Anesthesiology Expert Discusses Fatal Lapses in Pre-Operative Clearance Exam


Anesthesiology Expert WitnessThis case involves a male patient in his late 50s who had a tonsillectomy for recurrent sinus infections. Prior to surgery, he underwent a pre-op clearance exam by from his primary care provider, where an abnormality on EKG suggestive of ischemia was discovered. Consequently, he was sent for a stress test by a cardiologist which was interpreted as normal. A report issued by the cardiologist that the patient should be worked up for “reactive airway disease” due to difficulty breathing during the exam with no apparent cardiac cause. Regardless the Tonsillectomy went forward, and in post-op the nurses noted problems with O2 saturation. Regardless, the patient was discharged from the surgery center with Percocet for pain relief and instructions to lie propped up when sleeping. In the evening he was on the couch propped up, and was found unresponsive by his wife. An ambulance was called but he was pronounced dead in the home. On autopsy, the coroner found extensive blockages in coronary arteries, but no heart damage. The coroner indicated the likely cause of death was coronary artery disease.

Question(s) For Expert Witness

  • 1. Do you have extensive experience regarding appropriate pre-operative respiratory and clearance prior to an ENT case?
  • 2. Are you available to review case and determine whether patient was appropriately cleared from those standpoints?

Expert Witness Response E-008119

I have been an anesthesia attending working extensively with my ENT colleagues for the last 20 years. The issue of preoperative clearance is an issue I deal with daily, especially given the acuity of many of our patients. Preoperative clearance is a process to minimize risk for the patient and maximize optimum outcome. As for respiratory issues, these require a full history and physical including communication with the cardiologist. Reactive airways disease is very concerning and typically requires a focused visit with a PCP or pulmonologist. Reactive airways disease, if not managed, can easily cause perioperative complications. Narcotic administration is a focus within anesthesiology and we have the most extensive experience with managing them and determining risk. We develop PACU/discharge protocols. I would get the PACU/discharge protocols from the patient’s hospital to ensure that they were following their guidelines and that they were appropriate.

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