Risk alert and closed claim study — Wernicke's Encephalopathy after bariatric surgery

The TMLT claims and risk management departments have seen an alarming increase in the number of claims filed related to Wernicke’s encephalopathy (WE) following bariatric surgery.

These claims involve allegations of failure to monitor thiamine levels in post-bariatric surgery patients and failure to treat symptoms of nausea, vomiting, visual disturbances, and motor impairments with thiamine supplementation. Specialties included in these claims are general surgery, emergency medicine, internal medicine, and gastroenterology.

A high index of clinical suspicion is required when treating patients with a history of bariatric surgery presenting with symptoms suggestive of WE. Surgeons, emergency physicians, internists, gastroenterologists, and all health care professionals should be aware of the risk factors and symptoms associated with nutritional deficiencies to minimize any adverse effects. Early recognition of symptoms is important for ALL providers caring for this patient population.

Physicians who round on patients could be subjected to litigation if they do not order labs checking thiamine levels when a patient who has recently undergone bariatric or gastric surgery exhibits symptoms detailed in this risk alert.

CLOSED CLAIM STUDY: FAILURE TO DIAGNOSE THIAMINE DEFICIENCY

Presentation
A 22-year-old woman came to a bariatric surgery center for treatment of her morbid obesity. She underwent extensive diagnostic testing and education before being scheduled for a sleeve gastrectomy. A general surgeon performed the procedure on June 25.

Physician action
The patient’s postoperative course was complicated by persistent dysphagia and gagging when eating (as opposed to vomiting). On August 6, the general surgeon ordered multiple studies that ruled out a structural cause for the patient’s symptoms. Nutrition/vitamin levels were not checked.

The patient claimed that on August 20, her mother called the bariatric surgery center and reported that the patient was unable to drink protein drinks or take her multivitamins. The mother asked the nurse if the patient could switch to a gummy vitamin that would be easier to swallow. Purportedly, the nurse said that a gummy multivitamin would be fine.

No one spoke to the general surgeon about this change or about the patient’s inability to keep protein shakes down. The general surgeon later testified that she would not have recommended the change to a gummy vitamin.

The patient’s mother called the surgery center on August 23 to report that the patient had continued nausea, vomiting, diarrhea, and was now experiencing double vision. The nurse from the surgery center advised that she had spoken to the general surgeon who said the symptoms should go away within three months of the surgery.

On August 25, the patient came to the emergency department of a local hospital with symptoms of blurred and double vision. She was discharged and told to follow up with the general surgeon. The patient’s mother called the surgery center on August 26 to report that her daughter was seeing double. The general surgeon prescribed Pedialyte popsicles, Gatorade, and protein shake supplements. She also scheduled another EGD for August 27. This study did not reveal any cause for the nausea and vomiting.

Over the next week, the patient and her mother repeatedly called the surgery center to report nausea, vomiting, and blurry/double vision. The general surgeon prescribed metoclopramide and promethazine.

On September 6, the patient reported weakness, difficulty walking, and blurry/double vision. The general surgeon ordered additional labs and all results were reported as normal. Nutritional studies were not ordered.

The patient went to the ED on September 8 and was seen by a neurologist. He diagnosed Wernicke’s encephalopathy, and the patient was treated for thiamine deficiency. She recovered, but her visual disturbance is permanent and she has been determined to be legally blind. She also walks with an ataxic gait.

Allegations
Lawsuits were filed against the general surgeon and the bariatric surgery center. The allegations included:

failure to recognize thiamine deficiency (general surgeon);
failure to treat the patient’s nausea, vomiting, visual disturbances, and motor impairments with thiamine supplementation (general surgeon);
failure to test the patient’s thiamine levels (bariatric surgery center); and
failure to tell the patient that her multivitamins must contain thiamine (bariatric surgery center).

Legal implications
The plaintiff’s expert — a board certified general/bariatric surgeon — testified that the standard of care required the defendant general surgeon to monitor the patient postoperatively for nausea, vomiting, and symptoms of dehydration or vitamin deficiency. Further, the tests ordered by the general surgeon did not address the patient’s nausea.

To support their allegations against the bariatric surgery center, the plaintiffs pointed to the center’s Patient Education Manual that stated, “ . . . the patient’s nutritional status after surgery is vitally important because vitamin deficiency can cause illness, weakness, and death . . . the Bariatric Center will monitor the post-operative nutritional status of the patient and draw lab work to monitor the patient’s lab values.” None of these labs were drawn.

Among the defense experts, there were mixed opinions about whether the general surgeon should have checked the patient’s vitamin levels in light of her progressively worsening symptoms. The general surgeon stated that nutritional testing should be performed three months after the surgery. For the first eight to 12 weeks, the patient is healing and should be taking protein shakes and vitamins. The general surgeon was not advised that the patient had changed her postoperative vitamins from a “complete” multivitamin to a gummy vitamin.

During the investigation of this claim, it was discovered that the patient had a minor surgical procedure (IUD removal) on August 21. During this procedure, the patient received an IV of 5% dextrose, which is contraindicated in patients who may have vitamin deficiencies because 5% dextrose can quickly deplete thiamine levels. This surgical procedure took place two days before the patient’s first documented report of a visual disturbance. The patient never reported the procedure to the general surgeon.

Both the patient’s treating neurologist and the plaintiff’s expert stated that giving 5% dextrose to a patient with low thiamine or borderline normal thiamine could push a patient into thiamine deficiency and Wernicke’s encephalopathy.

Disposition
This case was settled on behalf of the general surgeon and the bariatric surgical center.

The aforementioned liability issues, coupled with the permanent nature of the patient’s injury, led to the decision to settle this case.

Risk management considerations
According to the American Society for Metabolic and Bariatric Surgery, an estimated 196,000 bariatric procedures were performed in 2015. (1) These procedures have the potential for providing great benefit to patients, but they also come with risks.

Nutritional deficiencies are well known complications following weight loss surgery. “Wernicke-Korsakoff Syndrome is the best known complication of thiamine (vitamin B1) deficiency. The term refers to two different syndromes, each representing a different stage of the disease. Wernicke encephalopathy (WE) is an acute syndrome requiring emergent treatment to prevent death and neurologic morbidity. Korsakoff syndrome (KS) refers to a chronic neurologic condition that usually occurs as a consequence of WE.” (2)

“Wernicke-Korsakoff Syndrome (WKS) classically, but not always, presents with the clinical triad of confusion, ataxia, and nystagmus. Eighty-five percent of the survivors of the acute phase of Wernicke encephalopathy who remain untreated go on to develop Wernicke-Korsakoff Syndrome.” (3)

In the case presented, there were several instances where a breakdown in communication and patient care occurred.

The bariatric surgery center nurse did not consult with the general surgeon regarding the patient’s symptoms and the request for a medication adjustment. Had this step been taken, the physician could have had an opportunity to agree with the patient’s request or implement a different treatment plan.
The surgery center did not follow the guidelines for monitoring patients’ post-operative nutritional status, as stated in their Patient Education Manual.
Not ordering nutritional studies when the patient reported neurological symptoms was another missed opportunity.
The physician performing the removal of the IUD administered 5% dextrose intravenously in a patient with a history of bariatric surgery, which is contraindicated.
The patient did not tell the general surgeon about the IUD removal procedure.
A high index of clinical suspicion is required when treating patients with a history of bariatric surgery presenting to any health care provider with symptoms suggestive of WE.
While not an issue in this case, there have been cases in which the physician defendants contend that it was someone else’s responsibility to check the patient’s vitamin levels. Ultimately, there was a delay in getting the needed lab work and this led to catastrophic patient outcomes. Some of these physicians stated that they felt the patient seemed to be eating well, so checking nutrition was not necessary.
Cases have also been documented in which the appropriate lab work was ordered, but not completed. Developing and consistently following procedures for monitoring and acting on test results may prevent these results — or lack of results — from being overlooked.

Sources

American Society of Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers, 2011-2015. Available at http://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Accessed December 1, 2016.
UpToDate. Wernicke encephalopathy. Available at http://www.uptodate.com/contents/wernicke-encephalopathy. Accessed December 1, 2016.
Medscape. Wernicke-Korsakoff Syndrome. Available at http://emedicine.medscape.com/article/288379-overview. Accessed December 1, 2016.