Allegation:
Plaintiff alleged the defendant, an eICU pulmonologist, should have recognized the limitations of eICU and advised nursing staff to contact the onsite physician regarding the patient's persistent post-operative hypotension.
The Case:
A 69 YOF (5’5”, 155 lbs.) had a previous right hip surgery for a comminuted unstable intertrochanteric fracture. Prior to surgery, an internal medicine physician instructed the patient to continue taking her prescribed Plavix® 75 mg and aspirin 162 mg due to the presence of medicated cardiac stents placed in 2007. The patient’s history showed coronary artery disease, left ventricular systolic dysfunction, HTN, hyperlipidemia, and GERD.
Six months later, the patient fell at home and was admitted to the hospital. A right hip x-ray revealed a failed fixation, delayed healing, and penetration of a hip screw into the joint. The patient underwent surgery two days later to remove the old hardware and place a cemented stem implant. Plavix, aspirin, and Lovenox® were held that morning. Surgery was lengthy and the patient lost 2,500 cc of blood during surgery. The patient was transferred to the ICU on a ventilator to be managed by an onsite pulmonologist, with care also monitored by an off-site eICU pulmonologist.
Early the next morning, the patient’s BP dropped. Nursing contacted the off-site monitoring defendant pulmonologist, who ordered a bolus of 500 cc of normal saline (NS), to which the patient responded quickly. The patient’s BP dropped again. A second 500 cc NS bolus was given per eICU order and the patient again responded quickly. Nurses observed mottling from the upper groin to the breasts. The defendant pulmonologist ordered cardiac enzymes with troponin, a CBC, and another 500 cc NS bolus. Labs revealed the troponin level was consistent with a myocardial injury, but also that mild elevation of troponin may indicate non-infarction cardiac injury or an early MI.
An hour-and-a-half later, the defendant pulmonologist ordered an increase in lactated Ringer’s to 200 cc per hour every two hours, and then a decrease to 75 cc per hour. Hemoglobin was stable and there were no signs of bleeding. The patient’s platelet count dropped to 56 (150-450), and the physician ordered 1 L NS and 250 cc of 5% albumin. An hour later, the patient’s Hgb and HCT were 11.8 (12-16) and 34.9 (36-48). The defendant pulmonologist requested discontinuation of the PEEP on the ventilator; it was her last involvement with the patient.
Later that morning, the patient’s surgeon noticed the patient was still intubated and requested a pulmonary/critical care consult. An onsite pulmonologist saw the patient for ventilator management and charted “the patient had significant blood loss in the OR due to being on Plavix and constant oozing.” The patient’s BP was low and she received six units of packed RBCs; IV fluids were ordered and systolic pressure was in the 130s. The patient began to awaken, but remained mechanically ventilated. A chest x-ray revealed a little haziness on the left side, but no clear pneumonic process. The plan was to start weaning the patient from the ventilator.
The following day, a consulting neurologist stated the patient suffered hypoxic encephalopathy secondary to prolonged hypotension from significant blood loss, presumably due to Plavix use preoperatively. Even though appropriate resuscitation efforts were managed in the OR and post-operatively, there were still episodes of transient hypotension. Over a period of 36 to 48 hours, it became clear the patient had mental status issues with decreased responsiveness, followed shortly by posturing and seizure activity. An EEG confirmed a seizure disorder, and anti-seizure medications were started. The patient was extubated after the posturing resolved.
The patient was transferred to the orthopedic floor and had progressive neurological improvement. She was alert, but memory was very poor and slow. She participated in rehabilitation and the feeding tube was eventually discontinued. Her discharge summary stated her hospital course was stormy, but vital signs were stable at the time of discharge. She was evaluated and accepted for an inpatient rehabilitation program after which she was transferred to an assisted living facility, where she continued to reside.
The patient continued to have spasticity in her lower extremities as well as a brain injury. Neurocognitive testing showed a neurocognitive profile reflective of vascular dementia, consistent with a mild to moderate level of severity. The etiology was felt to be related to her hypoxic encephalopathy. She suffered a stroke three years after her transfer to the assisted living facility.
The patient filed suit alleging an anoxic brain injury from blood loss during hip surgery. The plaintiff’s experts testified that an onsite pulmonologist should have been notified by nursing for a bedside consult due to the drop in BP, and that the eICU was too limited to rely on. Experts were also critical that there should have been better communication between the defendant pulmonologist and the onsite physician. Defense experts stated the injury must have occurred intraoperatively given the blood loss and anemia. From a neurological expert’s perspective, the administration of fluids relieved hypotension, providing benefit to the patient.
Verdict:
Although the patient experienced post-operative complications, the defendant eICU pulmonologist provided proper off-site care and her treatment was defensible. The jury returned a defense verdict.
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