IV Infiltration During Mastectomy [CRNA Pressure Bags It]

A 54-year-old woman was diagnosed with breast cancer.

After seeing a plastic surgeon (Dr. J), she was scheduled for a bilateral mastectomy and reconstruction.

On the day of surgery, a nurse placed a 20g IV in the left hand.

Anesthesia started at 7:37am with Dr. L (board-certified anesthesiologist) and a CRNA (Ms. W).

The CRNA placed another peripheral IV in the left forearm a few minutes later.

The left arm was then tucked against the patient’s body with gel padding, and the right arm was extended on an arm board.

A few hours into the procedure, the CRNA noticed the IV was not flowing well.

She decided to place a pressure bag on the fluids, and after this the fluids began to flow smoothly again.

The arm was not inspected at the time.

A total of 2.5L of LR was infused into the left arm.

Around 4:30pm, the surgeon changed position and the left arm was uncovered.

It was noted to be extremely swollen, pale, with no palpable pulse.

A hand surgeon was emergently consulted.

Compartment pressures were measured and were felt to be high, but not high enough to justify fasciotomy (exact measurements not listed in court records).

The hand surgeon recommended splinting the hand, keeping it elevated, and he would continue to monitor it.

The swelling slowly started to go down over the next few days.

She was left with permanent loss of sensation in the arm, damage to her left ulnar nerve, severe pain, and cosmetic disfiguration from extensive blistering and skin sloughing.

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A lawsuit was filed against the CRNA and the hospital.

Notably, they did NOT sue the supervising anesthesiologist.

A CRNA was hired as an expert witness

The plaintiff’s attorney had her complete an interview and assessment with a vocational expert.

This expert has a degree in “forensic vocational rehabilitation” and works for the federal government assessing disability claims.

The plaintiff offered to settle for $250,000.

A confidential settlement was reached and the lawsuit was withdrawn.

Many malpractice cases involve simple or basic issues, not advanced decision-making.

You are already familiar with these topics, but seeing how they play out in real malpractice cases will help reinforce these issues and help us focus on doing the basics well.

MedMalReviewer/Anesthesiologist Analysis:

1. It’s always interesting to see how plaintiff attorneys approach cases that involved both an anesthesiologist as well as a CRNA. Some will reflexively name both, no matter what the facts show. Some will try to focus their argument onto one or the other (as in this case). Sometimes it’s more about the business arrangement. If the CRNA and anesthesiologist are employed by the same private group, it may not be worth naming both because there’s only one business entity to go after. If the CRNA is employed by the hospital and the anesthesiologist is employed by a private group, the plaintiff may feel they can recover money from each party separately. There is a lot of variability between attorneys and jurisdictions, and any absolute claims are wrong.

2. Suffice it to say, blindly pressure bagging fluids into an IV that isn’t flowing properly is a bad idea. Especially when you can’t periodically reassess the IV site. In some regards the patient is lucky she didn’t need fasciotomies, although on the other hand (no pun intended) it does sound like she met the clinical criteria for compartment syndrome (pulseless and pallor). Compartment syndrome is a challenging diagnosis, and in borderline cases the treatment can sometimes be worse than just letting the disease run its course. Specialists sometimes like to measure pressures with a Stryker needle, although they’re notoriously difficult to calibrate, produce questionable results, and may seem like a random number generator at times. The clinical exam should be the primary factor in medical decisions.

3. A settlement offer for $250,000 is quite reasonable given it is well under the limits of most professional liability insurance policies. It indicates the plaintiff wants to settle without going to trial. Having to settle a lawsuit is not pleasant but these are the types of situations that you have insurance for, and it will resolve the case faster and with far less stress than going to trial.

4. This is the first case we’ve published that focused almost solely on the care provided by the CRNA, only tangentially involved the anesthesiologist during the medical care (and not involving him at all during the lawsuit). The authors of this newsletter are curious if these CRNA cases are beneficial/interesting to you or not. Would you prefer to focus only on cases involving physicians, or are you interested in seeing a mix of limited numbers of CRNA cases as well?