Leading Anesthesiology Expert Opines on Delay in Surgical Intervention for PACU Patient

This case involves an elderly woman who suffered a serious adverse event in the PACU following robotically-assisted laparoscopic surgery. The patient had a medical history significant for coronary artery disease, which had been treated with a number of stents, as well as a number of chronic health concerns. The patient underwent a sleeve gastronomy to manage chronic obesity, despite recently having a new cardiac stent placed just a few weeks before the gastric procedure was undertaken. Nevertheless, the patient’s surgery was completed in a few hours without complications, and she was transferred to the PACU in order to recover.

While in the PACU, the patient’s blood pressure was noted to be low, and the attending anesthesiologist as well as the bariatric surgeon were called to the patient’s bedside. Given the patient’s recent history of cardiac stent placement, the physicians agreed that an urgent cardiology consultation was warranted. The cardiologist examined the patient and performed an electrocardiogram which appeared normal. However, the patient’s condition continued to deteriorate, and she received packed red blood cells as well as epinephrine. Eventually, another electrocardiogram was performed which again produced results within the normal range, at which point the decision was made to bring the patient in for emergency surgery. The patient went into cardiac arrest while in surgery, and doctors resorted to heroic measures to save her life. It was eventually discovered that the patient had been bleeding into her abdominal cavity from an internal injury, which was further exacerbated by the presence of a clot in one of her cardiac stents. It was alleged that the PACU physicians should have called for surgical intervention sooner.

Question(s) For Expert Witness

1. Do you routinely administer anesthesia to patients suffering cardiac events?

2. When should this patient have been returned to OR?

Expert Witness Response E-036421

I have and do frequently provide anesthesia care for surgical patients with significant cardiac co-morbidity, including those having recent coronary artery stenting procedures. Moreover, much of my career has been spent with a focus on cardiac anesthesia, and I have served as the Director of Cardiac Anesthesia at a two-hospital community cardiac surgery programs. I have lectured on cardiac anesthesia on multiple occasions to anesthesiology resident physicians. In my view, based on the information provided, the patient should have been returned to the OR earlier. Reasonable measures had been taken to rule out an acute cardiac cause of the hypotension, leaving only postoperative surgical hemorrhage as a likely cause of the hypotension. With the significant serial drops in hemoglobin and hematocrit which are well documented, further cardiac workup, particularly to the extent that it would delay return to the operating room, was not needed or appropriate. Immediate transfusion and return to the OR for control of intra-abdominal bleeding were the indicated actions, and the latter was not undertaken for an extended period of time, by which time acute myocardial ischemia/infarction was occurring. The clot in the coronary stent was probably caused by low blood flow through the stent during the period of hypotension, compounded by the hypercoagulable state that is commonly associated with major surgeries.

Expert Bio

This highly qualified board certified anesthesiologist obtained his MD from University of Missouri-Columbia School of Medicine. He then completed a fellowship in Cardiac/Vascular/Thoracic Anesthesia at the University of Vermont School of Medicine. He is a member of numerous prestigious societies including the American Society of Anesthesiologists and the New England Society of Anesthesiologists. He is a former chairman of anesthesia at the Eastern Connecticut Health Network. Currently, he is a Clinical Instructor of Anesthesiology at a major medical university as well as an Attending Anesthesiologist at 6 major hospitals in CT.