Case Presentation

Pediatric Airway Obstruction During Transport

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

Anaphylaxis

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

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…

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“When the ETT was slightly withdrawn, the patient was accidentally extubated.”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