This Signal relates to the risk of bowel obstruction following orthopaedic surgery.
A sample incident reads:
“An orthopaedic patient who had undergone surgery for a fractured ankle had been acutely ill post op. Involvement by Outreach team, anaesthetist, surgeons and ortho team. Monitored and no surgical intervention for 2 days. I contacted Ortho Consultant expressing concerns that I felt if we continued to monitor the patient may worsen and die. Explained that we had 4 patients previously who were ortho and developed bowel obstruction who were not operated on and 3 died 1 was sent to ITU. At midnight that night the patient was found unresponsive and despite resuscitation attempt passed away.”
A search of all incidents reported to the National Reporting and Learning System (NRLS) from inception to May 2011 identified 55 further reports of issues relating to bowel obstruction following orthopaedic surgery and 14 incident reports confirmed that a bowel obstruction had occurred. Two of these patients subsequently died.
The most common theme identified was poor communication between orthopaedic and surgical teams as 21 incident reports related to delays in diagnosis or treatment of a bowel obstruction.
Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie Syndrome is an uncommon postoperative complication that is characterised by massive colonic dilatation in the absence of mechanical obstruction; it has the potential for substantial morbidity and mortality.
An American retrospective case-control study (2006) and a Turkish case study (2005) suggest that early recognition and appropriate management are critical tominimising high morbidity and mortality.Most patients who had Ogilvie Syndrome had risk factors that could be identified preoperatively. The authors recommend that this syndrome should be borne in mind following major orthopaedic interventions and be diagnosed and treated without delay.
We would like to hear from you – please contact us with your initiatives to reduce risks in these areas. We can share them with appropriate forums for example the Clinical Board for Surgical Safety.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.