Anaphylaxis and malignant hyperthermia - what was the cause of death?

The Victorian Coroner was recently required to consider whether the death of a child was due to an anaphylactic reaction suffered whilst an in-patient or whether the death arose due to the management of the anaphylaxis.
The facts
The deceased was a 13 year old with a past medical history of asthma and previously established allergies to cow's milk, raw egg, peanuts and tree nuts. He was admitted to hospital with an exacerbation of his asthma. His mother informed the registered nurse who was to care for him overnight of the food allergies. She further advised that for breakfast he could be given Weetbix, soy milk and fruit; but was not to be given cow's milk due to his established food allergy.  This information was formally documented by the nurse and the mother left the ward.
By 7:00am the deceased’s asthma had resolved.  The deceased’s breakfast was arranged by the personal care assistant at around 7.15am.
At about 7:19am the deceased reported to a registered nurse that virtually immediately upon tasting his Weetbix and milk, he experienced a "tingling" on his lips. He was reviewed by the paediatric resident doctor who said that he found the deceased "distressed, had trouble breathing and was wheezing on auscultation." The deceased advised the paediatric resident doctor that he was experiencing "mild tingling in his throat." He was given 12 puffs of Salbutamol and the nurse was to draw up 0.4mgs of adrenaline. The doctor made a differential diagnosis of asthma and/or anaphylactic reaction.  At 7:36am the Paediatric Registrar attended and confirmed the same differential diagnoses.
Between 7:40am and 8:42am the deceased was given 4 doses of adrenaline administered intra-muscularly. At approximately 7:45am, his condition suddenly deteriorated with increased difficulty breathing and his eyes rolling back. A MET call was made.  The Paediatric Infant Perinatal Emergency Retrieval Team (PIPER) were summoned at 8:16am.  At 8:42am a decision was made in conjunction with the anaesthetic team to transfer the deceased to theatre for intubation awaiting the arrival of the PIPER team.
The anaesthetist found intubation of the deceased at 9:00am to be straightforward with the child remaining "cardiovascularly stable throughout”. Shortly after, an adrenaline infusion was commenced. The anaesthetist described how after a period of relative stability, his management of the deceased became increasingly difficult as the deceased’s' end-tidal C02 (ETC02) increasing from 70-80mmHgs shortly after intubation, decreasing to approximately 58mmHgs, until rising alarmingly to over 100mmHgs, followed by a rapid deterioration of his condition with ETC02 rising to 108mmHgs.
It was concluded that the deceased was suffering from malignant hyperthermia. The malignant hyperthermia protocol was commenced and the deceased was administered Dantrolene via femoral venous catheter. At approximately 10:49am, the deceased suffered a cardiac arrest from which he could not be revived. CPR was abandoned and the patient was declared deceased.
The issues for consideration

The principal areas for investigation were:
  1. Did the deceased suffer an anaphylactic reaction to the breakfast and was the "food preparation and presentation regime" in place in the paediatric ward adequate?;
  2. If the deceased did suffer an anaphylactic episode, was a diagnosis, formal or differential, made in a timely manner?
  3. Were the steps taken to treat the deceased, once an anaphylactic reaction was suspected, reasonable and appropriate?
The Coroner was comfortably satisfied the deceased suffered anaphylaxis due to an undetermined allergen contained in the breakfast provided. It was not however, conceded by the hospital that the breakfast provided to the deceased contained anything that it was known he was allergic to. The hospital did concede that there were significant systemic failures in the food handling practices/policies in place at the time. For example, there was a lack of a written policy regarding food handling pertinent to patients with allergies on the paediatric ward as at the time. There was no policy in place at the time requiring a nurse to check the food prepared for a patient with food allergies prior to it being given to the patient.
The Coroner was satisfied that the hospital’s new policies, procedures and guidelines formulated in response to this incident were thorough and appropriate. As a result this relieved him of his obligation to make formal recommendations on the issue.
Although there was some divergence of opinions as to the efficacy of medical management from the time of anaphylactic episode to the time of intubation, overall the experts came to a consensus that in broad terms it was reasonable. The Coroner was comfortably satisfied there was no reasonable basis for an adverse finding in relation to the overall medical management of the deceased by medical staff who were involved in this treatment.
Further, the Coroner was satisfied that the that the anaesthetic agents utilised to facilitate intubation were appropriate and that the medical management of the deceased post intubation, including the method and timing of the administration of Dantrolene, was reasonable and appropriate. The Coroner noted that malignant hyperthermia is an extremely rare complication following the administration of standard anaesthetic agents and as such was not a foreseeable consequence.
The Coroner concluded that had the deceased not required intubation he would have survived.  That is because the cause of death was as a result of the malignant hyperthermia and not the anaphylaxis. The anaphylaxis was a contributing factor.
Management of anaphylaxis
Allergy and Anaphylaxis Australia (A&AA) sought input into the Coronial investigation. That is because A&AA state that there is currently no uniform standard for management of anaphylaxis in Australia but that there are hundreds of guidelines and protocols published by various stakeholders. The Coroner declined to accept A&AA as a formal "interested party" but invited their input in relation to Anaphylaxis Management Guidelines.  A&AA provided two submissions which the Coroner found most helpful and annexed to his findings. A&AA submitted that a mandatory clinical care standard for anaphylaxis be developed Australia wide. Paragraph 9 of the submissions sets out A&AA’s recommended guidelines. The submission also addressed an issue which arose in this matter, which related to the use of a patient’s EpiPen when suffering anaphylaxis as an in-patient. The Coroner elected not to make a formal recommendation in relation to the issues raised in the A&AA submissions on the basis that a specialist forum would be better placed to consider the issues.

This decision highlights the importance of having policies and procedures in relation to the handling of food for patients who suffer food allergies. A failure to ensure that such policies and procedures are in place can lead to catastrophic outcomes, such as what occurred in this matter. The Coroner noted that the cruel irony in this case was that but for the anaphylaxis, which resulted in the need for intubation and caused the resultant malignant hyperthermia, the deceased would have survived and been discharged home.

Post by Emma Ellis and Karen Kumar 

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