Failure to prevent aspiration

Presentation

A 54-year-old woman came to the emergency department (ED) with abdominal pain, nausea, and constipation. She was admitted for 23-hour observation, given a suppos­itory and a half bottle of magnesium citrate. Dicyclomine was also administered to alleviate cramping.

An abdominal film revealed evidence of a possible ileus or early small bowel obstruction. The patient was kept NPO in preparation for surgery.

Two days later, a small bowel series and a CT scan with contrast was obtained. The patient was given meperidine and promethazine for pain. The CT scan revealed a small bowel obstruction from an incarcerated right femoral hernia. The patient told the general surgeon that she had the hernia for years with no change, and that her physician had advised her to leave it alone.

The general surgeon planned to do a right femoral herniorrhaphy, but advised the patient there was a possibility that the bowel could be strangulated and would re­quire resection. The patient’s abdomen was noted to be distended and firm. She was subsequently taken to the anesthesia holding area.

Physician action

Prior to the induction of anesthesia, and while the general surgeon applied cricoid pressure, the patient vomited approximately two liters of gastric contents. The oropharynx was suctioned and the patient was placed in a Tren­delenburg position and intubated.

The anesthesiologist performed a bronchoscopy and the patient aspirated more material. The bronchi were suctioned. The surgery proceeded, and at the end of the surgery the anesthesiologist performed another bronchoscopy. Small amounts of material were removed.

The patient was transferred to the ICU where she suffered respiratory failure and was put on ventilator support. She later developed signs of sepsis. A week after the surgery, the patient became hypotensive and bradycardic and was placed on epineph­rine and atropine. The patient subsequently arrested and died despite resuscitative efforts.

Allegations

The patient’s family filed a lawsuit alleging the anesthesiologist failed to prevent the aspiration and failed to insert an NG tube before induction of anesthesia. The general surgeon was also named in the suit.

Legal implications

The primary issue in this case involved whether or not an NG tube should have been placed before induction of anesthesia, when the patient came to the holding area with a fully distended abdomen. The plaintiff’s expert testified that had an NG tube been placed before induction of anesthesia, the vomiting, the aspiration, and the sub­sequent complications leading to the patient’s death would not have occurred.

Defense experts testified that NG tubes are normally inserted after induction, but efforts should be made to reduce the volume in the abdomen. Defense consultants shared similar opinions. A consultant anesthesiologist stated that the placement of an NG tube is “the responsibility of the surgeon.” A consultant general surgeon stated, “it would have been appropriate to place a Levine tube to decompress the patient’s stomach prior to surgery and before sedation.” This reviewer felt that the anes­thesiologist had a patient who had not been properly prepped before surgery.

The anesthesia nursing notes indicated that the patient was alert, awake, and oriented times three. However, the anesthesiologist’s record contained a late entry and reflected that the patient was sedated upon arrival with decreased mental status. The patient’s sister (a fact witness and not a party to the suit) testified that the pa­tient was alert when she arrived at the holding area.

The anesthesiologist also wrote that this was an emergent situation, but the general surgeon did not indicate the surgery was emergent, only urgent. The plaintiff and defense experts all testified that if the patient had been awake and alert, it would have been appropriate to insert an NG tube in an effort to reduce the volume in the abdomen.

Disposition

This case was settled on behalf of the surgeon and the anesthesiology group.

Risk management considerations

The pre-anesthesia evaluation determines whether a patient can safely undergo anes­thesia and which precautions should be taken. The pre-anesthesia evaluation can also facilitate the relationship between the anesthesiologist, the patient, and the surgeon.

In this case, the anesthesiologist made a late entry in the record indicating that the patient was sedated with decreased mental status upon arrival. This contradicted the anesthesia nursing notes and the patient’s sister. Complete and timely pre-anesthesia notes serve as a comprehensive description of a patient’s medical and mental status and the rationale for the anesthesia plan. The pre-anesthesia evaluation also serves as a second opinion about the patient’s preoperative condition.

Errors or late entries in the anesthesia record can cause many legal problems, and may give the appearance of negligence when none actually occurred. If late entries must be made, they should be appropriately dated and signed.

Other anesthesia documentation pitfalls

• Advanced charting — a pre-charted entry in the anesthesia record could jeopardize the credibility of the entire record in the event of an adverse outcome. No matter how routine the procedure, no portion of the anesthesia record should be pre-charted.
• Blank spaces on preprinted forms — preprinted forms that contain blanks may be interpreted as showing that the question was not addressed. The use of N/A for non-applicable items where there are blanks is appropriate.
• Timing of events — the accuracy of timed events is critical, especially when an unan­ticipated outcome occurs. If more than one person documents in the anesthesia record during resuscitation efforts, inconsistencies can arise.
• Documenting unanticipated outcomes — if an unanticipated outcome occurs, review the completed anesthesia record and other pertinent forms. If inconsistencies are identified, a narrative progress note may be used to describe the discrepancies in the timed entries. Addenda should be appropriately timed, dated, and signed.