On May 5, 2023, a Virginia medical malpractice claim was settled for $850,000 for the death of a woman who was given too much propofol over too short a period of time during a colonoscopy procedure, resulting in her death.
The woman had been on dialysis for more than two years. She also had diabetes, hypertension, and recently had suffered a stroke. Because she was experiencing abdominal pain and a change in her bowel habits, her gastroenterologist recommended that she have a screening colonoscopy at an outpatient endoscopy center associated with a local hospital.
On the morning of the scheduled colonoscopy procedure, the woman met with the anesthesiologist who cleared her for the procedure. The CRNA (certified registered nurse anesthetist) administered 200 mg of propofol over a period of eight minutes during which the patient’s heart rate and blood pressure dropped. In response, the CRNA administered multiple doses of ephedrine but also continued to push large doses of propofol.
The woman’s heart rate continued to fall until she suffered cardiac arrest. A code was called at which time the anesthesiologist entered the room. A single dose of a resuscitative medication was administered but they failed to wait the required ten minutes before administering a second does of the potent medication. The woman’s heart rate recovered shortly after the second dose was given, but she had suffered a permanent anoxic brain injury. She died three weeks later after life support was withdrawn.
The CRNA reportedly stated that she had administered the maximum dose of propofol based on the woman’s weight. The plaintiff’s experts opined that dialysis patients are more sensitive to sedatives such as propofol and therefore the CRNA should have administered propofol slowly and carefully. The defendants argued that the woman’s death was an adverse reaction to propofol and that she had a vagal response to the scope used during the colonoscopy. The defendants also argued the low life expectancy of a dialysis patient who did not have a kidney transplant (the woman was in the beginning stages of being evaluated for a kidney transplant).
The Virginia medical malpractice wrongful death settlement was reached the day before the scheduled trial date.
A 2010 Kaiser Permanente review of monitored anesthesia care for gastrointestinal disorders reported findings from systematic reviews, meta-analyses, randomized controlled trials, and published internal data (KP MTAT 2010). Their findings included the following:
“There is good evidence of improved patient satisfaction and reductions in discharge and recovery times with propofol used alone or in combination with other agents compared to standard sedation for colonoscopy exams. There is fair evidence from a KP SCAL-based comparative study of improved cecal intubation rates with propofol used as a single agent for sedation during colonoscopy. The evidence is of insufficient quantity or quality to draw definitive conclusions on differences in polyp detection. There is less comparative data on EGD procedures, but some evidence of improved recovery and patient satisfaction with propofol sedation. The evidence is of insufficient quantity and/or quality to draw definitive conclusions on comparative risk of serious adverse events, including death, neurologic injury, endotracheal intubations, bleeding, and colonic perforations during these procedures. There does not appear to be a significant difference in the risk of cardiopulmonary and respiratory events with propofol compared to standard sedation and no evidence of greater risk for serious adverse events for either colonoscopy or EGD procedures in lower risk patients (ASA I or II).
Following the review of one systematic review and two comparative observational studies, the evidence is of insufficient quantity and quality to draw definitive conclusions on the safety of anesthesiologist- versus non anesthesiologist-directed or administered propofol sedation in GI endoscopy. Controlled prospective studies with standardized protocols, patient selection, and reporting are needed …
The evidence is of insufficient quantity and quality to draw conclusions on the safety of RN-administered propofol as compared to standard sedation for colonoscopy and EGD in ASA I and II patients. Based on a review of several systematic reviews and randomized controlled trials, there is no evidence of a significant increase in risk of adverse events with propofol compared to standard sedation and the risks appear to be comparable. However, these studies were not adequately sampled to detect or compare rates of serious adverse events. Comparative data from large and well-designed observational studies is needed. The existing series of RN-administered propofol are large and report low rates of adverse events …
A 2017 systematic review (k=27 studies; n=2,518 patients) evaluating sedation-related adverse events associated with the use of propofol vs. nonpropofol (i.e., midazolam, meperidine, pethidine, remifentanil, and/or fentanyl) for endoscopic procedures reports no significant differences in pooled odds ratios for rates of hypoxia, hypotension, or arrhythmia by sedation type. An analysis of studies of nonadvanced endoscopy procedures indicates that patients who received propofol were 39% less likely to develop any complications compared to those receiving non-propofol sedation (OR: 0.61; 95% CI: 0.38-0.99). No difference in the complication rate for advanced endoscopy procedures was found between sedation groups.”
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