Critical care expert witness discusses intensive care unit (ICU) monitoring procedures

A critical care expert witness opines on a case in which a patient is left in a persistent vegetative state after suffering a cardiac arrest in an intensive care unit following valve replacement surgery. This case involves a thirty-four-year-old female patient with a past medical history of type I diabetes and aortic stenosis for which she was under the care of a cardiologist. The patient’s valve disease was causing her increasing morbidity and it was decided that she should undergo surgical intervention. The patient underwent a cardiac valve replacement surgery that was reported to have gone very well with no intra-operative complications. The patient was transferred to an intensive care unit for post-operative monitoring. Four days after admission to the ICU the patient suffered a cardiac arrest. The incident occurred after several days of bradycardia was noticed but no code was called until the patient was in asystole. The patient suffered from anoxic brain injury and was left in a persistent vegetative state as a consequence. It was alleged that the health care professionals responsible for this patient were negligent for failing to adequately monitor her. Additionally, it was noted in the patient’s chart that she may have experienced an acute episode of hypoglycemia as the blood glucose level measured 13 on finger-stick. The patient was on an insulin drip in the days prior to the cardiac arrest and it was believed that an inadvertent dose of insulin was administered due to human error. It was believed that the dangerously low blood glucose level caused by the unnecessary dose of insulin may have been what precipitated the cardiac event.

Question(s) For Expert Witness

Have you seen cases like this before, can you comment on the monitoring protocols in an ICU setting?

Expert Witness Response E-001259

I have seen cases similar in which there were warning signs prior to a patient suffering a cardiac arrest (retrospectively, of course) which were not detected or acted on by physicians. Protocols should be in place in an intensive care unit (ICU) for escalation of care once there are significant events. Bradycardia and hypoglycemia certainly qualify. When it was noted that the patient was bradycardic immediate action should have been taken. The patient should not have been left with untreated bradycardia for several days with no intervention or further evaluation. This constitutes a breach of the standard of care. Additionally, a blood glucose level of 13 is a significant and life threatening value which could signify that too high a dose of insulin was administered or that the patient had contracted a life threatening infection.