This case involves a 70-year-old male with a past medical history of COPD, Hepatitis B, high blood pressure, and diabetes who underwent elective lumbar discectomy for radicular pain. The patient’s medical clearance from his primary care physician apparently did not have risk stratification. In the hospital, the patient was deemed an ASA class 2, indicating mild systemic disease. Later, however, his medical records listed him as an ASA class 3, denoting severe systemic disease. During surgery, the patient experienced multiple hypotensive episodes and dangerously low blood pressure. He was found to be severely acidotic and dehydrated post-operatively and was unable to be weaned from the ventilator. The patient coded and ultimately expired in the hospital.
Question(s) For Expert Witness
- 1. Do you routinely assess patients' pre-operative risk before surgery?
- 2. What should be included in a medical clearance note from a PCP?
- 3. What are fluid resuscitation guidelines for surgery?
Expert Witness Response E-002863
Yes, I routinely assess patients’ pre-operative risk before surgery. Hypotension and fluid replacement are issues in many cases of alleged perioperative medical malpractice where the end game is serious morbidity or death. The important thing is not the level of risk, but (a) making sure the patient is optimized before surgery if elective and not emergency and (b) making sure through joint decision making process with patient/family and surgeon that the level of risk as best as can be understood is acceptable/worth the possible benefits. A medical clearance note from a primary care physician may or may not be helpful to a proficient anesthesiologist. There are circumstances where the patient is “cleared” by the primary care physician or family physician or even cardiologist, but the anesthesiologist has a different expert opinion based on their greater knowledge of conditions during surgery and perioperative care and monitoring in general. The anesthesiologist may benefit from additional information supplied by the primary care physician, but it is up to the anesthesiologist how much weight they place on the PCP clearance when making their own independent determination. Fluid resuscitation guidelines for surgery are well accepted – the patient’s volume status preoperatively, their hemoglobin and hematocrit, the length and type of surgery, the weight of the patient and age, any co existing diseases all have an impact on the basic framework for elective surgery – (1) accounting for preoperative fasting/NPO (2) accounting for blood loss (generally 3 cc of crystalloid replacement for each 1 cc of blood loss in a patient with relatively normal blood volume and content (3) accounting for any bowel preparation or nasogastric tube suction not relevant in this case (4) accounting for any insensible losses from large open incisions not relevant in this case, and (5) balancing the use of vasopressor drugs and fluid resuscitation with depth of anesthesia for unexpected low blood pressure.