Presentation
A 41-year-old man came to the emergency room on August 21 with severe abdominal pain for 5 days, vomiting, nausea, and inability to eat. He had a history of excessive alcohol use and three episodes of acute alcoholic pancreatitis over the last year.
The patient’s medications included tizanidine, tramadol, and zolpidem. A CT scan showed acute pancreatitis for which he was admitted to the hospital.
Physician action
The patient was admitted under the care of Gastroenterologist A. The patient was placed on a patient-controlled analgesia (PCA) pump. He periodically received fentanyl throughout his admission. Four days after admission, a Dobhoff tube was placed to allow for tube feedings.
Serial CT scans over the next few days revealed acute pancreatitis. A CT scan of the pelvis and abdomen showed the feeding tube with the tip in the third portion of the duodenum, and an abdominal x-ray two days later confirmed that the feeding tube was correctly placed.
The gastroenterologist asked her partner, Gastroenterologist B, to evaluate the patient with an endoscopic ultrasound (EUS) to rule out structural problems with the pancreatic duct, and to consider performing a celiac block.
On September 14, the patient’s feeding tube became clogged and was replaced. Fluoroscopic studies taken during placement of the tube confirmed that the tube was advanced and in the fourth segment of the duodenum.
Two days later, the patient agreed to undergo the EUS. Gastroenterologist B ordered the tube feedings of 40 ml per hour to be stopped and asked for an anesthesia consult due to the patient’s severe pancreatitis. Nursing documentation reflected that the tube feedings were stopped at 11:25 am.
The patient was taken to the endoscopy suite at 1:25 p.m. Gastroenterologist B advised the anesthesiologist that the patient’s feeding tube was advanced past the stomach; the feedings had been stopped for 2-3 hours; and there should be no food in the patient’s stomach. The anesthesiologist initiated anesthesia at 1:30 p.m. and placed the patient under moderate sedation using IV propofol.
Shortly after the scope was inserted, the patient began coughing and his oxygen saturation dropped. Due to concerns about aspiration, the procedure was terminated, and the gastroenterologist initiated suction as he withdrew the scope.
The patient was transferred to the PACU, and a pulmonology consult was requested. The anesthesiologist did not suction the patient’s lungs. A chest x-ray performed at 2:35 pm showed infiltrates in the left lung. The pulmonologist transferred the patient to the ICU.
In the ICU, the patient developed necrotizing aspiration pneumonia, acute respiratory distress syndrome, renal failure, and acute respiratory failure requiring mechanical ventilation. The patient slowly improved and had a tracheostomy placed.
In mid-November, the patient was discharged to a rehabilitation hospital with a tracheostomy collar and a right foot drop caused by critical illness polyneuropathy and right peroneal neuropathy. Several months later, the patient was discharged.
In the following six months, the patient was hospitalized four times for pancreatitis-related problems. On the fourth admission, he was found to have pulmonary fibrosis and required constant supplemental oxygen. He was considered totally disabled.
Three years after the hospitalization for pancreatitis and the failed EUS, the patient died. The cause of death was listed as cardiopulmonary failure with secondary causes of chronic pancreatitis and chronic lung disease.
Allegations
The patient’s family filed a lawsuit against Gastroenterologist B and the anesthesiologist, alleging negligence in performing the endoscopy too soon after the tube feedings were stopped. They also claimed the physicians failed to take steps to protect the patient’s airway during the procedure.
Legal implications
Defense consultants were generally critical of the anesthesiologist for failing to protect the airway by intubation or using NG suction before the procedure. Most experts did not feel that a two-hour delay between discontinuing tube feeding and proceeding with anesthesia was adequate.
Consultants felt that the physicians should have considered the likelihood of aspiration due to the patient’s chronic pancreatitis and use of pain medications that may have contributed to poor gastric emptying. In addition, the patient was receiving a high calorie nutritional supplement that contained protein and should not have been considered a “clear liquid.” Therefore, they felt that the procedure should have been delayed four-to-six hours after discontinuation of tube feeding.
Disposition
The case was settled on behalf of the anesthesiologist. The case against the gastroenterologist was dismissed.
Risk management considerations
The American Society of Anesthesiologist (ASA) provides the following guidelines for evaluating patients and determining appropriate NPO status. Along with specific guidelines for liquids and solids, the guidelines state:
“Recommendations for Preoperative Assessment
Perform a review of pertinent medical records, a physical examination, and patient survey or interview as part of the preoperative evaluation.
The history, examination, and interview should include assessment of ASA physical status, age, sex, type of surgery, and potential for difficult airway management as well as consideration of gastroesophageal reflux disease, dysphagia symptoms, other gastrointestinal motility and metabolic disorders (e.g., diabetes mellitus) that may increase the risk of regurgitation and pulmonary aspiration.
Inform patients in a timely manner of fasting requirements and the reasons for them in advance of their procedures.
Verify patient compliance with fasting requirements at the time of their procedure. When these fasting guidelines are not followed, compare the risks and benefits of proceeding, with consideration given to the amount and type of liquids or solids ingested.” (1)
Physicians are encouraged to closely review the patient’s risk factors, medications, and complicating factors when deciding appropriate NPO guidelines for patients. Patients should be interviewed and asked to confirm NPO status, which should be recorded in the medical record.
Source
1. American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. Anesthesiology. V 126, No 3, March 2017. Available at http://www.asahq.org/coveo/~/media/sites/asahq/files/public/resources/standards-guidelines/practice-guidelines-for-preoperative-fasting.pdf. Accessed August 2, 2017.
