This case involves a 12-year-old paraplegic boy with spinal column malformation. After an extended hospital stay, the patient required surgery for a pressure sore. On the day of the surgery, the patient was given less than half his normal dosage of Levetiracetam. Before the surgery, the surgeon decided to limit the patient’s placement in unnatural positions. During the procedure, however, the patient was placed in the jackknife position. Postoperatively, the CRNA noted that there was a great deal of head swelling. The patient subsequently developed severe neurologic symptoms, including seizures, resulting in a stroke that damaged part of the patient’s brainstem. It was suggested that the patient’s head was down for too long a period of time. It was further alleged that the patient was insufficiently monitored during the procedure in spite of the high risk of the patient experiencing seizure activity following the operation.
Question(s) For Expert Witness
- 1. How often do you perform anesthesia on patients with a past medical history of severe neurological disorders?
- 2. In general, what aspects of the positioning of the patient are important in preventing neurologic sequelae in patients with severe neurological disorders?
- 3. What type of intraoperative neurological monitoring is important in patients like this undergoing general anesthesia?
Expert Witness Response E-037585
I currently am chief of the anesthesia department and manage 30 anesthesiologists. I do cases about once a week that involves patients with severe neurological deficits. The positioning of a patient with severe neurologic deficits is important to consider because of unexpected and unknown changes from the norm. I would look at the nurse’s notes preoperatively and intraoperatively to verify what is written by the anesthesia providers. Qualitative visual monitoring is important to make sure common areas of injury are monitored. Certain types of surgery would determine if quantitative neurologic monitoring is required. For instance, neurosurgical cases where neurologic damage is a possibility usually has evoked potential monitoring. In some general anesthesia cases, a BIS monitor is used to determine the depth of anesthesia. In other cases, cerebral pulse oximetry is used. I have reviewed a case in which a patient was left quadriplegic after open heart surgery. Positioning in the case was deemed the culprit.