The link between a common hospital drug and anaphylactic shock needs to be better known after a young man's appendix surgery led to his death, a coroner says.
Sydney law clerk Lucas Peyret was a healthy, fit man preparing to move house when struck down by appendicitis in May 2019.
While coming out of routine surgery to remove the 21-year-old's appendix, he suffered a "severe and unexpected" anaphylactic reaction to an anaesthetic reversal agent, a NSW coroner found on Wednesday.
Mr Peyret's heart stopped for 23 minutes, his brain was starved of oxygen and he never recovered, dying 10 days later on June 5.
"Hospital staff did all they could in the circumstances to save Lucas but ultimately were unable to do so," coroner Erin Kennedy said, summarising her findings on Wednesday.
The coroner recommended the Australian and New Zealand College of Anaesthetists and the Therapeutic Goods Administration consider further the incidence and risk management of severe reactions to the agent, sugammadex.
"There is a need to look at this issue ... to ensure any dangers are understood," Ms Kennedy said.
The full findings are expected to be published within a week.
Ms Kennedy extended her condolences to Mr Peyret's family, including his mother Katya Denomme.
Ms Denomme had raised concerns that the surgery occurred on a Sunday evening with an anaesthetist-in-training and without imaging to confirm the clinical diagnosis of appendicitis.
The disappointed mother was also concerned that "she was not getting the whole truth" from staff at Randwick's Prince of Wales Hospital, the inquest was told.
However, the inquest was told the hospital's discussions with the Peyret family had been given a positive assessment by an expert in open disclosure following adverse medical events, while an experienced anaesthetist said the surgery was well within the trainee anaesthetist's abilities.
The anaesthetist-in-training, Sukhi Hegde, said she spoke with Mr Peyret about the risks of aspiration and the roughly-1-in-4000 chance of a serious anaphylactic reaction to drugs used in surgery.
Surgical registrar Jakob Koestenbauer, who diagnosed appendicitis based on symptoms and blood results, told the coroner there wasn't sufficient uncertainty to delay treatment.
Meanwhile, the surgeon who led the appendectomy, Negin Sedaghat, said appendix removal was "the bread and butter of acute general surgery" and Mr Peyret's high score on a diagnostic scale fit the bill for someone needing urgent attention.
Concern was also raised about conducting imaging on a young man that would give him a dose of radiation.
When Mr Peyret crashed, Dr Sedaghat said she was "rather confused because the surgery was so routine".
The law clerk had felt unwell and in pain for about a day before his surgery and slept 12 hours the night of May 25.
With acute right abdominal pain, right shoulder pain, fever and vomiting, he visited a GP on May 26 and was referred to hospital.
He'd never been a patient in hospital and, beside mild asthma, had no medical history.
