Changing the procedure in the middle of the case

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Ok, here's my question. Today I had a case that was stated in the informed consent as "Left knee arthroscopic meniscectomy". That is what the patient told me she was having done and when I did the moment with the surgeon that is what was said. The patient was under MAC, but was watching the TV screen and talking with the surgeon during the case. The patient had a prior knee replacement and the surgeon noticed that the femoral component was loose, so the patient asked what that meant and the surgeon said they needed to replace the component. The surgeon offered to do it now adn the patient said that is what she wanted. So in a matter of seconds the patient is put off to sleep and I have to go running around getting all this stuff I was not prepared for, cause there was not mention of it. Now, the patient is sedated, so how do I know her choice to do this is valid? And another thing, is the surgeon allowed to just add a procedure like that, is this legal? The PA was saying that it was informed consent when the patient said yes, but I dont' think so. What do you think?

Christine

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this would be a question for your hospital's risk manager, but in my opinion, this patient was in no situation to give informed consent. Being under MAC, I would expect that she had recieved sedation, which would mean she couldn't properly consent, especially in the middle of another procedure.. This would also depend on your state's laws regarding consent, and your hospital's policy regarding informed consent. This situation might well violate your hopital's policy.

I expect this surgeon had an idea that the knee might need to be revised, and should have scheduled the case as an arthroscopy, possible total knee revision, so that the OR staff could have at least had the necessary supplies in the room.

What was your manager's response to this situation?

Did you fill out an incident report or otherwise document your concerns?

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informed consent - hahaha :chuckle

how can anyone give informed consent after having sedation .. are they not told not to make any important decisions for 24 hours!

If the procedure was an emergency - OK

if the consent included the possibility for further procedures - OK

but for a knee arthroscopy with menisectomy - that is what they are consented for.

I would not like to be the scrub RN in this situation.

squeek.

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informed consent - hahaha :chuckle

how can anyone give informed consent after having sedation .. are they not told not to make any important decisions for 24 hours!

If the procedure was an emergency - OK

if the consent included the possibility for further procedures - OK

but for a knee arthroscopy with menisectomy - that is what they are consented for.

I would not like to be the scrub RN in this situation.

squeek.

You know, I have to say I've done it--not switched midstream to playing around with previously implanted total knee components (How old WAS this patient, anyway? Odd that they would have a total knee and STILL be a candidate for a menisectomy) but I have switched from doing a diagnostic arthroscopy with intraarticular debridement for internal derangement of the knee to doing an unplanned and unscheduled ACL reconstruction while the patient was under spinal, I believe.

That's been years ago--at least 10--and in todays litigious environment, I do NOT think I'd do it again. However, in this case, the patient was a young man; I do not think he had received ANY sedation whatsoever--he wanted to be totally awake to watch the screen--and I remember the surgeon, who I knew and trusted, saying to him, "What you have here is known as a torn anterior cruciate ligament. Now, I could fix this today while we're in here--and then telling him the advantages and disadvantages and other options, which included coming back on another day--

I firmly believe the circulator is in charge of the room, so I rarely feel the need to consult "the desk" but I do remember going out and asking what they thought, just to cover my a**, and they cleared us to go ahead since he was awake, alert and under spinal. If I remember correctly, we added the new procedure to the informed consent and had him sign it then and there. Again, he'd had no sedation, so what the surgeon gave him in the room was truly a detailed, informed consent, with advantages and disadvantages both of the procedure and of having to come back another day. The entire crew--scrub, circulator, and CRNA felt comfortable proceeding as we did.

I think, if I was the patient, I would have appreciated being given the option and proceeded just as we did. I did have to run around gathering stuff for an ACL reconstruction, but it wasn't too chaotic; all the stuff was at least sterile and easily accessible right outside in the core. I started grabbing it as soon as the words "ACL" were out of his mouth.

In your case, though, he HAD been sedated, so what he got was NOT informed consent. I guess you could have asked the anesthesia provider just how sedated he WAS; if, in his opinion, his thinking was lucid enough to give informed consent, but, even then, I think I'd be really uncomfortable proceeding on a patient that had been sedated, especially when it involves total joint components.

Back in the '80s, the permits used to simply say "Arthroscopy and arthrotomy." That pretty much gave us carte blanche to open and do whatever we found needed to be done (as does "exploratory laparotomy") after seeing on the screen what the diagnostic arthroscopy revealed, to a point (we didn't proceed with a total knee, mostly because we didn't have the components in stock, a rep had to come, the increased op time would mess up the rest of the day's schedule)--I could see where a permit worded like that would clear you to do what you did involving the preexisting component--after all, it may have been part of the problem that caused the internal derangement of the knee. However, your permit WASN'T worded like that, so therein lies the problem.

This is a really good question. Shodobe does a lot of ortho currently; I wonder what he will say.

You may want to go on the AORN website, http://www.aorn.org, and ask them this question. Let us know what they say.

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informed consent - hahaha :chuckle

how can anyone give informed consent after having sedation .. are they not told not to make any important decisions for 24 hours!

If the procedure was an emergency - OK

if the consent included the possibility for further procedures - OK

but for a knee arthroscopy with menisectomy - that is what they are consented for.

I would not like to be the scrub RN in this situation.

squeek.

Agree whole heartedly! Best practice is to cover one's fanny!! If the consent eluded to the possibility of further procedures and was signed PRIOR to the sedation -- go for it!! Otherwise ---NOPE.

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Specializes in O.R., ED, M/S.

I posed this question to a few of my colleagues and all of them gave me the raised eyebrow response. We were all certain that unless the patient signed the consent prior to be given any sedation, it would be null and void. To have a surgeon change the procedure so drastically during surgery would not be acceptable in my book. All emergencies, at least in California, only needs to have the surgeon make a statement in the progress notes to make it legal. The need to have two MDs sign a consent is only a myth and not legal. We have always made adjustments in procedures depending on what we find but nothing as drastic as going from a simple scope to revision. Mike

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