Failure to discuss interruption of anticoagulation
Presentation
A 72-year-old man came to a general surgeon with a one-week history of pain in the right groin with a reducible mass. A physical exam confirmed a reducible right inguinal hernia. The patient’s medical history included a CVA four years earlier.
During the earlier evaluation for CVA, an arteriogram revealed “1) the right vertebral artery was occluded; 2) the left vertebral artery was relatively normal; 3) the left internal carotid artery had a 40 to 50% stenosis in the neck portion, but an 80% stenosis in the cavernous portion; 4) the right internal carotid artery had a very long, irregular stenosis in the neck . . . he also had a 95% distal internal carotid artery stenosis, again in the cavernous portion.”
Due to the severity of the disease, the patient had been placed on long-term anticoagulation therapy with warfarin. The patient continued to smoke one pack of cigarettes daily.
Physician action
The surgeon recommended surgical repair of the hernia. The patient was in considerable pain, and the surgeon felt he was at risk for incarceration, bowel obstruction, and strangulation. Further, if such a complication developed, the patient would require emergent surgery, which would occur while the patient was anticoagulated.
The risks and benefits of the elective surgery were explained, and the patient consented to the procedure. The surgeon also told the patient that he could not operate while the patient was taking warfarin. The surgeon instructed the patient to discontinue warfarin five to seven days before the hernia surgery. The patient complied and stopped taking warfarin for seven days.
The patient underwent a repair of his right inguinal hernia with mesh. The surgery went well; but, in the recovery room the patient was slow to awaken, was unable to speak, and had right-sided weakness. Neurology consultation concluded that the patient had suffered either an intraoperative or postoperative thrombotic ischemic infarct of his brain. The patient was given heparin, but developed a severe right-sided stroke with flaccid hemiparesis and global aphasia.
The patient was transferred to a skilled nursing facility and later to a nursing home where he died from sepsis five months later.
Allegations
A lawsuit was filed against the surgeon, alleging that he fell below the standard of care by failing to discuss the surgery and the interruption of anticoagulation with the patient’s neurologist, and by failing to initiate alternative anticoagulation therapy. It was further alleged that the interruption in anticoagulation was a significant contributing cause of the patient’s stroke.
Legal implications
The plaintiffs were able to locate experts supportive of their allegations regarding standard of care and causation. They claimed that alternative coagulation therapy could have been arranged that would have reduced the chances of intraoperative stroke. One expert stated that the “safest” alternative would have been to perform the surgery while the patient was in a “heparin window.” For this, the patient is hospitalized for intravenous Heparin infusion several days between discontinuing warfarin and the scheduled surgery. The expert also maintained the stroke occurred because the patient was not anticoagulated.
Defense experts were supportive of the surgeon’s action regarding the interruption of anticoagulation. This expert stated the “heparin window” was not the standard of care for patients on long-term anticoagulation. It is only recommended in extreme cases, specifically in patients who have suffered a recent acute venous thromboembolism in the three months before surgery.
Additionally, the expert stated there was no medical literature to support the fact that the warfarin was preventing the patient from having a stroke and discontinuing it was the cause of the stroke.
Defense experts pointed out that even if alternative anticoagulation had been arranged, the patient would still have been at high risk for developing a stroke. One expert described the patient as a “stroke waiting to happen” due to the severity of his disease and the fact that he continued to smoke.
One area of weakness in this case was that the surgeon did not contact the patient’s neurologist before surgery. The surgeon testified he did not contact the neurologist about discontinuing warfarin because he felt the surgery was necessary, and he would not operate as long as the patient was anticoagulated. Therefore, he did not feel the need to discuss options with the neurologist. While the experts stated this was not negligence, they did state that it would have been better if he had contacted the neurologist.
Disposition
This case was settled with the consent of the surgeon.
Risk management considerations
With a patient history indicating increased risk of intra- or postoperative complications, it is prudent to exercise extra caution. This could be done by soliciting input from the patient’s treating physicians for preoperative clearance and management decisions. Further discussion may allow the physicians involved to make a decision with the lowest risk for the patient. Such coordination of care may have a more positive effect on patient outcomes.
In this case, the patient was at risk either with or without the surgery or with or without the anticoagulation. Better documentation of discussions with the patient might have improved the physician’s defense.