Over the years, I have seen an increasing number of medical malpractice claims arising from the alleged failure to identify obstructive sleep apnea (OSA) when clearing a patient for anesthesia, surgery, and even opiate based pain management, whether it be perioperative pain management or other acute pain management. Unquestionably, any patient undergoing general anesthesia for surgery is at significantly increased risk with OSA than otherwise. As a result, they are placed in higher risk categories. But what about the non-surgical patient admitted for acute pain management?
While any relationship between alleged opioid induced respiratory depression (OIRD) and OSA has not been conclusively confirmed, there is evidence to indicate that patients with OSA may be at higher risk of OIRD, and therefore, a physician considering prescribing opioids to such patients should proceed cautiously.
In a recent Lippincott summary Opioids for Acute Pain Management in Patients with Obstructive Sleep Apnea: A Systematic Review, it is suggested that “the intrinsic nature of opioids to suppress respiratory function is of particular concern among patients with OSA.” The summary goes on to say that “the association of OSA with increased perioperative risk has raised the question of whether patients with OSA are at higher risk for opioid-induced respiratory depression (OIRD) compared to the general population.” Finally, the summary concludes: “While quality evidence is needed, retrospective analyses indicate that critical, life threatening OIRD may be preventable with a more cautious approach to opioid use, including adequate monitoring.”
Although not an Indigo case, a recent medical malpractice verdict in South Florida is on point. In May 2020, a 54-year-old male, a husband and father, was admitted to a South Florida hospital with a bout of acute pancreatitis. Over the first 28 hours following admission, the patient received 27 doses of Dilaudid, an opioid medicine, for pain management, before suffering respiratory collapse. He was taken off life support within a week and passed away.
In the plaintiff’s case, it was argued that the treating physician failed to determine whether the patient had OSA. Had he done so, he would have learned the patient did have OSA and would have ordered increased monitoring, including telemetry and pulse oximetry to keep an eye on any possible signs of respiratory depression. It was alleged that the failure to order the increased monitoring allowed the patient to develop respiratory depression and, by the time the nurses learned about it, it was too late.
In the defendant’s case it was argued that the treating physician followed an appropriate regimen of Dilaudid dosing, with an eye on the medical history he took from the patient, including the patient’s statement that he did not suffer from any respiratory issues.
In September 2023, following a 2 week trial, the jury returned a verdict for the plaintiff in the amount of $20M after just 4 hours of deliberation. Although the jurors were not polled, it appears, like me, they had concerns that the patient’s statement that he did not suffer from any respiratory issues was not sufficient to rule out OSA.
Although the lawyers for the physician were able to mount a defense, clearly the jury did not find it persuasive. I’m no clinician but my experience in reviewing these kinds of cases leads me to believe that clearly documenting that OSA was asked about and considered is important. It’s possible that in the South Florida verdict, the decedent’s passing had nothing to do with OIRD, but such an argument would have been far more convincing had OSA been appropriately considered, managed, and documented in the patient’s care. That might be the difference between simply defending a case at trial and winning that case at trial.
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