An 8-year-old girl with a history of a congenital bicuspid aortic valve and aortic stenosis was in need of restorative dental work for dental decay/cavities. Before scheduling the dental procedure, the patient was sent to her pediatric cardiologist for clearance. In February 2013, the pediatric cardiologist stated the patient was “not cleared to have IV sedation in the dental office” and instead needed to be in a children’s hospital where she could undergo IV sedation.
Later that month, the patient’s mother received information from one of the patient’s other pediatric cardiologists suggesting it was appropriate to undergo the dental procedure in the dentist’s office. In March 2013, the pediatric cardiologist stated that if the patient needed sedation, then it should be done by an anesthesiologist comfortable with patients who have cardiac disease. Two months later, the patient’s pediatric cardiologist provided a note that stated the patient required an anesthesiologist familiar with congenital heart defects in order for sedation to be given safely. There was no apparent limitation on where the procedure could be performed.
In June 2013, the patient was taken to the dentist’s office to undergo the dental procedure. A board-certified pediatric anesthesiologist was in charge of providing the sedation. The anesthesiologist presented to the dentist’s office with a fully equipped anesthetic cart, comparable to what would be available if she were to perform the procedure in a hospital setting.
The patient was sedated using a laryngeal mask airway (LMA). During the procedure, the patient’s airway became unstable and her oxygen saturations decreased. The anesthesiologist ordered the dentist to stop the procedure. The LMA was removed and the anesthesiologist began to ventilate the patient with a bag and mask. The patient’s condition continued to deteriorate. The anesthesiologist administered 1 mg of epinephrine by IV. The patient was then intubated and given atropine and another 1 mg of epinephrine. Chest compressions were started and EMS was called. When EMS arrived, they transferred the patient, along with the anesthesiologist, to the nearest hospital where the patient was pronounced dead.
The patient’s family filed a lawsuit against the anesthesiologist and the dentist alleging that the procedure should not have been performed in the dentist’s office due to the patient’s cardiac condition. The lawsuit against the anesthesiologist further alleged that she did not properly manage the code resulting in the patient’s death.
The plaintiffs provided a report from a well-qualified anesthesiology expert who was critical of the anesthesiologist’s decisions in the care of this patient. Specifically, the expert criticized the anesthesiologist for not performing this procedure in a hospital setting, where there is increased access to emergency equipment and personnel. The expert also expressed that the anesthesiologist administered four times the amount of epinephrine as required for a patient of this size. The expert also felt there was a delay in calling for paramedics.
Defense consultants were also concerned that this procedure was performed in the dentist’s office. However, they pointed out the outcome could have been the same even if the procedure took place in the hospital due to the patient’s congenital cardiac condition. One of the biggest challenges for the defense was the fact the dentist’s office actually had a camera present in the room recording the events as they took place. This made it more difficult to explain what took place during the code.
The defense was unable to obtain a supportive expert. Due to the lack of expert support and the possibility of a sympathetic jury verdict, this case was settled before trial with the consent of the anesthesiologist. The dentist also settled.
Risk management considerations
The American Society of Anesthesiologists (ASA) has written guidelines for office-based anesthesia. The recommendations focus on quality of anesthesia care and patient safety in the office. There is also a section on pediatrics. The clinical care subsection within these guidelines reads:
- “The anesthesiologist should be satisfied that the procedure to be undertaken is within the scope of practice of the health care practitioners and the capabilities of the facility.
- The procedure should be of a duration and degree of complexity that will permit the patient to recover and be discharged from the facility.
- Patients who by reason of pre-existing medical or other conditions may be at undue risk for complications should be referred to an appropriate facility for performance of the procedure and the administration of anesthesia.” (1)
The information within the third bullet raised concerns throughout the case about the defensibility of this anesthesiologist. Was it reasonable for this child to undergo a procedure in the office setting instead of a hospital setting? A change in the location may not have changed the outcome, but this question may have persuaded a sympathetic jury to side with the plaintiff.
It is important for health care providers to be prepared for medical emergencies that may arise with their patients. Preparation involves proper and up-to-date emergency training, and knowledge of medications, dosages, and equipment. If caring for adults and children, preparation should include knowing the differences in the emergency care for both patient populations.
1. Guidelines for Office-Based Anesthesia. American Society of Anesthesiologists. Standards & Guidelines. Ambulatory Office-based Nonoperating Room Locations. Available at: http://www.asahq.org/quality