A 28-year-old, blind and mentally retarded male with bleeding gums is scheduled for a dental exam, cleaning and scaling under general anesthesia at an ambulatory surgery center due to his inability to cooperate with a full exam and treatment. During the pre-op exam two days before, staff inform the patient's mother that her son must be NPO after midnight. On the day of the procedure, the mother reports that the patient last ate at 9:30 p.m., at which time he took his first dose of Diazepam 10mg PO. A nurse administers the second dose at 7:30 a.m. Anesthesia is induced without incident at 7:41 a.m. The procedure begins at 8:20 a.m. and ends without complications at 10:20 a.m.

But the patient vomits copious amounts of partially digested food - large pieces of hamburger and French fries - soon after he's extubated and has six episodes of emesis, one following the other. He thrashes about and is extremely combative. Staff don't administer antiemetics. They position the patient on his right side, and suction and insert an NG tube, pulling back large amounts of dark fluid.

His O2 saturation is 72 percent during this episode. He has upper airway congestion with breath sounds bilaterally and rhonchi increased on the right side. Staff administer 100 percent O2 by way of Ambu bag and maintain saturations in the 80 to 85 percent range. They decide to forego a reintubation. A chest X-ray reveals aspiration pneumonia on the right side. The patient continues to have diminished O2 sats. A neurological assessment is difficult to obtain. The medical record says that the patient was "unresponsive due to being under the effects of anesthesia."

A second chest film shows increased congestion on the right side. At 11:58 p.m., staff call EMS to take the patient to an acute care facility. He arrives in the ER at 12:42 a.m. and is intubated 30 minutes after his assessment. He is admitted with acute respiratory distress syndrome secondary to aspiration of gastric contents during the dental procedure.

Three days later, the patient suffers an arrest. A CAT scan shows diffuse cerebral edema and infarction through the entire left hemisphere. Serial EEGs confirm brain death. Two weeks later, the family decides to remove the ventilator; the patient dies.

Plaintiff's point of view
The plaintiff names three separate defendants: the anesthesiologist, CRNA and ASC. The crux of the plaintiff's complaint centers around two primary allegations:

• The defendants failed to administer anti-emetics during the episodes of emesis, thereby causing the aspiration to be more severe.
• The defendants failed to adequately manage the respiratory distress by not reintubating the patient whenever the patient had sustained low O2 saturations, thereby causing the patient to suffer a severe anoxic brain injury.

Defendant's point of view
The defendants respond to the initial complaint by adding the mother as a defendant, saying it was her responsibility to ensure that her mentally retarded son complied with the NPO order. Not only was her negligence a significant contributing factor to the patient's death, but also it was substantial enough to mitigate any negligence that might have been attributable to the defendants.

Further, the defendants argue that staff couldn't have given antiemetics because the patient was thrashing violently about and the six episodes of emesis came in rapid succession, so there was no time to administer them. The defendants also assert that there's no guarantee that the anti-emetics would have worked, and the patient, who was dry heaving after the initial bouts of emesis, had emptied the contents from his stomach.

The defendants considered reintubating, but chose not to because they were concerned about pushing more gastric contents down into the lung fields and possibly increasing the severity of the injury to the pleural lining. They also claim that the brain injury was a progressive anoxic injury that had occurred over the course of the patient's treatment. The patient had self-extubated himself at one point during the hospital stay, and had also suffered a cardio-pulmonary arrest in the ICU. Defendant's expert opines that it was small anoxic events that occurred during the entire admission that led to brain death. The fact that the patient hadn't been intubated immediately after aspiration was immaterial.

Plaintiff's rebuttal
The plaintiff counters the defendant's allegations of the mother's contributory negligence by asserting that the defendants should have a reasonable expectation that a patient could begin to vomit following an extubation. Ordering the NPO status is evidence they were aware this could occur. There's no reason, they argue, to be caught off guard.

A patient's having eaten doesn't preclude him from having emergency surgery. Everyone involved in the care of such a patient is careful to anticipate that this could occur. The same diligence should apply for ambulatory surgery given that the healthcare team must rely on the patient for accurate information regarding the last time he ate or drank. It's foreseeable that patients in this type of setting could give false information due to anxiety or simply being untruthful. The patient's mental incompetence should have put the defendants on alert that it was possible that the patient wouldn't comply with the NPO order. By joining the mother as a defendant, they're basically saying a 75-year-old woman should have stayed up all night and sat in the kitchen to make sure that her son didn't get up and eat after midnight.

Regarding the decision not to reintubate, the plaintiff's expert opines that the brain injury was acute and had he been intubated after the aspiration, the anoxia would have been less severe. The emphasis was placed on the fact that the patient had waited about three hours to be intubated after the aspiration and the medical record reflected low O2 saturations during that time frame.

Expect the worst upon extubation
Shortly before the trial was to begin, the primary defendant, the anesthesiologist, consented to settle the case for an undisclosed amount. The case was then discontinued against the CRNA and the ASC.

The moral of the story in this case is to expect the unexpected. Aspiration isn't that common and death from such an event is even more uncommon; however, it's something that you should anticipate every time you extubate someone. Particularly in circumstances where the patient is arriving from home, relying on accurate information from a patient that is nervous and anxious about impending surgery isn't the smartest strategy. For that reason, you should always anticipate that there is a possibility that the patient ate after midnight and be prepared for the worst upon extubation.