Allegation
A CRNA violated the standard of care by not properly supervising a SRNA (Student Registered Nurse Anesthetist) and failing to perform a timely intubation.
Case Details
A 76 YOF (5’5”, 134 lbs.) presented to the hospital via ambulance with complaints of right hip pain after a fall. X-rays showed a right femoral neck fracture. Her surgical history included heart catheterization, hysterectomy, thyroidectomy, cholecystectomy, tonsillectomy, appendectomy, breast biopsies, and left rotator cuff repair. Her current medications included Synthroid, Prevacid, Xanax, Lipitor, Benicar, Advair inhaler, lisinopril, vitamin B12, multivitamin, beta carotene, baby aspirin, calcium, and Combivent inhaler prn.
After examination by an orthopedic surgeon, the patient agreed to move forward with a right endoprosthesis. Prior to surgery, a SRNA proceeded to intubate the patient; he noted a leaky cuff. The SRNA reintubated the patient and noted positive EtCO2. He also noticed the monitor had malfunctioned. The defendant CRNA, who had been supervising, left briefly to retrieve a new monitor. Another CRNA came into the room and the patient was noted to be pale. The ETT was removed, and the second CRNA and the SRNA began to ventilate the patient. Upon returning to the room with a working monitor, the defendant CRNA successfully intubated the patient. The endoprosthesis procedure was performed without complication.
In the recovery room, the patient was difficult to arouse post-operatively and an internist was consulted. The patient was noted to be alert, but not answering questions appropriately; this condition resolved within one hour. A CT of the head without contrast revealed no abnormal findings.
The next day, the same internist saw the patient. He noted that within 12 hours of the leaky cuff event intraoperatively, the patient was alert, moving all extremities, and had no focal neurological changes whatsoever. His impression was mild transient hypoxemia in the perioperative period with no residual signs of injury or neurological deficits. Notes on this same day from physical therapy and nursing indicate the patient displayed intermittent confusion.
Several days later, the patient was discharged to a rehabilitation facility for continued rehab of her hip. Two days after this transfer, the patient was sent to the hospital for evaluation of left-sided weakness and blurred vision. The initial head CTs were unremarkable. Several days later, a head CT showed evidence of a cerebellar stroke. The patient was discharged from the hospital back to the rehabilitation facility.
The patient had a follow-up visit with the orthopedic surgeon months later. He noted the patient had a "perioperativehypoxic event which has caused obvious issues with her postoperative recovery." The orthopedic surgeon further noted clawing of her toes on both feet and equinus contractures of both heels. Aggressive physical therapy was recommended to correct the equinus contractures as much as possible. At a subsequent visit, he noted bilateral equinus contractures to her heels that made it difficult for her to stand. He felt she could benefit from heel cord lengthening. He requested a neurology consult.
At the neurology visit, the patient complained of slurred speech, weakness and numbness of the limbs, and impaired gait. She reported she had been previously told she had a stroke. The patient was now using a wheelchair. The neurologist ordered an MRI of the brain which showed small vessel change but no abnormality that would account for the neurological complaints. An MRI of the cervical spine showed degenerative changes without evidence of cord compromise, and also provided no explanation of her complaints. The patient was referred for neuropsychological testing which revealed early dementia. In the meantime, the patient underwent right achilles tendon release and left foot toe tenotomy performed by the orthopedic surgeon. She tolerated the procedure well.
The patient subsequently saw two different neurologists. After evaluating her, the neurologists also deemed her condition was not consistent with a hypoxic brain injury. Over the next year, the patient continued to decline; eventually she expired. Her cause of death was listed as anoxic brain injury. The patient’s family sued the defendant CRNA alleging failure to properly manage the SRNA.
Expert Testimony
An expert for the plaintiff was critical of the second intubation, and believed it was an esophageal intubation from the beginning. Another plaintiff expert testified the patient suffered from a hypoxic insult during the intubation process with delayed post-hypoxic encephalopathy; the expert further stated that the CRNA failed to provide appropriate supervision to the SRNA.
Defense experts countered that the delayed recovery noted for the patient is not uncommon for elderly patients and not indicative of an anoxic brain injury; rather, delayed recovery is the expected effect of anesthesia for elderly patients.
Resolution
The case went to trial and the jury returned a unanimous verdict in favor of the defense.
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