Allegation:
Failure to rescue following intubation complications during surgery.
Case Details
A 42 YOF, 5’3”, 175 lb patient with a BMI of 31 and a five-year history of smoking arrived at an ambulatory surgery center (ASC) to undergo abdominal liposuction and tummy tuck. The anesthesiologist completed a pre-surgery assessment, noting the patient as ASA II. The anesthesia plan called for general endotracheal anesthesia. After discussion, with all the patient’s questions answered, she signed a surgical consent form that included potential death from cardiac arrest.
The patient’s first set of vital signs were recorded at 8:30 a.m. At 9:10 a.m. the patient was in the operating room with an IV placed. The anesthesiologist induced the patient at 9:30 a.m. with an IV of propofol, midazolam, and fentanyl. Documentation showed the patient’s blood pressure at 140/100. Bradycardia was noted at 9:42 a.m. but the pulse was not recorded and 0.4 mg of IV atropine was administered.
Additional propofol was given at 9:45 a.m. Attempts were made to establish an airway with a laryngeal mask airway (LMA). On the second attempt laryngospasms were present. On the third attempt an LMA was placed, breath sounds noted to be equal, and CO2 noted to be present. No additional documentation regarding the intubation was completed, and the patient was never intubated.
Records show the patient’s BP at 9:50 a.m. reported to be 125/80. Sevoflurane was initiated but the time was not documented, nor was the flow rate. Vital signs were not continuously recorded. At 9:55 a.m. the inhalation agent was stopped due to patient instability.
A cardiopulmonary resuscitation flow sheet and nursing notes indicate that the patient received ventilation through LMA.
The patient received epinephrine at 9:57 a.m., and vitals were recorded as BP 180/109, P 55, 02 sat 92% at 9:59 a.m. The patient demonstrated coarse breath sounds with manual ventilation and albuterol was administered. At 10:01 a.m. the patient lost pulse on the monitor, and an AED was placed but no shock advised. The patient continued to receive manual ventilation.
The anesthesiologist administered naloxone 0.4 mg at 10:06 a.m., and EMS arrived at 10:10 a.m.
EMS maintained CPR for 27 minutes, transporting the patient to the nearest medical center and arriving at 10:38 a.m. The patient remained in asystole throughout treatment by EMS and the ED.
The ED physicians documented that upon arrival the patient was being bagged with the LMA in place. They achieved successful intubation in the ED on the second attempt using a video laryngoscope and stylet. Despite these efforts the patient was pronounced dead at 11:09 a.m. The ED physicians each separately documented that the patient had a difficult airway due to bleeding, a large tongue, obesity, and a short neck. The autopsy indicated the patient’s cause of death as history of bradycardia followed by cardiac arrest after multiple intubation attempts, with pulmonary congestion and edema.
Expert Testimony
Per the anesthesia standard of care expert:
“The anesthesiologist failed to obtain informed consent and recognize the patient had a difficult airway based on her obesity, thick enlarged tongue, and short neck. He was required to implement a safe anesthesia plan and use appropriate muscle relaxants to secure and maintain paralysis and prevent and treat laryngospasm. Video laryngoscope, stylet, and muscle relaxants were required for intubation. EMS was not timely called. The patient’s laryngospasm and bradycardia were not appropriately treated; anesthesia should have been stopped with no further intubation attempts once these complications were encountered. LMA was inappropriate to administer oxygen. The anesthesiologist failed to use proper equipment for administration of adequate oxygen and should have called for a surgical airway.”
Experts also discussed whether the surgeon or anesthesiologist should have attempted to create a surgical airway. Defense experts were supportive of the decision not to use a surgical airway as the ventilation used was working.
The anesthesiologist testified that the patient was an ASA II because of her smoking history. However, this observation was not recorded in the medical record. Further, there were inconsistencies in the record regarding the number of attempts at intubation.
Resolution
The case was settled.
Risk Reduction Strategies
The purpose of an informed consent discussion between an anesthesiologist and a patient is to educate the patient about the anesthesia process including the risks, benefits, and potential complications and facilitate their understanding of the process. A conversation allows the patient to ask questions and clarify concerns. Informed consent is a legal requirement that protects both the patient and the healthcare provider by documenting the patient’s awareness and agreement to the planned procedure and associated anesthesia.
In addition, by discussing the patient’s history an anesthesiologist may anticipate potential complications such as difficult intubations. The anesthesiologist can assess and plan for a potential difficulty—helping to ensure safer and more personalized care—using the following strategies:
- Develop clear policies and procedures for emergency protocols
- Identify potential risks and complications, such as difficult intubation
- Address individual factors like obesity or past anesthesia challenges
- Allow the patient to ask questions and express concerns
- Confirm the patient’s understanding and agreement to the anesthesia plan
- Evaluate patient selection criteria including ASA physical status classification and Mallampati score
- Determine suitability for the ambulatory surgery center based on health status and procedure type
- Ensure that emergency assistance measures are in place for potential complications
- Document that the informed consent process occurred
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