The patient’s family alleged that negligent management of general anesthesia by the certified registered nurse anesthetist (CRNA) resulted in cardiac arrest and death. The plaintiff asserted that the anesthesia team failed to order the necessary laboratory tests and failed to accurately document the care provided to the patient.
A 38 YOF, G4 P2 with a history of anemia presented at 40 weeks’ gestation and spontaneously delivered a female infant.
Post-delivery the patient began to hemorrhage. Upon assessment, the patient’s uterus was firm, no lacerations were noted, and methylergonovine and misoprostol were given without effect. The attending obstetrician was notified of the need for an emergent surgery. The patient continued to decompensate and was given supplemental oxygen until she was intubated in the operating room. Many physicians and advanced practice professionals, including CRNAs, certified nurse midwives (CNM), an anesthesiologist, and an obstetrician assisted in providing care during this chaotic emergency.
In the operating room, multiple lacerations were noted and repaired. During surgery, her heart rate remained unstable and was documented to be from 225 to 280 bpm. The patient was given 10 units of PRBC and multiple units of FFP. Estimated blood loss was 2500 cc. The patient’s instability produced artifact and caused the cardiac monitors to fail to record data or recorded inaccurate information. In some instances, a respiratory rate or end-tidal CO2 was recorded as 0. This produced sporadic gaps of critical information in the anesthesia record. Further, the CRNA had documented the epinephrine doses in micrograms instead of milligrams.
Upon admission to the ICU, the patient’s vital signs continued to be unstable with blood pressures between 40 to 80 mmHg systolic and heart rate in the 130s. Two hours after admission, the patient began to hemorrhage, coded, and died. The cause of death was noted to be postpartum hemorrhage due to cervical laceration and hypovolemic shock.
Days after the crisis, the CRNA made an addendum to the heart rates that reflected sinus tachycardia in the 130s. This created a contradiction in the heart rates recorded by the anesthesia monitor which were noted to be in the 200s. The CRNA did not note the rationale for the addendum or provide an explanation for the documentation that created incongruity within the medical record.
The family filed a lawsuit against the attending obstetrician, CNM, and various anesthesia providers alleging anesthesia mismanagement.
The anesthesia defense experts were supportive of care but critical of discrepancies in the documentation. The anesthesiologist and CRNA opined that the care and medications given were timely. It was estimated that the patient’s blood loss during the postpartum hemorrhage was 82%. The team managed the hemodynamic instability by appropriately initiating a massive transfusion protocol. Emergency medications and fluids were given and the patient’s blood pressure increased as a result. However, there were several issues of inaccurate documentation, and it was discovered that the CRNA amended the record to reflect heart rates that were much lower than she had previously documented.
The anesthesia experts explained that the artifact by the anesthesia monitor was due to the patient hemorrhaging. This also explained the end-tidal CO2 recording inaccurate information. They were also sympathetic toward the critical situation but felt the artifact should have been addressed within the documentation.
The experts believed that the team worked diligently in providing emergent care; however, documentation was lacking during intubation, transport to intensive care, and regarding the artifact recorded by the anesthesia machine.
The defense experts were critical of the CRNA’s amended record as it conflicted with the data recorded by the anesthesia machine and her original documentation.
The case was settled due to discrepancies in documentation.
The CRNA provided timely care and worked diligently to stabilize the patient. However, inaccuracies in documentation made the care provided to the patient difficult to defend as the plaintiff used the CRNA’s clinical documentation to discredit clinical care. Detailed events during a medical emergency can be lost when memories fade. Ensure that crucial treatment provided to the patient is documented and accurate information is reflected in the medical record.
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