Expert: Dr Ian Jackson - please note UK based - 2/1/2010

Question
QUESTION: Hi Dr Jackson,

I have a question re a spinal block for chronic pain management that was performed on a 67 year old Adv Prostate cancer patient.

Prior to the procedure his vital stats were monitored and the monitor jumped from 78 to 73 he had been nil by mouth 24 hours beforehand and on the day of the procedure was given 3 shots of hydromorphone x 20mg and 5mg Midazolam prior to procedure under local and general anesthetic.  

The spinal block was performed twice one after the other as the first had failed, the second time was performed in the Recovery room, 20 minutes post second procedure patient was able to converse and immediately after speaking went into respiratory arrest which was not corrected by the apporpriate staff, in fact his oxygen mask was removed after the orange light on monitor was flashing, he was unable to move his body, as it was limp to the left side, but he had facial spasms and his eyes were dilated.   

A few minutes later after being wheeled into recovery room two his facial distress stopped and he looked like he had just fallen asleep - he went into cardiac arrest and died.  During anaesthesia he was given propofal, and other anaesthetic drugs and was still wearing his fentanyl patch during both spinal block attempts.

My question is this, What could have caused the respiratory arrest 20 minutes post the second attempt at the spinal block? Was it possible opiod overdose or the spinal block itself had gone wrong?

Many thanks

ANSWER: Hi there
I am really sorry to hear about this patient. It is very difficult to piece this together from the story you have provided. It sounds amazing that he had so many drugs prior to a procedure being performed under general anaesthesia. You also state that the first spinal failed (but i am uncertain how this was assessed) Then it was repeated in Recovery - so was the patient awake by then?
There are too many questions for me to be certain as to what went wrong.
However you could guess that if the spinal started to work then the painful stimuli from his lower body would have been blocked and so the depressant effect of all the opioids he had been given would have caught up with him. This could lead to respiratory depression.
Sorry but I can't give you a clear answer.
Dr Ian Jackson

---------- FOLLOW-UP ----------

QUESTION: Thank you for your answer.  I just have a follow up question if you don't mind.  According to the hospital they acknowledge procedural breaches but having said this, this procedure was suggested because of his chronic pain issues with Adv Cancer - he was already on very high doses of opiods. I'm trying to keep it brief hence explaining the bare bones of what happened on that evening.

But having said this, yes he was awake after the first procedure and was still in pain and the second was attempted straight after, which mean't two lots of anesthesia, and received both local and general anaesthetics.

I have to ask, Considering his condition, he was hypoxic prior to procedure, and considering the risks of respiratory depression, Would the Anethesist not be aware of the effects of so many opioids on the patient? and would possibly realise that respiratory depression was a good possibiity and ensure the patient was monitored closely peroperatively?  Basically the patient's family were told he expired due to a loss of oxygen?  Is this not correctable had it been noticed.  Should the Durogesic patch have been removed during the procedure to avoid opiod overdose?

Thank you so much for your help

Answer
Hi there
It really sounds like he was in extremis and that people were persuaded to try and help due to his uncontrolled pain. If his sats were in the 70's before the procedure started then it is unlikley that supplemental oxygen would have helped.
Removing the durogesic patch wouldn't have helped due to the time lag of the absorption.
So it appears this chap was extremely high risk, indeed with low sats was probably already close to death and he died while people did try to help him but probably (quite rightly in my opinion) didn't strive too hard to resuscitate him when he ran into problems. When my time comes vigorous resusciation is the last thing I would want.
There is no doubt that these situations are distressing for all involved - I'm sure the anaesthetists involved are as upset by the outcome. There is a big picture that we are not very good at considering in modern medicine in that we are not always successful and often we strive too hard to keep severely ill patients and those that are terminal alive at all costs. We often do this without consideration of what the patient may have wanted, forgetting death can be a release from disability and pain.
I hope this helps a bit.
Kind regards
Dr Ian Jackson