Legal Review & Commentary: Lidocaine-induced seizures lead to $5.6 million verdict

News: A woman underwent elective breast augmentation and, in addition to general anesthesia, was given lidocaine as a local anesthetic. After surgery, in the recovery room, a nurse on duty noticed the patient was unresponsive and twitching. The surgeon and nurse anesthetist, joined by a cardiologist and a neurologist, saw the patient suffer a grand mal seizure and cardiac arrest. The patient never recovered and now requires around-the-clock medical care. The patient brought suit against all the physicians, the surgicenter, and the nurse anesthetist. After settling with two physicians, a jury awarded an apportioned verdict of $5.6 million.

Background: The 28-year-old patient underwent elective breast augmentation surgery at an outpatient surgical center. Surgery was performed by a plastic surgeon and anesthesia was administered by a certified registered nurse anesthetist (CRNA). Lidocaine, in addition to the general anesthesia, was administered during the procedure. The surgery was uneventful, and the plaintiff was moved to the recovery room.

After a few minutes in the recovery room, a nurse observed the patient twitch and realized the patient was no longer responsive. The recovery room nurse called the surgeon and nurse anesthetist into the room. A blood level for lidocaine was drawn; however, the medical records did not reflect any findings. The surgeon asked a cardiologist, whose office was in the same complex as the surgicenter, to see the patient on an emergency basis. The cardiologist’s recommendation was later disputed, but the cardiologist claimed he told the surgeon to intubate the patient and immediately transfer her to the hospital.

The surgeon countered that the cardiologist told him the patient had a neurological problem but was otherwise stable, and called a neurologist.

The neurologist arrived at the outpatient facility 30 minutes later. As he entered the recovery room, the patient had a grand mal seizure and went into cardiac arrest. Paramedics were called and, after 10 minutes of applying multiple medications and electric countershocks to her heart, the patient was resuscitated. The patient was taken to a nearby community hospital, where she was diagnosed with hypoxic encephalopathy.

The plaintiff spent 2½ months in the hospital. She then was transferred to a skilled nursing facility. Her medical condition deteriorated — she suffered pneumonia, decubitus skin ulcers, and pyelonephritis. Eventually, she was moved to a private, specialized neurocare facility. Her condition stabilized and improved somewhat, but she remains at a Rancho Level III (minimally responsive) condition.

The a plaintiff claimed the CRNA failed to recognize and treat her lidocaine-induced seizures, and that she experienced intermittent seizures for more than an hour before she went into cardiac arrest. The plaintiff also added that the attending nurses failed to recognize her increasing heart rate and respiration. Further, she averred that the surgicenter staff and physicians failed to appropriately intervene on her behalf and delayed in calling 911 to transfer her to the hospital.

The plastic surgeon settled prior to trial for a confidential amount. The cardiologist settled during trial for his policy limits, which also were confidential. The jury was told of the separate settlements, but not the amounts. The jury, awarding $5.6 million, found the plastic surgeon 40% negligent, the CRNA 35% negligent, the surgicenter 20% negligent, and cardiologist 5% negligent.

What this means to you: The facility staff seems to have been at complete odds on how to deal with an emergency situation.

"This is the type of situation in which the risk manager should become involved immediately. A patient who begins to twitch and then loses consciousness within minutes of her arrival in the post-anesthesia recovery unit [PACU] following an elective, cosmetic procedure should not have been allowed to languish while specialists were called. The gravity of the circumstances and outcome command review and investigation by risk management," states Cheryl A. Whiteman, RN, MSN, CPHRM, a risk manager for Cigna Healthcare of Florida Inc. Her opinion does not necessarily reflect Cigna’s.

"The first step in the risk-management investigation would be an evaluation of the pre-operative and postoperative documentation. Was the patient questioned about allergies, and was her response documented? Assuming that she did not have any known allergies to lidocaine or related drugs, the amount of local lidocaine administered by the surgeon should then be evaluated. As part of the routine in the operating room, the amount of a drug administered locally should be documented. The risk manager should also attempt to retrieve the vials that were used during the case. Having the actual vial[s] would confirm that the correct medication and dosage was administered. This would be a critical part of the investigation as lidocaine-induced seizures can be caused by sensitivity to the drug or by injecting more than the manufacturer’s recommended dosages. Patient safety dictates that limiting the amounts and concentrations of a drug available to the practitioner can prevent overdoses. Appropriately, postoperative orders were given to test her blood level for lidocaine. These results would have been helpful in determining whether or not she had a experienced an overdose or sensitivity. However, there is no documentation as to the findings, which raises additional issues regarding the facility’s documentation processes and/or cover-up measures. Either way, the indications are not positive," notes Whiteman.

"Second, the risk manager would evaluate whether there were any findings that would have alerted the nurse anesthetist to early seizure activity. A careful review of the vital sign flow sheet for unfavorable trends, regardless of how subtle, should be conducted to determine if there were any indications that should have alerted the CRNA to cardiac and/or neurological compromise," she adds.

"The record as to patient’s clinical course over the next 30 minutes is unclear. Documentation should again be reviewed and involved staff members should be interviewed as soon as possible. The report indicates that a nurse observed the patient twitch and subsequently realized the patient was no longer responsive. While the surgeon was called back to the PACU and both cardiology and neurology consults were requested, no medical treatment during the next 30 minutes was reported. The patient’s condition and corresponding interventions must be scrutinized. Apparently, the neurologist arrived 30 minutes after the patient initially lost consciousness, but unfortunately his arrival coincided with the patient’s grand mal seizure and cardiac arrest," states Whiteman.

"It appears that emergency rescue was summoned when the patient arrested. The activities during the 10-minute interval before their arrival also requires careful investigation. Did the surgicenter have a well-supplied crash cart’? Did the staff initiate cardiopulmonary resuscitation? Did the surgicenter have a team capable of providing advanced cardiac life support? The standard of care dictates that these emergency measures be available in a center that administers general anesthesia," she adds.

"Finally, if the risk manager was not immediately involved in the situation, then a retrospective review should be initiated. This situation would lend itself well to a root-cause analysis. Likewise, any facility in which surgery is performed could utilize this case to conduct a failure modes effects analysis exercise in order to identify potential problems within its organization. Regardless of the methodology used for appraisal, every aspect of the situation should be carefully reviewed. Appropriate actions to prevent recurrence need to be undertaken urgently," concludes Whiteman.

Reference

Monique Thompson and Brett Thompson v. Richard Bruck, MD, Keith Mathahs, CRNA and Upland Outpatient Surgical Center, San Bernardino County (CA) Superior Court, Case No. RCV 34534.