What's the latest data on closed claims study?

[deleted682700]

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What anesthesia complications have you had that you can share with others?
What are the trends in closed claims studies?

This happened 11 years ago but cannot forget the events. 49 yr old , slightly obese, with hypertension. patient fell of a ladder at job and was completely paralyzed from the waist down. Total paraplegia.Relatively new neurosurgeon wanted to fix the fracture. Patient is in icu, one Iv line. Wife and children were present
Instruments for this case was not available, case is delayed. Instrument trays coming from some other hospital. The anesthesiologist who was assigned to do the case wanted to go home. He requested me to do the case and he left. I agreed. First mistake.
I spoke with patient and family told them that would start Aline and second iv. Did RSI, incubated first attempt. Positive ETCO2. Everything fine started. Second I'v, neo synephrine drip given to titrate blood pressure above 100 systolic. Pt flipped into prone position. Surgery went on for 3 hrs. Pt turned back to supine. At the end surgeon requested the patient to be extubated. Pts blood pressure is high, so neo was turned off.

Patient was breathing on his own, opened eyes, met criteria for extubation. Extubated the patient, second mistake in hindsight. Took the patient to recovery room, report given to nurse and was eating my dinner in break room.

5 minutes into break, code blue in RR. The nurse apparently sat the patient and claims that Aline tracing went flat. Ran to the pacu, incubated. There is no capnometer in the pacu. There was an electrical rhythm. And I also remember bradycardia. The patient was getting CPR, epi given. Trauma surgeon and neuro surgeon was present Despite everything patient died. At the end I was not willing to give up, I removed the Ett and wanted to reintubate. Hindsight should have done earlier as soon as I was hearing bradycardia. No glide scope those days. It was already 20-30 min into the code. The surgeon called of the code.

Went to give the devastating news to the wife and children, they were distraught. They forgave all the doctors which made us feel terrible.

Autopsy was done. Showed MI. No PE. But I doubt if my tube was in the right spot. Next morbidity and mort conference I was asked by senior anesthesiologist why there was a rush to extubate, "doctor is this patient going to walk out. Why extubate in the night in questionable cases?

 

[criticalelement]

Why are you doubting your intubation? Was he difficult? True most of these arressts that leave you scratching your head are hypoxia related but was he difficult intubation that you struggled with?

I dont disagree with extubation at end of case. WHy would it be questionable extubation? Sounds pretty straightforward to me aside from the paraplegia/

 

[twoliter]

Why are you doubting your intubation? Was he difficult? True most of these arressts that leave you scratching your head are hypoxia related but was he difficult intubation that you struggled with?

I dont disagree with extubation at end of case. WHy would it be questionable extubation? Sounds pretty straightforward to me aside from the paraplegia/

I also don't disagree with extubation given the details we have. One could just as easily have questioned unnecessarily keeping someone intubated on mechanical ventilation for longer than necessary.

 

[IlDestriero]

I agree with criticalelement. I wouldn't have left him intubated either. Extubate and off to the neuro icu. That's where these guys went when I was doing adults.
If you ever doubt your tube position, just DL again to confirm, or Glide, or run a portable fiber down there. If he was in full arrest, the CO2 detector with the color change might not have been helpful anyway. I went to a code in the OR on a kid years ago where the baby arrested a couple minutes after induction. Very senior people were at the head of the bed. Everyone swore up and down the tube was in the trachea, until I DLd again and saw it clearly in the esophagus. When everything points to no oxygenation, it's always the tube until you prove otherwise. Breath sounds, etc are useless. See the tube in the trachea, make sure it's not plugged, then maybe it's PE or whatever.
I wouldn't pull the tube unless you were 100% certain it was not in the trachea or you thought it was plugged with a clot or something. And I'd never pull the tube on a dead guy, they would think you were covering up your missed esophageal intubation and try to hang it all on you, even though it was an MI. And probably be successful as well. The coroner can take it out after confirming its position.

 

[deleted682700]

Not difficult intubation. But without ETCO2 confirmation by capnometer reading, it is possible to be esophageal. When I was bagging after intubation the feeling was as if ventilating the lungs. Bbs present
I feel better that others also would have extubated. But the end result was unexpected.

 

[urge]

I don't think the focus should be whether you should have extubated or not. I would focus on why he arrested shortly in PACU. Did he have residual neuromuscular block? Was the minute ventilation enough? Too much narcotics? Was he ischemic? Autonomic dysfunction?

 

[GeorgiaAnes]

I have too many questions to ask here, story leaves a lot of details out.

He was paralyzed from the "waist down" and had "total paraplegia." Are you saying his level of paralysis was below say T6 or so? Knowing the level of paralysis is extremely important. I noticed a comment above ask about autonomic dysfunction. This is a great teaching point about acute vs chronic spinal cord injuries and the level that worries you. Also, would succinylcholine be a good choice in this patient?

You had a neo drip going, how much? To run a high neo drip on someone who is hypotensive for other reasons is a bad way to manage a patient. Are you aware of the negative cardiac effects neo can have? Did you draw several blood gases during the case? Was the patient acidotic, anemic, etc?

What meds did you give the patient during the case? High doses of paralytics for the whiney surgeon who says patient is never "relaxed?" How about long acting or high doses of opioids?

Exactly what "extubation criteria" did your patient meet? Opened eyes with spont ventilation by themselves are not part of the criteria. No offense to you since we are all guilty of this, but 99% of patients in the OR are never checked for "extubation criteria," except those who we are very concerned about and questionable whether they should be extubated. I definitely agree that if the patient can be extubated, you should. The senior anesthesiologist made a ridiculous comment. If he/she practices that way, they would leave half their patients on the vent for the ICU doc to manage. I will say that if the patient was difficult to intubate, unstable throughout the case, and there was high blood loss with resuscitation, then I'd tell the surgeon those concerns and plan to leave intubated overnight.

I still do not understand what you meant by I did not want to give up. Do you mean that patient was pronounced dead but yet you wanted to give the intubation another try? You can always DL with the tube in place and see if it appears it is going into the trachea or the goose. As someone else stated, put a fiberoptic down (unless of course you do not have one). Unless I am 100% confident the tube is in the goose, I would not remove it and try again and definitely do not remove at the end of the code.

I know we all do typos and I am not the grammar and spelling police, but you did write "incubtate" twice. Makes me wonder whether you are an anesthesiologist or someone else looking for ammo (which I've given).

I am not trying to be harsh, hindsight is 20/20 and I have certainly made more than my share of mistakes and regrets, but if you post a scenerio and want feedback, I'd give as much detail as possible.

 

[Noyac]

GeorgiaAnes, this was a spine case so I doubt the pt was paralyzed chemically. But if the damage was already done ( paraplegia) then I guess it's possible.
"Incubate" was probably a spell check error.

My only real criticism in this case was that the OP sounded like he/she was pressured into extubating this pt by the surgeon. Surgeons have very little idea of the anesthetic and what it may have taken to get the pt through the surgical assault. Therefore, they can make a request for extubation but the anesthesiologist should make the decision on their own.

This guy could have easily sat overnight in the neuro ICU on the vent. In hindsight, this would have been the right course of action.

 

[GeorgiaAnes]

GeorgiaAnes, this was a spine case so I doubt the pt was paralyzed chemically. But if the damage was already done ( paraplegia) then I guess it's possible.

I am sure there is a good chance that a neuromuscular blocker was used and re-dosed for the case but certainly it is possible none was given. Even if the patient had a high spinal cord lesion, the patient can still move and certainly cough or buck on the tube. A common reason for needing reintubation or crumping so soon in the PACU is too much paralytic that was either inadequately reversed or should not have been reversed. I have seen on many occasions a weak twitch with full reversal given only for the patient to be too weak to be extubated. Just a few months ago, I had a CRNA give a 30 mg re-dose of roc on an hour long case ... obviously that patient didn't do so well and spent another hour on the vent.

 

[pjl]

iPhones autocorrect intubate to incubate

 

[Noyac]

I am sure there is a good chance that a neuromuscular blocker was used and re-dosed for the case but certainly it is possible none was given. Even if the patient had a high spinal cord lesion, the patient can still move and certainly cough or buck on the tube. A common reason for needing reintubation or crumping so soon in the PACU is too much paralytic that was either inadequately reversed or should not have been reversed. I have seen on many occasions a weak twitch with full reversal given only for the patient to be too weak to be extubated. Just a few months ago, I had a CRNA give a 30 mg re-dose of roc on an hour long case ... obviously that patient didn't do so well and spent another hour on the vent.

I'm not talking about coughing or bucking on the tube. I'm talking about neuromonitoring. I would have done that Case without any neuromuscular blocking agent at all.
Do you do spine cases?

 

[GeorgiaAnes]

I'm not talking about coughing or bucking on the tube. I'm talking about neuromonitoring. I would have done that Case without any neuromuscular blocking agent at all.
Do you do spine cases?

Dang, really? Not all spine cases have neuromonitoring. Again another detail not included in the original post. We have an Orthopod who monitors every case while our Neurosurgeons do not monitor very frequently.

I've also seen the surgeon want us to use a paralytic if the patient is coughing or moving during the surgery even though there is neuromonitoring going on.
Do you get out much?

 

[Noyac]

Dang, really? Not all spine cases have neuromonitoring. Again another detail not included in the original post. We have an Orthopod who monitors every case while our Neurosurgeons do not monitor very frequently.

I've also seen the surgeon want us to use a paralytic if the patient is coughing or moving during the surgery even though there is neuromonitoring going on.
Do you get out much?

So I see you are new here. Please try to keep things cordial. Beating your chest won't endear yourself on this site.
I was asking you a serious question when I asked if you do spine cases. Not everyone does.
And if you want me to tell you how to stop a pt from moving without paralytics I'm happy too.

Have a nice day.

 

[pgg]

He was paralyzed from the "waist down" and had "total paraplegia." Are you saying his level of paralysis was below say T6 or so? Knowing the level of paralysis is extremely important. I noticed a comment above ask about autonomic dysfunction. This is a great teaching point about acute vs chronic spinal cord injuries and the level that worries you. Also, would succinylcholine be a good choice in this patient?

Are you pimping him, or offering feedback on his case? If you've got teaching points, give them. 🙂

 

[Mman]

Exactly what "extubation criteria" did your patient meet? Opened eyes with spont ventilation by themselves are not part of the criteria. No offense to you since we are all guilty of this, but 99% of patients in the OR are never checked for "extubation criteria," except those who we are very concerned about and questionable whether they should be extubated.

You say 99% of patients in the OR are never checked for "extubation criteria". Really? 100% of mine are. Am I putting them through formal testing to get NIF and an ABG after 15 minutes of SBT and other such things? Of course not. But they are meeting criteria for extubation. They have evidence of complete reversal of any NMB, they are following commands, they are generating adequate TVs, etc. Those are extubation criteria. They aren't as rigid as what you do in an ICU, but that's for obvious reasons. Our extubation failure rate is way lower than an ICU so we need far less stringent criteria.

 

[Mman]

Patient was breathing on his own, opened eyes, met criteria for extubation. Extubated the patient, second mistake in hindsight. Took the patient to recovery room, report given to nurse and was eating my dinner in break room.

My first thought is that if a patient is stable and ready to be extubated, extubate them. After the fact looking back on a bad event doesn't necessarily mean the extubation was the cause.

With this case I'm wondering if the nurse sat the patient up and they were hypovolemic and became hypotensive and bradycardic as a result.

 

[Arch Guillotti]

I probably would have extubated the guy also. I don't agree with leaving a tube in the mouth if you truly are unsure where it is.

I know an anesthesiologist who had an unrecognized esophageal intubation in the ICU during a code while a resident. This person is a very good anesthesiologist at a very good practice now. An unrecognized tube in the goose isn't beyond the realm of possibility.

 

[GeorgiaAnes]

Sorry I did not mean any ill will towards you, Noyac, but the way you phrased it sounded like a slam, my bad. But I have a strong feeling there was no neuromonitoring on that case. Also, though this is a new screen name, I am not new. I did create this name for other reasons but I have been a member here for over 7 years.

In terms of extubation criteria ... i doubt many people follow true "extubation criteria" except in certain situation. I am talking by the textbook, not just stable patient who is spontaneously breathing and looking good. 99% of cases are usually pretty straight forward and those patients are extubated .. again I am questioning exactly what did the OP do. Did he do what most of us do in a standard case, in which I will argue you are not following strict extubation criteria. If you think you're following extubation criteria 100% of the time, you're kidding yourself.

In terms of spinal cord lesions, I can certainly go into spinal shock vs autonomic dysreflexia and when is it ok to give sux in a spinal cord injury ... but that is a good thing for residents and med students to chime in.

 

[Mman]

If you think you're following extubation criteria 100% of the time, you're kidding yourself.

You seem to be implying there is only one standard set of criteria somebody needs to meet for extubation. I'd strongly disagree. Criteria for extubation in the OR need to be relative and cannot be the same ones used for ICU extubations or we'd leave millions of people on the vent unnecessarily.

So you can say they didn't meet formal ICU extubation criteria, but you can't say they didn't meet any extubation criteria.

 

[GeorgiaAnes]

You seem to be implying there is only one standard set of criteria somebody needs to meet for extubation. I'd strongly disagree. Criteria for extubation in the OR need to be relative and cannot be the same ones used for ICU extubations or we'd leave millions of people on the vent unnecessarily.

So you can say they didn't meet formal ICU extubation criteria, but you can't say they didn't meet any extubation criteria.

Yes, I believe there have been misunderstandings in what I am trying to get across. The OP said "met extubation criteria," but I am asking what criteria was that. Most anesthesiologist's typical daily, routine criteria are not what you would say during a board exam. I am not saying that is wrong since we all do it. You wake the patient up, they open their eyes, tidal volumes are reasonable, O2 sats are good, and tube comes out. The academic answer for extubation criteria is a lot more than that. I am not talking about ICU criteria either.

In the case mentioned above, the extubation criteria needed to be along the lines of the academic answer, not your standard routine case.

 

[Noyac]

Apology accepted. No hard feelings.

If you remember, I was a moderator here at one time ( not a very good one ) and I recall changing your name here was not allowed. Maybe thing have changed.

Since we are not getting the extubation criteria that this pt met from the OP would you mind telling us what you would have required from this pt to extubate him? I also think this is a great time to talk about spinal shock vs autonomic dysreflexia (hyperreflexia).

 

[Urzuz]

What anesthesia complications have you had that you can share with others?
What are the trends in closed claims studies?

I don't think this thread was meant to delve into the details of the OP's case. I think he meant for this to turn into a discussion of our own complications and what we learned from them.

 

[deleted59964]

congrats to the op for having the courage to air their case. a lot of people here are very focused on making other board members think they are the ultimate anaesthetist.

we learn more from our mistakes than our successes, and wise doctors learn from other people's mistakes rather than dismissing them as deficient.

to the op - maybe errors were made here, and maybe not. many people would have done as you did - we continuously walk a fine line with our patients.

 

[Noyac]

I don't think this thread was meant to delve into the details of the OP's case. I think he meant for this to turn into a discussion of our own complications and what we learned from them.

True but you can't post a case like this and not discuss it.

Plus, I don't really u derstand the OP's question what does he mean by "trends in closed claims"?

 

[Colba55o]

congrats to the op for having the courage to air their case. a lot of people here are very focused on making other board members think they are the ultimate anaesthetist.

we learn more from our mistakes than our successes, and wise doctors learn from other people's mistakes rather than dismissing them as deficient.

to the op - maybe errors were made here, and maybe not. many people would have done as you did - we continuously walk a fine line with our patients.

Best comment so far on this thread. I love how so many pedagogues here have pontificated about their stringent extubation criteria while a prior thread had multiple folks bragging about how slick they are about pulling tubes deep. Which is it? What if this patient had been NPO 8 hours, bad reactive COPD, hx of PTSD and was built like a quarterback? What are the chances you'd get him to follow commands wide awake with an tube in?

The OP has gotten quiet so speculating may be pointless plus we weren't there. I also congratulate the him/her for giving the details and opening the flood gates for judgment and hubris that take over most of these threads

 

[Planktonmd]

It sounds to me that if that was actually an airway complication then the problem was not in extubating the patient but in failing to confirm proper placement of the tube when he was reintubated.
Patients requiring reintubation in PACU is something we hate but it does happen and we should be able to handle it properly.

 

[pgg]

But I have a strong feeling there was no neuromonitoring on that case.

Is neuromonitoring ever used during emergency surgery for spinal injuries? I've never seen it. I'm not sure how the data would be interpreted. What are you looking for? Zero signal becoming some signal?

 

[IlDestriero]

Is neuromonitoring ever used during emergency surgery for spinal injuries? I've never seen it. I'm not sure how the data would be interpreted. What are you looking for? Zero signal becoming some signal?

You can (almost) always make things worse.
Taking out preserved bowel and bladder function, proximal loss of signals, etc.
Our neurosurgeons love monitoring everything, but this kind of trauma is rare for us, and I doubt they would delay decompression, etc for them to come in for a patient with an acute loss of function.

 

[Mman]

Is neuromonitoring ever used during emergency surgery for spinal injuries? I've never seen it. I'm not sure how the data would be interpreted. What are you looking for? Zero signal becoming some signal?

We neuromonitor plenty of trauma spine cases even in the middle of the night. Spine trauma tends to come with a big heads up that it is on it's way in the helicopter from somewhere so they have time to call in the neuromonitoring tech from home. What are they looking for? Depends on the state of the patient preop. If they are completely paraplegic before the case starts we won't monitor anything (usually). But if they are having some signs of cord compression but not a complete injury than we do full monitoring.

 

[Noyac]

As Mman stated, spine case are rarely emergent. Some are but usually there is some bit of setup time. Neuromonitoring is being used more and more these days. A few years back I was doing a case where we were decompressing and we lost all signals. Effectively, we had infarcts the cord when we relieved the compression. It was not a good scene. Had we not been monitoring it we would not have known about it as soon as we did. It probably didn't help but who knows.

In my institution we monitor nearly everything spine.

 

[dhb]

In my institution we monitor nearly everything spine.

I've never monitored a spine case and patients don't seem to fare to badly. We only do elective spine cases no intramedular tumors.

 

[Planktonmd]

I've never monitored a spine case and patients don't seem to fare to badly. We only do elective spine cases no intramedular tumors.

That whole neuro monitoring thing is at best of questionable value, but it is a lucrative business and there are people who have a very strong interest in making it the standard of care.

 

[Noyac]

That whole neuro monitoring thing is at best of questionable value, but it is a lucrative business and there are people who have a very strong interest in making it the standard of care.

I don't doubt that there are many folks making huge money on this upswing of neuromonitoring.

 

[deleted682700]

I don't think the focus should be whether you should have extubated or not. I would focus on why he arrested shortly in PACU. Did he have residual neuromuscular block? Was the minute ventilation enough? Too much narcotics? Was he ischemic? Autonomic dysfunction?

The nurse was trying to sit him up to ? Help him breathe?. There was some movement involving the patient before the art line went flat per Rn, I wasn't there. May be spinal shock variant of high spinal? But that should have responded to the epi.

 

[deleted682700]

I don't think this thread was meant to delve into the details of the OP's case. I think he meant for this to turn into a discussion of our own complications and what we learned from them.

Yes, exactly.
Yes, now I will not extubate a patient when it's questionable, I get a second anesthesiologist to look and concur.
I also insist on capnometer with etco2 numbers, if they need me to intubation in non or settings
As an anesthesiologist, of course sentinel events are difficult. Even the fact that the case is associated with my care, I need to thoroughly scrutinize where I can change for better patient care. At some point we all do this and that's what this thread is about.

 

[deleted682700]

Yes, I believe there have been misunderstandings in what I am trying to get across. The OP said "met extubation criteria," but I am asking what criteria was that. Most anesthesiologist's typical daily, routine criteria are not what you would say during a board exam. I am not saying that is wrong since we all do it. You wake the patient up, they open their eyes, tidal volumes are reasonable, O2 sats are good, and tube comes out. The academic answer for extubation criteria is a lot more than that. I am not talking about ICU criteria either.

In the case mentioned above, the extubation criteria needed to be along the lines of the academic answer, not your standard routine case.

The fact is that patient needed reintubation. Your question is very valid. Did the patient meet extubation criteria?
The retrospective answer is he did not as the case evolved. Did I have a clue what was coming? NO. And that where I missed and neurosurgeon missed too. In fact with the instrumentation, he could have poked something into the aorta? Or ivc? But autopsy did no show that.
That's 4 yrs into my anesthesia practice. However not much experience in neuro. Contextual experience matters.
Facts
Patient opened his eyes on command
Good head lift
Breathing well with adequate tidal volumes
Blood pressure and heart rate are stable and his blood pressure is on the higher side, that I had to turn the neo drip.
Surgeon already told me what he wanted from me.

 

[Planktonmd]

Saying "the surgeon wanted me to extubate" is never a good excuse coming from an anesthesiologist.
You extubate because YOU think it's appropriate, and in this case it seems it was appropriate.
If the autopsy is correct and the patient had an MI in PACU and arrested, then there was nothing you could have done to prevent that and your anesthetic care was not the cause.

 

[Mman]

Saying "the surgeon wanted me to extubate" is never a good excuse coming from an anesthesiologist.
You extubate because YOU think it's appropriate, and in this case it seems it was appropriate.

My only little issue with this is the apparent dichotomy between when a surgeon says please try to extubate vs please leave them intubated. If the surgeon asks to see if you can extubate the patient, we get all high and mighty about how that isn't their decision and this that and the other and we will do it if it appropriate. If the surgeon asks us to leave them intubated for whatever reason, we don't even say boo and the patient is on the way to the ICU with the tube in.

 

[Promethean]

My only little issue with this is the apparent dichotomy between when a surgeon says please try to extubate vs please leave them intubated. If the surgeon asks to see if you can extubate the patient, we get all high and mighty about how that isn't their decision and this that and the other and we will do it if it appropriate. If the surgeon asks us to leave them intubated for whatever reason, we don't even say boo and the patient is on the way to the ICU with the tube in.

I don't see the problem in that set of responses, given what is at stake.

If the surgeon asks you to see if you can extubate, they are saying that things have gone well on their end, and they are anticipating a good outcome, or at least that they aren't concerned about a bad one. So, let's get that tube out and go. It is prudent to say, hold up, buddy. I will pull it if that is the right thing to do. If you pull it and they go south on you, the judge isn't going to care that the surgeon said it was okay to extubate.

In the case where the surgeon is saying to keep the tube, they are saying that they have concerns. Maybe they know something about the patient or the procedure that they have just done that makes them feel that further invasive ventilation is the more prudent course. If they are having doubts about extubating, for whatever reason, who in their right mind would want to take on the liability for overriding them? No good can possibly come of it. If everything goes well, great, good on you for sparing the patient a few extra hours of intubation. If anything goes wrong, it is on your head.

 

[Noyac]

I think this pt had a PE. A big one.

 

[urge]

I think this pt had a PE. A big one.

I thought the autopsy said MI. No PE.

 

[Arch Guillotti]

Also, though this is a new screen name, I am not new. I did create this name for other reasons but I have been a member here for over 7 years.

Apology accepted. No hard feelings.
I recall changing your name here was not allowed.

He didn't change his name, (per his admission) he created a new screen name. This is generally frowned upon because sometimes problems can ensue. With that being said, had he not made this admission no one would no the difference (including me). We only check out new users if they are being trollish.

 

[Noyac]

I thought the autopsy said MI. No PE.

I must have missed that.

 

[Ronin786]

Sorry I did not mean any ill will towards you, Noyac, but the way you phrased it sounded like a slam, my bad. But I have a strong feeling there was no neuromonitoring on that case. Also, though this is a new screen name, I am not new. I did create this name for other reasons but I have been a member here for over 7 years.

In terms of extubation criteria ... i doubt many people follow true "extubation criteria" except in certain situation. I am talking by the textbook, not just stable patient who is spontaneously breathing and looking good. 99% of cases are usually pretty straight forward and those patients are extubated .. again I am questioning exactly what did the OP do. Did he do what most of us do in a standard case, in which I will argue you are not following strict extubation criteria. If you think you're following extubation criteria 100% of the time, you're kidding yourself.

In terms of spinal cord lesions, I can certainly go into spinal shock vs autonomic dysreflexia and when is it ok to give sux in a spinal cord injury ... but that is a good thing for residents and med students to chime in.

Do you mind telling us what the textbook extubation criteria are? Serious question.

 

[GeorgiaAnes]

He didn't change his name, (per his admission) he created a new screen name. This is generally frowned upon because sometimes problems can ensue. With that being said, had he not made this admission no one would no the difference (including me). We only check out new users if they are being trollish.

Yes, I had created a new one solely to post about an anesthetist job opening our practice had. I did not plan on joining in on any discussions. Sorry if this troubled anyone.