10.1: Anesthetic Deaths

Deaths Due to Anesthesia and Anesthetic Agents

• Anesthetic agents may sometimes result in hypersensitivity reactions resulting in death of the patient.

  • Certain anesthetics can directly act with a consequence of cardiac arrhythmia and cardiac arrest.

  • The use of certain drugs, which can create myoneural blockage, may give rise to death due to respiratory inadequacy.

  • There is evidence that halothane can cause liver necrosis resulting in malignant hyperpyrexia which is characterized by abrupt rise to dangerous temperature and may ultimately lead to death.

• Anesthetists who are using improper technique, improper equipment or one who has no familiarity with the equipment, having no adequate experience, or unable to adopt precautions when indicated, or careless in the methods, etc. can always land up with anesthetic deaths.

  • Hypoxia, improper depth of Anesthesia, vagal inhibition, etc. constitute usual causes of anesthetic deaths.

  • Human error alone was responsible for 82% of the anesthetic deaths, while equipment failure occurred in another 14% of cases and all other factors caused death in the rest of the 4% patients.

• Functional Problems

  • The common problems relate to vagal inhibition, obstruction of the glottis due to spasm, tube, or vomit; cardiac arrhythmia; and hypotension.

  • The unconscious patient poses a special problem in regard to anesthesia, as he is unable to take corrective reflex action against inhalation of foreign material.

Deaths Due to Factors other than Anesthesia

• Disease or injury for which the operation or anesthesia is being given.

• Disease or abnormality other than that for which the surgical operation is undertaken.

• Surgical mishaps and/or postoperative events.

• Physical status of the patient, e.g. old age, diabetes, high blood pressure, etc.

• Surgical mishaps such as unintentional accidental tearing or cutting of a major blood vessel during surgery resulting in death and therefore such deaths are detectable only at autopsy.

• Postoperative consequences such as death due to phlebothrombosis, pulmonary embolism, aspiration of the vomit, etc.

• Unforeseeable problems — patients with hemoglobinopathies are unduly susceptible to low oxygen tension in blood and this may pose a hazard to the unaware surgeon or anesthetist.

10.2: Mode and Cause of Death (Anesthesia)

Cardiac Arrest

• Cardiac arrest — happens due to either oxygen deprivation or carbon dioxide accumulation as a result of failure of technique or fault in technique.

Cardiac Arrest supervene in three ways:

• Asphyxia of Myocardium: Hypovolemia and some diseases of the cardiovascular system carry an enhanced risk.

• Overdose of Anesthetic Agents

• Reflex Vagal Stimulation: Hypoxia, sudden asystole can stimulate vagus nerve resulting in slowing of the heart.

Respiratory Failure

• Overdose of premedication drugs such as barbiturates, tranquilizers, morphine, pethidine, etc can depress respiration, leading to hypoventilation and anoxemia.

• Overdose of anesthetic drugs/administering deep anesthesia with the consequence of the respiratory muscles paralysis.

• Administration of opiates during the postoperative period for the relief of pain may depress the cough reflex causing retention of the sputum leading to secondary infection of the lung.

• Obstruction of the larynx or trachea by laryngospasm and/or bronchospasm, secretions from the throat, blood, swabs, dentures or gastric contents may lead to hypoxia.

• Hypoventilation and hypoxia due to hyperventilation by the anesthetic agents may cause depletion of carbon dioxide, during the recovery period.

10.3: Autopsy and Investigation Examination in a Case of an Anesthetic Death

• In investigating a case of an anesthetic death, a forensic pathologist should take several factors into consideration.

  • Condition for which surgery was performed.

  • Anesthetic agents

  • Burn or explosion

  • Shock and hemorrhage

  • Blood transfusion

  • Resuscitative measures

  • Equipment

Precautions

• Surgical mistakes are gross and anatomical and hence are observable at the postmortem.

• Anesthetic mistakes being physiological are no longer appreciable after death except where overdose with specific drugs is involved.

• Look for or exclude some of the natural disease or mechanical obstruction.

• Autopsy must be preferably done by a forensic expert and it must, however, be remembered that the findings of the autopsy surgeon alone will not be sufficient to explain death.

• It is imperative to hold a discussion across the autopsy table involving forensic expert/autopsy surgeon, anesthetist and the surgeon concerned.

• It is often stated that deaths under anesthesia were more often the fault of the anesthetist than the anesthetic.

Autopsy Procedure

• Note the odor: With inhalant anesthetics, specific odor of anesthetic agent may be detected at autopsy.

• Body cavities: Examine in situ all the cavities. Measure the contents or fluids if any and preserve for analysis.

• Site of surgical intervention: Examine the site of surgical intervention in situ and describe in detail.

• Surgical sutures and organs: Dissect all organs and inspect every surgical suture.

• Signs of prolonged anesthesia: Dependent parts of the viscera are usually seen engorged in cases of prolonged anesthesia.

• Effect of anesthetics: Chloroform and halothane are hepatotoxic and chloroform may rarely produce ventricular fibrillation.

• Evidence of pulmonary embolism and asphyxia: Look for presence of pulmonary fat or air embolism or evidence of asphyxia due to aspiration of regurgitated material which are diagnostic about cause of death.

• Internal findings of hemorrhage, peritonitis and retained swabs and instruments, or evidence of hypersensitivity reaction are obvious.

• Evidence unnoticed: Evidence of vagal inhibition, fall in blood pressure, cardiac arrhythmias, coronaries and laryngeal spasms, etc. could not be detected during an autopsy.

• Histopathological examinations: Collect the sample from all viscera for histopathological study.

  • Specimens should be taken particularly to exclude any cardiovascular disorder including occult conditions.

  • Histological examination of the brain is imperative which is primarily intended to demonstrate the effects of hypoxia.

  • Demyelination and obliteration of axons was also observed and at times, infarction of the basal ganglia.

  • Damage appeared limited to the white matter, which is explained on the basis of greater glycolysis in the white matter during hypoxia as compared with the gray matter.

Chemical Analysis

• A lung is removed and collected by clamping the main bronchus and retained in a nylon bag and sealed so that the headspace gas can be analyzed.

• Collect the alveolar air with a syringe by pulmonary puncture before opening the chest.

• Prior to autopsy to avoid loss of gasses due to exposure of the tissues to the air, it may be necessary to obtain samples of every viscera by the biopsy techniques and frozen immediately.

• At autopsy some portion of fat from the mesentery, skeletal muscle tissue, brain, liver, half of each kidney are retained.

• Blood should be collected under liquid paraffin.

• Urine should also be collected, if available.

• Bacteriological Examination: Adequate blood, urine and other body fluids may have to be collected.

• Hazards of Transfusion of Blood and Body Fluids: Blood and various body fluids should be preserved for analysis.

• Extraneous Specimens:Like residual solutions, medication containers, samples of gases used for the Anesthesia and samples of the operating room air may have to be collected in occasional cases.

10.4: Common Mishaps in Anesthetic Practice

• Mistaken Identity: It can result in mismatched transfusion leading to serious complications.

• Incorrect Positioning of the Patient

  • Eyes should be shut and well protected. Pressure on eyeballs can cause retinal vein thrombosis and blindness.

  • Elbows should be protected as allowing them to lie unprotected against table can cause ulnar nerve palsy.

  • Abduction of arms should not be done beyond 90o. Excess abduction can result in traction injury of bronchial plexus.

  • Sciatic nerve injury can occur during movement to lithotomy position, if both knees and hips are not flexed simultaneously.

  • If a patient is in a prone position, there may be pressure on abdomen, which can cause obstruction of venous return, and there may be restriction in the movement of diaphragm.

  • If there is sudden change of movement, it can cause venous pooling and interference with cardiac output. It may also cause sudden extubation.

  • Protect the patient from hazards of electrocution by avoiding contact of the patient with the metal parts of the operating table.

• Faults in the Anesthetic Machine

  • Faulty anesthetic circuit: The anesthetic circuit may be faulty due to disconnection or leaks or improper setting of APL valve and pressure limiting device.

  • Fault in ventilator: It may be due to disconnection or leak or electric current failure.

  • Laryngoscopes may cause injuries to lips and teeth. There may be failure in light supply.

  • Endotracheal tube may be leaking, cuff may be ruptured, obstruction may be present due to kinking. There may be bronchial or esophageal intubations.

• Failure of Suction Apparatus: This is grave especially in emergency cases.

• Perforation of Airway: Malleable style may cause such perforations.

• Electrocution or Burns: Electrocution can occur because of leakage in electric circuits commonly with use of cautery. Burns are also reported because of leakage of current.

• Fault with Intravenous Equipment: Catheters may be misplaced. Sometimes, air embolism or embolization of catheter fragments is reported.

• Mishaps with Drugs: Improper labeling can lead to the wrong drug being administered. If by mistake expired drugs are used, it can cause overdose or underdose.

• Monitoring of Vital Signs: Every anesthetic procedure requires close monitoring of vital signs at regular intervals. It is one of the most important areas of anesthetic care.

• Human Error

  • Errors due to failure of monitoring and vigilance.

  • Technical errors due to inefficiency in skills required or due to poor design of the equipment and apparatuses.

  • Judgmental errors due to bad decisions by improper/poor training in skills of decision making.

10.5: Preventing Anesthetic Mishaps

• Proper Maintenance of Equipment

  • Suction apparatus for tubing, catheter.

  • Endotracheal equipment like laryngoscope end tracheal tube. • Intravenous drugs for correct labeling date of expiry.

  • Ventilators.

• Proper vigilance: It is the cornerstone of anesthetic practice. Vital signs should be recorded every five minutes. Continuous monitoring of oxygenation and cardiac output should be done.

10.6: Handling Case of Anesthetic Mishaps

• Never panic.

• The situation should be corrected immediately.

• Call for help from other areas or request a surgical team to help you out.

  • Document all the procedures done in finest detail as this is the only defense a doctor can have later on that he has done judiciously what was the need of the time.

  • In the postoperative period, discuss with the patient the circumstances of the case.

  • If a patient is dead, talk to the relatives in detail and explain what happened.

  • Not talking to patients/relatives can lead to unnecessary litigation.

  • If you think litigation may follow, inform the insurance company from where you have taken the insurance policy.

10.7: Death On Operation Table

• Negligence attributed during surgical practice can be divided into the following:

  • Negligence due to Anesthesia and surgeon has no role to play.

  • Negligence primarily by the surgeon alone.

  • Negligence by operating assistants.

  • Corporate negligence during surgery or in the postoperative phase.

  • Negligence primarily due to Anesthesia and surgeon has no role to play.

Negligence Primarily by Surgeon Alone

• Acts of Omission

  • Failure to assess surgical condition properly.

  • Failure to decide whether surgery is required or not.

  • Failure to decide the correct surgical approach.

  • Delay in planning operations leading to complications.

  • Failure to use diagnostic techniques property.

  • Failure to take informed consent.

  • Failure to carry out operation properly.

  • Failure to provide good postoperative care.

  • Failure to provide instructions and precautions to patients.

  • Failure and follow up of patients regularly.

• Acts of Commission

  • Operation more extensively carried out than consented by the patient.

  • Operation conducted on the wrong patient or on the wrong side.

  • Leaving swabs or instruments in the body after surgery.

  • Unnecessary cutting of body tissues.

  • Applying plaster casts too tight or too light for a longer time than required.

  • Committing major blunders like cutting of big vessels or respiratory passages inadvertently.

  • Use of unsterile instruments or operation theater.

• Negligence by Operating Assistants: Surgeon is fully responsible for the mistakes of his assistants like nurses and other paramedical staff during operation.

• Corporate Negligence during Surgery or in Postoperative Phase

  • Leaking cautery during operation may electrocute a patient.

  • Patients may fall off from the operating table due to a defective table.

  • Patients may get injured while being shifted from one place to the other.