Reports from the coroner

This case involved a patient who died after suffering a cardiac arrest following elective bariatric surgery at a private hospital.

[Two days postoperatively] the patient developed abdominal pain. Although a major anastomotic leak was ruled out on CT scanning, but symptoms were indicative of SIRS (Systemic Inflammation Response Syndrome). The patient also had bi-basal atelectasis and/or consolidation of the lungs. Blood results, taken three days post operatively showed that the patient was in acute renal failure, and not compliant with oxygen administration, and there was a rapid deterioration in the evening of that day. A plan was made to intubate, ventilate, and insert a central line overnight at the independent hospital while awaiting a bed at the local NHS hospital. However, intubation proved extremely difficult and the airway was lost. Front of neck airway access was attempted via cricothyroidotomy, but successful access could not be confirmed as there was no EtCO2 tubing attached to the circuit being used in the emergency. The lack of a reassuring carbon dioxide waveform on the main monitor caused the anaesthetist to think that the tube was incorrectly sited. The patient then continued into cardiac arrest from which they could not be resuscitated, and died as a result.

The above details are included in the record of inquest, which noted the medical causes of death as: 1 (a) Hypoxia during emergency intubation procedure, (b) post-operative stage 3 acute kidney injury, systemic inflammatory response syndrome and respiratory failure, (c) laparoscopic sleeve gastrectomy for obesity and 2. Hypertensive heart disease, obstructive sleep apnoea:

Commentary:

According to the judgement, the tube was correctly sited, but due to the lack of a trace on the monitor, it was incorrectly diagnosed as being oesophageal intubation.

This is a rare but catastrophic example of when ‘No Trace’ did not indicate ‘Wrong place’.1 This case highlights the critical importance of machine checking. The Association’s guidance states that the capnograph should be checked before use. Capnography should be present on all cardiac arrest trollies.2

1. Royal College of Anaesthetists. Capnography: No Trace, Wrong Place: https://www.rcoa.ac.uk/safety-standards-quality/guidance-resources/capnography-no-trace-wrong-place 

2. Association of Anaesthetists. Checking anaesthetic equipment: https://anaesthetists.org/Home/Resources-publications/Guidelines/Checking-Anaesthetic-Equipment, 2012

Airway exchange catheters (AECs) can be used as a guide over which a tracheal tube can be passed, in a similar way to a bougie. Their use is associated with a high intubation success rate. Most of the morbidity is caused by barotrauma associated with their use as a means of oxygenation.

Readers are referred to 2 reports (listed below): The Sheriff's report into Mr Gordon Ewing and one where oxygenation via these long hollow catheters was a contributary factor to the patient’s death.

Commentary:

Insufflating oxygen through AECs with a 15mm connector should only be done in extremis and using a high-pressure source (jet) ventilation (with an associated Luer lock connector) should be avoided altogether.

The Difficult Airway Society guidelines for the management of tracheal extubation, also essential reading, list the use of AECs as an advanced technique where due diligence is needed.

Departments are further encouraged to deliver MDT training for airway procedures (eg e-FONA, unrecognised oesophageal intubation, and advanced airway kit). These cases lend support to this.

References:

1. Scottish Courts and Tribunals. Inquiry under the fatal accidents and injuries (Scotland) Act 1976 into the sudden death of Gordon Ewing, 2010FAI15

2. Courts and Tribunals Judiciary. Ian Jacka: Prevention of future deaths report - Courts and Tribunals Judiciary 2023. Ref 2023-0519

3. Difficult Airway Society. Guidelines for the management of tracheal extubation, Anaesthesia, 2012 Mar; 67(3): 318-340