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Is it the pilot or the plane?
Internotional Joumd of
Obstetric Anesthesia (1998) I, 275-284 0 1998 Harcourt Brace&Co. Ltd
CORRESPONDENCE
failed to appreciate.. .‘, and, ‘. . .the anaesthetist made no attempt to.. .‘. This tells us that it was the pilot who was responsible for the tragedy and not the plane. The fourth case was another example of an error of judgement by the pilot. The anaesthetist went ahead and gave a general anaesthetic to a patient who was known to be difficult to intubate and had a short neck and a receding chin. Contrary to basic principles of obstetric anaesthesia she was extubated in the supine position. The fifth patient died from aspiration of gastric contents. The report states, ‘.. .it must be concluded that the cricoid pressure was applied incorrectly or too late’. Again operator error not technique. In the most recent report, 1991-93,3 there were eight direct deaths. Substandard care was evident in seven of them. The report considered the first case to be a serious case of substandard care. Again it was the pilot not the plane. The second patient had a successful epidural during labour. She was obese with limited mouth opening. She refused permission for the section to be carried out under the epidural and her wish to have general anaesthesia was respected. I believe this was an error of judgement. This mother’s wish to have a general anaesthetic should not have been upheld. The anaesthetist should have insisted on epidural anaesthesia because, in this circumstance, the anaesthetist knows better. The third patient was anaesthetised in the anaesthetic room without monitoring. The cause of death may well have been suxamethonium anaphylaxis. The report was critical of the fact that a second dose was given despite preliminary diagnosis of anaphylaxis. General anaesthesia did not kill the fourth patient. She died because of the insertion of a neck line in the presence of clotting abnormalities. One death, the fifth in the report, was the result of an epidural given to a patient who complained of perineal pain 36 h after forceps delivery. No one blamed the technique but all blamed the operator. The report considered the sixth case to be a ‘serious case of substandard care’. The exact cause of death of the seventh case was not clearly established. The last case was the only case that was managed properly. Anaphylaxis is a recognized complication of suxamethonium. I am not defending a specific technique. I am saying that these deaths have been wrongly attributed to the technique and hence the hazards of general anaesthesia grossly exaggerated. The trainees are being taught to be prejudiced against the technique. I believe that in the hands of experienced and sensible anaesthetists
Is it the pilot or the plane? I attended a 3-day course in Obstetric Anaesthesia and Analgesia held in London, l-3 December 1997, which was organized by the Obstetric Anaesthetists’ Association. The following statement, ‘regional anaesthesia is safer than general anaesthesia’, was made by many of the lecturers and they all quoted as their only reference the Report on Confidential Enquiries into Maternal Deaths (CEMD). I disagree with the view expressed. In the CEMD of 1985-87 there were eight direct deaths.’ Two of them were late deaths. Five deaths were caused by misplacement of the tracheal tube. With continuous monitoring of end-tidal CO, this complication should be recognized immediately. If it is not, this is definitely an error of the operator (pilot) and not the technique (plane). One death was caused by inhalation of gastric contents but the report suggests that cricoid pressure may not have been properly performed. Two mothers died under epidural anaesthesia, one of whom was known to be difficult to intubate and yet was given a general anaesthetic. I believe this to be an error of judgement by the pilot who failed to intubate (as expected). The patient was allowed to wake up (still alive after a general anaesthetic) and a junior was asked to give epidural anaesthesia without supervision. The epidural was a total spinal and the mother died. There were five direct deaths in the 1988-90 report.2 One was a late death. The report comments on the first death: .for similar complications occurred on each of the three occasions when the patient was anaesthetized by experienced consultants, who used recognized monitoring techniques, kept detailed records and apparently took the appropriate action after the complication developed.2
Had this patient been anaesthetized by any of those consultants, she may well have been alive now. Again pilot error. The report also states that the immediate cause of death was: . . . widespread thromboses.2
pulmonary
embolisation
from pelvic
and calf vein
A spinal anaesthetic was the cause of death in the second case. Aortocaval compression contributed to her death in a significant way. Should we blame spinal anaesthesia or the anaesthetist? The third death was caused by inadequate postoperative care. The assessor’s report includes the phrases, ‘. . .the anaesthetist 215
276
International Journal of Obstetric Anesthesia
both techniques, general and regional, are equally safe. What matters really is sound clinical practice and judgement. S. Al Ramadhani MD FRCA Department of Anaesthesia, Al Corniche Hospital, PO Box 3788, Abu Dhabi, United Arab Emirates REFERENCES
1. Department of Health, Welsh Office, Scottish Home and Health Department, Department of Health and Social Services, Northern Ireland. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom: 19851987. London: HMSO, 199 1. 2. Department of Health, Welsh Office, Scottish Home and Health Department, Department of Health and Social Services, Northern Ireland. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom: 1988-1990. London: HMSO, 1994. 3. Department of Health, Welsh Office, Scottish Home and Health Department, Department of Health and Social Services, Northern Ireland. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom: 1991-1993. London: HMSO, 1996.
In reply: It was interesting to read the analysis by Dr Ramadhani’ of anaesthetic deaths featured in the three most recent Reports on Confidential Enquiries. He maintains that regional anaesthesia should not be considered safer than general, because in many of the reported deaths following general anaesthesia it is the operator rather than the technique itself which is at fault. It must be realized, however, that a technique is only as safe as its practitioners and when assessing the safety of any procedure it is invalid to exclude operator error. It is precisely because pilots make errors that safety elements are built in to aeroplanes, and safety checks are similarly built in to anaesthetic techniques. Moreover, while in aviation it is sometimes possible to separate pilot error from mechanical failure, in anaesthesia it is rarely so. It would be a foolish anaesthetist who would claim never to have made a mistake, or never to have failed in an attempt to perform a skilled task, Protocols are developed to minimize the possibility of disaster, and drills are designed to overcome difficulties should they be encountered. But no amount of careful instruction can make a trainee capable of intubating every trachea, and even the most skilled assistant applying cricoid pressure can push the larynx laterally or cause the cricoid ring to collapse, thereby hindering intubation.* By contrast, when teaching epidural insertion, minimizing dural puncture, aspirating the catheter, giving a test dose and assessing it, giving a large dose slowly,
watching the patient for signs of trouble and monitoring the effects of the block, all these safe practices can be instilled into the trainee given the will and the resources. It is good practice that has resulted in epidural services with much lower morbidity and mortality rates than in the early days. True, general anaesthesia has also become safer with improvements in techniques and monitoring, but difficulties can never be completely forestalled. It is noteworthy that the deaths described by Dr Ramadhani as following regional anaesthesia are, even more than those related to general anaesthesia, attributable to operator error or misjudgement. Does he, therefore, consider that every one of them should be excluded from assessment of the safety of regional anaesthesia? Indeed, every death associated with regional blockade in all the reports could be so considered, in which case it is a very safe technique indeed! A more sober estimate of mortality must include a denominator. Though general anaesthesia may in the past have been more frequently used than regional for operative obstetrics, this may no longer be the case even in the UK.3 Moreover it is appropriate to include analgesic blocks in the denominator. In the 21 years from 1970-90, there were 154 anaesthetic deaths, of which 9 were causally related to epidural anaesthesia or analgesia. During this time, it is likely that more parturients received epidural blockade than received general anaesthesia. No assessment of safety can ignore morbidity, however. To believe that the major complications of epidurals resulting from inadvertent dural puncture, subarachnoid and intravenous injection (which can all be circumvented by the use of spinal anaesthesia), are inevitable occasional accidents of epidural insertion is to overlook the huge differences in their frequency between modern centres with quality supervision4 and practice elsewhere,5 particularly when in its infancy. One should not overlook also the dramatic improvements in maternal satisfaction and postoperative well-being (not to mention the baby’s welfare) that have been demonstrated by Morgan et al6 and others when caesarean section is conducted under regional rather than general anaesthesia. For all these reasons we would do our mothers a disservice if we felt unable to recommend regional anaesthesia for caesarean section. The prerequisite for any such recommendation must be high quality training in the field for the next generation of anaesthetists. F. Reynolds Department of Anaesthetics, St Thomas’ Hospital London SEI 7EH, UK
Obstetric Anesthesia (1998) I, 275-284 0 1998 Harcourt Brace&Co. Ltd
CORRESPONDENCE
failed to appreciate.. .‘, and, ‘. . .the anaesthetist made no attempt to.. .‘. This tells us that it was the pilot who was responsible for the tragedy and not the plane. The fourth case was another example of an error of judgement by the pilot. The anaesthetist went ahead and gave a general anaesthetic to a patient who was known to be difficult to intubate and had a short neck and a receding chin. Contrary to basic principles of obstetric anaesthesia she was extubated in the supine position. The fifth patient died from aspiration of gastric contents. The report states, ‘.. .it must be concluded that the cricoid pressure was applied incorrectly or too late’. Again operator error not technique. In the most recent report, 1991-93,3 there were eight direct deaths. Substandard care was evident in seven of them. The report considered the first case to be a serious case of substandard care. Again it was the pilot not the plane. The second patient had a successful epidural during labour. She was obese with limited mouth opening. She refused permission for the section to be carried out under the epidural and her wish to have general anaesthesia was respected. I believe this was an error of judgement. This mother’s wish to have a general anaesthetic should not have been upheld. The anaesthetist should have insisted on epidural anaesthesia because, in this circumstance, the anaesthetist knows better. The third patient was anaesthetised in the anaesthetic room without monitoring. The cause of death may well have been suxamethonium anaphylaxis. The report was critical of the fact that a second dose was given despite preliminary diagnosis of anaphylaxis. General anaesthesia did not kill the fourth patient. She died because of the insertion of a neck line in the presence of clotting abnormalities. One death, the fifth in the report, was the result of an epidural given to a patient who complained of perineal pain 36 h after forceps delivery. No one blamed the technique but all blamed the operator. The report considered the sixth case to be a ‘serious case of substandard care’. The exact cause of death of the seventh case was not clearly established. The last case was the only case that was managed properly. Anaphylaxis is a recognized complication of suxamethonium. I am not defending a specific technique. I am saying that these deaths have been wrongly attributed to the technique and hence the hazards of general anaesthesia grossly exaggerated. The trainees are being taught to be prejudiced against the technique. I believe that in the hands of experienced and sensible anaesthetists
Is it the pilot or the plane? I attended a 3-day course in Obstetric Anaesthesia and Analgesia held in London, l-3 December 1997, which was organized by the Obstetric Anaesthetists’ Association. The following statement, ‘regional anaesthesia is safer than general anaesthesia’, was made by many of the lecturers and they all quoted as their only reference the Report on Confidential Enquiries into Maternal Deaths (CEMD). I disagree with the view expressed. In the CEMD of 1985-87 there were eight direct deaths.’ Two of them were late deaths. Five deaths were caused by misplacement of the tracheal tube. With continuous monitoring of end-tidal CO, this complication should be recognized immediately. If it is not, this is definitely an error of the operator (pilot) and not the technique (plane). One death was caused by inhalation of gastric contents but the report suggests that cricoid pressure may not have been properly performed. Two mothers died under epidural anaesthesia, one of whom was known to be difficult to intubate and yet was given a general anaesthetic. I believe this to be an error of judgement by the pilot who failed to intubate (as expected). The patient was allowed to wake up (still alive after a general anaesthetic) and a junior was asked to give epidural anaesthesia without supervision. The epidural was a total spinal and the mother died. There were five direct deaths in the 1988-90 report.2 One was a late death. The report comments on the first death: .for similar complications occurred on each of the three occasions when the patient was anaesthetized by experienced consultants, who used recognized monitoring techniques, kept detailed records and apparently took the appropriate action after the complication developed.2
Had this patient been anaesthetized by any of those consultants, she may well have been alive now. Again pilot error. The report also states that the immediate cause of death was: . . . widespread thromboses.2
pulmonary
embolisation
from pelvic
and calf vein
A spinal anaesthetic was the cause of death in the second case. Aortocaval compression contributed to her death in a significant way. Should we blame spinal anaesthesia or the anaesthetist? The third death was caused by inadequate postoperative care. The assessor’s report includes the phrases, ‘. . .the anaesthetist 215
276
International Journal of Obstetric Anesthesia
both techniques, general and regional, are equally safe. What matters really is sound clinical practice and judgement. S. Al Ramadhani MD FRCA Department of Anaesthesia, Al Corniche Hospital, PO Box 3788, Abu Dhabi, United Arab Emirates REFERENCES
1. Department of Health, Welsh Office, Scottish Home and Health Department, Department of Health and Social Services, Northern Ireland. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom: 19851987. London: HMSO, 199 1. 2. Department of Health, Welsh Office, Scottish Home and Health Department, Department of Health and Social Services, Northern Ireland. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom: 1988-1990. London: HMSO, 1994. 3. Department of Health, Welsh Office, Scottish Home and Health Department, Department of Health and Social Services, Northern Ireland. Report on Confidential Enquiries into Maternal Deaths in the United Kingdom: 1991-1993. London: HMSO, 1996.
In reply: It was interesting to read the analysis by Dr Ramadhani’ of anaesthetic deaths featured in the three most recent Reports on Confidential Enquiries. He maintains that regional anaesthesia should not be considered safer than general, because in many of the reported deaths following general anaesthesia it is the operator rather than the technique itself which is at fault. It must be realized, however, that a technique is only as safe as its practitioners and when assessing the safety of any procedure it is invalid to exclude operator error. It is precisely because pilots make errors that safety elements are built in to aeroplanes, and safety checks are similarly built in to anaesthetic techniques. Moreover, while in aviation it is sometimes possible to separate pilot error from mechanical failure, in anaesthesia it is rarely so. It would be a foolish anaesthetist who would claim never to have made a mistake, or never to have failed in an attempt to perform a skilled task, Protocols are developed to minimize the possibility of disaster, and drills are designed to overcome difficulties should they be encountered. But no amount of careful instruction can make a trainee capable of intubating every trachea, and even the most skilled assistant applying cricoid pressure can push the larynx laterally or cause the cricoid ring to collapse, thereby hindering intubation.* By contrast, when teaching epidural insertion, minimizing dural puncture, aspirating the catheter, giving a test dose and assessing it, giving a large dose slowly,
watching the patient for signs of trouble and monitoring the effects of the block, all these safe practices can be instilled into the trainee given the will and the resources. It is good practice that has resulted in epidural services with much lower morbidity and mortality rates than in the early days. True, general anaesthesia has also become safer with improvements in techniques and monitoring, but difficulties can never be completely forestalled. It is noteworthy that the deaths described by Dr Ramadhani as following regional anaesthesia are, even more than those related to general anaesthesia, attributable to operator error or misjudgement. Does he, therefore, consider that every one of them should be excluded from assessment of the safety of regional anaesthesia? Indeed, every death associated with regional blockade in all the reports could be so considered, in which case it is a very safe technique indeed! A more sober estimate of mortality must include a denominator. Though general anaesthesia may in the past have been more frequently used than regional for operative obstetrics, this may no longer be the case even in the UK.3 Moreover it is appropriate to include analgesic blocks in the denominator. In the 21 years from 1970-90, there were 154 anaesthetic deaths, of which 9 were causally related to epidural anaesthesia or analgesia. During this time, it is likely that more parturients received epidural blockade than received general anaesthesia. No assessment of safety can ignore morbidity, however. To believe that the major complications of epidurals resulting from inadvertent dural puncture, subarachnoid and intravenous injection (which can all be circumvented by the use of spinal anaesthesia), are inevitable occasional accidents of epidural insertion is to overlook the huge differences in their frequency between modern centres with quality supervision4 and practice elsewhere,5 particularly when in its infancy. One should not overlook also the dramatic improvements in maternal satisfaction and postoperative well-being (not to mention the baby’s welfare) that have been demonstrated by Morgan et al6 and others when caesarean section is conducted under regional rather than general anaesthesia. For all these reasons we would do our mothers a disservice if we felt unable to recommend regional anaesthesia for caesarean section. The prerequisite for any such recommendation must be high quality training in the field for the next generation of anaesthetists. F. Reynolds Department of Anaesthetics, St Thomas’ Hospital London SEI 7EH, UK