Bad cases, Strange cases & Legal cases Jerrold Lerman BASc, MD, FRCPC, FANZCA Clinical Professor of Anesthesiology Women’s & Children’s Hospital of Buffalo, SUNY and Strong Memorial Hospital, University of Rochester, New York

Ambulatory surgery History: 8 year old T&A outpatient Late am arrival in community hospital Prean nurse notified MD in the OR Weight: 85 kg Nursing h x : Ebstein's anomaly…"not sure what it is, will search it on the internet" In the meantime, 15 mg PO midazolam

History:

8 year old T&A outpatient

Late am arrival in community hospital

Prean nurse notified MD in the OR

Weight: 85 kg

Nursing h x : Ebstein's anomaly…"not sure what it is, will search it on the internet"

In the meantime, 15 mg PO midazolam

Ambulatory Surgery Course: Within 5 min of PO midazolam, nurse started IV Child sitting on the guerney Rolled his eyes and lost consciousness What do you do? Face mask, 100% oxygen, Observed ECG 15 minutes before tracheal intubation No definitive diagnosis…

Course:

Within 5 min of PO midazolam, nurse started IV

Child sitting on the guerney

Rolled his eyes and lost consciousness

What do you do?

Face mask, 100% oxygen, Observed ECG

15 minutes before tracheal intubation

No definitive diagnosis…

Ambulatory Surgery Considerations: Morbid Obesity Chronic hypoxemia ↓ cardiac function OSA: nocturnal hypoxemia Sensitivity to opioids ± benzos Pulmonary hypertension Obesity OSA Ebstein's anomaly Tricuspid regurgitation ?ASD WPW Right ventricular failure !

Considerations:

Morbid Obesity

Chronic hypoxemia

↓ cardiac function

OSA: nocturnal hypoxemia

Sensitivity to opioids ± benzos

Pulmonary hypertension

Obesity

OSA

Ebstein's anomaly

Tricuspid regurgitation

?ASD

WPW

Cardiac Arrest in the OR Surgeon: Healthy 10 y.o. child, outpatient surgery Just a little (hard) cervical node biopsy…. Proceed? Any tests?

Surgeon:

Healthy 10 y.o. child, outpatient surgery

Just a little (hard) cervical node biopsy….

Proceed?

Any tests?

Case Presentations Just a little node biopsy: Induction of anesthesia Tracheal intubation with a non-depolarizing relaxant Cardiac arrest! Management? Position Position Position

Just a little node biopsy:

Induction of anesthesia

Tracheal intubation with a non-depolarizing relaxant

Cardiac arrest!

Management?

Position

Position

Position

Simple hernia or not! Anesthetic: 13 kg 2 year old male for hernia repair Intravenous induction with thiopental, atropine and succ. and tracheal intubation; Maintenance: 1% halothane in N 2 O IPPV Within 5 min, after the first automatic BP, bradycardia and cardiac arrest occurred. Child died on the table!!! Why?

Anesthetic:

13 kg 2 year old male for hernia repair

Intravenous induction with thiopental, atropine and succ. and tracheal intubation;

Maintenance: 1% halothane in N 2 O

IPPV

Within 5 min, after the first automatic BP, bradycardia and cardiac arrest occurred.

Child died on the table!!!

Why?

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