What you should know about the risks of general anesthesia
Questions you should ask your anesthesia provider before surgery
As a Houston, Texas medical malpractice lawyer, new clients regularly call my office to discuss brain injury or death from general anesthesia.
Just recently, I reviewed a case involving a man who went to a hospital because, over the course of a few days, he was having ongoing congestion, coughing, weakness, dizziness, and fever and chills. He told the healthcare providers that he had a number of long-term conditions related to his heart and circulatory system.
After his blood work came back abnormal, a doctor suspected internal bleeding and ordered a blood transfusion. The next day, a surgeon saw the patient. As the saying goes, if your only tool is a hammer, everything looks like a nail. The surgeon knew about the patient’s chronic conditions, but scheduled an endoscopy for the following day.
An endoscopy is the procedure where equipment and a camera are passed through the patient’s mouth and throat, to allow the surgeon or gastroenterologist to see the gastrointestinal tract. Doctors sometimes use endoscopy to take a biopsy. In this case, the surgeon ordered the procedure to try and find a gastrointestinal bleed.
While endoscopy itself is not a particularly risky procedure, patients require general anesthesia because they cannot tolerate the equipment going down their throat.
Any time a patient is going to be placed under general anesthesia, the standard of care requires the anesthesia provider to perform a pre-anesthesia assessment. The assessment is designed to identify any risks unique to the patient that need to be considered in order to form an anesthesia plan.
Anesthesia patient risk classifications
The American Society of Anesthesiologists (ASA) has defined six different categories for anesthesia providers to use during the pre-anesthesia assessment. As the category numbers get higher, so, too, does the risk to the patient undergoing anesthesia.
ASA I is the category for normal healthy patients.
ASA II is the category for patients with a mild systemic disease, without substantial functional limitations.
ASA III is for patients with severe systemic diseases with substantial functional limitations. This category includes conditions like diabetes or hypertension, chronic obstructive pulmonary disease (COPD), or morbid obesity (body mass index of 40 or higher), hepatitis, alcohol abuse or dependence, pacemaker and some other heart issues, or kidney disease.
ASA IV is for patients with a severe systemic disease that is a constant threat to life. This category includes illnesses like a recent heart attack, stroke, transient ischemic attack, coronary artery disease/stents, sepsis, and end-stage renal disease without regular dialysis.
ASA V is for patients who are near death and will not likely survive without surgery. This category includes patients with conditions like a ruptured aneurysm, massive trauma, a severe brain bleed, or multiple organ failure.
ASA VI is for patients who are brain-dead whose organs are being removed for donor purposes.
Complications when patient risk is downplayed
In the case I was discussing earlier, the patient should likely been categorized as an ASA III. The anesthesia provider should have recognized that the patient had a significant risk in question whether the endoscopy was necessary under the circumstances.
Instead, the patient was cleared for the endoscopy. After general anesthesia began, his blood pressure plummeted and his circulation became unstable. After the procedure, he went into pulseless electrical activity (PEA). Despite these complications, the medical records have a 15-minute gap during which there is no monitoring or treatment of the patient, even though he was unresponsive. The man never regained consciousness and died shortly after the endoscopy procedure.
When reviewing a medical malpractice case of this nature, we always begin with looking at the qualifications of the anesthesia provider. There has been an emerging trend all over the country to have certified registered nurse anesthetists (CRNA) assume more and more responsibility in providing anesthesia care, as opposed to board certified anesthesiologist physicians.
In many instances, anesthesiologists perform the pre-anesthesia assessment, and then are uninvolved with the procedure itself. Other times, a certified registered nurse anesthetist handles both the pre-anesthesia assessment and administration of anesthesia during the procedure. In today’s healthcare climate, it is rare to have an anesthesiologist doctor in the operating room during the procedure.
On the occasions when a nurse anesthetist is the anesthesia provider during the procedure, the anesthesiologist physician is elsewhere, supervising several operations ongoing at once in different operating rooms. In the event of an emergency during the procedure, like a patient going into respiratory or cardiac arrest, or having a very low blood pressure, the providers scurry about to summon an anesthesiologist into the room. How long that takes depends on where the anesthesiologist is and what he or she is doing at the time.
What you can do
One of the first things that all patients should realize is that anesthesia is not risk-free. The informed consent conversation and paperwork is supposed to be the time where the risks and benefits of anesthesia are fully discussed and disclosed. Quite often, these are lightning-quick conversations that gloss over risks.
I recommend that informed patients talk to the anesthesia provider, during the pre-anesthesia assessment, about their potential risks of undergoing general anesthesia. Of course, an important part of this conversation is making sure that you disclose your complete medical history, as well as all medications that you are taking.
Another topic that I encourage to be broached during the pre-anesthesia assessment is who the anesthesia provider will be in the operating room. I believe it is important for this to be disclosed to patients as part of the informed consent process. If the plan is to have a certified registered nurse anesthetist (CRNA) handle all aspects of anesthesia during the surgery, then the patient should know that before giving consent. In such situations, the patient should also ask how many other procedures the anesthesiologist physician will be delegating or supervising at the same time.
We are here to help
If you or someone you care for has been seriously injured as a result anesthesia or medical malpractice, call the experienced attorneys at Painter Law Firm, in Houston, Texas, for a free consultation about your potential case. Our phone number is 281-580-8800.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC, in Houston, Texas. He represents patients and families in filing medical negligence and wrongful death lawsuits against anesthesiologists, doctors, surgeons, hospitals, and other healthcare providers. He frequently speaks and writes on topics related to medical malpractice. He is a past editor-in-chief of The Houston Lawyer magazine and is a current member of the editorial board of the Texas Bar Journal.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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Published in the July/August 2018 edition of "The Houston Lawyer" magazine