Patient went in for shoulder surgery at surgery center. Patient met Anesthesiologist and was put under for surgery. According to the records from the surgery center, after patient was put under, the CRNA realized that the patient had advanced to asystole and called for the anesthesiologist, who then came in and conducted the recovery of the patient. The surgery center staff admitted to the Fire Rescue personnel that the "Patient went into asystole (no heartbeat) during a missed intubation attempt.” Patient was taken by Fire Rescue to the hospital. Patient was able to be resuscitated with chest compressions and did not require defibrillation or atropine.
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Q: Can you provide the anesthesiologists statement on what happened?
A: —
Do you believe there might have been medical error?
Airway management is the number 1 priority for any anesthesia provider, and the ability to control the airway after induction of anesthesia is the paramount task. If the patient did not have a cardiac arrest due to medications or anaphylaxis the inability to control the airway led directly to cardiac arrest. Much more information is necessary to make a better judgement, and assign more or less blame to the practitioners 1. Significant PMH, cardiac, pulmonary or airway related 2. Physical exam findings to suggest difficult airway - mallampati score, thyromental distance, moth opening, neck mass and range of motion. 3. Could they mask ventilate the patient? When did they find before or after paralysis 4. Did they follow the difficult airway algorithm from the ASA. Did they use video laryngoscopy, did they attempt and LMA insertion? Did they attempt a surgical airway 5. Where was the anesthesiologist during this whole time 6. Was the airway ever secured?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient was alive and breathing before the induction of anesthesia. The meds used to induce anesthesia cause respiratory depression and if paralytics were used cease respiratory function. If the airway is not secured the patient will almost always have this outcome and possibly often die. Assuming no surgery took place, the only people responsible for this outcome is the anesthesiology staff.
What makes you a good expert for this case?
11 years attending anesthesiologist at large county hospital. 11 years as faculty at major academic medical center, now associate professor. Lead for ENT anesthesia at my institution. Cited in 2022 difficult airway algorithm by the ASA. Have performed cricothyrotomy for situations like this in past
How often do you encounter cases similar to this one in your practice?
Every other month a difficult airway like this comes around, rarely does it progress to asystole
Do you believe there might have been medical error?
An esophageal intubation should be recognized quickly by the absence of continuous end tidal carbon dioxide. Either the CRNA wasn't using capnography or was not paying attention for it to progress to asystole.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A failed intubation is the obvious cause of the hypoxia that led to arrest.
What makes you a good expert for this case?
I am board certified in critical care, anesthesiology and have been an expert witness in these fields for 7 years. I have also taught anesthesiology for 10 years.
How often do you encounter cases similar to this one in your practice?
I have encountered at least a dozen cases with failed airway management and related complications.
Do you believe there might have been medical error?
It's difficult to determine whether this was a medical error because it is unknown whether the patient had what seems to be a potentially difficult airway and whether or not the anesthesia team took the appropriate steps to address a potential difficult airway prior to induction of anesthesia. If the airway didn't seem to have the potential for being difficult and then the anesthesia team unexpectedly had difficulty intubating the patient, then i would say it was not a medical error but rather the inherent risks of undergoing general anesthesia. Was the anesthesiologist present for induction and intubation of the patient?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the intubation was unsuccessful and steps were not taken to address it, then hypoxemia would occur which would then lead to asystole.
What makes you a good expert for this case?
5 years experience as an attending anesthesiologist.
How often do you encounter cases similar to this one in your practice?
Thankfully, complications as a result of missed intubations are rare.
Do you believe there might have been medical error?
What is missing in the summary is how long after induction of anesthesia did the asystole event occurred. Also there is no mention of whether or not EtCO2 was being monitored and what that result was.. The initial focusefrom the info provided is of course failure to intubate. There are no details on what the anesthesiologist who responded found. Saying extremely likely a medical error i.e. failre to secure the airway but... the additional information is needed. Although there is a comment about a missed intubation attemt from the staff, you need the additional information. There are other causes for sudden cardiac arrest following induction of anesthesia: substance abuse methamphetaime/cocaine, use of ACE inhibitors fo BP control. and the list goes on
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If a failed intubation that was unrecognized of c0urse definitely yes. If just the stress of a missed airway but recovered, hmmm. Other casues listed above need more information
What makes you a good expert for this case?
40 years of anesthesia practice, a great portion as Dept Chief with active involvment in Qualty Assurance processes, Expert Reviewer for the California Medical Board, Significant experience as an expert review for malpractice cases
How often do you encounter cases similar to this one in your practice?
Rare failed and then missed airway management with the monitoring by EtCO2 is super rare and a gross error.
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