Mr W, a 30-year-old unemployed factory worker, was admitted to hospital for an elective intra-oral surgical procedure. His preoperative anaesthetic questionnaire was unremarkable except for a history of chronic mood disorder treated with carbamazepine and lithium.
He was assessed preoperatively by Dr X, anaesthetic specialist, who noted that Mr W had recently recovered from a cold.
Dr X used a standard anaesthetic induction protocol utilising fentanyl, propofol and succinylcholine. To allow surgical access to the mouth he intubated Mr W with a naso-tracheal tube.
Immediately after intubation, Dr X had difficulty ventilating Mr W and found evidence of widespread bronchospasm. He was forced to use supra-normal inspired oxygen concentrations, but Mr W’s pulse oximetry remained low at 80-90%; his chest was ‘wet-sounding’ with decreased right-sided air entry.
Dr X thought the most likely problems were drug-related anaphylaxis, pneumothorax or pulmonary collapse due to inhaling a plug of mucus or blood. He exchanged the naso-tracheal tube for an oro-tracheal tube.
An on-table CXR showed consolidation/collapse of the right middle lobe. In the absence of a rash or hypotension, anaphylaxis was thought unlikely. Dr X decided to abandon the procedure after Mr W started to cough forcefully; he extubated Mr W without difficulty.
Dr X immediately sought advice from Dr R, specialist physician. Dr R found scattered crackles with decreased air entry on the right side of Mr W’s chest. Mr W was apyrexial but reported dyspnoea at rest and some chest discomfort on inspiration.
Dr R considered aspiration pneumonitis as the most likely diagnosis and advised treatment with supplemental oxygen, chest physiotherapy, intravenous antibiotics and hydrocortisone. Dr R reviewed Mr W later that day.
He was coughing up some bloodstained sputum but felt and looked much better. Mr W was discharged home with oral antibiotics three days after his adverse anaesthetic event. He appeared to have fully recovered and a CXR showed some minor non-specific shadowing at the right mid/basal zone, significantly improved compared to previous x-rays.
Mr W sued Dr X, alleging that he had caused permanent damage to his trachea and lungs in the way he had used his equipment and that his suitability for anaesthesia had not been adequately assessed. Mr W also claimed that he was not adequately monitored during anaesthesia, that an anaesthetic was given when Dr X should have known that there was fluid or phlegm in his lungs, and that Dr X had given him insufficient oxygen.
An anaesthetic expert thought that Mr W had suffered aspiration of blood from the nasal passages or gastric contents into the right lung, or possibly atelectasis due to the presence of a mucus plug.
The expert could find no evidence of negligent or sub-standard conduct by Dr X in the way that he had administered the anaesthetic or managed its complications. He had kept good records of the course of events, his actions, clinical thought processes and Mr W’s physiological parameters.
The expert thought it unlikely that Mr W had suffered any permanent injury as a result of the anaesthetic. Similarly, an expert respiratory physician found no clinical, spirometric or radiological evidence of any harm to Mr W’s respiratory system.
It was noted that Mr W complained of difficulties in breathing but it was felt that there was no organic physical cause for these symptoms. Rather, Mr W’s mood and his weight disorder were more relevant to his symptoms. We rebutted the claim.
Mr W’s solicitors continued to pursue the case, obtaining expert opinion suggesting that gastric intubation may have caused the problems. Our experts reviewed the x-rays and notes. They agreed that there was no evidence to support this hypothesis, and that such an event would still be entirely defensible given Dr X’s management of events.
Shortly afterwards Mr W and his legal representatives withdrew the claim before it went to court.
Defence – Dr X’s rapid and appropriate management of the complication, his good documentation and timely involvement of a colleague from another specialty aided his defence.
Recent review papers – Asai T., Editorial II, Who Is at Increased Risk of Pulmonary Aspiration? Br J Anaesth 93 (4):497–50 (2004).
Kalinowski CP and Kirsch JR. Strategies for Prophylaxis and Treatment for Aspiration. Best Pract Res Clin Anaesthesiol 18 (4):719–37 (2004).