Standard operating procedure for peri-operative infiltration of hip and knee replacements

Background

The Chief Coroner on 2nd September 2024 published ‘Rachel Gibson: Prevention of Future Deaths Report’ (Ref, 2024-4076).

The Report was sent to the President of the Royal College of Anaesthetists. The joint response of the Royal College of Anaesthetists and Association of Anaesthetists can be viewed here.

Dr Rachel Gibson had severe osteoarthritis and underwent hip replacement surgery at Spire Lea Hospital, Cambridge on 12th April 2022. Towards the end of the procedure, an infiltration of Ropivacaine was used in excess of the recommended dose. Upon return to her room she suffered an unwitnessed cardiac arrest. She was resuscitated and transferred to Addenbrooke’s Hospital where she was found to have sustained irreversible brain damage. She died at Addenbrooke’s Hospital on 14th July 2022.

The evidence was that it is routine practice before the procedure for the anaesthetist to give oral instructions to the scrub nurse specifying the type and dose of local anaesthetic to be used to infiltrate the operation site. Towards the end of the operation the scrub nurse hands the local anaesthetic to the surgeon who then carries out the infiltration.

The intention in this case was for a 0.2% solution of Ropivacaine to be diluted 50/50 with normal saline before it was infiltrated. The evidence suggested that this was not done. The result was that excessive Ropivacaine was administered by mistake.

The Coroner raised the following matters of concern:

1. The responsibility for checking and administering the local anaesthetic is unclear:
   1. The instruction was given orally and not written down by the anaesthetist (the prescriber).
   2. The anaesthetist did not check what the nurse had written down.
   3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist.
   4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer.
2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced.

The evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation.

BOA guidelines

Whilst the Report has been sent to the President of Royal College of Anaesthetists, given the role of the surgeon, the BOA has produced the following SOP guidelines.

SOP guidelines:

1. The infiltration of local anaesthetic is to be discussed at the team briefing in the morning. Specific drug to be used, its dose, concentration and volume of LIA to be clearly stated by anaesthetist prior to commencement of the operation at ‘time out’.
2. There should be a commensurate reduction in ropivacaine dose when the anaesthetist has undertaken nerve blocks, and it should be ensured that a patient specific calculation is performed and recorded.

  3. (a) If Ropivacaine is to be used, it should be 0.2% ropivocaine +/- adrenaline +/- ketorolac.

      (b) If Bupivacaine is to be used, it should be either 0.25% or 0.5% with volume to be stated by                                anaesthetist.

4. All local anaesthetic infiltration is to be prescribed on ICM by the anaesthetist prior to infiltration. The responsibility for documentation will lie with the anaesthetist. 
5. The drawing up of the local anaesthetic at the stated concentration and volume is to be done by a theatre nurse and double checked with the scrub nurse.
6. Prior to LIA, the surgeon will check the drug ampoules, including dilution fluid used and expiry date.
7. The theatre team i.e. anaesthetist, surgeon and the two nurses involved in the steps outlined above carry collective clinical responsibility.

Example:

Local Infiltration of Anaesthetic to Surgical Wound (Hips and Knees)^1-3

References

1. NYSORA. (2018). Intra-articular and Periarticular Infiltration of Local Anesthetics. [online] Available at: www.nysora.com/topics/regional-anesthesia-for-specific-surgical-procedures/lower-extremity-regional-anesthesia-for-specific-surgical-procedures/anesthesia-and-analgesia-for-hip-procedures/intra-articular-periarticular-infiltration-local-anesthetics.
2. Lapidus O, Baekkevold M, Rotzius P, Lapidus LJ, Eriksson K. Preoperative administration of local infiltration anaesthesia decreases perioperative blood loss during total knee arthroplasty - a randomised controlled trial. J Exp Orthop. 2022 Dec 12;9(1):118.
3. National Institute for Health and Care Excellence Final Joint replacement (primary): hip, knee and shoulder [E] Evidence review for anaesthesia for knee replacement NICE guideline NG157. (2020). Available at: www.nice.org.uk/guidance/ng157/evidence/e-anaesthesia-for-knee-replacement-pdf-8771013042.