Articles  |   May 2020
A Case Report From the Anesthesia Incident Reporting System
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Airway Management / Cardiovascular Anesthesia / Critical Care / Patient Safety / Pharmacology / Respiratory System / Articles
Articles   |   May 2020
A Case Report From the Anesthesia Incident Reporting System
ASA Monitor 5 2020, Vol.84, 44-46.
ASA Monitor 5 2020, Vol.84, 44-46.
Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to Report incidents or download the AIRS mobile app at
Case 2020-5
Case #1: A 56-year-old man with history of severe CAD, CHF, DM, end-stage renal disease s/p failed kidney transplant, severe peripheral vascular disease and chronic non-healing lower-extremity wounds presents for irrigation and debridement. Last echocardiogram showed an ejection fraction of 15-20%. Planned regional anesthesia was thwarted by ongoing platelet inhibition and patient request. The patient underwent uneventful induction of general anesthesia with divided low-dose propofol, followed by sevoflurane inhalation with successful LMA placement. Within 10 minutes of induction, severe bradycardia developed with concomitant loss of EtCO2, refractory to glycopyrrolate and 2mg atropine I.V. The LMA was converted to assisted mask ventilation and then an endotracheal tube. As the procedure progressed, the patient became more hemodynamically unstable with hypotension, bradycardia and hypoxia. There was high suspicion for a pulmonary embolism, but no saddle embolus seen on TEE – just profound global hypokinesis of the heart. An arterial line was placed, and the hemodialysis catheter accessed for central access volume resuscitation and ACLS cardiopulmonary resuscitation efforts. After approximately 27 minutes, with four rounds of defib for Vtach/Vfib and a total of 10 mg of epinephrine, the patient remained in ventricular arrest and return of spontaneous circulation could not be achieved.
Case #2: A 70-year-old woman with sarcoidosis, home oxygen use, HTN and left vocal cord paralysis presented for awake laryngoplasty with hyaluronic acid injection. Anesthesia was not supposed to be involved, but the ENT service called for help with blood pressure control after nasal pledgets were placed and nebulized topicalization initiated. Blood pressure was 201/100; the patient was anxious but had no other complaints. She had not taken her morning medications. The anesthesia team reviewed the chart, discussed a plan with the patient and completed a preoperative consent. Metoprolol was administered, with decrease in systolic BP to 160. The procedure was uneventful, with no further anesthetics administered. Just prior to discharge from the facility, the patient became unresponsive. Resuscitation was initiated with return of spontaneous circulation and the patient was transferred to the cardiac catheterization laboratory. Cardiac arrest recurred and the patient could not be resuscitated.
“Only two things in life are certain: death and taxes” – Benjamin Franklin
“No one here gets out alive.” – Jim Morrison
Each of the cases illustrates an important principle for assessment of anesthesia adverse events: death is inevitable, and sometimes it will occur during the perioperative period. The fact that preventable mortality during or immediately after anesthesia is vanishingly rare is a tribute to our profession’s long history of research into patient safety and our advocacy for continuous improvement. Anesthesiologists have long regarded perioperative mortality as a personal affront and will deploy the full machinery of modern life support equipment and techniques to prevent it from occurring. But sometimes it happens anyway, often with devastating consequences for the morale of the providers involved. A robust anesthesia quality-improvement program can mitigate the sense of loss associated with any perioperative death by helping the clinicians work through the stages of grieving to put the event in the proper context.
As a serious outcome of anesthesia, perioperative mortality warrants a close focus in the department’s quality improvement process in any case. As an early step in development of the program, quality directors should seek to know whenever a death occurs in the O.R., PACU or prior to discharge, either through direct reporting from the clinicians or by automatic reporting from the electronic medical record. When a perioperative death is identified, it should be immediately referred for peer review within the practice group. One or more clinicians familiar with the local practice environment – true peers – should examine the available data, both from the medical record and by interviewing the clinicians involved, to determine if death could have been prevented. If there is any doubt that care could be improved, this primary review should be augmented by discussion within the entire QI committee, with a focus on identifying mitigating strategies to prevent similar mortalities in the future: typically by changes in department policy or new educational initiatives.

Perversely, our ability to identify and document increasingly subtle medical efforts may be leading to an incorrect conclusion regarding the role of errors in health care.

Review of mortalities can be frustrating for those involved. Many times, especially in patients with numerous comorbidities, the cause of death cannot be identified, and the positive or negative impact of anesthetic management is not clear. In such cases, the opinion of the QI committee may default to “potentially preventable but care appropriate.” Or more succinctly, “There but for the grace of God go I.” This simple opinion, rendered by one’s closest colleagues, can do a lot to provide closure to the anesthesiologist who experienced the event, while simultaneously identifying any potential improvements in clinical care.
Would this opinion apply to these cases from the AIRS registry? Both patients had significant premorbid comorbidities, despite presenting from home for minor surgical procedures. In the first case, the AIRS correspondent made it clear that the patient and surgeon rejected anything but general anesthesia, with the easy choice of a spinal having been contraindicated by the cardiologist-recommended need to remain on continuous platelet inhibition therapy (see AIRS case 2019-08 for a discussion of risks and benefits relative to epidural hematoma – potentially a fate worse than death). Despite a careful induction, the patient suffered a cardiac arrest and ultimately expired. While it is always possible in hindsight to find decisions that could have been made differently, honest prospective review of this patient’s prospects make the patient’s death relatively unsurprising. Whether the negative inotropy of low-dose anesthetics, the minor stimulation of airway management or even just 15 minutes in supine position, this patient’s condition was so very fragile that even a minor deviation of homeostasis was enough to produce a fatal cascade of failing physiology. Hindsight bias would lead us to conclude that management should have been different, but sober reality would say that it likely would not have mattered. Despite close and continuous monitoring and rapid performance of ACLS, endotracheal tube placement and transesophageal echocardiography, the situation could not be salvaged.
In the second case, there is less information available to determine the exact mechanism of death. Perhaps it was triggered by a transient hypoxic episode, by a chance reaction to the surgical procedure, or even by an intercurrent pulmonary embolus or myocardial infarct. Regardless of cause, this high-risk patient could not be resuscitated. Again, it would be easy to attribute this result to the anesthetic and blood pressure medications administered, but an honest appraisal of the overall case suggests that the patient’s underlying comorbidities were the largest contributors to her demise.
In each case the quality reviewers must also consider the role of shared decision making, i.e., the ability of competent and autonomous patients to make their own choices. Many anesthesiologists will agree to care for Jehovah’s Witness patients without transfusing blood products, even if the patient might die without this lifesaving therapy. In the same way, it is difficult to criticize the anesthesiologist in either of the presented cases, both of whom appeared to be acting at the behest of otherwise competent and well-informed patients and at the behest of fully cooperating surgeons. The risk of the anesthetic was abundantly clear in both cases.
Unstated in either case report is what happened to the second victim: the anesthesiologist involved in the event. We invest so much in our attempt to prevent the inevitable that it can take a serious toll. Any patient death is a complicated event, which takes time to properly document in a record that will surely be scrutinized by others. It is appropriate when an unexpected death occurs to offer the clinicians not just the long-term consolation of a favorable quality committee opinion, but also the immediate space to process the events and manage the immediate consequences – communication with the family, completion of the medical record and reorganization of the team. None of us would want an anesthesiologist pressured to return too quickly to routine care after managing either of the events described. A quality anesthesia department will find ways to relieve those involved until they can return to work at their best.
Health care is increasingly complicated, especially at the end of life. Even routine care involves hundreds of process steps for seemingly simple activities (e.g., a specific induction dose of propofol, the timely administration of antibiotics). The possibility of “perfect care” is a lofty ideal, but statistically unlikely. Most of us have never performed an anesthetic where, in retrospect, we couldn’t think of something we would have done differently – perhaps only minor changes in dose or timing of the medications. However, the definition of “medical error” becomes increasingly granular as we become more sophisticated. And as science advances, these minor imperfections of care will become increasingly apparent. It is likely that every death during health care can be associated with at least one error: one extra mL of propofol, a provider who didn’t wash their hands, a missed dose of a chronic medication, etc.
Perversely, our ability to identify and document increasingly subtle medical efforts may be leading to an incorrect conclusion regarding the role of errors in health care. A publication in the British Medical Journal in 2016 illustrated this point by claiming that “medical error” was now the third leading cause of death in the U.S. This article in turn led to a series of exaggerated and even hysterical articles in the lay press decrying the evils of modern health care. But a higher rate of identifying medical errors might really be a sign of advancing maturity, rather than some new crisis. Or a sign that simpler and more obvious causes of death – myocardial infarct and cancer, for example – are declining in number as we identify the underlying pathophysiologies and develop effective treatments. Perhaps this leads to a future in which every patient is perceived to die as the result of a medical error. Rather than deploring this development, we should celebrate the advances that have made it so – as we have long done in anesthesiology – while recognizing that we are engaged in a battle that can never be won.
In summary, we offer one more quote, from “Game of Thrones” by George R.R. Martin: “Valar morghulis” (“all men must die”). An essential contradiction of our profession is that anesthesiologists must remember this great truth, while also doing everything in their power to prevent it.
Makary MA and Daniel M . Medical error-the third leading cause of death in the US. BMJ. 2016; 353: i2139. [Article] [PubMed]
Abbasi J . Headline-grabbing study brings attention back to medical errors. JAMA. 2016; 316: 698–700. [Article] [PubMed]
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