An elderly patient underwent general anaesthesia for endoscopic retrograde cholangiopancreatography (ERCP). About 30 minutes into surgery, it was noted that the ventilatory parameters were showing reduced tidal volume [245-390ml] compared to the setting of 475ml tidal volume with increased airway pressure of 32cm H2O. This was attributed to endotracheal tube compression by the endoscope manipulation by the surgeon. As a result of this, the endotracheal tube position was re-adjusted with transient resolution of the problem.

A few minutes later, the same episode recurred and a gurgling sound was heard around the oro-pharynx. This was attributed to partial dislodgement of the endotracheal tube and onset of oxygen desaturation on the monitor. As a result of this, it was decided that surgery should stop and the trachea was rapidly re-intubated uneventfully. It was after this that it was noticed that the patient had suffered a ventricular fibrillation cardiac arrest and cardio-pulmonary resuscitation (CPR) was commenced immediately with chest compression and ventilation without interruption with the cardiac arrest team joining in the CPR. As soon as the crash trolley was brought in a DC shock with 150J was delivered. After two cycles, there was a return of spontaneous circulation for less than 2 minutes followed by a PEA arrest with recommencement of CPR including administration of Intravenous Adrenaline x 6 doses [total dose]. CPR continued for over 30 minutes with no return of spontaneous circulation. It was at this point that the team agreed to discontinue CPR and patient was pronounced  dead.

Commentary

General anaesthesia with tracheal intubation accounts for 7-10% of ERCP cases in tertiary centres in the UK. ¹ General anaesthesia is indicated where sedation has failed or for patients at high risk of sedation-related adverse events. Whilst general anaesthesia reduces the risk of sedation-related adverse events, hypoxic events are still frequent, occurring in 18.9% and persisting for more than 3 minutes in 8.5% of cases in one cohort study. ² Patients undergoing prone positioning during ERCP are at higher risk of endotracheal tube dislocation with neck extension.³ Whilst cardiac arrest due to endotracheal tube dislocation is rare, with no cases reported in NAP 7, ⁴ this case highlights the need for vigilance.

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