Allegation
The plaintiff alleged the defendant anesthesiologist administered an excessive dose of anesthetic that lead to seizure, cardiac arrest, and death of the patient.
Case Details
A 50 YOF (5’7”, 205 lbs.) presented to an outpatient orthopedic surgery center for a left shoulder arthroscopy with joint resection and lysis of adhesions. The patient's medical history included HTN, asthma, diabetes, reflux, and peptic ulcer disease. The patient was cleared for surgery by the orthopedist and a cardiologist. A normal EKG was in the admission chart. A consent form for the surgery and a separate anesthesiology consent form were signed by the patient. Prior to the procedure, the defendant anesthesiologist discussed the anesthesia options with the patient. An interscalene block was selected per orthopedist preference. The anesthesiologist assigned an ASA rating of 1.
At 09:35, while in the holding area, the patient was sedated with 2 mg Versed and 2 ml Alfenta; 100 mg propofol was given in divided doses over approximately 10 minutes. The defendant anesthesiologist then administered 40 ml 2% mepivacaine, injected in divided doses. No blood or other fluid was noted on aspiration, and the injection was finished at 09:50. At 09:55, the patient had a grand mal seizure. She was administered 2 mg Versed, then 50 mg propofol and O2. The seizure ceased at 09:58; 100% O2 via mask was continued. The patient’s vital signs were BP 100/60, P 54, and R 20; O2 saturation was 73%.
By 10:00, the patient was in ventricular tachycardia and was shocked with 360 joules by the defendant. CPR was started, the oral airway removed, and a laryngeal mask airway (LMA) was inserted. At this time, the patient had no pulse, no spontaneous respirations, and no oxygen saturation was detectable on the monitor. Epinephrine 1 mg was given via IV push. CPR continued. The LMA was removed by the defendant anesthesiologist, and a 7.5 endotracheal tube was inserted. An atropine IV was given, and EMS was called. By 10:10, her heart rate was 44. Several doses of IV epinephrine were administered and CPR continued.
EMS arrived at 10:15 and took over care of the patient. At this time, the patient had no BP and her pupils were unreactive. Enroute to the ED, the patient was administered IV epinephrine, atropine and Narcan. The ED physician diagnosed the patient with acute cardiopulmonary arrest. At 10:26, the triage nurse in the ED documented the event at the surgical center; the nurse also documented the patient was unresponsive for 35 minutes. The patient’s vital signs were BP 64/30, P 103, and R 18, and her pupils were dilated at 5 mm. She was stabilized and admitted to the ICU in critical condition.
The patient remained in a comatose state, and expired 20 days later. Autopsy findings did not show an etiology for the patient's initial seizure or cardiac arrest. There were some subtle tissue changes which could be consistent with an anoxic insult.
Expert Testimony
At trial, the plaintiff’s medical expert testified the defendant anesthesiologist breached the standard of care in several areas. The expert alleged 800 mg of mepivacaine was double the recommended maximum dose, and is only reserved for exceptional circumstances. The expert surmised the patient’s seizures, arrhythmias, cardiovascular collapse, cardiac arrest, and death were entirely due to toxicity from mepivacaine. Further allegations were that the patient’s life may have been saved if succinylcholine had been administered; metabolic demands would have ended and greatly facilitated ventilation. Succinylcholine also would have permitted rapid endotracheal intubation with resulting high oxygen delivery and total airway control. The expert testified the defendant additionally failed to administer lipids to help the heart absorb the mepivacaine. He stated that although not universally accepted, the technique of lipid rescue resuscitating local anesthetic toxicity with intravenous lipid infusions was well-researched and documented.
One defense expert countered that he had performed over 3,000 regional blocks using the same dose of mepivacaine in an interscalene injection. Another defense expert testified the dose of mepivacaine administered was a common one prescribed by anesthesiologists for interscalene blocks. The expert stated the dose was not excessive, lethal, or toxic. FDA guidelines and/or the manufacturers' recommendations for dosages do not establish the standard of care. Government and manufacturer recommendations for drugs frequently differ from the way drugs are used safely and typically by healthcare providers. Mepivacaine is known to cause cardiac complications with less frequency than other anesthetics and rarely causes seizures. Experts testified that given the patient’s cardiac history, regional anesthesia with mepivacaine was a lower risk than general anesthesia.
Resolution
The case went to trial and resulted in a mistrial. It was tried a second time and resulted in a defense verdict.
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