When the one hand doesn't know what the other is doing in the OR, disaster can strike. In this month's case, an 87-year-old woman recovering from successful knee replacement surgery was plunged into a drug-induced vegetative state because her anesthesiologist didn't bother telling the surgeon or the nursing staff that he changed from epidural to spinal anesthesia and that he left the unmarked spinal catheter in place in case additional pain medication would be needed later. He noted these facts in the patient's chart, but didn't communicate them to the people in the room.

A few hours after surgery, the patient was placed in an unmonitored bed and began to complain of pain. The orthopedic surgeon ordered a 6cc bolus of ropivacaine and increased the infusion rate from 1cc per hour to 2cc per hour. Based on the order, a CRNA who had no involvement with the patient left an operation in progress to administer a 6cc bolus of ropivacaine. The CRNA left the patient's room after approximately 3 minutes and returned to surgery. About 15 minutes later, a nurse came into the room and found the woman unresponsive.

The patient was diagnosed with a cardiac arrhythmia and a code was called. She was intubated and resuscitated, but she suffered severe anoxic brain damage. She could have lived in a vegetative state, but her family honored her living will and removed life support systems. She died 5 days later.

Plenty of blame to spread around
The woman's adult children sued the anesthesiologist, the anesthesiology group that employed the CRNA and the hospital. The surgeon was not sued.

The plaintiffs argued that the 6cc bolus of ropivacaine administered directly into the spine caused the patient to go into respiratory and cardiac arrest and that the nurses' failure to recognize cardiac arrest in a timely manner led to severe anoxic brain injury. The plaintiffs argued that the outcome would have been better had the medication been administered into the epidural space or the code called sooner.

The plaintiffs' experts criticized the anesthesiologist for not marking the catheter as a spinal cath-eter and for not telling the surgeon and nursing staff about the change from epidural to spinal anesthesia. They also criticized the CRNA for not recognizing that a spinal catheter was in place and for not monitoring the patient after the bolus to ensure that the patient did not have an adverse reaction.

The plaintiffs' experts were critical of the facility for not having protocols that require marking catheters and requiring adequate monitoring after a bolus of pain medication in order to diagnose and treat adverse reactions. The plaintiffs also argued that the facility was vicariously responsible for the actions of the anesthesiologist and the CRNA.

And now for the defense
The defense was very complicated due to overlapping issues among the defendants. The anesthesiologist's standard of care defense was that the change from epidural to spinal anesthesia was clearly reflected in the records. Had anyone bothered to review the records, the anesthesiologist said, they would have noticed the change. He said that no one contacted him about the order for a post-operative bolus of pain medication. Had he been informed, he wouldn't have administered it, he said. Lastly, he argued that while he could have marked the catheter, it wasn't necessary: Marking wasn't standard practice or facility policy.

The CRNA's and anesthesia service provider's standard of care defense was that the CRNA assumed that the patient had an epidural catheter in place because an epidural is the anesthetic of choice for this type of procedure. It was very unusual, he said, to have a patient in an unmonitored bed with a spinal catheter in place. The CRNA also argued that the surgeon's order for a 6cc bolus was consistent with a patient having an epidural catheter. Lastly, he argued that in his experience, administering a 6cc bolus of ropivacaine into the epidural space wasn't dangerous and didn't require more extensive monitoring.

The facility argued that it wasn't standard of care for facilities to have policies in place requiring marked catheters or to manage pain medication administration. It also said that it wasn't responsible for the actions of the anesthesiologist and the CRNA since they weren't hospital employees. All of the defendants argued that a 6cc bolus of ropivacaine administered through an epidural catheter and monitored for a longer period of time would have had the same outcome.

Fear of large verdicts
The trial was held in a liberal jurisdiction known for large plaintiff verdicts. The defense became even more complicated in the days leading up to trial since the hospital, the CRNA and the anesthesia service provider settled for an undisclosed amount. As a result, the plaintiff proceeded to trial against the anesthesiologist alone. The anesthesiologist had consented to settle the case, but the parties couldn't come to terms on the amount. The jury was unaware of the settlement attempt.

At the trial, family members and friends of the patient described her many interests and active social life including playing cards, dancing and exercise classes. The plaintiffs also shared photos of the patient attending birthday parties at ages 83 and 85. The evidence and testimony were certain to test the jurors' ability to refrain from letting sympathy influence their verdict.

Since the CRNA and the anesthesia service provider had settled, the anesthesiologist argued strongly that the CRNA failed to check the medical records to figure out which type of catheter had been used. Had he done so, the anesthesiologist argued, the poor outcome could have been avoided.

The anesthesiologist also argued that the CRNA was negligent for leaving the patient's room immediately. He should have monitored her for at least 10 minutes after the bolus to make sure that the patient didn't have an adverse reaction. Despite the CRNA's settlement, which didn't call for an admission of negligence, the CRNA admitted at trial that he made a mistake and apologized to the decedent's family.

Sympathetic jury
Regardless of the fact that the patient had exceeded her life expectancy, the jury let sympathy for the patient and her family influence their verdict. After 2 hours of deliberation, the jury unanimously found the anesthesiologist 35% negligent and the CRNA 65% negligent. They awarded $2 million for the wrongful death claim and $1 million for the survival claim.

This case presents another example of failed communication. While the anesthesiologist believed that his conduct in noting the chart to reflect spinal anesthesia was sufficient, the plaintiff's expert anesthesiologist felt otherwise, and the jury accepted his position. When faced with this situation, the anesthesiologist should communicate directly with the surgeon and facility staff about the anesthesia that was ultimately delivered. Of course, this should then be documented in the patient's chart as well.

The facility has since revised its policies to ensure proper marking of catheters and to require that the anesthesia provider wait 15 minutes after administering bolus doses of medications. We hope, too, that everyone on the perioperative team is talking to each other.