Coronial
VIChospital

Finding into death of G A

Demographics

86y, female

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2017-11-24

Finding date

2023-10-06

Cause of death

Bradycardic arrest secondary to relative hypoperfusion while undergoing surgery to the left hand in a patient with subclinical ischaemic heart disease

AI-generated summary

An 86-year-old woman underwent elective surgery to excise a probable squamous cell carcinoma from her left hand with split-thickness skin grafting under local anaesthesia with intravenous sedation. She suffered an unexpected cardiac arrest intraoperatively secondary to bradycardia and hypotension. Despite appropriate resuscitation, she sustained a hypoxic brain injury and died three days later. The coroner found she had subclinical ischaemic heart disease. While the second dose of anaesthetic drugs (50mg propofol and 50mcg fentanyl) was excessive, the evidence did not establish causation between this and her deterioration. The surgical decision and anaesthetic plan were appropriate. Her death was unpredictable and not preventable given the unknown coronary artery disease.

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

Specialties

dermatologyplastic and reconstructive surgeryanaesthesiacardiologyintensive care

Error types

medication

Drugs involved

propofolfentanylephedrineatropineadrenaline

Clinical conditions

ischaemic heart disease (subclinical)bradycardic arrestcardiac arresthypotensionhypoxic brain injurysquamous cell carcinoma (skin lesion)

Procedures

surgical excision of skin lesionsplit-thickness skin graftinglocal anaesthetic infiltrationdermatome usecardiopulmonary resuscitationintubationarterial line insertion

Contributing factors

  • Subclinical ischaemic heart disease (previously undetected)
  • Intravenous sedation with propofol and fentanyl during surgery
  • Relative hypoperfusion in setting of surgery
  • Excessive second dose of anaesthetic drugs
  • Low blood pressure maintained at lower acceptable limits during sedation
Full text

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