Case Report:

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. Many hands required due to the size of the patient. Not recorded but >100kg. Transferred across, saturations below acceptable and BP below acceptable BUT both monitoring devices inappropriately placed. Sats probe somewhere tangled in the sheets and the arterial line transducer on the floor under someone’s feet.  Monitors being replaced and positioned appropriately, pulse check done at the carotid, pulse not felt. CPR started. 2222 call put out and adrenaline sought from the anaesthetic room.”

Commentary:

The patient remained ventilated on ICU for about 20 hours. The organisation’s post-event analysis considered what may have been the cause of the collapse and what learning points exist. TOF monitoring had been used and had shown reversal. Several cardiac causes were considered, but post-op ABGs suggested a primary respiratory cause, maybe leading to hypoxia and cardiac depression. It was suggested that, on reflection, perhaps planned ventilation at the end of the operation would have been indicated. The team reflected that the noise and chaos at the time of moving the patient was not helpful and could have perhaps been controlled better.   They made the observation that monitoring systems that are transferrable between anaesthetic room, theatre and recovery and allow continuity of monitoring at all times would have allowed more attention to focus on the business of promptly transferring the patient to their bed. This case reinforces the need for quiet in theatre, leadership from anaesthetist and clear understanding of everyone’s roles during the transfer.