Clinical Cases

Emergency Error

Clinical Cases The July/August issue of AHRQ's Web M&M (http://webmm.ahrq.gov/) spotlights the case of an 81-year-old woman with a history of pancreatitis who arrived at the ED with acute onset of severe abdominal pain, nausea, and vomiting. She had low blood pressure and rapid heart rate. Based on the exam and initial imaging, there was concern about small bowel obstruction.

 The decision was made to take the patient to emergency laparotomy (surgery to explore the abdominal cavity). At the time of induction, she was given fentanyl, etomidate, and rocuronium. 

Almost immediately, her blood pressure dropped to 60/30 mm Hg. She was rapidly intubated, but her hypotension persisted despite epinephrine. Her heart rate slowed, and she ultimately developed asystole. Cardiopulmonary resuscitation was initiated. She received advanced cardiac life support for 10 minutes. She ultimately regained a pulse, but required high doses of vasopressors to maintain her blood pressure. The operation was cancelled and she was taken to the intensive care unit. Over the next 12 hours she had progressive multiorgan system failure, and she died the following morning.

The hospital's case review committee felt the patient likely had severe acute pancreatitis and not a small bowel obstruction. The committee's judgment was that this represented a diagnostic error and that this was a preventable death, because surgery would not have been indicated to manage her pancreatitis. The case raised many questions about the safety of and errors associated with emergency surgery.

The accompanying commentary written by Nicholas Symons, M.B.Ch.B., M.Sc., of the Imperial College London, points out that emergency surgery accounts for 80 to 90 percent of all surgical deaths, with emergency laparotomy particularly high risk, especially in elderly patients. Diagnosis and decisionmaking for these patients can be challenging, with senior physicians likely to be able to do this more reliably than those with less experience. Basic processes of care for these patients are frequently incomplete or omitted, such as administration of fluids, oxygen, and antibiotics and observation of patients' vital signs. Use of simple interventions such as checklists, clear job descriptions, and Plan-Do-Study-Act cycles can improve the reliability of care.

Discharge instructions in the PACU: Who remembers?Photograph shows a surgical team about to perform an operation from the point-of-view of a patient.

A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in her left knee after a skiing accident. Before arthroscopic surgery, she had been given postoperative instructions for ACL repair, which included 50 percent weight bearing starting immediately. 

Upon examination of the knee under anesthesia and with visualization from the arthroscope, the surgeon determined that the ACL was only partially torn and that the joint had sufficient stability. Rather than ACL repair, the surgeon performed microfracture to address damage to the intraarticular cartilage as well as meniscus repair. 

After the surgery, the surgeon briefed the patient in the post-anesthesia care unit (PACU) on his findings and the revised postoperative instructions. Because of the microfracture procedure, she was to be completely non-weight bearing for 6 weeks—a significant change from what had been originally anticipated. However, the patient was still groggy from the anesthesia and asked the doctor to give this information to her husband. 

When the doctor called the number in the chart, he made contact with the patient's mother-in-law who misunderstood that the original postoperative instructions had changed. None of this was in writing. When the husband picked up the patient, the written discharge instructions were generic and said "do as instructed." Confused, the patient followed the original, now incorrect, postoperative instructions. The confusion was never discovered at two subsequent postoperative visits. The patient pushed herself to bear weight several weeks after the surgery. When she experienced significant pain and called the surgeon, he chastised her for not following the postoperative plan. The patient was upset and concerned that she may have harmed her chances for a full recovery.

The accompanying commentary by Kirsten Engel, M.D., of Northwestern University Feinberg School of Medicine, points out the importance of clear patient-provider communication during transitions in care, such as at discharge. These are high-risk moments during which patients and families assume care of a medical condition that is often new and unfamiliar. Unfortunately, communication failures during these moments of transition are common. She recommends that communication with patients be at or below the 6th grade reading level and that the complexity and quantity of information be limited. She also suggests that repeating information to the patient, follow-up contact with the patient after discharge, and enhanced care coordination with other providers may improve patient outcomes during care transitions.

Anesthesia: A weighty issue

A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She reported a history of hypertension that was reasonably well controlled on procardia, atenolol, and lisinopril. The patient reported no history of bleeding disorders, tobacco use, anesthetic complications, or other significant comorbidities. She was obese, with a body mass index of 34. She was medically cleared for surgery. The following week, the patient underwent an uneventful left hip arthroplasty with general anesthesia via a laryngeal mask airway. She had stable vital signs throughout. She was breathing spontaneously following the procedure and was safely extubated and transferred to the recovery unit. 

The patient continued to receive doses of morphine sulfate for procedure-related pain, which became complicated by increasing somnolence. She was noted to have oxygen desaturations and, as these persisted, an arterial blood gas was drawn that demonstrated an acidosis with a markedly elevated partial pressure of carbon dioxide of 81 mm Hg. Attempts at noninvasive ventilation failed and the patient was reintubated for hypercarbic respiratory failure. After better pain control and airway assessment, the patient was extubated the following day and had an uneventful hospital course to discharge.

Providers suggested in the discharge summary that the patient likely had obstructive sleep apnea (OSA) and would benefit from outpatient testing. A review of the case by the hospital quality committee raised questions about whether obese patients undergoing anesthesia should receive formal preoperative screening for OSA.

In the accompanying commentary, Ashish C. Sinha, M.D., Ph.D., of Drexel University College of Medicine and Hahnemann University Hospital, notes that managing anesthesia in obese patients requires careful attention and understanding of respiratory and cardiac physiology. He suggests that when providing anesthesia for obese and overweight patients, clinicians should consider multimodal analgesia and minimize the use of narcotics. Patients diagnosed with OSA should be monitored carefully prior to discharge home. Clinicians should keep a high index of suspicion for inappropriate ventilation in the postoperative period; obese patients have a low functional residual capacity along with a high metabolic demand for oxygen. For short, supine procedures, spontaneous ventilation intraoperatively may be considered in patients who have no other contraindication like reflux.

Editor's note: To read more clinical cases and submit your own, you can access AHRQ's Web M&M at http://webmm.ahrq.gov.

DIL

Page last reviewed August 2013
Internet Citation: Clinical Cases. August 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsletters/research-activities/13aug/0813RA13.html