This document discusses several medical cases involving pediatric patients undergoing outpatient surgery: 1. An 8-year-old patient weighing 85kg arrived for a tonsillectomy and was given oral midazolam by the pre-op nurse. Within 5 minutes the child lost consciousness and had respiratory depression requiring oxygen and observation. 2. A surgeon asked if tests were needed before proceeding with a cervical node biopsy on a seemingly healthy 10-year old, as induction of anesthesia led to immediate cardiac arrest. 3. A 2-year old undergoing hernia repair suffered cardiac arrest within 5 minutes of induction, and died, raising questions about the vaporizer design used for halothane anesthesia.

1. 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

9. Vaporizer design