The RCoA was requested to respond to a report from a coroner following the death of a patient, Dr Rachel Gibson, who sustained irreversible brain damage following cardiac arrest caused by administration of excessive local anaesthetic (Ropivacaine) during surgery. 

The full response to the coroner’s request can be read on the RCoA website.¹

In the report, the coroner highlighted concerns regarding the wide variation in the way local anaesthetic is prescribed, checked and administered in procedures where local anaesthetic is infiltrated into the operation site.

SALG agreed that for any procedure where this surgical technique is used there should be a clear protocol in place that is understood and followed by the entire theatre team. This should include:

• Agreement during the multidisciplinary team brief prior to the procedure, about the type and dose of local anaesthetic to be given to each specific patient. The team should agree the maximum safe dose of local anaesthetic that can be given to the patient, calculated in milligrams. The concentration of local anaesthetic should be described in milligrams per milliliter and used to calculate the total allowable volume that can be injected by the surgeon and/or the anaesthetist. In accordance with the National Safety Standards for Invasive Procedures, all staff members who undertake an active role in the invasive procedure should be present, including the most senior members of the anaesthetic and surgical teams.² Some units have reported that they found it helpful to write the agreed drug dose and volume on the theatre whiteboard near to the swab counts.
• How and where the prescription for local anaesthetic should be documented. For example in units that use electronic systems, it might be appropriate to document on the e-prescribing system rather than the anaesthetic chart or in the surgeon’s operating notes. We recommend that local anaesthetic prescriptions are recorded as ‘the volume in ml of a solution containing a specified number of mg/ml of a named local anaesthetic’ to simplify any calculations of the total dose of local anesthetic received. We strongly encourage manufacturers to make the concentration in mg/ml more prominent on their product labelling rather than using percentages.
• Mandated pause prior to the surgeon undertaking the infiltration during which the whole theatre team verbally confirm that the correct drug, volume and concentration has been provided.

Human factors science indicates that engineered solutions are far more effective at reducing the risk of similar events occurring than procedural steps. The use of pre-filled syringes have been shown to reduce the risk of drug error by up to seventeen times and the use of a pre-filled syringe of local anaesthetic at the correct dilution would have substantially reduced the chance of an overdose of local anaesthetic.³ We recommend that pre-filled syringes are used by default where available. Where manufactured pre-filled syringes are not available, we recommend that doses are standardised for specific operations by patient weight and that dilutions are drawn up prior to the start of the procedure, potentially by colleagues within pharmacy to minimise the manipulation of medicines in clinical areas.⁴ Additionally, we recommend that local anaesthetics intended for intraoperative local anaesthetic infiltration are not provided in volumes larger than 100mls per bag to further reduce risk.

1. Response to the Coroner’s Prevention of Future Deaths Report concerning Dr Rachel Gibson | The Royal College of Anaesthetists

2. Centre for Perioperative Care, National Safety Standards for Invasive Procedures 2 (NatSSIPs),2023 

3. Adapa RM, Mani V, Murray LJ, et al. Errors during the preparation of drug infusions: a randomized controlled trial. British Journal of Anaesthesia 2012; 109: 729–34.

4. Royal Pharmaceutical Society, Professional Guidance on the Safe and Secure Handling of medicines, 2018