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A dangerous cough

01 May 2012

Mrs T, a 58-year-old music teacher, was admitted to her local hospital for an elective total abdominal hysterectomy for post-menopausal bleeding.

She was seen on the day of surgery by consultant anaesthetist Dr Q, who noticed she had a cough. Mrs T said she had recently had a chest infection and had been prescribed a course of antibiotics from her GP. However, she was vague about how long she had had her cough, and whether she had finished the antibiotics.

She dismissed her symptoms as a “smoker’s cough” and was insistent that the operation should go ahead, as she wanted it to be “all over and done with” in time for her son’s wedding a few weeks later. She also requested a general anaesthetic.

Dr Q did not discuss the case with the consultant gynaecologist Ms R. Later it was revealed that they had “fallen out following a disagreement”. Dr Q agreed to proceed with general anaesthesia. Dr Q induced general anaesthesia using a standard technique and intubated the trachea. However, he found the airway pressures unexpectedly high. He reasoned that the cause was bronchospasm. He adjusted the ventilator settings, deepened anaesthesia and administered intravenous salbutamol to relieve the spasm.

After a few minutes, things seemed to improve and the operation went ahead. Mrs T was coughing on the tube at the end of the operation, but was extubated. However, she continued to cough vigorously in the recovery area and was clearly in difficulty, with very low oxygen saturations and a high respiratory rate.

Shortly afterwards Mrs T rapidly developed subcutaneous surgical emphysema and suffered a cardiac arrest. Cardiac compressions were performed and intravenous adrenaline was administered. A circulation returned, although she remained very unstable. A chest x-ray was performed, which showed a tension pneumothorax. A chest drain was inserted, which improved stability, and she was reintubated. She was transferred to the intensive care unit, where she was found to have signs of a right lower lobar pneumonia. Oxygenation was very difficult.

She had a prolonged and turbulent course in intensive care, complicated by pneumonitis and multi-organ failure, and was eventually found to have cognitive impairment consistent with hypoxic brain injury. There were limited records of what happened during induction, anaesthesia and recovery, and most of the medical record was found to have gone missing. The recovery nursing notes included an incident form for “difficult airway maintenance” and she was noted to have arrived in recovery in a “very poor state”. A claim was brought on Mrs T’s behalf against Dr Q, which was settled for a high sum.

Learning points

  • Your first obligation is to act in the patient’s best interests and you should not be pressurised by the patient into doing anything that is counter to this. In elective surgery, it is important to avoid pressure to proceed. In this case, finding out that Mrs T had pneumonia might have prevented this outcome.
  • When administering anaesthesia during an elective procedure, it is preferable to stop should you encounter difficulties and reassess for surgery another time.
  • Good communication between professionals is essential in patient care. Had the anaesthetist and the surgeon discussed this patient, it might have been possible to perform a vaginal hysterectomy under spinal anaesthesia, or the case could have been postponed until later.
  • Good, careful, well-kept records help provide a good defence. In this case, the nursing records and their understanding of the events were the only written documents to go by. Safeguarding the integrity of records is even more important after an adverse event.
  • Bronchospasm is an important and treatable cause of high airway pressures and tension pneumothorax during ventilation, but not the only one. The differential diagnosis includes endobronchial intubation, foreign body in the airway, and equipment problems such as kinks and obstructions.
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