Case

An elderly patient with complex co-morbidities was admitted from a care home with probable large bowel obstruction. The patient appeared delirious on the ward and could not tolerate NG tube insertion. Conservative management was deemed to have failed and emergency surgery planned. 

Prior to induction, the oxygen saturations were between 85-87%. The patient was restless and could not cooperate with pre-oxygenation or tolerate cricoid pressure.

At laryngoscopy using a McGrath Video laryngoscope, the vocal cords were covered with what appeared to be bile fluids. The airway was secured with ETT after which the patient regurgitated and 1800ml stomach contents were aspirated via an NG tube. Subsequent CXR showed bilateral basal consolidation with an ARDS appearance. Following admission to intensive care the patient developed aspiration pneumonitis, SIRS and multiorgan failure and subsequently died.

Commentary

Patients with cognitive impairment present multiple challenges to the anaesthetist. Consent may be an issue. Every effort should be made to improve capacity, which can fluctuate, in order to make decisions about management and improve the ability to cooperate with care. The Association of Anaesthetists stipulate that even in an emergency there should be vigorous, multidisciplinary assessment and management of cognitive impairment. ¹ Where possible, carers/relatives should be allowed to stay with the patient and should be asked about the specific needs of that patient. When capacity is lacking, with no advanced directive in place, decisions about management should be based on the best interests [not just physical factors] of the patient.

Reference

1. Association of Anaesthetists. Peri-operative care of people with dementia (2019)