Patient Safety Update January - June 2023

This issue of PSU begins with two special pieces, one about the risks to anaesthesia breathing circuits of heavy items crushing the system hoses, and the other about the dangers of chlorhexidine-containing central venous catheters to patients with an allergy. It then concludes with the usual review of incidents, this time those reported to NRLS between 1 January and 30 June 2023, and reported by 28 June 2023

A joint National Patient Safety Alert has been issued on 31st January 2024 by NHS England National Patient Safety Team, Association of Anaesthetists, Royal College of Anaesthetists and the Safe Anaesthesia Liaison Group regarding the transition to NRFit™ connectors for intrathecal and epidural procedures, and delivery of regional blocks. Further details can be found here

The breathing system hoses and associated capnograph tubing on anaesthesia workstations are at risk of being crushed or run over by mobile theatre equipment and occluded which, in the severest cases, can lead to significant patient harm or death.

We received correspondence about a case in which a patient with known chlorhexidine sensitivity had a chlorhexidine-impregnated central line inserted and suffered a fatal anaphylactic reaction. Readers may have seen the letter in Anaesthesia News

Case 1: “Patient admitted last night and had central line inserted. Inotropes, sedation and fluids given via central line for 4+ hours. On assessment [in morning], noted CVP reading high and an arterial trace, suspected that central line was in artery. All infusions stopped and transferred peripherally. Patient became hypotensive and metaraminol given neat by anaesthetist. Patient became profoundly bradycardic and peri arrest…  on review of the never event guidance this incident is a never event under the wrong site surgery category.”

"Neurosurgeons informed us [at a time in the early morning] of a patient coming from [DGH] intubated with isolated head and a blown pupil. We were informed [at a time 55 minutes later] that they were just leaving and that he had blown a second pupil. He arrived at [tertiary centre] at [a time 40 minutes after the second call (1hr and 35 minutes after the original notification)].

“Patient scheduled for bilateral ureteric stent secondary to bilateral stones causing bilateral hydronephrosis, acute renal failure with anuria. On induction of anaesthesia unanticipated difficult airway and cannot intubate cannot ventilate scenario with front of neck access to secure his airway.”

Case 1: “Patient required urgent surgery for empyema. On amoxicillin and metronidazole. Mildly hypotensive following induction of anaesthesia. Treated with fluid and metaraminol.  Easy FM ventilation.  Intubated with 41Ch L DLT, position confirmed with waveform capnography, but high airway pressure alarm on ventilator, rapid desaturation and marked hypotension...

Case 1: A consultant on-call for ICU in a tertiary centre was contacted by a consultant cardiologist in the same centre to say they had been made aware that a ventilated patient was being transferred from a referring hospital after a cardiac arrest, possibly due to a STEMI: “Other clinical details unclear but reported to have had an approximately 1-hour downtime with Lucas Device chest compressions. Requesting urgent assistance...

“Accidental awareness under general anaesthesia. The patient had explicit recall after IV line for total intravenous anaesthesia became disconnected during surgery...

“Patient is cancer Pt that needed to have urgent hysterectomy under the Gynaecology Team at [DGH satellite] scheduled... She had F2F pre-assessment by a pre-assessment Nurse [two weeks beforehand]… together with her niece as Pt lacks capacity. Pt is with phenylketonuria which had not been communicated to anyone further and patient arrived for surgery without being referred to Consultant Anaesthetist review...

A patient returned to theatre for a wound exploration and wash-out, two days after more extensive surgery for necrotising fasciitis. “Patient on the operating table, fully reversed breathing spontaneously with assistance from pressure support. Being moved to bed, coughing. Switched to manual vent...

“Emergency operating patient for a below knee amputation. He had previously had the amputation of three toes [four days previously] under a local block, also on the emergency list. Assessed as unfit for general anaesthesia. Arterial line inserted prior to spinal anaesthesia. Senior trainee (ST7) attempted a spinal block with the patient in the standard sitting position but was unable to succeed. We then helped the patient into a left lateral position, used a forced air warmer and a low dose of propofol sedation for patient comfort and I tried to site the spinal at several levels before being successful at a higher level. Clear CSF seen and local anaesthetic injected without resistance...

Case 1: “Patient was booked for left inguinal hernia repair +/- bowel resection in CEPOD. Post-op during removal of I-gel, the patient vomited and aspirated. The patient was intubated and an NG tube was placed.”

Case 1: “Patient admitted to ED following 3/7 hx of sore throat, identified by SpR as being acutely unwell, moved to monitoring for closer observation, pt had audible stridor and low sats. Dr prescribed all necessary medications and these were given promptly by nursing staff. Medics requested anaesthetic review alongside ENT review, ENT reg attended department from [nearby tertiary centre, 10 minutes away by road] and examined and plan was discussed with HDU at [tertiary centre] for transfer when stable and suitable to do so.

“Patient presented with sudden onset severe breathlessness, severe type 1 respiratory failure despite 15L Non-rebreather mask. likely cardiogenic in nature. Patient was tiring, respiratory rate 45+, tripoding, HR 130, BP 110/70. Called ITU SpR on Call to refer for NIV/review...

“Underwent an elective revision total knee replacement in [private] hospital. Extensive co-morbidity including diabetes, ischaemic heart disease and chronic kidney disease. Arrived from Pakistan the night before surgery, therefore may not have been through usual pre-assessment process....

“NITU patient 4 days post extubation for empyema washout, increasing oxygen requirement for last 2 days with deteriorating GCS, being treated for chest infection. Acute further deterioration post CT head scan with desaturation to 80% on 100% O2 - intubated. Family updated....

“Patient was admitted to ITU after an epileptic seizure. Patient states on regaining consciousness had bilateral shoulder pain. Patient says they and their mother mentioned this repeatedly to staff (nursing staff and doctors) about shoulder pain and concerns, and was repeatedly reassured...

“Patient had cemented hemiarthroplasty of left hip under spinal anaesthetic… Patient’s surgery was delayed initially as unstable with fast AF and hypotension...

“… inadvertent pneumothorax during laparoscopic surgery, chest xray confirmed, requested chest drain and bottle kit, none to be found in hospital. We are the only theatre department in the trust who keep these drains…