48 year old female with a known history of heavy menstrual bleeds and fibroids, elects to undergo hysterectomy. She is significant for long-standing uncontrolled hypertension (per the record, 16 years). According to her cardiologist and her blood pressure record, she has a baseline systolic pressure between 180-200 with diastolic between 100-110. By all accounts this is her baseline.
Her cardiologist has cleared her for surgery (unsure of the exact nature of the clearance other than pre-op blood work, CXR). This is despite her not being on any long-term antihypertensives due to chronic resistance and adverse reactions.
At the request of the GYN performing the surgery, IP is pre-admitted one day prior for BP stabilization. Notes show concern that there might be a need for IV Nipride (or other antihypertensive IV medications during the procedure). Her cardiologist is aware and consulted.
Upon arrival to the hospital for admission, IP’s blood pressure was 280’s/140’s. They initiated a nitro drip and also consulted with critical care.
Cardiology makes a pre-op note that I have attached as a screenshot. In short, it discusses the importance of avoiding precipitous drops in blood pressure during the procedure. It also discusses the IV nitro and potential of IV cardine during the procedure and the significant risk for bleeding if her blood pressure is not controlled.
There's mention that if they're unable to control the blood pressures below 180 then they desire to maybe decrease the blood pressure to the 140 to 160 range.
The cardiologist reached out to the gynecologist who would be performing the surgery to discuss concerns about post-operative bleeding and risk for stroke. As mentioned, this note has been attached as a screenshot for review.
The decision is made the following day to go ahead with the procedure. The BP readings do show episodes of being under 160 systolic, however there are still fluctuations to above 180.
Intraoperatively there's a major concern about the handling of the case by the anesthesia team. There are some alarming blood pressure readings during the procedure (close to 300 systolic with heart rates above 150). There are notes concerning the nitro drip potentially being “turned off” intraoperatively (unable to find a reasoning). Also, notes indicate that there was a defective arterial line for monitoring and there was use of a manual BP cuff. This would be a secondary review not related directly to the cardiology portion of the case, but import to keep in mind considering the results of the case.
Post-operatively once returned to the ICU, the IP has a flaccid right upper and lower extremity. They perform a stroke alert in which the results are consistent with an ischemic stroke.
Post op CT showed acute infarct of the left occipital and mesial temporal lobes. MRI shows acute left PCA territory infarct with mild mass effect and edema
Post-operative echocardiogram shows severe LVH with an EF approximately 55%. Moderate dice dog dysfunction with right atrial enlargement. IVC is dilated.
IP was intubated and was followed closely by neurology. After approximately one month of admission, the IP was discharged and has full right sided hemiplegia, severe altered mental status and aphasia.
Our concern about cardiology would be the care plan and the willingness to go through with this elective procedure, especially with the seemingly risky nature of doing the hysterectomy with this complicated blood pressure issue. The contention we have with anesthesia would be a separate aspect to review, however, if this IP should have never been a candidate to go through this surgery in the first place, we want to ensure that the anesthesiologist did have opportunities to control and maintain the stability of the IP during this procedure. However, if cardiology handed it off an inappropriate patient, that would be an essential component of our investigation.
The records that we have are quite vast, however if you have any specific questions to clarify, we would be able to provide those on an individual question basis, as long as the information is available.
Thank you in advance for your time and opinions.
Files:
Q: Where is the cardiologist “clearance” note? No patient should ever be “cleared” for surgery. The cardiologist Should state the cardiac risk of this intermediate – risk surgery
A: —
Do you believe there might have been medical error?
Given the patients blood pressure is 279/114 on insertion of the arterial line- which must be immediately preoperative- it would be against standard of care to send such a patient to the operating room for an elective procedure. I am not giving a 10 because I have hesistations about 1) the good documentation of explaining the risks/benefits to the patient and 2) the documentation of severe drug reactions which makes me believe that she was unwilling or unable to take medications that would be able to control her blood pressure at any point in time and therefore one could argue that is as optimized as possible.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is no question whatsoever that the neurologic injury is a direct result of the blood pressure.
What makes you a good expert for this case?
I practice both inpatient and outpatient cardiology, including in a critical care setting where I frequently manage blood pressure requiring vasoactive drips such as was done in this case. I also routinely perform preoperative clearance for a variety of procedures.
How often do you encounter cases similar to this one in your practice?
I routinely evaluate preoperatively for surgery and routinely manage severe hyper or hypo tension. This though is a very rare case mostly because of the description of being unable to take additional blood pressure medications and failed secondary workup as briefly described above. More would need to be learned about this from the records.
Do you believe there might have been medical error?
I’m not sure why the decision to preform surgery while still not controlled with BP. Were there any other issues - coagulopathy, other risk factors. Did IR do a consult? Can that be provided? What reasoning did gyn give for relative urgency of the hysterectomy soon after hypertensive emergency? During hysterectomy was there massive bp fluctuations? Blood loss? Ischemic stroke in a 48 yo is very tragic.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I’m not sure why there was an urgency to preform hysterectomy when BP was still not relatively controlled. I feel IR would have been the more sensible choice to temporize until things were more stable. But as hind sight is 20/20 - I still feel BP should have been more controlled prior to surgery, especially since cardiologist was concerned over potential risk with hypertensive emergency.
What makes you a good expert for this case?
I have >10 years of experience as an interventional cardiologist. I am boarded in cardiology, interventional cardiology, echo, and nuclear cardiology. My perspective comes because I am not boxed into one sub-speciality. I am in private practice so I also see how ‘burnt out’ and boxed in most academic/instituional cardiologist have become.
How often do you encounter cases similar to this one in your practice?
Often enough, I take roughly 100 stemi calls a year and deal with life/death situations regularly. I believe in motivation of risk to patients.. I’m a second generation cardiologist - I work with my sister and my father (who started the practice). We have the strong trust of the community we serve - and the reputation to go along with it.
Do you believe there might have been medical error?
In this patient with long standing HTn seemingly untreated to undergo an elective procedure this was not an appropriate patient to deem appropriate risk. This is a high risk patient who should only have gone to surgery if it was an urgent or emergent situation. Clearly BP was very uncontrolled at baseline and should have been stabilized prior to surgery - both for use of anesthesia agents and risks associated e both drips and spikes in BP, and bleeding and other risks. Furthermore using a nitroglycerin drip is not the best strategy to try and control BP during a surgery. I don't know what was the exact risk level stated by cardiology but more preop optimization was warranted. Also unclear if a secondary work up for htn was ever done as this is a young patient and may have had an underlying cause
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Clearly patient had a hypertensive stroke and this could have been avoided by better stabilizing BP prior to this surgery.
What makes you a good expert for this case?
I have been practicing cardiology for 13 years. I have participated in a few expert witness cases in past as well. I do everything from office based general cardiology and advanced invasive coronary and structurla heart procedures.
How often do you encounter cases similar to this one in your practice?
Uncontrolled htn is very common in my practice population
Do you believe there might have been medical error?
Should have delayed surgery until BP controlled
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
More likely anesthesiologist at fault
What makes you a good expert for this case?
12 years experience as a cardiologist
How often do you encounter cases similar to this one in your practice?
Fairly often at least once a week to clear patients for surgery
Do you believe there might have been medical error?
My final and definitive opinion would be based on review of the entire medical record. below are simply initial thoughts after reviewing the summary. This was an elective procedure. There is no information on whether she had anemia resulting from fibroids that made the surgery urgent. There is no information on what outpatient workup and treatment she was on for hypertension prior to the surgery, so it is unknown if an adequate attempt was made the diagnose and treat her hypertension before coming up with the plan to admit her to the hospital for nipride gtt prior to surgery.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
My final and definitive opinion would be based on review of the entire medical record. below are simply initial thoughts after reviewing the summary. The lack of adequate blood pressure control in either direction (high or low) likely caused the stroke. However it is unknown from this summary whether other causes of stroke such as intracranial atherosclerosis or an embolism have been ruled out.
What makes you a good expert for this case?
I treat resistance hypertension all the time. I am asked to do "pre-operative clearance" all the time.
How often do you encounter cases similar to this one in your practice?
I see resistant hypertension at least twice a month in my clinic, and have treated it in the ICU before when patients like this one are admitted through the emergency room for hypertensive emergency.
Do you believe there might have been medical error?
To be clear, I do not think the cardiologist committed any medical error since he/she was very clear about the risk of bleeding and stroke with this high blood pressure. It seems the blood pressure was not well-controlled Most likely preoperatively and the patient probably had a “ischemic“ stroke precipitous drop in blood pressure.— Was there any sign of a “watershed” infarct? What does Neurology say about the brain imaging? Still, it seems that anesthesia did not do an appropriate job of regulating the blood pressure in the OR.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient had a stroke. Of course that is bodily injury. once we say there is Medical error, that must be causation by default.
What makes you a good expert for this case?
I see these patients all the time.. there is likely some blame to be placed on the patient who is walking around with a blood pressure that high for 15 years and I suspect that the patient has been not compliant with medication‘s in the past— If the patient had not had uncontrolled hypertension for the 15 years, the patient would have been less likely to have had an event during this surgery
How often do you encounter cases similar to this one in your practice?
Usually I see a blood pressures up to the 240s, systolic.. Very unusual to see Systolic blood pressure up to 300.— I would have repeated a complete work up for secondary causes— even if the patient states “I already had this“” I don’t trust the patient in this scenario
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