Allegation
Staff failure to appreciate multiple indications of IV infiltration resulted in emergency surgery and permanent scarring for a young patient.
Case Details
A 24 YOM patient presented to a hospital operating room for robotic assisted ileocecal resection. Preoperatively, a nurse placed a 20 gauge IV in the patient’s left arm. The anesthesiologist noted the site as unremarkable and that the IV flushed easily. Local anesthetic and other initial anesthesia medications were administered through the IV without resistance.
At 1:45 p.m., pre-anesthesia began with the patient receiving 2 mg midazolam and 50 mcg fentanyl. Anesthesia followed at 2:08 p.m. with 200 mcg fentanyl, 60 mg lidocaine, 160 mcg propofol, and 40 mg rocuronium. Intubation occurred at 2:10 p.m. and the anesthesiologist noted no complications.
Surgery began at 2:43 p.m. Following induction of anesthesia, additional doses of the neuromuscular blocker rocuronium were given at 2:45 p.m. (10 mg), at 3:10 p.m. (20 mg), at 3:45 p.m. (10 mg), and at 4:10 p.m. (20 mg).
The size of the robot used for the surgery created a relative lack of space in the room and staff tucked the patient’s arms with a sheet to prevent movement during the procedure. Tucking the patient’s arms rendered the IV site visually unobservable to staff.
A peripheral nerve stimulator, commonly known as a train-of-four monitor (TOF), assessed the patient’s neuromuscular transmission while under neuromuscular blocking agents (NMBAs) given to block musculoskeletal activity. By monitoring the level of neuromuscular blockade, peripheral nerve stimulation can ensure proper medication dosing and decrease the chance of side effects. At 4:45 p.m. the TOF score went from 0/4 to 4/4. During the patient’s course of anesthesia his scores remained mostly between 0/4 through 2/4. At 5:15 p.m. the TOF score went to 4/4 but no additional rocuronium was given.
The certified registered nurse anesthetist (CRNA) present with the patient from 1:45 p.m. through 5:22 p.m. took a dinner break and was relieved by a second CRNA (CRNA2) from 5:22 p.m. until 5:48 p.m.
When CRNA2 came on he administered another neuromuscular blocker, vecuronium at 2 mg. Deeming it ineffective, he gave another 1 mg.
At 5:39 p.m. CRNA2 noted the pulse oximetry “dampened” and read 83 percent. Believing this was caused by a physician’s assistant leaning on the patient’s arm, CRNA2 moved the pulse ox clip to the patient’s ear. Without documenting why, the CRNA2 also increased the IV pump to maximum volume.
At 5:45 p.m. the TOF score was listed as 0/4 but this is questionable as the scores at 6:00 p.m. and 6:15 p.m. both read 4/4.
The patient’s blood pressure began to decrease at 6:00 p.m. Three doses of phenylephrine were administered but the blood pressure did not respond accordingly.
Upon procedure completion, staff untucked the left arm and noted the limb to be tight and swollen. The IV had infiltrated. The patient’s fingertips were pale and dusky and, though warm to the touch, no radial pulse could be detected in the arm. Staff immediately engaged trauma service to address compartment syndrome in the limb. An orthopedic surgeon performed an emergency fasciotomy, noting upon arrival that the arm was dangerously swollen, with no palpable pulses distal to the axilla. The surgeon recorded serious blisters appearing at the volar wrist, the skin starting to appear ecchymotic within the palm, and lack of capillary refill distally. Following surgery, the patient went to the surgical intensive care unit for close monitoring and ongoing neurological assessments of the upper left extremity.
Three days after the initial robot assisted surgery, the orthopedic surgeon placed the patient back under general anesthetic and closed the six open incisions created during the emergent fasciotomy. This procedure required 80 stitches in the patient’s forearm and hand. The patient was released from the hospital two days later.
The patient attended physical therapy sessions but did not complete the full prescribed course due to anxiety over leaving his first full-time job to attend the appointments. While in therapy he performed home scar massage and applied a gel daily to the scars. Therapy reduced stiffness along the scars and improved the patient’s strength and mobility. However, two years later he still suffered scarring and numbness with possible permanent nerve damage in the left third, fourth, and fifth fingers.
Expert Testimony
An expert initially opined that a variety of factors could reasonably explain the TOF scores, the pulse ox issue, and the blood pressure variation. However, the explanation for increasing the IV pump speed to maximum was never documented. These clinical signs collectively should have raised suspicion that the IV was not flowing properly. The expert believed that the failure of the CRNA to investigate the IV would be difficult to defend retrospectively and resulted in the patient suffering compartment syndrome which required emergency surgery.
Resolution
The case settled prior to suit.
Risk Reduction Strategies
Conduct regular assessment of IV access sites and when indications of complications arise.
Accurately document assessment criteria using standardized language.
Communicate pertinent information at handoff whenever there is a change in coverage.
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