Missed Complication

Description

A 47-year-old man died from internal bleeding following back surgery.

Key Lessons

What communication improvements might prevent similar adverse outcomes?

• Generate a complete differential diagnosis; if a patient’s case takes an unexpected turn, step back and re-think the initial assumptions.
• Explore and address any cultural barriers to asking for help.
• Clarify the lines of communication and responsibility between residents and senior staff.
• Consider communication protocols around handoffs, e.g., a standardized checklist.
• Encourage staff to go up the chain of command if questions are not answered.

Clinical Sequence

A 47-year-old underwent surgical repair of his herniated left L4-L5 disk. The staff neurosurgeon scheduled the operation and was on-hand during the initial positioning. The surgery was performed by the chief neurosurgical resident who had done approximately 100 of these procedures. Near the end, the staff neurosurgeon returned to inspect the site and removed a small disk fragment. Post-operatively, the patient’s blood pressure initially dropped to 90/30 (40 points below his pre-operative systolic reading) and his heart rate increased. The chief neurosurgery resident saw the patient and ordered extra fluids. The patient’s systolic pressure came up to 100;soon after, the chief neurosurgery resident went off duty and an anesthesia resident assumed responsibility. Three times, nurses informed the anesthesia resident of the patient’s persistent low blood pressure. No further diagnostic testing was performed and he was not examined. At8:30 p.m., the anesthesia resident decided to transfer the patient to the floor. Upon arrival to the floor, the patient’s blood pressure was 86/43. At 10:00 p.m., he was given Percocet for relief of abdominal pain. No other record of his vitals signs was made until 10:40 p.m.

At that time, the patient again became unresponsive when his systolic blood pressure dipped below 60. After the first event, fluids and oxygen helped, but a second event was followed by progressive respiratory decline leading to apnea—at which point a code was called. At that time, his hematocrit was 14.

The patient was transferred to the medical intensive care unit. His abdomen was distended; an emergency thoracotomy was done and the aorta clamped. He was taken to the OR for a laparotomy; a large amount of blood was found in the peritoneal cavity and the surgeon could see that the left iliac vein was avulsed from the inferior vena cava (apparently triggered when bone fragments adhered to it were removed). After receiving massive amounts of blood and blood products, the patient developed acoagulopathy. With no chance for his recovery, the patient’s family chose to discontinue life support.

Allegation

The patient’s family sued the residents and the attending surgeon alleging negligent surgery and a delay in recognizing postoperative complications.

Disposition

The case was settled in excess of $1 million.

Discussion Points

What were this patient’s expectations?

During the consent discussion, the patient was informed that the laminectomy was a simple procedure and that he would be able to return home from the hospital the next day. As the staff neurosurgeon did not disclose the extent to which the neurosurgical resident would be involved in this surgery, the patient probably expected the attending to be fully in charge.Because no provider seemed concerned about his low blood pressure or his complaints of abdominal discomfort (the floor nurse advised him that the pain was probably the result of the way he was positioned on the operating room table, gave him pain medication, and left the room) he may well have assumed his situation was under control.

What led to the fatal outcome in this case?

A series of small events caused the adverse outcome. The patient suffered from a rare vascular injury that began when the bone fragments were removed (using the pituitary rongeur), weakening the wall of the iliac vein which later developed into active bleeding. The most critical errors were interpreting the blood pressure as normal and not appreciating that the potential existed that this patient was bleeding internally. In this case, the patient was not tachycardic. To the residents, his condition did not present a clear indication of bleeding. Most importantly, the residents were not expecting that disk surgery would cause trouble in the recovery period—and therefore did not recognize the significance of his blood pressure—and the need to call for help.

Where does the criticism fall most heavily in this case?

The greatest weakness in the case was the monitoring that followed this patient in the recovery room and then to the floor. The physicians did not seriously exclude a vascular injury. Missing multiple signs of trouble with his blood pressure and the loss of critical information at the handoffs meant that the patient’s underlying problem went undetected until it was too late to intervene. The missed clues and opportunities included:

• a recognized complication of the procedure (vascular injury) is a potential cause of low blood pressure
• the patient received three liters of intravenous fluid in the recovery room and his systolic pressure, which had been in the 140s prior to surgery, never rose above 100
• no one monitored the vital signs on a frequent basis
• no one ordered a hematocrit or blood gases
• no one performed an abdominal exam following the lumbar surgery
• no one re-examined the facts following repeated episodes of unresponsiveness
• neither the neurosurgery resident, the anesthesia resident, nor the nurses called for help from senior staff.