Page 36 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

CASE STUDY

A 50-year-old who had a Nissen Fundoplasty had an
epidural placed for post-operative pain management. There
was no consent for the epidural in the chart, and thus, it

was assumed that there was minimal discussion of risk for
the epidural with the patient. There was also no procedure
note for placement of epidural. The catheter was placed

while the patient was asleep in surgery. Post-operatively,
the patient was sent to the PACU and then to the medical-
surgical floor with the epidural. Neuro checks were normal.
The anesthesiologist who placed the epidural went on

vacation, and his on-call partner was to follow up. Nurses
noted normal neuro checks until the third postoperative

day. At that time, there was a complaint of leg numbness.
An initial MRI was normal, and a neurology consult was
obtained. The patient did not improve. A repeat MRI was
performed and demonstrated positive swelling around

the cord at the epidural site. The patient developed cauda
equina syndrome. This condition failed to improve with
steroids. The outcome was devastating with the patient

becoming a paraplegic with a T-12 lesion post-surgery. A
lawsuit was filed.

Because of the failures on the part of the anesthesiologist

to communicate the risk of the epidural, the partner on
call was apparently unaware of the epidural catheter,
and he did not perform a neurological evaluation during

the postoperative visits. As noted earlier, the procedural
anesthesiologist also failed to write a procedural note
on the epidural placement which could have served as

a prompt for the follow-up care. Because
of these failures, this patient suffered a
permanent and devastating neurological
injury that could have been foreseen with

proper evaluation and communication.

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