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

2. 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

3. 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…

4. 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 !

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

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

8. 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?

9. Vaporizer design