May 2024 
Comorbidities

This case represents a projection error and failure to account for patient comorbidities in anesthesia planning. One might consider how the outcome may have been different if the anesthesiologist had strategies in place to handle adverse impacts associated with these comorbidities. Of note, among the four most common “associated” or secondary issues stated in claims against anesthesiologists is patients with comorbid conditions (11%, based on claims data gathered in 2020).

Allegations: A patient was prematurely extubated, and her hypoxia/anoxia was not recognized in a timely manner, which resulted in her death.

A 40-year-old morbidly obese woman with hypertension, asthma, and obstructive sleep apnea (OSA) was referred to an orthopedic surgeon because of shoulder pain. Prior to surgery, the patient received midazolam 4 mg, fentanyl 250 mcg, and an interscalene block. General anesthesia was then induced with propofol. Rocuronium was used for muscle relaxation. The surgery was uncomplicated, and no respiratory issues were noted. Following surgery, the muscle relaxation was reversed, and the patient was transferred from the surgical table to a gurney. The anesthesiologist extubated the patient after he verified she was awake and breathing adequately through the ETT. A supplemental oxygen mask was placed following extubation, and the anesthesiologist observed spontaneous breathing, with normal oxygen saturation and ETCO. The patient was then detached from the monitors so she could be moved to the post-anesthesia care unit (PACU). Four minutes later, the anesthesiologist noticed the patient was not steaming her mask from breathing. He started bag ventilation. No pulse or heartbeat could be found. A code was called, but the patient could not be resuscitated. The patient’s family filed a wrongful death lawsuit against the anesthesiologist, surgeon, and hospital, contending the patient was prematurely extubated and her hypoxia/anoxia was not recognized in a timely manner.

Discussion: According to experts, the patient presented a classic risk profile for post-anesthesia respiratory arrest and hypoxia—she was morbidly obese; had a history of OSA, a thick neck, and an otherwise difficult airway; and had received an interscalene block and was heavily sedated. Experts also believed the anesthesiologist should have anticipated that the patient’s obesity and hypertension would significantly decrease the effectiveness of cardiopulmonary resuscitation (CPR) and bag ventilation.

The anesthesiologist’s first projection error involved his anesthesia plan. Nothing in the anesthesiologist’s documentation indicated he adjusted the course of the patient’s anesthesia or otherwise took her increased risk of respiratory arrest into consideration when planning the anesthesia. With an interscalene block, paralysis of the phrenic nerve secondary to local anesthetic administration can be an expected consequence leading to hemiparalysis of the diaphragm. Assuming the patient’s respiratory capacity was already compromised because of her obesity, asthma, and OSA, experts questioned the administration of 4 mg of midazolam (a benzodiazepine), 250 mcg of fentanyl (an opioid), and the interscalene block. The combination of neuromuscular-blocking drugs, anesthetics, and opioids most likely significantly reduced the patient’s respiratory drive, muscle strength, and airway patency. Furthermore, considering the administration of multiple depressive agents, experts believed continuous pulse oximetry was warranted postoperatively, and failure to do so was a breach of the standard of care. Anticipating a worst-case scenario could have prevented the outcome.

Immediate extubation following surgery was also a projection error. Respiratory problems may not occur immediately after extubation. Experts believed that because of her risk factors and the medications, the patient should have been intubated for a longer period of time. They pointed out that the anesthesiologist could have weaned the patient off the ventilator in the PACU, when it could be assured that she was awake and able to breathe independently.

In this example, multiple comorbidities including a history of hypertension, obesity, and anxiety, along with medication noncompliance, impacted the patient’s clinical course, including the physician’s impressions, diagnosis, and treatment decisions.

Allegations: Failure to investigate symptoms of acute coronary syndrome, perform an EKG, and refer to the ER resulted in a patient’s death five days after office visit.

A 51-year-old male with a history of hypertension, high cholesterol, obesity, and smoking visited a primary care physician in November 2012 for the first time in several years. He had an elevated BP of 142/108, and labs revealed high LDL cholesterol of 168. The physician discussed with him the risks of hypertension as well as the importance of lifestyle changes. She requested he follow up in one to four weeks, but the patient did not.

An EKG three weeks later identified a probable old anterior infarction and ischemic ST-T changes in the lateral leads, prompting the physician to order a stress test. The patient did not obtain a stress test but did follow up through several appointments over the next six years. The same physician ordered simvastatin, HCTZ, lisinopril, amlodipine, Norvasc, and other medications over this course and recommended diet and exercise for the patient. However, the patient was not compliant with BP medications. The physician assessed a hypertensive crisis at three of these appointments in 2013 and 2014. In October 2014, she assessed sinus bradycardia on the patient’s EKG printout but no active disease on a cardiology EKG overread, which was unchanged since 2012. On another visit in 2015 the patient again had an elevated BP of 161/110 and reported he had not taken BP medications for several months. In October 2017, his BP was 160/90, and the physician again warned him of the dangers of untreated hypertension.

At his last appointment in November 2018, the patient reported a two-week history of chest tightness, palpitations, shortness of breath, anxiety (related to his work and his son), and sleep disturbances. He had not taken his BP medication for two weeks and denied chest pain, cough, weakness, or night sweats. The physician assessed uncontrolled essential hypertension due to medication noncompliance and recommended a low-salt diet and exercise. She discussed anxiety with the patient and gave him information sheets on both anxiety and hypertension. She told him to return for his annual exam a little over a month later. She told him to return in one week or visit the ER if his symptoms worsened, though this was not documented. The physician prescribed him Zoloft 25 mg as well as chlorthalidone and metoprolol, and the pharmacy filled his medications the same day. Five days later the patient’s son found the patient dead on the couch in his home.

An autopsy was performed, and the medical examiner assessed cause of death to be acute coronary thrombosis due to hypertensive and arteriosclerotic cardiovascular disease, with obesity and COPD as contributing causes. The deceased had 80% stenosis of the LCA and LAD, and 70% stenosis of the RCA, with a thrombus occluding the lumen of the RCA. There was also emphysema of the pleural surfaces and red-purple pulmonary parenchyma with emphysema. Pulmonary arteries showed suggested emboli in multiple vessels. The deceased’s physician certified the death certificate, noting the patient died of natural causes, with a primary diagnosis of hypertension.

Opinions from experts were mixed. Both Plaintiff and Defense witnesses stated the patient did have multiple cardiac risk factors, including chest tightness, hypertension, obesity, COPD, hyperlipidemia, and smoking. There was agreement about the patient’s medication noncompliance and his physician’s repeated counseling to him about the importance of BP medication compliance and lifestyle changes. There was also some concurrence about the physician not collecting a thorough history of the patient, as well as some debate over the patient’s chest symptoms (whether they should be considered as pain or tightness, typical or atypical).

Plaintiff experts agreed on the emergent nature of the patient’s condition and the necessity of obtaining an EKG or of sending the patient to the ER. One physician asserted that the physician failed to equate the patient’s chest tightness with chest pain in an obese patient with uncontrolled BP on his final appointment in 2018. He asserted failure to follow up on abnormal EKGs from 2012 and 2014, and that the physician should have performed an EKG or sent the patient to the ER for EKG and troponins at that visit. The witness stated the patient’s chest tightness should have been viewed in consideration with the patient’s comorbid conditions, including the chronic hypertension, obesity, COPD, and dyslipidemia. This expert admitted chest tightness, shortness of breath, and palpitations could be caused by the patient’s anxiety; however, the physician should have first noted that standard of care required her to first rule out conditions that could potentially kill the patient. Another witness testified the physician failed to complete a thorough patient history. The witness felt an EKG, which was required for complaints of chest tightness and shortness of breath, should have been performed before the physician diagnosed anxiety as a cause of symptoms. The EKG, the expert argued, was warranted especially considering the patient’s comorbidities, and would have ruled out a cardiac origin or coronary syndrome. This witness stated that, yes, the patient was medication noncompliant, but that this put him at a greater risk for a cardiovascular event.

Defense experts elaborated on the patient’s chest tightness, stating the physician did not document the onset, number of episodes, location, evolution, and quality and characteristics of pain nor what was typical vs. atypical. A family physician testified the physician also did not recheck the patient’s 160/30 BP, which represented a hypertensive crisis. The same witness asserted the physician needed to send the patient to the ER or order an EKG, which would have shown ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI). An interventional cardiologist opined that the physician should have ordered a nuclear stress test in 2014 and referred the patient to a cardiologist after the EKG suggested an old myocardial infarction (MI). This cardiologist said a stress test and cardiac consult could have resulted in a timely diagnosis at his last appointment, with possible initiation of heparin to shrink the right coronary blood clot. The witness argued the patient might have had the benefit of catheterization, a stent placement, or even bypass surgery.

Another physician for the Defense testified the patient’s physician appropriately addressed the patient’s high BP, cholesterol, and anxiety on that visit but did not address his history and chest symptoms. The standard of care, the expert said, did require an EKG, but it could be argued the physician addressed the chest symptoms by prescribing metoprolol. The physician did chart palpitations but not chest pain, and the witness argued she should have charted atypical chest pain and recommended the patient to the ER. This expert agreed, however, that the patient was not open to aggressive treatments and had exhibited a history of noncompliance. She also stated chest tightness, palpitations, and shortness of breath were common in anxiety. Lastly, it was her opinion that the thrombus noted in the autopsy was most likely caused by plaque in the artery due to longstanding high cholesterol.

Finally, a family practice DO stated it was appropriate to adjust medications and schedule a follow-up exam for this patient. Further, though it would have been reasonable to order an EKG and repeat BP before the patient’s discharge, especially in a patient who was hypertensive with palpitations, it was not required as part of the standard of care. The standard of care also did not require labs. This witness did note a concern that the physician did not follow up on the 2014 EKG, which was shown as unremarkable but did show prior heart injury.

This case resulted in a reasonable settlement.

*The above case examples were taken from ProAssurance closed claims. Certain details have been changed to protect the identities of the patients, physicians, and other individuals involved in these claims.

NORCAL Mutual Insurance Company, Claims Rx: Clinical & Risk Management Perspectives: Current Issues in Anesthesiology Claims, October 2020.