Haste Makes Care UnsafeCommentary by John H. Eichhorn, MD
An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined elective coronary artery bypass graft (CABG) and Maze procedure (ablation of atrial fibrillation). A pulmonary artery (PA) catheter was placed after induction of anesthesia in order to closely monitor the patient's hemodynamic status. The surgery was proceeding uneventfully when the surgeon requested that the PA catheter be pulled back from the pulmonary artery into the right ventricle when he performed the actual ablation. At that point, the surgeon was informed that another patient in the cardiac intensive care unit (ICU) would require an emergency CABG. The surgeon was the only cardiac surgeon available that day, and there was also only one cardiac anesthesia team. The surgeon and attending anesthesiologist decided to begin the emergency CABG as soon as possible after completing the current procedure.
The remainder of the CABG was completed without incident, and the patient was weaned off cardiopulmonary bypass (CPB) easily, but this process took nearly another hour. By this point, the second patient was already being brought to another operating room (OR), and the team had received several pages about his clinical status. The surgeon was anxious to start the second case as soon as possible, so in order to speed up the transfer process, the attending anesthesiologist refloated the PA catheter himself back into the pulmonary artery, which required re-inflating the catheter's balloon. As soon as this was completed, the anesthesiologist rushed to the other OR in order to begin the emergency CABG. An anesthesia resident accompanied the first patient to the ICU.
In the ICU, the nurse who assumed care of the patient noticed that the PA catheter waveform was dampened (the tracing was flat and did not vary with the cardiac cycle). Further check by him and the anesthesia resident revealed that the PA catheter balloon was still inflated, and probably had been so the entire time after refloating. This was potentially very dangerous, as leaving the balloon inflated could have caused catastrophic damage to the pulmonary artery. Fortunately, the nurse recognized the situation quickly, and the resident deflated the balloon and withdrew the PA catheter without the patient experiencing any harm. The anesthesia resident realized that she had not discussed the PA catheter explicitly (including its inflation status) with the attending prior to transferring the patient out of the OR.