52 year old female called her PCP on 07-07-21 and reported that she thought she may have a cyst on her ovary as she was having some pain on right lower abdominal side. The PCP records indicate he ordered a STAT US Pelvis complete/transvaginal non-OB study. When patient called hospital radiology department to schedule she was told it was not ordered STAT and that they could only schedule routine the following week.
She was able to get the study performed at another imaging facility on 7-9-21 , which reported “Tubular structure right lower quadrant blind-ending with the appearance of an enlarged appendix. Findings worrisome for appendicitis given history.” The recommendation was “Surgical consultation advised. CT abdomen pelvis with IV contrast would offer further evaluation/confirmation as clinically directed.”
She presented to Hospital ED on 07-9-21 and underwent a CT Abdomen and Pelvis with IV Contrast. The impression was “Acute appendicitis with suspected early infiltration changes” and she was admitted with consult for surgery.
The Hospital chart reflects that the surgeon wanted to proceed with surgery but that lab work completed showed a persistently low potassium (2.3 and 2,5) and since it was persistently below 3 anesthesia would not put the patient under general anesthesia unless the level was above 3 due to the risk of cardiac arrhythmias. The patient was admitted to the floor and underwent serial replacement of potassium and magnesium and her level the morning of 07-10-21 was 3.6.
She subsequently underwent surgery on 07-10-21 at approx. 10:00 wherein the surgeon noted he found acute perforated appendicitis with phlegmon and abscess formation. The surgeon also had to perform a right colectomy with removal of ileostomy. Post-op she was diagnosed with intractable diarrhea secondary to the ileum being removed with colectomy.
Files:
No questions yet!
Do you believe there might have been medical error?
The doctor should have had patient come to office for a physical exam. Perhaps she would have been admitted to the ER for r/o acute appendicitis. General anesthesia was unnecessary in this case. Could have been done with spinal or epidural anesthesia or field block. K was low, but this was an emergency. We're there u waves on EKG? Was there low K dysrhythmias? Was cardiology consulted re: risk v. reward of surgery. The few day delay may or may not have changed the overall outcome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. Hard to know where she was clinically when she first called the doctor. She could have chosen to go to ER, and not her PCP..
What makes you a good expert for this case?
I'm a BC anesthesiologist with 35 years of experience.
How often do you encounter cases similar to this one in your practice?
Not that often. This is a problem with telemedicine, and anesthesiologists / surgeons who lack training in regional anesthesia.
Do you believe there might have been medical error?
The delay in getting to the OR seems more likely from the lack of urgency in obtaining imaging and the delay in diagnosis. The perforation likely happened during those days rather than the one while electrolytes were being replaced. Clinical judgment from postponing surgery because of the electrolyte abnormalities could have been prudent to avoid cardiac arrhythmias. It would not be outside the standard of care unless the surgeon had demanded the case was emergent based upon the patient’s current symptoms and examination. It would appear to me that both the surgeon and anesthesiologist believed her appendicitis was relatively stable. In addition, from the onset of her abdominal pain and the multiple days before having any imaging results, it is likely the perforation occurred im this time period and the ruptured appendix walled itself off to distort the symptoms that clinically were seen. The perforation is not always readily apparent from imaging. Therefore, I would not be able to say there was a clear deviation from the standard of care by the surgical team or anesthesiology team for their decisions.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I am assuming that even the patient believed her symptoms were not an emergency and mild because she did not seek out emergency care but rather planned outpatient imaging through non-urgent services. Abdominal pain has so many potential diagnoses and many of those are not serious. It is a vague complaint that could have many causes. Without more information, the patient did not appear so toxic in her symptoms that emergency and urgency would be brought to mind, even to her own judgment. Her symptoms were most likely mild and made the diagnosis in a prompt manner more difficult. The unusual presentation of her clinical symptoms appear to have confounded this scenario. It is more likely that the delay in obtaining proper imaging was related to the appendix perforation during that time frame and subsequently difficulty during the surgery. However, I cannot determine if the initial provider’s choice for outpatient imaging is was or was not an error.
What makes you a good expert for this case?
I have been reviewing quality cases for 9 years. I am currently the Chair of the Anesthesia Department in a community hospital setting. I have been practicing anesthesia for 19 years across multiple states and in a variety of clinical settings. Appendectomies are one of the most common general surgeries we see in the hospital setting. This specific surgical case is very well-known to me as well as the multitude of situations leading to the patient’s surgery via the Emergency Room.
How often do you encounter cases similar to this one in your practice?
We encounter these cases in our group practice nearly every day from the add in cases through the ER.
Do you believe there might have been medical error?
Standard of care was met/exceeded.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is no case here. Everything was done properly.
What makes you a good expert for this case?
Anesthesiologist dealing with these types of cases very frequently.
How often do you encounter cases similar to this one in your practice?
Multiple times per month, sometimes multiple times per week or day.
Do you believe there might have been medical error?
Multiple textbook and clinical guidelines exist in regards to potassium levels and proceeding with non-emergent surgery under anesthesia. My health system's current guideline is that the potassium should be above 2.9 prior to proceeding. U waves and other ECG changes are almost always present when K is 2.3 or less, so this patient definitely started out with dangerously low potassium levels that warranted repletion if this was not an emergency surgery. If this surgery had been designated as an emergency - with threat to life or limb, sepsis, etc, - then delaying was inappropriate. That being said, appendicitis is almost never a true emergency and waiting a few hours for potassium repletion is usually reasonable. Also, there are studies and the ACS agrees antibiotics are an acceptable 1st line treatment for acute appendicitis (see CODA trial in NEJM, 2021), so its unclear that appendicitis ever represents a true surgical emergency.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The only delay in treatment that could have resulted in harm is the incorrect radiological read done 7/7. Otherwise, in the absence of clear evidence and documentation that this was a surgical emergency there was no indication to operate immediately and given potassium levels were low enough to cause ECG changes delay was warranted for repletion.
What makes you a good expert for this case?
I am an attending anesthesiologist at one of the centers that performed the CODA trial. I provide care for acute appendicitis weekly, I deal with periop hypo and hyperkalemia on an almost daily basis.
How often do you encounter cases similar to this one in your practice?
Multiple times a week I deal with issues of periop hypo or hyperkalemia. I provide anesthesia for appendicitis 1 to 2 times a week.
Do you believe there might have been medical error?
Surgery Had to proceed in any case. Risk of EKG abnormalities is much lower than risk of waiting.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Hypokalemia cannot be corrected quickly. Appendicitis is a surgical emergency.
What makes you a good expert for this case?
I was professor of Anesthesiology at USC for 12 years. I have been a medical legal expert for over 20 years.
How often do you encounter cases similar to this one in your practice?
I encounter cases due to electrolyte abnormalities maybe once each year.
Do you believe there might have been medical error?
The fact that the surgeon allowed potassium replacement to proceed before operating suggests it was not an emergency surgery. The surgeon should have pressed upon the anesthesiologist about the case's urgency and said they could not wait to replace the potassium. I also think it is prudent and relatively unusual of the anesthesiologist to insist on replacing the potassium before proceeding with an appendectomy. While life-threatening arrhythmias are possible, delaying an appendectomy would likely have a more deleterious effect on the patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delay in treating acute appendicitis can lead to rupture and the resulting additional injuries. Delays in receiving care by everyone involved likely contributed to the outcome. The patient probably had appendicitis for a few days before the OR. It is also unclear if the patient was started on antibiotics at any point. Non-operative management of appendicitis with antibiotics is also a possibility.
What makes you a good expert for this case?
I am an anesthesiologist who has worked in academic and community environments taking care of trauma and acute care surgical patients for over five years. This is a very typical patient I see.
How often do you encounter cases similar to this one in your practice?
I encounter acute appendicitis requiring operative management quite often in my practice. I don't recall delaying a case of appendicitis (regardless of the patient's condition).
Want to open a case or submit response?
Comments are accepted only from Anesthesiology - includes all Subspecialties experts.