A 68 year old man was scheduled for an open AAA repair via a left retroperitoneal approach.

He was a lifelong smoker with COPD, aortic stenosis, hypertension, and peripheral vascular disease.

His anesthesiologist inserted a radial arterial line prior to induction of anesthesia.

No Allen test or variation was performed prior to placement.

The 9 hour surgery had a total blood loss of 4,000mL.

He received 5U PRBC, 1270mL cell saver, and 10L crystalloid throughout the operation.

Postoperatively he remained intubated and on pressors in the ICU.

The following morning his radial A-line waveform was dampened, so it was removed.

The plaintiff claimed his hand was discolored at this time, and “looked burnt.”

His hand had been hypoperfused resulting in ischemia.

The rest of the patients recovery was uneventful, but as a result of the ischemia he required an amputation of his thumb and index finger.

The patient sued the anesthesiologist citing a failure to ensure adequate perfusion to the hand and digits.

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The plaintiff’s attorney hired an anesthesiology expert

The defense hired an anesthesiology expert as well

Outcome

The case proceeded to a jury trial. After deliberation jurors returned a verdict in favor of the defendants.

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MedMalReviewer Analysis

1. Radial A-line complications are extremely rare. A search in Pubmed reveals an incidence of neurologic or vascular injury of around 3.4 per 10,000. It stands then that many of us will go our career without seeing such an injury. I don’t see anything here that would alter my practice habits. Although as evidenced by this expert opinion, a documented Allen test may provide some medicolegal protection.

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2. Perhaps a routine Allen test is a regional or institutional thing. I do think it is far fetched to call it a standard pre-procedural test for an A-line. The expert claim of the need for a Swan-Ganz catheter is even worse. Just when I think I’ve heard it all about SG catheters, now they can prevent digit amputation.

3. Every now and then I read an opinion that is so full of falsehoods and dishonesty that I consider reporting the individual. I looked up this plaintiff’s anesthesiology expert and found his obituary dated 1 year before this case went to trial. I happened to find his obituary stated he had been injured prior to his death, and he had not worked in several years. The ASA has released their own statement on expert witness qualifications. This includes active practice.

4. There seems to exist little accountability in the system of expert opinions. Plaintiff expert names specifically are even often redacted. That said, I will find the occasional expert to report. For particularly egregious opinions and testimony I’ll report to the state medical professional conduct board as well as the ABA and ASA.