A coroner has highlighted the importance of using CPAP and oxygen monitoring immediately after surgery to correct severe obstructive sleep apnea, in the case of a man who died from complications of hypoxia.
The Tasmanian coroner investigated the death of a 50-year-old man who developed deadly multiple pulmonary thromboemboli in the weeks after surgery to remove obstructive tissues to widen his airway at Calvary St John’s Hospital in Hobart.
His investigation concluded this would likely not have occurred had the man had oxygen saturation monitoring in the post-operative period and used the CPAP device he had been used for two years and had brought to the hospital from home.
Neither of these interventions occurred, partly because the hospital did not have in place a post-operative care pathway for the uvulopalatopharyngoplasty (UPPP) procedure he underwent.
The man had a long history of OSA, along with allergic rhinitis and a deviated nasal septum, and was first recommended a mandibular advancement device in 2001.
In 2014 moved onto CPAP and also saw surgeon who recommended a two-step surgery consisting of septoplasty and a reduction of the inferior turbinates followed by UPPP. The man underwent the first surgery in 2015. On August 2016, he was admitted to Calvary for the UPPP.
After uneventful surgery he was moved to the ward where nurses worked off a post-operative care pathway for adult tonsillectomy, in the absence of a specific protocol for UPPP.
There was also post-operative instructions from the surgeon, but these did not include instructions to administer oxygen saturation monitoring or the CPAP which she had advised the patient to bring from home.
At 5 am the morning after the surgery a nurse noted that the man was snoring loudly, but at 5.30 am became quiet.