Case Study: Patient suffers severe brain injury during routine colonoscopy

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Mark Clore, founding attorney at the national firm "Clore Law Group," recently obtained a five million dollar settlement in a case involving a middle-aged man who was admitted to an ambulatory surgical facility for a routine colonoscopy and upper gastrointestinal endoscope. Before the procedure, the man's medical history was known at the facility, including his sleep apnea. During the procedure, he experienced a low heart rate and low oxygen blood flow, which eventually led to a profound brain injury, and ultimately death, due to lack of oxygen.

The issue in the case was to determine why the man suffered a cardiorespiratory arrest during the procedure, whereby his lungs and then his heart stopped. Clore Law Group was able to show that the patient was over sedated during the procedure with Propofol, the very drug that killed Michael Jackson. As a result of the effect of the drugs, his lungs and heart stopped. Many times during endoscopic procedures, patients can become overly sedated and stop breathing, and they are at the mercy of the team doing the procedure to recognize and correct this condition before it progresses to the point where breathing, and then the heart, stops. This is especially true if someone has preexisting sleep apnea, is obese or elderly, or has other airway or breathing problems.

While it sounds obvious that doctors and nurses giving anesthesia drugs should, in a timely way, recognize signs of severe airway or breathing problems occurring in a procedure, in practice it may be more difficult if they are not using the best equipment to do so. In this patient's case, he was not being monitored with capnography equipment‚ a machine that indicates if the patient is adequately breathing out carbon dioxide (CO2). Detection of excess CO2 may be the first sign of an airway or breathing problem even before oxygen levels and the heart rate drops.

Clore Law Group was able to demonstrate, with highly qualified expert witnesses, that this situation should never have occurred. Capnography monitoring has been the standard of practice for moderate sedation procedures according to the American Society of Anesthesiology (ASA) for the last four years, and has been in practice even longer than that for procedures involving Propofol and for patients with sleep apnea. Tragically, however, medical malpractice insurance carriers have recognized for almost a decade that these types of cases continue to occur, and that they remain some of the most costly and potentially avoidable claims in endoscopy procedures.[1]

See article 12/4/14 Anesthesiology. 2006 Feb; 104 (2):228-34. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. Department of Anesthesiology, University of Washington, Virginia Mason Medical Center, Seattle, WA 98195, USA. [email protected]

BACKGROUND: To assess the patterns of injury and liability associated with monitored anesthesia care (MAC) compared with general and regional anesthesia, the authors reviewed closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1990.

METHODS: All surgical anesthesia claims associated with MAC (n = 121) were compared with those associated with general (n = 1,519) and regional (n = 312) anesthesia. A detailed analysis of MAC claims was performed to identify causative mechanisms and liability patterns. RESULTS: MAC claims involved older and sicker patients compared with general anesthesia claims (P < 0.025), often undergoing elective eye surgery (21%) or facial plastic surgery (26%). More than 40% of claims associated with MAC involved death or permanent brain damage, similar to general anesthesia claims. In contrast, the proportion of regional anesthesia claims with death or permanent brain damage was less (P < 0.01). Respiratory depression, after absolute or relative overdose of sedative or opioid drugs, was the most common (21%, n = 25) specific damaging mechanism in MAC claims. Nearly half of these claims were judged as preventable by better monitoring, including capnography, improved vigilance, or audible alarms. On-the-patient operating room fires, from the use of electrocautery, in the presence of supplemental oxygen during facial surgery, resulted in burn injuries in 20 MAC claims (17%).

CONCLUSION: Oversedation leading to respiratory depression was an important mechanism of patient injuries during MAC. Appropriate use of monitoring, vigilance, and early resuscitation could have prevented many of these injuries. Awareness and avoidance of the fire triad (oxidizer, fuel, and ignition source) is essential to prevent on-the-patient fires.

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