Case study on anaesthetic monitoring
Published in the December 2018 issue of Vetboard Victoria's newsletter
The following case study provides an opportunity for general reflection. The case study is based on a complaint about an individual set of circumstances at a particular time. As veterinary knowledge and professional and community standards and expectations change over time, readers should not assume that the Vet Board would make the same decision when presented with a similar complaint.
The Board received a complaint about the clinical management of a dog presented for exploratory surgery which died during the surgery after suffering a cardio-pulmonary arrest.
Initial assessment by the Board indicated that the complaint was neither lacking in substance nor vexatious, so the Board conducted a preliminary investigation assessing the complainant’s information and veterinary practitioner’s response.
The investigation indicated that there was a case to answer, so the matter was referred to an informal hearing to determine whether Dr G’s clinical management of the animal may have been of a lesser standard than that which might reasonably expected of a veterinary practitioner by his peers and/or the public.
The informal hearing
The Informal Hearing Panel considered the allegation that Dr G failed to keep an adequate record of the dog’s hospitalisation and anaesthetic monitoring so could not adequately monitor the dog’s status during the surgery.
Dr G’s description of events
Dr G informed the Panel that two veterinary nurses assisted with the dog’s surgery. The first assisted with patient preparation and premedication; the second assisted during the procedure.
During the surgery, the second nurse left the operating theatre to ring the owners and inform them of the initial surgical findings. A short time later, while Dr G was still performing surgery, the dog suffered a cardio-pulmonary arrest. The dog could not be resuscitated, although Dr G said that CPR was performed immediately and adrenaline and atropine were administered.
Dr G stated that the dog’s cardiac arrest occurred without precipitating signs.
Opinion from experienced anaesthetist
The evidence reviewed by the Informal Hearing Panel included an opinion from an experienced anaesthetist which raised several issues of concern about Dr G’s anaesthetic protocols, including:
- the lack of pre-operative examination results documented on the anaesthetic monitoring sheet
- the lack of any detail as to the type and rate of intravenous fluids administered
- the fact that during the procedure only limited parameters were monitored and recorded, and only infrequently, and
- the lack of recorded information on the anaesthetic monitoring sheet, which meant it was not a suitable documentary record to use to review the possible cause of and/or contributing factors to the dog’s death.
Monitoring and documentation of anaesthetic
During the Informal Hearing, the Panel questioned Dr G about his protocols for monitoring and documenting surgical cases.
The Panel asked Dr G to explain the dog’s anaesthetic record. Dr G acknowledged that the record contained no pre-operative examination details for heart rate, respiratory rate and temperature, and did not specify which inhalation agent had been administered to the dog. Dr G also conceded that the record of the fluids and medications administered to the dog was neither clear nor accurate.
The Panel was concerned that the anaesthetic chart showed that, while initially the dog’s O2 saturation had been recorded as 87%, subsequently this had been amended to 97%. The Panel questioned Dr G on this issue, pointing out that an O2 saturation of 87% would have indicated cardiopulmonary deterioration. Dr G’s answer to the panel was that the initial 87% reading had been recorded in error and that the amended figure of 97% was correct (though he accepted that a reading of 87% would have indicated a problem).
The Panel also asked Dr G how – in the absence of frequent and consistently documented readings, especially in the period immediately before the cardiac arrest – he had determined that the dog’s condition was stable during the surgery. The Panel suggested that it would be difficult to promptly identify deterioration without frequent recording of a patient’s vital parameters while anaesthetised.
Dr G responded that the electronic monitors in place during surgery would warn if a patient’s vital statistics had breached predetermined limits, and that the parameters set on each machine are constant and are not altered for individual cases. However, Dr G conceded that by the time the alarm was triggered during the surgery the dog’s condition had already deteriorated and it had gone into cardiac arrest. Dr G agreed that the anaesthetic monitoring had not been sufficient to allow critical review of the patient’s condition during surgery.
Panel findings and determination
After reviewing the evidence, the Informal Hearing Panel found that Dr G had engaged in unprofessional conduct and determined that he should be cautioned.
WHAT IS A CAUTION?
A caution is a formal notification, in the context of an advisory warning, to a registered veterinary practitioner.
A caution warns a registered veterinary practitioner that a change in his or her manner of practice is required to conform to the minimum standards of the profession as required by the Veterinary Practice Act 1997 or ancillary legislation, e.g. Drugs, Poisons and Controlled Substances law and regulations; by the Board’s Guidelines; or by commonly understood peer and community standards.
A caution is permanently recorded on a veterinary practitioner's file and may be referred to in any future Hearing or action taken by the Board.
Panel reasons
It was the Informal Hearing Panel’s opinion that Dr G’s monitoring methods were inadequate and inappropriate in the circumstances.
The Panel expected observation and monitoring of a patient’s parameters to be performed more frequently than had been done. It was also the Panel’s view that a practitioner should not solely rely on electronic monitoring and should ensure a patient is physically assessed while under anaesthesia.
The Panel agreed with the recommendations in the experienced anaesthetist’s report that Dr G should improve his record keeping so that changes in an animal’s condition can be observed. The Panel also expected observations to be recorded more thoroughly so that anaesthetic records are detailed and complete. Accurate records provide evidence for investigation and remediation in the event that things do go wrong.
The Panel also emphasised that it was imperative to educate attending nurses on the importance of completing detailed medical and surgical records.
Reflections and lessons learned
This case highlights the importance of competent and robust anaesthetic monitoring.
Every anaesthetic presents a risk to the patient.
Some of this risk can be mitigated by performing (and documenting) a thorough pre-anaesthetic clinical examination.
Identifying and recording an animal’s baseline health parameters allows for informed and individual review of a patient while they are under anaesthesia and may help a practitioner pick up early indications of a change in status.
While a patient is under anaesthesia, their condition should be regularly monitored and documented. The anaesthetic monitoring equipment used in veterinary practice provides valuable support to the monitoring process, but the Board does not recommend that practitioners rely only on electronic monitoring. Changes in a patient’s condition are more readily apparent when an animal’s clinical condition is regularly assessed and recorded. Anaesthetic monitoring records are a useful way to document and identify clinical changes during anaesthesia. If noted early, a deterioration in a patient’s condition may be able to be remedied.
It is imperative that all persons who are monitoring anaesthesia during procedures are adequately trained so they have enough knowledge to undertake appropriate clinical monitoring and identify changes of concern.
The veterinary practitioner is responsible for ensuring that all persons tasked with anaesthetic monitoring have the knowledge and skills to monitor an animal which is under anaesthesia.
Relevant guidelines