Case

Many decades ago, a 6-year-old boy was scheduled for the removal of pins from his right elbow. After inhalational induction, the airway was secured with a laryngeal mask airway (LMA). The child was allowed to breathe spontaneously, an NSAID was given and wound infiltration by the surgeon was planned.

After skin disinfection and draping, surgery started on the right elbow, where a scar was clearly visible. In the meantime, the anaesthesia team filled out the protocol, and realized that, in contrast to the surgical list, the anaesthetist had written ‘pin removal left elbow’ at the preoperative visit. The senior anaesthetist advised the trainee to correct the protocol, because, as a general rule, the surgical list was assumed to provide the correct facts. However, despite surgical exploration down to the bone, no pins could be seen or palpated, and the surgeon requested to see the x-ray. This x-ray revealed that the reduction and fixation of the fracture had been performed on the left elbow. Obviously, the indication of the site on the surgical list was wrong. Surgery proceeded on the opposite side, and the parents were informed about the error.

Discussion

This case of wrong-site surgery illustrates the importance of high-quality team performance. At first glance, wrong-site surgery seems to be a surgical problem. However, in this case, the anaesthesia team could have intervened and therefore has to share the blame. Whenever the slightest discrepancies are noted, alarm bells should ring and the situation has to be re-evaluated. This was not done in this case.

In those days, no use was made of a patient identification bracelet, or a formal checklist, or marking of the operation site. None of these was thought to be necessary. Patient identification is of paramount importance. The author is aware of a situation in which rectal premedication with midazolam 15 mg was given to the 3-month-old baby on the arm of the nanny and not to the 5-year-old patient playing hidden in a corner of the room. The children’s nanny had a sociocultural background that would not allow her to object to decisions of medical personnel. The author was impressed by this event and subsequently insisted, against the traditional attitude in his institution, that an identification bracelet must be introduced.

The use of a simple surgical checklist before skin incision, a so-called ‘time-out’, would have prevented this event without any doubt. Checklists are a strategy to improve patient safety and perioperative care (Treadwell et al. 2014). The introduction of a surgical safety checklist has even been shown to reduce hospital mortality (van Klei et al. 2012). If the baseline quality of the perioperative process is high, however, the additional impact of a checklist may be small, and it may not necessarily further improve outcome. This has been shown in adult (Urbach et al. 2014) and in paediatric populations (O’Leary et al. 2016). The delicious irony of the study findings is that, since the mean outcome remained unchanged, there must have been improvement in some institutions, whereas in others the implementation of a checklist in a formerly perfectly functioning system worsened outcome. With this in mind, it is probably good to concentrate on a few, really important checklists (Grigg 2015). The author believes that an inundation with checklists (especially with those in which electronic checkboxes are ticked on a screen) will not necessarily contribute to improvement of safety (de Vries et al. 2009).

Figure 2.1a Right elbow with a scar following a mosquito bite.

Figure 2.1b X-ray of left elbow with pins. In this more recent case, surgery was performed on the correct site.

Almost a decade ago, the author began to work through a very simple oral checklist before the induction of anaesthesia: patient, intervention, absent allergies, drawn-up medications (hypnotic, relaxant and atropine), anaesthesia machine with tubing, and airway equipment (laryngoscope with the correct blade and the correctly sized tube). This improved safety, because in numerous cases something could be added or improved.

Finally, it is always smart to have a look at the site of surgery before surgery starts. In the presented case, the anaesthetist would not have palpated any pins. This would have been unusual after an elbow fracture and, consequently, the x-ray would have been checked. In addition, such an evaluation might also allow some prediction of the potential duration of surgery.

Summary and Recommendations

This case of wrong-site surgery emphasizes the importance of a high-quality, standardized process in perioperative care.

Following a preoperative checklist (so-called ‘time-out’) would surely have prevented this complication.

Wrong-site surgery is not a complication caused exclusively by the surgeon. In most cases, it is the consequence of insufficient team performance. In the presented case, the anaesthesia team noted the discrepancy but, unfortunately, none of the members spoke up to stop the start of surgery.

Case

Many decades ago, an 8-month-old boy, weighing 8 kg, presented with a rapidly growing cavernous haemangioma involving the neck and face on the right side. The surgical plan was to ligate the external carotid artery, and then, if feasible, partially resect the haemangioma. Both a low platelet count, 20 000/µl, and an elevated prothrombin time were known preoperatively.

A moderately experienced anaesthesiology trainee was in charge, intermittently supervised by a senior staff member. Anaesthesia was induced with ketamine and succinylcholine; enflurane and repeated boluses of ketamine and alcuronium (a non-depolarizing muscle relaxant with some potential for histamine release) were used for maintenance. Monitoring included a precordial stethoscope, ECG and the new oscillometric blood pressure monitoring device Dinamap. The described incident happened well before the introduction of pulse oximetry into clinical practice, continuous capnography was not yet available, and invasive blood pressure monitoring had never been used in children in this institution before.

First, venous access was achieved by surgical cut-down at both elbows, and two units of platelets (about 70 ml each) were administered. Shortly after incision at the neck, the Dinamap could not record ‘interpretable values’ and was thought to be malfunctioning. Noise impeded the use of the precordial stethoscope. Only minutes later, the surgeon could no longer feel the pulsating carotid artery used for orientation. This was followed by bradycardia with wide complexes on the ECG screen.

The supervising anaesthetist rushed in and suggested the administration of Lanoxin, a digitalis preparation, and left to calculate the dose. The trainee remembered that he had used dopamine in adults in cases with cardiovascular instability and started a dopamine drip. Surgery was cancelled, and the infant was transferred to the ICU. Despite the fact that circulation could be restored, the pupils remained dilated and the patient died.

Discussion

This case highlights the importance of an adequate anaesthetic plan and the understanding of the pathophysiology of the underlying disease. The anaesthesia team was not aware of congestive heart failure caused by massive hypercirculation through large haemangioma vessels (Fig. 2.2). Fluid overload by approximately 20 ml/kg of platelet concentrates led to circulatory collapse in this frail patient. Today, hyperdynamic pump failure would be documented by echocardiography prior to surgery and would therefore be known to the anaesthetist. Undoubtedly, such a complex case would be done by a senior staff member and not by a superficially supervised young trainee. It is well known that the experience of the anaesthetist and the age of the patient are the main predictors of complications (Habre et al. 2017).

Figure 2.2 Another large haemangioma related to increased cardiac output. A photo of the boy from the presented case is unfortunately not available.

From today’s point of view, invasive monitoring, including an arterial line, would be considered standard for such a case. In addition, vasoactive drug drips, e.g. dopamine or noradrenaline, would be prepared before starting the case. In those days, oscillometric blood pressure monitoring was a new technology, and invasive blood pressure monitoring, both in adults and in children, was mainly used in cardiac centres. In this institution, it had never before been used in children. At the time, many practitioners felt that arterial and central venous lines could not be used in small children. Physicians working in university centres, except perhaps for those with experience in dedicated cardiac units, shared this attitude. Surgical cut-downs were often performed for the insertion of venous lines. Pulse oximetry did not yet exist, and capnography was not available.

In summary, from today’s perspective, a team with insufficient experience started the case without being adequately equipped and prepared. This case impressively shows that the customary standard in an institution does not necessarily meet the desirable standard. This emphasizes the importance of continuous exchange between institutions. What was standard practice yesterday may no longer be acceptable today.

Kasabach–Merrit syndrome is characterized by giant haemangioma(s) and thrombocytopenia, often complicated by hyperdynamic cardiac failure (Kumar et al. 2013, Wang et al. 2014). Recently, beta-blockers, especially propranolol, have become the first-line treatment for cutaneous (Kum & Khan 2014) as well as subglottic (Hardison et al. 2016) haemangiomas. For these conditions, treatment with surgical excision or laser therapy has become rare. Initially, the patient should be monitored, since hypotension, bradycardia and hypoglycaemia can occur. Obviously, beta-blockers should not be used in patients with high-output cardiac failure.

Summary and Recommendations

The presented case illustrates that an insufficiently prepared and equipped team can contribute to a bad outcome. To be fair, the described events should be seen in their historical context, when the approach taken was the accepted standard of care.

Another important conclusion that can be drawn from this case is the fact that when blood pressure cannot be measured, it is usually not a technical problem, but blood pressure is really low and urgent treatment is needed.

The key message of this case is that every anaesthetist should continuously examine his or her own practice. Improvements in the field of anaesthesiology will continue to be made. What was standard practice yesterday may no longer be good enough today.

Case

A 7-month-old boy, weighing 6 kg, with Cornelia de Lange syndrome was scheduled for laparoscopic fundoplication and gastrostomy tube insertion. He had a cleft palate. Echocardiographic findings were normal with the exception of an aberrant right subclavian artery (so-called arteria lusoria).

From previous anaesthetics, difficult intubation was anticipated. He was induced by mask and fibreoptically intubated via the Frei endoscopy mask with a size 3.0 cuffed endotracheal tube (ETT). Anaesthesia was maintained over more than 6 hours with sevoflurane 2 V%, small doses of fentanyl, and mivacurium as a continuous infusion. A 4F double-lumen central venous catheter was inserted into the right internal jugular vein. A 2F 5 cm arterial line was inserted under ultrasound guidance into the right radial artery without difficulties and a stable tracing was observed.

When the surgeons were working on the fundoplication and requested the insertion of a large-bore orogastric tube, the arterial tracing suddenly disappeared. A similar episode occurred during gastroscopy, which was performed for gastrostomy tube insertion (Fig. 2.3). When repeated flushing of the right radial line was unsuccessful, oscillometric blood pressure measurements on the left arm were obtained. Patient positioning was carefully checked to rule out the possibility that direct pressure on the right arm was responsible for the loss of the arterial tracing. It was then speculated that the flat arterial tracing could have something to do with the use of a large gastric tube in the presence of the arteria lusoria.

Figure 2.3 The disappearance of the arterial tracing during the insertion of a large gastric tube or a gastroscope in a child with an arteria lusoria.

When fundoplication was completed, the gastric tube was removed, and immediately a normal arterial tracing reappeared. Because a gastrostomy tube was also inserted, there was no need for another gastric tube.

Discussion

This case of compression of an aberrant subclavian artery by a large gastric tube and then by a gastroscope illustrates that surgical manipulations can interfere unexpectedly with anaesthesia management. It also shows that every small detail, such as the presence of an arteria lusoria, should be evaluated preoperatively for its potential relevance to the intraoperative course.

The most common abnormality of the aortic arch (0.6–1.4%) is an aberrant right subclavian artery, a so-called arteria lusoria (Polguj et al. 2014). The vessel arises from the descending aorta and runs behind the oesophagus and the trachea to the right clavicular region. While the large majority of patients are asymptomatic, compression of adjacent structures can cause symptoms. Compression of the oesophagus can cause dysphagia (Barone et al. 2016) and compression of the trachea can cause dyspnoea and stridor (Derbel et al. 2012). Interestingly, as demonstrated by the presented case, a large foreign body in the oesophagus can compress the subclavian artery, leading to the disappearance of the pulse at the wrist. This phenomenon has already been reported during transoesophageal echocardiography in a neonate (Koinig et al. 2003). If unknown, the presence of an arteria lusoria presents a major risk during oesophageal surgery (Lacout et al. 2012). The author is aware of a baby with oesophageal atresia where this large abnormal arterial vessel lying behind the oesophagus was not correctly identified and ligated. Immediately, the pulse oximeter signal from the right hand was lost. An arteria lusoria may also be detected during right transradial coronary interventions (Allen et al. 2016). Associated vascular malformations may include a common carotid trunk or a left-sided vena cava.

Cornelia de Lange syndrome is a clinically variable disorder that affects multiple organs (Boyle et al. 2015). Severe intellectual disability and a difficult airway due to a short neck and micrognathia are major challenges for the paediatric anaesthetist. But, in contrast to current belief, there is no elevated risk for malignant hyperthermia (Emerson & Nguyen 2017).

Summary and Recommendations

The presented case of a child with an arteria lusoria interfering with blood pressure monitoring when a large gastric tube was in place shows that even after a careful preoperative workup, the anaesthetist may fail to recognize the cause of the observed changes. Only lifelong experience and learning will further improve competence.

This story also supports the practice of always installing oscillometric blood pressure monitoring equipment on a different extremity when an arterial line is used, in order to have a valuable back-up ready when the invasive method fails.