Lessons for anaesthesia
Steve Yentis: London 9th Dec 2014
Paul Clyburn: Edinburgh 12th Dec 2014
Mike Kinsella: Belfast 22nd Jan 2015
Anaesthetic direct deaths pre-2009
n.b. previous 20 years: 20-50 direct deaths per year
9
8
7
6
n
%
5
4
3
2
1
0
1985-87 1988-90 1991-93 1994-96 1997-99 2000-02 2003-05 2006-08
Direct
deaths
Triennium
attrib. to
anaesthesia
% Direct
deaths
Rate per
100 000
maternities
95% CI
1985-87
6
4.3
0.26
0.12
0.58
1988-90
4
2.8
0.17
0.07
0.44
1991-93
8
6.3
0.35
0.18
0.68
1994-96
1
0.7
0.05
0.01
0.26
1997-99
3
2.8
0.14
0.05
0.42
2000-02
6
5.7
0.30
0.14
0.66
2003-05
6
4.5
0.28
0.13
0.62
2006-08
7
6.5
0.31
0.15
0.64
2009-11
3
3.6
0.12
0.03
0.37
2010-12
4
5.1
0.17
0.05
0.43
Comparing changes in anaesthetic deaths
•
•
•
•
Small numbers
Deaths are often complex
Difficult to attribute to one cause
Previously some deaths ?arbitrarily attributed
to anaesthesia
• Easy to overlook important anaesthetic
lessons in ‘non-anaesthetic deaths’
→ Hence ‘Lessons for Anaesthesia’
Lessons for anaesthesia
• Anaesthetic reviewers looked at all 203 deaths
– very many examples of good practice
– areas where improved anaesthetic care may
have affected outcome
• No. of direct anaesthetic deaths remain low (4)
• Clear that anaesthetists should be involved in
critical periods of care in high-risk women
• Need to be proactive not reactive
Anaesthetic lessons from
direct deaths
Complications after PDPH
• Two women with post-dural puncture headache
– one managed with blood patch
– one managed conservatively
• Not followed up or referred to GP
• Persistent headache for weeks
• Emergency presentation
– cavernous venous sinus thrombosis
– subdural haematoma
Complications after PDPH
• Lessons:
– women with PDPH should be followed up
– GP should be notified
– PDPH is not the only cause of headache
– serious neurological symptoms / signs require
urgent appropriate referral / imaging
– inter-hospital transfer of woman with reduced
consciousness requires medical supervision
– appropriate prescription of anti-VTE prophylaxis
is a team responsibility
Hypoventilation
• Two women had prolonged hypoventilation
during or following GA for PPH
– both overweight
– one possible severe bronchospasm after
induction
– one following extubation + long delay before
re-intubation
• Airway problems + fixation error
• Inadequate post-operative monitoring
Hypoventilation
• Lessons:
– awareness of fixation errors; use of simulation
– value of practice drills of common emergencies
• severe bronchospasm / mechanical obstruction
• difficult or oesophageal intubation
– uniform standards of postoperative monitoring
– recognition of hypoventilation
– adequate volume replacement in (ongoing)
haemorrhage
[Anaphylaxis]
• Peri- / post-mortem tryptase is often elevated
→ Hence elevated peri-mortem tryptase
does not necessarily indicate anaphylaxis
Collapse after anaesthesia
• Two cases of collapse shortly after receiving
bupivacaine
– one following epidural top-up
– one following wound infiltration with 100 mg
• Prompt management incl. use of lipid rescue
• Not attributed to anaesthesia but highlights
ever-present risk
Collapse after anaesthesia
• Lessons:
– be prepared to deal with adverse effects of LA
– availability of Intralipid and protocols
– sudden collapse can occur at any time and the
cause not always apparent
– prompt action & good teamwork / communication
important in managing unexpected catastrophe
Hyperkalaemia
•
•
•
•
•
Pre-eclampsia with mild renal impairment
C-section under spinal anaesthesia
Given postoperative diclofenac
Found to be hyperkalaemic
Not treated immediately → cardiac arrest
Hyperkalaemia
• Lessons:
– hyperkalaemia is a medical emergency &
requires immediate treatment
– NSAIDS contraindicated in impaired renal
function
Anaesthetic lessons from
other cases
Teamworking & crisis management
• Human factors remain an important issue
– communication between and within teams
– leadership
– fixation errors
• Lessons:
– need for ongoing (multidisciplinary) training
– place of simulation
Uterine displacement
• Often not mentioned, or mentioned but
initiated late
• ‘Out of hospital’ use inconsistent
• Lesson:
– ambulance staff should be trained to apply and
record uterine displacement during transfer
Early warning scores
• Sometimes poorly recorded or not acted upon
• Lessons:
– if EWS are in use, they should be applied and
acted upon
– compliance with EWS requires auditing
Abdominal pain
• Severe abdominal pain (not due to labour)
requiring opioids often associated with severe
underlying condition
• Lesson:
– pregnant women with severe abdominal pain
need senior medical review including anaesthetic
Recognition of critical illness
• Failure to recognise critical illness
• Doses of iv induction agents (especially
thiopentone) sometimes felt to be excessive
for critically ill women
• Lessons:
– continued training in recognising critical illness
– improved training in use of thiopentone
– ?continued place of thiopentone in obstetrics
Management of major cases
• Inadequate preparation for / management of
long procedures & major haemorrhage
– temperature measurement & warming
– invasive monitoring
– appropriate volume replacement
• Lesson:
– basic principles of anaesthesia for major
surgery should be applied
Serious Untoward Incident investigations
• SUIs sometimes inadequate
• Frequently no anaesthetist on panel
• Lesson:
– All SUI investigations of pregnant and postpartum
women should include an obstetric anaesthetist
Conclusions
• No. of directly attributed deaths remains low
• Focus on drawing out lessons from all cases
• Much good practice with detailed reflection by
anaesthetic teams
• Anaesthetists are integral members of
multidisciplinary obstetric care & must be
involved proactively
• Important to appreciate human factors
• Anaesthetists must be involved in SUI
investigations
Acknowledgements
• All anaesthetic assessors
• All ICM assessors
• OAA & RCoA