Unravelling the fatal chain: A detailed investigation into catastrophic events following anaesthesia in a feline patient

An 8-year-old male neutered British Shorthair cat, weighing 5.12 kg, was referred for chronic mild inappetence, lethargy, bilirubinuria, weight loss and icterus. Diagnostic imaging and serum biochemistry suggested a partial biliary tract obstruction caused by an enlarged pancreas. An exploratory laparotomy was scheduled to perform biopsies of the liver, pancreas and duodenum. Preanaesthetic medication included fentanyl (10 μg kg^-1) and midazolam (0.3 mg kg^-1), given intravenously (IV) through a catheter in a cephalic vein. General anaesthesia was induced with IV propofol (3 mg kg^-1). After endotracheal intubation with a cuffed endotracheal tube (4.5 mm inner diameter), general anaesthesia was maintained with isoflurane in oxygen (fresh gas flow 3 L minute^-1) using a mini Mapleson D (modified T piece). A cholecystoduodenostomy was performed. Intraoperatively, the cat was hypotensive and tachycardic and unresponsive to analgesic therapy (ketamine and fentanyl boluses) and a fluid bolus. At the end of surgery, a concern raised by a nurse that the catheter site was wet, potentially indicating the catheter no longer being in the vein, was dismissed. In recovery, this suspicion was confirmed when bandage material overlying the catheter was removed. An attempt was made to place a central venous catheter but, during placement, the cat showed signs consistent with agonal gasps, followed by cardiopulmonary arrest. Cardiopulmonary resuscitation attempts were unsuccessful. Retrospective analysis of this case allowed identification of a series of active failures, such as not checking the patency of the intravenous catheter by unwrapping it before beginning anaesthesia and system failures, such as inadequate communication.