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MEDICOLEGAL ISSUES
Year : 2011  |  Volume : 55  |  Issue : 3  |  Page : 307-308  

Intraoperative bronchospasm leading to hypoxic brain damage: Medicolegal update


Assisstant Professor Anaesthesia, G. S. Medical College and K. E. M. Hospital, Assisstant Professor Anaesthesia, T. N. Medical College and B.Y. L. Nair Hospital, Consultant Pediatrician, Appollo Clinic, Visiting Professor, University of Law, Mumbai, India

Date of Web Publication7-Jul-2011

Correspondence Address:
Namita M Baldwa
Assisstant Professor Anaesthesia, G. S. Medical College and K. E. M. Hospital, Assisstant Professor Anaesthesia, T. N. Medical College and B.Y. L. Nair Hospital, Consultant Pediatrician, Appollo Clinic, Visiting Professor, University of Law, Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.82677

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How to cite this article:
Padvi AV, Baldwa NM, Baldwa MS. Intraoperative bronchospasm leading to hypoxic brain damage: Medicolegal update. Indian J Anaesth 2011;55:307-8

How to cite this URL:
Padvi AV, Baldwa NM, Baldwa MS. Intraoperative bronchospasm leading to hypoxic brain damage: Medicolegal update. Indian J Anaesth [serial online] 2011 [cited 2019 Oct 16];55:307-8. Available from: http://www.ijaweb.org/text.asp?2011/55/3/307/82677

One of the common litigation problems is life-threatening perioperative anaesthetic complications. One such complication is intraoperative bronchospasm during anaesthesia. The causes of intraoperative bronchospasm range from intubation problems to catastrophic anaphylactic reactions. Common causes of perioperative bronchospasm are patient with asthma, light plain of anaesthesia and anaphylaxis. There are anecdotal case reports of unexpected bronchospasm during spinal anaesthesia that are unresponsive to beta-agonists and atropine. [1]

We present a decided medicolegal court case of Johnson Thomas versus Bishop Vayalil Medical Centre vide First Appeal NO.225 OF 1998 decided on 12 th April, 2010 by the Apex consumer court "National consumer disputes redressal commission, New Delhi (NCDRC)." Johnson Thomas and the other family members aggrieved by the order dated 25.5.1998; dismissing their complaint by the Kerala State Consumer Disputes Redressal Commission, Thiruvananthapuram (in short, "the State Commission"), the unsuccessful complainants had filed the appeal before the Apex consumer court.

  1. The Apex consumer court thought it proper to obtain the opinion of an independent expert medical board.
  2. Therefore, as per the direction of NCDRC, Director, AIIMS, New Delhi constituted a Board of three doctors. The relevant portion of the said report is reproduced below.



   Case Summary Top


The patient underwent caesarean section under general anaesthesia, despite h/o recent rhinitis. Pre-operative anaesthesia assessment as well as anaesthesia induction and tracheal intubation were unremarkable. The patient was given intermittent positive-pressure ventilation with 100% oxygen for maintaining anaesthesia. The patient developed severe bronchospasm and cyanosis within a few minutes of starting surgery, which improved with medications within a few minutes. At the end of surgery, the neuromuscular blockade was reversed and the patient was extubated. She had a delayed recovery and was diagnosed as having hypoxic encephalopathy, which was attributed to the short period of bronchospasm. She died subsequently after a few days.

3. The following issues were noted by the medical board to be significantly unusual:

  1. Inferred that general anaesthetic was given to the patient with recent h/o of rhinitis, where there were no contraindications to neuraxial blockade (SA).
  2. Inferred that no antacid, pro-kinetic prophylaxis was given before giving general anaesthesia.
  3. The patient was pre-oxygenated for 5 min (around 9.20 am as per the anaesthesia records), then intubated and positive-pressure ventilation was maintained with 100% oxygen. This procedure was uneventful. Bronchospasm and cyanosis were noted around 9.22 am and the same was treated with parenteral Deriphylline, Betnesol, and Lasix. The cyanosis and bronchospasm were absent when the patient was examined by the physician around 9.30 am. The committee was of the opinion that it is unlikely for an American Society of Anaesthesiologists (ASA) -gradeI patient to develop hypoxic encephalopathy after receiving pre-oxygenation for 5 min, with uneventful induction, intubation, and ventilation with 100% oxygen, in spite of developing bronchospasm in a time span of few minutes.
  4. Inferred that the anaesthesia record was poorly maintained.
  5. Inferred that treatment of severe bronchospasm was not aggressive.
  6. Inferred that medications used - Lasix and, subsequently, soda bi carbonate - are not normally used for the treatment of bronchospasm.
  7. Inferred that total duration of surgery (125 min) is unusual without any intraoperative complications.
4. Earlier, in the lower court in Kerala, the State Commission had examined two experts in anaesthesia with cross-examinations. Their testimony did not throw enough light on the disputed questions as to whether there was or not any negligence on the part of the doctors.

5. The Apex consumer court observed that, "Having considered the respective contentions of the litigant parties, the inevitable conclusion which should follow in the present case is that both respondent no.3-Dr. Mammen Easaw (Anaesthetist) as well as respondent no.4-Dr.Marykutty Ilickal (Gynecologist) have not followed the standard medical protocol. They have committed several acts of omission and commission as have been noticed by the Medical Board. Larger portion of the blame is attributable to the Anaesthetist because it was due to his mishandling/improper handling of the anaesthological procedure that the patient developed Hypoxic Encephalopathy leading to her death. Negligence on the part of gynaecologist is limited."

6. The Apex consumer court said that the total payable compensation worked out to Rs. 10,00,000, only. Respondent no. 3, Dr. Mammen Easaw (Anaesthetist) and respondent no. 4, Dr. Marykutty Ilickal (Gynaecologist) along with respondent nos. 1 and 2 are jointly and severally liable to pay.

Lessons learnt from the case are:

  1. Use the most commonly used anaesthesia for the operative procedure and, if you deviate, write down the indications/causes explicitly to explain the deviation from usual.
  2. Use standard pre-operative preventive medication using pro-kinetic prophylaxis before giving general anaesthesia - a standard practice all over the world.
  3. Anaesthesia records should show explicitly the complication of bronchospasm, and the same should be shown, treated diligently and prudently with due care and caution.
  4. Drugs other than those treating bronchospams - like Lasix - should find rationale for its use.
  5. Explanations for bronchospasm causing haemodynamic variations that led to patient developing hypoxic encephalopathy.


 
   References Top

1.Edward K. McGough MD and Jerry A. Cohen MD, Department of Anesthesiology, University of Florida College of Medicine Gainesville, FL, USA, Received 9 March 1989. Available from: http://www.sciencedirect.com/science. [cited on 2011 Jan 6].  Back to cited text no. 1
    




 

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