Skip to main content Accessibility help
×
Hostname: page-component-77c78cf97d-7rbh8 Total loading time: 0 Render date: 2026-04-23T20:10:16.973Z Has data issue: false hasContentIssue false

Chapter 38 - Understanding Intraoperative Death

Published online by Cambridge University Press:  18 August 2022

By
Daniel Rodger  and
Heather Hartley
Edited by
Daniel Rodger ,
Kevin Henshaw ,
Paul Rawling  and
Scott Miller
Daniel Rodger
Affiliation:
Senior Lecturer in Perioperative Practice, London South Bank University
Kevin Henshaw
Affiliation:
Associate Head of Allied Health Professions, Edge Hill University, Ormskirk
Paul Rawling
Affiliation:
Senior Lecturer in Perioperative Practice, Edge Hill University, Ormskirk
Scott Miller
Affiliation:
Consultant Anaesthetist, St Helens and Knowsley Hospitals NHS Trust
Get access

Summary

Surgery and general anaesthesia are invasive and inherently risky. A rarely discussed reality of perioperative care is that sometimes patients die during anaesthesia and surgery, and many perioperative practitioners are not suitably prepared to handle such an event and its aftermath. Despite the rarity of intraoperative deaths, the experiences of those involved show that there is the potential for a long-lasting impact on individuals and teams. This chapter summarises the incidence of intraoperative death, reviews the potential impact on perioperative practitioners, and explores the different approaches to navigate their aftermath.

Keywords

DeathStressDebriefingMortalitySurgeryMental HealthDepressionTrauma

Information

Type
Chapter
Information
Fundamentals of Operating Department Practice , pp. 432 - 442
Publisher: Cambridge University Press
Print publication year: 2022

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Book purchase

Temporarily unavailable

References

Pinto, A., Faiz, O., Bicknell, C., et al. Surgical complications and their implications for surgeons’ well-being. British Journal of Surgery 2013; 100: 1748–1755.CrossRefGoogle ScholarPubMed
May, E.. Nothing prepared me for my first death in surgery. The Guardian, 26 November, 2015. Available from: www.theguardian.com/healthcare-network/2015/nov/26/nothing-prepared-me-for-my-first-death-in-surgery.Google Scholar
Stylianou, M. and Johnson, S.. I still remember the boy who died in our theatre. Now I help traumatised NHS. The Guardian, 24 October 2019, Available from: www.theguardian.com/society/2019/oct/24/remember-boy-died-theatre-now-help-traumatised-nhs-staff.Google Scholar
Rodger, D. and Hartley, H.. In the aftermath of a perioperative death: who cares for the clinician? Evidence-Based Nursing 2019; 22: 1–2.Google Scholar
Gazoni, F. M., Amato, P. E., Malik, Z. M., et al. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesthesia and Analgesia 2012; 114: 596–603.CrossRefGoogle ScholarPubMed
White, S. M. and Akerele, O.. Anaesthetists’ attitudes to intraoperative death. European Journal of Anaesthesiology 2005; 22: 938–941.CrossRefGoogle ScholarPubMed
Soto, R., Kado, J., Kerner, B., et al. Caring for the care-giver: debriefing following intra-operative death. The Midwestern Journal of Anesthesia Quality and Safety 2019; 1: 1–4.Google Scholar
Haslam, J.. Death on the table. UK Casebook 2005; 13: 7–10.Google Scholar
Haynes, A. B., Weiser, T. G., Berry, W. R., et al. A surgical safety checklist to reduce morbidity and mortality in a global population. The New England Journal of Medicine 2009; 360: 491–499.Google Scholar
Schiff, J. H., Welker, A., Fohr, B., et al. Major incidents and complications in otherwise healthy patients undergoing elective procedures: results based on 1.37 million anaesthetic procedures. British Journal of Anaesthesia 2014; 113: 109–121.CrossRefGoogle ScholarPubMed
Argo, A., Zerbo, S., Lanzarone, A., et al. Perioperative and anesthetic deaths: toxicological and medico legal aspects. Egyptian Journal of Forensic Sciences 2019; 9: 20.CrossRefGoogle Scholar
Lienhart, A., Auroy, Y., Pequignot, F., et al. Survey of anesthesia-related mortality in France. Anesthesiology 2006; 105: 1087–1097.CrossRefGoogle ScholarPubMed
Gazoni, F. M., Durieux, M. E, and Wells, L.. Life after death: the aftermath of perioperative catastrophes. Anesthesia and Analgesia 2008; 107: 591–600CrossRefGoogle ScholarPubMed
Gottschalk, A., Van Aken, H., Zenz, M., et al. Is anesthesia dangerous? Deutsches Ärzteblatt International 2011; 108: 469–474.Google Scholar
Cronjé, L.. A review of paediatric anaesthetic-related mortality, serious adverse events and critical incidents. Southern African Journal of Anaesthesia and Analgesia 2015; 21: 147–153.Google Scholar
Avidan, M. S. and Kheterpal, S.. Perioperative mortality in developed and developing countries. Lancet 2012; 380: 1038–1039.CrossRefGoogle ScholarPubMed
Ng-Kamstra, J. S., Arya, S., Greenberg, S. L. M., et al. Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Global Health 2018; 3: e000810.CrossRefGoogle ScholarPubMed
American College of Surgeons. ACS National Surgical Quality Improvement Program. Available from: www.facs.org/quality-programs/acs-nsqip.Google Scholar
Ozdemir, B. A., Sinha, S., Karthikesalingam, A., et al. Mortality of emergency general surgical patients and associations with hospital structures and processes. British Journal of Anaesthesia 2016; 116: 54–62.CrossRefGoogle ScholarPubMed
Bainbridge, D., Martin, J, Arango, M, et al. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 2012; 380: 1075–1081.Google Scholar
Gaba, D. M.. Anaesthesiology as a model for patient safety in health care. British Medical Journal 2000; 320: 785–788.Google Scholar
Lagasse, R. S.. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology 2002; 97: 1609–1617.CrossRefGoogle ScholarPubMed
Pearse, R. M., Harrison, D. A., James, P., et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Critical Care 2006; 10: R81.Google Scholar
Gonzalez, L. P., Pignaton, W., Kusano, P. S., et al. Anesthesia-related mortality in pediatric patients: a systematic review. Clinics (Sao Paulo) 2012; 67: 381–387.CrossRefGoogle ScholarPubMed
Cavill, G. and Kerr, K.. Preoperative management. In Smith, T., Pinnock, C., and Lin, T. (eds.), Fundamentals of Anaesthesia, 3rd ed. Cambridge: Cambridge University Press, 2009, pp. 1–24.Google Scholar
de Bruin, L., Pasma, W., van der Werff, D. B. M., et al. Perioperative hospital mortality at a tertiary paediatric institution. British Journal of Anaesthesia 2015; 115: 608–615.CrossRefGoogle Scholar
Abbott, T. E. F., Fowler, A. J., Dobbs, T. D., et al. Frequency of surgical treatment and related hospital procedures in the UK: a national ecological study using hospital episode statistics. British Journal of Anaesthesia 2017; 119: 249–257.Google Scholar
Ricciardi, R., Roberts, P. L., Read, T. E., et al. Mortality rate after nonelective hospital admission. Archives of Surgery 2011; 146: 545–551.CrossRefGoogle ScholarPubMed
Sun, J., Girling, A. J., Aldridge, C., et al. Sicker patients account for the weekend mortality effect among adult emergency admissions to a large hospital trust. BMJ Quality and Safety 2019; 28: 223–230.CrossRefGoogle ScholarPubMed
Gillespie, B. M. and Kermode, S.. How do perioperative nurses cope with stress? Contemporary Nurse 2004; 16: 20–29.Google Scholar
Michael, R. and Jenkins, H. J.. Work-related trauma: the experiences of perioperative nurses. Collegian 2001; 8: 19–25.CrossRefGoogle ScholarPubMed
Todesco, J., Rasic, N. F., and Capstick, J.. The effect of unanticipated perioperative death on anesthesiologists. Canadian Journal of Anesthesia 2010; 57: 361–367.Google Scholar
Martin, T. W. and Roy, R. C.. Cause for pause after a perioperative catastrophe: one, two, or three victims? Anesthesia and Analgesia 2012; 114 (3): 485–487.Google Scholar
Pratt, S. D. and Jachna, B. R.. Care of the clinician after an adverse event. International Journal of Obstetric Anesthesia 2015; 24:54–63.CrossRefGoogle ScholarPubMed
Baas, M. A. M., Scheepstra, K. W. F., Stramrood, C. A. I., et al. Work-related adverse events leaving their mark: a cross-sectional study among Dutch gynecologists. BMC Psychiatry 2018; 18: 73.CrossRefGoogle Scholar
Wahlberg, Å, Andreen Sachs, M., Johannesson, K., et al. Post‐traumatic stress symptoms in Swedish obstetricians and midwives after severe obstetric events: a cross‐sectional retrospective survey. BJOG 2017; 124: 1264–1271.Google Scholar
Wu, A. W.. Medical error: the second victim. The doctor who makes the mistake needs help too. British Medical Journal 2000; 320: 726–727.Google Scholar
Hartley, H., Wright, D. K., Vanderspank-Wright, B., et al. Dead on the table: a theoretical expansion of the vicarious trauma that operating room clinicians experience when their patients die. Death Studies 2019; 43: 301–310.CrossRefGoogle ScholarPubMed
Rickerson, E. M., Somers, C., Allen, C. M., et al. How well are we caring for caregivers? Prevalence of grief-related symptoms and need for bereavement support among long-term care staff. Journal of Pain and Symptom Management 2005; 30: 227–233.CrossRefGoogle ScholarPubMed
Hartley, H.. Intraoperative death: the untold stories of perioperative teams. Master’s Thesis, University of Ottawa, 2018. Available from: http://dx.doi.org/10.20381/ruor-21489.Google Scholar
Wilson, J. and Kirshbaum, M.. Effects of patient death on nursing staff: a literature review. British Journal of Nursing 2011; 20: 559–563.Google Scholar
Zimmermann, C.. Denial of impending death: a discourse analysis of the palliative care literature. Social Science and Medicine 2004; 59: 1769–1780.Google Scholar
Tucker, T.. Culture of death denial: relevant or rhetoric in medical education? Journal of Palliative Medicine 2009; 12: 1105–1108.Google Scholar
Haslam, N.. Dehumanization: an integrative review. Personality and Social Psychology Review 2006; 10: 252–264.Google Scholar
Barnard, A. and Sandelowski, M.. Technology and humane nursing care: (ir)reconcilable or invented difference? Journal of Advanced Nursing 2001; 34: 367–375.CrossRefGoogle ScholarPubMed
Kompanje, E. J. O., van Mol, M. M., and Nijkamp, M. D.. ‘I just have admitted an interesting sepsis’. Do we dehumanize our patients?. Intensive Care Medicine 2015; 41: 2193–2194.CrossRefGoogle ScholarPubMed
Edrees, H., Connors, C., Paine, L., et al. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. British Medical Journal Open 2016; 6: e011708.Google Scholar
Goldstone, A. R., Callaghan, C. J., Mackay, J., et al. Should surgeons take a break after an intraoperative death? Attitude survey and outcome evaluation. British Medical Journal 2004; 328: 379CrossRefGoogle Scholar
Jithoo, S. and Sommerville, T. E.. Death on the table: anaesthetic registrars’ experiences of perioperative death. Southern African Journal of Anaesthesia and Analgesia 2017; 23: 1–5.Google Scholar
Clegg, I. and MacKinnon, R.. Strategies for handling the aftermath of intraoperative death. Continuing Education in Anaesthesia, Critical Care and Pain 2014; 14: 159–162.CrossRefGoogle Scholar
National Institute for Health and Care Excellence. Post-traumatic stress disorder. Available from: www.nice.org.uk/guidance/ng116/resources/posttraumatic-stress-disorder-pdf-66141601777861.Google Scholar
Royal College of Surgeons. Morbidity and mortality meetings: a guide to good practice. Available from: https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/good-practice-guides/morbidity-and-mortality-meetings/ (accessed 29 May 2020).Google Scholar
Gispen, F. and Wu, A. W.. Psychological first aid: CPR for mental health crises in healthcare. Journal of Patient Safety and Risk Management 2018; 23: 51–53.Google Scholar
Bass, S. and Cowman, S.. Anaesthetist’s guide to the coroner’s court in England and Wales. BJA Education 2016; 16: 130–133.Google Scholar
Edwards, G.. Death on the table. British Journal of Anaesthesia 1938; 15: 87–103.CrossRefGoogle Scholar

Accessibility standard: Unknown

Why this information is here

This section outlines the accessibility features of this content - including support for screen readers, full keyboard navigation and high-contrast display options. This may not be relevant for you.

Accessibility Information

Accessibility compliance for the HTML of this chapter is currently unknown and may be updated in the future.

Save book to Kindle

To save this book to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×