A British coroner has raised concerns about inconsistency in how local anaesthetic is administered after a patient was given too much during an operation and later died.
The BBC reports that Rachel Gibson (47) went into cardiac arrest after hip replacement surgery at Spire Lea Hospital in Cambridge on 12 April 2022. She sustained irreversible brain damage and died three months later.
In a “prevention of future deaths” report to the Royal College of Anaesthetists (RCOA), Coroner Philip Barlow said there was “inconsistency” with how local anaesthetic was measured, increasing the risk of mistakes.
In the report, he said: “The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted.”
In the case of Gibson, an inquest found the intention was for a 2% solution of Ropivacaine to be diluted with normal saline before it was infiltrated.
Evidence suggested it was not done and an excessive amount of the drug was administered by mistake.
Barlow said evidence suggested this type of practice was common nationally, and that the hospital in question had now introduced a system for labelling and countersigning the drug that was given during the operation.
“However, the evidence at the inquest was that, on a national basis, there is wide variation in how local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation.”
Rachel-Gibson-Prevention-of-Future-Deaths-Report-2024-0476BBC article – Coroner issues anaesthetic warning after death (Open access)
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