A surgeon excised a pilonoidal cyst from a 34-year-old man under general anesthesia in the prone position. Other than obesity (5 feet, 8 inches and 280 pounds) and a questionable history of sleep apnea, the patient was healthy. No pre-op electrocardiogram was performed. A hemoglobin was normal.

A board-certified anesthesiologist who administered general endotracheal anesthesia didn't note any problems during the 45-minute procedure. The patient was brought to the PACU, where nurses instituted routine monitoring and applied nasal oxygen. Vital signs were stable on admission. The admitting nurse's note stated the patient was awake and responsive.

The alarm sounds
Soon after he arrived in PACU, the nurse caring for the patient was assigned another patient. While admitting the new patient, she heard the alarm sound on her previous patient (PACU policy was to assign nurses to no more than two patients at a time). She was shocked to see the patient cyanotic, bradycardic and hypotensive.

She summoned assistance and began CPR. The anesthesiologist who'd performed the case directed the resuscitation. In spite of maximum pharmacologic intervention and CPR lasting more than an hour, the patient couldn't be resuscitated and was pronounced dead. A postmortem examination was indeterminate as to cause of death.

Surgeon administered bupivicaine
The family filed suit against the anesthesiologist, hospital and PACU nurses, alleging negligence in the administration of anesthesia and negligence in the monitoring and care of the patient in the PACU. Curiously, the surgeon wasn't named in the suit, for reasons unknown to the defendants. It couldn't be determined whether the family consulted with the surgeon before naming a lawyer.

During discovery, the plaintiff's expert said general anesthesia was an extremely risky choice and that regional anesthesia should have been offered. The defense expert disagreed and discovered from the chart that the surgeon, at the conclusion of the case, had administered 75cc of 0.5% bupivicaine in the surgical site to provide post-op analgesia. The anesthesiologist was unaware that the bupivicaine had been injected, as he was busy preparing for the emergence and wasn't observing the surgeon. The circulating nurse didn't question the surgeon as to the volume of drug he was administering. The defense expert's opinion: The patient died of a toxic dose of bupivicaine administered by the surgeon.

After many attempts at settlement, the case against the anesthesiologist and the PACU nurse went to trial. Should the anesthesiologist have been aware of the surgeon's actions? Could the PACU nurse have mitigated the effect of the anesthetic toxicity?