Arizona – Maxillofacial Surgery – Administration Of Droperidol, Propofol, Ketamine, And Midazolam For Oral Surgery

On 11/17/2010, a maxillofacial surgeon performed oral surgery on a 68-year-old man.  He administered droperidol, propofol, ketamine, and midazolam for sedation.  While being administered these medications, his blood oxygen saturation level dropped by 50% after being given labetalol.  The patient became asystolic.  The maxillofacial surgeon and his assistants administered cardiopulmonary resuscitation, which included compressions and administration of naloxone and flumazenil.  The patient did not recover and died.

On 07/15/2011, the Dental Board ordered that the maxillofacial surgeon complete 16 hours of CME.  The maxillofacial surgeon appealed, but the Arizona Court of Appeals upheld the Dental Board’s decision.  As of 03/16/2015, the maxillofacial surgeon completed the CME required by the Dental Board.

A medical consultant reviewed the case and judged the maxillofacial surgeon’s conduct to be below the minimum standard of competence by failing to obtain pre-operative clearance from the primary care physician, which would have included an EKG, and by failing to monitor the patient with the use of telemetry and continuous ETCO2 monitoring.  The maxillofacial surgeon also failed to have at least one member of his operative staff to be ACLS certified and failed to document the indication for use of the medications he used during the procedure and the code.

The maxillofacial surgeon testified that he completed six months of residency training in anesthesia.  He testified that his goal with the patient was to place the patient in deep to moderate sedation.  He testified that while he was ACLS certified, his two assistants were not.  During an interview with him, the Board expressed concern with the maxillofacial surgeon’s level of understanding of the different types of anesthesia as well as the anesthesia that was administered to the patient.

The Board ordered the maxillofacial surgeon be reprimanded, be placed on probation for 6 months, and take 15 hours of continuing medical education on sedation and general anesthesia.

State: Arizona


Date: October 2016


Specialty: General Surgery, Anesthesiology


Symptom: N/A


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Post-operative/Operative Complication


Medical Error: Improper medication management, Failure to properly monitor patient, Lack of proper documentation, Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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