Something’s not right….
Some months ago when the sun was high in the sky and the dawn chorus at its maximum, I went to work for my usual Wednesday all-day operating. I was scheduled to have a trainee with me but she phoned in sick, so I was anaesthetising only with my assistant. Everything was going smoothly, all my patients were absolutely lovely, and grateful to be getting their long awaited surgery after years on the waiting list. Most of my usual operating lists are well within my comfort zone – the routine is well practised, the script of my interaction with the patients is similar, as are the movements of my hands as I cannulate, site a spinal anaesthetic for post op pain relief, place an endotracheal tube and settle them on a ventilator.
My last patient of the day was no exception. She was a lovely, engaging, funny woman who was anxious and nervous about her anaesthetic. She had been told that she had a “cardiac arrest” in a previous anaesthetic which the team blamed on her wearing a morphine patch for pain. However, she had since had two uneventful anaesthetics. This sort of history is more common than you would think, as often physiological responses to the anaesthetic drugs can lead to a slowing of the heart rate or even a brief “cardiac arrest”, usually very easily treatable with full recovery. I reassured her that it was highly unlikely anything would go wrong and we proceeded with the anaesthetic. The cannula went in first time, the spinal took about a minute and I gave the same drugs I always give and intubated her. Her intubation was also easy, however when I tried to ventilate her, it felt very tight, like trying to ventilate someone with an asthma attack.
She did in fact have mild asthma, I thought to myself and I could feel the ventilation become a little easier. I relaxed, but then looked at my monitors. Normally, when you break the bronchospasm of asthma, you see a high peak of CO2 coming back as the body tries to release the waste product of metabolism, however this time it was very low. I looked at my ODP assistant:
“Something’s not right”.
I looked at her heart rhythm, which was slowing down, and the ECG complexes looked a bit wrong. I needed help. Now, normally there is plenty of help around, but I was in a peripheral building, my registrar had phoned in sick, and there was no operating going on in the next door theatre. I was the only anaesthetist there.
What was going on? Was the tube in the wrong place? I’d seen it go in the right place, but that isn’t enough. However I could ventilate and there was CO2 coming back. Was it just bronchospasm? Not with such a low CO2, no, and her pulse by now was pretty thready and weak. I realised it was probably anaphylaxis – a highly dangerous allergic reaction – and started treating it as such. Still in the back of my mind I knew she could have had a heart attack, a clot on the lung or various other things, but everything just fitted the diagnosis of anaphylaxis.
I remembered our surgeons were just outside, so I called Patricia and Jasmine and they came in to help. We gave adrenaline, fluid, and Jasmine couldn’t feel a pulse so we started CPR. The atmosphere was calm, efficient, and quiet. Nothing like what you would expect in one of the television dramas. The four of us worked hard, Lyndsey the ODP keeping one step ahead of us and getting the “next thing” ready before I’d even asked for it. After what felt like for ever, but probably was only around 30 seconds to a minute we started to see the effects of the adrenaline. The ECG complexes became a little more normal, the heart rate picked up, and on stopping CPR for a second we could feel a pulse. Up to now I’d not really thought about much, apart from going through a well-rehearsed drill that I test my trainees on regularly when they’re preparing for their exams. This was actually the first time in my career I’d had to treat a proper severe anaphylaxis myself. When I felt the pulse return, some of the magnitude of the situation made me feel the relief that my patient, who I’d got to meet and like, wasn’t going to die due to my anaesthetic. This was mixed with guilt, and also uncertainty whether I had got the diagnosis right. The co-ordinating anaesthetist had by this point sent me over a colleague with extensive experience in cardiac anaesthesia, and we went through the alternatives, had a look at the heart with the ultrasound, inserted arterial and central venous lines and informed the intensive care unit. We took the bloods needed for diagnosing anaphylaxis, and got the protocol out to make sure we hadn’t forgotten anything.
One of the drugs more likely to cause anaphylaxis is the muscle-paralysing drug rocuronium. This has an antidote called suxammadex and I gave that early on. To my disappointment it made absolutely no difference, and thinking about it, once the avalanche of anaphylaxis has started it probably doesn’t help very much to remove the yodeller who caused it in the first place.
My patient needed a lot of adrenaline to keep her blood pressure up, and we took her to the intensive care unit after we stabilised her. She was still pretty unwell, and all I could think of when I walked home along the canal that evening was how she might end up with brain damage. The brain doesn’t tolerate a drop in blood pressure or being starved of oxygen very well, and the brain cells die very quickly. If I hadn’t acted quickly enough there was a chance she could be permanently disabled, or even brain dead!
I may have drowned these thoughts out that evening with a glass or two of wine, and the next morning I did my usual gynaecology operating session, but my thoughts were with the poor lady on ICU. I looked at her notes on the system regularly and was reassured by the fact that she seemed to be responding well to treatment. She was definitely not brain dead, but it was way too early to make a judgement about how well her brain would recover. She came off the ventilator the next day, and I know this time was very stressful for her and her family. This was just at the end of the 2021 covid surge, visits were severely limited, the intensive care unit was still a very strange and different place to normal, and the stress of uncertainty was beginning to take its toll.
But, she was alive. And the relief for me was enormous.
Over the next few months her recovery continued and she slowly returned to normal. She still had some residual effects including short term memory loss and flashbacks that could come without any warning. I referred her to my colleague and friend Dr Sophie Farooque. We are lucky to have an allergy specialist within our hospital and she confirmed our suspicion that this was indeed an anaphylactic reaction to rocuronium. Not only that, but she was allergic to several of the other drugs we use for the same purpose, including suxamethonium. Both rocuronium and suxamethonium are drugs we frequently use in the emergency department when resuscitating critically ill patients, and as such it’s vital that she carry a medi-alert bracelet.
Skin test showing a clear reaction to rocuronium, suxamethonium, vecuronium and pancuronium.
A couple of months ago, she requested a telephone consultation with me. I picked up the phone and called her, not really knowing what to expect. I was nervous that she might be angry – my anaesthetic had after all brought her to the brink of death – and even all those months later the events of that Wednesday were crystal clear in my mind (and still are as I write this).
My anxieties soon melted away as the same engaging and friendly voice that I had met before the operation thanked me for everything we’d done. My sense of guilt was replaced by a really quite emotional sense of relief as she asked about what happened and whether she would ever safely be able to have the operation she had been scheduled for. I took a deep breath in and said yes – we could avoid the drugs she was allergic to and give her a safe anaesthetic. Obviously there are risks to anything we do, but the risk of another reaction was very low after Dr Farooque’s thorough allergy testing. She also wanted me to anaesthetise her!
She ended up being scheduled on the day my colleague was anaesthetising, however I think the fates had decreed it was supposed to be me, as she was off sick. I was rescheduled onto her list and anaesthetised her this week.
I was nervous, she remembered the anaesthetic room as the same place that she entered those months before. I missed her vein as I tried to cannulate, probably through nerves, but then everything went well. When she woke up she pinched her thigh and said to herself “I’m alive! Thank God!”
She is now home recovering, and I want to thank her for being an inspiration.