April 2016

  A four year-old child was administered morphine during tonsillectomy and adenoidectomy surgery.  An anesthesiologist determined that 1.5 mg of morphine was appropriate for a child of his age and size and that dose was given either by the anesthesiologist or a certified registered nurse anesthetist who was involved in the case.

  The mother’s lawsuit later tried to claim that 15 mg was given, but the hospital pointed out the largest vial of morphine available at the hospital held only 10 mg. The wasting of the remaining 8.5 mg of morphine was not documented in the chart.  However, the wasting of the fentanyl that was ordered but not used was documented.

  The child’s pulse oximetry was documented at 99-100% O2 saturation while he was intubated throughout the procedure.  In the post-anesthesia care unit (PACU) the child was given 20 mcg of Narcan because he was still very sleepy after he was extubated.  A hospital pharmacist testified that that Narcan dose would have completely reversed a 15 mg dose of morphine even if that much morphine had in fact been given.  The anesthesiologist who was on call for the PACU who ordered the Narcan also wrote an order that morphine was to be discontinued.

  Based on that order in the chart the nurses who were on duty that afternoon in the PACU all testified they would have given no morphine to the patient. Drowsiness continued in the PACU after the Narcan was given.  The child was given albuterol breathing treatments, O2 was continued through a mask and a chest x-ray was taken.  A pediatric consult recommended transfer to the city’s children’s hospital, which was done later that night.