Is it medical malpractice if a patient with 5 days of abdominal pain, nausea, poor oral intake, acid reflux, dizziness, and fatigue, and lab results showing metabolic acidosis (pH 7.24, low bicarbonate, elevated anion gap (AG), and elevated C-reactive protein (CRP)), was diagnosed with early acute appendicitis and underwent surgery despite worsening metabolic acidosis, and was discharged without treatment for the acidosis, only to be readmitted with severe metabolic acidosis?

Medical Negligence Assessment: Failure to Recognize and Treat Progressive Metabolic Acidosis

This case represents a catastrophic failure in perioperative care, with multiple critical deviations from standard medical practice that directly resulted in life-threatening metabolic acidosis. The patient presented with clear laboratory evidence of metabolic acidosis (pH 7.24, bicarbonate 17, anion gap 15) that was ignored, progressively worsened during prolonged NPO status and surgery (bicarbonate dropping from 17→13→6→4), and the patient was discharged despite severe acidosis requiring immediate intensive intervention. 1, 2, 3

Critical Failures in Standard of Care

Failure to Recognize Pre-operative Metabolic Acidosis

The initial presentation with pH 7.24, bicarbonate 17, anion gap 15, and elevated lactate 1.3 should have triggered immediate investigation for the underlying cause before any surgical intervention. 1, 3

• The combination of 5 days of poor oral intake, nausea, and these laboratory values suggests starvation ketoacidosis or medication-related metabolic derangement that required correction before elective surgery 4, 5
• The elevated anion gap (15) indicates accumulation of unmeasured anions beyond simple dehydration 6, 5
• No ketone or beta-hydroxybutyrate levels were ever checked despite clear indication—this represents a fundamental diagnostic failure 4, 5

Catastrophic Intraoperative Management

Proceeding with surgery when bicarbonate dropped from 17 to 13 (10 hours pre-operatively) demonstrates gross negligence, as this progressive worsening should have prompted immediate surgical cancellation and metabolic stabilization. 1, 2

• The American Society of Anesthesiologists recommends immediately addressing underlying causes of metabolic acidosis and considering abbreviated surgery when pH < 7.2 or base deficit > 8 1
• Keeping the patient NPO for 20+ hours without adequate intravenous dextrose or bicarbonate replacement in the setting of known acidosis directly worsened the metabolic crisis 1, 3
• Surgery should have been delayed until the cause of acidosis was identified and corrected—proceeding with elective appendectomy in this metabolic state violates fundamental perioperative principles 1, 2

Egregious Post-operative Discharge Decision

Discharging a patient with bicarbonate of 6, anion gap 21, and potassium 5.5 represents one of the most dangerous decisions in this case sequence. 2, 3, 7

• Bicarbonate of 6 mmol/L indicates severe, life-threatening metabolic acidosis requiring immediate intensive care admission, not discharge 7, 6
• The FDA label for sodium bicarbonate explicitly states that severe metabolic acidosis requires urgent treatment, and bicarbonate of 6 would typically correspond to pH < 7.0 7
• This patient required immediate ICU admission, continuous hemodynamic monitoring, arterial blood gas monitoring every 2-4 hours, and likely bicarbonate therapy or renal replacement therapy 1, 3, 7

Failure to Investigate Medication History

The medication use "until the morning of presentation" was completely ignored despite being a critical piece of the diagnostic puzzle. 4, 5

• Multiple medications can cause high anion gap metabolic acidosis, including metformin (lactic acidosis), acetaminophen (5-oxoproline acidosis), and salicylates 4, 5
• The failure to obtain and act on medication history represents a fundamental breach in diagnostic evaluation 4, 5

Specific Deviations from Guidelines

Fluid Management Failures

• Prolonged NPO status (20+ hours) without adequate intravenous dextrose in a patient with poor oral intake for 5 days directly caused or worsened starvation ketoacidosis 1, 3
• The World Journal of Emergency Surgery recommends balanced crystalloid resuscitation and early enteral nutrition, not prolonged fasting in metabolically compromised patients 8, 3

Monitoring Failures

• Serial lactate measurements and base excess monitoring should have been performed every 2-4 hours given the progressive acidosis 1, 3
• No ketone or beta-hydroxybutyrate levels were ever checked despite clear indication 4, 5
• The progressive drop in bicarbonate (17→13→6→4) over 30+ hours without intervention represents complete failure of monitoring protocols 1, 2

Treatment Failures

When bicarbonate reached 6 post-operatively, immediate treatment was mandated, not discharge. 7

• Sodium bicarbonate administration is indicated for severe metabolic acidosis, particularly when pH < 7.15 or bicarbonate < 10 mmol/L 1, 7
• The patient required 2-5 mEq/kg sodium bicarbonate over 4-8 hours, with careful monitoring to avoid overcorrection 7
• Urgent hemodialysis or continuous renal replacement therapy should have been considered for acidosis this severe and refractory 3

Life-Threatening Readmission

The readmission within 2 hours with bicarbonate 4, anion gap 23, base excess -25, and respiratory rate 42/min represents near-fatal metabolic acidosis that was entirely preventable. 2, 3

• This degree of acidosis (bicarbonate 4) typically corresponds to pH < 6.9, which is incompatible with life without immediate intervention 6
• The respiratory rate of 42/min represents maximal respiratory compensation (Kussmaul breathing) for severe metabolic acidosis 6
• This patient was at imminent risk of cardiac arrest, as severe acidosis causes decreased cardiac output, arrhythmias, and catecholamine resistance 1, 6

Standard of Care Violations

Pre-operative Assessment

Any patient with metabolic acidosis (pH < 7.35, bicarbonate < 22) requires identification and correction of the underlying cause before elective surgery. 1, 3

• The creatinine of 55 μmol/L (if this is the unit) suggests normal renal function, ruling out renal failure as the cause 6
• The elevated CRP (39) suggests inflammation but does not explain the metabolic acidosis 8
• The diagnosis of "very early acute appendicitis" cannot explain pH 7.24 and bicarbonate 17 on presentation—this degree of acidosis requires a different or additional diagnosis 8, 2

Intraoperative Decision-Making

The Society of Critical Care Medicine recommends avoiding surgical intervention delay when peritonitis is present, but also states that few hours of resuscitation are necessary before surgery to prevent hemodynamic instability. 1

• In this case, the patient had 5 days of symptoms without peritonitis, making this a semi-elective rather than emergent case 8
• The progressive worsening of acidosis during the pre-operative period (bicarbonate 17→13) should have prompted surgical cancellation 1, 2

Post-operative Management

The Enhanced Recovery After Surgery (ERAS) guidelines emphasize early feeding and mobilization, but these principles cannot be applied to a patient in severe metabolic crisis. 8

• This patient required ICU-level care, not discharge 2, 3
• The failure to recognize that bicarbonate 6 represents a medical emergency, not a discharge criterion, is indefensible 7

Health Canada and Medical Negligence Standards

While I cannot provide a definitive legal opinion on whether this constitutes medical malpractice under Health Canada guidelines (as medical malpractice is determined by provincial medical regulatory authorities and courts, not Health Canada), this case demonstrates multiple severe deviations from the standard of care that any reasonable physician would recognize as dangerous:

1. Failure to diagnose the cause of metabolic acidosis before surgery 1, 3, 5
2. Proceeding with surgery despite worsening acidosis 1, 2
3. Discharging a patient with life-threatening metabolic acidosis (bicarbonate 6) 2, 3, 7
4. Failure to check ketones or beta-hydroxybutyrate despite clear indication 4, 5
5. Failure to obtain and act on medication history 4, 5
6. Failure to provide adequate monitoring and treatment for progressive acidosis 1, 2, 3

Each of these failures independently represents a significant deviation from standard care; collectively, they resulted in a preventable near-fatal outcome. 1, 2, 3