Expert: Dr Ian Jackson - please note UK based - 2/11/2010

Question
QUESTION: Hi Dr Jackson,

Thank you for all your previous help! You're brilliant.  I'll try to make it brief.

Firstly, Post a spinal block (attempted twice), the patient makes it through the procedure, Considering most of their body will be numbed from the anaesthetic, How does a Anaesthetic recognise symptoms of Respiratory Arrest in that type of patient?  And what intervention should be undertaken once respiratory arrest has commenced?

Lastly, In Australia, if a death occurs within 24 hours of an anaesthetic procedure, the death must be reported to the Coroner, not sure what happens in the UK.  But could you possibly provide some reasons as to why this must be reported to a Coroner?

Thank you so  much!

ANSWER: Flattery will get you everywhere...
Post spinal block respiratory arrest is very rare - it can happen for two main reasons
1. total spinal anaesthetic
This is where the spread of local anaesthetic goes too high i.e. up to the brain in the CSF and the patient goes unconscious and stops breathing - this is very obvious when it happens.
2. central effect of opioids administered either spinally or otherwise around the time of the spinal.
Usual fear here is late onset respiratory depression secondary to giving a drug like intrathecal morphine which can cause patients to stop breathing several hours after it has been administered. Usually before this we see an increase in sedation scores in the patient and their respiratory rate goes down. They then stop breathing.

Once respiratory arrest occurs we would provide full respiratory support - bag and mask while we try drug reversal of any opioids moving onto intubation and ventilation if needed.

The Coroner is informed of all deaths within 24 hrs of a surgical procedure (not specifically anaesthetic) plus numerous others e.g. deaths shortly after admission. Reason is for them to consider the circumstances and decide if a post mortem is required. There are lots of reasons for this not the least to make sure there is no chance of someone killing off patients.
Hope this helps
From  freezing cold UK
Dr Ian Jackson

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

QUESTION: Hi Dr Jackson,

I truly appreciate your answering my questions.  I have another to ask if you don't mind :)

The patient I have been refering to in all my questions, in fact received three injections during this time, the first two were for the intrathecal phenol which failed and the third and final was attempted with Ropivacaine and the dosage was not noted on the anaesthetic report or the nurse scouting sheet.  During all three injections he was initially under a local and then a general anaesthetic. I would assume attempting this sort of procedure 3 times on a patient who was reported by way of the pre anesthesia report has having deterioated that morning would be a very risky move?

I have a feeling it was possibly an opioid overdose and a lack of experience on the part of the anaethesist that led to the fatality of that patient.

Thank you Dr Jackson, you have truly helped alot.  It's certainly an eyeopener.

From a humid Sydney
Cheers

Answer
Hi there
I'm afraid we have come round full circle again and I can't really comment on the experience of the anaesthetist. I can only assume they were trying their best for someone they knew was in terrible pain and somewhat close to death. I am certain that deterioration in the patients condition prior to the procedure would have played second fiddle to thoughts of trying to help relieve pain, especially with the possibility of reducing the need for systemic opioids.
It is all very harrowing and difficult but I'm afraid this goes with the territory we work in. It is important that we look at how we and colleagues manage patients and discuss any issues that concern us. Usually this should be with peers locally but I recognise this can be difficult and so if I have been able to help then I am happy.
I wish you all the best and I'm still jealous about your weather.
Kind regards
Dr Jackson