A 53-year-old man, 5-foot-6-inches and 306 pounds, arrives in the hospital outpatient unit for arthroscopic repair of a torn rotator cuff of his shoulder. A three-packs-a-day smoker, he's recently had a cardiac workup for a syncopal episode that occurred during a prolonged coughing spell. That workup revealed concentric left ventricular hypertrophy, normal cardiac function and significant supra ventricular extrasystoles, which were treated with a beta-blocker. A pre-op note from his internist "cleared" him for surgery and listed no allergies.

Fentanyl allergy?
The anesthesiologist interviews the patient shortly before surgery and completes a pre-anesthesia evaluation form. The patient reports he'd undergone a lumbar laminectomy and shoulder surgery under general anesthesia four years ago without complication. The chart from that procedure, which was available to the anesthesiologist, noted allergies to penicillin, sulfa and mycins. The patient mentions he had had "some sort of reaction" to morphine or another narcotic. The anesthesiologist notes in his pre-anesthesia evaluation that there's a possible allergy to fentanyl. (He later explaines in his pre-trial deposition testimony that he didn't believe that the patient actually suffered from a fentanyl allergy and that true allergies to fentanyl were exceedingly rare.)

General anesthesia is induced using, among other agents, fentanyl in small doses. Muscle relaxation is achieved and the trachea incubated. The patient is placed in a beach chair position in preparation for surgery. Vancomycin is then started as a slow drip.

Blood pressure plummets
The patient's blood pressure decreases from 140/70 to 100/50; the anesthesiologist administers neosynephrine, which promptly restores blood pressure. After 10 minutes, blood pressure again falls; the anesthesiologist administers another dose of neosynephrine, along with benadryl and epinephrine on the "chance" of an allergic reaction.

Blood pressure returns to pre-induction values, but a profound tachycardia ensues, accompanied by ST segment depression. The anesthesiologist tries to control the tachycardia and resulting myocardial ischemia with esmolol and nitroglycerine. Shortly after, intense bradycardia and hypotension ensues.

Staff begin CPR and apply an external pacemaker; pharmacologic intervention returns cardiac function. Staff transfer the stabilized patient to intensive care. He never regains useful consciousness, is removed from life support on the ninth post-op day and expires shortly thereafter.

Wrongful death suit
The family files a medical malpractice action alleging negligence resulting in wrongful death. The suit names the anesthesiologist, internist, surgeon and hospital, and seeks economic damages for lost income, medical costs, and compensation for pain and suffering. What do you think? Should the anesthesiologist have done anything different pre- or intraoperatively?

Answer and Explanations
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