Chatham Orthopaedic ASC complaint alleges elective cervical surgery proceeded despite hypertensive emergency

The complaint alleges that Chatham Orthopaedics, Chatham Orthopaedic ASC, related surgery-center entities, an orthopaedic surgeon, a medical director, and an anesthesiologist approved and performed elective outpatient ACDF surgery on a patient with morbid obesity, sleep apnea, renal disease indicators, elevated blood pressure, and a day-of-surgery blood pressure the complaint characterizes as a hypertensive emergency. After surgery, the patient self-extubated, developed pulmonary edema and hypoxia, was transferred to Memorial Health University Medical Center, and later died, with the complaint citing an autopsy that identified pulmonary embolism as the immediate cause of death.

System: Chatham Orthopaedics
Facility: Chatham Orthopaedic ASC, LLC
Providers involved: Chatham Orthopaedic Associates, P.A. / Chatham Orthopaedic ASC, LLC / Surgical Care Affiliates, LLC / Sentry Anesthesia Management, LLC d/b/a Northstar Anesthesia / Dmitri Sofianos, M.D. / Robert Hoffman, M.D. / Stephen Miller, M.D.
Pattern: Alleged outpatient cervical surgery clearance despite hypertensive emergency and high-risk comorbidities
Harm: Alleged postoperative airway and ventilation complications followed by death from pulmonary embolism

Overview

This page concerns a public complaint alleging that elective outpatient anterior cervical discectomy and fusion proceeded at Chatham Orthopaedic ASC despite high-risk comorbidities and a blood pressure reading the complaint characterizes as a hypertensive emergency.

Chronology

The complaint alleges as follows:

The patient was treated by Chatham Orthopaedics in 2022 for neck pain, back pain, cervical radiculopathy, and lumbar radiculopathy.
Pre-operative review documented morbid obesity, treatment-noncompliant sleep apnea, renal-disease concerns, untreated elevated blood pressure, and a history of post-anesthesia complications.
On January 24, 2023, the patient arrived for surgery with a blood pressure of 188/134, and the non-emergent outpatient ACDF procedure proceeded.
Shortly after surgery, the patient became combative, self-extubated, developed pulmonary edema and hypoxia, and required emergent transfer to Memorial Health University Medical Center.
Post-transfer imaging showed the endotracheal tube positioned in the right mainstem bronchus, and the complaint later cited an autopsy identifying pulmonary embolism as the immediate cause of death.

Alleged failures

The complaint alleges the following failures:

The medical director approved the patient for elective outpatient surgery despite comorbidities and risk factors that allegedly counseled against proceeding.
The orthopaedic surgeon proceeded with elective cervical surgery despite the patient’s day-of-surgery blood pressure and other risk factors.
The anesthesiologist approved surgery and allowed the procedure to proceed despite alleged hypertensive emergency and comorbidity concerns.
Post-operative airway and ventilation management was inadequate after the patient self-extubated and developed pulmonary edema and hypoxia.

Entities and tags

Chatham Orthopaedic ASC, LLCChatham Orthopaedic Associates, P.A.Surgical Care Affiliates, LLCNorthstar AnesthesiaDmitri Sofianos, M.D.Robert Hoffman, M.D.Stephen Miller, M.D.ACDFHypertensive emergencyPulmonary embolismSurgical errorCardiac and vascular emergenciesPost-operative complicationsAnesthesia and airwayOrthopaedic surgeryAnesthesiologyAmbulatory surgeryPost-operative airway management