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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.


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