among other ailments. He alleges that he slid off the table while in the
Trendelenburg position. Mr. Purvis sued the surgical facility, claiming
it had failed to properly secure him on the tilted operating table, lead-
ing him to slide off and fall on the floor while he was under anesthe-
sia. After a 9-year legal battle, the medical center last year admitted its
error and settled out of court with the patient.
• Pulseless electrical activity. Another cautionary tale from anes-
thesiologist Jayesh Dayal, MD, owner of the White Flint Surgery
Center in Rockville, Md., serves as a reminder to check your patient's
radial pulse during surgery, particularly longer cases. During his resi-
dency, he remembers the case of an obese 22-year-old woman in
Trendelenburg for a tubal ligation. Her EKG and blood pressure both
looked perfectly normal on the monitor, but when Dr. Dayal happened
to check the patient's pulse, there was none. The weight of the
woman's internal organs was pressing against her heart and "wringing
it like a rag, literally squeezing the life out of it." This caused the heart
to beat but not pump any blood, a condition known as pulseless elec-
trical activity — cardiac arrest in which the electrocardiogram shows
a heart rhythm that should produce a pulse, but does not. If it went
unrecognized for long, the patient likely would have been brain dead,
says Dr. Dayal.
"This happens commonly enough, but most people aren't aware of
it," he says. "I just happened to check the pulse — everything else
looks perfectly normal. How many times do you check a pulse during
a case?"
The OR team eased the patient off Trendelenburg so the heart had
room to fill, which brings Dr. Dayal to his next point: A few degrees
less of Trendelenburg could reduce the risks of position-related com-
plications without increasing the difficulty of the surgical procedure.
"Surgeons keep asking for more and more Trendelenburg, espe-
7 2 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J A n U A R Y 2 0 1 8
