A 49 year old obese woman presented for an elective gastric banding procedure.

Physical exam revealed a MP III with a large neck circumference.

She was induced as an RSI with Versed 2mg, Fentanyl 50mcg, Propofol 200mg, Succinylcholine 100mg.

The CRNA giving breaks and helping to get the case started attempted DL, but could not see cords.

At this point the other CRNA returned from break.

When the second CRNA failed, the anesthesiologist also attempted DL, unsuccessfully.

This was followed by Glidescope, and then fiberoptic scope, all unsuccessful.

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An intubating LMA was tried and also unsuccessful.

Per testimony the patient was able to be mask ventilated in between attempts without issue, this is around 40 minutes of anesthesia time total.

At this point the decision was made to give another dose of paralytic to further attempt to secure the airway.

At this point rocuronium 30mg and Decadron 8mg were given.

Another anesthesiologist came to assist, and with ventilation now challenging and no success securing the airway, the decision was made to wake the patient up.

However, rocuronium had just been given 10 minutes previously and as this case occurred in 2012, there is no Sugammadex.

Per the record, no further doses of sedatives were administered beyond the initial induction almost 1 hour previously.

Neostigmine and glyco were given to attempt to reverse the paralytic, but the patient was not breathing on her own.

Mask ventilation continued to decline.

ENT was called for a surgical airway. The ENT was in clinic and not at the hospital, but drove over immediately. He performed a fiberoptic exam but found only redundant tissue and swelling.

At this point he performed a cricothyroidotomy and placed a 6.0 ETT into the trachea.

An attempt was made to turn this into a trach tube.

She was brought to the PACU being bagged, her arrival sat was 75%.

They attempted to switch her to a vent but airway pressures were too high, which they suspected was due to ETT kinking.

Attempts were made to manipulate the tube in PACU and ventilate by hand, but airway pressures remained high and she arrested.

After 17 minutes of ACLS, she was resuscitated.

The ENT was called back from his office again.

He took her back to the OR and was able to successfully change the ETT to a trach tube.

The patient unfortunately had suffered an anoxic injury throughout this ordeal and never woke up.

She died in the ICU later that week.

The distraught boyfriend wrote a letter to the CEO of the hospital.

A formal complaint was also submitted against the anesthesiologist to the state medical professional conduct board.

Expand your medicolegal expertise.

There’s always something that can be learned from lawsuits that other anesthesiologists have faced, whether frivolous or valid.

The family sued those involved including both CRNAs and the anesthesiologist.

They also sued the ENT.

The defense asked the judge to dismiss the case via a motion for summary judgment.

An anesthesiologist expert was hired by the plaintiff’s attorney to oppose this effort.

An expert opinion from an anesthesiologist hired by the defense is uploaded here for anyone interested in further reading.

Outcome

The case was settled prior to trial for a total settlement value of $1 million.

The anesthesiologist was responsible for $975,000.

The bariatric surgeon responsible for $25,000.

MedMalReviewer/Anesthesiologist Analysis

1. Can’t intubate and can’t ventilate is a nightmare scenario for any of us. This case was tough for me to even read and write. I was hoping for a different outcome, but knew where it was headed. A good skill of any surgeon or proceduralist is knowing when to stop, and it is no different here. You will not be sued for canceling her case and waking her up. Avoid tunnel vision, forget pride. She can come back another day for an awake fiberoptic, or re evaluate the necessity of her surgery.

2. The anesthesia record did not display any additional sedatives given for almost an hour after induction. In a deposition a CRNA claimed the des vaporizer was turned on but it is not written anywhere. Should this case have gone to trial it would have been easy for an attorney to elicit a strong visceral reaction from a jury surrounding this lack of sedation. The hired expert addressed this, laying out a picture of horror of an awake paralyzed patient having her airway instrumented. I can imagine the court room theatrics on this one, and it would not look good for the defense.

3. I have a hard time seeing the point of a 25k settlement from the bariatric surgeon other than the insistence that she was under the authority of his care when she stepped foot in that hospital, and he should accept some responsibility for what occurred. There is no record that the surgeon pressured the anesthesiologist to keep attempting intubation or influenced the case in any other way.

   There is a legal doctrine called “captain of the ship” with regards to med mal.

   It puts liability on the surgeon for any action conducted in the course of an operation. This was likely the plaintiff’s argument, but I’ll leave the reader to decide the ethics of that claim.

4. The letter from the medical professional conduct board (OPMC) is bizarre. This board has no oversight over the decision-making algorithm in securing an airway. In my opinion their response to comment on rocuronium and put blame on the anesthesiologist in a formal letter, no matter how true this statement, was inappropriate.

5. Based on the (paper) anesthesia record her sats were 70s-80s around the time rocuronium was administered and ENT called. ENT also let her leave the OR with a kinked tube as a surgical airway, which led to a code. After the anesthesiologist and surgeon settled, the case was dropped. It strikes me as somewhat odd that the ENT was not pursued despite some of his decisions potentially playing into the bad outcome.

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