66 year old female presented to the ED on January 13, 2023 with sharp lower abdominal pain, nausea, and vomiting similar to when she had a small bowel obstruction in 2019. There were no relieving factors. She had a history of diabetes, poorly controlled hypertension, hyperlipidemia, history of smoking, cardiovascular atherosclerotic disease, prior anteroseptal heart attack, ulcerative colitis, a prior cholecystectomy, prior bowel obstruction surgery, and hysterectomy. She is on mesalamine which weakens her immunity. She was admitted for small bowel obstruction and started on NG tube fluids.
January 14 chest X ray reports left lung collapse (atelectasis), opacity (density/mass) or infiltrate (lung infection).
X ray taken of the abdomen on January 14, showed persistent obstruction and she was scheduled for a diagnostic laparoscopy on January 15.
On January 15, noted in the records that the Patient stated she could not stop shaking, glucose check 243, sbp 130's. patient found to be sensitive to morphine.
EKG revealed a likely prior anteroseptal heart attack. No further evaluation or testing was performed as to her heart and lungs, nor was a cardiologist or pulmonologist consulted.
She was evaluated by the anesthesiologist, who reviewed her medical history and determined to be ASA III and Mallampati II and an appropriate candidate for anesthesia.
The patient was brought to the operating room at 1705. Induction began at 1721. Decedent was intubated at 1723. The tube was secured, and the ventilator was activated with oxygen and air and low dose sevoflurane turned on. At approximately 1731, versed (1 mg), fentanyl (100 mcg), lidocaine (100 mg), propofol (150 mg) and rocuronium (50 mg) were administered while cricoid pressure was held. Dexamethasone (4 mg), metoclopramide (10 mg), and ondansetron (4 mg) were then administered. A few doses of phenylephrine (200 mcg) were administered prior to the incision to maintain resting blood pressure. Two grams of cefazolin were requested by the surgeon and given at 17:43.
The surgeon then made a five-millimeter incision in the right lateral abdomen, a five-millimeter port was then introduced into the abdomen under direct visualization with the help of a five-millimeter laparoscope. The surgeon then attempted to insufflate the peritoneum. However, the pressure was very high, and this was not successful. The surgeon requested a longer five-millimeter port. In the interim, the surgeon decided to insert a Veress needle to insufflate the abdomen. The surgeon made a two-millimeter stab incision in the left upper quadrant two-centimeters below the costal margin at the midclavicular line. The surgeon then inserted a Veress needle into the peritoneum. At that point, the anesthesiologist informed the surgeon that Decedent had a sudden decrease in her end tidal co2, and Decedent was unstable. Shortly thereafter, she became bradycardic. The surgeon withdrew the Veress needle and began chest compressions. At approximately 17:49, the ventilator alarmed to a sudden decrease in end-tidal carbon dioxide on the capnograph. The surgical team was alerted and attempts at insufflation were halted. Within a few seconds, Decedent's heart rate began to decrease. Epinephrine was given to Decedent. Chest compressions were started as the bradycardia had converted into ventricular fibrillation.
Code blue called at 17:50. The anesthesiologist switched the ventilator to manual mode and began to ventilate the decedent by manually squeezing the anesthesia circuit reservoir bag. end-tidal carbon dioxide level remained low. Compressions and ventilation continued with another dose of epinephrine given at approximately 17:55 by another anesthesiologist, who had been called to assist. The anesthesiologist continued to ventilate Decedent throughout the code, and Decedent had bilateral breath sounds as heard with a stethoscope. A second fluid bag was attached to a preexisting IV, and both fluid bags were placed on pressure for volume. Throughout the code, multiple doses of epinephrine, bicarbonate, and calcium were given. Pads were attached early in the code, but no shockable rhythm was ever seen after the initial shock at 17:52. Advanced cardiovascular life support was continued until 18:30 with no improvement in the patient’s condition. Decedent was pronounced dead at 18:30.
Autopsy Report stated:
“Post mortem examination, limited to chest and abdominal cavities, shows marked adhesion related changes involving bilateral lungs, liver, spleen and large and small intestines. No thrombosis or thromboemboli are seen. The left anterior descending exhibit significant calcific stenosis, 30% patent and the .left circumflex artery shows mild stenosis. No acute myocardial infarct is identified. No acute pneumonia or saddle emboli is noted. The liver shows mild steatosis and mild congestion. The kidney demonstrates acute kidney injury. The proximal small bowel shows focal dilation with fecal content. No marked acute inflammatory changes are noted within large and small Intestines.
Overall, the immediate cause of death is unclear. Speculation includes metabolic and hemodynamic instability from underlying small bowel obstruction. The presence of small bowel obstruction and dilation Is most likely secondary to pronounced adhesion, involving multiple organs, including the mesentery and small bowel. There is no histologic evidence of active ulcerative colitis. There is no bowel perforation or bowel injury identified from the latest attempt of laparoscopic procedure.”
Did it fall below the standard of care for the anesthesiologist to determine decedent was an appropriate candidate for anesthesia given her ASA III status due to significant comorbidities including a history positive for 1) smoking 2) diabetes, 3) hypertension, 4) hyperlipidemia, 5) atherosclerotic disease, 6) elderly age > 65 7) prior heart attack, 8) adhesions 9) prior surgeries for bowel obstruction, gallbladder and hysterectomy, 10) an X-ray the morning of the surgery which demonstrated an active lung process occurring in patient and 11) an EKG that same day confirming a likely prior anteroseptal heart attack There had been no cardiac consultation or clearance nor a pulmonary consultation related to her documented heart and lung issues, prior to the procedure.
Did it fall below the standard of care for the anesthesiologist to administer the nature and amount of the anesthesia and other medicines administered to decedent prior to her death?
Did the conduct of the anesthesiologist comply with the standard of care during the code blue?
Files:
No questions yet!
Do you believe there might have been medical error?
The deterioration occurred in proximity to the surgeon placing the trocar/needle, the patient was previously stable.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is possible the "needle" or trocar was placed too hight, above the diaghphram, Insufflation in that case would have collapsed the lung.
What makes you a good expert for this case?
I am board certified in anesthesiology and critical care medicine. I have been an expert witness for 8 years.
How often do you encounter cases similar to this one in your practice?
I encounter them all the time. Hundreds a year.
Do you believe there might have been medical error?
Despite having roughly 36 hours before an “urgent-but-not-emergent” laparoscopy, they skipped the minimum cardiac and pulmonary checks that current ASA and ACC/AHA guidelines require once a patient shows an RCRI ≥ 2, a fresh chest X-ray opacity, and poorly controlled comorbidities. A rapid troponin/BNP panel, point-of-care echo, and clarification of the lung finding could have been completed in under an hour and would likely have upgraded her risk profile, prompted a cardiology or pulmonary consult, and driven either further optimisation or a re-weighing of surgical timing. I likely would have placed this patient at an ASA IV. That said, the proximate cause of death appears to be a CO₂ gas embolism during Veress-needle insufflation—a surgical complication that optimisation alone may not have prevented.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The most plausible immediate cause of death was a massive CO₂ gas embolism that occurred the moment the Veress needle was used; that event is fundamentally surgical and can be lethal even in optimally prepared patients. The anesthesiology lapse (failure to obtain rapid cardiac and pulmonary optimisation) likely reduced the patient’s physiologic reserve—e.g., an unsuspected depressed ejection fraction or occult pneumonia would make right-heart failure and hypoxia from an embolus harder to reverse. Better pre-op assessment could have led to invasive monitoring, higher baseline FiO₂, or even a decision to delay or alter the surgical approach, any of which might have improved the odds of return of spontaneous circulation. Therefore, while the breach did not create the embolism, it plausibly contributed to the inability to resuscitate.
What makes you a good expert for this case?
Here’s why I’m a strong fit to serve as an expert on this anesthesia-related wrongful-death case: Board-certified anesthesiologist and ABA examiner. I hold an active, unrestricted ABA certificate and serve as an American Board of Anesthesiology oral examiner, demonstrating peer-recognized expertise in evaluating safe anesthesia practice nationwide. Hands-on experience with exactly this scenario. My routine call work includes 40–50 urgent exploratory laparoscopies/laparotomies for bowel obstruction in ASA III–V elderly patients each year, giving me real-world insight into pre-op optimisation, intra-op monitoring, and management of rare but catastrophic events such as CO₂ embolism. Specialised training and scholarship. I completed a fellowship in Regional Anesthesiology & Acute Pain Medicine at UCLA and hold the FASA designation—reserved for diplomates who demonstrate excellence in clinical care, teaching, and leadership. Quality-of-care and peer-review credentials. I serve as an independent medical case reviewer for Maximus and SJMD Solutions. I provide expert-witness opinions and dispute-resolution reviews, and I work directly analogous to analysing perioperative standard-of-care and causation questions. Joint Commission and patient-safety expertise. My prior role as a Physician Field Representative for The Joint Commission involved on-site hospital surveys focused on perioperative safety, credentialing, and quality improvement—experience that informs authoritative opinions on institutional processes and guideline adherence. Leadership in guideline-shaping organisations. As an ASA Fellow and current member of ASA Governmental Affairs and Regional Anesthesia committees, plus extensive service in AMA CPT/RUC coding, I stay at the centre of evolving practice standards. I can clearly explain them to a jury. Seasoned educator and communicator. Former Assistant Professor at USC and Associate Residency Program Director at Houston Methodist; 60+ national presentations and frequent media expert (CNN, NEJM Catalyst). That background helps translate complex anesthetic and surgical concepts into accessible testimony. No conflicts, clean professional record, multistate licensure. Active, unrestricted licenses in CA, TX, FL, and OR; no malpractice judgments or credentialing issues. Collectively, this mix of high-acuity clinical practice, formal quality-review work, leadership in professional bodies, and proven teaching/communication skill set positions me to offer credible, authoritative, and easily understandable expert opinions on whether the anesthesia care in this case met— or fell below—prevailing standards and whether any breach contributed to the patient’s death.
How often do you encounter cases similar to this one in your practice?
In my current clinical mix, I provide anesthesia for a broad spectrum of inpatient general-surgery cases, many of them urgent “exploratory laparoscopy or laparotomy for bowel obstruction” in ASA III–V patients. At Dignity Health Mercy Redding, I serve as a sole practitioner and “frequently” manage ASA 4–5 E cases; similar high-acuity work occurs at the other community hospitals where I cover call. Putting numbers on it: during an average call week, I will see one to two urgent abdominal cases in patients over 65 with significant cardiac or pulmonary disease, roughly 40–50 such cases per year. Actual catastrophic events like massive CO₂ embolism are fortunately rare. Still, the pre-operative risk-stratification and intra-operative vigilance issues raised in this lawsuit are part of my routine clinical decision-making.
Do you believe there might have been medical error?
In short, there should have been proper, cardiac and pulmonary consultation prior to the patient undergoing general anesthesia. this case demonstrates a patient with already compromised, lungs and heart, who is undergoing a laparoscopic procedure. In the case presented here, it’s a little bit unclear as to the timing of bradycardia and chest compressions. Typically when there is bradycardia with insufflation from laparoscopic procedure, there is an immediate notification to the surgeons, who then should immediately decrease in circulation and remove the needles and ports. I don’t think it’s 100% clear that this is a medical error. However there could’ve been better optimization for the patient and for the sequence of events that happened during general anesthesia.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I think that the insufflation caused an already compromised patient to have bradycardia and subsequently needing compressions. There is a causation, whereas the insufflation likely caused the sequence of events. However, having said that, it may still have had happened, even without the insufflation during the course of the actual case.
What makes you a good expert for this case?
I am a double board-certified, anesthesiologist and pain management position. I work at a large academic center and I am the program Director for the pain management Fellowship. I have been practicing since 2015.
How often do you encounter cases similar to this one in your practice?
Often enough as we see insufflation injuries, as well as very sick patients in our hospitals.
Do you believe there might have been medical error?
This is a complex case requiring careful evaluation of the anesthesia standard of care. Several critical details are needed to assess the cause of death, which, based on autopsy findings, appears likely cardiac-related. Potential etiologies include a vagal reflex (common during insufflation), venous air embolism, pulmonary embolism, or gross metabolic abnormalities. It would be essential to determine if the anesthesiologist and surgeon evaluated and addressed metabolic status preoperatively, including arterial blood gas, base deficit, or stroke volume variation. Significant volume depletion is also common in such patients, often necessitating aggressive fluid resuscitation. Clarification on whether a central line or arterial line was placed would provide insight into intraoperative management. The surgeon’s documentation regarding the procedure’s urgency is critical. In an emergent case, the anesthesiologist may have had insufficient time to pursue additional workup, such as a cardiology consult, echocardiogram, or stress test, relying instead on available data to proceed. Conversely, if the case was semi-urgent, the anesthesiologist should have adhered to the ACC/AHA guidelines on perioperative cardiovascular management for noncardiac surgery. These were recently updated in the last year, so it's important to obtain a copy the guidelines active at the time of this case. Depending on the patient’s functional status, this could involve an echocardiogram, stress test, cardiology consult, or cardiac catheterization. If retained, I would review the applicable guidelines, as I currently have only the most recent version. Pulmonary pathology is unlikely to have contributed to the outcome, and the standard of care for lung-related management appears met. A pre-op note detailing lung exam findings would be helpful; if wheezing was noted, a preoperative breathing treatment would be standard, but a pulmonary consult would not typically be required. The reported glucose level of 243 is notable, as guidelines for colorectal surgery generally recommend maintaining blood sugar below 180 to reduce surgical site infection risk. However, varying society recommendations make it challenging to definitively assess standard of care without further context. The 150 mg propofol dose raises concerns, particularly if the patient was hemodynamically unstable or had significant cardiomyopathy. A lower dose or an alternative agent, such as etomidate, might have been more appropriate and could have influenced subsequent events. The other induction drugs appear appropriate based on available information. Post-insufflation, the anesthesiologist’s prompt recognition of decreased CO2 suggests a significant drop in cardiac output, with initial management appearing consistent with the standard of care. However, a thorough review of the anesthesia record is necessary to confirm this. The focus should remain on the preoperative evaluation, choice of induction drugs, and the patient’s metabolic status prior to surgery. For instance, if an echocardiogram indicated reduced ejection fraction, a reasonable anesthesiologist might have selected a different induction strategy. Additionally, assessing whether metabolic derangements could have been optimized preoperatively is critical to determining if the standard of care was met.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As noted earlier, determining the appropriateness of the anesthesiologist’s actions requires more context. Key factors include the surgeon’s urgency assessment, the patient’s functional status, and additional lab results (e.g., chemistries, lactate, blood gas). While an echocardiogram could have been considered, an emergent case may have precluded this due to time constraints.
What makes you a good expert for this case?
In addition to being the anesthesia medical director for my group, I'm also the director for our anesthesia perioperative surgical home (pre-op clinic) and a member of our mortality review committee. As director, I'm often involved with pre-op evaluations and risk stratifications for our complex patients. I also review cases similar to this during our monthly mortality review meetings. I'm most concerned about a patient who was not fully optimized prior to the anesthetic, but I would like to know how rushed this patient was brought to the OR by the surgeon. It's also worth noting, it's entirely possible the unfortunate events were related to surgeon error and unrelated to the anesthesiologist's actions. However, thats pure speculation since I am not a surgeon.
How often do you encounter cases similar to this one in your practice?
I encounter cases very similar to this at least several times a week while on call. It's very common to get a call from a general surgeon stating they have a patient with significant cardiac pathology requiring an exploratory laparotomy. Sometimes these are urgent, meaning I have a few hours to work with the surgeon and cardiologist for further optimization. Sometimes they are emergent, and we don't have time.
Do you believe there might have been medical error?
The time line as laid out is confusing. According to time line the patient was intubated PRIOR to the induction of anesthesia at 1723- induction medications were delivered at 1731; either the patient was intubated prior to the start of anesthesia or the record is not correct. As to the underlying medical conditions of the patient-this procedure does not appear to have been scheduled as an emergency since the KUB was done on the 14th and surgery scheduled the following day. The anesthesiologist should have been consulted at the time of scheduling surgery so the medical record was reviewed and the patient examined. If the CXR showed collapse of the left lung and there was no further follow up by internal medicine or pulmonology, especially if surgery were being consider, would rise to level of negligence, Did the anesthesiologist detail heart and lung sounds during their initial physical exam? If breath sounds were absent on the left why did the anesthesiologist feel the patient was an appropriate candidate for a non emergent procedure? Were the patients SpO2( oxygen saturations) docuented anytime prior to surgery? Given the patients medical co-morbidities( and the non emergent nature of the surgery, cardiology and pulmonology should have had input into the patients care. Consults to both cardiology and pulmonology were indicated, especially if surgery was being considerd. Patient would be considered high risk given her poor blood pressure control, ASCAD ,DM and "other heart conditions". The patients weight was not mentioned but this would also be a factor in risk stratification. One glaring concern is that during the code the anesthesiologist describes hearing bilateral breath sounds-given the X-ray report from the 14th showing collapse (or non ventilated Left lung) I would doubt that the breath sounds would be ascultated on the left chest
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The Preop workup of this patient appears to fall short of standards of care prior to a non emergent surgical procedure. The surgery likely need to be done but the patient should have been optimized prior to the induction of anesthesia. A CT scan of chest and abdomen should have been considered and performed prior to surgery to better define the chest and abdomen pathology. In all likelyhood the patient was volume depleted in addition to having a comprised CV and pulmonary process in play. Abdominal insufflation has profound effects on both these systems. The timeline on the anesthesia intubation and induction is confusing and does not appear to be an accurate representation of the perioperative period. The lack of a detailed physical exam by the anesthesiologist is concerning; and if it was done in the preoperative, period should have raised red flags on the patients current likelihood of safely undergoing the planned anesthetic/surgery at that particular moment in time
What makes you a good expert for this case?
I have 30 plus years of experience as a Board certified anesthesiologist. I had extensive trainng as a cardio- thoracic anesthetist/anesthesiologist and have worked in private practice, academic practice/ academic credentials with teaching responsibilities, as well as a senior medical officer at The National Institutes of Health. I have been appointed to the scientific staff and medical staff of several prominent medical universities and I have personally had cases similiar to this with positive outcomes/no fatalities
How often do you encounter cases similar to this one in your practice?
I practice at an academic center and these cases happen several times in a year
Do you believe there might have been medical error?
Given the description of what occurred during the surgical procedure and what anesthetic was prescribed, the development of an unstable arrhythmia is not without a root cause stemming from an undiagnosed underlying medical condition. It concerns me that the patient was noted to be shaking uncontrollably during the preoperative phase on the day of surgery and this was not investigated further. There is a much broader differential diagnosis for that phenomenon that merely just a reaction or sensitivity to morphine. Given that the patient was given the morphine on her second day of admission in the hospital, it is unlikely that was her first dose of the medication and she did not previously have a similar reaction to it prior. Therefore, perhaps the hospitalist team could have investigated the reason for her shivering further. The patient certainly does have many significant medical co-morbidities, however the findings on the autopsy do not point to issues that would have needed further preoperative workup by the request of the anesthesiologist. The finding of a metabolic derangement seems the most plausible and is likely due to the process of her bowel obstruction worsening. Potentially, impending systemic shock was overlooked, but this did not necessarily negate the need to proceed for surgery. If anything, this may have only changed the ASA Physical Status classification from III to IIIE. If the patient's medical condition was worsening, there would likely not have been more time or testing that could have been done to optimize her condition rather than attempt to surgically correct the original medical issue.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Given the facts that have been presented and main causes of cardiovascular complications (acute myocardial infarction) were ruled out with the autopsy, the likely cause of the patient's demise seems most related to the root of her surgical indication and the natural progression of that disease process into a cardiogenic or septic shock. There are many surgeries indicated that do not allow reasonable time to optimize every one of a patient's medical co-morbidities especially in an acute care setting such as this case. Once again, in retrospect, the patient's shivering may have been one of few non-specific signs of her bowel obstruction progressing into a metabolic derangement and shock. However, this would have only increased the urgency of the surgery, rather than the anesthesiologist deeming she should not be a candidate for surgery. Any invasive procedure does carry with it the risk of death and especially more often in an urgent situation such as this.
What makes you a good expert for this case?
I am a board certified anesthesiologist who has practiced in the field for over 20 years and in multiple areas of the country. I have been recognized with a designation as a Fellow of the American Society of Anesthesiologists. I am currently the chair of the Department of Anesthesiology at my facility which involves quality review of cases, root cause analysis work for serious adverse events, and review of quality and patient safety metrics. I also perform work on steering committees for the larger healthcare system to cultivate policies and procedures to reduce perioperative events such as this one. While the outcome of this case is quite unfortunate, it is a clear example that there is risk with the decision to proceed with surgery, This risk can occur as a result of the disease process despite all the clinicians' best efforts to heal.
How often do you encounter cases similar to this one in your practice?
This type of surgical case is fairly common with at least 3-5 patients who present to the practice as a whole each week. This type of case is encountered at any hospital with an OR, whether a small community hospital, critical access hospital or large tertiary center.
Want to open a case or submit response?
Comments are accepted only from Anesthesiology - includes all Subspecialties experts.