AHRQ WebM&M: Case & Commentary

Surgery/Anesthesia | June 2010
Tacit Handover, Overt Mishap

The Case

A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdominal aortic aneurysm. In preparation for surgical removal of the infected stent and graft repair of the abdominal aorta, a spinal drain was placed by an anesthesiologist. The spinal drain, a small soft catheter, was inserted into the lower spinal cord to remove cerebrospinal fluid—these drains lower pressure in the spinal cord and thereby reduce the risk for post-surgery paralysis.

The patient underwent uncomplicated removal of the infected stent and graft repair of the aorta. Per protocol, the spinal drain remained in place for 48 hours after the procedure. At that time, the anesthesiologist attempted to remove the drain, but aggressive pulling resulted only in stretching of the catheter. Concerned about causing injury to the patient, he consulted a neurosurgeon who recommended that further attempts to remove the catheter be done under general anesthesia in the operating room (OR) in hopes that anesthesia would relax the back muscles. The patient was placed on the OR schedule for the following day. The anesthesiologist and neurosurgeon both clearly documented the plan of care in the chart.

The following morning, the five anesthesiologists on duty met to discuss all of the cases scheduled for the day, including the catheter removal, so all of them were aware of the plan. Unfortunately, because of prolonged surgeries, the case was pushed to the end of the day. By that point, the anesthesiologist on call for the night had arrived, unaware of any of the treatment plans. She noticed that this case was labeled "Spinal Drain Removal" on the schedule. Confident that she knew how to manage these devices, she approached the head anesthesiologist for the day and asked if she could "take care of the spinal drain case." The head anesthesiologist knew that she had experience in the area and simply said "yes" without conveying any further information. The on-call anesthesiologist did not review the patient's chart or obtain any further information.

Unaware of the plan for general anesthesia, the on-call anesthesiologist proceeded to try to pull out the drain while the patient was awake in the preoperative area. Unfortunately, the catheter broke, leaving a portion inside the spinal canal. Consequently, the neurosurgeon had no choice but to surgically remove the catheter. Luckily, the patient suffered no major consequences, but was at risk for spinal cord injury and had to undergo a second surgical procedure.

open here please:
AHRQ WebM&M: Case & Commentary