SAFETY AND QUALITY
Anaesthesia-related deaths
Death of 45-year old patient following vascular surgery The NSW Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) has been reviewing deaths associated with anaesthesia and sedation since 1960. Example cases from the 2019 special report are being reproduced in the ANZCA Bulletin in an effort to enhance reporting back to the medical community.
CASE 10 – VASCULAR SURGERY
During resuscitation:
A 45-year-old female for superficialisation of left arm AV fistula.
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Lung ultrasound showed no evidence of pneumothorax.
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TOE showed no obvious PE.
Background history
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No rash noted.
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End stage renal failure secondary to diabetes.
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Adrenaline 7mg and intralipid given.
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Super-morbid obesity (BMI 70).
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Obesity hypoventilation syndrome.
For the entire surgical procedure 21mls of 1% xylocaine with adrenaline had been given.
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Pulmonary embolism on warfarin.
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Recent lower respiratory tract infection.
ANAESTHETIC DETAILS Local anaesthetic with sedation was used for the case.
Postmortem showed mild atherosclerosis of coronary vessels and a heart blood tryptase of 478 µg/L indicative of anaphylaxis.
LEARNING POINTS •
The patient was commenced on high flow nasal prongs and sedated with dexmedetomidine. Loading dose (68 µg) and then an infusion (34 µg/hr).
It is very challenging to sedate someone with obstructive sleep apnoea. There is a very fine line between patient comfort and obstruction in this population.
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Cephazolin 2g was given. The patient was prepped and surgery commenced.
Always suspect anaphylaxis in a patient with a sudden cardiorespiratory deterioration.
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Anaphylaxis caused the patient’s death in this case but to what substance remains unclear.
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Resuscitation in obese patients is always difficult. Despite superb resuscitation efforts in this case the patient still died.
About 30 minutes into the procedure the patient complained of feeling short of breath and hot, saturations began to fall and then the patient lost consciousness, which progressed to a cardiorespiratory arrest. 200mg of suxamethonium was given, the patient was intubated, and CPR started. For 30 minutes resuscitation continued with PEA.
Source: Clinical Excellence Commission, 2021. Activities of the Special Committee Investigating Deaths Under Anaesthesia, 2019 Special Report. Sydney, Australia. SHPN: (CEC) 210176; ISBN: 978-1-76081-648-3.
Fellows are encouraged to read the SCIDUA report in its entirety. The detailed cases and data analysis presented are paving the way forward to a more informative and educational mortality analysis.
Safety alerts
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ANZCA Bulletin
Safety alerts appear in the “Safety and quality news” section of the ANZCA E-newsletter each month. A full list is available on the ANZCA website: www.anzca.edu.au/safety-advocacy/safety-alerts.
Recent alerts: •
Australian impact of regional and global shortage of intravenous solutions (26 July 2024)