CASE 1

Following surgery, several prescribed insulin doses were missed, resulting in the development of diabetic ketoacidosis. The patient subsequently suffered a cardiac arrest, was transferred to  ITU and later died.

CASE 2

A patient suffering end stage liver failure underwent emergency gastroscopy for upper gastrointestinal bleeding in the early hours of the morning. At the time, the patient was significantly acidotic.  Post-procedure, the patient was transferred to recovery as ICU-level care was deemed inappropriate.

Later that morning the patient began fitting and subsequently suffered a cardiac arrest. The recovery nurse reported shortly beforehand the patient had been speaking to family on the phone but had a low NEWS score, and had appeared mottled with a capillary refill time of 10 seconds. ABG taken at this time showed glucose <1 mmol/L and pH 6.5.

Lorazepam was administered for seizures. Return of spontaneous circulation was achieved after one cycle of CPR but the patient remained unconscious and apnoeic, requiring ongoing adrenaline infusion. After discussion with the gastroenterologist and the arrest team (including two ICU consultants), life support was discontinued.

There were questions over whose responsibility it was to monitor sick patients in Recovery overnight as failure to repeat ABG overnight and optimise postoperative care may have contributed to the timing of death.

Commentary

Clarifying responsibility for post-operative care is a key part of perioperative planning, especially for patients where there is a treatment escalation plan for end-stage liver failure.  Acute GI haemorrhage may be associated with hepatic encephalopathy, hyponatraemia and changes in potassium and glucose concentration.  Where patients undergo extended recovery overnight, the recovery team need to know how frequently observations should be made, who to contact if the patient deteriorates and criteria for discharging back to the medical wards. 

References

1. Gilbert-Kawai N, Hogan B, Milan Z. Perioperative management of patients with liver disease. In BJA Education 2022; 22(3): 111–117 https://doi.org/10.1016/j.bjae.2021.11.006
2. Angeli P, Bernardi M, Villanueva C, Francoz C, et al. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol, 2018; 69(2): 406–460.