Hypoxic Brain Injury During Sedation
A Case Analysis of MAC Monitoring Failure in a High Risk Patient
Case Law Index · MAC Failure · Airway Management
TL;DR
58 y/o patient with extensive comorbidities undergoes routine procedure under Monitored Anesthesia Care. Shortly after the procedure was initiated, the patient went into cardiac arrest secondary to respiratory depression. The anesthesiologist was criticized for poor airway management and delayed intervention. Citing breaches in the standard of care, and the poor management of a high risk patient, the jury made a verdict exceeding $13 million.
Context
The Patient
58 y/o female, 153kg, morbid obesity, diabetes, end stage renal disease, obstructive sleep apnea, stroke history, hypertension, GERD.
ASA status of 4 attributed due to recent cerebrovascular accident, diabetes, hypertension, and being a dialyzed patient.
Pre-induction assessment: BP 163/72 · HR 63 · SpO₂ 100%
The Procedure
Scheduled esophagogastroduodenoscopy (EGD), pre-op workup for lap band surgery.
Anesthesia Plan
Monitored Anesthesia Care using propofol. The anesthesia team consisted of a supervising anesthesiologist and an anesthesiology assistant (CAA).
Intubation was likely avoided due to EGD typically being a brief diagnostic procedure. In addition, intubating a patient requires an endotracheal tube to occupy the same anatomical pathway as the endoscope.
Timeline
November 15, 2017
17:00
MAC initiated with 150mg propofol (≈1mg/kg). Fentanyl and lidocaine administered. Attending anesthesiologist leaves the room; PA-A is the sole anesthetist for the patient.
17:07
Apnea occurs. Oxygen waveform dampens, respirations no longer audible. BP stable. Laryngeal mask airway placed. Attending anesthesiologist paged; endotracheal intubation subsequently performed.
17:18
Cardiac arrest occurs. Code blue initiated. Atropine and epinephrine administered. Circulation restored.
17:40
Patient transferred to ICU, remains unresponsive. Mechanically ventilated. Fixed pupils with rigid extremities. Dx: acute respiratory failure post cardiac arrest, anoxic brain injury.
December 31, 2017
Patient never had improvement in mentation and had continued chronic hypercapnic respiratory failure following cardiac arrest. Patient deceased.
Mechanism of Injury
Pharmacodynamics
Propofol and fentanyl were both administered. These are both routine anesthesia medications given, however, both of these medications suppress the brain’s natural urge to breathe in response to rising CO2 levels.
- Propofol: a potent intravenous hypnotic agent used to induce and maintain anesthesia. It causes a dose-dependent decrease in respiratory rate and tidal volume.
- Fentanyl: a powerful synthetic opioid. When used alongside propofol, it acts synergistically, meaning the two drugs together produce a much stronger respiratory depressant effect than either would alone.
Pathophysiology
Due to the patient’s high weight (337 lbs.) and morbid obesity, the soft tissues of the neck and oropharynx were prone to collapsing under deep sedation. This is likely why following drug administration the patient became apneic. Since the patient’s airway was not secured in any fashion, O2 saturation fell rapidly, starving vital organs of oxygen needed for respiration. This is what prompted the cardiac arrest. Due to the extended period of anoxia, the patient suffered brain injury; the brain is the most oxygen-sensitive organ in the body — within minutes of oxygen deprivation, neurons begin to die.
The Law
The Breach
Plaintiff alleged that the anesthesia providers fell below the standard of care in the following ways:
- Failing to properly manage the airway of a high-risk patient (ASA status 4) during MAC.
- Inadequate supervision by the anesthesiologist who was not present during the critical administration of sedation.
- Failing to recognize and intervene in respiratory distress in a timely manner to prevent cardiac arrest.
The Outcome
On January 17, 2025, a jury found in favor of the Plaintiff, awarding damages across two claims:
- Wrongful Death (Surviving Spouse): $10,500,000 total ($1,837,500 against the doctor/practice and $8,662,500 against the PA-A/practice).
- Estate Claim (Pain and Suffering/Medical Bills): $3,274,875 total ($573,000 against the doctor/practice and $2,701,875 against the PA-A/practice).
- Total Judgment: $13,774,875, plus court costs and interest at a legal rate of 10.50%.
Reflection
This case highlights the extreme risks associated with non-invasive sedation in patients with complex comorbidities like morbid obesity and sleep apnea. The transition from MAC to deep anesthesia can occur rapidly and imperceptibly. The primary takeaway for practitioners is the necessity of vigilant, continuous monitoring and the immediate availability of advanced airway intervention when managing high-risk patients.
References