Endoscopy case highlights risks of complex patients in ASCs

Editor's Note

A malpractice case involving a 69-year-old man undergoing an endoscopy at an ambulatory surgery center (ASC) spotlights the risks of managing high-comorbidity patients outside a hospital setting. According to a May 13 report in Anesthesiology News, the patient experienced a hypoxic event that led to permanent brain injury and, ultimately, death 4 years later. The case settled for $2.1 million, with experts citing poor patient selection, inadequate documentation, and lack of medical clearance as key liability issues.

As detailed in the article, the patient’s medical history included coronary artery disease with a stent, sleep apnea, hypertension, diabetes, COPD, obesity, and end-stage renal disease requiring dialysis. Despite this, he was scheduled for an upper endoscopy at an ASC and classified ASA physical status III. Sedation with propofol led to oxygen desaturation, bradycardia, and subsequent blood pressure instability. While the anesthesiologist intervened with airway support, atropine, and labetalol, the patient never regained full responsiveness. He was later diagnosed with anoxic brain injury and required long-term assistance with daily living.

Per the outlet, reviewers flagged several missteps: failure to obtain preoperative clearance, lack of documentation of history and vitals, and the choice of an ASC for such a medically complex patient. Experts emphasized while the anesthesiologist managed intraoperative crises appropriately, the broader issue was whether this patient was ever a suitable candidate for an outpatient facility.

According to Patricia Fogarty Mack, MD, of Weill Cornell, even if multiple subspecialists had cleared the patient, the combination of end-stage renal disease, coronary stent, and other comorbidities made an ASC setting unsafe. She noted this type of case belongs in a hospital where full resources are available. Michael Schoppmann, JD, CEO of MLMIC Insurance Co, added that clinicians should heed their own instincts about clearance: if the thought arises, it is usually an indication that clearance is necessary. Having documented approval from another physician strengthens both patient safety and legal defensibility. Experts caution that anesthesia providers must evaluate not only their immediate management but also whether the care setting itself is appropriate for the patient’s risk profile.