56-year-old male was getting a right sided rotator cuff repair in an outpatient setting. Prior to the procedure, the patient received a supraclavicular brachial plexus block that was documented to be ultrasound guided throughout. By all accounts, there were no complications during that time or intraoperatively. Postoperatively, PC continued to have right shoulder pain and a rescue block was ordered. PC was administered 100mcg Fentanyl and the second rescue block was performed (also ultrasound guided). PC’s blood pressure was elevated post-op with an oxygen saturation of 95%. Required 2L N/C as he did eventually desaturate into the 80s. Approximately 1 hour post-rescue block, PC was deemed stable for discharge. It was notated that he was experiencing relief of pain. Last documented vital signs were normal however O2 saturation showed 94% on room air and were approx 30 min prior to leaving the facility
The following evening, PC had slow onset but continued shortness of breath and went to the emergency room. Was found to have a moderate right pneumothorax. PC was treated with a chest tube and was eventually discharged two days later.
PC does not have any physical deficits currently but does claim to have substantial mental anguish from this event.
I have attached various screenshots of documentation of the nerve blocks, time in the PACU and other handwritten notes. We're looking to ensure that the pneumothorax was not preventable and/or the vital signs were sufficient for discharge and did not reflect the possibility of pneumothorax complication.
Appreciate your opinion in advance and please notify with any questions or concerns.
Files:
Q: We’re images saved
A: Unfortunately, we do not have that information. I would say likely not.
Q: Was the procedure done under general anesthesia in addition to the block, and if so, was patient intervention bated and on the ventilator
A: —
Do you believe there might have been medical error?
Given the background of the case, I believe that the rescue block was warranted status post the surgery. With the rescue block that was placed, there does carry a risk of a pneumothorax from the procedure. It usually is around 0.5% for those who experienced with an increase to about 5% for those who are slightly less experienced. So although this carries a risk it’s not a necessary causation from the block.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Although it cannot certainly be proven as a causation, this type of lock can carry as very small risk/sequela of a pneumothorax. This should have been spoken about in the informed consent.
What makes you a good expert for this case?
I am a double board-certified, anesthesiologist and interventional pain management position. I am the program Director for the pain management fellowship program in my institution. Although I wear many different hats and assume many different roles, we see these type of patients almost every day.
How often do you encounter cases similar to this one in your practice?
Almost every day. Although we don’t necessarily see pneumothorax, we do participate in these blocks very frequently.
Do you believe there might have been medical error?
Although it is relatively uncommon, pneumothorax after supraclavicular has been reported and should be discussed with patient during preop interview and when obtaining consent. Images should be obtained during the procedure and a copy saved to the patient’s medical record
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again video documentation would be helpful‘; clearly a pneumothorax developed post procedure and required chest tube placement. Pneumothoraxes has been documented in shoulder surgery‘/rotator cuff repair without anesthetic block being performed but those occurrences are rare. I think that in this case there is strong temporal relationship to the block placement and development of the pneumo
What makes you a good expert for this case?
I have done many anesthetic for rotator cuff repairs both with supraclavicular and interscalene blocks along with general anesthesia
How often do you encounter cases similar to this one in your practice?
Rare when using US guidance and I have seen less than a handful of cases when US was not utilized
Do you believe there might have been medical error?
Based on the information provided: Supraclavicular Brachial Plexus Block: The initial block was performed under ultrasound guidance, which is considered standard practice to reduce complications and ensure accurate placement of the local anesthetic. There were no documented intraoperative complications related to the block. Postoperative Management: Due to continued pain, the patient received a rescue block, which was also performed under ultrasound guidance. Post-rescue block, the patient's blood pressure was elevated, and there was a transient desaturation requiring supplemental oxygen. However, the patient eventually stabilized and was deemed fit for discharge approximately one hour after the rescue block. Subsequent Event: The patient presented to the emergency room the following evening with slow-onset shortness of breath and was diagnosed with a moderate right pneumothorax, requiring chest tube placement. Evaluation for Medical Error: Supraclavicular Block: The ultrasound-guided technique suggests that the initial block was performed precisely. There is no indication of a procedural error during the block itself. Postoperative Management: The elevation in blood pressure and transient desaturation post-rescue block are concerning but do not necessarily indicate a preventable complication related to the block technique. The patient stabilized and was discharged with relief of pain. Pneumothorax: The development of a pneumothorax the following day raises the question of whether there was a delayed complication related to the block procedure. Pneumothorax is a recognized but uncommon complication of supraclavicular blocks, often related to inadvertent puncture of the pleura during needle placement. Conclusion: Based on the information provided, it does not appear there was a clear procedural error during the nerve block procedures themselves (both initial and rescue blocks were ultrasound-guided). However, the occurrence of a pneumothorax raises concerns about the management post-discharge. The vital signs at the time of discharge were reportedly typical. Still, the subsequent development of symptoms and diagnosis of pneumothorax suggest that close monitoring post-discharge may have been warranted, especially given the nature of the procedure and potential for complications like pneumothorax. Further review of the patient's postoperative course and documentation, including the timing and progression of symptoms, would be necessary to determine if any lapses in monitoring or indications could have preempted the development of the pneumothorax. This would involve a detailed analysis of the clinical notes, vital signs trends, and timing of symptom onset relative to discharge.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
In this case, establishing a direct causation between a potential medical error and the injury (pneumothorax) requires careful consideration of several factors: Pneumothorax Risk: The supraclavicular brachial plexus block inherently carries a risk of pneumothorax, especially if the pleura is inadvertently punctured. While this is a recognized complication, it does not necessarily indicate an error in technique, primarily when the block is performed under ultrasound guidance, which aims to minimize such risks. Timing of Symptoms: The patient developed shortness of breath and was diagnosed with pneumothorax the day after the procedure. This delayed presentation raises questions about whether the pneumothorax resulted from the block or if it developed independently. Postoperative Monitoring: The patient exhibited elevated blood pressure and transient desaturation post-rescue block but was deemed stable for discharge. Additional monitoring or intervention could have been warranted before discharge if there were signs of respiratory distress or other concerning symptoms. Injury and Mental Anguish: While the patient did not suffer physical deficits, the substantial mental anguish following the event could be linked to the unexpected complications. The psychological impact of experiencing a significant health event often leads to claims of injury, even if physical impairment is absent. Conclusion: While pneumothorax is a recognized risk associated with the procedure, determining causation due to a medical error would depend on whether there were lapses in monitoring, assessment, or decision-making postoperatively. If the patient's vital signs or clinical status indicated a potential issue, and those were not adequately addressed, this could suggest a degree of negligence. Conversely, if the discharge criteria were met based on established protocols and the patient's condition, it may be difficult to attribute the pneumothorax directly to a medical error.
What makes you a good expert for this case?
As an experienced fellowship-trained regional anesthesiologist with extensive clinical and advisory experience in pain management and anesthesia, I comprehensively understand the complexities associated with procedures like supraclavicular brachial plexus blocks. My background includes: Clinical Expertise: I have significant hands-on experience performing regional anesthesia procedures, including ultrasound-guided blocks, which are critical in minimizing complications such as pneumothorax. Academic and Leadership Roles: As an Assistant Clinical Professor and Principal of SJMD Solutions, I have a deep knowledge of best practices, safety protocols, and emerging trends in anesthesia and pain medicine. This experience enables me to critically evaluate both the technical aspects of the procedure and the postoperative care provided. Policy and Advisory Experience: Serving on various medical and veterans organizations has honed my ability to assess clinical practices in the context of health policy and patient safety. This perspective is valuable in understanding the systemic factors that influence patient outcomes. Research and Publications: My strong record of research and contributions to the field allows me to analyze and interpret clinical data effectively, facilitating a thorough evaluation of the circumstances surrounding the patient’s care. Leadership in Crisis Situations: My involvement in disaster relief efforts and pandemic responses has given me insights into managing unexpected complications and the importance of vigilant monitoring in outpatient settings. In summary, my blend of clinical proficiency, academic involvement, leadership experience, and a commitment to patient safety positions me as a knowledgeable and credible expert in evaluating the circumstances of this case.
How often do you encounter cases similar to this one in your practice?
I have seen this complication once, and it was identified and managed before the patient was discharged.
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