This case involves a 35-year-old male patient with a history of low platelet levels who underwent a splenectomy. The patient had a past medical history of obesity and asthma for which he was receiving high dose steroids and immunoglobulins. The patient had an abnormal preoperative chest x-ray which was interpreted as a partial lung collapse. The patient underwent general endotracheal anesthesia with a thoracic epidural. During the procedure, the patient lost the CO2 waveform and suffered from oxygen desaturation. A code was called. The patient subsequently underwent multi-organ failure and died. It was alleged that the attending nurse anesthetist (CRNA) failed to maintain the patient’s steroid regimen and failed to take his comorbidities into consideration when clearing him for anesthesia during the surgery.
Question(s) For Expert Witness
- 1. How frequently do you anesthetize patients like the one described in this case (obese, on steroids with asthma)?
- 2. What factors should be taken into consideration preoperatively/intraoperatively for a patient with these comorbidities?
Expert Witness Response E-127172
I have 22+ years experience as a CRNA, including working in a level one trauma center for 10 years. I previously served as the associate director of a university nurse anesthesia program. I have anesthetized many asthma patients that were obese and were on steroids. I have taught how to treat asthma patients over the last 12 years and have personally anesthetized these types of patients without incidences. The evaluation of patients with asthma requires an assessment of the disease severity. This includes knowing the use of bronchodilators and the effectiveness of all their current pharmacologic management. Also, it is important to know the frequency of emergency room visits, the occurrence of hospitalization, and if tracheal intubation was ever needed. For a patient with severe asthma, a pulmonary consult (or a consultation with the patient’s pulmonologist) should be required to ensure the patient is at their optimum condition for treatment and to receive any additional treatment recommendations the day of surgery. The goal during induction and maintenance of general anesthesia in patients with asthma is to depress airway reflexes and avoid bronchoconstriction in response to mechanical stimulation of the airway. There are many techniques to achieve this standard.