The Medico-Legal Advisor ®
DEATH IN THE RECOVERY ROOM
Next to the operating room, the recovery period following anesthesia is most likely to be associated with anesthetic-related deaths. As reported in our article on death during anesthesia, no good reporting methods are used or available. Any death during or subsequent to an anesthetic is reported as related to anesthesia only if a specific anesthetic error is identified. From experience, anecdote, extrapolation of mortality data and a few foreign studies we can draw a few interesting conclusions: 1. Males are more likely victims by a 1.5 to 1 ratio. 2. Having more than one operation during the same hospitalization or in a short time span is more lethal. 3. The very young and very old are at the highest risk. 4. Risk rises with concurrent disease especially heart or lung problems. Recent myocardial infarction carries a risk of fatal infarction following anesthesia. Risk of reinfarction declines to near normal when six months or more have elapsed between original infarct and anesthesia. 5. Emergency procedures carry a much higher mortality rate during the recovery period. 6. Mortality rates probably rise during the evening and night when fewer nurses are present, and during shift changes. 7. Persistent myoneural blockage and relative anesthetic overdose are commonly associated with post-anesthesia mortality 8. Human error is associated with most disasters unless concurrent disease states dominate. 9. Risk of postoperative anesthetic-related death diminishes when the patient is not transferred from one unit of a hospital to another until he is fully awake. 10 Anesthetic risk is probably inversely proportional to the number of cases done by each anesthetist in a given day and inversely proportional to the ratio of recovery room nurses to occupant. Obviously these relationships vary with the seriousness of the patient's condition. One nurse might care for three or four healthy individuals undergoing relatively routine surgery or she might be incapable of taking care of more than one especially demanding situation. We can count ourselves fortunate in having recovery rooms. Only recently has England begun to develop them. Recent English articles speak of the relative frequency of anesthetic-related disasters once the patient returns to her room after surgery. In many hospitals, clear lines of responsibility and authority for patient care decisions are absent. The recovery room can become a high risk no man's land where the surgeon and the anesthesiologist knock heads over who is caring for the patient. Worse are the frequent occurrences where each thinks the other is taking responsibility. Recovery room nurses often end up in a void where no clear authority exists and it is natural that they frequently act independently in such circumstances in spite of their lack of authority and training to do so. Thus, in reviewing an unexpected recovery room death, it is important to determine how much attention was given the patient and by whom. Was the system overtaxed at the time and does the hospital provide enough personnel for the case load? What are the lines of authority and how closely are they followed? RESPIRATORY CAUSES OF THE RECOVERY ROOM DEATH: Two classes of drugs account for more anesthetic deaths than they should. The first are blocking agents. Persistent myoneural blockade (paralysis induced by agents such as succinyl choline and curare which paralyze by blocking transmission of nerve and the muscle) is common, usually recognized by measuring the patients volume of breathing or the transmission of impulses to the muscle, and easily treated by assisted ventilation. If recognition of the problem is delayed the patient becomes starved for oxygen and arrests. Because of changes in the acid-base balance which accompany the oxygen depletion, resuscitation is difficult and permanent brain damage is common. A sure sign that an arrest is associated with hypoxemia (lack of adequate oxygenation) is the slowing of the heart beat which precedes arrest. In one series, each time a patient arrested secondary to persistent myoneural blockade , the anesthetist had voiced the suspicion and contemplated assisted ventilatory support with a "wait and see" attitude. A good dose of an aminoglycocide antibiotic such as gentamycin may enhance the effect of all blocking agents. Measuring tidal volume or transmission of nerve impulses across the myoneural junction can prevent such disasters. Yet as simple, safe, and quick as these tests are persuading personnel to perform them in the production line atmosphere of the busy operating room or recovery area is nearly impossible. Of equal frequency is the manifestation of relative overdose of anesthetic agent. The patient may be somewhat responsive amidst the turmoil of "getting him off the table" but lapses into a coma in the recovery room and follows the well known pattern of hypoxemia to bradycardia to cardiopulmonary arrest. As opposed to anesthetic deaths in surgery, inhalation agents are seldom indicated in recovery room disasters. FENTANYL, a commonly used and extremely potent narcotic, seems to be the most common narcotic associated with death in the recovery room. Because of the usefulness, anesthesiologists seem to want to overlook its shortcomings. Fentanyl (sublimaze manufactured by Janssen Pharmaceutica) is used either alone as a preoperative sedative or in combination with inhalation agents during anesthesia. Is has a long biological half-life of 2 to 3 hours and a peculiar biphasic decay curve in some individuals (probably between 25 and 50% of the population) which means that there is a secondary rise in concentration of the drug and its respiratory depression about 45-60 minutes after injection. Shortly after the injection of an high dose of fentanyl, the anesthetist may discover inability to adequately ventilate the patient. Fentanyl cause chest wall rigidity and/or rigidity of the glottus, making mask breathing of the patient difficult or impossible. If recognized, this problem is easily handled by endotracheal intubation. Chest wall or glottic rigidity can also occur in the recovery room and mimic grand mal seizures since there is gross twitching of all extremities. If the phenomenon occurs in the recovery room it is usually related to high dosages. The real danger of the drug results from its long half-life and peculiar double-humped decay curve. The average short procedure such as hemorrhoidectomy, nose job, dental extraction or arthoscopy takes less than 30 minutes. By 45 minutes the patient has arrived in the recovery room, received her initial assessment by the cautious and attentive recovery room nurse (one thing we have found in even some substandard hospitals is the quality, concern and attentiveness of the recovery room nurses) and is allowed to rest undisturbed. A few minutes later the recovery room nurse turns around and the patient is blue and pulseless. The exact mechanism by which fentanyl works its troublesome and disastrous magic is not clear. It seems that much of the drug is taken up selectively in the stomach and released later into the small bowel where it is reabsorbed. Thus the patient gets two divided doses for the price of one. The later dose comes at a time when the short procedure patient is thought to be out of danger. Plenty of disasters occur because the anesthesiologists continue to use the drug incautiously. We believe that the following warnings to all anesthesia personnel would be appropriate: 1. Use fentanyl in minuscule dosages, if at all for short procedures. 2. If a sizable dose has been administered within an hour of reaching the recovery room, constant monitoring is warranted with the realization that assisted ventilation may be necessary. 3. Inhalation techniques are much safer than the use of fentanyl (or probably any opiate- synthetic or natural) for short procedures. 4. A high percentage of patients receiving fentanyl will require narcotic antagonists to maintain effective spontaneous respirations. Decreased use of long-acting myoneural blocking agents and fentanyl and improved monitoring of ventilation in the recovery room have significantly reduced post-anesthetic mortality in many settings. Unfortunately the latency built into our system of health care delivery and the profit motive so vigorously pursued by pharmaceutical manufacturers inhibit changes in methods until there have been many unnecessary injuries and deaths. Prior to the advent of fentanyl, post-arousal respiratory depression was a known hazard of anesthesia with morphine and its relatives. Narcotic anesthesia fell into disrepute. With the advent of fentanyl, all of the hazards of narcotic anesthesia have been rediscovered. Other causes of respiratory embarrassment and death in the recovery room are: 1. Failure to protect against aspiration pneumonia. This frequent complication, may occur with removal of the endotracheal tube. Failure to turn and suction the patient may result in aspiration pneumonitis of fatal or near fatal proportions. 2. Dislodgement of an endotracheal tube and other respiratory equipment failures which involve lack of careful monitoring and recognition. 3. Failure to recognize and promptly treat airway obstruction. CAUSES OF RECOVERY ROOM DEATH RELATED TO INTRAVENOUS FLUIDS: 1. Inadvertent fluid overload. 2. Air embolus from injection of air into the line. This was more common when blood was administered in bottle and air was pumped into the bottle to make the blood flow faster. 3. Inadvertent administration of drugs. Most notable is the accidental administration of potassium chloride in a concentrated bolus. This can occur either by picking up potassium chloride and assuming that it is another drug (usually saline solution for irrigation of the IV tubing) or by insufficient mixing of the bag of IV fluid once potassium chloride has been added to it. Some IV administration bags such as those made by Travenol make even mixing of the additives a problem. The additive port is situated at the bottom of the bag near the port which connects to the tubing. If the bag is not taken down and thoroughly shaken, the fluid in the bottom of the bag may contain very high concentrations of any additive, the most common of which is potassium. In summary, while deaths in the recovery room are relatively rare, many that do occur are preventable with a few precautions. Bibliography Baraka, A.: Cardiac arrest associated with anaesthesia. Criteria for successful resuscitation. Middle East Journal of Anaesthesia, 5: 387-95, 1980. Boulton, T.B. et al.: Deaths and anaesthesia. British Medical Journal, 285: 730-732, 1982. Bowers, D.M.: Deaths and anaesthesia. British Medical Journal, 285: 891, 1982 Burnham, M. and Craig, D.B.: A post-anaesthetic follow-up program. Canadian Anaesthesiology Society Journal, 27: 164, 1980. Davies, J.M. and Stunin, L.: Anesthesia in 1984: how safe is it? Canadian Medical Association Journal, 131: 437-431, 1984. Farrow, S.C. et al.: Epidemiology in anesthesia no. 2: factors affecting mortality in hospital. British Journal of Anaesthesia, 54: 811-817, 1982. Fowlkes, F.G.R. et al.: Epidemiology in anesthesia no. 3: Mortality risks in patients with coexisting disease. British Journal of Anaesthesia, 54: 819-825, 1982. Kenan, R.L. and Bowan, C.P.: Cardiac arrest due to anaesthesia. The Journal of the American Medical Association, 253: 2373-2415, 1985. Lunn, J.N. et al.: Anaesthesia-related surgical mortality. Aneasthesia, 38: 1090-1096, 1983. Deaths and aneasthesia. British Medical Journal, 285: 530, 1982. |