Clinincal Negligence
Case Studies - Anaesthesia Problems
A claim arose from the complications of an epidural anaesthetic during a vascular operation for a left femero-popliteal bypass on 17 May 2000. The case raised a difficult consent issue.
The Claimant was referred to the hospital in December 1998 for investigation of walking difficulties caused by a cramp-like sensation. He underwent a duplex scan which showed long bilateral superficial femoral artery occlusion.
On 21 July 1999 an angiogram and arteriography showed he would require a bilateral femer- popliteal bypass graft.
On 27 August 1999 he was seen by a Vascular Surgeon who noted that he required "bilateral common femoral endarterectomy and femero-popliteal bypass.
On 19 January 2000, the Claimant was admitted to the hospital and underwent a right above-knee femoro- popliteal bypass, under epidural anaesthetic. When he recovered from the anaesthetic he had no feeling or movement in the foot. Gradually over the next 48 hours it returned, leaving only slight loss of sensation over the front surface of the right thigh.
On 16 May 2000 the Claimant was readmitted for a bypass operation on the left leg. He signed a consent form which specifically mentioned the risks of bleeding, infection, recurrence of symptoms, blockage and loss of limb.
On the of 17 May (the date for the operation) the Claimant was seen by a consultant anaesthetist, and provided a warning about some of the risks incidental to anaesthesia. The Claimant was not informed that an epidural block was to be used, nor warned of the following risks of the anaesthetic procedure which he was about to undergo, that he might suffer loss of sensation in his legs, buttocks, perineum and genitals, that he might lose control over his bladder or bowel function in the short or long term or that he might be unable to obtain an erection or have sexual intercourse to completion.
Later on 17 May 2000 the operation was carried out. An epidural needle was inserted. Bupivacaine was injected at 8.20 hours. General anaesthesia was then induced. The lungs were ventilated artificially. Further doses of Bupivacaine were injected through the epidural catheter.
After the procedure was finished, the Claimant was transferred to the recovery area, where he was noted to be awake. He was returned to the ward at 14.00 hours, when an epidural infusion of Bupivacaine 0.125% containing diamorphine 1 mg/12 ml was running. He was pain-free. The Claimant had a good first post-operative night.
At 08.15 on 18 May 2000 the Claimant was noted to be hot and sweaty and complaining of dizziness. Oxygen was given. His blood pressure had decreased to 94/48 mm Hg. He was examined by a consultant. A saline infusion was given and epidural infusion continued at a rate of 4 ml/hr. There were no complaints of pain and pulses were felt in the foot, which was warm. Blood pressure gradually recovered to 128/58 at about 10.00hrs. An ECG was performed. There was no oozing from the wound. Gelofusine was infused. Later it was noted that the Claimant was "much better". His leg was comfortable but slightly swollen.
The epidural infusion was discontinued by the time of a nursing note 20.50 hours on 18 May 2000. At 21.00 hours the Claimant was incontinent of faeces, but was unaware of the fact that he had passed faeces. Nurses contacted an anesthetist.
The Claimant was aware of the effects of the anaesthetic wearing off late on 18 May or early on 19 May. He became aware that he had a significant loss of sensation around his buttocks, tops of both legs, his genitalia and perineum.
At 12.20 hours on 22 May 2000 the anaesthetist reviewed the Claimant.
On 23 May 2000 it was noted by nurses in the morning that the Claimant had slept well. There was no complaint of pain. The circulation to both feet was good. He was discharged home at 9.30 hours. The discharge summary does not mention epidural block and asserts no post-operative complications occurred.
On 4 August 2000 the Claimant was seen at an outpatient clinic, who noted a complaint of "numbness which is coming from the waist downwards involving both legs and it seems to be related to the epidural he had". He said he would give the Claimant an open appointment to attend the hospital.
The cause of the Claimant's nerve damage was an epidural haematoma (probably related to the insertion of the epidural catheter) which compressed the sacral nerve roots.
The burden of the case against the Trust was this: -
The anaesthetist failed to give any or any adequate explanation of the risks incidental to the anaesthetic procedure.
There was a post-operative failure to assess, monitor, or investigate in time or at all the Claimant's neurological complications.
Doctors failed to suspect or diagnose a lesion inside the vertebral column causing compression of the nerve roots or the spinal cord (whether an epidural haematoma, epidural abscess or coincidental disc prolapse).
Doctors failed to perform any or any sufficient investigation of the Claimant's signs and symptoms. Competent assessment by an anaesthetist or other doctor would have caused a CT or MR scan to be performed on 19 May to confirm or exclude a compressive cause.
This failure continued between 20 May and 22 May 2000
Permanent neurological damage to the cauda equina was caused by an epidural haematoma associated with the epidural procedure. Had it not been for the failure to perform timely assessment and investigation of his signs and symptoms, the Claimant would have been scanned and undergone decompression surgery on 19 May 2002, in which case he would have avoided neurological injury and recovered normal or virtually normal cauda equina function.
If he had been diagnosed and had decompression surgery on 20 or 21 May he would have suffered some degree of cauda equina compromise, of lesser severity and allowing recovery of some of the lost physical functions.
The Claimant suffers bladder function impairment, including loss of sensation of a full bladder, causing urgency or leakage, difficulty in urinating, and post-urinating dribbling.
There is bowel function impairment, involving loss of sensation of rectal filling, lack of warning of the need to empty his bowels. The Claimant was initially incontinent of faeces. This has settled and he is able to have bowel control by evacuation once a day, but if he is unable to do so, he has occasional faecal incontinence.
He suffers impairment of sexual function, involving erectile dysfunction, loss of sensation to the tip of the penis and ejaculatory dysfunction (therefore loss of orgasmic sensation).
Liability was denied. Causation was denied.
A relatively short time prior to trial the Defendants made an offer of settlement the Claimant accepted.