Inappropriate Anesthesia Administration Results in Severe Consequences

Key Lessons

Communication between Certified Registered Nurse Anesthetist (CRNA) and attending is essential. Despite completing a pre-operative assessment, the providers did not follow the necessary safety guidelines. Adhering to anesthesia safety guidelines following the pre-op evaluation is essential to patient safety.

Description

The administration of fentanyl and propofol without appropriate assessment, resources, and a defined airway led to a patient’s death.

Clinical Sequence

A 40-year-old male patient with a history of obesity, hypertension, diabetes, and diabetic retinopathy had been under the care of internal medicine, endocrinology, and nephrology for renal dysfunction, neuropathy, and other comorbidities.

The patient received inpatient treatment for left big toe osteomyelitis and was later readmitted with left foot wounds and an infection, and also received a vascular consultation. The patient was diagnosed with gangrene in the same toe and was scheduled to receive a partial amputation. A podiatrist completed a debridement. However, the amputation was delayed due to poor renal function.

The patient was readmitted for the amputation several weeks later and, following an evaluation by cardiology, was cleared for surgery. The CRNA completed the anesthesia evaluation and planned for monitored anesthesia care (MAC). The supervising anesthesiologist, who oversaw four CRNAs, assessed the patient, noting comorbidities, including obstructive sleep apnea (OSA). Based on the American Society of Anesthesiologists (ASA) physical status classification system, the anesthesiologist classified the patient’s status at ASA IV, which is defined as “a patient with severe systemic disease that is a constant threat to life.”

The CRNA began the induction of anesthesia. The anesthesiologist was not present at this time; however, the patient’s vital signs were stable. The patient was receiving oxygen through a mask while the CRNA administered Fentanyl 100mcg and Propofol 50mg. Simultaneously, the podiatrist injected 15cc of 1% Lidocaine into the patient’s left foot. The patient became unresponsive immediately.

The anesthesiologist was called to the operating room (OR) seven minutes after induction. The patient initially received ventilation via a bag/mask and was then intubated. Five minutes later, the patient was in pulseless electrical activity (PEA). The code team arrived. After 15 minutes, the patient was in ventricular fibrillation, and the code team defibrillated the patient. He returned to a normal rhythm and was then transferred to the intensive care unit (ICU) on a ventilator. It was later noted that documentation on the code sheet was inconsistent with care provided and illegible due to handwritten notes.

MRI findings identified an anoxic brain injury, and the patient was diagnosed with irreversible anoxic encephalopathy and later passed away.

Allegation

The patient’s family alleged improper management of anesthesia leading to an adverse reaction, cardiac arrest, anoxic brain injury, and death.

Disposition

The case was settled in the medium range ($100K–$499.9K).

Clinical Analysis

• Incorrect decision to start anesthesia without a secure airway in a patient with multiple comorbidities.
• Strict adherence to recommendations and guidelines for high-risk patients undergoing anesthesia is vital.
• Documentation should be consistent and thorough to support the care provided.

Discussion Questions

1. In what ways might enhanced teamwork, communication, and documentation have aided in caring for a patient with a difficult airway?
2. How could more thorough documentation in the code sheet and elsewhere in the medical record have strengthened the defense of this case?
3. What policies and protocols do you have in place in your institution to ensure safety guidelines are adhered to?

Additional Resources

Guidelines: 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway* | Anesthesiology | American Society of Anesthesiologists

Video: ASA Difficult Airway Trigger Film

Article: How to align provider-to-provider communication across the care continuum | David Hoover