Surgeons have issued a warning that the death of a patient was linked to a rare but fatal drug interaction following a surgical quality audit.

The death occurred after the patient was prescribed Lyrica (pregabalin) in conjunction with other opioids to manage their recovery following minor foot surgery. Some 10 hours later, the patient was found unresponsive and unable to be resuscitated.

The case was highlighted in the ‘Case of the Month’ series released by the Australian and New Zealand Audit of Surgical Mortality (ANZASM) managed by the Royal Australasian College of Surgeons (RACS).

Audit Chairman Professor Guy Maddern said while the case was concerning, he hoped that by raising awareness of the fatal interaction that future deaths would be avoided.

“It is now clear that under certain conditions this type of interaction can cause severe respiratory depression, resulting in death. These circumstances are extremely rare and, in the case highlighted by ANZASM, the patient did present with existing co-morbidities.

“However, the use of Lyrica in conjunction with other opioids is a widespread practice, and it is therefore very important that we communicate the risks to surgeons and other clinicians as much as possible.

“As the research and health warnings are only starting to emerge now, many surgeons will not be familiar with these interactions and consequently may not be fully aware of the associated risks.

“By releasing the findings of this case note review and publicly promoting them, we are encouraging all surgeons to discuss these risks with their anaesthetic colleagues and alert the relevant committee at their hospital.”

Professor Maddern said that while the findings were concerning, its detection by ANZASM was a testament to the valuable role that the audit plays in surgery and the health system.

“The principal aims of the audit are to inform, educate, facilitate change and improve the quality of practice within surgery, and in some cases, related specialties. ANZASM has also proven invaluable in identifying nationwide trends and issues in surgical care.

“By paying special attention to the details of deaths, the audit is able to ascertain whether it was a direct result of the disease process alone, or if aspects of patient management might have contributed to that outcome.

“Since the audit’s inception in 2002, we have seen significant reduction in surgical related deaths. Cases like this one, demonstrate the value of the audit and are an excellent example of how a relatively modest investment can lead to considerably improved outcomes.”