Upper endoscopy preoxygenation, anesthesia and medical malpractice

I handled a case several years ago involving the drowning death of an athletic young man who was training to hold his breath under water so he could join an elite military unit. His family told me that over the course of the summer he went to his neighborhood pool and shooed away lifeguards who checked on him as he held his breath for increasingly long amounts of time.

I don’t even know if it’s humanly possible, but his brother said that the man could hold his breath for close to four minutes.

Then the day came when he held his breath just a little too long. He passed out and drowned. Two lifeguards were on duty and the young man was only one of two swimmers in the pool. It’s hard to know how long he had been unconscious by the time the lifeguards checked on him. They got him out of the pool and started cardiopulmonary resuscitation (CPR). Somehow an ambulance crew restored his heartbeat and respiration, but he never woke up again.

Eventually, the hospital convened an ethics committee meeting to consider whether further care was medically futile. I got involved on behalf of the family to make sure things were on the up and up. After investigating what happened, and the long time the man was under water, I thought that he had essentially no functional reserve or supply of oxygen at the time he passed out.

Most medical experts say that an average person can go without oxygen (hypoxia or anoxia) for around five minutes before there’s a permanent brain injury. The person who drowned in the pool wasn’t an average person, though, because he had used up all of his oxygen reserves as he held his breath for so long under water.

This same basic analysis comes up frequently in operating room medical malpractice cases.

That’s why a letter to the editor of Anesthesiology News dated July 5, 2021, entitled “A Further Comment on Catastrophic Sedation Errors: The Role of Hypoxia” caught my attention.

The risk of hypoxia during an upper endoscopy

The letter discussed the problem of hypoxia (lack of adequate oxygenation) during upper endoscopies. An upper endoscopy is a procedure where a patient is placed under anesthesia and then the physician uses a flexible endoscope (surgical instrument with a camera) to examine the upper gastrointestinal (GI) tract—the esophagus, stomach, and duodenum.

Upper endoscopies are considered quick, routine procedures. In my experience, they’re entirely routine procedures—right up until the moment they’re not. That’s what happened in a medical malpractice wrongful death case that I handled involving a healthy woman in her 40s who died on the operating room table from hypoxia during an upper endoscopy.

A certified registered nurse anesthetist (CRNA) was handling the anesthesia, instead of an anesthesiologist physician. The CRNA didn’t know how to handle the situation and the patient died. The CRNA issue is a whole other story, though.

Back to the interesting letter to the editor. There’s a new specialized face mask—that is, specialized for upper endoscopies—that will deliver maximal oxygen to patients during this common procedure.

Here’s a summary of the different modes of supplemental oxygen delivery:

Full-face oxygen masks have solid domes that prevent insertion of the endoscope, so they aren’t used during these procedures.

Nasal cannulas (tubing that delivers supplemental oxygen into each nostril) provide a lower fraction of inspired oxygen (FiO2) than a full-face oxygen mask. That’s mainly because nasal cannula oxygen delivery isn’t secure and is diluted by room air. Despite the sub-optimal oxygen delivery, nasal cannulas have been the method of choice for supplemental oxygenation during an upper endoscopy.

• There’s now a new FDA-approved specialized endoscopy oxygen mask. They’re disposable and have self-sealing for the mouth and nasal ports to prevent dilution by room air. Additionally, they have a build-in port for capnography, to measure carbon dioxide levels and ventilation.

Hopefully, the news of this new oxygen delivery device will spread quickly and become the standard of care for upper endoscopies.

The larger role of maximal preoxygenation of surgery patients

In addition to the medical device news shared in the letter to the editor, the author shared an important reminder that, “The principle of maximally preoxygenating the patient to significantly prolong the safe apneic time until the onset of critical hypoxemia is well established in the anesthesia literature and in clinical practice in the operating room.”

In Dr. Jonathan Benumof’s classic study published in 1999 in the peer-reviewed journal Anesthesia (1999;91[3]:603-605), there’s a discussion of the compelling reasons for preoxygenating all patients:

• Provide the maximum time for patients to tolerate apnea (sudden cessation of respiration/breathing).

• Provide the maximum time for the anesthesiologist or CRNA to solve an emergency situation of a difficult airway/intubation and lack of oxygenation.

Given that these medical emergencies are unpredictable, the study concluded that it was desirable to maximally preoxygenate all patients. That means that the anesthesiologist or provider must decide to administer supplemental oxygen and also give attention to using the optimal oxygen delivery device.

Failing to deliver proper supplemental oxygenation during anesthesia and surgery is medical negligence. It can mean the difference between a brain injury or death and recovery if a patient crashes or desaturates in the operating room.

If you or someone you care for has been seriously injured in Texas because of poor upper endoscopy, anesthesia, or surgery care, then contact a top-rated experienced Texas medical malpractice lawyer for a free consultation about your potential case.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.