Case 1

A  patient who had become hypotensive with ECG changes during attempted spinal insertion was transferred to a nearby hospital for monitoring. Cardiologists at this hospital  considered the patient required primary percutaneous coronary intervention (PPCI) which was not available  so the patient was transferred for a second time.  On arrival at the Cath Lab the patient was in cardiogenic shock.  Following resuscitation, the consultant cardiologist diagnosed severe biventricular impairment, (there was no previous echo for comparison). This cardiologist did not feel there was a clear indication for PPCI. The patient was taken to ICU for vasopressor and inotropic support but continued to deteriorate and passed away later in the night.

Case 2

An in- patient in one hospital was referred to another  for endoscopic retrograde cholangiopancreatography (ERCP) under general anaesthetic. The patient had significant cardiorespiratory comorbidities and was deemed high risk for anaesthesia. Following extubation, the patient became hypotensive and hypoxic. There was only a temporary response to adrenaline, blood gas analysis showed a pH 7.1. The patient passed away in the endoscopy suite.

Case 3

During hemiarthroplasty  a patient developed signs myocardial ischaemia. Unknown to either the surgeon or anaesthetist, a pre-operative test had shown  raised D-Dimers   A CT pulmonary angiogram (CTPA) showed massive bilateral pulmonary emboli.

Case 4

Retrospective review of a perioperative death, during a urological procedure, under spinal anaesthesia, uncovered a 6-9 month history of worsening chest pain in an elderly patient with a history of cardiovascular disease.  This was not highlighted during the surgical and anaesthetic pre-assessment of the patient.

Commentary

GPAS for Perioperative Care of Elective and Urgent Care patients¹ states that “each hospital should have a consistent system in place to identify high risk patients who require additional assessment”.  This is pertinent for  the patient in case 3 who had elevated D-dimers and the patient in case 4 whose angina was not detected before urological surgery, and may have been relevant to the patient in case 1 who was found to be in biventricular failure but had not had preoperative echocardiography,

High-risk patients  can deteriorate at any time during the perioperative journey, as illustrated by Case 2 where the patient experienced acute deterioration following extubation.² When ICU is deemed unsuitable, managing these cases in the non-theatre environment can be particularly challenging. Patients in the non-theatre environment   should receive the same standard of care as that would be provided in an operating theatre.³

1. Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients 2024, Royal College of Anaesthetists
2. At the heart of the matter: Report and findings of the 7^th National Audit Project of the Royal College of Anaesthetists examining perioperative cardiac arrest (NAP 7). Royal College of Anaesthetists, November, 2023.
3. Guidelines for the Provision of Anaesthesia Services in the Non-theatre Environment 2025, Royal College of Anaesthetists