On March 17 a 56 y.o. man is brought to the OR for CABG x1 (LIMA to LAD) using single cross-clamp technique and cardiopulmonary bypass. EBL is 200 ml. Two mediastinal Blake drains are left in place.
Post-op Hb is 8.5, and goes up to 10 with 1 PRBC, but then down again to 8.3. ABG shows no acidosis.
Post-operatively the patient develops hemothorax, hypoxemia, multi-system organ failure (renal, pulmonary, hepatic).
On March 18 (POD #1) the patient remains intubated, requiring vasopressin and epinephrine.
By March 19 (POD #2) the patient is extubated and off pressors but complains of chest pain. Hb 8.3.
On March 20 (POD #3) the patient become lethargic, hypoxemic and hypercapnic. He is reintubated and again requires pressors. CXR shows atelectasis of the right lobe and a bronchoscopy is done. Mucopurulent secretions are seen in the right lobe. Blood cultures are positive for Gram negative rods and IV antibiotics are started. Creatinine is trending up. Renal is consulted. CT head is negative. CT chest shows mediastinal and right pleural fluid.
Apparently, the attending surgeon was not appraised of the March 20 developments.
By the early hours of March 21 (POD #4), the patient is anuric, hypoxemic with severe metabolic acidosis. TTE shows no diastolic relaxation or RA and RV.
The same day, on March 21 the patient is brought back to the OR for tamponade and a large hemothorax is evacuated. Additionally, hemodialysis catheters are placed. The op report is vague but does mention that “bleeding points were ligated”.
The remaining hospital course is prolonged and complicated. He required additional trips to the OR for washout of the chest and debridements, as well as for a tracheostomy.
The patient also suffered from severe GI bleeding, for which EGD and colonoscopies were performed. Eventually he develops serratia marcescens bacteremia. In an infectious disease consult note it is mentioned that a left atrial thrombus septic clot was believed to be the source of the refractory bacteremia. The infection does not respond well to antibiotics and the family was told that it would be terminal because they could not control the source.
No action is taken to remove the clot from the left atrium.
The patient does not survive.
Files:
Q: What was the cross clamp and bypass time? Were cxr done daily?
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Q: If surgeon wasn't apprised who was managing? Does the surgeon or his surrogate see his patient daily?
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Q: If surgeon wasn't apprised who was managing? Does the surgeon or his surrogate see his patient daily?
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Do you believe there might have been medical error?
The two biggest red flags from this summary include the fact that the patient had significant postoperative bleeding and was not taken back sooner for re-exploration/washout. The second is mention of an infected left atrial appendage thrombus as a source of bacteremia/sepsis which is extremely unlikely. The delay in re-exploration likely ultimately lead to the downward spiral in this patient's outcome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the patient did indeed have postoperative bleeding leading to tamponade and cardiogenic shock, then that would explain the multi system organ failure and other complications leading to death.
What makes you a good expert for this case?
I have 10 years of experience as an attending cardiac surgeon at academic and non-academic hospitals including University of Washington, University of Southern California, and in my current role as Chief of the Division of Cardiothoracic Surgery at an academic institution in California. I have performed over 1000 open heart surgeries in my career.
How often do you encounter cases similar to this one in your practice?
Routinely. There will need to be a review of the medical records to determine if there was a delay in bringing this patient back to the OR.
Do you believe there might have been medical error?
This appears to be an elective operation with presumably a short cross clamp time, short bypass time. Therefore the likelihood of these complications in a 56 year old would be expected to be very low. Although the hemoglobin may initially go down to 8.5, active bleeding issues should be investigated. Even bleeding and hemothorax should not lead to renal failure, etc if appropriately taken care of in a timely fashion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I would query the post operative management of the patient. Why was the patient only extubated on pod 2? He should have been expected to be extubated on Pod 0 (day of operation) after a routine cabg x1. The prolonged intubation likely increased his risk of hospital acquired pneumonia and ultimately the sepsis.
What makes you a good expert for this case?
I do these operations. I also manage my patients or am closely involved with their management.
How often do you encounter cases similar to this one in your practice?
Our most commonly performed case is CABG.
Do you believe there might have been medical error?
The reason for the drop in hemoglobin on POD1 should have been addressed earlier, The hemothorax was a sign of active bleeding and the patient should have been explored and the problem solved. The accumulated fluid could have got infected. Antibiotics can also be nephrotoxic. Would be interesting to have operative report and report of daily CXR.The rest of the problems come in a chain of events that might have been avoided with a more aggressive practice.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As explained above, I should have more tools to understand the chain of events, but likely the patient's problems should have been addressed more aggressively
What makes you a good expert for this case?
I operate on patients like this and I take care of them in the ICU after surgery. I know what to do
How often do you encounter cases similar to this one in your practice?
CABG cases are very common, management of these cases like the one described are not frequent in my practice
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