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Cutting corners

01 January 2014

L was a healthy four-year-old boy who had accidentally caught his finger in a bicycle wheel, amputating part of the distal phalanx. In the Emergency Department of the local hospital, it was found that the pulp and nail bed of the finger were lost and the bone of the terminal phalanx was exposed. L was admitted under plastic surgery, fasted, and booked for theatre for terminalisation of the finger.

He was assessed for general anaesthesia by consultant anaesthetist Dr B, who noted that L was a fit and well boy weighing 17.5kg, had no medical problems or allergies, and had been appropriately fasted. Dr B conducted an inhalational induction of anaesthesia, with 70% nitrous oxide, 30% oxygen and 4% sevoflurane via a modified Ayre’s T-piece, using fresh gas flows of 8l/min.

Dr B inserted a laryngeal mask airway (LMA) to maintain the airway, and maintained the anaesthetic with a mixture of nitrous oxide, oxygen and sevoflurane. An intravenous cannula was inserted once L was asleep; 15mcg of fentanyl and 2mg of ondansetron were given during the case and a slow infusion of dextrose saline was administered.

Plastic surgeon Mr T performed the surgery, which proceeded uneventfully. Mr T performed a ring block with 3ml of 0.5% plain bupivacaine for postoperative analgesia. Towards the end of the operation, as Mr T was applying the dressings, the theatre sister, Sr S, noted that L’s pulse was very slow at 45 beats per minute. The pulse oximeter showed that the saturations were 52%.

Dr B removed the drapes and L’s face was noted to be cyanosed and his pupils widely dilated. Dr B removed the LMA, but the throat was clear. He applied 100% oxygen by facemask and an oropharyngeal airway. No pulse was palpable after 20 seconds of high flow oxygen, so Dr B instructed the surgeon to perform external chest compressions. He gave 0.1mg of adrenaline and a second dose after two minutes. The second dose was effective in restoring a palpable pulse, and the oxygen saturations recovered to normal.

Upon attempting to wake L from the anaesthetic, he manifested severe extensor spasms and epileptiform movements of his limbs. He was intubated, sedated and transferred to intensive care. After a prolonged period of care, he was discharged from intensive care with extensive neurological damage consistent with hypoxic brain injury.

An extensive inquiry was undertaken, which highlighted several areas of very deficient anaesthetic care. Dr B had not spoken to L’s parents before the anaesthetic, and had not warned them of the risks of anaesthesia. Dr B said he had finished a 12-hour list with another surgeon and had agreed to help out at short notice. After induction, Dr B had left the reservoir bag concealed under the drapes, where he could not see its movement. He had not used a capnograph to monitor respiration.

He had not recorded a blood pressure or respiratory rate at any time during the case. The monitor alarms had all been switched off earlier in the day and he had not checked or reinstated them. Dr B accepted that there was a protracted period of inadequate vigilance during the case, during which a prolonged episode of severe hypoxia occurred.

This case occurred over a decade ago and L is now a teenager. He has profound impairment of sensation, movement, communication, intellectual function and memory. L’s parents made a claim against Dr B, which was settled for a high sum.

Learning points

  • A series of human and equipment factors interacted in a catastrophic way to bring about this tragic outcome from a trivial initial injury.
  • Fatigue can be a powerful cause of reduced vigilance, and is associated with increased risk of error. It does not amount to a defence. The mnemonic HALT reminds all healthcare professionals to be extra careful if they are Hungry, Angry, Late or Tired. Ask yourself: am I safe to work?
  • Most anaesthetic machines now incorporate capnography automatically. It is also more difficult to switch off all the alarms on the anaesthetic machine. However, distractions in theatre have become more common, including portable electronic devices that can distract healthcare professionals with text messages and emails.