Cardiac Arrest in PACU After Right Hip Hemiarthroplasty

A 70-year-old woman presented to the ED after she became lightheaded at home and fell, landing on her right hip.

Workup revealed a right femoral neck fracture, as well as right pubic rami fractures.

She was admitted to the hospital.

The next morning she was taken to the OR by the orthopedist, Dr. L.

Dr. H provided her anesthesia.

An L3-L4 subarachnoid block was done.

She developed hypotension shortly after the block, and continued to have very soft pressures throughout the entire surgery.

She was given several doses of ephedrine and 500mL LR, without significant improvement.

She arrived to the PACU at 11:28am, where another anesthesiologist (Dr. W) continued her care.

Her hypotension continued, with LR running at 100mL/hr and 2 boluses of 250mL Hespan given.

iStat hematocrit had fallen from 33% in the ED, to 26% pre-op, to 21% in the PACU.

A unit of RBCs was ordered.

She was given additional doses of ephedrine and glycopyrolate.

Dr. W was called back to the bedside as the patient was becoming more confused.

She witnessed the patient brady down to the 30s, at which point atropine was given.

The patient then went into asystolic cardiac arrest.

After about 25 minutes, Dr. W called the code, and notified the family of her death.

However, the patient spontaneously developed a junctional rhythm, so CPR was resumed.

The family requested to stop CPR during the second code and let her pass in peace.

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Her family contacted a law firm and filed a lawsuit against both anesthesiologists, their group, and the hospital.

The expert witness opinion from the plaintiff is shown here:

The plaintiff hired a second expert witness (Dr. S), who placed a great emphasis on the theory that she was overloaded with fluid and needed escalating pressors.

The defense hired their own expert, who primarily disputed the theory held forth Dr. S.

A settlement offer was made to all of the defendants for $4,500,000.

A confidential agreement was reached and the lawsuit was withdrawn.

The records do not reflect which of the defendants actually paid the settlement.

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MedMalReviewer/Anesthesiologist Analysis:

1. There was debate about the importance of the patient’s 90% RCA lesion, which was discovered at autopsy. It would be easier to attribute her death to this finding if her presenting cardiac arrest rhythm had been VF or VT, but it appears that she rapidly became bradycardic, then went in to asystole. If she had presented in VF/VT, the defense would have had a stronger argument that her cardiac lesion caused her death and that her intraoperative care only played a minor contributing role. It’s worth noting that while VF/VT is strongly associated with ischemic cardiac disease, it’s the presenting rhythm in 59% of cardiac arrests that are caused by ischemic heart disease. Asystole (28%) and PEA (13%) are also commonly found, so relying solely on the presenting rhythm to determine etiology is unwise (source is from out-of-hospital cardiac arrests, so let the reader decide if this generalizes to post-op patients).

2. The plaintiff’s anesthesiology experts seem to contradict each other in regards to their theory of the patient’s fluid status. The first expert writes that she died due to “intravascular volume depletion” and claims that the anesthesiologists should have given “persistent, titrated amounts of fluid, blood replacement and vasopressors”. The second expert states “she was overloaded with fluid” and claims that only vasopressors should have been given. This key discrepancy indicates unsophisticated and inelegant work by the plaintiff’s attorney, who needs to present a unified theory of the case in order to be effective.

3. I bet the family was not filled with confidence when Dr. W called the code, told them their loved one was dead, then realized the patient had a rhythm and re-started compressions. Unfortunately, this does happen in a minority of cardiac arrests after the code is called. A few minutes of additional cardiac rhythm after a period of asystole, a few random muscle twitches, or even the sound of air escaping the lungs can seem like a sign of hope to lay people. Despite this, ongoing resuscitation is futile and the odds of survival are zero. It is sometimes smart to warn family members about these things. A Lazarus moment might make a great Biblical parable but in this case resulted in the patient’s family becoming even less impressed with the anesthesiologist.