Point of view | Is the hospital responsible for the death of patients caused by postoperative venous thromboembolism?

Published:

2024-10-11

Introduction The patient recovered well after surgery, but died suddenly before or even after discharge? At autopsy, it was found that the cause of death was venous thromboembolism (VTE), which seemed unrelated to the operation. In fact, the occurrence of VTE in patients after surgery is not an isolated case, especially in surgery, blood flow slows down, after lower extremity venous thrombosis (DVT), because the newly formed thrombus is easy to break away from the venous wall and be pushed into the pulmonary artery, a series of symptoms will occur and even lead to sudden death, which is clinically called pulmonary embolism (PET). Pulmonary embolism, when it occurs, is often very dangerous. If the patient died of postoperative venous thromboembolism, should the hospital be responsible for the death of the patient? If the hospital needs to bear the responsibility, then what kind of nature and degree of responsibility will it bear? The author analyzes the above-mentioned problems in this paper combined with the actual situation in the judicial trial. 1. Venous Thromboembolism (VTE) Pulmonary embolism is a general term for a group of diseases or clinical syndromes caused by various emboli blocking the pulmonary artery or its branches, including pulmonary thromboembolism (PTE), fat embolism syndrome, amniotic fluid embolism, air embolism, tumor embolism, etc. PTE is the most common type of pulmonary embolism. Thrombosis that causes PTE is mainly from deep vein thrombosis (DVT) of the lower extremities. PTE and DVT are known as venous thromboembolism (VTE). They have the same risk factors and are two clinical manifestations of VTE in different parts and stages. The common cause of VTE after surgery is that the patient's preoperative activity is reduced, anesthesia and intraoperative braking, postoperative long-term bed rest and other reasons cause the patient's venous blood flow to slow down significantly; anesthesia and surgical trauma activate the coagulation system to appear hypercoagulable state. Blood flow slows down, and even blood clots can occur in the lower extremities to form a thrombus, known as deep vein thrombosis. After venous thrombosis of the lower extremities, the newly formed thrombus is easy to break away from the venous wall and flow back into the right ventricle with the blood. In addition, the right ventricle contracts and pushes it into the pulmonary artery, which will cause a series of symptoms and even lead to sudden death. It is called pulmonary embolism. Most patients with pulmonary embolism have no typical clinical symptoms, and the rate of definite diagnosis of fatal pulmonary embolism before death is extremely low, but once it occurs, it is often very dangerous. Clinicians have little time to rescue patients. Severe cases can be within two hours. Death, and there is still a risk of recurrence of death from pulmonary embolism in patients after the dangerous period. In addition, VTE is the third leading cause of cardiovascular disease-related deaths worldwide, after myocardial infarction and stroke. In recent years, the number of VTE cases in China has increased rapidly, and the number of VTE cases diagnosed in most hospitals has increased by 10 to 30 times compared with 20 years ago. Statistics from 60 large hospitals in China show that the proportion of PTE in hospitalized patients increased from 0.26 per cent in 1997 to 1.45 per cent in 2008. 2. the VTE is not related to the operation and the hospital has done its duty of care, the hospital is not liable As we all know, the liability for medical technology damage is the medical behavior of medical institutions and medical personnel engaged in the inspection and diagnosis of the disease, the selection of treatment methods, the implementation of treatment measures, the tracking of the development of the disease, and postoperative care, which does not conform to the existing medical care at the time. For negligent acts of professional knowledge or technical standards, medical institutions should bear the tort liability for compensation. The principle of fault liability applies to the liability for medical technology damage. The constituent elements of proving the liability of medical institutions and medical personnel for medical damage shall be borne by the plaintiff, I .e. the injured patient, and even the elements of medical negligence shall be borne by the injured patient. Therefore, if the patient died of VTE after surgery, the patient should prove the causal relationship between VTE and surgery and the cause force. The court also judges whether the hospital should bear the responsibility. If the patient's VTE is not related to the surgery performed by the hospital, and the hospital also does its reasonable duty, the hospital is not responsible. Case:(2023) Shan 03 Min Zhong No. 481 In this case, after the patient was admitted to the hospital due to right knee trauma, the hospital made a diagnosis conclusion of right knee osteoarthritis and acute synovitis after the trauma was diagnosed and treated accordingly. After ten days of hospitalization, the patient was discharged from the hospital. The doctor's advice for discharge was: avoid strenuous exercise and knee joint weight-bearing exercise after discharge. Exercise can be carried out for cycling, swimming and other activities, and long-term bed rest can be avoided to prevent deep vein thrombosis, outpatient right knee joint cavity puncture injection of sodium hyaluronate injection, once a week, 3-5 times in a row, the observation effect is not good, it is recommended that the superior hospital for further diagnosis and treatment. More than 20 days after discharge, the patient due to circulatory failure, pulmonary embolism, causing respiratory and cardiac arrest, died after rescue. The family members of the patient believed that the hospital did not find out whether the right lower limb of the patient had formed thrombosis before and after admission due to trauma, and there was a medical fault of missed diagnosis and misdiagnosis of thrombosis, so they sued the hospital to the court and requested the hospital to bear the liability for medical damage compensation. The judicial appraisal institution responsible for the judicial appraisal work in this case believes that the patient died suddenly due to acute pulmonary embolism, lost the opportunity to pursue the cause, and had no DVT symptoms and signs during the treatment of the original medical institution, and DVT had nothing to do with the treatment of the primary disease of the knee joint of the patient. On the 23rd day after discharge, the patient had no history of pulmonary embolism and DVT symptoms before sudden death. There was no DVT prevention required by the original medical institution, so the sudden death of the patient had nothing to do with the medical behavior of the original medical institution. In addition, the hospital believes that the discharge doctor's order clearly tells the patient to "avoid long-term bed inactivity to prevent the formation of deep venous thrombosis of the lower extremities", which can also prove that the hospital has fulfilled its duty of reminding. According to the judicial appraisal opinion, the court held that the hospital was not at fault for the patient's diagnosis and treatment. There was no causal relationship between the hospital's diagnosis and treatment behavior and the patient's death. Thus, the decision rejected the patient's family's claim for compensation from the hospital. 3. If the hospital fails to exercise reasonable care, the prevention of VTE is inadequate, and the evaluation of patients is inadequate, the hospital shall be liable Any factors that can lead to venous blood stasis, vascular endothelial damage and blood hypercoagulability are risk factors for VTE, including genetic and acquired. Among them, acquired risk factors refer to a variety of pathophysiological abnormalities that are acquired and prone to VTE, mostly temporary or reversible. Such as surgery, trauma, acute medical diseases, it can be seen that perioperative deep vein thrombosis and pulmonary embolism are common complications and important causes of death in patients. If the hospital fails to prevent the possibility of deep venous thrombosis of the lower extremities during hospitalization, and there is a fault of failing to do enough duty of care, it should be responsible for the death of the patient. Case:(2021) Liao 01 Min Zai No. 189 In this case, the patient was admitted to the hospital for "swelling and pain, deformity and limited movement for 10 hours after a fall in the left hip". The main diagnosis was left femoral neck fracture. The hospital performed "closed reduction and cannulated screw internal fixation for left femoral neck fracture" and was discharged 9 days later. Discharge doctor's advice: 1. Oral orthopedic drugs to prevent DVT; 2. Functional exercise according to rehabilitation plan, etc. But a few days later, the patient went to the hospital for "difficulty breathing for 2 hours". After treatment, he died on the same day. The cause of death was pulmonary infarction. After the patient's family sued the hospital to the court, the court entrusted a judicial appraisal agency to conduct judicial appraisal. The judicial appraisal agency believed that: the patient was admitted to the hospital for surgical treatment due to fracture, and the preoperative examination found that the left calf muscular vein thrombosis and D-dimer were elevated., Have risk factors for pulmonary embolism, is the objective internal cause of the patient's death; in addition, in the process of diagnosis and treatment of patients, the hospital has not fulfilled the duty of reasonable care and the prevention of pulmonary embolism is not sufficient, and the negative impact on the death of patients can not be ruled out. Therefore, it is determined that "there is a fault in the process of diagnosis and treatment of patients by the hospital, and there is a certain causal relationship between the damage consequences of patients, and the size of the cause force can be considered as the same." The court held that the appraisal opinion had fully considered the actual situation, and ruled that the hospital should bear 50% of the compensation liability for the death of the patient according to the appraisal opinion. In addition to the above, VTE shares risk factors with certain arterial diseases, especially atherosclerosis, such as smoking, obesity, hypercholesterolemia, hypertension and diabetes. Myocardial infarction and heart failure can also increase the risk of VTE. Acquired risk factors can be pathogenic alone, can also exist at the same time, synergistic effect. At the same time, age is also an independent risk factor, with the increase of age, the incidence of VTE gradually increased. In addition, malignant tumor is also an important risk factor for VTE, but the risk of VTE is different in different types of tumors. Malignant tumors of pancreatic, brain, lung, ovary and hematological system are considered to have the highest risk of VTE, and the risk of VTE increases in active malignant tumors. Therefore, if the hospital fails to conduct adequate examination, diagnosis and risk assessment of the patient's physical condition before surgery, and ultimately leads to the death of the patient due to postoperative VTE, the hospital should bear the responsibility. Case:(2016) Shanghai 02 Minzong No. 6135 In this case, the patient was admitted to the hospital due to "repeated intermittent left waist pain for 10 years, aggravated for more than 2 weeks". After the failure of percutaneous nephrolithotomy after diagnosis, the hospital performed left renal parenchyma incision fistula plus left ureteroscopy. The patient recovered poorly after surgery and died in the afternoon of the same day after discharge. After the patient's family sued the hospital to the court, the court entrusted the medical association to identify whether the hospital has medical fault, grade and degree of responsibility in the medical behavior of the patient. After the analysis of the medical association, it is believed that the patients are obese women, and the surgical trauma and postoperative activities are the influencing factors of pulmonary embolism. Chest tightness, shortness of breath, increased pulmonary artery pressure and elevated D-dimer values were found at discharge, which were in line with the clinical diagnosis of "pulmonary embolism". There was no direct causal relationship between the death of the patient and the operation. However, pulmonary embolism is relatively rare after urinary system surgery, and it is difficult to completely avoid it under the existing medical technical conditions. Once the consequences are serious, the success rate of large vessel embolism rescue is low, which is the root cause of the final death of the patient. Therefore, the court decided that the court should bear 10% of the compensation liability according to the liability determined by the appraisal opinion. 4. If there is a clinical regular medical procedure error in the diagnosis and treatment of the hospital, causing the patient to have VTE after the operation, the hospital shall bear the responsibility. In the process of postoperative care, the hospital needs to monitor the patient's vital signs continuously and carefully. However, if there is negligence in this process, the early symptoms of pulmonary embolism in patients can not be found in time, such as sudden dyspnea, chest pain, heart rate, etc., which may lead to serious consequences. This lack of supervision may be caused by a variety of reasons, such as insufficient human resources, insufficient experience of medical staff, or weak sense of responsibility. These factors may cause medical staff to fail to identify the patient's condition changes in time. If VTE occurs after surgery, the hospital should bear the responsibility. Case:(2022) No. 31288 Minchu, Beijing 0102 In this case, the patient was admitted to the hospital for 4 years due to right facial pain. After microvascular decompression, the right facial pain improved without facial convulsions, fever and chills, nausea and vomiting, stable vital signs and clear mind. But the next afternoon after the sudden dizziness, sweating, chest tightness, suffocation. After the emergence of rapid breathing, blood oxygen saturation decreased, the hospital to take emergency measures, continuous chest compressions, but the patient's spontaneous heartbeat has not been restored, bedside ECG monitoring was a straight line, ECG showed total cardiac arrest, declared clinical death. The pathological diagnosis results of autopsy were as follows: 1. Thromboembolism in the main pulmonary artery; 2. Acute myocardial ischemic and hypoxic lesions; 3. Chronic cardiac ischemic and hypoxic lesions. After the patient's family sued the hospital to the court, the court entrusted a judicial appraisal institution to carry out judicial appraisal. The judicial appraisal institution believed that the patient's BMI value met the criteria for diagnosis of obesity, and the patient had a history of gallbladder removal (due to gallbladder removal, the digestive tract lacks bile, and the bile is composed of bile salt or bile acid, which can be used as emulsified fat, reduce the surface tension of fat, and emulsify fat into position droplets, improve the efficiency of pancreatic lipase. bile is important for the absorption of fat). Patients with preoperative examination of blood glucose above the normal range, and have a previous medical history, should consider the consultation to exclude the risk. From the perspective of internal medicine, the main cause of postoperative pulmonary embolism is insufficient body fluid. Surgical patients need to fast and forbid water for a long time before surgery. In this case, 250ml of 25% mannitol was input to reduce intracranial pressure during surgery (mannitol is a hypertonic tissue dehydrator, which clinically treats cerebral edema, accelerates the excretion of poisons and drugs from the kidney, resulting in further water loss). According to the doctor's order form and nursing records of this patient, no continuous fluid infusion after surgery was found. Combined with intraoperative bleeding and no apparent water loss during the postoperative recovery period, it can be inferred that the patient has insufficient body fluid volume during the operation. (There is no discrepancy recorded in the nursing record). Patients in the postoperative blood glucose decreased compared with the preoperative, and fasting water related, can not be considered as blood glucose returned to normal value. In general, patients have insufficient fluid intake for 48 hours before and after operation, and there are risk factors such as obesity and diabetes. In addition, prolonged bed rest will further increase blood viscosity, which will increase the risk of lower extremity venous thrombosis. After synthesizing the appraisal opinions of the judicial appraisal institution, the court held that there were no obvious high-risk factors for pulmonary embolism before the patient was admitted to the hospital, and the analysis opinions of the appraisal institution had no clear basis to support, so the conclusion was partially adopted by the hospital. However, there were clinical regular medical procedure errors in the diagnosis and treatment of the hospital, and the patient's failure to replenish fluid in time after the operation was also a factor causing pulmonary embolism after the patient's operation. Therefore, the defendant should bear the corresponding liability, the degree of responsibility is considered secondary, with a responsibility ratio of 20 per cent. 5. epilogue Whether the hospital is responsible for the death of patients with postoperative pulmonary embolism depends on the specific case and the diagnosis and treatment behavior of the hospital. Hospitals may be considered at fault if they fail to comply adequately with their duty of care, such as failing to take appropriate precautions or failing to diagnose and treat pulmonary embolism in a timely manner. In addition, the hospital usually clearly informs the surgical risks, including the possibility of pulmonary embolism, in the preoperative notice. However, simply informing the hospital of the risk does not completely absolve the hospital of the legal responsibility. Hospitals may still be held responsible if they fail to implement appropriate preventive measures or manage complications that arise inappropriately. Generally speaking, when hearing such cases, the court will consider whether the diagnosis and treatment behavior of the hospital conforms to the medical norms, whether the necessary preventive measures have been taken in time, and whether there is a causal relationship between the fault of the hospital and the death of the patient. If the hospital fails to meet the above obligations, it may be sentenced to liability. This also requires hospitals to be vigilant against venous thromboembolism and encourage patients to get out of bed as soon as possible after surgery to promote blood circulation and reduce blood stasis. If the patient cannot get out of bed, regular leg massage and passive exercise should be performed. In addition, anticoagulant therapy should be taken when necessary to prevent thrombosis; ensure adequate drinking water for patients: timely fluid infusion to reduce blood viscosity; actively control high-risk factors, for patients with high-risk factors (such as obesity, smoking, hypertension, diabetes, hyperlipidemia, etc.), these basic diseases should be actively treated and controlled; postoperative monitoring should be improved, and the vital signs and lower limbs of patients should be closely observed, if the patient has unexplained dyspnea, chest pain, lower limb swelling and other symptoms, it should be treated in time to avoid personal injury due to venous thromboembolism.

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