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Management of patient following post-anaesthetic complications (01HDC02221)
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(01HDC02221, 12 November 2002)
Anaesthetist ~ Labour ~
Post-anaesthetic complications ~ Standard of care ~Record-keeping ~
Rights 4(1), 4(2)
A 24-year-old woman was admitted to
hospital at term for induction of labour because of probable mild
pre-eclampsia. Labour was induced with prostin, and an epidural was
provided by an anaesthetist for analgesia. This was initially
successful, but later in labour it became less effective. She did
not progress well in labour, and the obstetrician decided to carry
out a Caesarean section. The anaesthetist assessed her
epidural block and, finding no block, gave a bolus top-up, which
failed to show any effect. He then gave a spinal anaesthetic, but
the woman had some difficulty breathing. Consequently a general
anaesthetic was administered.
On extubation the patient's airway
was not maintained, and she appeared to have bitten her tongue. She
was re-intubated and ventilated until gag reflexes returned, at
which point she was extubated. On return to the ward she was
agitated and appeared confused. Her verbal response was
inappropriate, and she was noted to have marked flexor spasm of the
hands with extension of the elbows, and marked extensor spasm of
the right foot. Her pupils were dilated with only some response to
light. She was transferred to the delivery suite and treated with
magnesium and diazepam. Good oxygen saturation was maintained and
there was a reduction in muscle spasm. A CT scan showed no apparent
cause, and she improved with time and reversal of the diazepam. Her
confusion resolved over the following two days, but she continued
to have a memory deficit and some cognitive impairment. No clear
diagnosis was made.
The woman complained that her brain
injury and subsequent cognitive impairment was the result of
inadequate management by the anaesthetist.
It was held that the anaesthetist
complied with professional, ethical and other relevant standards in
all but two areas. First, he should not have discharged the woman
from the recovery room to the maternity ward. Staff caring for the
woman were clearly concerned about her condition, and a house
surgeon was required to assist when she arrived in the ward. The
anaesthetist should have discharged the woman to an area where
skilled personnel could provide intensive monitoring of her
condition; in not doing so, he was found in breach of Right
4(1).
Secondly, his record-keeping was
inadequate. There is no clear record of which drugs were used when
anaesthetising and intubating the patient. There is a brief
note in the anaesthetic record concerning the progression from
epidural, to spinal, to general anaesthetic, but it is unsigned,
and does not provide a complete record. In failing to comply with
the professional standards for anaesthetic record-keeping, the
anaesthetist was held to have breached Right 4(2).
The matter was referred to the
Director of Proceedings, who decided not to issue proceedings.