Death after bone marrow donation

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XRanger

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www.nj.com

Family of ‘hero’ principal says he deserves justice after bone marrow donation procedure turned fatal

Attorneys for the fiance of Westfield High School Principal Derrick Nelson, who died after donating bone marrow to a teenage cancer patient, filed a wrongful death lawsuit Monday against Hackensack University Medical Center.
www.nj.com www.nj.com

Nelson, who was at a slightly higher risk for undergoing anesthesia due to his sleep apnea and being overweight, had an oxygen saturation of 91 when anesthesia was induced, according to the lawsuit.
Despite the low oxygen levels, the suit states, he was administered anesthesia and was not supplied with additional oxygen during the operation. He became bradycardic and his oxygen levels plummeted to a saturation of 31, according to the complaint.
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I wonder what happened here. I’m assuming he gave propofol and he became apneic and desatted. But no oxygen mask or pulse ox?

Have any of you done anesthesia for bone marrow donation?
 
He had sleep apnea.
Also it was mentioned at the end that they were going to do this under local? I wonder if the anesthesiologist was called after sedation led to obstruction?
 
XRanger said:
www.nj.com

Family of ‘hero’ principal says he deserves justice after bone marrow donation procedure turned fatal

Attorneys for the fiance of Westfield High School Principal Derrick Nelson, who died after donating bone marrow to a teenage cancer patient, filed a wrongful death lawsuit Monday against Hackensack University Medical Center.
www.nj.com www.nj.com



I wonder what happened here. I’m assuming he gave propofol and he became apneic and desatted. But no oxygen mask or pulse ox?

Have any of you done anesthesia for bone marrow donation?
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I've only done anesthesia for bone marrow biopsies in children. GA with LMA. Sad story. As usual, there is not enough info.
 
I recall doing these in med school on a heme-onc rotation with just local and a pillow for the patient to scream into. At the time it seemed a little barbaric.

Less so now.
 
Sounds like a MAC in the prone position. See recent discussion on ERCP...
 
Likely sedation prone in a poor candidate. I personally would never try to do a bone marrow aspiration under sedation prone, too painful to do anything but GA.

The article is missing too much info to tell what happened.
 
Just requires some finesse and local anesthesia. You could make the argument that every GA with an ETT is "safer" than a propofol sedation case. Hemorrhoids, anal fistulas, epidural steroid injections can all develop complications with mac if done incorrectly or on the wrong patients.

Patients have complications from both types of anesthesia for a myriad of reasons. I have done many bone marrow biopsies (i dont have experience with bone marrow donation) and the cases are simple and quick and suitable for propofol sedation with local anesthesia in the average patient.

However, I am assuming that bone marrow donations require significantly more time and perhaps multiple injection sites? And this gentleman looked older, overweight, probably history of OSA. So that would prompt me towards a GETA.
 
There's a huge difference between bone marrow donations and bone marrow biopsies. Our bone marrow donations are all general anesthesia, prone with ETT. They get a 16ga IV because they're drawing off a liter of bone marrow in a fairly short period of time, so adequate fluid replacement is required. A bone marrow biopsy is basically an office procedure, frequently done with local anesthesia only, although it's certainly a big poke and I'm not sure I'd want one without something for sedation. We do some CT guided biopsies, and some of those get MAC from us.
 
Sad situation, details are murky as usual. What a tragedy, sounds like he was a great guy. The article seems to suggest no supplemental oxygen was given until things had gotten pretty bad. If that is true then they should try and settle, that would be a clear deviation from the standard of care.

I am also curious to learn more about the "Laryngel Mask Airway" mentioned. Typo makes it sound like a slick brand of LMA or something.
 
jwk said:
There's a huge difference between bone marrow donations and bone marrow biopsies. Our bone marrow donations are all general anesthesia, prone with ETT. They get a 16ga IV because they're drawing off a liter of bone marrow in a fairly short period of time, so adequate fluid replacement is required. A bone marrow biopsy is basically an office procedure, frequently done with local anesthesia only, although it's certainly a big poke and I'm not sure I'd want one without something for sedation. We do some CT guided biopsies, and some of those get MAC from us.
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Ya if the cases are that invasive...prone ETT seems prudent.
 
jwk said:
There's a huge difference between bone marrow donations and bone marrow biopsies. Our bone marrow donations are all general anesthesia, prone with ETT. They get a 16ga IV because they're drawing off a liter of bone marrow in a fairly short period of time, so adequate fluid replacement is required. A bone marrow biopsy is basically an office procedure, frequently done with local anesthesia only, although it's certainly a big poke and I'm not sure I'd want one without something for sedation. We do some CT guided biopsies, and some of those get MAC from us.
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This.

We do bone marrow biopsies/aspirations in heme/onc clinic with propofol/native airway, usually prone. Can talk the heme/onc into lateral or supine if worried about the airway. 5-15min depending on proceduralist.

Bone marrow harvest (donation) is about 2 hours, pulling off very large quantities of fluid (a liter or more, as noted). Prone/ETT/large PIVs for everyone, as you can get hypotensive. Need volume +/- pressors occasionally. Maybe not the best to be doing in pts with coronary artery disease, sickle cell, etc, but I don't make the rules about who's eligible.

I love the conflicting statements that they were worried about his obesity and sleep apnea so wanted to do "local only," which presumably means "with sedation," which we all know means GA without an airway.

Obese + OSA + prone + no airway + sickle cell trait + GA + hypotension = badness. They were right to be worried. But then they chose the more dangerous of the two options available to them.
 
I have always done these cases with a secured airway and a good IV. Adults and kids.
I wonder if the anesthesiologist was called in late to rescue some kind of poorly planned sedation and then he had to deal with the disaster.
I’ve been called a few times to rescue sedation in various offsite locations from the peds sedation service and the formula is always the same. Rescue airway/fix BP, end procedure, wake patient, and figure out what went wrong. Reschedule with GA. The only time this doesn’t apply is if it’s mid procedure in IR where they’re in the middle of placing a line or something, which has also happened.
I am not taking over someone else’s train wreck polypharmacy lost airway/whatever and giving GA like nothing happened. F that. Some of my partners will and I think they’re crazy. Not long ago I was told after giving Neo/Ephedrine/fluid for significant (and somewhat prolonged) hypotension in radiology that I had to finish the case as the peds folks don’t give those drugs and couldn’t continue. I said “OK. We’re done, get him out.” FY for thinking I’m going to inherit your complication. Of course everything was fine, but how do I know that is going to work out that way after the scans. Your patient, not my patient. This case is exactly why.
My first step in this case would have been canceling the case, recommending an urgent pulmonary and or cardiac consult to evaluate why his room air saturation was 91%. Evaluate, optimize and get back on the schedule. I’m a conservative guy with a lot to lose. I’ll always take the safe choice and not lose a second of sleep about it, especially for something elective like this.
As always there’s not enough details to know what really went down.
 
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Based on the fact that there was allegedly no monitoring, no O2, etc. I’d bet it was sedation gone wrong that the anesthesiologist was called in to assist and they proceeded after securing the airway, but the brain damage was already done. I don’t see an anesthesiologist doing sedation without O2 and monitors. Not in this generation anyway. Maybe we will see more details in the future. Keep this and what I wrote above in mind when you’re called in for help and asked to take over.
 
IlDestriero said:
Based on the fact that there was allegedly no monitoring, no O2, etc. I’d bet it was sedation gone wrong that the anesthesiologist was called in to assist and they proceeded after securing the airway, but the brain damage was already done. I don’t see an anesthesiologist doing sedation without O2 and monitors. Not in this generation anyway. Maybe we will see more details in the future. Keep this and what I wrote above in mind when you’re called in for help and asked to take over.
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I don’t see any doctor doing sedation with no 02 and at least a Sat probe.
Another thing, how do we know the anesthesiologist finished the case? He may have cancelled it but it was already too late anyway?
It’s all speculation. I don’t believe the entirety of the story. Because what kind of doctor, unless they are using no sedation would not monitor the sats at least. IDK.
I don’t think an anesthesiologist was involved at all until too late. They talk about inducing anesthesia and then talk about the plan for local? Weird.

Then again, a lot of people think they can do what we do in their sleep without training so there’s that.
 
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IlDestriero said:
My first step in this case would have been canceling the case, recommending an urgent pulmonary and or cardiac consult to evaluate why his room air saturation was 91%. Evaluate, optimize and get back on the schedule. I’m a conservative guy with a lot to lose. I’ll always take the safe choice and not lose a second of sleep about it, especially for something elective like this.
As always there’s not enough details to know what really went down.
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Are there any prone cases that you would do without an ETT?
 
Silo004 said:
Are there any prone cases that you would do without an ETT?
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Pain cases, hemorrhoidectomy, anal fistula, lipomas are probably the most common ones. You need a procedure that can be done with local anesthesia providing sufficient pain control and a patient that does not have significant airway concerns, severe obesity, aspiration concerns, etc.

Also alot is based on community standards and expectations. If you tube every pain case, for example, you will quickly be kicked out of the pain room haha
 
Prone MAC cases I have routinely done include spinal cord stimulator and Kyphoplasty. Both procedures involve patients with multiple co-morbidities. Standard monitoring, including CO2 is performed.
 
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