Medical and Legal Aspectsof

Anaesthetic ANAESTHETIC DEATHS

Death due to Anaesthesia.

12/2/2017
Forensic Medicine and Toxicology.
DR. Roman Al Mamun

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Roman Al Mamun
DR.
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Roman Al Mamun
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Roman Al Mamun
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Medical and Legal Aspects

of Anaesthetic ANAESTHETIC
DEATHS:

Majority of the operations require the administration of anaesthesia to the patient.

This being a complex and special procedure demands special knowledge and
experience.
As far as possible the anaesthetist should be an expert.
He should examine the patient properly prior to the surgery.
He should also plan and prepare for administration of anaesthesia
depending on the surgery.
A written informed consent from the patient or his/her guardian must be
obtained in advance.
In recent years, claims of awareness under anaesthesia have become a frequent
complaint.
One of the most tragic and expensive anaesthetic mishaps is the production of
cerebral damage from hypoxia due to failure to maintain oxygenation during the
operation.
Inattention on the part of the anaesthetist is a more common cause than failures of
equipment and recent surveys have shown that inexperienced junior anaesthetist is
a major cause of problems.

A great variety of unfortunate events/mishaps can occur during or following the

administration of anaesthesias and operative or investigational procedures. These
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do not necessarily convey an error of judgement or negligence on the part of the

surgeon or the anaesthetist and can happen in spite of properly calculated risk.
Anaesthetic deaths are very rare and only one in ten thousand person die totally as
a result of anaesthesias.
Anaesthetist should ensure the safety of the patient.

At autopsy, known sites of sudden catastrophe should be carefully investigated for,

such as coronary disease, pulmonary embolism and inhalation of vomit or blood.
All too often the tragedy may be due to a combination of errors in varying
proportions rather than one particular mistake.

However, any such death believed to be caused, or contributed to, by any of these
procedures may be adequately investigated both from the point of view of the
satisfaction of the relations of the deceased and instituting future safety/ preventive
measures.

Anaesthetic deaths are of two types:

1. Deaths due to anaesthesia and anaesthetic agents.

2. Deaths due to factors other than anaesthesia.

Deaths Due to Anaesthesia and Anaesthetic

Agents:
Deaths due to anaesthesia and anaesthetic agents could be due
to three reasons:
1. Anaesthetic agents
2. Anaesthetists
3. Functional problems.
Anaesthetic Agents:
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Anaesthetic agents may sometimes result in hypersensitivity reaction resulting in

death of the patient. Certain anesthetics can directly act with a consequence of
cardiac arrhythmia and cardiac arrest.
The use of certain drugs, which can create myoneural blockage, may give rise to
death due to respiratory inadequacy/ failure.
There is evidence that halothane can cause liver necrosis resulting in malignant
hyper pyrexia which is characterised by abrupt rise to dangerous temperature
(about 110°F) and also may be associated with tachycardia, hyperpnoea, cyanosis
and stiffening of the muscles and may ultimately lead to death.

Causes of death due to anaesthetic agents:

• Hypersensitivity
• Cardiac arrhythmia
• Cardiac arrest
• Respiratory inadequacy
• Malignant hyperpyrexia

Incidence of anaesthetic deaths:

Reported causes Incidence(%)

Disease for which the operation was conducted -56%
Shock and inevitable risks of the operation -30%
Risks and complications of anaesthesia -08%
Over dosage, maladministration or bad choice of the anaesthetic agent- 06%

Anaesthetists:
Anaesthetists who are using improper technique, improper equipments or one who
has no familiarity with the equipment, having no adequate experience, or unable to
adopt precautions when indicated, or careless in the methods, etc. can always land
up with anaesthetic deaths.
Hypoxia, improper depth of anaesthesia, vagal inhibition, etc. constitutes usual
causes of anaesthetic deaths.
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Basically, all these causes are secondary to obstruction of the airways, or a faulty
gas connection, etc. due to mechanical problems consequent to several causal
agents.
However, it is reported that of all these causal agents, human error alone was
responsible for 82 per cent of the anaesthetic deaths, while equipment failure
occurred in another 14 per cent of cases and all other factors caused death in rest
of the 04 per cent patients.

Functional Problems:

The common problems relate to vagal inhibition, obstruction of the glottis due to
spasm, tube, or vomit; cardiac arrhythmia; and hypotension.
The unconscious patient poses a special problem in regard to anesthesia, as he is
unable to take corrective reflex action against inhalation of foreign material.

Deaths Due to Factors other than Anaesthesia:

Deaths due to factors other than anaesthesia are enumerated

and discussed as follows:

• Disease or injury for which the operation or anaesthesia is being given. Here the
anaesthesia or surgery is playing no role in causing the death of the patient. Rather
it is the disease or the injury in itself has resulted in death.

• Disease or abnormality other than that for which the surgical operation is
undertaken.
• Surgical mishaps and/or postoperative events.

• Physical status of the patient, e.g. old age, diabetes, high blood pressure, etc.

• Surgical mishaps such as unintentional accidental tearing or cutting of a major

blood vessel during surgery resulting in death and therefore such deaths are
detectable only at autopsy.
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• Postoperative consequences such as death due to phlebothrombosis, pulmonary

embolism, aspiration of the vomit, etc. These cannot be considered as part of
anaesthetic procedure or that of surgery.

• Unforeseeable problems—patients with haemoglobinopathies, especially sickle

cell anaemia, are unduly susceptible to low oxygen tension in blood and this may
pose a hazard to the unawarded surgeon or anaesthetist. Coronary thrombosis may
supervene in a patient operated upon for injuries. Transfusion hepatitis is not
unknown. AIDS infection through transfusion is another possibility.

MODE AND CAUSE OF DEATH:

Two important modes of death are cardiac arrest and respiratory

failure.
Cardiac Arrest
Cardiac arrest is the most common mode of death. Basically, this is due to either
oxygen deprivation or carbon dioxide accumulation as a result of failure of
technique or fault in technique.
Cardiac arrest, thus supervene in three ways:
1. Asphyxia of myocardium.
2. Overdosing of anaesthetic agents
3. Reflex vagal stimulation.
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Presenting cardiac arrest due to asphyxia of myocardium

Asphyxia of Myocardium
Hypovolaemia and some diseases of the cardiovascular system
carry an enhanced risk.
Overdose of Anaesthetic Agents
Over dosage during anaesthesia, act in two different ways:

Firstly, there may be an inadvertently high concentration of the agent in the

bloodstream. This will produce marked vasodilatation, causing a fall in blood
pressure while the heart is receiving a relatively high concentration of the agent via
the coronary vessels. The heart may become sufficiently poisoned so that it is
unable to produce a compensatory rise in output and will fail ultimately.

Secondly, cardiac arrest may be caused by prolonged administration of an

anaesthetic in concentrations sufficiently high to gradually poison the myocardium.

Reflex Vagal Stimutation

Hypoxia, sudden asystole can stimulate vagus nerve resulting in slowing of the
heart. Vagal stimulation per se is unlikely to occur spontaneously when the
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circulation is hypoxic, but respiratory irritation causing bronchial spasm results in

vagal over activity and hypoxia.

Respiratory Failure:

Death due to respiratory failure may result during and/ or after

the anaesthesia and surgical procedure. Various potential causes
are enumerated as below:

• Overdose of premedication drugs such as barbiturates, tranquilizers, morphine,

pethidine, etc can depress respiration, leading to hypoventilation and anoxaemia.

• Overdose of anaesthetic drugs/administering deep anaesthesia with consequence

of the respiratory muscles paralysis.

• Administration of opiates during postoperative period for the relief of pain may
depress the cough reflex causing retention of the sputum leading to secondary
infection of lung.

• Obstruction of larynx or trachea by laryngospasm and/or bronchospasm,

secretions from the throat, blood, swabs, dentures or gastric contents may lead to
hypoxia.

• Hypoventilation and hypoxia due to hyperventilation by the anaesthetic agents

may cause depletion of carbon dioxide, during the recovery-period.

Causal agents and cause of death:

Human error (82%)

• Carele • In-experien • Unfamiliarity with equipment • Inability to adopt

precautions • Mishaps due to intubation/bronchoscopy
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Equipment failure (14%)

• Kinked pipes • Cross tubes • Over dosage • Malfunction of the apparatus •

Explosion
Other factors (04%)

• Inadequate communication between staff • Haste • Distraction

Functional problems of anaesthetic deaths:

• Vagal inhibition
• Obstruction of the glottis due to spasm, tube, or vomit
• Cardiac arrhythmia
• Hypotension
• Unconscious patient

AUTOPSY EXAMINATION IN A CASE OF AN ANAESTHETIC

DEATH:

This includes three things: Precautions, Autopsy procedures and Chemical

analysis.

Precautions
In order to avoid criticisms it is better take all necessary cautions
preventing all harms or dangers.
Surgical mistakes are gross and anatomical and hence are observable at the
postmortem.
Anaesthetic mistakes being physiological are no longer appreciable after
death except where overdose with specific drug is involved.
Look for or exclude some of the natural disease or mechanical obstruction.
Autopsy must be preferably done by a forensic expert and it must, however,
be remembered that the findings of the autopsy surgeon alone will not be
sufficient to explain death.
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It is imperative to hold a discussion across the autopsy table involving

forensic expert/autopsy surgeon, anaesthetist and the surgeon concerned.
It is often stated that deaths under anaesthesia were more often the fault of
the anaesthetist than the anaesthetic.

Autopsy Procedure

Autopsy in a case of an anaesthetic death must be performed methodically

adopting all the standard procedures. However, care is taken to undertake
following unfailingly:

• Note the odour: With inhalant anaesthetics, specific odour of anaesthetic agent
may be detected at autopsy.
• Body cavities: Examine in situ all the cavities. Measure the contents or fluids if
any and preserve for analysis.
• Site of surgical intervention: Examine the site of surgical intervention in situ and
describe in detail.
• Surgical sutures and organs: Dissect all organs and inspect every surgical suture.

Chemical Analysis:
• A lung is removed and collected by clamping the main bronchus and retained in a
nylon bag and sealed so that the headspace gas can be analyzed.
• Collect the alveolar air with a syringe by pulmonary puncture before opening the
chest.
• Prior to autopsy to avoid loss of gases due to exposure of the tissues to the air, it
may be necessary to obtain samples of every viscera by the biopsy techniques and
frozen immediately.
• At autopsy some portion of fat from the mesentery, skeletal muscle tissue, brain,
liver, half of each kidney are retained.
• Blood should be collected under liquid paraffin.
• Urine should also be collected, if available.
All these specimens should be collected in containers with as little headspace as
possible, sealed and immediately refrigerated or frozen.
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Bacteriological Examination:
Adequate blood, urine and other body fluids may have to be
collected.
Hazards of Transfusion of Blood and Body Fluids
Blood and various body fluids should be preserved for analysis.
Extraneous Specimens
Like residual solutions, medication containers, samples of gases used for the
anaesthesia and samples of the operating room air may have to be collected in
occasional cases.

INVESTIGATION AND EXAMINATION OF A CASE OF AN

ANAESTHETIC DEATH:

In investigating a case of an anaesthetic death, a forensic pathologist should take

several factors into consideration. A thorough review of hospital chart and
discussions with the surgical and anaesthetic team is essential collecting relevant
history pertaining to victim about how was his period prior to hospitalisation;
during stay in the hospital, at the phase of preparation of anaesthesia, and for how
long the anaesthesia affect lasted.
Some of the important factors to be evaluated individually:

• Signs of prolonged anaesthesia: Dependent parts of the viscera are usually seen
engorged in cases of prolonged anaesthesia.
• Effect of anaesthetics.
• Evidence of pulmonary embolism and asphyxia.
• Internal findings of haemorrhage, peritonitis and retained swabs and instruments,
or evidence of hypersensitivity reaction are obvious.
• Evidence unnoticed: Evidence of vagal inhibition, fall in blood pressure, cardiac
arrhythmias, coronaries and laryngeal spasms, etc. could not be detected during an
autopsy.
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• Histopathological examinations: Collect the sample from all viscera for

histopathological study.

– Specimens should be taken particularly to exclude any cardiovascular disorder

including occult conditions like myocarditis as well as relavent specimens for
assessing the severity of disease for which the operation was carried out.
– Histological examination of the brain is imperative which is primarily intended
to demonstrate the effects of hypoxia, particularly in the region of Sommer’s area
of the hippocampal gyrus and the cerebellum, where changes are expected even if
the victim suffers hypoxia for a short period.
– Morphological changes in the brains of victims who suffered hypoxia for a short
period but survived for long periods after anaesthesia included-diffuse, severe
leucoencephalopathy of cerebral hemispheres with sparing of the immediate
subcortical connecting fibres.
Demyelination and obliteration of axons was also observed and at times, infarction
of the basal ganglia. Damage appeared limited to the white matter, which is
explained on the basis of greater glycolysis in the white matter during hypoxia as
compared with the grey matter.

COMMON MISHAPS IN ANAESTHETIC PRACTICE:

Common mishaps in anaesthetic practice

• Mistaken identity
• Incorrect positioning of the patient
• Fault in the anaesthetic machine
• Failure of suction apparatus
• Perforation of airway
• Electrocution or burns
• Fault with intravenous equipment,
• Mishaps with drugs
• Monitoring of vital signs
• Human error

HANDLING CASE OF ANAESTHETIC MISHAP:

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• Never panic.
• The situation should be corrected immediately.
• Call for help from other areas or request surgical team to help you out.
 Document all the procedures done in finest detail as this is the only defense
a doctor can have later on that he has done judiciously what was the need of
the time.
 In postoperative period, discuss with patient the circumstances of the case.
 If patient is dead, talk to the relatives in detail and explain what happened.
 Not talking to patient/relatives can lead to unnecessary litigation.
 If you think litigation may follow, inform insurance company from where
you have taken insurance policy.

MEDICOLEGAL CONSIDERATIONS:

• Code of Criminal Procedure, 1973, Sec. 39—All deaths occurring during the
course of anaesthesia and surgery or within a reasonable period thereafter should
be reported to the police.
• These deaths, all too often the tragedy may be due to a combination of errors
rather than one particular mistake or sometimes due to some significant pre-
existing disease or some co-existent condition.
• Tendency on the part of the relatives of the deceased to impute negligence on the
part of the anaesthetist and/or the surgeon merely because of the fact that the death
was closely associated with the anaesthesia and surgical intervention.
• Apportioning relative contribution between the anaesthetist and the surgeon is
extremely difficult and both are required to exercise due care and skill. Each one is
responsible for negligent acts of oneself and not of the other.
• As the surgeon possesses absolute control over the staff that assists him in the
operation he will be liable for the negligent acts of his assistants. However, the
surgeon, has no absolute control over the activities of the anaesthetist and the
connected staff.
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• If the postmortem examination yields negative results and the autopsy-surgeon

may not be in a position to express conclusive opinion and the cause of death
remains nothing more than conjectural one.
• The role of autopsy surgeon may remain limited, largely to the detection of some
natural disease, overt signs of damage by the anaesthetic procedure or errors in the
surgical procedures.