Any time a patient is facing a surgical procedure requiring general anesthesia, safety rules require an individualized anesthesia plan. Under American Society for Anesthesiologists standards, the anesthesia plan should be formulated by a fully-trained anesthesiologist physician, as opposed to a certified registered nurse anesthetist (CRNA).
The anesthesia plan reflects that administering anesthesia to a patient is serious business. When something goes wrong, the anesthesiologist and staff only have a few short minutes to correct things before cardiac/heart or respiratory/breathing problems cause the patient to die.
An anesthesiologist starts this process by performing a pre-anesthetic evaluation on the patient. In addition to a physical exam, the doctor asks many questions designed to uncover potential risks—things like medications that the patient takes and a history of medical conditions, diagnoses, and surgical complications. When those risks are identified, the anesthesiologist makes advance preparations with proper planning and supplies.
Sometimes there are conditions or risks that the patient doesn’t know anything about. An experienced anesthesiologist will ask the right questions or make the right observations to account for these things, too. Take sleep apnea, for example.
What is sleep apnea?
Obstructive sleep apnea is a medical condition where the back of the throat collapses and closes during sleep, causing the person to stop breathing temporarily. The body re-starts or jump-starts breathing by waking you up when this happens. This can happen many times during a night, causing the person to feel tired during the day and having a tough time staying asleep at night.
Family members often describe people with sleep apnea as being loud snorers or making loud snorting noises when sleeping. These noises happen when you stop breathing and are waking up to try and catch your breath.
Experts believe that close to 20 million people in America suffer from sleep apnea, but most of them don’t even know that they have this serious condition. Overweight men over 40 are the most common group to have obstructive sleep apnea.
How does sleep apnea affect anesthetic risk?
Even when a patient doesn’t report a diagnosis of sleep apnea, it’s something that the anesthesiologist has to keep in mind. Just think about it.
When patients are put to sleep with anesthesia, they can lose control of the ability to keep their airway open. That’s doubly important in patients with sleep apnea, though. If their airways collapse because of sleep apnea and they’re sedated, they won’t snore or snort to start breathing again.
Under anesthesia standards, sleep apnea is a big deal. The standard of care requires anesthesiologists to make a clinical finding of likely sleep apnea in patients with high risk factors for the condition, even if they’ve not been previously diagnosed with the condition by another physician.
In a medical malpractice case where we’ve sued an anesthesiologist and a CRNA on behalf of clients of Painter Law Firm, I asked the anesthesiologist about sleep apnea during her deposition. She testified that she “felt like he was positive screening for sleep apnea, which is also an indicator for difficult airway.”
The anesthesiologist explained that she wasn’t sure if she specifically asked the patient about snoring but looked at him and based on his body habitus, she felt like he was positive for sleep apnea and made a mental note of it. In that case, the man was obese and had a thick neck—those factors alone made him a positive risk for sleep apnea.
Next, we discussed STOP-BANG, a screening tool that many anesthesiologists use to assess patients for obstructive sleep apnea. The yes or no questions include the following (note that the first letters of the all caps bolded text spell STOP-BANG):
• Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
• Do you often feel TIRED, fatigued, or sleepy during daytime?
• Has anyone OBSERVED you stop breathing or choking/gasping during your sleep?
• Do you have or are being treated for high blood PRESSURE?
• Is your BODY mass index (BMI) more than 35?
• Is your AGE older than 50?
• Is your NECK size large? This is a shirt collar size of 17 inches or more for men, or 16 inches or more for women
• Is your GENDER male?
The STOP-BANG scoring is interpreted as: (1) low apnea risk: 0-2 yes answers; (2) intermediate apnea risk: 3-4 yes answers; and (3) high apnea risk: 5-8 yes answers, 2 or more yes answers to STOP questions + male gender, 2 or more yes answers to STOP questions + BMI over 35, or 2 or more yes answers to STOP questions + meet neck circumference criteria.
The long and short of it is that when patients have been diagnosed with obstructive sleep apnea or have a high risk under the STOP-BANG screening, the anesthesiologist has to make special plans to preserve patient safety. These include:
• Consider changing medication doses.
• Using caution when extubating (removing the breathing tube) before the anesthesia medications have worn off and the normal airway reflexes have returned.
• Consider extending monitoring in the recovery room and admission to a floor with more monitoring.
• Encourage patients to bring their own CPAP machines to the hospital, if they have them.
• Make sure that a positive airway pressure (PAP) machine is available in the post-anesthesia recovery unit (PACU)/recovery room.
Unfortunately, the anesthesiologist whom I deposed recognized the patient’s high risk of obstructive sleep apnea but made no special preparations in case something went wrong.
She left the operating room and let a CRNA nurse anesthetist who was one year out of training handle the case. The CRNA prematurely removed the breathing tube before the anesthesia drugs wore off, and our medical experts believe he never took a breath. As a result, this man in his 30s needlessly died after an elective surgery.
What you can do
If you’re facing surgery where you’ll have general anesthesia, have a detailed conversation with your anesthesiologist about your risks. Sleep apnea is one of many things that a competent anesthesiologist should consider when making an anesthesia plan for your surgery. Inquire if your risks require any special precautions that will be provided.
Finally, ask if the anesthesiologist will be in the operating room the whole time. If a CRNA nurse anesthetist will be handling most of your case, ask about that provider’s training and experience.
If you or a loved one has been seriously injured because of anesthesia or surgical errors, then contact an experienced Houston, Texas medical malpractice lawyer for help with your potential case.