldn't have defended you at all in this case (or in any case!). First off, the evidence in preventing awareness is just not there. And second, in this particular case, a large portion of the anesthetic was nitrous. Nitrous doesn't affect frontal EEG very much compared to other agents and even when well anesthetized you'll get a higher BIS number. Then how does that help you in this lawsuit?

In general, if you are going to argue in court that there's no way the patient was aware because the BIS was 45 or whatever the number is, that line of reasoning will get burned. Similarly, just because the BIS was 70, doesn't mean the patient WAS aware.

The counter argument to just add the BIS is to never put information or numbers on the chart that are just fodder for the attorneys. Skin temp under a bair hugger comes to mind...drives me crazy when our CRNA's do that.

 

[Swamp Gas]

But if you actually use it correctly which as Blade stated is about 10% of the time at best (probably more than that in my practice since we do so much tiva w/o paralysis for spine cases) then you can actually gain something from it.

What are your thought's on adding < 0.5 MAC of volatile for spines? Would better ensure an adequate depth and give a stronger legal leg to stand on.

 

[GravelRider]

Documentation issues are definitely a problem and can totally make a lawsuit. However, a BIS wouldn't have defended you at all in this case (or in any case!). First off, the evidence in preventing awareness is just not there. And second, in this particular case, a large portion of the anesthetic was nitrous. Nitrous doesn't affect frontal EEG very much compared to other agents and even when well anesthetized you'll get a higher BIS number. Then how does that help you in this lawsuit?

In general, if you are going to argue in court that there's no way the patient was aware because the BIS was 45 or whatever the number is, that line of reasoning will get burned. Similarly, just because the BIS was 70, doesn't mean the patient WAS aware.

The counter argument to just add the BIS is to never put information or numbers on the chart that are just fodder for the attorneys. Skin temp under a bair hugger comes to mind...drives me crazy when our CRNA's do that.

The problem with information that is not present is malpractice lawyers are often given leeway in making inferences if there is no documentation to refute those inferences.

I'm not arguing about the scientific and medical utility (or lack thereof) of the BIS monitor. I agree with much of what you say in that regard. However, I do think there is CYA utility in cases where there is an increased incidence of intraoperative awareness. There are many CYA things that we do. It's annoying, but that's the reality of the medical environment we practice in.

 

[Noyac]

What are your thought's on adding < 0.5 MAC of volatile for spines? Would better ensure an adequate depth and give a stronger legal leg to stand on.

It doesn't hurt.
We do a ton of spine. I rarely turn on any gas and to my knowledge have never had a case of awareness but if I am concerned I will turn it on.

 

[deleted162650]

What are your thought's on adding < 0.5 MAC of volatile for spines?

No problem in >90% of cases. I run 0.4-0.5MAC volatile for nearly all my spines. SSEP's are pretty resilient to volatile (until you get above 1 MAC). MEP's are a bit more sensitive, but it's usually still not a problem unless the pt has significant preop deficits with crappy baseline signals already. You can always "cheat" a little too by running analgesic dose ketamine which amplifies the signals and will allow you to get away with some more volatile. This approach gives me better wake-ups than running a full TIVA (but that's just me - you may be a propfol gtt wizard). Don't believe everything those pesky neuromonitoring techs tell you.

I am always willing to adjust things as necessary though if they are struggling to get good signals. It's just exceedingly rare that I need to change anything.

 

[BLADEMDA]

No problem in >90% of cases. I run 0.4-0.5MAC volatile for nearly all my spines. SSEP's are pretty resilient to volatile (until you get above 1 MAC). MEP's are a bit more sensitive, but it's usually still not a problem unless the pt has significant preop deficits with crappy baseline signals already. You can always "cheat" a little too by running analgesic dose ketamine which amplifies the signals and will allow you to get away with some more volatile. This approach gives me better wake-ups than running a full TIVA (but that's just me - you may be a propfol gtt wizard). Don't believe everything those pesky neuromonitoring techs tell you.

I am always willing to adjust things as necessary though if they are struggling to get good signals. It's just exceedingly rare that I need to change anything.

That's what I do for thousands of these cases; no issues whatsoever due to the low dose volatile agent. The few cases (less than 3) they blamed the volatile agent on poor SSEP/MEP I switched to pure TIVA and the signals didn't change one bit. Two of those cases ended up getting cancelled per the Neurosurgeon.

I recommend 0.5 MAC Volatile agent combined with Propofol/Ketamine (I mix them together) infusion. I prefer the Propofol/Ketamine over a Sufenta drip but either will work well for the case.

 

[Swamp Gas]

That's what I do for thousands of these cases; no issues whatsoever due to the low dose volatile agent. The few cases (less than 3) they blamed the volatile agent on poor SSEP/MEP I switched to pure TIVA and the signals didn't change one bit. Two of those cases ended up getting cancelled per the Neurosurgeon.

I recommend 0.5 MAC Volatile agent combined with Propofol/Ketamine (I mix them together) infusion. I prefer the Propofol/Ketamine over a Sufenta drip but either will work well for the case.

Yup, that has been my approach for the pediatric spines. 0.5 MAC, Propofol, Ketamine and also Remifentanil. I try to keep the Remi <0.3 mcg/kg/min as this has been associated with increased incidence of post-op opioid tolerance and hyperalgesia.

When I first started my peds fellowship everyone was running a straight TIVA so I just went with the flow (even though I knew adding a volatile shouldn't effect the monitoring and did it routinely in residency). After talking with the neurophysiologist, he told me it was purely cultural so I added the volatile back to my anesthetic. I also give valium and methadone up front. The kids do great!

What ratio are you using with your Ketafol mix?

 

[deleted162650]

I like to run my prop and ket separately so I can cut-off the prop as early as possible and keep the ket going until just before emergence. Ketamine is a 0.5mg/kg bolus and then 5-10mcg/kg/min depending on baseline pain med usage/tolerance. Prop at 50-120ish depending on the particular pt.

 

[Noyac]

I like to run my prop and ket separately so I can cut-off the prop as early as possible and keep the ket going until just before emergence. Ketamine is a 0.5mg/kg bolus and then 5-10mcg/kg/min depending on baseline pain med usage/tolerance. Prop at 50-120ish depending on the particular pt.

This is a great discussion because it just shows how many ways there are to achieve the same results.
We use remi in much lower doses than 0.3mcg/kg/min. We have found that we rarely need more than 0.15mcg/kg/min.
We have also moved away from ketamine for one reason, our surgeons want pts able to follow commands to the point of nearly doing calisthenics in the PACU on arrival. This is so that they can go on to the next case and not have to worry or return to evaluate the pt at the end of the day. We have found that the ketamine, while an excellent drug in these cases, just keeps the pts a bit more sleepy while in PACU. Therefore, we use it sparingly.
Things I would like to experiment with in the near future are: melatonin and methadone. We don't have these at this time.

 

[anbuitachi]

For little spines i just use straight propofol with fentanyl bolus. ( or remifentanil infusion esp for cervical spines). Our neuromonitor crew dont like any gas so we leave it off, and sometimes when their signals weaken, it doesn't give them or the surgeon an excuse. Big spines i do fent, prop, ketamine infusion. Gas when done monitoring. Patients do great. The closure is long enough that ketamine isn't an issue when they go to PACU. Usually i stop ketamine after 200-300mg infusion for big spine cases

I find prolonged remi does sometimes cause hyperalgesia after long infusions despite papers saying its low incidence at <.2.

 

[Noyac]

For little spines i just use straight propofol with fentanyl bolus. ( or remifentanil infusion esp for cervical spines). Our neuromonitor crew dont like any gas so we leave it off, and sometimes when their signals weaken, it doesn't give them or the surgeon an excuse. Big spines i do fent, prop, ketamine infusion. Gas when done monitoring. Patients do great. The closure is long enough that ketamine isn't an issue when they go to PACU. Usually i stop ketamine after 200-300mg infusion for big spine cases

I find prolonged remi does sometimes cause hyperalgesia after long infusions despite papers saying its low incidence at <.2.

This is basically my exact approach minus the ketamine usually.

 

[BLADEMDA]

I typically bolus the ketamine 0.5 mg/kg with induction then mix it in with the propofol. Typically, I'll run low dose Ketafol ( 1mg of ketamine per ml of propofol) at 80-100 ug/kg/min but titrate to effect. When the surgeon starts to close I shut off the ketafol and turn on the nitrous oxide (if added MAC is needed). Typically, this works out quite well and the Fentanyl usage for the case is greatly reduced.

 

[facted]

Methadone at .1-.15 per kg is phenomenal for bigger spine cases or smaller spine cases with an opiod tolerant pt. Highly recommended. No ketamine in that situation.

 

[waterbottle10]

I prefer ketamine nmda over methadone nmda. What txa doses do you use?

 

[facted]

I prefer ketamine nmda over methadone nmda. What txa doses do you use?

Not sure the ketamine vs methadone trials have been done yet, though I know there was some talk ) IRB work at my institution looking at that. But there are two or three big trials in the last few years that show methadone is superior to straight fentanyl, sufaenta infusion etc...

 

[waterbottle10]

Not sure the ketamine vs methadone trials have been done yet, though I know there was some talk ) IRB work at my institution looking at that. But there are two or three big trials in the last few years that show methadone is superior to straight fentanyl, sufaenta infusion etc...

Superior in what ways?

 

[facted]

Superior in what ways?

Pain scores, opioid consumption, and satisfaction, even days out from surgery:

Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, C... - PubMed - NCBI
Intraoperative methadone improves postoperative pain control in patients undergoing complex spine surgery. - PubMed - NCBI

Here's one that says ketamine and methadone better than methadone alone:
The perioperative combination of methadone and ketamine reduces post-operative opioid usage compared with methadone alone. - PubMed - NCBI

 

[waterbottle10]

Pain scores, opioid consumption, and satisfaction, even days out from surgery:

Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery: A Randomized, Double-blinded, C... - PubMed - NCBI
Intraoperative methadone improves postoperative pain control in patients undergoing complex spine surgery. - PubMed - NCBI

Here's one that says ketamine and methadone better than methadone alone:
The perioperative combination of methadone and ketamine reduces post-operative opioid usage compared with methadone alone. - PubMed - NCBI

I need to read those papers. It just seems hard to compare when methadone is long acting vs short acting fentanyl + nmda antagonism which has known analgesic effects. But I'll read the papers

 

[propadope]

Maybe, maybe not. This is why documentation is so important and is your biggest defense against a lawsuit. If you had great documentation, including a BIS, a lawyer might have told the patient that this could be a difficult case to win and might not have taken it. Inconsistencies in documentation, illegible documentation, or missing documentation are big reasons why malpractice suits are filed in the first place.

Agreed. Documentation is key.

 

[propadope]

Not sure if this has any relevance but the defendant has a history of fibromyalgia. Perhaps has higher anesthetic requirements? I don't think it was mentioned if she was on chronic pain medications but there is a good chance she was.

 

[BLADEMDA]

Methadone at .1-.15 per kg is phenomenal for bigger spine cases or smaller spine cases with an opiod tolerant pt. Highly recommended. No ketamine in that situation.

I just did a case on a chronic pain patient already on Methadone preoperatively plus a whole lot of other meds. The procedure was a 2 level fusion (posterior) and he did quite well with the ketafol mix intraop. Pain scores in the PACU were reported to be 2-3 which is quite good for that patient.

I've got no problems giving the methadone but why wouldn't you add the ketamine as well?

If the Ketafol wasn't enough to control the postop pain in the PACU I've added a low dose POSTOP Precedex infusion for 24-48 hours along with the PCA. This works on even on the most opioid tolerant patient.

Dexmedetomidine in Postoperative Analgesia in Patients Undergoing Hysterectomy: A CONSORT-Prospective, Randomized, Controlled Trial
Effect of Dexmedetomidine combined with sufentanil for post- thoracotomy intravenous analgesia:a randomized, controlled clinical study. - PubMed - NCBI

Dexmedetomidine during total knee arthroplasty performed under spinal anesthesia decreases opioid use: a randomized-controlled trial. - PubMed - NCBI

 

[facted]

I just did a case on a chronic pain patient already on Methadone preoperatively plus a whole lot of other meds. The procedure was a 2 level fusion (posterior) and he did quite well with the ketafol mix intraop. Pain scores in the PACU were reported to be 2-3 which is quite good for that patient.

I've got no problems giving the methadone but why wouldn't you add the ketamine as well?

If the Ketafol wasn't enough to control the postop pain in the PACU I've added a low dose POSTOP Precedex infusion for 24-48 hours along with the PCA. This works on even on the most opioid tolerant patient.

Dexmedetomidine in Postoperative Analgesia in Patients Undergoing Hysterectomy: A CONSORT-Prospective, Randomized, Controlled Trial
Effect of Dexmedetomidine combined with sufentanil for post- thoracotomy intravenous analgesia:a randomized, controlled clinical study. - PubMed - NCBI

Dexmedetomidine during total knee arthroplasty performed under spinal anesthesia decreases opioid use: a randomized-controlled trial. - PubMed - NCBI

Most of our spine patients aren't getting PCA, for starters, so a precedex infusion would drive the nurses bananas. I'm not opposed to ketamine plus methadone, but 0.15-.2 mg/kg (max dose 20mg) of methadone makes for happy patients for 2-3 days postop and no infusions needed.

Side note: Precedex as we all know is very pricey. What I did not know until a few months ago that methadone IV is also super pricey. Check with your pharmacy about methadone syringes pre-drawn because it usually comes in a 200mg vial that is expensive and to use it 20mg and waste the 180 is not a great use of resources.

 

[BLADEMDA]

Most of our spine patients aren't getting PCA, for starters, so a precedex infusion would drive the nurses bananas. I'm not opposed to ketamine plus methadone, but 0.15-.2 mg/kg (max dose 20mg) of methadone makes for happy patients for 2-3 days postop and no infusions needed.

Side note: Precedex as we all know is very pricey. What I did not know until a few months ago that methadone IV is also super pricey. Check with your pharmacy about methadone syringes pre-drawn because it usually comes in a 200mg vial that is expensive and to use it 20mg and waste the 180 is not a great use of resources.

Or, simply put the patient on PO Methadone several days prior to the case and save big money. My suggestion about Precedex is a solution to a real clinical problem when all Opioids (even Methadone) fail to control postop pain.

 

[epidural man]

Definitely agree, but that doesn't make me do things that don't work.

Ummm...
It absolutely DOES work as an anesthetic depth monitor. I have never seen it NOT work as that.

If you have - please record and post here. Everytime I give propofol, or give gas, the numbers decrease. EVERY time.

To say it doesn't work - well that is just disengenious.

(are there other things that decrease the number? Yes. Does it give any indication of conscious vs unconscious state? No. But so what...it shows anesthetic depth, whether that number starts at 80 after neuromusclular blockage, or whatever...it still measures anesthetic depth.)

 

[epidural man]

I think to say you won't use BIS because it doesn't prevent awareness 100% of the time is incredibly hypocritical - and I would ask...

Have you ever used a pulse OX and it not work?

Have you ever used an A-line and it crap out on you and not work?

How about a blood pressure cuff using oscillimetery - has that worked for you 100% of the time?

Well if you have used any one of those monitors, and forgave them for not working 100% of the time, and still find them useful, yet because the BIS hasn't worked for you 100% of the time and you refuse to use it and you talk bad about it - well that is the tip top prime of hypocrisy.

 

[anbuitachi]

Most of our spine patients aren't getting PCA, for starters, so a precedex infusion would drive the nurses bananas. I'm not opposed to ketamine plus methadone, but 0.15-.2 mg/kg (max dose 20mg) of methadone makes for happy patients for 2-3 days postop and no infusions needed.

Side note: Precedex as we all know is very pricey. What I did not know until a few months ago that methadone IV is also super pricey. Check with your pharmacy about methadone syringes pre-drawn because it usually comes in a 200mg vial that is expensive and to use it 20mg and waste the 180 is not a great use of resources.

The surgeons do intrathecal morphine for the bigger spines, not sure how well it works according to studies. Cause my 15 level fusion this week had 8/10 pain 30 min after PACU arrival. Ran ketamine, fentanyl, propofol for the case.

 

[partydoc]

I just did a case on a chronic pain patient already on Methadone preoperatively plus a whole lot of other meds. The procedure was a 2 level fusion (posterior) and he did quite well with the ketafol mix intraop. Pain scores in the PACU were reported to be 2-3 which is quite good for that patient.

I've got no problems giving the methadone but why wouldn't you add the ketamine as well?

If the Ketafol wasn't enough to control the postop pain in the PACU I've added a low dose POSTOP Precedex infusion for 24-48 hours along with the PCA. This works on even on the most opioid tolerant patient.

Dexmedetomidine in Postoperative Analgesia in Patients Undergoing Hysterectomy: A CONSORT-Prospective, Randomized, Controlled Trial
Effect of Dexmedetomidine combined with sufentanil for post- thoracotomy intravenous analgesia:a randomized, controlled clinical study. - PubMed - NCBI

Dexmedetomidine during total knee arthroplasty performed under spinal anesthesia decreases opioid use: a randomized-controlled trial. - PubMed - NCBI

Are you able to run precedex on your floors?

 

[sevoflurane]

Love ketafol and methadone.
Dash of mag and you are good to go.

 

[Ronin786]

Love ketafol and methadone.
Dash of mag and you are good to go.

How do you give your mag? Wide open?

 

[sigrhoillusion]

How do you give your mag? Wide open?

Rectally...

 

[deleted162650]

How do you give your mag? Wide open?

2g in 50mL (comes from pharmacy that way) wide open on a mini dripper.

 

[Noyac]

How do you give your mag? Wide open?

I squirt it into my IV bag as long as there is more than 100cc still in it. If less than 100cc then 1gm in it and 2gms in the next bag. Don't overthink it. Just don't give it IV push.

 

[Ronin786]

I squirt it into my IV bag as long as there is more than 100cc still in it. If less than 100cc then 1gm in it and 2gms in the next bag. Don't overthink it. Just don't give it IV push.

Cool. I've been wanting to experiment with it a little. Do you use it for everybody or reserve it for cases where you think a little more pain control will be needed?

 

[anbuitachi]

1 gram is enough to have significant pain control?

 

[Laryngophed]

For big backs, I have added a lidocaine infusion. Anecdotally, seems to have helped my pain scores in PACU. Also a fairly small sample size, but I like 0.5mg/kg ketamine after induction before incision then 10 mg an hour or so (to use the same syringe and save some $$$ for the patient), 1mg/kg of lidocaine at induction and then 1mg/kg/hr, and then I titrate in 0.5mcg/kg of dexmedetomidine over the last 20-30 minutes of the case as I'm dropping ETagent. I like it and the patients do well. I leave he lidocaine running through PACU because my PACU nurses will run it and be fine, but have to shut it off because nurses on the floor don't want an "ACLS drug" running on a pump. But they are okay with bupivicaine in an epidural.

 

[anbuitachi]

For big backs, I have added a lidocaine infusion. Anecdotally, seems to have helped my pain scores in PACU. Also a fairly small sample size, but I like 0.5mg/kg ketamine after induction before incision then 10 mg an hour or so (to use the same syringe and save some $$$ for the patient), 1mg/kg of lidocaine at induction and then 1mg/kg/hr, and then I titrate in 0.5mcg/kg of dexmedetomidine over the last 20-30 minutes of the case as I'm dropping ETagent. I like it and the patients do well. I leave he lidocaine running through PACU because my PACU nurses will run it and be fine, but have to shut it off because nurses on the floor don't want an "ACLS drug" running on a pump. But they are okay with bupivicaine in an epidural.

Wow, your floor nurses know its an ACLS drug. Thats impressive

 

[BLADEMDA]

For big backs, I have added a lidocaine infusion. Anecdotally, seems to have helped my pain scores in PACU. Also a fairly small sample size, but I like 0.5mg/kg ketamine after induction before incision then 10 mg an hour or so (to use the same syringe and save some $$$ for the patient), 1mg/kg of lidocaine at induction and then 1mg/kg/hr, and then I titrate in 0.5mcg/kg of dexmedetomidine over the last 20-30 minutes of the case as I'm dropping ETagent. I like it and the patients do well. I leave he lidocaine running through PACU because my PACU nurses will run it and be fine, but have to shut it off because nurses on the floor don't want an "ACLS drug" running on a pump. But they are okay with bupivicaine in an epidural.

Perioperative Lidocaine Offers No Benefits in Patients Undergoing Spinal Fusion

Postoperative use of opioid analgesics increases the risk of respiratory depression, which can lead to brain damage or death.
Perioperative lidocaine does not reduce morphine use in the first 24 hours after posterior spinal arthrodesis and offers no measurable benefits, according to a randomized placebo-controlled trial recently published in Pain.1

Postoperative use of opioid analgesics increases the risk of respiratory depression, which can lead to brain damage or death.2 Several studies seeking to evaluate whether administering intravenous (IV) lidocaine before or during a surgical procedure can reduce pain and postoperative opioid use have yielded conflicting results.3,4

For the trial, investigators enrolled 70 patients, age 15 to 56 (median age, 49 years) who were scheduled to undergo spinal arthrodesis at a Belgian hospital. One group of patients received an IV bolus injection of lidocaine (1.5 mg/kg) administered concurrently with anesthesia, and followed by a continuous infusion of lidocaine (1.5 mg/kg/h), continued for 6 hours after surgery. Patients in the control arm received an identical saline regimen. After surgery, all patients were given acetaminophen and a morphine pump for pain. In patients with persistent pain, nurses could supplement on-demand morphine with a morphine injection.

Patients in both arms of the trial used similar amounts of morphine in the first 24 hours after surgery even when the cumulative doses were weight-adjusted (P =.22). Morphine use on the second and third days after surgery was also similar in the lidocaine arm and the control arm.

Systemic lidocaine fails to improve postoperative morphine consumption, postoperative recovery and quality of life in patients undergoing posterior spinal arthrodesis. A double-blind, randomized, placebo-controlled trial | BJA: British Journal of Anaesthesia | Oxford Academic

 

[Noyac]

Cool. I've been wanting to experiment with it a little. Do you use it for everybody or reserve it for cases where you think a little more pain control will be needed?

I use it in any case that comes with some pain.
It works very well for uterine pain and cramps like after ablations.

 

[Noyac]

Lidocaine infusions have not proved to be worth the hassle.

 

[dhb]

Lidocaine infusions have not proved to be worth the hassle.

That's my impression and why i don't do them.
The people that see a reduction in morphine consumption are those that do an anesthetic that leads to high morphine needs post-op.