Post op Hypoxia

[yogenbhatt1]

Female / 46 , C / O Hoarseness of Voice 3 days, H / O ingestion of chicken bone 5 days back. CT scan showed FB in Esophagus. Reports normal, but WBC count 17000. Posted for Rigid Esophagoscopy. Standard induction with Fentanyl, Medaz, Propofol, Scoline, O2, IPPV, Tube 6.5 with difficulty. Maintained on Propofol, Vecuronium, Gas Oxygen, IPPV. Over in 20 mins. Reversal started on attempts of breathing. Inadequate reversal picture. Extubated on struggles. SpO2 drops to 80. Reintubated and ???? pink liquid noted in throat. May be froath may be blood stained saliva.
    At that moment some one informed that actual printed report of CT has now come and it showed a rent in esophagus.
Pt given Medaz and O2 and shifted to Recovery for observation. ABG showed pH 7.2 and PCO2 70.Connected to venti and Vecuronium given. CXR showed pulm edema pattern.
OK by evening but not sustaining BP. Dopamin and Dobut given. 2D Echo 30% LVEF, WBC 24000.
Imporved over 24 hours and discharged in 2 days. and ok.

Question is was it a picture of early sepsis due to mediastinal infection which can spread rapidly or was it an improperly managed reversal? Later picture is of clear cut septic shock and septic cardiomyopathy.
I am putting this case for discussion tomorrow in society meet.
Let me many opinions.
The anaesthesiologist feels that it was her fault. I feel it was sepsis. Is it that uptill now the society used to say that it was over dose of anaesthesia, and now we have also started feeling the same!!!!!

[Dr.Madhav]

Dear Yogen,
I agree with your diagnosis.Anything and everything happening under the sun during any surgery,is always blamed on the anaesthesiologists.We are tuned into accepting everything due to our fault.Why?to please the surgeon?At what cost?
Overdose of anaesthesia is another loose and fancy word used by our surgical colleagues to explain any intra or post operative problem while explaining things to the patients relatives or the media.

[yogenbhatt1]

That patient went home, but take this one now.
Was called by a colleague, for a child of 2yr and 6 mth, FB esophagus, a coin this time. Standard induction, of Fentanyl, Medaz, Ketamine, Profol, Sux and tube, vecuronium and Gas oxygen. Coin was out in 20 mins, child did not start breathing. I was called to send a PNS to check. All TOF were good and equal. She was preparing to reverse. Later I was called to come to the hospital to help. I could hear a clearcut severe bradycardia on my mobile phone. On reaching, I saw that CPR was being done, and later the child was declared dead. body sent for PM.
Again, Anaesthesia, or some kind of trauma to the tiny delicate esophagus?
If I ever get the PM report, I will publish it too.

[jafo1964]

9 out of 10 causes for intra-operative bradycardia in paediatric age group is HYPOXIA
Was Atropine or Glyco used during induction
Was the bradycardia unresponsive to Atropine
Was the possibilty of endobronchial migration of ETT ruled out
Vigorous IPPV or injury during instrumentation could have produced a Tension Pneumothorax. Could that be a possibility
Hypovolemia and Blood loss in paediatric age group may also present as bradyasystolic rhythm

With regard to reversal and extubation, i think it poses more problems than intubation because we dont anticipate them
I beleive that it is better to delay extubation than trying to reintubate in treacherous conditions. If we reintubate the patient within 24 hours due to surgery related problem then I deem the intubation to be premature
Most of the private places dont have ventilators or people trained to provide ETT care, hence we tend to try and extubate at end of surgery. This may not always be rationale and scientific. That is why PACU 's exist.
We should remember that our job is not merely putting a tube in and removing it out at the end of the surgery. Our goal shoul be aimed at helping the patient heal from his ailment. Maybe we need to redefine our goals of anaesthesia esp since international guidelines say that all deaths until 24 hours post-surgery are deemd to be anaesthetic deaths unless proven otherwise.

regs

[yogenbhatt1]

Atropine was given and ventillation was on, atleast when I was summoned to help. The question later asked to me was that, can PNS at 10mAmp give sufficient current to cause cardiac disturbance? the child was 16 kg. I do not have any figures to reply that question.
Brady lead to arrest and then onwards no activity. At least on auscultation there was good and equal air entry and no obvious tension pneumo. It was not possible to take a portable CXR.

My next question follows in my next letter.
Thanking you

[yogenbhatt1]

       Legal Position:
I get these kind of dystress calls little too frequently. There are cases, in which I get called by authorities for enquiry also.
I was wondering about the stand a senior anaesthetist should take. How many of us go to salvage another colleague. and what is their legal standing in other countries? Is it safe to go and help others in trouble?
But then, we all need someone to help when things  go wrong. Half the time we do not know what is happening and why. That too, with poor monitoring and post op in our countries, specially when a young anaesthetist is involved, who has to do a case in compromised conditios.
Think.
Should I stop helping our ppl to save my neck???

[Dr.Madhav]

Regarding an anaesthesiologist irrespective of whether he is senior or junior can go to help his colleague in times of distress as a good samaritan.This has been told by Dr.Gopinath shenoy repeatedly.Remember the case which was discussed at the ISA conference,where the second anaesthesiologist who went to help her colleague was also implicated in the medico legal case.As you have said, we have to make it 100% sure from various senior colleagues and medico legal experts regarding the good samiratans role in case the patient dies.Our colleagues from abroad should enlighten us aboput this.

[jafo1964]

YOU ARE EQUALLY LIABLE
this is what the law states even if you go to help a collague in trouble and the out comes are bad
Remember they have to prove negligence beyond doubt
If you went to help somebody in trouble how can you be negligent?

So please follow protocols and ensure documentation of all events from your arrival

But Dr. Bhatt you are such a respected senior because you are always there to help anybody in trouble. Keep the camaraderie going and hopefully if you ever need help you will have plenty of helping hands

Please also inculcate the need to
1. Keep All OTs equipped with all necessary monitors and drugs
2. Keep all anesthesiologists educated about all the recent developments in anes esp CPR
3. Insist on meticulous record keeping
4. Make all collagues follow established protocols

reg

[yogenbhatt1]

Dearest Jafo,
Out of the four needs that you mentioned, not one is in action here in India. Every thing here is budget oriented. This I am talking after 29 yrs in this field.It is a very slow improvement. Do we want to improve only after we get bitten?
To top up the pleasures, the legal proceeds take nearly 20 years, and the records show that the anaesthesiologist usally dies of trauma before the final verdict is out.
But I feel, as you rightly mentioned, keep doing the good work, It evntually works.
Thanks all the same.
It seems, there are many readers of this message, but only 2-3 reply. Let us open out a bit more. No one knows each other personally so, no hard feelings at any level.

regards to all.

[Dr.Madhav]

Dear Yogen,I totally agree with jaffo's reply and your rejoinder to it.Dont you think we can still do something to revolutionise this branch of ours i.e. Anaesthesiology?
It is high time we seniors and even juniors opened up,accept our faults and errors and narrate our tales of trials and tribulations,which will be an eye opener to our fraternity members.
Let us all come under one platform in mumbai and stand united.It will send shivers down the spine of several of our colleagues from various other branches.
Are you game for it yogen?

[mchoo]

Dear colleague,

With regards to your case above, the lady probably did suffer from a post op SURGICAL problem. It could be lugwig's angina (oedema of the pharyngeal fascia coat) or any of the paralaryngeal structure oedema. Tell the surgeons to keep their comments to themselves as they may encounter similar litigation problems themselves. Telling the patient's family it is our fault is seriously undermining professional relationships and you may want to reconsider ever anaesthetising for him.