Case Studies of Near Misses in Clinical Anesthesia

Case 1. A patient with a mediastinal mass.- Case 2. Stick out your tongue.- Case 3. An epidural blood patch. What went wrong?.- Case 4. A lack of communication leads to a bad outcome.- Case 5. Hyperkalemia during Coronary Artery Bypass Graft.- Case 6. A adjuvant to the cuff leak test.- Case 7. Acinetobacter baumannii outbreak in an ICU. Can our equipment be at fault?.- Case 8. A complication with the use of the intubating Fiberscope.- Case 9. Interscalene block in concern in cardiac patients.- Case 10. Epidural analgesia for labor. Watch out.- Case 11. Past history of esophagectomy. Any concern?.- Case 12. A case of Myasthenia Gravis.- Case 13. Where are my teeth?.- Case 14. An unusual Capnograph tracing.- Case 15. A VP shunt.- Case 16. Shoulder surgery. Watch out.- Case 17. An ambulatory surgical patient with no escort.- Case 18. A complication during laprascopy.- Case 19. A patient with Amyotrophic lateral sclerosis.- Case 20. Repair of a thoracic duct.- Case 21. Occuled reinforced (armored) endotracheal tube.- Case 22. A difficult nasogastic tube insertion.- Case 23. Antiphospholipid antibody syndrome. Any concern for general anesthesia?.- Case 24. An airway surprise.- Case 25. Difficulty with breathing in the postoperative period.- Case 26. Severe systemic local anesthetic toxicity.- Case 27. A motorcycle accident with neck injury.- Case 28. Thoracic incisional injury.- Case 29. Bronchospasm. An unusual cause.- Case 30. Post bariatric surgery. Any concerns?.- Case 31. Valuable information from an implanted pacemaker.- Case 32. Allen's test in an anesthetized patient. Is it possible?.- Case 33. A loss of the only oxygen supply you have during an anesthetic.- Case 34. An aggressive surgeon.- Case 35. A pharyngeal mass.- Case 36. Retained laps.- Case 37. A "Code Blue".- Case 38. A complication of Transesophageal echocardiography (TEE).- Case 39. LMA in elective orthopedic surgery.- Case 40. What would you do?.- Case 41. Preeclampsia.- Case 42. A failed "test dose".- Case 43. A simple cystoscopy with biopsy.- Case 44. An orthopedic trauma.- Case 45. Blood in the endotracheal tube.- Case 46. A longstanding tracheostomy.- Case 47. An airway problem during MAC.- Case 48. Is the patient extubated?.- Case 49. A leaking anesthesia machine.- Case 50. A most important lesson.- Case 51. Transsphenoidal resection of a pituitary tumor.- Case 52. Spinal reconstruction and fusion in a chronic pain patient.- Case 53. A repeat back operation in a patient who has had postoperative visual loss in the past.- Case 54. Respiratory arrest in the recovery room.- Case 55. Bispectral Index. What does it mean?.- Case 56. Neonatal laprascopic surgery.- Case 57. Total IV anesthesia.- Case 58. An ICU Patient.- Case 59. A new onset of arterial fibrillation in the recovery room.- Case 60. A rapid increase in core body temperature.- Case 61. Prolonged surgery.- Case 62. Persistent intraoperative hiccups. What to do?.- Case 63. Internal jugular cannulation.- Case 64. Endobronchial foreign body.- Case 65. A cyst in Fourth ventricle.- Case 66. Generalized convulsions after regional anesthesia.- Case 67. Cardiac arrest in a prone patient.- Case 68. A short patient with a high BMI.- Case 69. Bleeding after oral surgery.- Case 70. Selecting the right size double lumen tube.- Case 71. A low normal preoperative blood glucose level.- Case 72. Things to remember when you change a Cordis Catheter to a triple lumen.- Case 73. An intraoperative malfunctioning vaporizer.- Case 74. An abnormal EKG first discovered in the operating room.- Case 75. A cardiac arrest in ICU.- Case 76. A severe case of metabolic acidosis.- Case 77. Bunionectomy under both general and regional anesthesia.- Case 78. Now what would you do?.- Case 79. A strange case.- Case 80. A chronic pain patient

John Brock-Utne is an Emeritus Professor of Anesthesia and a previous Associate Director of the Anesthesia Residency Program at Stanford University School of Medicine. He has written over 200 peer-reviewed articles and about 400 abstracts and letters, and several books, including Near Misses in Pediatric Anesthesia and Clinical Anesthesia: Near Misses and Lessons Learned.