General Anaesthetic
In any operation involving the administration of a general anaesthetic, an anaesthetist has to be present. The role of the anaesthetist throughout the procedure is not simply to dispense drugs, but to monitor the patient's overall physiological condition. If there are worrying systemic imbalances during the operation (for example, if the patient suffers a sharp or prolonged drop in blood pressure), the anaesthetist's role is to correct these.
There is a degree of risk to the brain in all operations which involve the administration of a general anaesthetic. General anaesthetics are powerful chemical cocktails, and need to be deployed with skill. Anaesthetics contain 3 constituent agents:
- a narcotic (sends the patient to sleep);
- an analgesic (blocks pain);
- a paralysing agent (stops the patient from moving about).
The dosage of each of these groups of chemicals will usually be calculated by reference to the patient's bodyweight and may factor in various other physiological considerations. Dosage having been calculated, the drugs which make up the anaesthetic are then each given at set intervals. There are several problems associated with general anaesthesia, which include the following:
Anaesthetic Awareness
Anaesthetic awareness is a problem which affects a significant minority of patients. Most people who have experienced this phenomenon report a range of symptoms, from awareness of conversations amongst the surgical team (one patient in a recent study reported hearing a member of staff talking about how best to cook spaghetti), to prolonged sensations of agony. In the vast majority of reported cases, the patient, whilst aware of what was going on around him or her, was unable to communicate or move. The psychological damage caused by anaesthetic awareness can be severe: some patients who have undergone this experience have suffered horrendous psychological complications, and a few have found it difficult to set foot in a hospital again.
Anaesthetic awareness may sometimes be due to errors in drug dispensation. If enough paralysing agent is given to prevent the patient from moving, direct communication becomes impossible, and the patient is effectively helpless. If an insufficient or badly-timed dispensation of the narcotic portion(s) of the anaesthetic cocktail occurs in this setting, then it is likely the patient will retain some level of awareness during part of the procedure. If this is compounded by insufficient analgesia, then it is highly likely that sensations of pain will occur - the degree of pain is likely to depend partly on the extent of the error in drug dispensation, but also upon the individual patient's pain threshold.
There is a continuing debate as to the preventability of anaesthetic awareness: some studies have suggested that, even if the patient is not able to communicate effectively, there may be telltale signs, such as sudden rises in pulse and blood pressure immediately following surgical manoeuvres. Such physiological responses to pain are "automatic" and are therefore not suppressed by the paralysing agent.
How do we investigate the claim?
Investigating anaesthetic awareness is frequently complex. Many patients report the occurrence of an incident of anaesthetic awareness immediately after it has happened, but this is by no means always the case. In order to win an anaesthetic awareness claim, we need to prove that contemporaneous clinical guidelines were not followed (breach of duty), and that if they had been, then, on the balance of probabilities the condition would not have developed (causation). But in these cases we have an additional problem: we need to establish that the events from which the complaint stems actually happened.
As with virtually all clinical negligence claims, the first prerequisite is to obtain your medical records, including any incident reports if you reported your experiences at the time. These records will then need to be assessed by an expert practising in a relevant field - usually an anaesthetist. The anaesthetist will go through the records, and comment upon any apparent anomalies - these may consist of apparent errors in drug dispensation, but physiological factors which allow us to "second guess" the presence of anaesthetic awareness (e.g. sudden rises in blood pressure and pulse) may also be highly important.
In order to assess the nature of the trauma, your solicitor will then need to approach an independent clinician with expertise in this field - usually a psychiatrist or psychologist. It would normally be necessary for you to be seen by this expert. This expert's job will be to comment upon the extent of any psychological injury that you have sustained. We will need to argue that you have suffered some recognised form of psychological injury in order for the claim to succeed.
Anaesthetic Maladministration in Vulnerable Patients
Poorly administered or badly monitored general anaesthetic can have disastrous consequences, which include anaesthetic awareness (see above), strokes, and even death. It is therefore vitally important that factors such as blood pressure are monitored by the anaesthetist, since if these are allowed to drop for any length of time, there may be extremely damaging neurological and other systemic consequences.
Whilst it is dangerous for anyone to undergo a prolonged and severe drop in blood pressure, problems are likely to occur faster, and to be more severe in the form they take, in patients with pre-existing vascular problems and/or diabetes. In one case of which we are aware, an anaesthetist allowed a patient's blood pressure to drop dangerously for a period of hours, without administering any of the usual counter-measures for this. As a result, the patient (a diabetic) went into a coma, suffering a stroke and permanent neurological impairment.
How do we investigate the claim?
How we investigate the consequences of an anaesthetic error is obviously predicated upon the type of injury that has been sustained. We will need to prove that contemporaneous clinical guidelines were not followed (breach of duty), and that if they had been, then, on the balance of probabilities the condition would not have developed (causation).
We will first of all need to obtain your medical records, including any incident reports if there was an immediate appreciation that something had gone catastrophically wrong. These records will then need to be assessed by an expert practising in a relevant field - almost certainly an anaesthetist. The anaesthetist will go through the records, and comment upon any apparent anomalies, which may consist of a failure to respond sufficiently swiftly to an evolving clinical situation as much as questionable drug dispensation.
As stated above, the question as to how "causation" is investigated depends on what harm occurred. However, we have noticed that many of these cases involve brain injury. Assuming that a neurological injury has occurred, we would need to go through the records and ascertain the diagnosis, and thus the type of injury that has occurred. We would then instruct a clinician from a relevant medical field - probably a neurologist or neuropsychiatrist (possibly both) in order to determine what harm has arisen as a result of the incident. We would also have to determine the likely prognosis.
Physiological Support Systems
The anaesthetist may not be the only person in theatre responsible for the patient's physiological status. In "open heart" cardiac surgery, a perfusionist is likely to be present. The perfusionist will be responsible for the cardiopulmonary bypass machine - the machine which supplies the patient with an independent supply of oxygenated blood whilst the heart is operated upon.
During and after (for example) liver or heart surgery, it is quite likely that the body will not be able to cope unassisted for some while afterwards. It needs a support system. Whilst such machines are often vital to survival, they can also expose the patient to risks.
In the context of surgical procedures which rely upon physiological support systems such as cardiopulmonary bypass, the brain is quite likely to be exposed to some risk of damage. This is because machines can replicate bodily functions pretty well, but not exactly: minor anomalies such as microemboli (literally, very small particles or bubbles of air) can cause injury to blood vessels in the brain over any length of time. Equally, the strain that surgery – especially surgery conducted on vital organs – imposes on the brain can be profound. It is mercifully uncommon for such surgery to cause major or prolonged disturbances in the supply of oxygen to the bodily organs, but unfortunately, if this does occur, the brain is likely to be among the organs to suffer first.
The risk to the brain is unfortunately not limited to the operating room. Generally, in the post-operative period, it is broadly true that the longer somebody spends on one or more physiological support systems, the higher will be the risk of some form of neurological deficit.
Contact
Angelina Rigby Head of Clinical Negligence
Steve Duddell Partner
Nye Moloney Trainee Legal Executive
Jane Beresford-Huey Assistant
Angela Konstanz Assistant
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