A Difficult Airway and a Systemic Failure

In April and May this year, an inquest was held into the 2003 death of a 31 year old woman in Perth. The patient died prior to surgery, after she was unable to be ventilated following the administration of a non-depolarising muscle relaxant. The inquest was notable due not only to its involving the management of an extremely difficult airway, but also for the resulting coronial recommendations, pertaining to the availability of information relating to prior anaesthetic difficulties.

The facts of the case

On June 17th, 2003, a 31 year old mother of three was admitted to the Joondalup Health Campus, an integrated public/private facility in Perth's northern suburbs. She was in hospital for an elective left inguinal hernia repair. She was seen on the day prior by a general practice trainee, who was working as a registrar in anaesthesia. His assessment was that her unusual anatomy might present a potentially difficult intubation (Mallampati score of 4.) Crucially, no attempt was made to access the previous anaesthesia records. The unusual anatomy was later described by the forensic pathologist: "the neck was significantly reduced in length, with the left ear 2cm below the left shoulder and the right ear lobe resting on the right shoulder. The neck showed no mobility and was deviated to the right." In addition, her trachea was deviated to the left and covered anteriorly by a large goitre. The surgeon, who was to have operated that day, described co-morbidities for anaesthesia as including dysmorphia, torticollis of the neck and flexion deformity of the neck, as a result of operative cervical spinal fusion.

In theatre the consultant anaesthetist administered atracurium, a non- depolarising muscle relaxant. The anaesthetist was unable to ventilate her using a bag and mask or laryngeal mask airway (LMA). He removed and repositioned the LMA but was still unable to ventilate. A Guedel airway and another LMA were tried, to no avail.

At this point, the anaesthetist called for help and another anaesthetist offered assistance. He too was unable to ventilate the patient or secure the airway and an arrest was called. Various attempts were made to establish an airway by those in theatre, including further LMAs, nasal fibre-optic intubation, cricothyroidotomy and tracheostomy. None was successful. Despite the efforts of those in theatre, the patient remained unventilated and, tragically, died.

It is worth noting here that the coroner stated in his report that he had, with regard to those who were subsequently called in to assist:

. nothing but praise for all of the doctors involved in what were desperate attempts to save the life of the deceased. Tragically at the stage when it was clear that the deceased was not able to be ventilated the time available to achieve effective resuscitation was limited.

He went on to comment that, as the surgeon had observed:

. any attempts to obtain surgical airway in this particular case would have been extremely difficult due to the patient's anatomical features.

The coroner found that the cause of the patient's death was cerebral anoxia and that her death arose by misadventure.

Coronial recommendations

Of interest to all practitioners should be the lessons that can be learned from such a case. The coroner found that there were systemic issues which should be addressed, primarily relating to the availability of information through TOPAS (The Open Patient Administration Scheme - WA Health patient record system), regarding prior anaesthetic difficulties experienced in the management of a patient. The patient had undergone two prior general anaesthetics in the WA system, both of which were associated with difficulties in management of the airway.

In brief, the recommendations¹ were that:

1. Representatives of Anaesthesia WA and the Health Department, meet to discuss improvement to the consistency of recording of anaesthetic difficulties in TOPAS, such that practitioners will be able to search and find information on previous difficulties with ventilation and intubation;
2. The WA Health Department review the current system of access to the Med-Alert system, such that it be made available to privately operated hospitals (and hence all anaesthetists), so that potentially life saving information is readily available and can be acted upon; and
3. Anaesthetists adopt the practice of reporting any difficulty with anaesthesia or intubation of patients to the referring physician and to the patient, in writing, and that a copy be placed in the medical record

Had the anaesthetist had access to such information, he would have been aware that a 1989 cervical spinal fusion operation had involved a difficult intubation, with a:

"valve effect" noted when the epiglottis had applied firmly to the posterior pharyngeal wall. The epiglottis had gone to the back of the throat closing the airway.

Notes from a surgical procedure in 2000, indicated that use of an LMA did not achieve ventilation, with a sharp angle introducer required to insert an endotracheal tube. It was only when ventilation was achieved, that atracurium was given. As noted by the coroner, none of this information was available to the anaesthetist on June 17th, 2003.

Although the patient was asked by both the anaesthetic registrar and the consultant about prior anaesthetic difficulties, the coroner made it clear that this is not a reliable means of ascertaining if such difficulties had ever arisen. As one retired GP submitted to the inquest:

Patients are often informed of how a procedure went and any problems encountered immediately after an operation but their ability to recall details, even important details, is markedly impaired by the effects of anaesthetic drugs. Patients generally see the attending surgeon at a later date post-operatively but not usually the anaesthetist so anaesthetic difficulties may well be overlooked by the surgeon in discussions with the patient.

Medicolegal opinions

Another salient point to emerge was the importance of maintaining impartiality when submitting medicolegal opinions on behalf of other practitioners. While the coroner was broadly complimentary of the opinions submitted in the case, he was critical of one submission written by another anaesthetist, on behalf of the anaesthetist in question.

The opinion was at odds with others submitted and, in the view of the coroner, ". was not balanced and did not comply with the Position Statement of the Australian Society of Anaesthetists (ASA), which provides guidelines for anaesthetists in giving expert evidence." This is a timely reminder that though, at the time of writing the opinion, the doctor in question was not aware that it would be submitted to the Coroner's Court as evidence, this is always a potential outcome. Opinions must be written impartially and ". must not adopt a position of advocacy."

The lessons

This tragic case underlines the importance of clear communication and the way that a series of smaller problems can compound to create a disastrous outcome. The coroner's recommendation that practitioners communicate difficulties to the patient and referring physician, should encourage us as anaesthetists to provide more information to our patients. This should be in writing and should err on the side of caution. If for example, a difficult airway is managed uneventfully using awake fibreoptic intubation by one anaesthetist in one hospital, this patient may well be problematic for another anaesthetist at another time in another hospital. There is much to be gained by alerting the patient as to the problem and its successful management. In response to the issues raised in this case, the (ASA) is providing members an anaesthesia alert card. This can be filled in and given to the patient to keep in their wallet in the event of future anaesthesia. This will be a useful tool until such time as electronic patient records are available to practitioners in the public and private sector at all times.

In addition, doctors should be aware of their responsibilities when composing medicolegal opinions.

Dr Richard Grutzner, MB BS FANZCA Grad Dip Appl Fin
Medical Adviser - Invivo

1. http://ctec.uwa.edu.au/anaesthesiawa/inquest.html
   All other quotations are directly from the coroner's report entitled, "Inquest into the death of Rachael Anne Rasmussen," Ref. No. 12/07