Coronial
NSWhospital

Inquest into death of Lucas PEYRET

Deceased

Lucas Peyret

Demographics

21y, male

Date of death

2019-06-05

Finding date

2022-10-26

Cause of death

Hypoxic brain injury arising from severe anaphylactic shock due to administration of Sugammadex following laparoscopic appendicectomy

AI-generated summary

Lucas Peyret, a 21-year-old with no significant medical history, presented to hospital with acute appendicitis and underwent emergency laparoscopic appendicectomy. Surgery was routine and uneventful. Upon emergence from anaesthesia, after administration of Sugammadex (neuromuscular reversal agent), Lucas developed severe anaphylactic shock with bronchospasm, wheeze, desaturation and rapid loss of consciousness. Cardiac arrest ensued and required 23 minutes of CPR with appropriate advanced life support protocol adherence. Return of spontaneous circulation was achieved but prolonged hypoxia caused irreversible global cortical ischaemia and brainstem death. The coroner found no fault with surgical decision-making, anaesthetic conduct, or resuscitation management. Sugammadex anaphylaxis, though rare (2 per 100,000 incidence), remains an important safety consideration in anaesthetic practice.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Contributing factors

  • Severe anaphylactic reaction to Sugammadex
  • Prolonged hypoxia during cardiac arrest (23 minutes)
  • Global cortical ischaemia from oxygen deprivation

Coroner's recommendations

  1. That the findings of this inquest be referred to both the Australian and New Zealand College of Anaesthetists and the Therapeutic Goods Administration to consider further the incidence of anaphylaxis from the use of Sugammadex and risk management of the same in light of the facts of the death of Lucas Peyret
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