Sinus Surgery With 18-Minute Monitoring Gap

A Massachusetts woman, age 37, underwent elective outpatient sinus surgery to address recurrent sinus infections. Shortly after the procedure began, the patient was administered cocaine as an anesthetic, which triggered an expected rise in her blood pressure. The defendant anesthesiologist administered a 10-mg dose of labetalol to treat the blood pressure. The patient was given a second dose only five minutes later.

Another five minutes later, after the patient’s blood pressure had already fallen, the defendant administered a third dose of labetalol. Eighteen minutes passed without documentation of the patient’s vital signs, apparently during a shift change of the nursing staff. After the 18 minutes, the record indicated that the patient’s blood pressure was not obtainable; she was cyanotic and mottled and in cardiac arrest.

Resuscitation was initiated and the patient was defibrillated three times, with a return to normal sinus rhythm after 12 minutes. She was subsequently diagnosed with anoxic encephalopathy, cerebral edema, and hypoxic brain injury. Since the incident, she requires ongoing supervision and care.

The plaintiff alleged that the anesthesiologist failed to monitor the patient. The plaintiff also claimed that normal practice is to wait 10 minutes, not five minutes, before administering a second dose of labetalol, and that a third dose should not have been administered.

Outcome
According to a published account, a $2 million settlement was reached.

Comment
Medical malpractice cases involving anesthesia are common, and anesthesia is considered a “high-risk” practice environment. Given the inherent hazards of managing a patient’s airway, ventilation, and perfusion status, errors can cause rapid deterioration and a poor outcome.

From the layperson juror’s point of view, the utmost care and vigilance are always required when a patient is “under the gas.” Jurors expect careful preoperative screening, direct and attentive intraoperative management, and close postoperative observation.

Here, we do not know how high the patient’s blood pressure rose before labetalol was administered. We do know that no intraoperative vital signs were recorded for 18 minutes. We also know that the plaintiff’s expert witness testified that the patient was improperly administered the second dose of labetalol after five minutes, and a third dose after another five minutes—after the patient’s pressure had already started to drop.

Generally, the anesthesiologist/anesthetist records vital signs; it is probable that the 18-minute gap occurred after the patient’s condition deteriorated, while the anesthesiologist was attempting to correct the patient’s hypotension and was thus distracted from recording vital signs.

In this case, jurors would have little trouble concluding that the standard of care was breached. This case settled before going to trial, likely on the recognition that the missing vital signs records provided a problem for the defense.

It has been said that the practice of anesthesia is “usually terribly simple but sometimes simply terrible”; and that it is defined by “hours of boredom punctuated by moments of sheer terror.” Regardless of how you feel about these characterizations, cases can go bad quickly. Like the airline pilot who must immediately transition from cruising on autopilot to operating in “mayday” mode, anesthesia practitioners must have systems in place to recognize danger and quickly transition from the routine to the emergent. Additionally, anesthesia departments must have a plan in place to assist anesthesia personnel who are in trouble, and issue a “mayday” call—allowing help and resources to be dispatched quickly to the patient’s side. —DML

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A Massachusetts woman, age 37, underwent elective outpatient sinus surgery to address recurrent sinus infections. Shortly after the procedure began, the patient was administered cocaine as an anesthetic, which triggered an expected rise in her blood pressure. The defendant anesthesiologist administered a 10-mg dose of labetalol to treat the blood pressure. The patient was given a second dose only five minutes later.

Another five minutes later, after the patient’s blood pressure had already fallen, the defendant administered a third dose of labetalol. Eighteen minutes passed without documentation of the patient’s vital signs, apparently during a shift change of the nursing staff. After the 18 minutes, the record indicated that the patient’s blood pressure was not obtainable; she was cyanotic and mottled and in cardiac arrest.

Resuscitation was initiated and the patient was defibrillated three times, with a return to normal sinus rhythm after 12 minutes. She was subsequently diagnosed with anoxic encephalopathy, cerebral edema, and hypoxic brain injury. Since the incident, she requires ongoing supervision and care.

The plaintiff alleged that the anesthesiologist failed to monitor the patient. The plaintiff also claimed that normal practice is to wait 10 minutes, not five minutes, before administering a second dose of labetalol, and that a third dose should not have been administered.

Outcome
According to a published account, a $2 million settlement was reached.

Comment
Medical malpractice cases involving anesthesia are common, and anesthesia is considered a “high-risk” practice environment. Given the inherent hazards of managing a patient’s airway, ventilation, and perfusion status, errors can cause rapid deterioration and a poor outcome.

From the layperson juror’s point of view, the utmost care and vigilance are always required when a patient is “under the gas.” Jurors expect careful preoperative screening, direct and attentive intraoperative management, and close postoperative observation.

Here, we do not know how high the patient’s blood pressure rose before labetalol was administered. We do know that no intraoperative vital signs were recorded for 18 minutes. We also know that the plaintiff’s expert witness testified that the patient was improperly administered the second dose of labetalol after five minutes, and a third dose after another five minutes—after the patient’s pressure had already started to drop.

Generally, the anesthesiologist/anesthetist records vital signs; it is probable that the 18-minute gap occurred after the patient’s condition deteriorated, while the anesthesiologist was attempting to correct the patient’s hypotension and was thus distracted from recording vital signs.

In this case, jurors would have little trouble concluding that the standard of care was breached. This case settled before going to trial, likely on the recognition that the missing vital signs records provided a problem for the defense.

It has been said that the practice of anesthesia is “usually terribly simple but sometimes simply terrible”; and that it is defined by “hours of boredom punctuated by moments of sheer terror.” Regardless of how you feel about these characterizations, cases can go bad quickly. Like the airline pilot who must immediately transition from cruising on autopilot to operating in “mayday” mode, anesthesia practitioners must have systems in place to recognize danger and quickly transition from the routine to the emergent. Additionally, anesthesia departments must have a plan in place to assist anesthesia personnel who are in trouble, and issue a “mayday” call—allowing help and resources to be dispatched quickly to the patient’s side. —DML

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A Massachusetts woman, age 37, underwent elective outpatient sinus surgery to address recurrent sinus infections. Shortly after the procedure began, the patient was administered cocaine as an anesthetic, which triggered an expected rise in her blood pressure. The defendant anesthesiologist administered a 10-mg dose of labetalol to treat the blood pressure. The patient was given a second dose only five minutes later.

Another five minutes later, after the patient’s blood pressure had already fallen, the defendant administered a third dose of labetalol. Eighteen minutes passed without documentation of the patient’s vital signs, apparently during a shift change of the nursing staff. After the 18 minutes, the record indicated that the patient’s blood pressure was not obtainable; she was cyanotic and mottled and in cardiac arrest.

Resuscitation was initiated and the patient was defibrillated three times, with a return to normal sinus rhythm after 12 minutes. She was subsequently diagnosed with anoxic encephalopathy, cerebral edema, and hypoxic brain injury. Since the incident, she requires ongoing supervision and care.

The plaintiff alleged that the anesthesiologist failed to monitor the patient. The plaintiff also claimed that normal practice is to wait 10 minutes, not five minutes, before administering a second dose of labetalol, and that a third dose should not have been administered.

Outcome
According to a published account, a $2 million settlement was reached.

Comment
Medical malpractice cases involving anesthesia are common, and anesthesia is considered a “high-risk” practice environment. Given the inherent hazards of managing a patient’s airway, ventilation, and perfusion status, errors can cause rapid deterioration and a poor outcome.

From the layperson juror’s point of view, the utmost care and vigilance are always required when a patient is “under the gas.” Jurors expect careful preoperative screening, direct and attentive intraoperative management, and close postoperative observation.

Here, we do not know how high the patient’s blood pressure rose before labetalol was administered. We do know that no intraoperative vital signs were recorded for 18 minutes. We also know that the plaintiff’s expert witness testified that the patient was improperly administered the second dose of labetalol after five minutes, and a third dose after another five minutes—after the patient’s pressure had already started to drop.

Generally, the anesthesiologist/anesthetist records vital signs; it is probable that the 18-minute gap occurred after the patient’s condition deteriorated, while the anesthesiologist was attempting to correct the patient’s hypotension and was thus distracted from recording vital signs.

In this case, jurors would have little trouble concluding that the standard of care was breached. This case settled before going to trial, likely on the recognition that the missing vital signs records provided a problem for the defense.

It has been said that the practice of anesthesia is “usually terribly simple but sometimes simply terrible”; and that it is defined by “hours of boredom punctuated by moments of sheer terror.” Regardless of how you feel about these characterizations, cases can go bad quickly. Like the airline pilot who must immediately transition from cruising on autopilot to operating in “mayday” mode, anesthesia practitioners must have systems in place to recognize danger and quickly transition from the routine to the emergent. Additionally, anesthesia departments must have a plan in place to assist anesthesia personnel who are in trouble, and issue a “mayday” call—allowing help and resources to be dispatched quickly to the patient’s side. —DML

Cases reprinted with permission fromMedical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.