This OR operations case involves a patient in Arizona who underwent a surgical procedure to remove part of his colon. A preoperative workup including a pulmonary and critical care consultation was conducted by the defendant pulmonologist. The consultation revealed that the patient likely had a paralyzed left diaphragm from a workplace accident that occurred many years prior. The defendant recommended deep incentive spirometry. He also recommended that long acting opiates should be limited, and the suggested pain control should be by epidural analgesia to decrease the risk of respiratory depression. On the morning of the surgery the patient underwent a pre-anesthesia assessment. The anticipated anesthetic plan was listed as general. His anesthesia pre-op orders called for him to receive benzodiazepine as well as an opioid pain medication. The patient was taken to the operating room where an additional dose of benzodiazepine was given, and the patient was immediately intubated. Surgery ended and the anesthesiologist noted that the surgeon requested the patient remain on a ventilator. The patient was extubated. Instead of taking the patient to the surgical intensive care unit as ordered the patient was left in the post-anesthesia care unit waiting area. He was later seen by the defendant who observed him to be sleepy. He informed the post-anesthesia care unit staff to be careful about the use of narcotics in the light of the patient’s present clinical situation and past medical history. He was later found to be unresponsive, and was declared dead shortly afterwards.
Question(s) For Expert Witness
- 1. How often do you treat patients with a similar past medical history to the one described in this case?
- 2. What measures should be taken pre-operatively, intra-operatively, and post-operatively to ensure the safety of the patients while under anesthesia?
Expert Witness Response E-009677
I treat patients with a similar past medical history on a weekly basis. Deep vein thrombosis prophylaxis is critical, including intermittent compression devices, and consideration for anticoagulation when deemed safe from a surgical perspective. Reduction of narcotics is important but challenging given peri-operative pain; however ketamine may provide analgesia without respiratory depression. Regional anesthesia such as an epidural may also help decrease narcotic use. Post-operative monitoring should include intensive or respiratory-specialized nursing with continuous pulse oximetry and telemetry, as well as consideration of continuous non-invasive capnography. ICU admission is warranted if body mass index is greater than 60 and/or if severe sleep apnea is confirmed or suspected. Consideration of CPAP and/or non-invasive ventilation should also be a component of care if there is evidence of apnea.