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Never forget a lesson learned.

Take a look at stories that have helped nurse anesthetists around the world learn and grow in their field.

Narcotized in the PACU

“The anesthesia provider asked for an Ambu® bag and the recovery room nurse realized all…

Carpal Tunnel Release

“The patient, who had previously been alert and oriented, was now complaining of tinnitus, dizziness,…

Anesthesia Machine Failure

“Everything went black. Once the power came back on, the provider attempted ventilation and could…

Pulseless Electrical Activity

“…the surgeon requested that the head of the bed be raised another 20° for improved…

Tunnel Vision

“The manual BP was attempted several times with only a single reading obtained, which was…

Pediatric Airway Obstruction During Transport

“Upon arrival in the PACU, I first noticed a change in the color of the…

Fire in the Operating Room
Electrocautery Unit Fire in the Operating Room

“Shortly thereafter, the electrocautery unit was utilized to facilitate excision of the lesion and almost…

Failed Intubation and Mask Ventilation in an Emergency Cesarean Section

”There was no chest rise, no ETCO2, and the oxygen saturation was plummeting into the…

Anaphylaxis

“…the patient stated, ‘I’m burning’. The nurse anesthetist questioned the patient regarding burning at the…

Stretcher Lock Failure

“The stretcher lock failed…creating a small divide between the stretcher and bed.”

Oxygen Desaturation After Extubation

“Upon arrival to PACU, the patient’s overall color was ashen and his lips became cyanotic.”…

Negative Pressure Pulmonary Edema with Use of a Laryngeal Mask Airway

“… at which time copious quantities of pink, frothy secretions poured out of the laryngeal…

Anticipated Difficult Airway

“The moment the anesthesia provider said, ‘I can see the cords, please thread the tube’, the patient vomited.”

Accidental Extubation in the Prone Position

“…the patient was returned to the supine position on a stretcher. The reason for the…

Loss of Situation Awareness Leading to Fatal Hemorrhage

“As the blankets and drapes that covered the patient were pulled back to start the…

Shift in Patient Position During Surgery

“ The surgeon was having difficulty exposing the polyp and requested steeper Trendelenburg position. [The…

Unintentional Intraoperative Extubation

“When the ETT was slightly withdrawn, the patient was accidentally extubated.”   Case Context   …

Muscle Relaxant Administration Error

“Another member of the anesthesia team began going through the anesthesia drug drawer and administered…

Severe Hypotension During Induction

“His arterial BP was 40s/20, HR 90s. Soon the arterial waveform was lost. Both carotid…

Massive Pulmonary Embolism
Massive Pulmonary Embolism

“There were no other available extremities to place the pulse oximeter…The anesthesia provider…attempted to feel…

Cardiac Arrest After Anectine Administration

“An intubating laryngeal mask airway was placed but was also unsuccessful in facilitating ventilations. The…

Interoperative Cardiac Arrest
Intraoperative Cardiac Arrest

“The surgery progressed without incident until the tourniquet developed a leak. With the inadequate occlusion…

Airway Fire in the Operating Room

“ …they were in the process of recording vital signs on the anesthetic record when…

Pulmonary
Pulmonary Embolus Under Anesthesia

“ …after several minutes it was noted that all the adjustments were not helping and…

Complete Airway Obstruction After Tonsillectomy and Adenoidectomy

“The SpO2 fell to less than 50%, the heart rate was less than 40 beats…

Pediatric Laryngospasm

“Spontaneous respirations ceased at this point and positive pressure through the anesthesia circuit did not…

Epidural Syringe Swap
Epidural Syringe Swap

“plan was to slowly load the epidural prior to incision with an intended initial bolus…

Local Anesthetic Toxicity

“…gentle aspiration was performed and was negative for blood. Approximately one minute after the local…

Breathing Circuit MISconnect

“The next patient, an adult, was brought back to the operating room… The pressure check…

Aspiration
Aspiration

“The trainee stated he did not have a good view, so the attending took over…