A 21-year-old woman with a history of multiple birth defects, was scheduled for hip surgery. She was non-verbal (but could communicate with facial expressions, and to a limited extent, via a computer translator) and dependent on family members for all aspects of daily living. She also suffered mild diabetes insipidus (DI), otherwise known as “water diabetes.” DI is a rare disease in which the kidneys produce abnormally large volumes of diluted urine. This patient’s DI was managed at home by her mother with careful attention to her fluid intake. Three years prior to this surgery, she had undergone a similar orthopedic procedure and had an extended admission due to hypernatremia.
Two weeks prior to surgery, at the pre-op appointment, the patient’s mother reminded the surgeon—and the resident assisting him—of her daughter’s DI and her previous post-op complication. They acknowledged her concern, and the attending told her to “make sure” that the anesthesiologist understood. The mother spoke with the anesthesiologist later that day.
Upon admission, the patient’s DI was documented by the nurse practitioner on the anesthesia assessment form. Pre-op serum sodium was in the normal range (normal = 135-148). Because of the patient’s DI, the anesthesiologist closely monitored her electrolytes during surgery.
Halfway through the procedure, the resident surgeon was called to another case. He was replaced by an orthopedic fellow, who did not know the patient, and the surgery was completed successfully. Immediately after the surgery, the attending surgeon left for vacation. The fellow wrote the post-op orders but—unfamiliar with the patient’s medical history—did not include serial labs or adequate fluid intake. The PACU nurse did not pay particular attention to the patient’s electrolytes or fluid balance. The patient was transferred to the floor, where the nurse was unaware of her DI.
The next day, the mother told the nurse on duty that her daughter had DI, and gave her a worksheet of what her hour-by-hour fluid intake should be. This nurse made note of it, but did not follow up on it, assuming the physician’s orders covered the patient’s needs. The patient was visited by the orthopedic resident each post-op day.
Four days post-op, she became somnolent and experienced seizure-like activity. Not understanding DI, the nurses had not made it known when the patient was becoming more withdrawn. When she slipped into a coma and developed aspiration pneumonia, a chart review indicated that her sodium levels had gone unchecked for three days; upon testing, it was 185. She was transferred to the MICU where, over several days, her electrolyte and fluid imbalance was corrected. An MRI showed brain damage (including changes of osmotic demyelinating syndrome of the pons, thalamus, cerebellum, and basal ganglia). She is no longer able to communicate in any fashion with her family and now lives in a long-term nursing home.