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
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.
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