Daniel E. Holloway
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American Anesthesiology of Georgia complaint alleges extubation and airway failures after kidney transplant at Piedmont Atlanta Hospital

The complaint alleges that anesthesia providers employed by American Anesthesiology of Georgia, LLC and Piedmont Anesthesia Associates, LLC failed to plan for a kidney-transplant patient’s post-extubation breathing risk despite noting sleep apnea and obesity, and that minutes after he was extubated in the operating room at Piedmont Atlanta Hospital his respiratory and cardiac monitors were found disconnected. He went into cardiac arrest, suffered a hypoxic brain injury, remained unresponsive in intensive care, and was transferred to hospice care on May 10, 2025 before his death.

System
Piedmont Atlanta Hospital
Facility
Piedmont Atlanta Hospital
Providers involved
American Anesthesiology of Georgia, LLC / Piedmont Anesthesia Associates, LLC / Vadim Katsenovich, D.O. / Jiyeong West, P.A.-A.A. / Piedmont Atlanta Hospital
Pattern
Alleged failure to plan for post-extubation breathing risk and to monitor a kidney-transplant patient after extubation
Harm
Alleged cardiac arrest, hypoxic brain injury, and death

Overview

This page concerns a public complaint alleging that anesthesia providers failed to plan for and monitor a kidney-transplant patient’s breathing after extubation at Piedmont Atlanta Hospital, leading to an alleged cardiac arrest, hypoxic brain injury, and death.

Chronology

The complaint alleges as follows:

  1. The patient was admitted to Piedmont Atlanta Hospital on April 27, 2025, and on April 28, 2025 Vadim Katsenovich, D.O. evaluated him, noted sleep apnea and obesity, and rated him at higher risk for difficult intubation.
  2. Jiyeong West, P.A.-A.A. administered the anesthetic drugs, the patient was intubated at 9:56 a.m., and the transplant was completed at 1:16 p.m.
  3. The patient was extubated at 1:20 p.m. and at 1:26 p.m. Dr. Katsenovich was called back to the operating room because the pulse oximeter was not reading and found him on bag-mask oxygen with his respiratory and cardiac monitors disconnected.
  4. The reconnected monitor showed a heart rate in the 30s, the patient had no pulse at 1:38 p.m., a laryngeal mask airway was placed at 1:42 p.m., and he was reintubated at 1:47 p.m. before transfer to intensive care on a ventilator.
  5. A May 4, 2025 brain MRI showed findings consistent with acute ischemia, and the patient was transferred to hospice care and extubated for withdrawal of care on May 10, 2025.

Alleged failures

The complaint alleges the following failures:

  • Dr. Katsenovich failed to appreciate that the patient’s BMI and sleep apnea put him at risk for post-anesthesia hypoxia.
  • Dr. Katsenovich failed to include BiPAP oxygen delivery in the post-extubation anesthesia care plan.
  • Dr. Katsenovich failed to ensure that the anesthetists under his direction used quantitative twitch criteria for Train of Four monitoring.
  • Ms. West failed to use quantitative twitch criteria for Train of Four monitoring, failed to maintain vital-sign monitoring after extubation by removing monitoring devices, and failed to timely establish an airway during resuscitation efforts.

Entities and tags

Piedmont Atlanta HospitalAmerican Anesthesiology of Georgia, LLCPiedmont Anesthesia Associates, LLCKidney transplantExtubationSleep apneaBiPAPTrain of Four monitoringSugammadexCardiac arrestHypoxic brain injuryIntensive care unitAnesthesia and airwayFailure to monitorBrain or spine injuryWrongful deathAnesthesiologyPost-operative airway managementTransplant surgeryCritical care