perioperative death


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Perioperative Death An Anesthetist’s Perspective:

Perioperative Death An Anesthetist’s Perspective Muralidharan

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2 Working as, anesthesiology. Now exposed to critical care unit.

Point of interest:

Point of interest Deaths that occur during or within a short time after a surgical operation, invasive diagnostic procedures or an anesthesia are usually the subject of medico legal investigations 3

Perioperative Death:

Perioperative Death It is potentially the most stressful event we experience as anesthetists. With feelings of sadness built in regret. 4

Perioperative Death:

Perioperative Death 5 SOMETIMES TITLED AS Anesthetic death Death on Table

Unfortunate title for us:

Unfortunate title for us 6


Definition Death from any cause within 48hrs of surgery. The lancet. 7

In England:

In England National confidential enquiry into perioperative death (NCEPOD) consider perioperative death as death within 30 days of a surgical intervention 8

Classified as::

Classified as: Due to anesthesia Due to surgery Due to invasive procedures 9

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My is only on anesthetic death . 10

Anesthetic Death Definition :

Anesthetic Death Definition The recent studies defined mortality associated with anesthesia as a death under anesthesia or as a result of anesthesia and death within 24hrs of an anesthetic procedure. Dept . of Anaesthesia , Aga Khan Univ. Karachi, Pakistan. FCPS Assist. Professor . FRCA Professor. 11

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Can be classified further into 4 groups according to the cause of the death Journal of clinical pathology 1999 52 640-652 Roger. D. Start et al 12

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Directly caused by the disease for which anesthesia was being performed eg: aneurysmal rupture during aneurysmal repair Caused by a disease other than for which anesthesia was being performed eg: CAD patient dying in a whipples resection Resulting from a mishap of the surgery eg: rebleeding in Tonsillar surgeries Resulting from a mishap of anesthesia eg: slipped ETT in cleft lip and palate surgery 13

We call it as Catastrophes in anesthetic practice :

We call it as Catastrophes in anesthetic practice 14

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Although anesthetic mortality remains low compared with traffic fatalities or suicide, it still remains high compared with death caused by air travel , which is a commonly used yardstick to benchmark the risk of anesthesia. 15


Incidence High in the developing countries High with emergency and complex surgeries High with age High with inadequate preop preparation Inappropriate postop care Lack of supervision 16

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It has been suggested that anesthesia related mortality has decreased in the last 3 decades and currently ranges between 0.05 to 10 per 10000 anesthetic procedures. Kawashima et al British journal 95 (1) 95-109 2005 17

Timing of perioperative mortality:

Timing of perioperative mortality Majority occurs in the postoperative(51%) Intraoperative(37%)and during induction(9%) of anesthesia 18

Specifically Speaking:

Specifically Speaking 19 Cause Frequency (%) Drug overdose or selection error 15.3 Serious arrhythmia 13.9 Myocardial infarction, ischemia 8.8 Inadequate airway management 7.9 High spinal 7.4 Inadequate vigilance 6.9

Human errors can be of 3 types :

Human errors can be of 3 types Technical - Machine error Judgmental - Poor decision making Monitoring and vigilance failure Cooper et al 1978 20

Elaboration on this can be as follows:

Elaboration on this can be as follows 21

Problems with breathing system:

Problems with breathing system Disconnections Misconnections Leaks 22

Problems in administration of drugs :

Problems in administration of drugs Over dosage Under dosage Wrong drug NO SAFE DRUGS; ONLY SAFE ANAESTHESIOLOGIST 23

Problems with intubation and airway:

Problems with intubation and airway Failed intubation Difficult ventilation Esophageal intubation Endobronchial intubation Accidental or premature extubation Aspiration 24

Failure of equipment :

Failure of equipment Laryngoscopes Intravenous infusion devices Anesthesia work station Monitoring devices 25

Why does this occur ?:

Why does this occur ? Inattention/carelessness Haste Unfamiliarity with equipment Failure of planning Lack of skilled assistance Lack of supervision Fatigue and decreased vigilance 26

Prophylactic measures:

Prophylactic measures Improve the preoperative assessment Provide preoperative preparations Improve the monitoring standards Provide balanced anesthesia Provide adequate post operative care Provide adequate supervision Proper auditing of critical incidents 27

It should have been prevented by above measures:

It should have been prevented by above measures 28

It had happened:

It had happened 29

The impacts:

The impacts Professional malfunctioning undermines confidence Communication struggle during breaking news Medico legal Fear of litigation 30

Prayer is always appropriate :

Prayer is always appropriate 31 Aftermath We breathe curse, pray, sit down and take a moment to regain our composure

Proper documentation:

Proper documentation Helps anesthesiologists, surgeon and forensic expert 32

Put every moment in black and white:

Put every moment in black and white The more detail, the better 33

Documentations after the event:

Documentations after the event P repare the accurate records Don’t alter the original notes Amendments and additions are recorded separately Preoperative visit details are included Consent form and relevant investigation reports are collected 34

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2 copies (twins) of all the above documents are collected and 1 set is kept as personal copy for further reference. 35

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Documentation should be completed as soon as possible to facilitate transfer of the body to the mortuary 36

Documentation checklist :

Documentation checklist When the patient was first seen by whom? What was prescribed? Investigation reports Plan of anesthesia Critical incidents Remedial measures Senior Help sought 37

Dealing with the deceased:

Dealing with the deceased 38

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Death occurring whilst under anesthesia will necessitate further investigation and necropsy So all lines, tubes, drains, and other equipment are left in place Detailed description should be made thereof . 39

Handling the relatives:

Handling the relatives 40

Be empathetic:

Be empathetic 41

Communicating with relatives :

Communicating with relatives Quiet comfortable room to sit Help from a senior Surgical and nursing colleague are included Explain the serious complications Tried remedial measures detailed Answer all immediate questions 42

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We don’t give too much detailed info initially, but rather schedule a second meeting if necessary to answer further questions 43

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Information about the procedure that will follow regarding the necropsy and whom they can liaise with to enquire when the body will be released to funeral arrangements 44

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We complete an un natural death form which will go to the forensic pathologist for necropsy 45

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If basic standard of care was applied to the patient and reasonable steps were taken to prevent the anticipated complication, the clinicians have no reason to fear the outcome of necropsy 46

Tug of war begins here:

Tug of war begins here 47

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The investigation of these death by no means is always easy. The dividing line of responsibility between the surgeon and anesthetist is not well defined. 48

Before Peri operative death:

Before Peri operative death Surgeons and anesthesiologists team up for a common goal 49

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After on table death:

After on table death 51 They usually fight and blame each other

Surgical Mishap:

Surgical Mishap Anatomical, so often observable at necropsy But if necropsy is delayed autolysis ensues, so it will be difficult to arrive at a conclusion regarding the cause of death 52

Anesthetic Mishap:

Anesthetic Mishap Morphological findings maybe minimal or absent Toxicological investigations inconclusive Usage of complex anesthetic agent further complicates 53

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That doesn’t mean that clinicians are safe from litigation 54

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It should be like that, Shouldn’t it ? 55

You people :

You people are the best judges 56

The big Question in front of you is :

The big Question in front of you is 57

Would death have occurred, if the operation had not been performed? :

Would death have occurred, if the operation had not been performed? 58 Difficult to answer Isn’t it?

Here starts the War Between:

Here starts the War Between Anesthesiologist & Forensic Pathologist 59

This often happens nowadays:

This often happens nowadays 60

This attitude between forensic pathologist and clinician should not happen:

This attitude between forensic pathologist and clinician should not happen 61

Let’s team up and avert perioperative death:

Let’s team up and avert perioperative death 62


N ecropsy It is the Search for the Cause Not for the Culprits 63

Your role starts here:

Your role starts here 64

It’s not easy. Proceed with caution:

It’s not easy. Proceed with caution 65

Hurdles in front of you are due to the following factors:

Hurdles in front of you are due to the following factors 66

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Effects of surgery and anesthesia super-imposed on pre-existing natural disease Naked eye changes may be limited or absent Possible mechanism of death is complicated Lack of communication between forensic pathologist and clinicians 67

Hurdle clearing:

Hurdle clearing Perform necropsy with minimal delay Ask clinician to leave medical interventions intact Study case notes, x-rays lab results prior Polite and professional first-hand discussions with clinicians involved 68

Tread slowly and cautiously:

Tread slowly and cautiously You can do justice to the both clinician and the deceased 69

Prerequisites for necropsy:

Prerequisites for necropsy Devices inserted should not be removed Collect anti mortem blood samples Collect anti mortem culture reports Collect images and radiographs These may give you evidence 70

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Clinicians / experts have to be invited to attend autopsy and to discuss the finding Specimen should be retained for toxicology, bio-chemistry, micro-biology and histology Modifications of necropsy technique can be done 71

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Searching the cause for perioperative death, the forensic pathologist should know about the pre morbid status of the deceased person which can be very well assessed by the classification system to grade the preoperative condition of the patient 72

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All anesthetists in India follow American Society of Anesthesiologists classifications preoperatively 73

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The American Society of Anesthesiologists (ASA) has classified patients into a number of grades according to their clinical condition for assessing their physical fitness to undergo anesthesia . Dripps et al 74

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ASA Class 1-3 requires full medico legal investigation Class 4-5 where death is anticipated , there is less need for full investigation 77

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If the operation is an emergency, the letter ‘E’ is placed beside the numerical classification and the patient is considered to be in poorer physical condition. 78

Review of case ends here:

Review of case ends here 79

Next is the preparation of necropsy and necropsy dissection which includes internal and external examination :

Next is the preparation of necropsy and necropsy dissection which includes internal and external examination 80

The next few slides may give you an idea about what had happened inside the operation suite where you are barred:

The next few slides may give you an idea about what had happened inside the operation suite where you are barred 81

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It’s not magic’s, but anesthesia’s 82

I am not a:

I am not a 83

Tips for grabbing some evidences during necropsy:

Tips for grabbing some evidences during necropsy 84

Infer CPR and defibrillation:

Infer CPR and defibrillation Fracture of the ribs Fractured sternum Contusions and burns over chest 85

Infer Fall from operation table :

Infer Fall from operation table Slipped shoulder and hip Fractured rib Any other fracture not recorded premorbidly 86

Infer fluid overload :

Infer fluid overload Edema Conjunctival chemosis Bloated look with sacral edema Voluminous lung 87

Infer difficult mask ventilation :

Infer difficult mask ventilation Erythema and contusion over face Cuts on lips Erythema over angle of mandible Distended stomach and intestine Jaw dislocation 88

Infer difficult intubation:

Infer difficult intubation Cuts on lips Injury to tongue Loss of teeth Injury to pharyngeal wall Injury to vocal cord Tracheal injury 89

Infer hypotension:

Infer hypotension Multiple venous puncture sites Central venous canulation Necrosis of tissue around venous puncture site maybe due to extravasation of vasopressors Multiple blood transfusion 90

Infer hypoxemia:

Infer hypoxemia Arterial canulation Multiple ABG reports 91

Infer pneumothorax:

Infer pneumothorax Chest drain Needle thorachotomy 92

Infer difficult spinal/epidural:

Infer difficult spinal/epidural Multiple skin puncture over the back at lumbar or thoracic area This area should be dissected till Dura to find out multiple Dural puncture Multiple skin puncture does not necessarily indicate multiple Dural puncture 93

Death following Tonsillar surgery:

Death following Tonsillar surgery Tonsillar surgery-coroner clot Distended stomach with blood Aspiration of blood to the lung 94

Death following Nerve Block :

Death following Nerve Block Dissect the site to find out in advertant vessel puncture Look for any extravasation and necrosis This will give you an idea that the local anesthetic was mixed with adrenaline 95

Death following ophthal surgeries:

Death following ophthal surgeries Purely negative necropsy because the death may be due to occulocardiac reflex Search for limbal incision over the eyeball Look for chemosis 96

Got the tips? So, we are proceeding to external examination :

Got the tips? So, we are proceeding to external examination 97

External examination:

External examination Prepare body chart Note all invasive lines, surgical scars, wounds, etc. Look for edema, jaundice and rashes Look for bruising and loss of dentition 98

Internal examination:

Internal examination Commonly recommended incision for head and neck region begins behind the ears on both sides, passes down over the posterolateral aspect of the neck and crosses the clavicle over the outer third Cotton DWK. The basic hospital autopsy. In: Cotton DWK, Cross SS, eds.The hospital autopsy, 1st ed. Oxford: Butterworth Heinemann, 1993:37–66 99

Collect samples from ::

Collect samples from : Effusions Hemorrhages Pus No preservatives And send for microbiology and histopathology 100

Internal Examination includes various organ specific searches for evidences:

Internal Examination includes various organ specific searches for evidences 101

During examination of the heart:

During examination of the heart 102 Air embolism Venous Embolism Central Venous Cath Pacemakers Prosthetic valves Bypass Grafts Angioplasty

Look for ::

Look for : Thrombo Embolism Pneumo thorax Hydro thorax Haemo thorax Voluminous Lung 103

The Brain:

The Brain Air Embolism Stents and clips Shunts Bleeding Contusions 104

Look for ::

Look for : Stents Clips Dilatations Anastomosis Slipped sutures Perforations 105

Musculoskeletal System:

Musculoskeletal System Rule Out Fractures Look for prosthesis 106

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Even then, it is very difficult to find out evidences in perioperative mortality 107

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So as to decrease perioperative mortality, the clinicians can follow these steps 108

What we clinicians can do?:

What we clinicians can do? Use guidelines Team training Implement safety check list Critical incident reporting Regular morbidity mortality meeting 109

What should you do?:

What should you do? Refer hospital notes Refer operation, anesthetic records, lab reports Video Records, if any, should be examined It is prudent to Contact the relevant clinician Collect lab reports and radio-graphs, if any 110

SO let’s stop blaming each other and avert Perioperative Death:

SO let’s stop blaming each other and avert Perioperative Death 111


References 1. White SM., 2003. Death on the table . Anaesthesia , (58) p.515-519 2. Aitkenhead AR., 1997. Anaesthetic disasters: handling the aftermath. Anaesthesia , (52) p.477-482 3. Bacon AK., 1989. Death on the Table. Anaesthesia , (44) p.245-248 4. Association of Anaesthetists of Great Britain and Ireland (AAGBI), 2005. Catastrophes in Anaesthetic Practice – Dealing with the Aftermath. London: Association of Anaesthetists of Great Britain and Ireland. 5. Australian Society of Anaesthetists ; Catastrophes in Anaesthetic Practice.http :// 6. Health Professions Amendment Act 29 of 2007, Section 48 7. Madiba , TE. Naidoo P., Naidoo , SR., 2011. The Amended legislation on procedure-related deaths – an advance in patient care? SAMJ , (101) p.234-236 8. Health Professions Act 56 of 1974, Section 56 9. McQuoid Mason DJ., Dada M., 2011. A-Z of Medical Law, 1st ed. Cape Town, Juta Publishers 10. The Inquests Act 58 of 1959 112

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11. Saayman , G., 2010. Death and the Doctor, Medicolegal Perspectives. Heart Matters (1) p.8-10 12. Lourens , D. 2006. Procedure related deaths - aspects to keep in mind. CME (24:3) p.140-141 13. The Births and Deaths Registration Act 51 of 1992 14. Kirk, G. 2006. Guidelines for the completion of the Notification/Register of Death/Stillbirth (BI-1663) form.CME (24:3) p.138-139 15. Bacon et al, 2005. Crisis management during anaesthesia : recovering from a crisis. Downloaded from; 14 : e25 16. White SM., Akerele O., 2005. Anaesthetists ‟ attitudes to intraoperative death. European Journal of Anaesthesiology ,(22) p.938-41 17. Aitkenhead AR. Injuries associated with anaesthesia . A global perspective. BJA 2005; 95(1):95-109. 18. Todesko et al, 2010. The effect of unanticipated perioperative death on anaesthesiologists . Canadian Journal of Anaesthesiology ,(57) p.361-367 19. McCready , S., Russell, R. 2009. A National Survey of support and counseling after maternal death, Anaesthesia (64:11) p.1211-1217 20. Gazoni et al, 2008. Life after death: The aftermath of perioperative catastrophes. Anaesthesia and Analgesia ,(107)p.591-600 21. Redinbaugh et al, 2003. Doctor‟s emotional reactions to recent death of a patient: cross sectional study of hospital doctors. British Medical Journal , (327) p.185-191 113

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