This case involves a 59-year-old woman who had a past medical history that was significant for hypertension, hypothyroidism, and liver cirrhosis. The patient was scheduled for an elective total knee replacement for osteoarthritis and underwent pre-admissions testing in preparation for her surgery. At this time, the medical records demonstrated that the patient had a poor overall medical status and was on several medications including lactulose, levothyroxine, spironolactone, furosemide, and propranolol. The patient was cleared for surgery despite abnormal coagulation values and a deteriorating clinical picture. The knee replacement surgery went ahead without any complication, however, in the immediate postoperative period, the patient became severely hypotensive and experienced persistent tachycardia. Fluid resuscitation with normal saline was administered and orders for blood products were entered. Subsequently, a transfusion was initiated and transfer of the patient to a critical care setting with vasopressor support was suggested. Throughout the evening the patient’s blood pressure remained low, her urine output was poor, and she was given additional blood products. Renal failure quickly developed and was attributed to the bleeding and hypotension. Over the next few days, there were consults from a variety of physicians, including a gastroenterologist, who diagnosed the patient with Disseminated Intravascular Coagulation and a severe gastrointestinal bleed. Despite continued medical treatment that included transfusions, hemodialysis, and other lifesaving measures, the patient expired.
Question(s) For Expert Witness
- 1. Who has the final say in sending an unstable patient into elective surgery?
Expert Witness Response E-000116
In a case that presents like this, where a patient may not be in the best possible health for surgery, it is up to the anesthesiologist to make the final call on whether to cancel a procedure or not. If labs are abnormal, especially if there are coagulation issues or if the patient is having problems with arousal, then there is no need to move forward with an elective procedure. This operation was not needed emergently and waiting until the patient was more stable could have prevented this adverse outcome.