The Verdict Is In

If your Bartholin's case ends up in the ICU... there's a chance you might be named in a lawsuit

2:44 am: 25 y/o presents requesting pain control for her Bartholin's cyst. Onset of symptoms was 1.5 days. Med hx (per prior records) was obesity, kidney stones, migraines and cholecystectomy. She had been seen in the ED 6 hours prior by the same physician and given 100mcg fentanyl and ceftriaxone, as well as an rx for Percocet and abx. A word catheter was not available on the first visit so the ED physician deferred the I&D until she could f/u with her GYN in 1-2 days. Her pharmacy was closed so she returned requesting medicine to control her pain through the night. She rated her pain 10/10. V/S: O2 sat 99% on RA, BP 117/77, P 123, T 98.1. BMI 63.7 (163kg. 160 cm). Dilaudid 2mg IV was ordered. Prior records indicated she had received Dilaudid in the past and tolerated well.

3:05 am: Dilaudid given.

3:23 am: The nurse reassessed her and vitals were similar. O2 sat 99% on RA, HR 115, BP 141/77. The pt was sleepy but arousable, and stated her pain was now 2/10. The sleepiness did not cause concern as it was 3:23 am and the pt had been exhausted.

3:35 am: RN called a code.

The physician went to the room noting she was hypoxic in the 70s and had a weak pulse. He repositioned her airway and gave Narcan. She lost her pulse at 3:50 am and chest compressions were initiated. Repeat Narcan was given. She was intubated and given 1 round of epi. She had a return of spontaneous pulse at 3:54 am and her O2 sat rose quickly to 100% via ETT with high flow O2. After she stabilized she was transferred to the ICU.
Clinical Impressions: Respiratory failure, hypoxia, Cardiopulmonary arrest, Bartholin cyst, Obstructive sleep apnea.

Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest.

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Survey Questions

1. Due to complications in the ICU of aspiration pneumonia, a-fib, acute heart and kidney failure, she was intubated for several weeks. She developed a DVT. The plaintiff improved but alleges she suffers from memory loss, cognitive deficits and foot drop all as a result of:

  1. Dilaudid 2mg IV overdose
  2. Sepsis from delayed definitive treatment of the Bartholin's

2. Defense experts were mixed on their ability to support the Dilaudid 2mg IV order. One felt due to the pt’s intractable pain plus her weight this was an appropriate dose. The other defense expert was critical due to a black box warning created in 2017 for Dilaudid and potential for life-threatening respiratory depression. Are you familiar with the dosage and administration instructions for Dilaudid?
https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/019034s021lbl.pdf Which statements below are true?

  1. Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals
  2. Initial Dosage: Intramuscular or Subcutaneous Use: Usual starting dose is 1 mg to 2 mg every 2 to 3 hours as necessary. Depending on the clinical situation, the initial starting dose may be lowered in patients who are opioid naïve
  3. Initial Dosage: Intravenous Use: Usual starting dose is 0.2 mg up to 1 mg every 2 to 3 hours
  4. In renal impairment: Initiate treatment with one-fourth to one-half the usual starting dose, depending on degree of renal impairment.
  5. Life-Threatening Respiratory Depression has occurred in patients with Chronic Pulmonary Disease or in Elderly, Cachectic, or Debilitated Patients. Monitor closely, particularly during initiation and titration
  6. All the above

3. Obstructive Sleep Apnea (OSA) may increase the risk of Opioid-induced respiratory depression (OIRD) and may result in legal claims.

  1. True
  2. False

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