Waiting to Exhale: When Negligence Complicates Anesthesia and Aspiration Results

Waiting to Exhale: When Negligence Complicates Anesthesia and Aspiration Results

Aspiration is a serious complication that can occur during surgery and the administration of anesthesia. This can cause severe damages for patients up to and including wrongful death.?

Aspiration is a term that describes what happens when food, fluid, or other foreign objects are breathed into the lungs, leading to respiratory distress and other complications. Normally, the body is equipped with a number of protective mechanisms to prevent the aspiration of food and drink into the lungs.?

In addition to the gag reflex, the epiglottis is a flap of cartilage that closes when you swallow, creating an airtight seal between the food pipe and the windpipe. At the same time, saliva and other muscle movements help to move food down the food pipe and away from the lungs. With the help of these protective measures, the risk of aspiration is greatly reduced in our day- life.

Nevertheless, aspiration is a significant risk that is inherent in any surgical procedure that involves general anesthesia or sedation. Anesthesia suppresses the body’s natural reflexes, including the gag reflex. When aspiration develops into bacterial pneumonia, which can sometimes happen, this can become life threatening.

Anesthesia care providers like anesthesiologists and CRNAs must follow certain standards of care to ensure that aspiration is prevented insofar as it can be, that it is identified quickly when it does occur, and that it is managed properly and promptly to avoid damages.?

In this article, we will discuss the causes, risk factors, symptoms, prevention, and management of aspiration as a surgical complication so that attorneys faced with cases involving aspiration as a complication of a surgical procedure will be better equipped to know what to look for to know if the outcome may have been proximately caused by negligence of the hospital staff or health care workers.

Causes of aspiration during surgery

Aspiration during surgery can be caused by a number of factors, including underlying medical conditions, delayed gastric emptying, and anesthesia-related complications.

Underlying medical conditions that increase the risk of aspiration include gastroesophageal reflux disease (GERD), hiatal hernia, neurologic disorders, and other conditions that affect the muscles and nerves involved in swallowing.

Underlying delayed gastric emptying can also increase the risk of aspiration during surgery. This can occur in patients who have conditions that affect the movement of food through the digestive system, such as diabetes, or those who have had recent abdominal surgery.

Finally, the anesthesia includes the risk of aspiration during surgery. As mentioned, anesthesia can have common complications, including impacting the protective reflexes in the throat and lungs, making it easier for foreign material to enter the airway. It can also slow down gastric emptying and increase the risk of reflux.?

That said, because of the patient's vulnerability during this time, it is all the more important for anesthetic management providers to take every measure possible to mitigate this liability and ensure patient safety.

Risk factors for aspiration during surgery

Attorneys who are handling medical malpractice cases involving repercussions from aspiration pneumonia during surgery must be aware of the various risk factors that can increase the likelihood of aspiration during surgery, which can be presented as defenses in reducing the liability of the provider. Anesthetic complications and medical errors can occur during medical procedures and having an understanding of these risk factors is important. These risk factors may include:

• Underlying medical conditions: Patients with certain medical conditions such as gastroesophageal reflux disease (GERD), hiatal hernia, and other conditions that affect the muscles and nerves involved in swallowing are at an increased risk of aspiration during surgery.
• Age: Older patients are at a higher risk of developing aspiration during surgery. This is because aging can affect the protective reflexes in the throat and lungs.
• Obesity: Obese patients are at an increased risk of aspiration during surgery because excess weight can put pressure on the stomach and increase the likelihood of reflux.
• Smoking: Patients who smoke are at an increased risk of aspiration during surgery. Smoking can weaken the muscles involved in swallowing and increase the likelihood of reflux.
• Previous aspiration events: Patients who have had previous episodes of aspiration are at a higher risk of developing aspiration during surgery.
• Type of surgery: Certain types of surgery, such as those involving the gastrointestinal tract or head and neck, are associated with a higher risk of aspiration.
• Medications: Certain medications such as opioids and sedatives can increase the risk of aspiration during surgery.

Symptoms and complications of aspiration

Symptoms and side effects may not become apparent until the patient is conscious in recovery and can vary depending on the amount, acidity and make-up of material that has been aspirated, as well as the location of the aspiration in the respiratory tract. Common symptoms include:

• Coughing or choking after surgery
• Low oxygen saturation or need for high supplemental oxygenation and difficulty in weaning
• Difficulty breathing or shortness of breath
• Chest pain or discomfort
• Hoarseness or changes in voice
• Wheezing or noisy breathing
• Fever or other signs of infection

Complications of aspiration can be serious and can include:

• Pneumonia: Aspiration of bacteria or other infectious material can lead to pneumonia, which can be life-threatening.
• Acute respiratory distress syndrome (ARDS): Aspiration can cause inflammation in the lungs, which can lead to ARDS, a severe form of respiratory failure.
• Pulmonary embolism: Aspiration of blood or other material can lead to a pulmonary embolism, which is a blockage of the pulmonary artery that can be life-threatening.
• Brain damage: If aspiration causes a lack of oxygen to the brain, it can lead to brain damage or other neurological complications.
• Death: In severe cases, aspiration can lead to death.

Prompt recognition and treatment of aspiration are important to prevent complications and improve outcomes.?

Prevention of aspiration during surgery

Prevention of aspiration during surgery is crucial to avoid potential complications. There are several measures healthcare providers must take to reduce the risk of the patient aspirating during or after surgery, including:

Preoperative assessment: The standard of care requires anesthesia providers to perform a thorough preoperative history,? assessment and exam to identify any underlying medical conditions that could increase the risk of aspiration. A case reviewer who has conducted such assessments will know where to find reports of these assessments, how to? evaluate their thoroughness, and know how to interpret them.?

Fasting: When providers fail to instruct patients completely on the importance of fasting prior to surgery in order to reduce the amount of stomach contents and minimize the risk of reflux, the provider may have failed to meet the standard of care Education about these pre-operative measures is often allocated to the nursing staff.?

Case reviewers with familiarity with the nursing documentation relevant to education will know where to locate the documentation that proves or disproves the occurrence of and completeness of this education or assessment. A patient’s date and time of last meal is also information that is collected several times in nursing pre-op documentation, especially for elective surgeries. Failure to collect this information can be considered a breach in standard of care.?

It is important for attorneys to note that if a patient was properly instructed to fast, and such education is well-documented, and the patient did not fast as they were told, this can present a patient-caused variable that can overcome many of the other otherwise causative factors. (i.e. “But for” the patient having eaten recently when they were explicitly instructed to have fasted, and misrepresenting to the staff the time of their last meal, the patient would not have aspirated.)

In reality, failing to educate a patient on fasting is rare, so documentation of this education and its reception is critical to provide defensibility for the healthcare team in cases of allegedly malpractice-related aspiration. If it exists and is thorough and credible, a plaintiff attorney had better leave well enough alone.?

On the other hand, when a patient informs the admitting pre-op nurse or the anesthesia provider that they have not properly fasted, such information should be communicated to the surgeon, that communication should be documented, and the surgery should be postponed to another day; production pressure and inconvenience to all parties notwithstanding.?

A nurse anesthesia medical legal consultant reviewing the records will know which records will contain documentation of precisely that education and precisely the reported hour of last meal.?

Airway management: Proper airway management during anesthesia is essential to prevent aspiration. This may include the use of endotracheal tubes, laryngeal masks, or other devices to protect the airway. A case reviewer familiar with the various considerations when choosing an appropriate airway device will be able to call out when a provider failed to prudently consider the best approach, leading to a bad outcome.

Use of medications: Certain medications can be used to reduce the risk of aspiration, such as proton pump inhibitors to reduce stomach acid production or antacids to neutralize stomach acid. Having a case reviewer who, themselves, routinely administer anesthesia will be familiar with when the anesthesia provider should have considered the use of acid-reducing medications to mitigate inherent risks.

Monitoring: Patients should be monitored closely during and after surgery to detect any signs of aspiration and intervene promptly. A case reviewer that is a nurse anesthesia medical legal consultant has intricate familiarity with the degree and type of documentation that anesthesiologists and CRNAs use when administering anesthesia, and can call out when the documentation suggests that the patient was being inadequately monitored.

Note on Positioning: Positioning of the patient in the surgical suite is entirely dependent on the procedure being performed and the surgeon’s preference for access to the patient’s anatomy. So, at times the desired position is on which–in a conscious patient with a blunted gag reflex–might put the patient at risk for aspiration, such as supine or even with the head below the feet.?

There is very little consideration that can be taken for protection of the airway via positioning. This is why intubation is so important, as this provides the anesthesiologist? direct access to provide pressure and oxygen into lungs regardless of body position.

?Contrary to what may seem like common sense, positioning is rarely a factor in aspiration in the operating room, and attorneys should be leery of aspiration cases where the alleged standard of care violation relates to operating room positioning alone “causing” aspiration.

Conclusion

Aspiration is a serious, and potentially preventable surgical complication that can lead to significant damages or wrongful death if not reasonably prevented, promptly recognized and managed. While the risk of aspiration cannot be eliminated entirely, healthcare providers have a duty to meet standards of care in reducing the risk of death or serious permanent damages. They do this by implementing standards of care such as thorough preoperative assessment, proper fasting instructions, proper patient positioning, airway management, appropriate determination of the need for preventative medication, and intense intra- and post-operative monitoring, healthcare providers can avoid liability associated with surgical aspiration events. Because the occurrence of surgical aspiration is multifactorial, and because it can result in potentially preventable lifelong damage or death, an attorney evaluating or litigating a case involving aspiration during surgery would do well to engage a nurse anesthesia medical legal consultant who is intimately familiar with and knows where to look to find documentation of all the standards of care that should have been followed to prevent this occurrence.