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A 32-year old woman with a history of recurrent tonsillitis was admitted to a private hospital for tonsillectomy. She was overweight with a BMI of 35. The consultant anaesthetist, an MDU member, saw the patient before surgery, established an unremarkable past history but made no note of his visit. No pre-medication was prescribed.
Induction of anaesthesia and intubation were straightforward despite the presence of large tonsils. The claimant was paralysed and ventilated throughout an uncomplicated procedure and a total of 10mgs of morphine was administered intravenously.
Following extubation, the patient suffered a brief period of hypoxia which was rapidly corrected by pharyngeal suction and the administration of 100% oxygen by facemask.
In recovery, she continued to receive supplemental oxygen and intravenous fluids. In view of the patient's build, our member advised that oxygen therapy be continued overnight on the ward and recorded this instruction on the recovery care plan.
Overnight, nursing staff recorded the patient's pulse rate at between 80 and 95 beats per minute. They did not record oxygen saturation or blood pressure. At midnight, they discontinued the oxygen and gave intramuscular analgesia.
Early the next morning, the patient was found unconscious, pale and snoring with blood pressure of 85/41, pulse 72 and oxygen saturation 87%. The patient was given naloxone, with no effect. The nursing staff rang the consultant anaesthetist who advised a further dose of naloxone. He saw the patient 30 minutes later, recording that she was unrousable, hypotensive, had a gag reflex and that her pupils reacted to light. He sought the advice of a neurologist.
Transfer to another hospital ITU department was arranged. At this stage, the patient's Glasgow Coma Scale was recorded as 3.
At this stage, the patient's Glasgow Coma Scale was recorded as 3
On arrival, the patient was intubated, ventilated and resuscitated, requiring fluids and inotropic support. The patient made a rapid recovery. Her cerebral function improved and within three weeks she was responding appropriately to verbal stimuli and commands.
Two years later, she brought a claim against the hospital and the anaesthetist stating that she had continuing cognitive problems and was depressed.
Her CT imaging demonstrated damage in the region of the basal ganglia and the peri-ventricular areas. She claimed that she had suffered a brain injury during the night following surgery, as a result of inadequate oxygenation and a further, secondary injury as a result of a failure to provide adequate resuscitation the next morning.
The MDU sought the advice of experts in the fields of anaesthesia, intensive care and stroke medicine. They thought it likely that severe hypoxaemia had occurred during the night as a consequence of obstructed ventilation and discontinuation of oxygen therapy. This resulted in a primary anoxic injury to the brain. A secondary, lesser injury occurred as a result of continued hypoxia and hypotension caused by inadequate resuscitation.
Experts were critical of the failure to resuscitate the patient more actively the morning after surgery. They considered that the anaesthetist should have intubated and ventilated the patient and stabilised her condition before transfer. However, neurology advice was that the secondary injury was unlikely to have made a great deal of difference overall.
It was agreed that some liability would be likely to fall to the MDU member at trial despite these arguments. The hospital swiftly acknowledged their liability and settled the claim accepting a 15% contribution to the damages on behalf of the MDU member.
Dr Alison Cooper
Senior medical claims handler
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