Deterioration whilst awaiting theatre
Case
Three days after an oesophagectomy, a patient in their 70s started complaining of abdominal pain. After 5 days of conservative treatment a CT revealed extra luminal contrast leak at the pyloroplasty site, free fluid in the abdomen, pleural effusion, atelectasis, small pneumothorax and a splenic infact. There were increasing oxygen requirements and Intra-abdominal sepsis was suspected. The on-call anaesthetic team assessed the patient and a management plan discussed with the consultant who planned to join the team in the anaesthetic room. By the time the patient was brought to theatre 2 hours later their condition had markedly deteriorated. Because of the decreased level of consciousness. The trachea was rapidly intubated, following rapid sequence induction with cricoid pressure. At laryngoscopy there were signs of aspiration. Surgery was cancelled and subsequently the patient died.
Commentary
Patients with serious complications following major surgery can deteriorate suddenly and unexpectedly. Having made the decision to return to surgery, it vital that this should be expedited as soon as possible. The patient should be regularly and closely observed in the interim. The multidisciplinary team caring for acutely ill surgical patients on the ward should include intensive care consultants and critical care outreach as the level of care required may escalate. Any deterioration should trigger review by a senior clinician. The care of surgical patients on the ward is the responsibility of the surgical team, but following assessment the anaesthetic team should liaise closely with them to ensure timely transfer of patients for emergency surgery.
The Health Services Safety Investigations Body reported a similar case in their report entitled ‘Recognising and responding to critically unwell patients.1 In this report, Appendix 2 comprehensively summarises previous national publications and guidance on the topic of ‘the deteriorating patient’, which is very useful.
Reference