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An anaesthetist's nightmare

01 February 2005

An hour after apparently recovering well from an operation on her thyroid gland, Mrs J started to bleed severely from her wound. She was immediately returned to the operating theatre and Dr F, her anaesthetist, was called to see her.

On examining Mrs J, Dr F could see that the bleeding was indeed severe and that her airway was becoming obstructed. He concluded that the wound should be re-opened as soon as possible and decided to proceed with anaesthetising the patient while waiting for the surgeon to arrive.

He carried out a brief check of the anaesthetic machine and quickly prepared the endotracheal tube and drugs. The carbon dioxide monitoring system was prepared by an operating department assistant and handed to him fully assembled by the time he had finished intubating the patient.

The next thirty minutes were probably the longest and worst of Dr F’s life as he found himself in an escalating nightmare. It began when he turned to check the monitor screen and noticed that the normal end-tidal carbon dioxide wave forms were not present.

Dr F immediately switched off the ventilator, turned the gas onto 100% oxygen and ventilated the patient by hand, but he found inflating the lungs difficult and asked the nurses to go and find anaesthetists and surgeons to help him.

Thinking that the bleeding might be distal to the tip of the endotracheal tube, Dr F re-intubated the patient with a longer tube; ventilation was still difficult, however, so he tried suction to clear the endotracheal tube and the lower trachea of any possible obstructions, but again with no effect.

He concluded that blood must be compressing the lower airways and that the wound must be re-opened immediately.

With his free hand he took a scalpel and cut the wound, opening it with a pair of forceps, all the while ventilating the patient manually with his other hand. Although opening the wound released a gush of blood, he found it no easier to inflate the patient’s lungs; her oxygen level was becoming critically low. Changing the endotracheal tube for a third time made no difference.

He was no doubt much relieved when two consultant anaesthetists and two surgeons arrived to help him. They checked that the anaesthetic machine was functioning properly but there were no obstructions or problems with the oxygen flow from the Y-piece; a repeat endobronchial suction confirmed that there was no obstruction in the endotracheal tube. Meanwhile, one of the surgeons and an anaesthetist administered adrenaline, aminophylline, steroids and mannitol to Mrs J.

Mrs J’s oxygen saturation levels were plummeting and about eight minutes after the anaesthetic had been started she was showing signs of brain hypoxia.

The two surgeons explored the surgical site and stopped the bleeding, but the patient’s heart rate began to slow. After a further injection of adrenaline failed to help, the surgeons started external cardiac massage.

The anaesthetists meanwhile were still vainly trying to track down the cause of the problem and Dr F decided to change the endotracheal tube one more time.

As he disconnected it from the circuit, one of his colleagues deflated the reservoir bag and could immediately feel from the way the oxygen left the bag that something was wrong with the outlet. He quickly removed the carbon dioxide straight connector from the circuit.

Inside was a foreign object – a small piece of plastic. Unfortunately this discovery came too late to save Mrs J who suffered irreparable brain damage and died a few days later.

Her family sued both Dr F and the hospital, and accepted an out-of-court settlement.

Learning points

Reporting in May 2004, an expert group commissioned by the CMO in England made a series of recommendations for protecting breathing circuits. Among these were:

  • keeping small disposable plastic waste out of the anaesthetic area
  • protecting vulnerable PBC components by keeping them wrapped (with warning labels) until use
  • reinforcing checking procedures and training staff to be aware of the hazard

The full report, ‘Protecting the Breathing Circuit in Anaesthesia’, can be viewed on the Department of Health website – www.gov.uk/government/organisations/department-of-health.

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