Allegation
Plaintiff alleged patient injury to aorta resulted from inadequate anesthesia.
Case Details
A 38 YOWF (5'3", 148 lbs.) underwent a diagnostic laparoscopy due to complaints of unexplained, progressively worsening abdominal pain. Past surgical history included a gastric bypass eight months prior, a cholecystectomy, and a cesarean section.
The same surgeon performed the gastric bypass and the diagnostic laparoscopy. The operative report indicated the patient understood the risks of bleeding, infection, and possible injuries to the intestine. The report also noted the patient understood other unexpected complications from proximity injury and anesthetic risk.
Prior to the procedure, the defendant anesthesiologist met with the patient for approximately 10 minutes. He outlined his anesthesia plan, but did not choose the medication dosages because the CRNA chooses the dosages. When she arrived, the defendant CRNA found the patient was already sedated in the operating room, as another CRNA had already administered the pre-op medications and narcotics. Notes as to medications administered during the first few minutes of surgery are somewhat incomplete.
The operative note indicated that after the surgeon went through the peritoneum, the patient “bucked” unexpectedly, and the surgeon lost visualization of all tissue planes. He could not identify where the tip of the trocar was through the scope, so the trocar was removed. Of note, an OR nurse and surgical tech later testified that the patient did not “buck.” However, the assistant surgeon testified he saw the patient’s back arch up and off the table during the procedure. The defendant CRNA documented a sudden increase in the patient's heart rate, decreased end-tidal CO2, and loss of blood pressure. The documentation went on to note that more relaxant was given, the trocar was replaced, and the surgeon entered the abdomen without difficulty.
When the surgeon looked through the trocar with the scope, he saw blood in the abdomen. The defendant anesthesiologist was paged and came to the OR. The patient was placed in steep Trendelenburg position, and her medications were modified and changed accordingly. An incision was rapidly extended across the abdomen, converting the procedure from a laparoscopy to a laparotomy. A tremendous amount of blood was coming from the incision and it was estimated that the patient had lost half of her blood volume.
An aortic clamp was placed beneath the diaphragm to gain control of the aorta. The operative note indicated there was significant bleeding at the retro-peritoneum and the bright red blood indicated there was possibly an aorto-iliac injury. Once the clots were removed, the surgeon dissected through the retro-peritoneum and could see that the patient had an unusual aorta. His operative report described the aorta as firm and tortuous.
After anastomosis and resection of the distal portion of the aorta, the surgeon reported excellent reestablishment of blood flow distally. However, within 20 minutes, there was significant oozing from all the other non-surgical abdominal sites, indicating the onset of disseminated intravascular coagulation (DIC).
Despite receiving a total of 34 units of blood, 45 units of plasma, and multiple platelet packs, the patient’s left colon became ischemic and appeared infarcted. The patient arrested, resuscitative efforts failed, and the patient expired later that night. Immediately after the patient’s death, the anesthesiologist and the surgeon spoke with the family, explaining the patient bucked during the procedure, implying that due to inadequate anesthesia the patient moved which likely caused the bleed. The co-defendant surgeon created several different operative reports; the first two versions concluded that a trocar-related injury was caused by patient movement. An autopsy concluded that the cause of death was due to a spontaneous dissecting aortic aneurysm.
The patient’s spouse filed a lawsuit alleging that the trocar injury to the patient’s aorta resulted from inadequate anesthesia. The plaintiff also alleged fraud and intentional wrongdoing. The allegations of fraud and intentional wrongdoing were dismissed prior to trial.
Expert Testimony
A plaintiff expert who was board certified in forensic pathology performed a second autopsy. He stated the cause of death was massive internal hemorrhage due to inadvertent perforations of the aorta during laparoscopy. The manner of death was characterized as accidental.
Another plaintiff expert, board certified in internal medicine and anesthesiology, thought the CRNA’s technique, supervised by the defendant anesthesiologist, fell below the standard of care. The expert further stated that the CRNA’s technique was negligent for failing to provide an adequate depth of anesthesia and analgesia. Since the patient had been taking opioid analgesic medications for her chronic abdominal pain, the expert stated it should have been expected she had a high degree of tolerance. The expert surmised that this, coupled with the CRNA’s failure to properly assess the degree of muscle relaxation present at trocar insertion, resulted in a violent movement which directly contributed to the patient's death.
The defendant anesthesiologist stated it was obvious this was not a normal aorta, but one that was very friable. He went on to attest that the patient could have had an ongoing abdominal aortic aneurysm without symptoms, or her unexplained abdominal pain could have been from the aortic aneurysm.
Resolution
Despite a poor outcome for the patient — the jury returned a unanimous verdict for the defense.
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