Loss of Situation Awareness Leading to Fatal Hemorrhage

“As the blankets and drapes that covered the patient were pulled back to start the arterial line, it was quickly evident that something was wrong.”

Case Context    Provider Narrative    Lessons Learned

Case Context

Patient: middle-aged adult
Presenting diagnosis: hemodynamic instability, abdominal pain, suspected ischemic bowel s/p repair of ruptured abdominal aortic aneurysm (AAA)
Planned procedure: urgent laparotomy for colon resection
Past medical history: ASA IVE: hypertension, mild gastroesophageal reflux, postoperative day 8 s/p AAA repair complicated by postoperative left lower lobe pneumonia and sepsis
Anesthetic plan: general endotracheal anesthesia