Hydromorphone (brand name Dilaudid) is a powerful analgesic that can cause death if not carefully monitored.
At 28 years old, Anders Pederson had been close to his older sister, Kelly, their entire lives. After a childhood E.coli infection damaged her kidneys, Kelly needed a kidney donation and her brother stepped up. Following a rigorous work-up and preparation, the siblings underwent the transplant procedure at The University of California San Francisco (UCSF), which had a good record and annually performed a large number of kidney transplants.
Following the procedure, Kelly showed quick improvement while Anders struggled with significant pain. Given his discomfort, a nurse practitioner altered his medication from Fentanyl to Dilaudid, quadrupling his dose by some media reports. Mr. Pederson was on a patient-controlled anesthesia pump (PCA). The following morning, Anders mom checked on her son to find him cold. While the crash team was able to restart his heart, he never regained consciousness and was declared brain dead and removed from life support nine days later. The family was told Anders had a congenital heart issue that caused his heart to stop.
Dilaudid is a powerful opioid pain reliever. As a sedative, hydromorphone can and does interfere with breathing and can lead to respiratory arrest. A study published in the Journal of Patient Safety from Dartmouth-Hitchcock Medical Center found approximately 180,000 people experience adverse opioid events each year in hospitals. Of those, an estimated 5,000 people die. A legislative bill requiring hospitals to monitor patients for opioid-induced respiratory distress was introduced in the House in November 2021.
The recent donation of a kidney left Anders even more vulnerable to opioid overdose. Dilaudid packaging warns of using the medication in patients with renal impairment. Staff did not provide a simple pulse oximeter to Anders, which would have sounded if his blood oxygen dropped. Further, despite being on Dilaudid, nursing staff did not monitor his vital signs for approximately five hours.
When the family requested the medical records, the hospital provided 40 pages of records. After the family retained an experienced medical malpractice attorney, the hospital provided another 44,000 pages. On review, an expert witness testified to 30 failures in the post-operative care of Mr. Pederson.
The hospital denied any liability for the death. The court ultimately found in favor of the family and ordered the hospital to pay $2 million, which was reduced to $250,000 given California liability caps. UCSF has since modified their transplant program protocol to include continuous pulse-ox monitoring for post-operative pain control.
If the Opioid Safety Act is eventually passed, all patients on opioids would be required to have continuous monitoring. Until then, the tragedy that occurred to Anders Pederson is likely to happen again.
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